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Smoking Cessation

Essentials

6-7 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 Physician's Advice for Smoking Cessation.
Ask about the patient's smoking habits and discuss with him/her about his/her willingness to stop.
Motivational interviewing Motivational Interviewing for Smoking Cessation can reinforce the patient's readiness, willingness, and ability for a lifestyle change.
Varenicline Varenicline for Smoking Cessation, bupropion Antidepressants for Smoking Cessation and nortriptyline Antidepressants for Smoking Cessation are effective in supporting smoking cessation.
Nicotine replacement therapy increases the success rate of smoking cessation 1.5-2 fold Nicotine Replacement Therapy for Smoking Cessation.
Support combined with pharmacotherapy enhances the success of cessation Combined Pharmacotherapy and Behavioural Interventions for Smoking Cessation.
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 The Most Important Known Health Risks of Smoking.

Smoking cessation

Readiness to stop smoking

Motivational interviewing Motivational Interviewing for Smoking Cessation can reinforce the patient's readiness, willingness, and ability for a lifestyle change.
Determine your patient's present stage in order to be able to support him/her in the best way possible Tobacco Cessation Interventions for Young People.
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 Interventions for Recruiting Smokers into Cessation Programmes.
Smoking cessation often is a long process, and support is required.
Support to smoking cessation should be organized as a part of health care services.

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 Change in Mental Health after Smoking Cessation. 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 Interventions for Preoperative Smoking Cessation.
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. Periodontitis and loss of teeth become less common.

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 T1).
Coffee may aggravate withdrawal symptoms.

Weight gain

Weight gain should be expected after stopping smoking.
The average weight gain is 3-5 kg during the first 6-12 months following stopping, but it is very individual. Women have a tendency to higher increase in weight. The increased feeling of hunger lasts about 3 months.
Individualized guidance in dietary measures and exercise Behavioural and Exercise Interventions for Preventing Weight Gain after Smoking Cessation in association with smoking cessation may reduce weight gain.
Nicotine replacement therapy, bupropion or varenicline may reduce weight gain Smoking Cessation Medication for Preventing Weight Gain after Cessation.
The benefits of cessation, however, always exceed the adverse health effects caused by possible weight gain.

Guidance and management Enhancing Partner Support to Improve Smoking Cessation, , , Competitions and Incentives for Smoking Cessation, Relapse Prevention Interventions for Smoking Cessation, Combined Pharmacotherapy and Behavioural Interventions for Smoking Cessation, Interventions for Tobacco Use Cessation in People in Treatment for or Recovery from Substance Use Disorders, Smoking Cessation Interventions for Smokers with Current or Past Depression, Legislative Smoking Bans for Reducing Secondhand Smoke Exposure and Smoking Prevalence, Family-Based Programmes for Preventing Smoking by Children and Adolescents, Psychosocial Interventions for Smoking Cessation in Patients with Coronary Heart Disease, Internet and Mobile Phone-Based Interventions for Smoking Cessation, School-Based Programmes for Preventing Smoking, Biomedical Risk Assessment as an Aid for Smoking Cessation, Training Health Professionals in Smoking Cessation

Discussion and single brief intervention

The opportunity to discuss smoking should be offered to all smokers. Motivational interviewing is particularly useful Motivational Interviewing for Smoking Cessation http://www.motivationalinterview.org/.
A three minute counselling session is more effective than simple encouragement as an aid to smoking cessation Physician's Advice for Smoking Cessation.
Motivational interviewing and the 5 A's model
- Ask about the patient's smoking status and discuss it at least once a year (duration in pack-years, amount, benefits and adverse effects, attempts to quit)
  - This is easy to achieve in connection with medical examinations, treatments or prophylaxis for an illness.
  - Smoking habits and quantity (cigarette, cigar, snuff, pipe, electronic cigarette)
  - Duration (in total pack-years of smoking; e.g., 20 years of ½ a pack per day = 10 pack-years)
  - How did the ealier attempts to quit smoking succeed, what were the reasons for relapse, etc.?
- Advise the patient about the importance of cessation of smoking, particularly from the viewpoint of his/her possible diseases.
- Assess the patient's willingness to stop.
- Assist and help the patient with a quit plan, including the means, medication, support and timeline.
  - Provide advice on how to prepare for situations in which the temptation to start smoking again is great, as well as on the withdrawal symptoms that are to be expected.
- Arrange follow-up appointments to take place at least at 1-2 weeks, 1 month and 3 months after stopping.
  - Positive feedback helps in succeeding.
  - Each smokeless day is an achievement.
  - Where necessary, guide the patient towards further intervention (an organized group, nurse, regional centre of expertise).

