SMOKING CESSATION

Quitting a smoking habit can be extremely challenging because it involves overcoming a physical addiction as well as deeply ingrained psychological and social patterns. Although the chances of successfully quitting may often be very low for any given attempt, they can clearly be improved by looking for different kinds of help and making repeated attempts.

If you are trying to quit smoking, you are not alone. A survey conducted by the Centers for Disease Control and Prevention in 2010 found that over two-thirds of adult smokers wanted to quit smoking, and a little more than half attempted to quit in the year prior to the survey.[1]

The length of time you have smoked, your age at which you started smoking and the strength of your motivation to quit all affect the outcome of a single cessation attempt. But success is possible for everyone, and the number of successful quitters is steadily growing. Since 2002, the number of former smokers in the U.S. has exceeded the number of current smokers.[1]

Reasons to quit smoking

If you are a smoker, quitting is the most important thing you can do for your health. The 2010 surgeon general’s report How Tobacco Smoke Causes Disease detailed how smoking damages practically every organ in the human body and found that smoking causes an overwhelming number of deadly diseases, from lung cancer and chronic obstructive pulmonary disease to heart attack and stroke.[2]

Quitting really does help. The Centers for Disease Control has estimated that about half of all smoking related deaths for former smokers age 45 and older could be prevented if all smokers in this age group were to give up smoking.[3] Some of the health benefits, such as lowered blood pressure and other indicators of risk, are detectable very quickly, even within the first few days of quitting.[4] The benefits increase the longer you stay smoke-free. Studies have found that two thirds of the excess risk of developing coronary heart disease can be eliminated within 2 years of quitting.[5] Within 5 years of smoking cessation, the relative risk for stroke can be the same as if a person had never smoked.[6] Individuals in one study who remained smoke free for 15 years decreased their risk of dying from lung cancer by about half compared to what it would have been had they continued smoking.[7]

Quitting can also have an impact on family and friends. Every year, thousands of nonsmokers die from heart disease and lung cancer attributable to secondhand smoke, and hundreds of thousands of children suffer from respiratory infections due to secondhand smoke.[2]  There is no safe level of exposure to secondhand smoke.[2] If you are a smoker, the single best way to protect your family from secondhand smoke is to quit smoking.

Talking with your doctor

One of the first and easiest steps you can take to quit smoking is talking with your primary care doctor. Studies have shown that even a brief conversation with a doctor who advises a patient about quitting can improve the patient’s chances of quitting successfully.[8]

A physician can also help you access other important forms of treatment, such as nicotine replacement therapy or intensive counseling. You should report any medical conditions to your doctor that he or she does not already know about, such as diabetes, heart disease, asthma, stomach ulcers or high blood pressure. Also share whether you have recently had a heart attack for which your current doctor did not treat you or if you have tried or are taking other medications to help you quit smoking. These factors may affect the type of smoking cessation support you should receive.

Tell (or remind) your doctor if you take insulin, medicines for asthma or chronic obstructive pulmonary disease, blood thinners, antidepressants, or antipsychotic medications. These medicines may work differently when you quit smoking and may need to be adjusted to avoid serious side effects.

Be open with your doctor about repeated attempts to quit that failed or led to severe withdrawal. Your doctor can help by referring you to a smoking cessation counseling provider to improve your chances of success.

When you talk with your doctor, schedule a follow-up visit in the next week or two to assess how the strategy is working. Check in regularly after that if possible.

Ask your health care provider the following questions:

1. How can you help me to be successful at quitting?
2. What medication do you think would be best for me, and how should I take it?
3. What should I do if I need more help?
4. What is smoking withdrawal like? How can I get information on withdrawal?

Strategies for smoking cessation

Counseling

Counseling is a very effective way to boost chances of quitting smoking long term, and it comes in a variety of forms. These include self-help materials, brief advice sessions from a health professional such as your primary physician, or more intensive counseling by a health professional in repeated one-on-one or group sessions.

There is not a lot of evidence that written self-help materials alone provide any advantage in terms of quitting success.[9] However, other forms of therapy, such as telephone counseling or conversations with a health professional, do seem to help.[10]

Professional counseling can be provided by a primary care doctor, psychologist, nurse, social worker or tobacco treatment specialist who has been trained to provide smoking-cessation counseling services. A number of hospitals or clinics now offer intensive one-on-one or group sessions with a trained professional. In this setting, smokers wishing to quit are taught coping skills and offered social support. This type of counseling from a trained provider has been shown to be very effective at helping smokers quit.[11],[12]

When considering which type of professional counseling to use, note that there is no clear difference in success rates based on the particular approach to counseling, method of counseling (individual or group, phone or in-person), or the number and intensity of counseling sessions.[11],[12] Any form of more intensive counseling with a professional is more effective than a single, short (10 minutes or less) advice session or no counseling at all.[11] Successful counseling programs usually include at least one intensive, in-person session and repeated follow-up contacts, either in person or by telephone. These multiple sessions could be with a professional counselor or with your doctor or nurse, if they provide such services.

