Drugs Expert

Smoking cessation (colloquially quitting) is the process of discontinuing the practice of inhaling a smoked substance. Smoking cessation programs mainly target tobacco smoking, but may also encompass other substances that can be difficult to stop using due to the development of strong physical addictions or psychological dependencies resulting from their habitual use.

It is believed that very few smokers can successfully quit the habit in their very first attempt. Many studies indicated that many smokers find it difficult to quit, even after they get afflicted with tobacco related diseases. A serious commitment and resolve is required to arrest nicotine dependency.

• In a growing number of countries, there are more ex-smokers than smokers. (In the U.S. as of 2010, 47 million ex-smokers and 46 million smokers.)
• Up to three-quarters of ex-smokers have quit without assistance (“cold turkey” or cut down then quit), and unaided cessation is by far the most common method used by most successful ex-smokers.
• A serious attempt at stopping need not involve using nicotine replacement therapy (NRT) or other drugs or getting professional support.
• Early “failure” is a normal part of trying to stop. Many initial efforts are not serious attempts.
• NRT, other prescribed pharmaceuticals, and professional counselling or support also help many smokers, but are certainly not necessary for quitting.

What problems are caused by smoking?

By smoking, you can cause health problems not only for yourself but also for those around you.

Hurting Yourself

Smoking is an addiction. Tobacco contains nicotine, a drug that is addictive. The nicotine, therefore, makes it very difficult (although not impossible) to quit. In fact, since the U.S. Surgeon General’s 1964 report on the dangers of smoking, millions of Americans have quit. Still, approximately 440,000 deaths occur in the U.S. each year from smoking-related illnesses; this represents almost 1 out of every 5 deaths. The reason for these deaths is that smoking greatly increases the risk of getting lung cancer, heart attack, chronic lung disease, stroke, and many other cancers. Moreover, smoking is perhaps the most preventable cause of breathing (respiratory) diseases within the USA.

Hurting Others

Smoking harms not just the smoker, but also family members, coworkers, and others who breathe the smoker’s cigarette smoke, called secondhand smoke or passive smoke. Among infants up to 18 months of age, secondhand smoke is associated with as many as 300,000 cases of chronic bronchitis and pneumonia each year. In addition, secondhand smoke from a parent’s cigarette increases a child’s chances for middle ear problems, causes coughing and wheezing, worsens asthma, and increases an infant’s risk of dying from sudden infant death syndrome (SIDS).

Smoking is also harmful to the unborn fetus. If a pregnant woman smokes, her fetus is at an increased risk of miscarriage, early delivery (prematurity), stillbirth, infant death, and low birth weight. In fact, it has been estimated that if all women quit smoking during pregnancy, about 4,000 new babies would not die each year.

Exposure to passive smoke can also cause cancer. Research has shown that non-smokers who reside with a smoker have a 24% increase in risk for developing lung cancer when compared with other non-smokers. An estimated 3,000 lung cancer deaths occur each year in the U.S. that are attributable to passive smoking. Secondhand smoke also increases the risk of stroke and heart disease. If both parents smoke, a teenager is more than twice as likely to smoke as a teenager whose parents are both nonsmokers. Even in households where only one parent smokes, young people are more likely to start smoking.

What are the signs of cigarette addiction?

The signs of addiction to cigarettes include:

• smoking more than seven cigarettes per day;
• inhaling deeply and frequently;
• smoking cigarettes containing nicotine levels more than 0.9mg;
• smoking within 30 minutes of awakening in the morning;
• finding it difficult to eliminate the first cigarette in the morning;
• smoking frequently during the morning;
• finding it difficult to avoid smoking in smoking-restricted areas; and
• needing to smoke even if sick and in bed.

Methods of smoking cessation

Robert West and Saul Shiffman have authored works on smoking cessation. They believe that, used together, “behavioral support” and “medication” can quadruple the chances that a quit attempt will be successful. Both, however, disclosed that they are paid researchers or consultants to pharmaceutical companies or manufacturers of smoking cessation medications.

Cold turkey

“Cold turkey” is abrupt cessation of all nicotine use. It is the quitting method used by 80 to 90% of long-term successful quitters in some populations. 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 remainder found it very difficult. Methods advanced by J. Wayne McFarland and Elman J. Folkenburg (an M.D. and a pastor who wrote their Five Day Plan in about 1959), Joel Spitzer and John R. Polito (smoking cessation educators whose work is free at WhyQuit.com) and Allen Carr (who founded Easyway® during the early 1980s) are cold turkey plans.

Cut down to quit

Gradual reduction involves slowly reducing one’s daily intake of nicotine. This can be done in two ways: by repeated changes to cigarettes with lower levels of nicotine, or by gradually reducing the number of cigarettes smoked each day. As of 2010, and unlike earlier studies who claimed some benefit for gradual reduction, a Cochrane review found that abrupt cessation and gradual reduction with pre-quit NRT produced similar quit rates.

