Smoking cession

# Smoking cessation

**Smoking cessation**, usually called **quitting smoking** or **stopping smoking**, is the process of discontinuing tobacco smoking. Tobacco smoke contains nicotine, which is addictive and can cause dependence. As a result, nicotine withdrawal often makes the process of quitting difficult.

Smoking is the leading cause of preventable death and a global public health concern. Tobacco use leads most commonly to diseases affecting the heart and lungs, with smoking being a major risk factor for heart attacks, strokes, chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), emphysema, and various types and subtypes of cancers (particularly lung cancer, cancers of the oropharynx, larynx, and mouth, esophageal and pancreatic cancer). Smoking cessation significantly reduces the risk of dying from smoking-related diseases.

From 2001 to 2010, about 70% of smokers in the United States expressed a desire to quit smoking, and 50% reported having attempted to do so in the past year. Many strategies can be used for smoking cessation, including abruptly quitting without assistance ("cold turkey"), cutting down then quitting, behavioral counseling, and medications such as bupropion, cytisine, nicotine replacement therapy, or varenicline. In recent years, especially in Canada and the United Kingdom, many smokers have switched to using electronic cigarettes to quit smoking tobacco. However, a 2022 study found that 20% of smokers who tried to use e-cigarettes to quit smoking succeeded but 66% of them ended as dual users of cigarettes and vape products one year out.

Most smokers who try to quit do so without assistance. However, only 3–6% of quit attempts without assistance are successful long-term. Behavioral counseling and medications each increase the rate of successfully quitting smoking, and a combination of behavioral counseling with a medication such as bupropion is more effective than either intervention alone. A meta-analysis from 2018, conducted on 61 randomized controlled trials, showed that among people who quit smoking with a cessation medication (and some behavioral help), approximately 20% were still nonsmokers a year later, as compared to 12% who did not take medication.

In nicotine-dependent smokers, quitting smoking can lead to nicotine withdrawal symptoms such as nicotine cravings, anxiety, irritability, depression, and weight gain. Professional smoking cessation support methods generally attempt to address nicotine withdrawal symptoms to help the person break free of nicotine addiction.

## Smoking cessation methods

### Unassisted

It often takes several attempts, and potentially utilizing different approaches each time, before achieving long-term abstinence. Over 74.7% of smokers attempt to quit without any assistance, otherwise known as "cold turkey", or with home remedies. Previous smokers make between an estimated 6 to 30 attempts before successfully quitting. 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. The majority of quit attempts are still unassisted, though the trend seems to be shifting. In the U.S., for example, the rate of unassisted quitting fell from 91.8% in 1986 to 52.1% during 2006 to 2009. The most frequent unassisted methods were "cold turkey", a term that has been used to mean either unassisted quitting or abrupt quitting and "gradually decreased number" of cigarettes, or "cigarette reduction".

#### Cold turkey

"Cold turkey" is a colloquial term indicating abrupt withdrawal from an addictive drug. In this context, it 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. Studies have found that two-thirds of recent quitters reported using the cold turkey method and found it helpful.

#### Cutting down to quit

Gradual reduction involves slowly reducing one's daily intake of nicotine. This method can theoretically be accomplished through repeated changes to cigarettes with lower nicotine levels, by gradually reducing the number of cigarettes smoked daily, 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. There is 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. The same review also looked at five pharmacological aids for reduction. When reducing the number of smoked cigarettes, it found some evidence that additional varenicline or fast-acting nicotine replacement therapy can positively affect quitting for six months or longer.

