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'''To review the wikidoc chapter on [[smoking]], click [[Smoking|here]].
==Overview==
==Overview==
[[Image:Rauchen Verboten.svg|thumb|A 'No Smoking' sign]]  
[[Tobacco]] use is the leading cause of preventable disease, disability, and death in the United States. Each year, nearly half a million Americans die prematurely of smoking or exposure to secondhand smoke and 16 million live with a serious illness caused by [[smoking]]. [[Smoking]] can cause repairable damage to various organs including the [[heart]], [[lungs]], [[kidneys]], [[stomach]] and [[intestines]]. [[Smoking]] is associated with the causation of various cancers in the humans. Quitting [[smoking]] cuts [[cardiovascular]] risks, reduces risk for stroke to about half that of a nonsmoker’s, reduces risks for cancers of the [[mouth]], [[throat]], [[esophagus]], and [[bladder]] by half within 5 years and ten years after quitting [[smoking]], the risk for lung cancer drops by half. [[Smoking cessation]] can be achieved by some general, non-pharmacological and pharmacological strategies.
'''Smoking cessation''' is the effort to stop [[tobacco smoking|smoking]] [[tobacco]] products. [[Nicotine]] is an [[addiction|addictive]] substance, especially when taken in by inhaling tobacco smoke, probably because of the rapid absorption through the lungs. Tobacco use is one of the major causes of death worldwide, according to the [[World Health Organization]].<ref> [http://www.who.int/tobacco/en/index.html World Health Organization, Tobacco Free Initiative] </ref>.
 
==Description==
Research in western countries has found that approximately 3-5% of quit attempts succeed using willpower alone (Hughes et al, 2004) and clinical trials have shown that [[Nicotine replacement therapy|Nicotine Replacement Therapy]] (NRT) (see below) can double this rate to approximately 6-10% (Silagy et al, 2004). This is a small effect but is considered very worthwhile. Multi-session psychological support from a trained counselor, either individually or in groups has been shown in clinical trials to have an effect similar to that for NRT. The best chances of success can be obtained by combining medication and psychological support (see below) (USDHHS, 2000). Apart from NRT, medication that have been shown to be effective in clinical trials are: the tricyclic anti-depressant [[nortriptyline]], [[bupropion]] (Zyban,or Quomem in some countries) and the nicotinic partial agonist, [[varenicline]] (Chantix in the US and Champix elsewhere). Thorough reviews of the evidence for all these methods of stopping are available via the Cochrane Library website [http://www.theCochraneLibrary.com Cochrane Library]
 
There are many people and organizations touting what are claimed to be effective methods of helping smokers to stop. Any smoker thinking of paying money for such help would be well advised to ask whether the claims of success are backed up by indepedent comparative clinical trials, how the success rates have been calculated and what numbers of smokers have been included in the figures. It is very easy to make misleading claims of success rates which are not adequately supported by evidence.
 
A range of population level strategies such as [[tobacco advertising|advertising campaigns]], smoking restriction policies, and tobacco taxes have been used to promote smoking cessation. Of these, raising the cost of smoking is the one that has the strongest evidence (West, 2006).
 
Smoking cessation will almost always lead to a longer and healthier life. Stopping in early adulthood can add up to 10 years of healthy life and stopping in one's 60s can still add 3 years of healthy life (Doll et al, 2004). Stopping smoking is also associated with better mental health and spending less of one's life with diseases of old age.
 
The most common short-term effects of stopping smoking are: increased irritability, depression, anxiety, restlessness, difficulty concentrating, increased appetite, constipation, mouth ulcers and increased susceptibility to upper respiratory tract infections. These mostly last for up to 4 weeks, though increased appetite typically lasts for more than 3 months. The most obvious long-term effect is weight gain (Hughes, 2007).
 