Pharmacological

The U.S. Food and Drug Administration has approved seven medications for treating nicotine addiction. All of these helped with withdrawal symptoms and cravings.

• Nicotine replacement therapy (NRT) Five of the approved medications are different methods of delivering nicotine in a form that does not involve the risks of smoking. The five NRT medications, which Cochrane found in 1996 increased the chances of stopping smoking by 50 to 70% compared to placebo or to no treatment, are:
  • 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. Cochrane 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.
  • Gum
  • Lozenges
  • Sprays
  • Inhalers.

A study found that 93 percent of over-the-counter NRT users relapse and return to smoking within six months.

• Antidepressants: bupropion is an antidepressant 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)
• Nicotinic receptor agonist: varenicline is a marketed by Pfizer in the U.S. as Chantix and Champix in the UK and Canada. Varenicline Tartrate is a prescription drug that can be used to alleviate some of the withdrawal symptoms. It can also be taken as a form of aversion therapy by smokers to make the act of smoking non-appealing or with adverse effects, similar to acamprosate or disulfiram for ethanol addiction.

• Cytisine (Tabex) is the basis of Pfizer’s development of varenicline, and is an extremely inexpensive plant extract. It 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. Pfizer funded and managed all studies of varenicline that were reviewed in a 2008 Cochrane review and unfortunately as of 2009, Cochrane reports, “The evidence on cytisine is limited at present, and no firm conclusions can yet be drawn about its effectiveness as an aid to quitting.”

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 craving for cigarettes after cessation. However, it does not consistently ameliorate other withdrawal symptoms.

2) Nortriptyline, another antidepressant, has similar success rates to bupropion.

Psychosocial approaches

• Great American Smokeout is an annual event that invites smokers to quit for one day, hoping they will be able to extend this forever.
• The World Health Organization’s World No Tobacco Day is held on May 31 each year.
• Smoking-cessation support and counseling is often offered over the internet, over the phone quitlines, or in person.
• Attending a self-help group such as Nicotine Anonymous and electronic self-help groups such as Stomp It Out.

Smoking cessation services

Group or individual therapy can help people who want to quit. Some smoking cessation programs employ a combination of coaching, motivational interviewing, cognitive behavioral therapy, and pharmacological counseling.

Self-help

• Interactive web-based programs which specialize in teaching participants how to quit.
• Quit meters: Small computer programs that keep track of quit statistics such as amount of “quit-time”, cigarettes not smoked, and money saved.
• Self-help books.
• Spirituality Spiritual beliefs and practices may help some smokers quit.
• Newsgroups: dating back to Usenet days, alt.support.stop-smoking has been used by people quitting smoking as a place to go to for support from others. It is accessible through Google Groups.

Substitutes for cigarettes

• Vaporizer: heats to 410 °F (210 °C) or less, compared with 1,500 °F (820 °C) in the tip of a cigarette when drawn upon; eliminates carbon monoxide and other combustion toxins.
• Electronic cigarette: Shaped like a cigar or cigarette, this device contains a rechargeable battery and a heating element that vaporizes liquid nicotine (and other flavorings) from an insertable cartridge, at lower initial cost than a vaporizer but with the same advantages including significantly reducing tar and carbon monoxide. However, in September 2008, the World Health Organization issued a release proclaiming that it does not consider the electronic cigarette to be a legitimate smoking cessation aid, stating that to its knowledge, “no rigorous, peer-reviewed studies have been conducted showing that the electronic cigarette is a safe and effective nicotine replacement therapy.”
• Smokeless tobacco: There is little smoking in Sweden, which is reflected in the low cancer rates for Swedish men. It is claimed that Swedish men are more likely to use snus (a form of steam-cured, rather than heat-cured, smokeless tobacco) than to smoke. There is a scientific debate over claims that spit tobacco might reduce the exposure of smokers to carcinogens or the risk for cancer (and even be used as a way to stop smoking). Some oral and spit tobaccos increase the risk for leukoplakia a precursor to oral cancer. Chewing tobacco has been known to cause cancer, particularly of the mouth and throat.
• Smoking herb substitutions (non-tobacco).

Alternative medical approaches

• Hypnosis clinical trials studying hypnosis as a method for smoking cessation have been inconclusive (The Cochrane Database of Systematic Reviews 2006, Issue 3.) and found that hypnotherapy has no specific effect.
• Aromatherapy based treatments and herbal preparations such as Kava and Chamomile, the efficacy of which has not been established.
• Acupuncture clinical trials have shown that acupuncture’s effect on smoking cessation is equal to that of sham/placebo acupuncture. (See Cochrane Review)
• Laser therapy based on acupuncture principles but without the needles.

