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Smoking cessation 

Smoking cessation
Chapter:
Smoking cessation
Author(s):

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

DOI:
10.1093/med/9780198703860.003.0061
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date: 27 October 2021

Aims and nicotine replacement therapy

Smoking is the main cause of COPD and lung cancer. In 2005, tobacco smoking accounted for ~19% of all UK deaths and cost the NHS at least £5 billion. The UK government has set targets to reduce the number of smokers, with substantial funding for smoking cessation services (£66.4 million in 2011).

  • ~22% of men and 20% of women over 16 in England smoked in 2009; 82% of smokers start as teenagers

  • The incidence of smoking is increasing, particularly amongst women and in developing countries

  • Smoking is associated with cardiovascular and cerebrovascular disease and bladder, oesophageal, cervical, and renal cancers. It is also associated with increased post-operative complications

  • Nicotine exerts its effects on the CNS and is very addictive

  • Reducing number of cigarettes smoked may not give health benefits, as cigarettes smoked ‘harder’—more puffs, greater inhalation

  • Peak nicotine withdrawal time is 2–3 days

  • 0.4% of smokers manage to stop each year

  • Stopping smoking is associated with an average weight gain of 2–5kg, and this deters many, especially women, from quitting

  • UK government legislation in 2007 banned smoking in workplaces and public places and increased the age for sale of tobacco from 16 to 18.

Aims of smoking cessation interventions

Smoking cessation is a cost-effective treatment (£2, 000 per QALY for patients with COPD). To achieve sustained abstinence, the aims are to reduce short-term nicotine cravings (nicotine and non-nicotine replacement therapy) and to modify behaviour in the long term (counselling, telephone or group support-buddy systems). It is vital that the smoker is motivated to quit, or attempts will fail. Health professionals should address smoking cessation at all opportunities, as they can trigger quit attempts by giving brief advice to smokers (advice from doctors often has the strongest impact.). This can lead to 1–3 out of 100 people stopping smoking for 6 months. People may be more receptive to smoking cessation advice during times of concern for their own or their families’ health. A guide to approaching the topic is:

  • Ask how much a person smokes, and document pack years (number of cigarettes smoked per day ÷ 20 × no of years smoked)

  • Ask about non-conventional tobacco smoking, e.g. with cannabis, with a waterpipe (Shisha)

  • Advise on risks of continued smoking. Assess commitment to quitting

  • Assist by offering behavioural therapy ± pharmacotherapy

  • Provide self-help material, and refer to stop smoking services

  • Arrange follow-up.

Some hospitals and general practices have smoking cessation counsellors. The best results in terms of quit rates are achieved by combining counselling and nicotine replacement therapy (NRT), bupropion, or varenicline, with regular support and follow-up. These can improve quit rates to around 25%. NICE has issued guidance on the use of NRT, bupropion, and varenicline for smoking cessation. It advises that pharmacotherapy should only be for smokers committed to a target stop date. Choice of therapy is based on a patient’s likely compliance, availability of counselling, previous experience of therapies, contraindications, and personal preference. Prescribe 2 weeks of NRT or 3–4 weeks of bupropion/varenicline, and only give further prescription if individual shows a continuing attempt to quit. If they fail to quit, a second attempt within 6 months is not usually funded.

NRT

minimizes short- and medium-term nicotine withdrawal symptoms. Should not be used whilst still smoking, as potential for nicotine overdose (symptoms: agitation, confusion, restlessness, palpitations, hypertension, dilated pupils, SOB, abdominal cramps, vomiting). Can be bought over the counter or be prescribed by GP. Cheaper than cigarettes. In 2005, Medicines and Healthcare Regulatory Authority licensed NRT products in pregnancy, breastfeeding mothers, people aged 12–17, and those with cardiovascular disease.

  • Patches Give small amounts of nicotine via transdermal patch to decrease cravings before they occur. Dose (15, 10, 5mg) depends on amount smoked. Use a higher dose if >10 cigarettes/day smoked. Convenient. Worn continuously throughout day, but removed at night due to vivid dreams. Can get localized irritation at patch site. Patches should be used for 6–8 weeks at the higher dose, then weaned to a lower dose for 2–4 weeks. Available over the counter.

  • Chewing gum Different strengths of gum that release nicotine as they are chewed (Smoke <20/day—chew one 2mg piece slowly for 30min when urge to smoke occurs. Smoke >20/day or needing >15 pieces of 2mg gum daily—use 4mg strength gum. Max 15 4mg pieces/day). Relieves cravings as they occur. When mouth tingles and has peppery taste, should stop chewing and ‘park’ the gum inside the cheek. Nicotine is then absorbed through the lining of the mouth. Should not chew continuously or may develop nausea. Nicotine needs to be absorbed through mouth and not swallowed in saliva. Therefore, do not drink with gum. Physical act of chewing can relieve craving. Can taste unpleasant and may need to use several packs of gum a day. Use for 3 months, then reduce the strength and amount of gum used. Available over the counter in a variety of flavours

  • Sublingual tablets used on demand to help with cravings. Discrete form of treatment. 1–2 tablets should be placed under the tongue every hour when needed. Dissolve over 30min. Licensed for use in pregnancy (one tablet only). Use for 3 months, and then gradually reduce the number of tablets used a day. Available on prescription

  • Lozenges Suck every 1–2h if urge to smoke (smoke >30/day = 2mg lozenge, <30/day = 1mg lozenge). Available over the counter

  • Inhalator Cigarette-style appliance giving small amounts of nicotine when used. Useful for people who are habitual or ritualistic in that they have ‘restless hands’ or want the ‘hand to mouth’ routine. Nicotine is absorbed through the lining of the mouth, not via the lungs. Use for 2 months, then gradually reduce. Available on prescription

  • Nasal spray provides rapid relief of craving. Faster absorption than other forms of NRT. May cause local irritation. Use for 2 months, then reduce. Available on prescription.