If you are not able to meet with your doctor to discuss counseling options, you can access a telephone “quitline” serving your area by calling 800-QUIT-NOW (800-784-8669) or visiting www.smokefree.gov. These services can refer you to providers in your area who offer specialized smoking cessation services, such as group counseling or services for special populations. Depending on your area, the quitline may also provide you with free smoking cessation counseling over the phone.

Nicotine replacement therapy

Nicotine replacement therapy includes any product approved by the Food and Drug Administration (FDA) that delivers nicotine (COMMIT, HABITROL, NICODERM, NICORETTE, NICOTROL, THRIVE) to your body to help you overcome the craving to smoke (or the craving to use other nontherapeutic tobacco products, like chewing tobacco). It comes in various forms, including gum, patches placed on the skin, nasal spray, inhalers, tablets and lozenges.

While these products help to overcome the pharmacologic addiction and to reduce withdrawal symptoms — such as irritability, depression and craving — they do not eliminate the symptoms entirely.

Numerous studies have shown that a person who uses nicotine replacement therapy is more likely to quit and stay smoke-free long-term than a person who uses the same quitting strategy but takes a placebo or uses no pharmacological treatment.

This therapy generally doubles the chance of quitting regardless of other support used.[13],[14],[15] All types of nicotine replacement therapy are successful at helping smokers quit. There are not a lot of studies comparing different forms of nicotine replacement therapy with one another (for example, inhaler versus patch), but the few studies that exist have not shown strong evidence favoring one type of product over another.[14]

Nicotine replacement therapy usually provides nicotine in a slower and less satisfying way than do cigarettes, but it is also safer and less addictive. It does not contain tar and carbon monoxide as tobacco smoke does. Still, nicotine itself can have negative health effects. Be careful to follow the instructions for use, and do not smoke cigarettes while you are using another nicotine product.

Side effects for nicotine replacement products can vary, and most frequently involve pain or irritation at the place where the nicotine enters the body. Adverse events can include upset stomach, jaw pain, sore throat and ulcers (for gum or lozenges), skin sensitivity or irritation (for the patch), and local irritation in the mouth and nose (for the inhaler and nasal spray). You should avoid using lozenges if you live with young children, because there is a risk of nicotine poisoning if a child mistakes them for candy.

It is important to realize that nicotine replacement therapy is not a magic bullet. It does nothing to address deeply ingrained psychological and social patterns that can lead to the resumption of a smoking habit.

To increase the chance of success, consult a doctor about treatment strategies before starting nicotine replacement therapy, rather than simply purchasing these products over the counter.

Comparing and combining approaches

Nicotine replacement therapy and counseling have shown equal effectiveness when each was compared with no treatment, and there is no evidence showing that one is more effective than the other when used separately.

The most effective approach to quitting is to combine the two approaches. Nicotine replacement therapy and counseling complement one another by addressing both the physiological aspects and the sociopsychological sides of the addiction. Studies have shown that the chance of quitting can be improved by combining counseling with nicotine replacement therapy rather than using nicotine replacement therapy alone.

The results of using both approaches together can be dramatic. In one large, randomized study, smokers who used nicotine gum and went to 12 group sessions using behavior modification techniques over a period of 10 weeks were nearly four times more likely to remain smoke-free after five years, compared with those who had not received any special assistance (that is, they did not receive nicotine gum or counseling as part of the study).

Antidepressant drugs for smoking cessation

One antidepressant medication, bupropion (ZYBAN), has been approved by the FDA for smoking cessation. Multiple trials of bupropion have shown it to increase the number of successful quit attempts, although the precise mechanism by which it works is unclear. There is no evidence that bupropion is any more or less effective than nicotine replacement therapy or that it helps quitting efforts to combine bupropion with nicotine replacement therapy.

You do not have to be depressed to use bupropion as a smoking cessation aid. However, the drug does have side effects, including a risk of seizures (about 1 in 1,000).

There is also some evidence that nortriptyline, a generic antidepressant, increases quit rates. However, fewer trials have been conducted with this drug, and it is not FDA-approved for smoking cessation. Nortriptyline also has side effects, including dry mouth, constipation, nausea and sedation.

Other antidepressants, such as selective serotonin reuptake inhibitors (for example, paroxetine [PAXIL, PEXEVA]), have not been shown to help smoking cessation.

Varenicline (CHANTIX): a drug of last resort

Varenicline is effective for smoking cessation and has been approved by the FDA for this indication. It works by acting on the sites in the brain affected by nicotine to ease withdrawal symptoms and block the effects of nicotine if users do attempt to smoke.

However, varenicline poses substantial health risks and should not be used unless all other methods of smoking cessation support have failed. The drug carries a black box warning, the strongest warning the FDA can require, for severe mental health side effects, including behavioral changes such as depressed mood, hostility, and suicidal thoughts or actions. Varenicline has been associated with these mental health symptoms even in people without a history of mental illness.