Individual monitoring and support

Individual counselling is effective Individual Behavioural Counselling for Smoking Cessation.
Repeated contacts and follow-up increase the possibility of success Physician's Advice for Smoking Cessation.
Telephone counselling provides additional benefit Telephone Counselling for Smoking Cessation. Tailored withdrawal programmes based on the Internet or mobile phone contacts may help in cessation Internet and Mobile Phone-Based Interventions for Smoking Cessation.
Counselling by a nurse alone also has a positive effect Nursing Interventions for Smoking Cessation.
An organized, gradual smoking reduction might be a beneficial treatment formNicotine Replacement Therapy to Reduce Continued Tobacco Use, but it is less effective than abrupt cessation Reduction Versus Abrupt Cessation in Smokers Who Want to Quit.
Counselling especially provided by oral health professionals may help in cessation of snuff use Interventions for Tobacco Cessation in the Dental Setting.

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 Group Behaviour Therapy Programmes for Smoking Cessation.
- Individual or group counselling provided at the workplace is also helpful in smoking cessation Workplace Interventions for 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 Varenicline for Smoking Cessation. Interventions for Smokeless Tobacco Use Cessation, Varenicline for Smoking Cessation in Individuals with Schizophrenia, Smoking Cessation for People with Chronic Obstructive Pulmonary Disease, Relapse Prevention Interventions for Smoking Cessation, Varenicline and Bupropion and Suicidal Behaviour
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 12-24 weeks.
Support and follow-up form a part of the treatment Combined Pharmacotherapy and Behavioural Interventions for Smoking Cessation.
Should not be used in severe renal insufficiency.
May cause nausea.
Combining nicotine patch with varenicline can enhance cessation Combination of Varenicline with Nicotine Replacement Therapy for Smoking Cessation.

Bupropion

Bupropion is effective Antidepressants for Smoking Cessation. Interventions for Smoking Cessation in Patients with Psyhiatric Disorders
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 Combined Pharmacotherapy and Behavioural Interventions for Smoking Cessation.
It is possible to combine bupropion and nicotine replacement therapy even if the effect is not necessarily enhanced Combination of Nicotine Replacement Therapy and Bupropion for Smoking Cessation.
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 Nicotine Replacement Therapy for Smoking Cessation. Smoking Cessation for People with Chronic Obstructive Pulmonary Disease
Follow-up and support should be offered Combined Pharmacotherapy and Behavioural Interventions for Smoking Cessation.
All forms of nicotine replacement therapy (chewing gum, transdermal depot 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 for Smoking Cessation. Combining a long-acting patch with a short-acting product increases the cessation success rate to the level of varenicline Nicotine Replacement Therapy for Smoking Cessation.
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 T1.
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 Combined Nicotine Replacement Therapy for Smoking Cessation.
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.
Combining nicotine patch with varenicline can enhance cessation Combination of Varenicline with Nicotine Replacement Therapy for Smoking Cessation.
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 Pharmacological Interventions for Promoting Smoking Cessation during Pregnancy. Smoking cessation during pregnancy may reduce the incidence of prematurity and low birth weightPsychosocial Interventions for Supporting Women to Stop Smoking in Pregnancy . Short-acting preparations are recommended.

Fagerström two question test for nicotine dependence

Question	Time/Amount	Points
How soon after waking up do you smoke your first cigarette?	within 6 minutes	3
	6-30 minutes	2
	31-60 minutes	1
	after 60 minutes	0
How many cigarettes do you smoke each day?	0-10	0
	11-20	1
	21-30	2
	more than 30	3

Interpretation: Total number of points 0-1 point = minor nicotine dependence, 2 points = moderate nicotine dependence, 3 points = heavy nicotine dependence, 4-6 points = very heavy nicotine dependence

Other drugs and interventions

Nortriptyline is effective Antidepressants for Smoking Cessation.
- 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, treatment period 8-12 weeks.
- Inexpensive
Other antidepressants than bupropion and nortriptyline are not effective in smoking cessation Antidepressants for Smoking Cessation
Anxiolytics are of no benefit in cessation therapy Anxiolytics for Smoking Cessation.
There is no evidence of the effectiveness of naltrexone Naltrexone for Smoking Withdrawal.
Neither acupuncture Acupuncture for Smoking Cessation nor hypnosis Hypnotherapy for Smoking Cessation are effective treatment forms. Physical exercise may aid in smoking cessation as part of the treatment Exercise Interventions for Smoking Cessation. Cytisine may be effective Cytisine for Smoking Cessation.
Electronic cigarettes (electronic nicotine delivery systems) have not been proven to help people quit smoking E-Cigarettes and Smoking Cessation in Real-World and Clinical Settings.
Tobacco smoke induces CYP1A2 enzyme activity 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, 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. Smoking reduces cutaneous superficial circulation thus decreasing the absorption of subcutanously injected insulin.

References

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. [PubMed]
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. [PubMed]
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. [PubMed]
Rigotti NA, Kruse GR, Livingstone-Banks J ym. Treatment of Tobacco Smoking: A Review. JAMA 2022;327(6):566-577. [PubMed]
US Preventive Services Task Force, Krist AH, Davidson KW et al. Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons: US Preventive Services Task Force Recommendation Statement. JAMA 2021;325(3):265-279.[PubMed]
Danan ER, Joseph AM, Sherman SE et al. Does Motivation Matter? Analysis of a Randomized Trial of Proactive Outreach to VA Smokers. J Gen Intern Med 2016;31(8):878-87. [PubMed]

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