Helping smokers to quit involves 2 processes—motivating them to attempt to quit and helping them to stop once they try. At any given time, only about 10% of smokers are planning to quit in the next month, 30% are contemplating to quit in the next 6 months, 30% plan to quit at some unknown time, and 30% have no plans to quit10
; thus, the large majority of clinician interventions involve motivating smokers to try to stop.
Most requests to stop smoking may appear to have little or no effect; however, consider the scenario in , Scenario 1. A clinician asks a smoker to stop and the smoker does not. Then the smoker's spouse asks the smoker to stop; then his/her kids ask; then his/her friends ask; then a year after the clinician first gave advice, the smoker's uncle who is dying of lung cancer asks and the smoker decides to quit. Now the clinician may conclude that his/her advice was not effective and it took the scare of a relative with cancer to motivate a quit attempt. However, consider the scenario in which the clinician's advice and the uncle's cancer switch places (, Scenario 2). Here many prior requests for smoking have preceded clinician advice and when the clinician asks, the smoker now agrees to quit. In this scenario, the clinician may believe he/she is especially effective but in reality it is the cumulative effect of prior requests that is important. Thus, the clinician should not expect any given piece of advice to have much of an immediate effect. Rather, the clinician should give the advice, knowing that it will move a smoker that much closer to a quit attempt.
Two scenarios of the natural history of brief advice and subsequent cessation.
The 3 most commonly cited approaches to making requests or giving advice about smoking are the U.S. Public Health Service's (USPHS) 5 As/5Rs,8
and Stage of Change12
models. The 5 As outlined in the recent USPHS guideline are: ask about tobacco use, advise to quit, assess willingness to make attempt to quit, assist with treatments, and arrange follow-up.8
The major emphasis in this model is a clear statement advising the smoker to quit. If upon assessment in the 5 A program the smoker is unwilling to quit, one is to motivate the smoker using the 5 Rs; i.e., focus on personally relevant information on, risks of smoking, rewards of stopping, roadblocks to quitting, and repeating this advice.
There is substantial evidence from randomized trials that brief advice based on these models is effective.8
In the most recent meta-analyses, even 3 minutes of such advice done in a systematic and diplomatic manner () increases quit rates by a factor of 1.3 to 1.7.8,9
Validated Cessation Treatments
Unfortunately, half of smokers never quit.13
Three strategies have been proposed to help reduce tobacco risks for these recalcitrant smokers: switching to low-tar cigarettes, switching to pipes, cigars, or smokeless tobacco, or reducing the amount smoked. Currently, none of these have solid evidence of benefit either to raise quit rates or to improve long-term health.14
The 8 scientifically proven medications for smoking cessation are nicotine gum, inhaler, lozenge, patch, and nasal spray and the nonnicotine medications bupropion, clonidine, and nortriptyline.8,15
All are equally effective; i.e., they increase quit rates by a factor of 1.5 to 2.7 (). However, clonidine, nicotine nasal spray, and nortriptyline appear to have more side effects and thus are considered second line. Because we have no scientifically proven method to match patients to a specific treatment, most experts suggest patients themselves should decide which treatment should be used. Some have suggested that these medications will not work if used without psychosocial therapies. However, multiple randomized trials of use of over-the-counter (OTC) medications with no psychosocial therapy indicate this is effective.8,15
However, combining psychosocial and pharmacological treatments clearly increases success ().
Percent of Quitters Who Use Each Cessation Therapy and Long-term Quit Rates Among Those Who Use the Therapy*
Nicotine replacement therapies (NRTs) appear to work because they relieve withdrawal symptoms of anxiety, depression, difficulty concentrating, insomnia, irritability, restlessness, and nicotine craving.8
Because NRTs provide much lower levels of nicotine than does smoking and because the nicotine is absorbed more slowly than it is from cigarettes, they do not appear to cause cardiovascular harm and their dependence potential is very small (<2%).16
Four types of NRTs use ad-libitum dosing: nicotine gum, inhaler, lozenge, and nasal spray. Their major advantage is they can be used to cope with situationally induced cravings or withdrawal. Their disadvantage is the need to use multiple doses per day, the need to avoid acidic beverages when using the product, and possible embarrassment with use.
Nicotine gum is an OTC medication that is available in 2 mg (<25 cigarettes/day smoker) and 4 mg (>25 cigarettes/day smoker) doses.8,15
The recent provision of mint and citrus flavors has significantly improved the taste of the gum. Side effects include jaw ache, nausea, and stomach ache.