==Statistics==
 
* [http://tc.bmjjournals.com/cgi/content/full/12/1/21?ijkey=5.ko5/Oz4yutI Seven percent] of over-the-counter nicotine patch and gum quitters quit for at least six months
 
* A physician's advice to quit can increase quitting odds by 30 percent to [http://surgeongeneral.gov/tobacco/treating_tobacco_use.pdf ten percent] at six months
 
* High intensity counseling of greater than 10 minutes can increase six month quitting rates to [http://surgeongeneral.gov/tobacco/treating_tobacco_use.pdf 22 percent] when added to any quitting method, cold turkey or NRT (see Table 12)
 
* Quitting programs involving 91 to 300 minutes of contact time can increase six month quitting rates to [http://surgeongeneral.gov/tobacco/treating_tobacco_use.pdf 28 percent], regardless of quitting method
 
* Quitting programs involving 8 or more treatment sessions can increase six month quitting rates to [http://surgeongeneral.gov/tobacco/treating_tobacco_use.pdf 24.7 percent]
 
* Bupropion (Zyban/Wellbutrin) use can generate quitting rates [http://surgeongeneral.gov/tobacco/treating_tobacco_use.pdf 13 percentage points] above placebo rates at six months (see Table 25). This fact is stated as such in that all bupropion studies to date have included counseling or support elements (having their own proven efficacy) and bupropion has not been tested in an over-the-counter type setting, as have nicotine replacement therapy (NRT).
 
==Information for smokers trying to quit==
 
Smoking cessation services, which offer group or individual therapy can help people who want to quit. Some smoking cessation programs employ a combination of [[coaching]], [[motivational interviewing]], [[cognitive behavioral therapy]], and pharmacological counseling.  


Trials have shown that an effective method for quitting smoking is [[cognitive behaviour therapy]] or CBT. For example, the QUIT FOR LIFE Programme ([[David Marks (psychologist)|David Marks]], 1993, 2005) has produced quit rates that are 5-6 times higher than quitting by willpower alone (Marks & Sykes, 2002).
==Clinical practice guidelines==


While some smokers are successful with their first attempt, many people fail several times. Many smokers find it difficult to quit, even in the face of serious smoking-related disease in themselves or close family members or friends. A serious commitment to arresting dependency upon nicotine is essential.
Clinical practice guidelines by the [[USPSTF]] recommend<ref>USPSTF (2015). [https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1?ds=1&s=smoking%20cessation Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions]</ref>:


Some studies have concluded that those who do successfully quit smoking can gain weight. "Weight gain is not likely to negate the health benefits of smoking cessation, but its cosmetic effects may interfere with attempts to quit." (Williamson, Madans et al, 1991) Therefore, drug companies researching smoking-cessation medication often measure the weight of the participants in the study.
* "Adults who are not pregnant: The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration – approved pharmacotherapy for cessation to adults who use tobacco. GRADE A"
* "Pregnant women: The USPSTF recommends that clinicians ask all pregnant woment about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. GRADE A"
* "Pregnant women: The USPSTF concludes that the current evidence is insufficient ot assess the balance of benefits and harms of pharmacotherpay interventions for tobacco cessation in pregnant women. GRADE I"
* "All adults, including pregnant women: The USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults, incuding pregnant women. The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety. GRADE I"


Tobacco smoking has a [[laxative]] effect, smoking cessation may lead to [[constipation]], however this is by no means inevitable and is easily treated. <ref> {{cite web|url=http://www.helpwithsmoking.com/nicotine-withdrawal.php#constipation |title=Nicotine withdrawal symptoms:Constipation |accessdate=2007-06-29 |date=2005 |publisher=helpwithsmoking.com }}</ref>
==Smoking and Health==
The impact of smoking on the health can be summarized as follows:<ref name="urlCDC - 2010 Surgeon Generals Report - Consumer Booklet - Smoking & Tobacco Use">{{cite web |url=https://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/index.htm |title=CDC - 2010 Surgeon General's Report - Consumer Booklet - Smoking & Tobacco Use |format= |work= |accessdate=}}</ref><ref name="urlQuickStats: Number of Deaths from 10 Leading Causes — National Vital Statistics System, United States, 2010">{{cite web |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6208a8.htm?s_cid=mm6208a8_w |title=QuickStats: Number of Deaths from 10 Leading Causes — National Vital Statistics System, United States, 2010 |format= |work= |accessdate=}}</ref><ref name="urlCDC - 2014 Surgeon Generals Report - Smoking & Tobacco Use">{{cite web |url=https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm |title=CDC - 2014 Surgeon General's Report - Smoking & Tobacco Use |format= |work= |accessdate=}}</ref>
[[image:Smoke.jpg|center]]