Non-nicotine replacement therapy

Drugs

Pharmacotherapy should not be used without behavioural support.

Bupropion

is promoted as an aid to smoking cessation, in combination with motivational support. It is an antidepressant that was found to reduce the desire to smoke, even in the absence of depression. It weakly inhibits dopamine, serotonin, and noradrenaline reuptake in the CNS. It counteracts nicotine withdrawal symptoms by increasing these levels in the brain. It is suitable for individuals who smoke ≥10 cigarettes a day. Liver metabolism and 20h half-life. Smokers start taking bupropion 1–2 weeks before their intended ‘quit day’. Continue for 7–9 weeks after. Leads to improved abstinence rates, compared with placebo or nicotine patch, if associated with counselling (30% 12-month abstinence rate with bupropion, 16% with nicotine patch, 15% with placebo, 35% with patch and bupropion) (N Engl J Med 1999;340:685–91). Also thought to lessen weight gain associated with stopping smoking. Contraindicated in patients with epilepsy or at risk of fits, those with a CNS tumour, those acutely withdrawing from alcohol or benzodiazepines, pregnancy, those with eating disorders, bipolar disorder, and those on monoamine oxidase inhibitors. Preferentially used in some patient groups, e.g. those with schizophrenia or depression. Reduce dose if elderly or has hepatic or renal impairment. Well tolerated. Recognized adverse effects include dry mouth, hypersensitivity, insomnia, seizures (1:1, 000), and death. Prescription only.

Varenicline

is a drug also promoted as an aid to smoking cessation, in combination with motivational support. It binds to the A4B2 nicotinic acetylcholine receptor and acts as a partial agonist. Its binding alleviates symptoms of craving and withdrawal. It reduces the rewarding and reinforcing effects of smoking by preventing nicotine binding to the A4B2 receptors. Smokers start taking varenicline 1–2 weeks before their intended ‘quit day’ and continue for 12–24 weeks. Starting dose is 500 micrograms od for 3 days, 500 micrograms bd for 4 days, then 1mg bd for 11 weeks, if tolerated. If smokers are abstinent after 12 weeks, they should continue for another 12 weeks to avoid relapse. Avoid abrupt withdrawal. Side effects include nausea, vomiting, appetite change, change in taste, headache, difficulty sleeping, abnormal dreams, dry mouth, and tiredness. Use with caution if breastfeeding, in renal impairment, and in those with a history of psychiatric disease. It has been associated with neuropsychiatric disorders (depression, agitation, behavioural changes). RCTs have shown significantly higher quit rates with varenicline than with bupropion or placebo. Quit rates are higher with higher doses (e.g. continuous quit rate for any 4 weeks: 48% with 1mg bd (p = 0.01 vs placebo), 37% with 1mg od (p = 0.01), 33% with bupropion (p = 0.02, 17% with placebo). Adverse drug effects leading to stopping treatment were lower than with bupropion (Arch Int Med 2006;166:1561–8). Prescription only. Recommended by NICE in 2007.

Hypnosis

aims to improve willpower in the subconscious state with therapeutic suggestion. Anecdotal success, but Cochrane review of trials showed no greater abstinence rate with hypnosis than with any other treatment or placebo treatment.

Acupuncture/acupressure

No evidence in favour of it over placebo acupuncture. Less effective than NRT.

Electronic cigarettes

or e-cigarettes are battery-powered and vaporize nicotine and other chemicals in a liquid solution to an aerosol mist. The nicotine contained is approximately the same amount as in a cigarette. They simulate the act of smoking and are therefore controversial. To be regulated by MHRA from 2014, with all nicotine-containing products requiring a licence from 2016. Not approved by the USA’s FDA. Although some studies suggest that they help smokers decrease cigarette consumption, even when they do not intend to quit, the effectiveness of e-cigarettes is unknown, their contents variable, and the short- and long-term effects on pulmonary health unknown. Therefore, should not be recommended as an aid to smoking cessation until a stronger evidence base emerges.

Future developments

  • Plain packaging campaign to discourage younger smokers

  • Campaign to ban smoking in cars when children present

  • Increasing and improving hospital-based smoking cessation services with links to community-based services

  • Effectiveness of long-term smoking cessation interventions and relapse rates

  • New medications: clonidine—approximate doubling of abstinence rates, compared to placebo. However, a high incidence of adverse effects, including significant sedation, postural hypotension, and bradycardia

  • Dopamine D3 antagonists—the dopamine D3 receptor is involved in mechanisms of nicotine dependence. Trials undergoing

  • Nicotine vaccines—induces antibodies directed against nicotine from tobacco smoking, leading to a decrease in the rate and amount of nicotine entering the brain (thus reducing the pleasurable effects of smoking). Phase II trials ongoing.

Further information

Brief interventions and referral for smoking cessation in primary care and other settings. March 2006, NICE PH10 & Smoking cessation services 2008. Smoking cessation http://www.nice.org.uk.

ABC of smoking cessation series. BMJ Feb–April 2004.Find this resource:

Riemsma RP et al. Systematic review of the effectiveness of stage based interventions to promote smoking cessation. BMJ 2003;326:1175.Find this resource:

West R et al. Smoking cessation guidelines for health professionals. Thorax 2000;55:987–99.Find this resource:

Smoking cessation http://www.nosmokingday.org.uk.

Roy Castle Fag Ends. Smoking cessation http://www.stopsmoking.org.uk.

Quitline Smoking cessation 0800 002200.

BTS Recommendations for Hospital Smoking Cessation Services for Commissioners and Health Care Professionals (with link to BTS website).