In the September 2011 Worst Pills, Best Pills News, Public Citizen recommended against using varenicline until 2013, applying our Seven Year Rule, which advises readers to avoid using new drugs for the first seven years following FDA approval if other effective treatments are available. Varenicline should remain a drug of last resort even after 2013 because of its significant risks.

Varenicline also increases cardiovascular risks (for example, heart attacks) for people with heart problems. The drug can lead to serious allergic or skin reactions, such as life-threatening swelling around the face, mouth and throat, which can interfere with breathing. Among the common side effects are nausea, difficulty sleeping, constipation, gas and vomiting.

Avoid using varenicline if you have a history of mental illness or heart problems. Stop using varenicline and talk with your doctor immediately or call 911 if you experience signs of a heart attack or are concerned by signs of depression or thoughts of harm to yourself or others. For more information on varenicline, see the September 2007 Worst Pills, Best Pills News article "A Review of Varenicline (CHANTIX) To Quit Smoking."

Smoking cessation drugs and pregnancy

Quitting smoking should be a top priority if you are a smoker who is pregnant or plans to become pregnant. Smoking can reduce fertility and exposes the fetus to serious health risks by decreasing the amount of oxygen it receives.

There is very little information on how nicotine replacement therapy or other smoking cessation drugs affects the chances of becoming pregnant or the health of a fetus or newborn. Nicotine replacement therapy does not contain certain chemicals found in cigarettes that can harm a fetus, such as carbon monoxide and tar. However, nicotine replacement therapy does continue to supply nicotine, which also has an impact on fetal health. Varenicline and bupropion have been shown to cause adverse effects on fetuses in animal studies and are listed as FDA “pregnancy category C” (meaning risks cannot be ruled out but the drug also has significant benefits).

If you are pregnant, the safest approach for your baby would be to quit smoking as soon as you can without using nicotine replacement therapy or a smoking cessation drug. If you believe you cannot quit without using these aids, talk with your physician about the risks and benefits of each approach before making a decision.

Support from family and friends

Having the support of friends and family, particularly a spouse, can have a big impact on chances of successfully quitting smoking. In addition to a spouse, children, parents, friends, relatives and co-workers can offer positive support. Support can even come from someone outside usual social networks, such as a buddy found through a smoking cessation program.

Studies have shown that success at being smoke-free is more likely with supportive behavior from loved ones. This supportive behavior can include talking the smoker out of smoking a cigarette or engaging in activities to replace smoking, such as going for a walk to relieve stress. It can also include encouraging the smoker by expressing pleasure at the smoker’s efforts to quit or predicting that the smoker will be successful at quitting.

Negative behavior can also substantially affect a smoker’s chances of successful quitting, particularly when the negative behavior comes from a spouse. In studies, smokers were more likely to relapse if they reported that the people who constituted their support systems complained about smoking or predicted that their quitting attempt would fail.

Researchers have not conducted enough quality studies of partner support to show what methods are most effective in increasing the amount of such support. Reactions to smoking or quitting attempts are often deeply ingrained, and changing the patterns of others may be as challenging as changing your own smoking behavior.

Smokers who are married to nonsmokers or ex-smokers are more likely to quit and remain smoke-free. If your spouse or close friend is a smoker, you may improve your chances of quitting successfully by doing so together.

It may help to talk with your friends and loved ones about your desire to quit smoking. Ask for their support. Talk about positive and negative behaviors, and create a plan for giving each other feedback. If you have trouble breaking patterns of negative behavior with a loved one, consider attending counseling together.

What You Should Do

Don’t give up!

If you have tried to quit in the past and relapsed, don’t worry! Most smokers have to make several attempts to stop before finally succeeding (the average number of tries is around four before successfully quitting). Relapse is a normal part of the process that can be overcome. Be proud that you fought hard to quit, and treat it as a learning experience for next time.

Follow these steps for preparing to quit:

• Set a quit date.
• Change your environment.
  • Get rid of ALL cigarettes and ashtrays in your home, car and place of work.
  • Don’t let people smoke in your home.
• Review your past attempts to quit. Think about what worked and what did not.
• Once you quit, don’t smoke — NOT EVEN A PUFF!

It is important to distract yourself from any urges to smoke. To do so, try the following approaches:

• Talk to someone, go for a walk or get busy with a task.
• When you first try to quit, change your routine. For example, use a different route to work, drink tea instead of coffee or eat breakfast in a different place.
• Do something to reduce your stress. Take a hot bath, exercise or read a book.
• Plan something enjoyable to do every day.
• Drink a lot of water and other fluids.

Try thinking about the reasons you relapsed and what you could do differently. Talk with your family and friends — and your doctor — and stay motivated. Smoking cessation is a huge effort, but you are worth it. Your health is valuable to you and those who care about you.

Learning About and Reporting Adverse Events