[[Major depression]] may challenge smoking cessation success in women. Quitting smoking is especially difficult during certain phases of the [[reproductive cycle]], phases that have also been associated with greater levels of [[dysphoria]], and subgroups of women who have a high risk of continuing to smoke also have a high risk of developing depression. Since many women who are depressed  may be less likely to seek formal cessation treatment, practitioners have a unique opportunity to persuade their patients to quit.<ref> [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8909649&dopt=Citation The impact of depression on smoking cessation in women.]</ref>


===Modalities===
===Effect of Smoking Cessation on various Risks===
[[Image:Nicoderm.JPG||thumb|right|A 21mg dose [[Nicoderm]] CQ patch applied to the left arm]]
*Quitting [[smoking]] cuts cardiovascular risks<ref name="pmid31429895">{{cite journal| author=Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA| title=Association of Smoking Cessation With Subsequent Risk of Cardiovascular Disease. | journal=JAMA | year= 2019 | volume= 322 | issue= 7 | pages= 642-650 | pmid=31429895 | doi=10.1001/jama.2019.10298 | pmc=6704757 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31429895  }} </ref>. Just 1 year after quitting smoking, your risk for a heart attack drops sharply.
*Within 2 to 5 years after quitting smoking, your risk for stroke may reduce to about that of a nonsmoker’s.
*If you quit [[smoking]], your risks for cancers of the [[mouth]], [[throat]], [[esophagus]], and bladder drop by half within 5 years.
*Ten years after you quit [[smoking]], your risk for lung cancer drops by half.


Techniques which can increase smokers' chances of successfully quitting are:
==Smoking cessation==
*Quitting "[[cold turkey]]": abrupt cessation of all nicotine use as opposed to tapering or gradual stepped-down nicotine weaning. It is the quitting method used by 80<ref>Doran CM, Valenti L, Robinson M, Britt H, Mattick RP. Smoking status of Australian general practice patients and their attempts to quit. Addict Behav. 2006 May;31(5):758-66. PMID 16137834</ref> to 90%<ref>{{cite web| title=Cancer Facts & Figures 2003 | author=American Cancer Society | url=http://www.cancer.org/downloads/STT/CAFF2003PWSecured.pdf}}</ref> of all long-term successful quitters.
===General Principles===
*Smoking-cessation support and counselling is often offered over the internet, over the phone [[quitline]]s (e.g. 1-800-QUIT-NOW), or in person.
The 5As are an evidence-based framework for structuring smoking cessation in health care settings. The 5As include: '''''Ask, Assess, Advise, Assist and Arrange follow-up'''''.
*[[Nicotine replacement therapy]], NRT: pharmacological aids that are clinically proven to help with withdrawal symptoms, cravings, and urges (for example, transdermal [[nicotine patch]]es, [[nicotine gum|gum]], lozenges, sprays, and [[inhaler]]s)
<br>
*The antidepressant [[bupropion]], marketed under the brand name Zyban®, helps with withdrawal symptoms, cravings, and urges.
<br>
Bupropion is contraindicated in [[epilepsy]], seizure disorder; anorexia/bulimia (eating disorders), patients use of psychosis drugs (MAO inhibitors) within 14 days, patients undergoing abrupt discontinuation of ethanol or sedatives (including benzodiazepines such as Valium)<ref>Charles F. Lacy et al, ''LEXI-COMP'S Drug Information Handbook 12th edition''. Ohio, USA,2004</ref>
{| align=center
*Nicotinic receptor antagonist [[varenicline]] (Chantix®) (Champix® in the UK)
|-
*Recently, a shot given multiple times over the course of several months, which primes the immune to produce antibodies which attach to nicotine and prevent it from reaching the brain, has shown promise in helping smokers quit. However, this approach is still in the experimental stages.  [http://news.wired.com/dynamic/stories/T/TOBACCO_VACCINE?SITE=WIRE&SECTION=HOME&TEMPLATE=DEFAULT&CTIME=2007-11-07-23-20-38]
|
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
!align="center" style="background:#4479BA; color: #FFFFFF;" |The 5As
!align="center" style="background:#4479BA; color: #FFFFFF;" |Technique
|-
|align="center" style="background:#DCDCDC;"|'''A'''sk
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Identify and document tobacco use status for every patient at every visit
|-
|align="center" style="background:#DCDCDC;"|'''A'''dvise
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |In a clear, strong, and personalized manner, urge every [[tobacco]] user to quit.
Advices should be:
* Clear:
** I think it is important for you to quit smoking now and I can help you. Cutting down while you are ill is not enough.
* Strong:
** As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you.
* Personalized:
** Tie tobacco use to current health, and its social and economic costs, motivation level to quit, and the impact of [[tobacco]] use on children and others in the household.
|-
|align="center" style="background:#DCDCDC;"|'''A'''ssess
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Assess willingness to make a quit attempt.
* Is the [[tobacco]] user willing to make a quit attempt within the next 30 days?
|-
|align="center" style="background:#DCDCDC;"|'''A'''ssist
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit.


