Smoking Cessation

Overview

According to the Centers for Disease Control and Prevention (2010), smoking is the most common preventable cause of death and disability in the U.S. The report estimates that roughly half of smokers who don't quit will die from smoking-related disease.

Brunnhuber, Cummings, Feit, Sherman, & Woodcock (2007) list strong incentives for quitting: "Soon after you quit, your circulation begins to improve, and your blood pressure starts to return to normal. Your sense of smell and taste return and breathing starts to become easier. In the long term, giving up tobacco can help you live longer. Your risk of getting cancer decreases with each year you stay smoke-free." The authors point out the health hazards of smoking as including, "cardiovascular and respiratory disease, cancer (e.g., lung, larynx, esophagus, mouth, bladder, cervix, pancreas, kidneys), and infant deaths related to maternal smoking. Increasingly, the dangers of secondhand smoke, such as cardiac disease and lung cancer, are also recognized by researchers and policy makers." Extensive information on the effects of smoking are available from the Surgeon General.

The challenge of cessation: Despite the strong incentives to quit, it is estimated that only 7% of Americans that attempt to quit are successful for twelve months. (Zhu, Melcer, Sun, Rosbrook, & Pierce, 2000) Factors that contribute to relapse include weight gain, irritability, and anxiety. Addiction also operates in unconscious ways, leading many to relapse without a conscious feeling or understanding that they are verging on relapse. This is likely because of the profound effects of the insula and dopamine-based reward functions of the brain in shaping behavior that is not directly dependent on higher cortical processing.

A public health burden: There are many people who say that they quit with no support after merely deciding to. However, most people who try to quit relapse repeatedly. The highly addictive nature of smoking, coupled with ongoing recruitment of new smokers, has maintained a large number of smokers. The CDC (2010) states that there are 46 million smokers in the U.S., constituting about one fifth of the adult population. Another 20% are ex-smokers. (Brunnhuber, Cummings, Feit, Sherman, & Woodcock, 2007) At the same time, the CDC (2010) states that 443,000 people die of smoking-related illnesses annually and another 8.6 million have serious smoking-related illnesses.

The effect on the vascular system can also affect the brain. A number of studies have established that current smokers are at higher risk for dementing illnesses, including for Alzheimer's disease, and associated cognitive decline. (Peters, Poulter, Warner, Beckett, Burch, & Bulpitt, 2008) The studies have not established that a history of smoking is associated with such decline. (Peters, et al., 2008) This is another incentive for quitting. People should not feel that, since they have smoked for many years, that it is too late to get significant health benefits.

The consequences of smoking are not limited to smokers. The CDC (2010) states that 126 million nonsmokers (many of them children) are exposed to significant levels of second-hand smoke. This is also a serious public health concern. The CDC (2010) states:

Secondhand smoke exposure causes serious disease and death, including heart disease and lung cancer in nonsmoking adults and sudden infant death syndrome, acute respiratory infections, ear problems, and more frequent and severe asthma attacks in children. Each year, primarily because of exposure to secondhand smoke, an estimated 3,000 nonsmoking Americans die of lung cancer, more than 46,000 die of heart disease, and about 150,000–300,000 children younger than 18 months have lower respiratory tract infections.

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All in all, this results in burdensome economic consequences; according to the CDC (2010), "more than $96 billion per year in medical expenditures and another $97 billion per year resulting from lost productivity."

The challenge of quitting is evidenced by the fact that 40% of smokers make a serious attempt to quit each year (CDC, 2005) but most attempts fail (Brunnhuber, Cummings, Feit, Sherman, & Woodcock, 2007) and the results of current interventions are limited. This includes individual and group counseling. (Brunnhuber, et al., 2007; Lancaster & Stead, 2005) Programs for smoking cessation scrutinized by researchers have low rates of long-term success. (CDC, 2010) For these reasons, prevention of smoking should be a high priority for social policy and programs. Clearly, there is much room for improvement in cessation and relapse prevention treatments. Fortunately, research is also pointing to means of improving success in smoking cessation efforts.

Successful cessation: The clinician should bear in mind that, while there is no guaranteed method to prevent relapse, any period of not smoking can contribute to improved health and lower cancer risk, and each period of not smoking may strengthen the individual's capacity to stop permanently in the future. Successful, long-term cessation can result after a number of efforts at quitting smoking.

Recruitment of new smokers: More than 80% of new smokers begin before they reach eighteen years of age. Critics have pointed out various ways that cigarette manufacturers target this group and attempt to avoid accountability for this. Many young people do not realize that clove cigarettes such as Bidis contain 60 to 80% tobacco and their less porous wrappers cause higher doses of addictive nicotine. These cigarettes appear to be innocent and exotic and produce smoke that smells like marijuana. Additive-free cigarettes are attractive to young people as well, because of the perception that natural products are not harmful. Of various forms of cigarettes tested, blood plasma and heart rate were affected the most by the additive-free and clove cigarettes.

