Smoking Cessation

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Key points

  • Smoking is the major risk factor for lung cancer and contributes to risk for heart disease and many other conditions.

  • Although the risks of smoking and the benefits of cessation are well recognized, for both generalist and specialist physicians, smoking cessation is often not a priority.

  • Cigarette smoking should be regarded as a chronic relapsing disease.

  • Optimal treatment requires a long-term approach, combining pharmacologic and nonpharmacologic interventions and close interactions between

Physiology of smoking

There is a traditional view that regards smoking as a lifestyle choice and a habit. The decision to begin smoking is a choice, and in that context, it is a lifestyle choice. However, almost all smokers begin smoking in adolescence.5 The choice to begin smoking is influenced by numerous social factors, which include not only the behaviors of family and friends but the promotion of smoking through advertising and public image. Smoking behavior is also strongly influenced by other social factors,

Approach to a quit attempt

As noted earlier, smoking should be regarded as a primary addictive disorder.4 Seventy-five percent of Americans wish to quit, but only 3% achieve prolonged abstinence in any year, indicating both the involuntary nature of the established addiction and the substantial need for treatment.25 It is recommended that smoking status and willingness to quit be assessed at every health care visit.4, 26, 27 However, individual readiness to quit (Table 2) is likely variable and may be related to acute

Strategy for the quit attempt

The greatest quit rates are achieved when nonpharmacologic support is combined with pharmacotherapy. The more extensive the support, the greater the success. However, many smokers do not accept referral to a group program. Limited counseling in the office can be provided to these individuals. In addition, telephone quit lines, which have shown efficacy,39 are available toll-free and at no cost in many countries, including the United States and Canada. In the United States, the phone number is

Pharmacotherapy

Three classes of medication are approved as aids to smoking cessation (nicotine replacement, bupropion [Zyban, also sold under the trade name Wellbutrin to treat depression], and varenicline [Chantix]) and 2 others are available off-label (nortryptiline and clonidine), which have documented efficacy and are recommended as alternative therapies in current guidelines.4, 26, 27, 40

Harm reduction

Cigarette smoke contains up to 6000 components, which are generated by the complex chemical processes associated with curing and pyrolysis of the tobacco.80 Nicotine is not among the most important toxic compounds in smoke. This factor has led to the concept that nicotine addiction could be addressed by nicotine replacement using a preparation that does not include the health-compromising toxins. This approach, termed harm reduction, is inherently controversial, because it involves supporting

Summary

Cigarette smoking should be regarded as a chronic relapsing disease. However, it is a disease that can be effectively treated in many cases. Optimal treatment requires a long-term approach combining pharmacologic and nonpharmacologic interventions and close interactions between patient and clinician.

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References (86)

  • M. Borgerding et al.

    Analysis of complex mixtures–cigarette smoke

    Exp Toxicol Pathol

    (2005)
  • P.N. Lee

    Summary of the epidemiological evidence relating snus to health

    Regul Toxicol Pharmacol

    (2011)
  • King James I of England. A counterblaste to tobacco. 1604. Available at:...
  • US Department of Health, Education, and Welfare. Smoking and health. Report of the Advisory Committee to the Surgeon...
  • US Department of Health and Human Services

    The health benefits of smoking cessation. A report of the Surgeon General

    (1990)
  • M.C. Fiore et al.

    Treating tobacco use and dependence: 2008 update. Clinical practice guideline

    (2008)
  • L.G. Escobedo et al.

    Sociodemographic characteristics of cigarette smoking initiation in the United States

    JAMA

    (1990)
  • J.P. Pierce et al.

    What public health strategies are needed to reduce smoking initiation?

    Tob Control

    (2012)
  • S.W. Headen et al.

    Are the correlates of cigarette smoking initiation different for black and white adolescents?

    Am J Public Health

    (1991)
  • In: Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta (GA):...
  • L.D. Johnston et al.

    Monitoring the future national survey results on drug use, 1975–2012

    (2013)
  • R.M. Drenan et al.

    Insights into the neurobiology of the nicotinic cholinergic system and nicotine addiction from mice expressing nicotinic receptors harboring gain-of-function mutations

    Pharmacol Rev

    (2012)
  • J.P. Changeux

    Nicotine addiction and nicotinic receptors: lessons from genetically modified mice

    Nat Rev Neurosci

    (2010)
  • F.M. Leslie et al.

    Nicotinic receptors in addiction pathways

    Mol pharmacol

    (2013)
  • N.A. Goriounova et al.

    Short- and long-term consequences of nicotine exposure during adolescence for prefrontal cortex neuronal network function

    Cold Spring Harb Perspect Med

    (2012)
  • S. Shiffman

    Tobacco “chippers”–individual differences in tobacco dependence

    Psychopharmacology

    (1989)
  • S. Shiffman et al.

