|Year : 2013 | Volume
| Issue : 2 | Page : 27-31
Smoking cessation: How to achieve
Department of Pulmonary Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
|Date of Web Publication||18-Dec-2013|
Rabindra Pally, 1st Lane, P. O. Nimta, Kolkata - 700 049, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Saha K. Smoking cessation: How to achieve. J Assoc Chest Physicians 2013;1:27-31
| The Clinical Problem|| |
There are currently an estimated 250 million tobacco users aged 10 years and above in India.  Prevalence of regular tobacco users is 51.3% in males and 10.3% in females; 35.3% males and 2.6% females are regular smokers; 24.0% males and 8.6% females are regular users of smokeless tobacco in the country.  Tobacco smoking prevalence is 14.3%, 13.9% and 12.4% in rural, semi-urban and urban areas respectively. The corresponding values for smokeless tobacco use are 9.5%, 7.0% and 7.0% respectively.  Among rural males in Punjab, the prevalence was 12.8% but it was 69.8% in Mizoram. Among urban males, the lowest rate was seen in Pondicherry at 16.6% and the highest prevalence of 66.9% was noted again in Mizoram. Similar variations in prevalence were noted among women also. 
The potential health benefits of smoking-cessation are substantial. Cessation reduces the risk of tobacco-related diseases, slows the progression of established tobacco-related diseases and increases life expectancy, even when smokers stop smoking after the age of 65 years or after the development of a tobacco-related disease. 
Nearly all smokers acknowledge that tobacco use is harmful to health, but underestimate the magnitude of their own risk. Few know the full spectrum of health risks. , For many smokers, the risk of future disease does not outweigh the current perceived benefits of smoking or barriers to cessation. Yet 70% of smokers' report that they want to quit.  Approximately one-third of smokers try to stop smoking each year, but only 20% of them seek help. , Fewer than 10% of smokers who attempt to quit on their own are successful over the long-term. , Smokers have a higher rate of success when they seek help with quitting.  Even then, several attempts are often required before long-term abstinence is achieved.  The chief physiological obstacle to quitting is the addictive nature of nicotine. Nicotine causes tolerance and physical dependence. Psychological factors also contribute to the difficulties that smokers have when they try to quit. Smokers also use cigarettes to handle stress and negative emotions such as anger or anxiety. To stop smoking, a smoker must learn new coping skills and break old patterns, an incremental process in which attempts to quit often end in the resumption of smoking until abstinence is achieved.
| Strategies and Evidence|| |
Two approaches have strong evidence of efficacy for smoking-cessation: Pharmacotherapy and counseling. ,, Each is effective by itself, but the two in combination achieve the highest rates of smoking-cessation. The efficacy of a treatment correlates with its intensity, but even brief interventions by physicians during an office visit promote smoking-cessation.
Interventions by physicians
Randomized, controlled trials conducted in primary care practices demonstrate that a physician's advice to stop smoking increases the rates of smoking-cessation among patients by approximately 30%.  Providing a brief period of counseling (3 min or less) is more effective than simply advising the patient to quit and doubles the cessation rate, as compared with no intervention. Effective interventions have a common approach [Figure 1].  Optimal implementation requires support from the health care system to bolster the efforts of individual physicians. ,
Counseling about smoking-cessation can be delivered effectively in person or by telephone. , Group or individual counseling is effective when it is provided by trained counselors and includes repeated contacts over a period of at least 4 weeks.  The efficacy of this approach increases as the amount of time spent with the patient increases.  Cognitive behavioral methods form the core of most counseling programs. In general, smokers learn to identify smoking cues and then use cognitive and behavioral methods to break the link between the cues and smoking. They also learn strategies for coping with stress, managing symptoms of nicotine withdrawal and once they quit, preventing relapse, such as anticipating tempting situations and rehearsing coping strategies.
The Food and Drug Administration (FDA) has approved five products for smoking-cessation: Sustained-release bupropion and four nicotine-replacement products (gum, a transdermal patch, a nasal spray and a vapor inhaler) [Table 1].  Each has demonstrated efficacy in randomized double-blind trials, approximately doubling the long-term (1-year) rates of abstinence, as compared with placebo. ,, Most clinical trials combine drug therapy with counseling; typical rates of smoking-cessation are 40-60% at the end of drug treatment and 25-30% at 1 year.  Few randomized, controlled trials have directly compared one drug with another. Nortriptyline and clonidine have also been found to aid smoking-cessation, but they have not been approved by the FDA for this indication. 
| Nicotine-Replacement Therapy|| |
Nicotine-replacement therapy provides an alternative form of nicotine to relieve symptoms of withdrawal in a smoker who is abstaining from tobacco use. The patch provides a relatively stable, fixed dose of nicotine over a period of 16 or 24 h. The other products have a more rapid onset and a shorter duration of action, allowing the user to adjust the dose of nicotine. Blood nicotine levels peak 5-10 min after the administration of nicotine nasal spray, 20 min after the user begins chewing nicotine gum or uses a vapor inhaler and 2-4 h after the application of a nicotine patch. The nicotine gum and the inhaler have similar pharmacokinetic properties since in both the nicotine is absorbed through the oral mucosa.