Enhancement of Addictiveness: While nicotine is an addictive drug, cigarette manufacturers have a documented history of manipulating their product so as to make it more addictive. A major way that this is done is though free basing. (Claude, 1973)

By using ammonia-like chemicals, alkalinity is increased so that less of the addictive drug is eliminated by burning. This way, more of the drug is absorbed by the lungs and taken rapidly to the brain. Freebasing was a drug culture breakthrough that made it possible to smoke cocaine in the 1970s.  The use of this technology in cigarettes resulted in a tremendous gain in market share for Phillip Morris and propagation of the method throughout the industry. The smoker experiences an added and desirable kick from this kind of cigarette.

There are numerous other ways manufacturers manipulate cigarettes to increase profit. Documents uncovered during major tobacco litigation have led to many surprising revelations. In a detailed scientific review of these documents, Rabinoff, Caskey, Rissling, and Park (2007) stated that "more than 100 of 599 documented cigarette additives have pharmacological actions that camouflage the odor of environmental tobacco smoke emitted from cigarettes, enhance or maintain nicotine delivery, could increase the addictiveness of cigarettes, and mask symptoms and illnesses associated with smoking behaviors."

Availability and affordability of treatment: Many people have insurance coverage for smoking cessation. The clinician or client can check with the insurer regarding what is covered. Cessation assistance ranges from non-professional programs such as Nicotine Anonymous and groups supported by organizations such as the American Cancer Society, to commercial programs and professional services. Phone services provide free support and referrals. Websites and software programs are available with various forms of support, including discussion forums. Thus, free help is available as well as commercial and professional help. The availability of over-the-counter nicotine replacement products in the U.S. such as gum, the patch, and e-cigarettes has reduced potential costs of quitting.

Unaided Cessation and Problems with Research Statistics

Critics are concerned about what they call the "medicalization" of smoking cessation. They point out that 65 to 75% of smokers who quit do so without assistance, but research focuses far more attention on medical approaches to cessation. (Chapman & MacKenzie, 2010) This situation is similar for problem drinking, gambling, and narcotics use. Only 8.8% of esmokers were found to use behavioral treatment in their quit efforts. (Shiffman, Brockwell, Pillitteri, & Gitchell, 2008)

The most common method of quitting: Thus, the most common method of quitting is unassisted, either cold turkey or with reduction over time. This means that clinicians should be supportive of people who intend to quit on their own, especially given that research on pharmaceutical and behavioral methods for the most part do not show impressive results.

Before assistance for quitting was popularized, there was a precipitous decline in smoking that resulted from media attention to the 1964 US Surgeon General report on health effects of smoking, and from the warning notices posted on cigarette packs. Warner (1977) estimated that, by 1975, smoking rates were 20 to 30% lower than they would have been without this decline.

Problems with statistics: Worse, non-industry studies have shown much poorer results than industry-funded studies for nicotine replacement therapy (51% industry-funded vs. 22% non-industry-funded studies showing significant cessation effects, according to a Cochrane meta-study). (Etter, Burri, & Stapleton, 2007; Stead., Perera, Bullen, Mant, & Lancaster, 2007) Worse yet, the placebo control condition is fundamentally flawed, because most people in cessation studies can tell whether they have received the placebo. (Mooney, White, & Hatsukami, 2004) Also, trial conditions generally involve superior levels of attention, and this can be an important variable. Free provision of drugs improves compliance rates. When Monney, et. al. (2004) reviewed the integrity of nicotine replacement therapy trials, they found assessment for blindness integrity in only 23% of the studies.

These factors suggest that research study outcomes on smoking cessation are inflated. The smokers in some the studies include a very large percentage, perhaps over 50%, for whom quitting was "not at all difficult." If the research on pharmacological or behavioral methods for smoking cessation were on the 20% or so that find it very difficult, the outcomes would most likely be much poorer. Also, remember that an impressive doubling of the odds of success is a small percentage when the original odds are small. For example, doubling of a 7% success rate means an increase of 7% overall. For a large population, this will amount to a large number of people, but is leaves a lot of room for improvement (86%, to be exact).

Many find it not difficult to quit: Before the US National Center for Health Statistics stopped including "cold turkey" in it's surveys of ways people stopped smoking, and before the public literature emphasized the difficulty of quitting, there was a large British study that found ex-smokers recalled the experience as much less difficult than one might expect. 53% said that it was “not at all difficult” to stop, while only 27% said it was “fairly difficult”, and 20% found it very difficult. (Marsh & Matheson, 1983) However, this statistic could be misleading unless the reader remembers that these were ex-smokers. If the survey included people who had not succeeded, many more would probably have indicated that it was difficult to quit.

