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Information ⬇

Editors

EBMG

Smoking Cessation

Essentials

Smoking cessation

Readiness to stop smoking

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

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

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

Bupropion

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

QuestionTime/AmountPoints
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
How soon after waking up do you smoke your first cigarette?within 6 minutes3
6-30 minutes2
31-60 minutes1
after 60 minutes0
How many cigarettes do you smoke each day?0-100
11-201
21-302
more than 303

Other drugs and interventions

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]

Evidence Summaries ⬆