===Alternative techniques===
* For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts.
Some 'alternative' techniques which have been used for smoking cessation are:
|-
*[[Hypnosis]] clinical trials studying hypnosis as a method for smoking cessation have been inconclusive. (The Cochrane Database of Systematic Reviews 2006, Issue 3.)
|align="center" style="background:#DCDCDC;"|'''A'''rrange follow-up
*[[Herbalism|Herbal preparations]] such as [[Kava]] and [[German_Chamomile | Chamomile]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Acupuncture]] clinical trials have shown that acupuncture's effect on smoking cessation is equal to that of sham/placebo acupuncture. (See Cochrane Review)
* For the patient willing to make a quit attempt, arrange for followup contacts, beginning within the first week after the quit date.
*Attending a self-help group such as [[List of Twelve-Step groups|Nicotine Anonymous]][http://www.nicotine-anonymous.org/] and electronic self-help groups such as Stomp It Out[http://www.experienceproject.com/mk/smokefree/index.php]
*Laser therapy based on [[acupuncture]] principles but without the needles.
*Quit meters: Small computer programs that keep track of quit statistics such as amount of "quit-time", cigarettes not smoked, and money saved.
*[[Self-help|Self-help books]] ([[Allen Carr]], FreshStartMethod etc.) Some of these claim very high success rates but little externally verified evidence of this success exists.
*[[Spirituality]] Spiritual beliefs and practices may help smokers quit.[http://www.sciencedaily.com/releases/2007/05/070507154054.htm]
*[[Smokeless tobacco]]: [[Snus]] is widely used in Sweden, and although it is much healthier than smoking, something which is reflected in the low cancer rates for Swedish men, there are still some concerns about its health impact. [http://www.snus.cc/snuff-health.aspx]
* Herbal and aromatherapy "natural" program formulations.
*[[Smoking reduction utensil]] ([[minitoke]])<ref>{{cite web | title="Smoking reduction may lead to unexpected quitting" | Author=Hughes et al. | accessdate=2007-12-27 |url=http://www.medicalnewstoday.com/articles/58430.php}}</ref>
*Smoking herb substitutions (non-tobacco)[[http://en.wikiversity.org/wiki/Smoking_Cessation]]


==Information for healthcare professionals==
* For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.
|}
|}


Several studies have found that smoking cessation advice is not always given in primary care in patients aged 65 and older<ref>Maguire CP, Ryan J, Kelly A, O'Neill D, Coakley D, Walsh JB. Do patient age and medical condition influence medical advice to stop smoking? Age Ageing. 2000 May;29(3):264-6. PMID 10855911</ref><ref>Ossip-Klein DJ, McIntosh S, Utman C, Burton K, Spada J, Guido J. Smokers ages 50+: who gets physician advice to quit? Prev Med. 2000 Oct;31(4):364-9. PMID 11006061</ref>, despite the significant health benefits which can ensue in the older population<ref>Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction. 2005 Apr;100 Suppl 2:59-69. PMID 15755262</ref>.
===Pharmacological===
First-line pharmacotherapy includes the multiple forms of nicotine replacement therapy (patch, nasal spray, losenge, gum, inhaler), sustained- release [[Bupropion extended release|bupropion]] hydrochloride, and [[varenicline]]. Second line therapy includes [[clonidine]] and [[nortriptyline]] and have been found to be efficacious.<ref name="urlwww.vapremier.com">{{cite web |url=https://www.vapremier.com/assets/SmokingCessationGuideline.pdf |title=www.vapremier.com |format= |work= |accessdate=}}</ref><br>
'''The following is a description of the various treatment modalities available:'''<ref name="pmid18617085">{{cite journal| author=Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff| title=A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. | journal=Am J Prev Med | year= 2008 | volume= 35 | issue= 2 | pages= 158-76 | pmid=18617085 | doi=10.1016/j.amepre.2008.04.009 | pmc=4465757 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18617085  }} </ref>
*'''[[Bupropion extended release|Sustained release bupropion]] hydrochloride:'''
**Dose: 150 mg every morning for 3 days, then 150 mg twice daily.
**Duration: The duration of treatment is 7–12 weeks followed by a maintenance therapy up to 6 months.
**Adverse effects: [[Insomnia]] and [[dry mouth]].
**Treatment must be initiated 1-2 weeks prior to the quit date.
** Number needed to treat: 22<ref name="pmid27158893">{{cite journal| author=Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T| title=Nicotine receptor partial agonists for smoking cessation. | journal=Cochrane Database Syst Rev | year= 2016 | volume=  | issue= 5 | pages= CD006103 | pmid=27158893 | doi=10.1002/14651858.CD006103.pub7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27158893  }} </ref>