Population-level studies: Supporting this line of thought are several population level studies. Overall smoking rates have not been affected significantly by "proliferation, deregulation, and widespread promotion of NRT and other pharmacotherapies..." (Wakefield, Durkin, Spittal, Siahpush, Scollo, et al., 2008) On the other hand, research has repeatedly shown smoking rates to be influenced by social policy measures and market factors, including, anti-smoking public service announcements, and the price of cigarettes. (Wakefield, et al., 2008)

The prevalence of smoking has decreased by roughly 50% over the past 50 years, but treatment for smoking addiction is too recent a phenomenon to get the credit. Besides, treatment has not been shown to have dramatic results. The decrease in smoking was initially driven by public education. Social policies began having their effects on smoking rates well after the decline began. 

Unplanned: According to Ferguson, et al. (2009), a studies have found that unplanned quit attempts are more successful than planned attempts. In a recent study by the authors, unplanned attempts were found to be twice as successful. A large majority of these unplanned attempts did not involve counseling, medication or nicotine replacement therapy.

Guidance: Smokers who are under the impression that it is unwise to attempt cessation unaided by medication may feel it is hopeless if they relapse after a medication-aided quit attempt. People with poor financial resources should not be under the impression that they cannot quit without making what for them is a major financial sacrifice. It is very important that smokers understand that multiple attempts are often required. They should also understand that any unaided or spontaneous quit attempt may be one that is successful. An incentive for quitting without medication is concern regarding side effects. Although the risk may be statistically low, the side effects can be very serious. Many people prefer to be conservative and avoid medication, especially given the limited success shown, as discussed above. It is ultimately the client's personal decision. Professional ethics dictate that clients should not be coerced to take medication for smoking cessation.

Pharmacological Approaches

Nicotine Receptor Partial AgonistsVarenicline (trade name Chantix in the USA and Champix in Europe and other countries, is an FDA-approved prescription medication for smoking addiction. Varenicline is a nicotinic receptor partial agonist. This causes it to both reduce cravings and other withdrawal symptoms as well as reduce the pleasurable effects of smoking. It appears that this makes it helpful in smoking cessation.

Cytisine is a similar drug that has been in use in Europe for some time, but also has a limited research base.

Controlled trials of varenicline began to be published in 2006, so there is not an extensive base of research as of this writing. A 2008 Cochrane meta-study found nine randomized controlled trials of varenicline that included over 7,000 participants. (Cahill, Stead, & Lancaster, 2008) Seven of the trials were placebo controlled. Some of the studies included biochemically validated abstinance rates. Only two studies involved treatment beyond twelve weeks. These found varenicline to be well-tolerated. The data indicate that varenicline improved odds of quitting from two to three times compared with placebo. There was some improvement over nicotine patches in one study, and some improvement over bupropion (Zyban) in two studies.

Side effects: The studies reported that nausea was the main adverse effect, but it was mostly mild or moderate and typically subsided over time. But concern over "serious neuropsychiatric symptoms" (FDA, 2009) that appear to result from varenicline have come from various legitimate sources. According to the FDA (2009), they include "changes in behavior, hostility, agitation, depressed mood, suicidal ideation, suicidal behavior and attempted suicide." Adding to the concern, the FDA stated that, "These symptoms have occurred in patients without pre-existing psychiatric illness and have worsened in some patients with pre-existing psychiatric illness.  In most cases, neuropsychiatric symptoms developed during treatment with varenicline or bupropion but in others, symptoms developed after stopping drug treatment."

In some cases, mild or undiagnosed pre-existing mental illness may have contributed to reactions to the drug. Also, agitation, suicidal thinking, and other symptoms have been documented as side effects of tobacco withdrawal. (Soares, 2008) However, a study attempting to determine whether a history of major depression was a risk factor for psychiatric symptoms during varenicline administration found little difference in side effects between those with or without a history of major depression. It noted "slightly worse confusion, nausea and trouble sleeping at 21 days." (McClure, Swan, Jack, Catz, Zbikowski, McAfee, et al., 2009)

It is possible that suicides, violent acts, and other bad outcomes are being attributed to varenicline as a result of media attention to such claims along with side effects of cessation. However, the number and timing of complaints suggest that this probably does not explain all the complaints.