### Medications

The American Cancer Society notes that "Studies in medical journals have reported that about 25% of smokers who use medicines can stay smoke-free for over 6 months." Single medications include:

* Nicotine replacement therapy (NRT): Five medications have been approved by the U.S. Food and Drug Administration (FDA) to deliver nicotine in a form that does not involve the risks of smoking: transdermal nicotine patches, nicotine gum, nicotine lozenges, nicotine inhalers, nicotine oral sprays, and nicotine nasal sprays. High-quality evidence indicates that these forms of NRT improve the success rate of people who attempt to stop smoking. NRTs are meant to be used for a short period of time and should be tapered down to a low dose before stopping. NRTs increase the chance of stopping smoking by 50 to 60% compared to placebo or to no treatment. Some reported side effects are local slight irritation (inhalers and sprays) and non-ischemic chest pain (rare). Others include mouth soreness and dyspepsia (gum), nausea or heartburn (lozenges), as well as sleep disturbances, insomnia, and a local skin reaction (patches). A study found that 93% of over-the-counter NRT users relapse and return to smoking within six months. There is weak evidence that adding mecamylamine to nicotine is more effective than nicotine alone.
* Antidepressants: The antidepressant bupropion is considered a first-line medication for smoking cessation and has been shown in many studies to increase long-term success rates. Although bupropion increases the risk of getting adverse events, there is no clear evidence that the drug has more or less adverse effects when compared to a placebo. Nortriptyline produces significant rates of abstinence versus placebo. Other antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and St. John's wort have not been consistently shown to be effective for smoking cessation.
* Varenicline decreases the urge to smoke and reduces withdrawal symptoms and is therefore considered a first-line medication for smoking cessation. The number of people stopping smoking with varenicline is higher than with bupropion or NRT. Varenicline more than doubled the chances of quitting compared to placebo, and was also as effective as combining two types of NRT. 2 mg/day of varenicline has been found to lead to the highest abstinence rate (33.2%) of any single therapy, while 1 mg/day leads to an abstinence rate of 25.4%. A 2016 systematic review and meta-analysis of randomized controlled trials concluded there is no evidence supporting a connection between varenicline and increased cardiovascular events. Concerns arose that varenicline may cause neuropsychiatric side effects, including suicidal thoughts and behavior. However, more recent studies indicate less serious neuropsychiatric side effects. For example, a 2016 study involving 8,144 patients treated at 140 centers in 16 countries "did not show a significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo". No link between depressed moods, agitation or suicidal thinking in smokers taking varenicline to decrease the urge to smoke has been identified. For people who have pre-existing mental health difficulties, varenicline may slightly increase the risk of experiencing these neuropsychiatric adverse events.
* 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.
* There is no good evidence anxiolytics are helpful.
* Previously, rimonabant, which is a cannabinoid receptor type 1 antagonist, was used to help in quitting and moderate the expected weight gain. But it is important to know that the manufacturers of rimonabant and taranabant stopped production in 2008 due to serious CNS side effects.}}

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)

A meta-analysis from 2018, conducted on 61 RCTs, showed that during their first year of trying to quit, approximately 80% of the participants in the studies who got drug assistance (bupropion, NRT, or varenicline) returned to smoking, while 20% continued to not smoke for the entire year (i.e.: remained sustained abstinent). In comparison, 12% the people who got placebo kept from smoking for (at least) an entire year. This makes the net benefit of the drug treatment to be 8% after the first 12 months. In other words, out of 100 people who will take medication, approximately 8 of them would remain non-smoking after one year thanks to the treatment. During one year, the benefit from using smoking cessation medications (Bupropion, NRT, or varenicline) decreases from 17% in 3 months, to 12% in 6 months to 8% in 12 months.

### Community interventions

Community interventions using "multiple channels to provide reinforcement, support and norms for not smoking" may have 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 Substance 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, including the significant dangers of secondhand smoke infiltration for residents of multi-unit housing.
* Increasing the price of tobacco products, for example by taxation. The US 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. There is evidence to suggest that when combined with other types of interventions, mass media campaigns may of benefit.
* Weak evidence suggests that imposing institutional level smoking bans in hospitals and prisons may reduce smoking rates and second hand smoke exposure.

#### Pharmacist Interventions

Pharmacist-led interventions have proven to be effective in helping smoking cessation attempts. Many systematic reviews have looked at the importance of pharmacist involvement. In Malaysia, their study looked at how pharmacist intervention in patients' overall healthcare showed improvements in screening early stages of disease. This allowed for earlier treatment starts in smoking-caused COPD. In addition, pharmacists in Malaysia could prescribe NRT products, and when they led a smoking cessation service, it was more successful than other smoking cessation trials in Malaysia. It was also shown that pharmacist counselling and NRT products were more effective in smoking cessation than using NRT alone.