One effective way to assist smokers who want to quit is through a telephone [[quitline]] which is easily available to all. Professionally run quitlines may help less dependent smokers, but those people who are more heavily dependent on nicotine should seek local smoking cessation services, where they exist, or assistance from a knowledgeable health professional, where they do not. Some evidence suggests that better results are achieved when counselling support and medication are used simultaneously. Quitting with a group of other people who want to quit is also a proven method of getting support, available through many organizations.  
*'''[[Nicotine]] gum:'''
**Dose: 1–24 cigarettes/day: 2mg gum (up to 24 pieces/day). ≥ 25 cigarettes/day: 4 mg gum (up to 24 pieces/day).
**Duration: Up to 12 weeks
**Adverse effects: Mouth soreness and [[dyspepsia]]
*'''[[Nicotine (inhalant)|Nicotine inhaler]]:'''
**Dose: 6–16 cartridges/day
**Duration: Up to 6 months
**Adverse effects: Local irritation of [[mouth]] and throat
*'''[[Nicotine]] lozenges:'''
**Dose: Time to 1st cigarette > 30 min: 2 mg lozenge. Time to 1st cigarette ≤ 30 min: 4 mg lozenge. 4–20 lozenges/day can be used based on the need.
**Duration: Up to 12 weeks
**Adverse effects: [[Nausea and vomiting|Nausea]] and [[heartburn]]
*'''[[Nicotine]] nasal spray:'''
**Dose: 8–40 doses/day
**Duration: 3–6 months
**Adverse effects: Nasal irritation
*'''[[Varenicline]]:'''
**Dose: 0.5 mg/day for 3 days followed by 0.5 mg twice/day for 4 days. Then, 1 mg twice/day
**Duration: 3–6 months
**Adverse effects: [[Nausea and vomiting|Nausea]], [[Sleeping difficulty|trouble sleeping]], vivid/strange dreams and [[depressed mood]]
** Number needed to treat: 11<ref name="pmid27158893">{{cite journal| author=Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T| title=Nicotine receptor partial agonists for smoking cessation. | journal=Cochrane Database Syst Rev | year= 2016 | volume=  | issue= 5 | pages= CD006103 | pmid=27158893 | doi=10.1002/14651858.CD006103.pub7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27158893  }} </ref>