The FDA has required a black box warning based on the following: (FDA, 2009)

The added warnings are based on the continued review of postmarketing adverse event reports for varenicline and bupropion received by the FDA.  These reports included those with a temporal relationship between the use of varenicline or bupropion and suicidal events and the occurrence of suicidal ideation and suicidal behavior in patients with no history of psychiatric disease.  Some of these cases may have been confounded by symptoms typically seen in people who have stopped smoking and are experiencing withdrawal from nicotine.

The FDA (2009) offers these recommendations to health professionals:

Healthcare professionals should advise patients to stop taking varenicline or bupropion and contact a healthcare provider immediately if they experience agitation, depressed mood, and any changes in behavior that are not typical of nicotine withdrawal, or if they experience suicidal thoughts or behavior.  If varenicline or bupropion is stopped due to neuropsychiatric symptoms, patients should be monitored until the symptoms resolve.

Family members and caregivers should also be alerted to the potential for changes in mood or behavior and contact the health care provider if they observe these changes in the person taking varenicline or buporpion.

Updated and additional information can be found at the FDA website, FDA.gov.

Nicotine Replacement The Replacements: Nicotine replacement products include gum, transdermal patch, nasal spray, inhaler, sublingual tablets or lozenges, and electronic cigarettes. The term "nicotine replacement" seems to imply that a substitute for nicotine is used. Actually, it means that cigarettes are replaced by another form of nicotine delivery.

As of this writing, electronic cigarettes (e-cigarettes or e-cigs) are not well researched or adequately regulated, so they have not gained widespread acceptance by the medical community, but this is likely to change. Electronic cigarettes cost less than cigarettes over time. They do not involve burning. Instead, they create a vapor.

The other nicotine sources were found to improve cessation rates by 50-70% across 132 trials (111 of which each had over 40,000 participants) in a Cochrane metastudy. (Stead, Perera, Bullen, Mant, & Lancaster, 2008) The addictiveness of cigarettes has been compared to that of heroin, so we might compare alternative nicotine sources to the use of methadone for heroin addicts whether it is maintenance use or for the purpose of graduated cessation.

Effectiveness: Duke University Medical Center (2009) points out that, "although there are studies showing improvement of success rates with NRT, up to 90 percent of smokers who receive nicotine replacement therapy relapse within one year." Their effectiveness has not been shown to be improved by additional support such as counseling.

Misconception regarding cancer and nicotine: There is a common misconception that nicotine causes cancer, and that any nicotine source, especially taken orally, can cause cancer, but there is has been no convincing evidence of this. (Shiffman, Hughes, Pillitteri, & Burton, 2003) except for more recent speculation that there may be a risk or oral nicotine under very specific circumstances: the combination of upregulation of the FOXM1 gene in combination with precancerous cells in the mouth. There is concern that chewing tobacco can cause a precancerous condition known as leukoplakia which, if untreated, may develop into cancer. (American Cancer Society, 2010) Mostly, however, the belief that nicotine causes cancer appears to be a product of its mental association with smoking and the power of repetition.

 There is abundant evidence that the substances produced by smoking (burning) the contents of cigarettes are the source of the identified health problems. This means that smoking cessation does not necessarily have to include nicotine cessation. That is, given the high rates of relapse, a legitimate intervention can be continuing to dose with nicotine through means other than burning tobacco until such time as the nicotine user decides to quit.

Given the high risk of cancer from smoking, maintenance dosing with nicotine may be a life-saving strategy for those not ready or willing to give up nicotine. However, it may be advisable to avoid gum, lozenges, or especially chewing tobacco. This leaves the patch, which is expensive, and e-cigarettes, which save money compared to smoking. At any time, someone using maintenance nicotine may elect to quit through graduated or cold turkey cessation. A survey of 85 e-cigarette users indicated that 95% had found e-cigarettes to be at least somewhat useful in smoking cessation. (Etter, 2010)

When used for graduated withdrawal according to directions, use of gum or lozenges is considered sufficiently safe because it is temporary. The distinction should be made between chewing tobacco and chewing nicotine gum, which does not contain tobacco and does not cause as much irritation. Of course, the clinician should be attentive to any new data that requires a revision to this position.

OTC: In 1996, the US Food and Drug Administration (FDA) approved switching nicotine gum and patch from prescription to over-the-counter (OTC) status. The purpose was to increase use of these smoking cessation tools, and this was moderately successful. As of this writing, e-cigarettes are not FDA approved for smoking cessation or any other use, but they are sold legally. It is widely believed that e-cigarettes are not adequately regulated or consistent in quality. Uncertainty about the products has caused them to be outlawed in some countries.