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Side effects of smoking cessation

Weight gain

Some studies have concluded that those who do successfully quit smoking may gain weight. “Weight gain is not likely to negate the health benefits of smoking cessation, but its cosmetic effects may interfere with attempts to quit.” (Williamson, Madans et al., 1991). Therefore, drug companies researching smoking-cessation medication often measure the weight of the participants in the study. In 2009, it was found that smoking over expresses the gene AZGP1 which stimulates lipolysis, which is the possible reason why smoking cessation leads to weight gain. Ex-smokers have to overcome the fact that nicotine is an appetite suppressant. Also, heavy smokers burn 200 calories per day more than non-smokers eating the same diet.

Depression

In the case of especially women, a major hurdle for quitting may emanate through clinical depression and challenge smoking cessation. Quitting smoking is especially difficult during certain phases of the reproductive cycle, phases that have also been associated with greater levels of dysphoria, and subgroups of women who have a high risk of continuing to smoke also have a high risk of developing depression. Since many women who are depressed may be less likely to seek formal cessation treatment, practitioners have a unique opportunity to persuade their patients to quit.

Health benefits

The immediate effects of smoking cessation include:

• Within 20 minutes, blood pressure decreases, pulse returns to its normal level
• After 8 hours, carbon monoxide levels in the blood return to normal, oxygen level increases
• After 24 hours, chance of heart attack starts to decrease; breath, hair and body stop smelling like smoke
• After 48 hours, damaged nerve endings begin to recover; sense of taste and smell improve
• After 72 hours, the body is virtually free of nicotine; bronchial tubes relax, breathing becomes easier
• After 2–12 weeks, lungs can hold more air, exercise becomes easier and circulation improves

Longer-term effects include:

• After 1 year, the risk of coronary heart disease is cut in half
• After 5 years, the risk of stroke falls to the same as a non-smoker
• After 10 years, the risk of lung cancer is cut in half and the risk of other cancers decreases significantly
• After 15 years, the risk of coronary heart disease drops, usually to the level of a non-smoker

Many of tobacco’s health effects can be minimized through smoking cessation. The British doctors study showed that those who stopped smoking before they reached 30 years of age lived almost as long as those who never smoked. Smoking cessation will almost always lead to a longer and healthier life. Stopping in early adulthood can add up to 10 years of healthy life and stopping in one’s sixties can still add three years of healthy life (Doll et al., 2004). Stopping smoking is associated with better mental health and spending less of one’s life with diseases of old age.

Some research has indicated that some of the damage caused by smoking tobacco can be moderated with the use of antioxidants.

Upon smoking cessation, the body begins to rid itself of foreign substances introduced through smoking. These include substances in the blood such as nicotine and carbon monoxide, and also accumulated particulate matter and tar from the lungs. As a consequence, though the smoker may begin coughing more, cardiovascular efficiency increases.

Many of the effects of smoking cessation can be seen as landmarks, often cited by smoking cessation services, by which a smoker can encourage himself to keep going. Some are of a certain nature, such as those of nicotine clearing the bloodstream completely in 48 to 72 hours, and cotinine (a metabolite of nicotine) clearing the bloodstream within 10 to 14 days. Other effects, such as improved circulation, are more variable in nature, and as a result less definite timescales are often cited.

What is in the future for smoking?

Health care workers have become extremely active in publicizing the negative effects of smoking. In fact, health care workers have been instrumental in passing various legislation to limit smoking in public; as a result, the proportion of people in the US who smoke has dropped from 40.4% in 1965 to 22.5% in 2002 (data from the US Department of Health).

This reduction in the percent of people who smoke, however, has been significantly less in women than in men. That is, from 1965 to 2002, smoking among men dropped from 50.2% to 25.2% while during the same period, smoking among women dropped from 31.9% to 20.0%. So, in the future, efforts need to be made to understand and eliminate this difference between the genders.

One interesting area of the current research on smoking is the study of the population distribution of the genes for smoking (genetic epidemiology). (Genes determine an individual’s inherited characteristics.) Only a small fraction of individuals who start smoking as an adolescent will actually become nicotine dependent. So, what determines which individuals will become nicotine-dependent? Investigators have found that smoking initiation (the obligatory first step) and the development of nicotine dependence are both influenced by genetic factors. The genetic factors appear to play a larger role in nicotine dependence than in smoking initiation. The next step will be to identify these genes and learn how they work in order to facilitate the development of effective prevention and treatment strategies for tobacco addiction.

Teen smoking rates remain of concern; in 2003, approximately 22% of high school students were smokers. According to the American Cancer Society, the majority of cigarette use begins before a person reaches 18 years of age. Those who do not begin smoking by age 18 generally do not start to smoke later in life. Education of the at-risk teen population is therefore critical for prevention of tobacco use. Various celebrities and activist groups actively promote campaigns aimed at a teen audience that educate about the consequences of smoking and offer advice on smoking cessation and prevention. While teen smoking rates increased during the 1990s (36% of teens smoked in 1997), prevention and education campaigns have brought about a decrease in teen smoking in recent years.