In pharmacist-led smoking cessation services in Ethiopia, the study found statistically and clinically significant benefits favouring pharmacist intervention. They found that structured care, and regular visits, easy accessibility to pharmacists helped more people trying to quit than without. However, the study concluded that more research should be done in the area as they found an unknown risk of bias in the studies included

Another systematic review analyzed pharmacist intervention in smoking cessation and alcohol and weight interventions. They found that evidence suggests that the longer the duration of pharmacist-led intervention, the more influential the attempt at quitting was In addition, they found that community pharmacists were beneficial in delivering public health information. Pharmacists have a great reach in the community to help with smoking cessation and have proven to help with lifestyle modifications and proper NRT use.

### Digital interventions

* Interactive web-based and stand-alone computer programs and online communities assist participants in quitting. For example, "quit meters" keep track of statistics such as how long a person has remained abstinent. Computerised and interactive tailored interventions may be promising, ; however, the evidence base for such interventions is weak.
* A mobile phone-based intervention where automated, supportive text messages are sent alongside other forms of support helps more people quit smoking: "The current evidence supports a beneficial impact of mobile phone-based cessation interventions on six-month cessation outcomes. A 2011 randomized trial of mobile phone-based smoking cessation support in the UK found that a Txt2Stop cessation program significantly improved cessation rates at six months. A 2013 meta-analysis also noted "modest benefits" of mobile health interventions.
* Interactive web-based programs combined with a Mobile phone: Two RCTs documented long-term treatment effects (abstinence rate: 20-22 %) of such interventions.

### Psychosocial approaches

* The 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 is often offered over the telephone quitlines (e.g., the US toll-free number 1-800-QUIT-NOW), or in person. Three meta-analyses have concluded that telephone cessation support is effective when compared with minimal or no counselling or self-help and that telephone cessation support with medication is more effective than medication alone, and that intensive individual counselling is more effective than the brief personal counselling intervention. A slight tendency towards better results for more intensive counselling was also observed in another meta-analysis. This analysis distinguished between reactive (smokers calling quitlines) and proactive (smokers receiving calls) interventions. For people who called the quitline themselves, additional calls helped to quit smoking for six months or longer. When proactively initiating contact with a smoker, telephone counselling increased the chances of smoking cessation by 2–4% compared with people who received no calls. There is about 10% to 25% increase in the chance of smoking cessation success with more behavioral support provided in person or via telephone when used as an adjunct to pharmacotherapy.
* Online social cessation networks attempt to emulate offline group cessation models using purpose built web applications. They are designed to promote online social support and encouragement for smokers when (usually automatically calculated) milestones are reached. Early studies have shown social cessation to be especially effective with smokers aged 19–29.
* Group or individual psychological support can help people who want to quit. Recently, group therapy has been more helpful than self-help and some other individual intervention. The psychological support form of counselling can be effective alone; combining it with medication is more effective, and the number of support sessions with medication correlates with effectiveness. The counselling styles that have been effective in smoking cessation activities include motivational interviewing, cognitive behavioral therapy and acceptance and commitment therapy, methods based on cognitive behavioral therapy.
* The Freedom From Smoking group clinic includes eight sessions and features a step-by-step plan for quitting smoking. Each session is designed to help smokers gain control over their behavior. The clinic format encourages participants to work on the process and problems of quitting both individually and as part of a group.
* Multiple formats of psychosocial interventions increase quit rates: 10.8% for no intervention, 15.1% for one format, 18.5% for 2 formats, and 23.2% for three or four formats.
* The transtheoretical model, including "stages of change", has been used in tailoring smoking cessation methods to individuals, however, there is some evidence to suggest that "stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling are neither more nor less effective than their non-stage-based equivalents."

#### How to set a quit date

Most smoking cessation resources such as the Centers for Disease Control and Prevention (CDC) and The Mayo Clinic encourage smokers to create a quit plan, including setting a quit date, which helps them anticipate and plan for smoking challenges. A quit plan can improve a smoker's chance of a successful quit as can setting Monday, as the quit date, given that research has shown that Monday more than any other day is when smokers are seeking information online to quit smoking and calling state quitlines.