Nicotine replacement therapy: The use of alternative delivery products is called nicotine replacement therapy (NRT), and this term normally refers to the use of the products to terminate both smoking and nicotine dependence. Because it is highly addictive, and because the rituals involved in smoking can reinforce the addictive behavior, it is believed that eliminating smoking while maintaining nicotine constitutes a step toward breaking the addiction. This is followed by reduction of the nicotine dosing until it is terminated. E-cigarettes could be used with the logic reversed: maintaining the ritual of smoking might ease the reduction of nicotine consumption. This can be aided by the use of lower-strength cartridges over time or simply allowing the cartridge to run out of nicotine.

Persistent use: Evidence suggests that addiction to replacement products is rare among those using them for cessation. People who are afraid of becoming addicted to these products may terminate early, and relapse as a result. Therefore, education about the importance of following the instructions may improve success. (Shiffman, Hughes, Pillitteri, & Burton, 2003)

Studies indicate that a modest minority of users persist in using the products for six months or more, despite the intended use as a temporary measure to allow for termination of nicotine use as well as smoking. There has been little study of people who persist in using alternative nicotine delivery measures. It is likely that those who persist eventually terminate use of nicotine, resume smoking, or continue to use alternative delivery products. The numbers of people who persist beyond 12 months is markedly lower than the six month group. In one study, 6.7% of the gum users persisted beyond six months, (17% in another study) and only 1.7% of the patch users (8% in another study). (Shiffman, Hughes, Pillitteri, & Burton, 2003) This difference may have to do with the higher cost of the patch.

Long-term use of nicotine products may be contraindicated for conditions in which effects such as vasoconstriction may be a risk factor.
Pre-cessation use: There is some evidence suggesting that cessation rates may be improved by starting nicotine replacement prior to actual cessation. This is contrary to current guidelines as of this writing, but it has been investigated by a number of studies. One study by Duke University Medical Center (2009) found that this strategy doubled quit rates. The authors state, "The current labeling resulted from concerns that using a patch while smoking could lead to nicotine overdose. However, a literature review found concurrent use of a nicotine patch and cigarette smoking appears to be safe."

Zyban (bupropion) and Pamelor (nortryptaline)

Bupropion is an atypical antidepressant as well as a treatment for smoking cessation. It is a norepinephrine and dopamine reuptake inhibitor (NDRI), and a specific nicotinic receptor antagonist. Bupropion use is associated with risk of seizures, currently estimated to be 1:1,000. (Hughes, Stead, Lancaster, 2007) However, the risk of seizures is very dose-dependant, and is similar to that observed for other antidepressants at the currently recommended dose. An advantage of bupropion is that, unlike SSRIs, it does not cause weight gain or sexual dysfunction. For this reason, it may be of interest to smokers who fear weight gain following cessation. Also, bupropion is added to existing antidepressant treatment in case of an inadequate response to an SSRI.

Nortriptyline is a second-generation tricyclic antidepressant that, as of this writing, has not been approved by the FDA for smoking cessation. It is used for depression and a number of other conditions.

According to a Cochrane metastudy (Hughes, et al., 2007) bupropion and nortriptyline are similar in effectiveness to nicotine replacement therapy (NRT) in cessation and six-month minimum abstinence. (Hughes, Stead, and Lancaster, 2007) It appears that their effectiveness is not the result of their antidepressant action, but it may be that this aspect is helpful for smokers who may be at risk for relapse because of depression that emerges following reduction or cessation of smoking. (Hughes, et al., 2007) Antidepressants may counter the loss of the antidepressant effect of nicotine.

Neither bupropion nor nortryptaline increased the effectiveness of treatment that included NRT. (Hughes, et al., 2007)

Behavioral Approaches

Overview

A Cochrane meta-analysis of behavioral interventions for smoking cessation found increases in smoking abstinence for these approaches. (Mottillo, Filion, Bélisle, Joseph, Gervais, O'Loughlin, et al., 2009) The trial included 50 RCTs (randomized controlled trials), all of which validated smoking cessation biochemically at six and/or twelve months after the target quit date. The analysis looked at studies of, "minimal clinical intervention (brief advice from a healthcare worker), and intensive interventions, including individual, group, and telephone counselling."

Interventions that attempt to prevent relapse after quitting are also of interest. Strong studies have not occurred in sufficient numbers to yield certainty, but there is good initial evidence in support of identifying and dealing with relapse triggers, such as specific situations or feelings that lead to relapse. (Hajek, Stead, West, Jarvis, & Lancaster, 2009) This is the most researched approach to relapse prevention, and is widely used in addiction treatment.

Brief Intervention

Communication from health care providers: It has been shown that clear communication from health care providers (including counselors) regarding addiction and the importance of quitting increase the odds of an attempt at smoking cessation. This means that all health care providers should assess for and provide at least basic information to smokers about the importance of cessation and what kind of help and treatment exists, and that this should be provided to people regardless of whether they have expressed an interest in cessation.