The nicotine patch, or transdermal nicotine, is available OTC as a 24-hour patch in doses of 21, 14, and 7 mg, and as a 16-hour patch at a 15-mg dose.8,15
The major advantage of the patch is that it requires only a once per day dosage and it is more socially acceptable and confidential than the gum. The major disadvantage is that it cannot be used for sudden cravings. Whether 24-hour versus 16-hour patch use or whether tapering doses improves quit rates is unclear. Side effects include insomnia and skin rash.
The nicotine inhaler consists of a plug impregnated with nicotine in a plastic rod.8,15
When warm air is pulled through the rod, nicotine is absorbed. The inhaler is available as a prescription (Rx) item in a single dose. Although labeled an inhaler, this product actually delivers nicotine not via the lungs but through the mouth, like gum. The major advantage of the inhaler is that it replicates the habit feature of smoking. Its major disadvantage is the need for multiple puffs to obtain sufficient nicotine. The main side effect is throat irritation.
The nicotine nasal spray is available Rx as a single dose. The major advantage of the spray is that it provides higher and more rapid nicotine doses compared to other NRTs8,15
; however, this still is less than one-tenth the arterial nicotine levels seen with cigarettes. Its major disadvantage is that nasal irritation, lacrimation, rhinitis, coughing, sneezing, and facial flushing are experienced by more than 75% of users.
Finally, a nicotine lozenge has just become available as an OTC medication in the U.S. in a 2-mg dose for those smoking their first cigarette after 30 minutes of arising and a 4-mg dose for those smoking less than 30 minutes after arising. The lozenge produces nicotine levels, efficacy, and side effects similar to nicotine gum but may be more acceptable.17
Although current FDA-approved labeling advises against combining NRTs, adding ad-lib use of nicotine gum, inhaler, nasal spray, and probably lozenge to the nicotine patch does increase quit rates without increased side effects.8,15
Buproprion is an Rx medication first used as an antidepressant.8,15
Bupropion's efficacy for smoking is unrelated to its antidepressant effects—it works equally well in smokers with and without a history of depression. The major advantages of bupropion are that many smokers prefer a nonnicotine medication. Side effects include seizure (risk < 1/1,000), insomnia, dry mouth, and nausea. Bupropion combined with NRT increased quit rates slightly in 1 study.18
Both clonidine and nortriptyline appear to be as effective as bupropion and NRT but appear to have more side effects than first-line therapies.8,15
Clonidine can cause hypotension and drowsiness; nortriptyline can cause sedation, nausea, dry mouth, constipation, and urinary retention.
Current labeling calls for physicians to decide if the above medications should be used in pregnant women or smokers with heart disease.8,15
Stopping smoking in the first 2 trimesters of pregnancy reverses most of the risk of smoking to the fetus. How much of the harmful effects of smoking in pregnancy are due to nicotine, carbon monoxide, or other constituents is unclear.16
Since NRT produces lower levels of nicotine and no carbon monoxide, recent reviews have suggested using NRT in pregnant women who cannot quit on their own. The major remaining concern is the role of nicotine in Sudden Infant Death Syndrome.16
Despite initial concerns, many studies have demonstrated that NRT in patients with active heart disease is not especially risky.19
Concurrent use of NRT and cigarettes also does not substantially increase the risk of heart or other diseases.19
focuses on building skills to resist relapse such as developing incompatible behaviors (e.g., exercise), coping thoughts, refusal skills, etc.20
This therapy increases quit rates by a factor of 1.5 to 2.1.8,21,22
Social support identifies persons who will be encouraging about cessation, finds “buddies” who are also either trying to quit or have done so, etc. Social support increases quit rates by a factor of 1.3 to 1.5.8
Behavioral and supportive therapies were developed initially for use in individual or group therapy formats. However, less than 5% of smokers will attend such therapy ().21
Written materials do not appear to be effective8,23
; however, delivering behavior therapy via the telephone increases quit rates by a factor of 1.2.8,24
Although less effective, this format is so much more acceptable that it has a bigger impact than group or individual counseling. Whether therapy could be delivered via the Internet is being tested. Acupuncture, hypnosis, inpatient treatment, and Twelve-Step therapy (Nicotine Anonymous) have not been shown effective thus far.8