## self-help

Self-help materials may produce a small increase in quit rates specially when there is no other supporting intervention form. "The effect of self-help was weak", and the number of types of self-help did not produce higher abstinence rates. Nevertheless, self-help modalities for smoking cessation include:

* In-person self-help groups such as Nicotine Anonymous, or web-based cessation resources such as Smokefree.gov, which offers various types of assistance including self-help materials.
* WebMD: a resource providing health information, tools for managing health, and support.
* Self-help books such as Allen Carr's *Easy Way to Stop Smoking*.
* Spirituality: In one survey of adult smokers, 88% reported a history of spiritual practice or belief, and of those more than three-quarters were of the opinion that using spiritual resources may help them quit smoking.
* A review of mindfulness training as a treatment for addiction showed reduction in craving and smoking following training.
* Physical activities help in the maintenance of smoking cessation even if there is no conclusive evidence of the most appropriate exercise intensity.

#### Biochemical feedback

Various methods 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 monitoring throughout an effort to quit can increase motivation to quit. Evidence-wise, little is known about the effects of using biomechanical tests to determine a person's risk related to smoking cessation.

* Breath carbon monoxide (CO) monitoring: carbon monoxide is a significant component of cigarette smoke, and a breath carbon monoxide monitor can be used to detect current cigarette use. Carbon monoxide concentration in breath is 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. CO concentrations show a noticeable decrease within hours of quitting, which can encourage someone to work on quitting. Breath CO monitoring has been utilized in smoking cessation as a tool to provide patients with biomarker feedback, similar to how other diagnostic tools such as the stethoscope, the blood pressure cuff, and the cholesterol test have been used by treatment professionals in medicine.
* Cotinine: Cotinine, a metabolite of nicotine, is present in smokers. Like carbon monoxide, a cotinine test can be a reliable biomarker to determine smoking status. Cotinine levels can be tested through urine, saliva, blood, or hair samples. One of the main concerns of cotinine testing is the invasiveness of typical sampling methods.

While both measures offer high sensitivity and specificity, they differ in usage method and cost. For example, breath CO monitoring is non-invasive, while cotinine testing relies on bodily fluid. For instance, these two methods can be used alone or together when abstinence verification needs additional confirmation.

#### Competitions and incentives

Financial or material incentives to entice people to quit smoking improve smoking cessation while the motivation is in place. Competitions that require participants to deposit their own money, "betting" that they will succeed in quitting smoking, appear to be an effective incentive. However, it is more difficult to recruit participants for this type of contest in head-to-head comparisons with other incentive models, such as giving participants NRT or placing them in a more typical rewards program. Evidence shows that incentive programs may be effective for pregnant mothers who smoke. As of 2019, there is an insufficient number of studies on "quit and win," and other competition-based interventions and results from the existing studies were inconclusive.

##### Workplace incentives

A 2008 Cochrane review of smoking cessation activities in work-places concluded that "interventions directed towards individual smokers increase the likelihood of quitting smoking". A 2010 systematic review determined that worksite incentives and competitions needed to be combined with additional interventions to produce significant increases in smoking cessation rates.

### Healthcare systems

Interventions delivered via healthcare providers and healthcare systems have been shown to improve smoking cessation among people who visit those services.

* 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 effectively promote 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. Even brief advice from physicians may have "a small effect on cessation rates", and there is evidence that the physicians' probability of giving smoking cessation advice declines with the person who smokes age. There is evidence 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 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 opposed to 10.9% for "no contact" over 300 minutes of contact time made 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 58 studies found that nursing interventions increased the likelihood of quitting. Another review found some positive effects when trained community pharmacists support patients in their smoking cessation trials.
* 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":
	+ Ask — Systematically identify all tobacco users at every visit
	+ Advise — Strongly urge all tobacco users to quit
	+ Assess — Determine willingness to make a quit attempt
		- Assist — Aid the patient in quitting (provide counselling-style support and medication)
		- Arrange — Ensure follow-up contact