The use of all nicotine-replacement products increases the long-term rates of smoking-cessation and relieves cravings for nicotine and symptoms of nicotine withdrawal. For heavy smokers (those who smoke at least 25 cigarettes/day), the gum that contains 4 mg of nicotine per piece is more effective than that containing 2 mg/piece. Fewer studies have assessed the nasal spray and the vapor inhaler, but in meta-analyses both products doubled the cessation rates, as compared with placebo inhaler.
One randomized, controlled trial directly compared the four nicotine-replacement products.  The efficacy of each product was similar at week 12 of follow-up, but the rates of compliance varied, being highest for the patch, intermediate for the gum and lowest for the vapor inhaler and the nasal spray. Different nicotine-replacement products can be combined safely.
The safety of nicotine-replacement products is underscored by the fact that the patch and gum, initially sold only by prescription, are now available without a prescription. Although nicotine's hemodynamic effects increase the myocardial workload, nicotine-replacement therapy is safe in patients with cardio-vascular disease, including stable angina. , Unlike smoking, nicotine-replacement therapy does not increase the coagulability of blood or expose a patient to carbon monoxide or oxidizing gases that damage endothelium.  The side-effects of these products vary according to the manner in which nicotine is administered [Table 1].
| Non-Nicotine Therapy|| |
Bupropion, an antidepressant with dopaminergic and noradrenergic activity, was efficacious for smoking-cessation when combined with counseling in randomized, controlled trials. , The efficacy of bupropion when accompanied by minimal levels of psychosocial support, as occurs in medical practice, is unknown. Like nicotine-replacement therapy, treatment with bupropion doubles smoking-cessation rates as compared with placebo treatment. ,, Bupropion lowers the threshold for seizure and is contraindicated in patients who are at risk for seizures. Treatment with both bupropion and the nicotine patch was safe but did not lead to significantly higher cessation rates than did treatment with bupropion alone (36% and 30%, respectively). Nonetheless, many clinicians use the combination for smokers who are very dependent on nicotine.
Nortriptyline was effective for smoking-cessation in two small studies that used 75-100 mg daily for 3 months, starting 10-28 days before the quitting date. , Treatment with clonidine reduces the symptoms of nicotine withdrawal and has been effective for smoking-cessation, but the high frequency of adverse effects limits its use. ,
Hypnosis and acupuncture have also been suggested as therapies for smoking-cessation. However, few controlled trials of hypnosis have been conducted and acupuncture was found to be ineffective in randomized trials. ,
| Conclusions and Recommendations|| |
There is broad agreement, based on strong evidence, about what constitutes effective treatment of tobacco use and dependence. Physicians should routinely identify patients' smoking status and readiness to quit, advise and assist smokers to quit and offer pharmacotherapy to help them quit [Figure 1].  There is insufficient evidence to determine whether nicotine-replacement products or bupropion is superior. Current guidelines and most experts regard them as roughly equivalent. ,, The choice of pharmacotherapy [Table 1] should take the patient's preferences and past experiences into consideration, unless one agent is contraindicated. A general approach is to start with a single agent and add a second if the smoker has severe withdrawal symptoms, cravings, or difficulty maintaining abstinence. Nicotine-replacement products can safely be combined with one another and with bupropion. Drugs are most effective when accompanied by counseling, whether delivered in person or by telephone. The addition of pharmacotherapy to counseling doubles the cessation rate.  Counseling is also effective by itself and should not be neglected.
The case vignette highlights common challenges facing physicians who treat smokers. The patient has repeatedly failed to quit smoking on her own, she has coexisting medical and psychiatric conditions and she is concerned about gaining weight if she does quit smoking.  Often, smokers who repeatedly fail to quit have never received effective treatments (especially counseling) or have used pharmacotherapy incorrectly. Such patients may also have coexisting psychiatric conditions or substance abuse. When a smoker has a history of depression, careful screening for symptoms of depression is warranted before and during treatment.
Smoking is a chronic problem, such as hypertension or hyperlipidemia, that requires long-term management.  Assistance with smoking-cessation is a cost-effective intervention that is underused by physicians and inadequately covered by many health insurers. , For physicians and health care systems alike, the challenge is implementing effective treatment in routine medical practice.
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