It has been shown that this kind of intervention is not sufficiently commonplace among health care providers, including physicians. Further, the intervention is more effective when two or more health professionals provide it. (An, Foldes, Alesci, Bluhm, Bland, Davern, et al., 2008)

In research on physician-provided intervention, it was found that a significant effect was found for interventions that were less than five minutes in duration. (Catley, Harris, Okuyemi, Mayo, Pankey, & Ahluwalia, 2006) The more commonplace this is, the more times a given individual will encounter it, thereby increasing the odds of a successful cessation attempt. In addition, the individual will be more likely to retain materials that direct him or her to support resources such as telephone quitlines and Internet discussion forums.

Counselors should, at the minimum, provide the approach recommended by The U.S. Public Health Service known as the five A's: Ask, Advise, Assess, Assist, and Arrange. (Catley, et al., 2006)

Biomedical risk assessment feedback: There is evidence to suggest that feedback regarding health or medical status in relation to smoking can help motivate smokers to quit. (Bize, Burnand, Mueller, Rège Walther, & Cornuz, 2009)  The results are mixed, but the trend was positive. Feedback derived from spirometry to create a "lung age" figure is an example of a successful approach. There is not enough data as of this writing to produce a meta-study.

Telephone Counseling

According to a Cochrane Review, telephone contact with a smoking cessation counselor can improve cessation rates and duration of cessation. The review identified 48 randomized or quasi-randomized trials of current or recently abstinant smokers. However, single calls, or phone contact in response to the caller only had a minor effect. Significant results came from multiple proactive calls. (Stead, et al., 2006) The interventions with the higher number of calls produced better results.

Unfortunately, public use of quitlines is very poor. In the UK, where participation is highest, only 6% of smokers used such support services, despite wide publicity. (Milne, 2005)

Individual Counseling

Research on counseling for smoking cessation has shown some effectiveness, but it has not shown individual counseling to be more effective than group treatment or even brief intervention. (Mottillo, et al., 2009) No behavioral counseling method is proven to prevent relapse. (Brunnhuber, et al., 2007) Given that people that are dependent on highly addictive drugs are referred to structured outpatient or inpatient programs whenever possible, the limited effects seen for counseling should not be a surprise.

Researchers are seeking ways to improve the effectiveness of counseling. For example, the motivational interviewing style has been found to improve the therapeutic alliance. According to a study by Boardman, Catley, Grobe, Little, and Ahluwalia (2006), "Results indicated that an MI-consistent style (average of the global ratings of collaboration, egalitarianism, and empathy) was positively associated with alliance and engagement, whereas confrontation was negatively related to alliance." Counseling that emphasizes relapse prevention through identification and dealing with relapse triggers is demonstrating superiority over other counseling approaches.

Group Counseling

A Cochrane review of 53 studies on this subject found that group treatment was more effective than self-help programs, but that it did not show more or less effectiveness than individual counseling. (Stead & Lancaster, 2005) Surprisingly, programs that included cognitive and behavioral skill building components did not show an advantage over other group formats of similar length.

Deconditioning Craving, Non-aversively

Techniques that emphasize deconditioning or desensitization, include eye movement desensitization and reprocessing (EMDR) and emotional freedom technique (EFT). These modalities have accumulated many clinical reports of effectiveness for reducing cravings and thus rates of quitting and abstinence for cigarettes and other drugs. There is a smoking cessation protocol (Popky, 1994) that is used by many EMDR practitioners. These approaches have not been proven by research for use with addictions as of this writing.

The most salient aspect of these treatments appears to be the focusing of attention on the thoughts and feelings associated with craving and relapse triggers while providing stimuli that induce relaxation and possibly hemispheric coherence. Additionally, EMDR emphasizes cognitive reprocessing, which may prove to be helpful in relapse prevention work. As discussed above, therapy that emphasizes work on relapse triggers appears to be superior to treatment that lacks this component.

EFT is primarily promoted as a self-help technique, but it has also found its way into the hands of coaches and clinicians. The reputation of EFT has been tarnished by metaphysical and medical claims, but the method itself appears to use a fundamental pattern that is found in various formats in other treatments associated with rapid reductions in chronic anxiety.

Hypnotherapy

Dramatic claims have been made for many years regarding the power of hypnotherapy to enhance smoking cessation and relapse rates. Earlier, less rigorous studies seemed to confirm some of these claims. However, a Cochrane metastudy of nine sophisticated studies did not show superiority over other behavioral approaches such as counseling or even placebo.  (Abbot, Stead, White, & Barnes, 1998) However, the results of the studies varied a great deal, making it impossible to pool the data and assess the degree of effect. In the nine studies, there were fourteen control conditions. There are diverse approaches to hypnosis, and varying levels of sophistication in understanding addiction among practitioners of hypnosis. This further challenges efforts to assess the utility of hypnosis in a meta-study.