## Substitutes for cigarettes

* Nicotine replacement therapy (NRT) is the general term for using products that contain nicotine but not tobacco to aid smoking cessation. These include nicotine lozenges, nicotine gum and inhalers, nicotine patches, and electronic cigarettes. In a review of 136 NRT-related Cochrane Tobacco Addiction Group studies, substantial evidence supported NRT use in increasing the chances of successfully quitting smoking by 50 to 60% in comparison to placebo or a non-NRT control group.
* Electronic cigarettes (ECs): There is high‐certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate‐certainty evidence that they increase quit rates compared to ECs without nicotine. Little is known regarding the long-term harms related to vaping. A 2016 UK Royal College of Physicians report supports using e-cigarettes as a smoking cessation tool. A 2015 Public Health England report stated that "Smokers who have tried other methods of quitting without success could be encouraged to try e-cigarettes (EC) to stop smoking and stop smoking services should support smokers using EC to quit by offering them behavioural support." However, since little is known about long term effects, other regulated options such as nicotine replacement therapy, varenicline or bupropion should be discussed primarily.

### Alternative approaches

It is important to note that most of the alternative approaches below have minimal evidence to support their use, and their efficacy and safety should be discussed with a healthcare professional before starting.

* Acupuncture: Acupuncture has been explored as an adjunct treatment method for smoking cessation. A 2014 Cochrane review was unable to make conclusions regarding acupuncture as the evidence is poor. A 2008 guideline found no difference between acupuncture and placebo, found no scientific studies supporting laser therapy based on acupuncture principles but without the needles.
* Hypnosis: Hypnosis often involves the hypnotherapist suggesting the unpleasant outcomes of smoking to the patient. Clinical trials studying hypnosis and hypnotherapy as a method for smoking cessation have been inconclusive. A Cochrane review was unable to find evidence of benefit of hypnosis in smoking cessation, and suggested if there is a beneficial effect, it is small at best. However, a randomized trial published in 2008 found that hypnosis and nicotine patches "compares favorably" with standard behavioral counseling and nicotine patches in 12-month quit rates.
* Herbal medicine: Many herbs have been studied as a method for smoking cessation, including lobelia and St John's wort. The results are inconclusive, but St. Johns Wort shows few adverse events, but is a contraindication to many medications. Lobelia has been used to treat respiratory diseases like asthma and bronchitis, and has been used for smoking cessation because of chemical similarities to tobacco; lobelia is now listed in the FDA's Poisonous Plant Database. Lobelia can still be found in many products sold for smoking cessation and should be used with caution. Herbal products should be discussed with healthcare professionals before use to confirm safety with other medications.
* Smokeless tobacco: There is little smoking in Sweden, which is reflected in the very low cancer rates for Swedish men. Use of snus (a form of steam-pasteurized, rather than heat-pasteurized, air-cured smokeless tobacco) is an observed cessation method for Swedish men and even recommended by some Swedish doctors. However, the report by the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) concludes "STP (smokeless tobacco products) are addictive and their use is hazardous to health. Evidence on the effectiveness of STP as a smoking cessation aid is insufficient." A recent national study on the use of alternative tobacco products, including snus, did not show that these products promote cessation.
* Aversion therapy: It is a method of treatment works by pairing the pleasurable stimulus of smoking with other unpleasant stimuli. A Cochrane review reported that there is insufficient evidence of its efficacy.
* Nicotine vaccines: Nicotine vaccines (e.g., NicVAX and TA-NIC) work by reducing the amount of nicotine reaching the brain; however, this method of therapy needs more investigations to establish its role and determine its side effects.
* Technology and machine learning: Research studies using machine learning or artificial intelligence tools to provide feedback and communication with those who are trying to quit smoking are increasing, yet the findings are so far inconclusive.
* Psilocybin has been being investigated as a potential smoking cessation aid for several years. In 2021, Johns Hopkins Medicine has been awarded a grant from the National Institutes of Health to explore the potential impacts of psilocybin and talk therapy on tobacco addiction.