    Nicotine withdrawal in chippers and regular smokers: subjective and cognitive effects

    Health Psychol

    (1995)
  • N.L. Benowitz et al.

    Intravenous nicotine replacement suppresses nicotine intake from cigarette smoking

    J Pharmacol Exp Ther

    (1990)
  • N.L. Benowitz et al.

    Influence of smoking fewer cigarettes on exposure to tar, nicotine, and carbon monoxide

    N Engl J Med

    (1986)
  • P. Olausson et al.

    Repeated nicotine exposure enhances reward-related learning in the rat

    Neuropsychopharmacology

    (2003)
  • J.E. Henningfield et al.

    Arterial-venous differences in plasma concentrations of nicotine after cigarette smoking

    JAMA

    (1990)
  • J. Hukkanen et al.

    Metabolism and disposition kinetics of nicotine

    Pharmacol Rev

    (2005)
  • T.F. Heatherton et al.

    The Fagerstrom Test for nicotine dependence: a revision of the Fagerstrom Tolerance Questionnaire

    Br J Addict

    (1991)
  • Centers for Disease Control and Prevention (CDC)

    Cigarette smoking among adults and trends in smoking cessation–United States, 2008

    MMWR Morb Mortal Wkly Rep

    (2009)
  • M.C. Fiore et al.

    Smoking cessation. Guideline technical report no. 18

    (1997)
  • M. Fiore et al.

    Treating tobacco use and dependence

    (2000)
  • D.M. Daughton et al.

    Transdermal nicotine therapy and primary care: importance of counseling, demographic and patient selection factors on one-year quit rates

    Arch Fam Med

    (1998)
  • C.J. Gwaltney et al.

    Self-efficacy and smoking cessation: a meta-analysis

    Psychol Addict Behav

    (2009)
  • S.B. Gulliver et al.

    An investigation of self-efficacy, partner support and daily stresses as predictors of relapse to smoking in self-quitters

    Addiction

    (1995)
  • J. Cromwell et al.

    Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation

    JAMA

    (1997)
  • N. Lindson-Hawley et al.

    Reduction versus abrupt cessation in smokers who want to quit

    Cochrane Database Syst Rev

    (2012)
  • N.R. Anthonisen et al.

    Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1

    JAMA

    (1994)
  • N.A. Rigotti et al.

    Interventions for smoking cessation in hospitalised patients

    Cochrane Database Syst Rev

    (2012)
  • Cited by (21)

    • Modelling a budgetary impact analysis for funding drug-based smoking cessation therapies for patients with major depressive disorder in Spain

      2017, European Psychiatry
      Citation Excerpt :

      Within Spain, smoking accounts for approximately 60,000 deaths per year and, as in other countries, is associated with high healthcare resource utilisation and cost to society [3,4]. Smoking cessation is a medical objective that continues to be pursued by both clinicians and public health authorities alike, particularly in patient populations who are at high risk for developing comorbidity [5–8]. Individuals suffering from major depressive disorder (MDD) are considered to be a vulnerable smoking population due to the greater risk of developing nicotine dependence compared to smokers without comorbid psychiatric disorders [9,10].

    • Neuroscience of nicotine for addiction medicine: novel targets for smoking cessation medications

      2016, Progress in Brain Research
      Citation Excerpt :

      Nicotine is the major psychoactive component of tobacco smoke (Stolerman and Jarvis, 1995). The effects of nicotine are mediated by neuronal nicotinic acetylcholine receptors (nAChRs) and current first-line Food and Drug Administration (FDA)-approved smoking cessation medications such as varenicline and nicotine replacement therapies target these nAChRs (Nides, 2008; Rennard and Daughton, 2014; see Table 1). However, these FDA-approved medications are not effective in all smokers who express a desire to quit.

    • Cardiovascular disease in patients with chronic human immunodeficiency virus infection

      2014, International Journal of Cardiology
      Citation Excerpt :

      A comprehensive smoking cessation program is more likely to achieve higher success rates than individual therapies. Counseling, nicotine replacement therapy (patches, gum and inhaler) and medications (buprorpion and varenicline) are all effective, however, the overall efficacy depends on their integration into an effective management plan and support throughout cycles of remission and relapse [75]. Lipid management to reduce CVD is particularly challenging in patients with HIV.

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    Disclosures: Since 2010, S.I. Rennard has consulted with Pfizer on the topic of smoking cessation and conducted clinical trials sponsored by Pfizer. He has also consulted on other topics for GlaxoSmithKline which has smoking cessation products.

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