Smoking Cessation Smoking cessation is the process of discontinuing tobacco smoking. Tobacco contains nicotine, which is addictive. Smoking cessation can be achieved with or without assistance from healthcare professionals, or the use of medications. However, a combination of personal efforts and medications proves more effective to many smokers. Methods that have been found to be effective include interventions directed at or via health care providers and health care systems; medications including nicotine replacement therapy (NRT) and varenicline; individual and group counselling; and Web-based or stand-alone and computer programs. Although stopping smoking can cause short-term side effects such as reversible weight gain, smoking cessation services and activities are cost-effective because of the positive health benefits. • In a growing number of countries, there are more ex-smokers than smokers. • Early "failure" is a normal part of trying to stop, and more than one attempt at stopping smoking prior to longer-term success is common. • NRT, other prescribed pharmaceuticals, and professional counselling or support also help many smokers. • However, up to three-quarters of ex-smokers report having quit without assistance ("cold turkey" or cut down then quit), and cessation without professional support or medication may be the most common method used by ex-smokers. Tobacco contains nicotine. Smoking cigarettes can lead to nicotine addiction. The addiction begins when nicotine acts on nicotinic acetylcholine receptors to release neurotransmitters such as dopamine, glutamate, and gamma aminobutyric acid. Cessation of smoking leads to symptoms of nicotine withdrawal such as anxiety and irritability. Professional smoking cessation support methods generally endeavour to address both nicotine addiction and nicotine withdrawal symptoms. Studies have shown that it takes between 6 to 12 weeks post quitting before the amount of nicotinic receptors in the brain return to the level of a non smoker.
Methods
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Unassisted methods As it is common for ex-smokers to have made a number of attempts (often using different approaches on each occasion) to stop smoking before achieving long-term abstinence, identifying which approach or technique is eventually most successful is difficult; it has been estimated, for example, that "only about 4% to 7% of people are able to quit smoking on any given attempt without medicines or other help.". However, in analysing a 1986 U.S. survey, Fiore et al. (1990) found that 95% of former smokers who had been abstinent for 1–10 years had made an unassisted last quit attempt. The most frequent unassisted methods were "cold turkey" and "gradually decreased number" of cigarettes. A 1995 meta-analysis estimated that the quit rate from unaided methods was 7.3% after an average of 10 months of follow-up. Cold turkey "Cold turkey" is a colloquial term indicating abrupt withdrawal from an addictive drug, and in this context indicates sudden and complete cessation of all nicotine use. In three studies, it was the quitting method cited by 76%, 85%, or 88% of long-term successful quitters. In a large British study of ex-smokers in the 1980s, before the advent of pharmacotherapy, 53% of the ex-smokers said that it was "not at all difficult" to stop, 27% said it was "fairly difficult", and the remaining 20% found it very difficult. Healthcare provider and systems Interventions delivered via healthcare providers and healthcare systems have been shown to improve smoking cessation among people who visit those providers. A clinic screening system (e.g., computer prompts) to identify whether or not a person smokes doubled abstinence rates, from 3.1% to 6.4%. Similarly, the Task Force on Community Preventive Services determined that provider reminders alone or with provider education are effective in promoting smoking cessation. •
A 2008 Guideline meta-analysis estimated that physician advice to quit smoking led to a quit rate of 10.2%, as opposed to a quit rate of 7.9% among patients who did not receive physician advice to quit smoking. A Cochrane review found that even brief advice from physicians had "a small effect on cessation rates." However, one study from Ireland involving vignettes found that physicians' probability of giving smoking cessation advice declines with the patient's age, and another study from the U.S. found that only 81% of smokers age 50 or greater received advice on quitting from their physicians in the preceding year. •
For one-to-one or person-to-person counselling sessions, the duration of each session, the total amount of contact time, and the number of sessions all correlated with the effectiveness of smoking cessation. For example, "Higher intensity" interventions (>10 minutes) produced a quit rate of 22.1% as •
Dr. Sanjiv Haribhakti
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opposed to 10.9% for "no contact"; over 300 minutes of contact time produced a quit rate of 25.5% as opposed to 11.0% for "no minutes"; and more than 8 sessions produced a quit rate of 24.7% as opposed to 12.4% for 0–1 sessions. Both physicians and non-physicians increased abstinence rates compared with self-help or no clinicians. For example, a Cochrane review of 31 studies found that nursing interventions increased the likelihood of quitting by 28%. •
Dental professionals also provide a key component in increasing tobacco abstinence rates in the community through counseling patients on the effects of tobacco on oral health in conjunction with an oral exam. •
According to the 2008 Guideline, based on two studies the training of clinicians in smoking cessation methods may increase abstinence rates; however, a Cochrane review found and measured that such training decreased smoking in patients. •
Reducing or eliminating the costs of cessation therapies for smokers increased quit rates in three meta-analyses. •