[[Health professional]]s may follow the "five As" with every smoking patient they come in contact with:<ref>{{cite journal |journal=CMAJ |date=2007 |volume=177 |issue=11 |pages=1373–80 |title= Treatment of tobacco dependence: integrating recent progress into practice |author= Le Foll B, George TP |doi=10.1503/cmaj.070627 |pmid=18025429 |url=http://www.cmaj.ca/cgi/content/full/177/11/1373}}</ref>
===Cost-effectiveness===
#Ask about smoking
The cost per year of life save from smoking cessation<ref name="pmid9388153">{{cite journal| author=Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T| title=Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. | journal=JAMA | year= 1997 | volume= 278 | issue= 21 | pages= 1759-66 | pmid=9388153 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9388153  }} </ref><ref name="pmid16706571">{{cite journal| author=Kaper J, Wagena EJ, van Schayck CP, Severens JL| title=Encouraging smokers to quit: the cost effectiveness of reimbursing the costs of smoking cessation treatment. | journal=Pharmacoeconomics | year= 2006 | volume= 24 | issue= 5 | pages= 453-64 | pmid=16706571 | doi=10.2165/00019053-200624050-00004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16706571  }} </ref> is less than the costs per year of life saved from [[lung cancer screening |screening for lung cancer]] with low-dose [[computed tomography]]<ref name="pmid31683314">{{cite journal| author=Criss SD, Cao P, Bastani M, Ten Haaf K, Chen Y, Sheehan DF et al.| title=Cost-Effectiveness Analysis of Lung Cancer Screening in the United States: A Comparative Modeling Study. | journal=Ann Intern Med | year= 2019 | volume=  | issue=  | pages=  | pmid=31683314 | doi=10.7326/M19-0322 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31683314  }} </ref><ref name="pmid25372087">{{cite journal| author=Black WC, Gareen IF, Soneji SS, Sicks JD, Keeler EB, Aberle DR et al.| title=Cost-effectiveness of CT screening in the National Lung Screening Trial. | journal=N Engl J Med | year= 2014 | volume= 371 | issue= 19 | pages= 1793-802 | pmid=25372087 | doi=10.1056/NEJMoa1312547 | pmc=4335305 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25372087  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25715973 Review in: Evid Based Med. 2015 Apr;20(2):78] </ref>.
#Advise quitting
#Assess current willingness to quit
#Assist in the quit attempt
#Arrange timely follow-up


==See also==
==See also==
Line 93: Line 112:
*[[Tobacco cessation clinic]]
*[[Tobacco cessation clinic]]
*[[Tobacco and health]]
*[[Tobacco and health]]
==Notes==
{{reflist}}


==References==
==References==
* Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. Bmj 2004;328(7455):1519.
{{reflist|2}}
* [[Helgason AR]], Tomson T, Lund KE, Galanti R, Ahnve S, Gilljam H. Factors related to abstinence in a telephone helpline for smoking cessation. European J Public Health 2004: 14;306-310.
* {{cite journal | author = Henningfield J, Fant R, Buchhalter A, Stitzer M | title = Pharmacotherapy for nicotine dependence. | journal = CA Cancer J Clin | volume = 55 | issue = 5 | pages = 281-99; quiz 322-3, 325 | year = | id = PMID 16166074}} ''[http://caonline.amcancersoc.org/cgi/content/full/55/5/281 Full text]''
* Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004;99(1):29-38.
* Hutter H.P. et al. Smoking Cessation at the Workplace:1 year success of short seminars. International Archives of Occupational & Environmental Health. 2006;79:42-48.
* Marks, D.F. The QUIT FOR LIFE Programme:An Easier Way To Quit Smoking and Not Start Again. Leicester: British Psychological Society. 1993.
* Marks, D.F. & Sykes, C. M. Randomized controlled trial of cognitive behavioural therapy for smokers living in a deprived area of London: outcome at one-year follow-up
Psychology, Health & Medicine. 2005;7:17-24.
* Marks, D.F. ''Overcoming Your Smoking Habit''. London: Robinson.2005.
* Peters MJ, Morgan LC. ''The pharmacotherapy of smoking cessation''. Med J Aust 2002;176:486-490. [http://www.mja.com.au/public/issues/176_10_200502/pet10850_fm.html Fulltext]. PMID 12065013.
* Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004(3):CD000146.
* USDHHS. Treating Tobacco Use and Dependence. Rockville, MD: Agency for Healthcare Research Quality; 2000.
* West R. Tobacco control: present and future. Br Med Bull 2006;77-78:123-36.
* Williamson, DF, Madans, J, Anda, RF, Kleinman, JC, Giovino, GA, Byers, T '''Smoking cessation and severity of weight gain in a national cohort''' N Engl J Med 1991 324: 739-745
* [http://www.who.int/tobacco/en/index.html World Health Organization, Tobacco Free Initiative] 
* [[Zhu S-H]], Anderson CM, Tedeschi GJ, et al. Evidene of real-world effectiveness of a telephone quitline$for smokers. N Engl J Med 2002;347(14):1087-93.