Aversion

Programs that use aversion attempt to condition smokers to want to avoid smoking through behavior modification in which an aversive stimulus is pared with the act of smoking. Aversive stimuli include rapid smoking and electrical shocks. Rapid smoking refers to excessive smoking in which the smoker draws on the cigarette according to an abnormally short time interval.

A Cochrane meta-study found a slight effect for aversives, and there appeared to be a dose-dependent response. However, there was not sufficient evidence to draw a firm conclusion. Rapid smoking was shown to be ineffective. (Hajek & Stead, 2001) Twelve of the studies used rapid smoking and nine used other aversives. There are ethical concerns regarding inducing a client to smoke excessively. 

Social Approaches

Enhancing Partner Support

A Cochrane meta-study found eleven studies that met criteria. The results showed that improving partner support for smoking cessation improves quit rates, but not relapse rates. It is unclear whether this is because the programs did not improve long-term partner support or if factors most important in reducing relapse had not been addressed. (Park, Schultz, Tudiver, Campbell, & Becker, 2004)

Social Policy and Programs

A great variety of social policies and programs have been instituted in efforts to prevent smoking and promote cessation. Many of them have proven successful across large populations. Workplaces have helped to provide smokers with services to help them quit. Workplace programs that target the workforce as a whole have not been shown to reduce overall rates of smoking in the employee population, however. (Cahill, Moher, & Lancaster, 2008)

Targeting Demographics and Meeting Special Needs

Demographic groups with higher rates of smoking are considered important to target for smoking cessation through programs and policies. Also, some groups may have special needs or challenges that should be specifically considered.

Wallace (2007) states that people with less socioeconomic resources have higher smoking rates, and there is concern that industry advertising targets them. The characteristics of such demographic groups may help to determine what strategies might be most effective. For example, they may be more likely to be involved with certain social agencies or programs.

Wallace also states that people with a number of psychiatric disorders are disproportionately represented among smokers. People with mental illnesses are twice as likely as the general population to smoke. (Breslau, Novak, & Kessler, 2004)

This has led to study of these populations for special needs regarding prevention and cessation. The author cites numerous studies indicating that higher rates of smoking and nicotine dependence occur for individuals with mental illnesses, including, "schizophrenia, major depressive disorder, any alcohol use disorder, any substance abuse disorder, anxiety disorders, mania, and personality disorders." Wallace also cites a study indicating the following conditions that have received less research attention: "social phobia, agoraphobia, panic disorder, panic attacks, dysthymia, antisocial behavior and conduct disorders, and post-traumatic stress disorder." Wallace states that, "these associations appear to be robust, reproducible, and of an important magnitude."

There is a perception among many mental health professionals that people with mental illnesses smoke in order to self-medicate and are too limited in their functioning to make a serious attempt at quitting, and generally don't want to quit. It appears to be a matter of letting sleeping dogs lie. However, Wallace cites studies that counter some of these perceptions. One study found that 82% of mentally ill subjects wanted to quit or cut down. There is limited research on the ability of persons with various psychiatric disorders to quit, but one study cited "found no association between having an Axis I or II diagnosis and smoking cessation treatment success." A survey found that persons with mental illnesses, whether active or remitted, were just as likely to quit successfully during the preceding year as the general population. (Breslau, Novak, & Kessler, 2004) However, there is research suggesting that post-cessation depression can hamper success. (Wallace, 2007) A literature survey claims that mental illness has been associated with poorer quit or relapse rates in some studies. (Fagerström & Aubin, 2009) Another literature review expresses concern that psychiatric symptoms may emerge during cessation, including major depression, even in individuals that have not been previously diagnosed. (Aubin, 2009)

In children and adults, ADD/ADHD, conduct disorder, and antisocial behavior are associated with higher prevalence of smoking and other substance abuse disorders. Females with a history of physical or sexual abuse have elevated rates of smoking. (Wallace, 2007) Treating mental health conditions may help with cessation and prevention. Identifying children that smoke may help in identifying untreated mental health and family problems. Flagging children with behavioral and learning problems can support these aims.

Self Help Techniques, Groups, and Seminars

Self Help Materials 

The provision of self help materials of various kinds has not been found to improve quit rates very much. According to a Cochrane Review meta-study of 68 trials, the effect barely reached statistical significance. (Lancaster, & Stead, 2005) Even tailoring materials so that they are more individualized had only a small effect, and the effect may have been due to additional attention required to customize the materials. Adding such materials to face-to-face counseling or nicotine replacement therapy did not improve success.