In one systematic review and meta-analysis, multi-component interventions increased quit rates in primary care settings. "Multi-component" interventions were defined as those that combined two or more of the following strategies known as the "5 A's": •
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Ask — Systematically identify all tobacco users at every visit
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Advise — Strongly urge all tobacco users to quit
Biochemical feedback Various methods exist which allow a smoker to see the impact of their tobacco use, and the immediate effects of quitting. Using biochemical feedback methods can allow tobacco-users to be identified and assessed, and the use of monitoring throughout an effort to quit can increase motivation to quit. Breath carbon monoxide (CO) monitoring: Because carbon monoxide is a significant component of cigarette smoke, a breath carbon monoxide monitor can be used to detect recent cigarette use. Carbon monoxide concentration in breath has been shown to be directly correlated with the CO concentration in blood, known as percent carboxyhemoglobin. The value of demonstrating blood CO concentration to a smoker through a non-invasive breath sample is that it links the smoking habit with the physiological harm associated with smoking. Within hours of quitting, CO concentrations show a noticeable decrease, and this can be encouraging for someone working to quit. Breath CO monitoring has been utilized in smoking cessation as a tool to provide patients with biomarker feedback, similar to the way in which other diagnostic tools such as the stethoscope, the blood pressure cuff, and the cholesterol test have been used by treatment professionals in medicine. •
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Cotinine: A metabolite of nicotine, cotinine is present in smokers. Like carbon monoxide, a cotinine test can serve as a reliable biomarker to determine smoking status. Cotinine levels can be tested through urine, saliva, blood, or hair samples, with one of the main concerns of cotinine testing being the invasiveness of typical sampling methods. •
While both measures offer high sensitivity and specificity, they differ in usage method and cost. As an example, breath CO monitoring is non-invasive, while cotinine testing relies on a bodily fluid. These two methods can be used either alone or together, for example, in a situation where abstinence verification needs additional confirmation. Single medications A 21mg dose Nicoderm CQ patch applied to the left arm. The American Cancer Society estimates that "between about 25% and 33% of smokers who use medicines can stay smoke-free for over 6 months." Single medications include: Nicotine replacement therapy (NRT): Five medications approved by the U.S. Food and Drug Administration (FDA) deliver nicotine in a form that does not involve the risks of smoking. NRTs are meant to be used for a short period of time and should be tapered down to a low dose before stopping. The five NRT medications, which in a Cochrane review increased the chances of stopping smoking by 50 to 70% compared to placebo or to no treatment, are: •
1. transdermal nicotine patches deliver doses of the addictive chemical nicotine, thus reducing the unpleasant effects of nicotine withdrawal. These patches can give smaller and smaller doses of nicotine, slowly reducing dependence upon nicotine and thus tobacco. A Cochrane review found further increased chance of success in a combination of the nicotine patch and a faster acting form. Also, this method becomes most effective when combined with other medication and psychological support. 2. gum 3. lozenges 4. sprays 5. inhalers A study found that 93 percent of over-the-counter NRT users relapse and return to smoking within six months. Antidepressant: Bupropion is FDA-approved and is marketed under the brand name Zyban. Bupropion is contraindicated in epilepsy, seizure disorder; anorexia/bulimia (eating disorders), patients' use of antidepressant drugs (MAO inhibitors) within 14 days, patients undergoing abrupt discontinuation of ethanol or sedatives (including benzodiazepines such as Valium). Evidence from a systematic review suggests that antidepressants such as Bupropion and Nortriptyline help in long-term smoking cessation and that adverse events with both drugs are rarely serious enough to cause stopping of the medication. The •
Dr. Sanjiv Haribhakti
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evidence also points out that Bupropion is less effective than Varenicline however this needs to be further validated. •
Nicotinic receptor partial agonists:
• Cytisine (Tabex) is a plant extract that has been in use since the 1960s in former Soviet-bloc countries. It was the first medication approved as an aid to smoking cessation, and has very few side effects in small doses. • Varenicline tartrate is a prescription drug marketed by Pfizer as Chantix in the U.S. (under FDA approval) and as Champix outside the U.S. Synthesized as an improvement upon cytisine, varenicline decreases the urge to smoke and reduces withdrawal symptoms. Two systematic reviews and meta-analyses supported by unrestricted funding from Pfizer, one in 2006 and one in 2009, found varenicline more effective than NRT or bupropion. A table in the 2008 Guideline indicates that 2 mg/day of varenicline leads to the highest abstinence rate (33.2%) of any single therapy, while 1 mg/day leads to an abstinence rate of 25.4%. A 2011 Cochrane review of 15 studies (13 of which had been sponsored by Pfizer) found that varenicline was significantly superior to bupropion at one year but that varenicline and nicotine patches produced the same level of abstinence at 24 weeks. A 2011 review of double-blind studies found that varenicline has increased risk of serious adverse cardiovascular events compared with placebo. Varenicline may cause neuropsychiatric side effects; for example, in 2008 the UK. Medicines and Healthcare products Regulatory Agency issued a warning about possible suicidal thoughts and suicidal behavior associated with varenicline.