==External links==
* [http://www.helpguide.org/mental/quit_smoking_cessation.htm Helpguide.org - How to Quit Smoking]
* [http://www.metacafe.com/watch/756818/quit_smoking Quit Smoking Video]
* [http://www.cancer.org/docroot/PED/ped_10.asp?sitearea=PED American Cancer Society Quit Tobacco Resources]
* [http://www.smokefree.gov/ National Cancer Institution Online guide to quitting]
* [http://whyquit.com WhyQuit.com]
* [http://www.ctri.wisc.edu/Smokers/smokers_Quit.Tips.htm University of Wisconsin Center for Tobacco Research and Intervention]
* [http://cpmcnet.columbia.edu/dept/nursing/clin_resources/mods-apn/ebp_pt_resources/SmCessationResources.htm Columbia University School of Nursing Smoking Cessation Portal]
* [http://www.lifesolved.com/story.php?title=Canrsquot_Quit_Smoking_Try_Calendar_Technique-1 Technique to Quit Smoking]
* [http://www.stop-tabac.ch Stop-tabac.ch: smoking cessation website in 5 languages]
* [http://www.smokefreeme.com SmokeFreeMe is an online guide to quit smoking]
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Latest revision as of 21:27, 25 January 2020

WikiDoc Resources for Smoking cessation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2],Usama Talib, BSc, MD [3],Aravind Kuchkuntla, M.B.B.S[4]

To review the wikidoc chapter on smoking, click here.

Overview

Tobacco use is the leading cause of preventable disease, disability, and death in the United States. Each year, nearly half a million Americans die prematurely of smoking or exposure to secondhand smoke and 16 million live with a serious illness caused by smoking. Smoking can cause repairable damage to various organs including the heart, lungs, kidneys, stomach and intestines. Smoking is associated with the causation of various cancers in the humans. Quitting smoking cuts cardiovascular risks, reduces risk for stroke to about half that of a nonsmoker’s, reduces risks for cancers of the mouth, throat, esophagus, and bladder by half within 5 years and ten years after quitting smoking, the risk for lung cancer drops by half. Smoking cessation can be achieved by some general, non-pharmacological and pharmacological strategies.

Clinical practice guidelines

Clinical practice guidelines by the USPSTF recommend[1]:

  • "Adults who are not pregnant: The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration – approved pharmacotherapy for cessation to adults who use tobacco. GRADE A"
  • "Pregnant women: The USPSTF recommends that clinicians ask all pregnant woment about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. GRADE A"
  • "Pregnant women: The USPSTF concludes that the current evidence is insufficient ot assess the balance of benefits and harms of pharmacotherpay interventions for tobacco cessation in pregnant women. GRADE I"
  • "All adults, including pregnant women: The USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults, incuding pregnant women. The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety. GRADE I"

Smoking and Health

The impact of smoking on the health can be summarized as follows:[2][3][4]


Effect of Smoking Cessation on various Risks

  • Quitting smoking cuts cardiovascular risks[5]. Just 1 year after quitting smoking, your risk for a heart attack drops sharply.
  • Within 2 to 5 years after quitting smoking, your risk for stroke may reduce to about that of a nonsmoker’s.
  • If you quit smoking, your risks for cancers of the mouth, throat, esophagus, and bladder drop by half within 5 years.
  • Ten years after you quit smoking, your risk for lung cancer drops by half.

Smoking cessation

General Principles

The 5As are an evidence-based framework for structuring smoking cessation in health care settings. The 5As include: Ask, Assess, Advise, Assist and Arrange follow-up.

The 5As Technique
Ask Identify and document tobacco use status for every patient at every visit
Advise In a clear, strong, and personalized manner, urge every tobacco user to quit.

Advices should be:

  • Clear:
    • I think it is important for you to quit smoking now and I can help you. Cutting down while you are ill is not enough.
  • Strong:
    • As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you.
  • Personalized:
    • Tie tobacco use to current health, and its social and economic costs, motivation level to quit, and the impact of tobacco use on children and others in the household.
Assess Assess willingness to make a quit attempt.
  • Is the tobacco user willing to make a quit attempt within the next 30 days?
Assist
  • For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit.
  • For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts.
Arrange follow-up
  • For the patient willing to make a quit attempt, arrange for followup contacts, beginning within the first week after the quit date.
  • For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.

Pharmacological

First-line pharmacotherapy includes the multiple forms of nicotine replacement therapy (patch, nasal spray, losenge, gum, inhaler), sustained- release bupropion hydrochloride, and varenicline. Second line therapy includes clonidine and nortriptyline and have been found to be efficacious.[6]
The following is a description of the various treatment modalities available:[7]

  • Sustained release bupropion hydrochloride:
    • Dose: 150 mg every morning for 3 days, then 150 mg twice daily.
    • Duration: The duration of treatment is 7–12 weeks followed by a maintenance therapy up to 6 months.
    • Adverse effects: Insomnia and dry mouth.
    • Treatment must be initiated 1-2 weeks prior to the quit date.
    • Number needed to treat: 22[8]
  • Nicotine gum:
    • Dose: 1–24 cigarettes/day: 2mg gum (up to 24 pieces/day). ≥ 25 cigarettes/day: 4 mg gum (up to 24 pieces/day).
    • Duration: Up to 12 weeks
    • Adverse effects: Mouth soreness and dyspepsia
  • Nicotine inhaler:
    • Dose: 6–16 cartridges/day
    • Duration: Up to 6 months
    • Adverse effects: Local irritation of mouth and throat
  • Nicotine lozenges:
    • Dose: Time to 1st cigarette > 30 min: 2 mg lozenge. Time to 1st cigarette ≤ 30 min: 4 mg lozenge. 4–20 lozenges/day can be used based on the need.
    • Duration: Up to 12 weeks
    • Adverse effects: Nausea and heartburn
  • Nicotine nasal spray:
    • Dose: 8–40 doses/day
    • Duration: 3–6 months
    • Adverse effects: Nasal irritation
  • Varenicline:
    • Dose: 0.5 mg/day for 3 days followed by 0.5 mg twice/day for 4 days. Then, 1 mg twice/day
    • Duration: 3–6 months
    • Adverse effects: Nausea, trouble sleeping, vivid/strange dreams and depressed mood
    • Number needed to treat: 11[8]

Cost-effectiveness

The cost per year of life save from smoking cessation[9][10] is less than the costs per year of life saved from screening for lung cancer with low-dose computed tomography[11][12].

See also

References

  1. ↑ USPSTF (2015). Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions
  2. ↑ "CDC - 2010 Surgeon General's Report - Consumer Booklet - Smoking & Tobacco Use".
  3. ↑ "QuickStats: Number of Deaths from 10 Leading Causes — National Vital Statistics System, United States, 2010".
  4. ↑ "CDC - 2014 Surgeon General's Report - Smoking & Tobacco Use".
  5. ↑ Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA (2019). "Association of Smoking Cessation With Subsequent Risk of Cardiovascular Disease". JAMA. 322 (7): 642–650. doi:10.1001/jama.2019.10298. PMC 6704757 Check |pmc= value (help). PMID 31429895.
  6. ↑ "www.vapremier.com" (PDF).
  7. ↑ Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff (2008). "A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report". Am J Prev Med. 35 (2): 158–76. doi:10.1016/j.amepre.2008.04.009. PMC 4465757. PMID 18617085.
  8. ↑ 8.0 8.1 Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T (2016). "Nicotine receptor partial agonists for smoking cessation". Cochrane Database Syst Rev (5): CD006103. doi:10.1002/14651858.CD006103.pub7. PMID 27158893.
  9. ↑ Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T (1997). "Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research". JAMA. 278 (21): 1759–66. PMID 9388153.
  10. ↑ Kaper J, Wagena EJ, van Schayck CP, Severens JL (2006). "Encouraging smokers to quit: the cost effectiveness of reimbursing the costs of smoking cessation treatment". Pharmacoeconomics. 24 (5): 453–64. doi:10.2165/00019053-200624050-00004. PMID 16706571.
  11. ↑ Criss SD, Cao P, Bastani M, Ten Haaf K, Chen Y, Sheehan DF; et al. (2019). "Cost-Effectiveness Analysis of Lung Cancer Screening in the United States: A Comparative Modeling Study". Ann Intern Med. doi:10.7326/M19-0322. PMID 31683314.
  12. ↑ Black WC, Gareen IF, Soneji SS, Sicks JD, Keeler EB, Aberle DR; et al. (2014). "Cost-effectiveness of CT screening in the National Lung Screening Trial". N Engl J Med. 371 (19): 1793–802. doi:10.1056/NEJMoa1312547. PMC 4335305. PMID 25372087. Review in: Evid Based Med. 2015 Apr;20(2):78


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