Moclobemide has been tested in heavy dependent smokers against placebo based on the theory that tobacco smoking could be a form of self medicating of major depression, and moclobemide could therefore help increase abstinence rates due to moclobemide mimicking the MAO-A inhibiting effects of tobacco smoke. Moclobemide was administered for 3 months and then stopped; at 6 months follow-up it was found those who had taken moclobemide for 3 months had a much higher successful quit rate than those in the placebo group. However, at 12 month follow-up the difference between the placebo group and the moclobemide group was no longer significant. •
Two other medications have been used in trials for smoking cessation, although they are not approved by the FDA for this purpose. They may be used under careful physician supervision if the first line medications are contraindicated for the patient. 1. Clonidine may reduce withdrawal symptoms and "approximately doubles abstinence rates when compared to a placebo," but its side effects include dry mouth and sedation, and abruptly stopping the drug can cause high blood pressure and other side effects. 2. Nortriptyline, another antidepressant, has similar success rates to bupropion but has side effects including dry mouth and sedation. Dr. Sanjiv Haribhakti
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Combinations of medications The 2008 US Guideline specifies that three combinations of medications are effective: Long-term nicotine patch and ad libitum NRT gum or spray Nicotine patch and nicotine inhaler Nicotine patch and bupropion (the only combination that the US FDA has approved for smoking cessation) • • •
Cut down to quit Gradual reduction involves slowly reducing one's daily intake of nicotine. This can theoretically be accomplished through repeated changes to cigarettes with lower levels of nicotine, by gradually reducing the number of cigarettes smoked each day, or by smoking only a fraction of a cigarette on each occasion. A 2009 systematic review by researchers at the University of Birmingham found that gradual nicotine replacement therapy could be effective in smoking cessation. A 2010 Cochrane review found that abrupt cessation and gradual reduction with pre-quit NRT produced similar quit rates whether or not pharmacotherapy or psychological support was used. According to a more recent 2012 Cochrane systematic review analysis of 10 studies and 3670 patients, overall relative risk reduction between smokers who attempted to quit with abrupt cessation or with gradual reduction techniques was 0.06. This analysis demonstrated that there was no significant difference in quit rates between smokers who quit by gradual reduction or abrupt cessation as measured by abstinence from smoking of at least six months from the quit day, suggesting that patients who want to quit can choose between these two methods. Community interventions A Cochrane review found evidence that community interventions using "multiple channels to provide reinforcement, support and norms for not smoking" had an effect on smoking cessation outcomes among adults. Specific methods used in the community to encourage smoking cessation among adults include: Policies making workplaces and public places smoke-free. It is estimated that "comprehensive clean indoor laws" can increase smoking cessation rates by 12%–38%. In 2008, the New York State of Alcoholism and Substantance Abuse Services banned smoking by patients, staff and volunteers at 1,300 addiction treatment centers. •
Voluntary rules making homes smoke-free, which are thought to promote smoking cessation. •
Initiatives to educate the public regarding the health effects of second-hand smoke. •
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Increasing the price of tobacco products, for example by taxation. The US
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Task Force on Community Preventive Services found "strong scientific evidence" that this is effective in increasing tobacco use cessation. It is estimated that an increase in price of 10% will increase smoking cessation rates by 3–5%. Mass media campaigns. The US Task Force on Community Preventive Services declared that "strong scientific evidence" existed for these when "combined with other interventions", but a Cochrane review concluded that it was "difficult to establish their independent role and value". •
Competitions and incentives One 2008 Cochrane review concluded that "incentives and competitions have not been shown to enhance long-term cessation rates." However, a trial published in 2009 found that financial incentives for smoking cessation led to significantly higher rates of smoking cessation 15–18 months after enrollment. Furthermore, a different 2008 Cochrane review found that one type of competition, "Quit and Win," did increase quit rates among participants.
Dr. Sanjiv Haribhakti
Gisurgery.info