Online Forums, Websites, and Automated Help

A great number of people are getting support for very diverse personal issues through online support and discussion forums. Websites may include various features such as automated support, discussion forums, and helpful articles. Stand-alone forums exist as well. Such forums can be found through Yahoo Groups and Google Groups. People can assess the value of a discussion forum by looking at the level of activity and the type of participation. Clinicians can help clients in assessing the helpfulness of such forums in terms of how supportive, non-commercial, and evidence-based they are. It is too soon to conclude very much from research, but websites have been shown to be effective in improving cessation and relapse prevention. (Shahab & McEwen, 2009) Interactive sites did not show superiority over static sites. This is surprising, given the poor results of research on self-help materials.

Researchers are beginning to look at automated systems for providing reminders or other kinds of communications or stimuli to people attempting to quit smoking. One study found that increasing worry (negative affect) about the health effects of smoking had a greater effect on the intention to quit than messages with a more cognitive focus on risk awareness. The study used personal digital assistants (PDAs). (Magnan, Köblitz, Zielke, & McCaul, 2009) PDA is a term that is going out of style as the functions of these devices have been incorporated into smart phones. Quit meters show promise. These are computer programs that keep track of quit statistics such as amount of "quit-time", cigarettes not smoked, and money saved. There are interactive web-based programs that teach participants how to quit. Interactive websites can incorporate any of these features, and they can be used throughout the day via smart phone.

Cutting Back for Harm Reduction

Recent large studies have not supported the idea that reduced cigarette consumption will also reduce the health effects of smoking. (Brunnhuber, Cummings, Feit, Sherman, & Woodcock, 2007) This appears to contradict studies showing a dose-response effect, but those studies are not of large populations in the field.

Nicotine Anonymous

Nicotine Anonymous (NicA) is a twelve-step program based upon the same principles and structure as Alcoholics Anonymous. It is very difficult to assess the effectiveness of twelve step programs because they are anonymous and have a high drop out rate. However, research studies of various types have supported their use. There is also professional therapy for addictions based on the twelve-step model called twelve step facilitation therapy. 

The Easyway Method

Clients may ask about popular books and programs, because of word of mouth or the dramatic claims made. One of the more popular programs is Alan Carr's Easyway program. The method is offered in the form of books and seminars (live and online). As of this writing, there are two studies published in peer-reviewed journals of the seminars. Success rates were approximately 50% and adequate follow up periods were used. (Moshammera, & Neuberger, 2007; Hutter, Moshammer, & Neuberger, 2006) The 2006 study provided six hours of counseling to those who quit. 96% of the quitters continued to be abstinent from smoking at 12 months.

Smoke-Free Homes

Ex-smokers that establish smoke-free home policies are at lower risk for relapse, and smokers with such homes are more likely to quit. (Hyland, Higbee, Travers, Van Deusen, Bansal-Travers, King, et al., 2009) While 28% of smokers with smoke-free homes quit smoking during the study, 16% without smoke-free homes did so. The proportion of such homes is increasing. (Hyland, et al., 2009)
The most likely individuals, according to data on 4,963 individuals, to have smoke-free homes are males, ex-smokers, people with lower levels of smoking per day (if they smoked at the time of the study), people with higher incomes, and people with no other smokers in the home. (Hyland, et al., 2009) 

Cold Turkey or Gradual Reduction?

A Cochrane meta-study found ten studies examining this question. Both approaches had the same results, regardless of the supportive methods used in quitting. (Lindson, Aveyard, & Hughes, 2010)

Exercise

Evidence for exercise as a cessation aid is weak, but other benefits should be considered. Many smokers need to rebuild their capacity for exercise, so a graduated program would serve this purpose. It could also modify the identity of smokers, making them less willing to give up their regained stamina and feelings of well being. Exercise can also help to combat the weight gains associated with cessation.

Complementary Medicine

Acupuncture and Related Methods

Acupuncture has been used in efforts to assist with smoking cessation, but research does not support its use or its underlying traditional theory. Acupuncture is used in an attempt to reduce withdrawal symptoms associated with smoking cessation. The 2006 meta-study looked at research on related methods, including acupressure, laser therapy, and electrical stimulation.
Meta-studies have not shown that it is any better than sham acupuncture or other control conditions. (White, Rampes, & Campbell, 2006; White, Resch, & Ernst, 1999) In the 2006 meta-study (a Cochrane Review study), the authors stated that there was not sufficient evidence to dismiss the possibility that acupuncture is better than placebo.

Policy and Social Approaches

The difficulty of quitting and the high social costs of smoking are strong incentives to prevent initiation of smoking. This has led to various campaigns, laws, and programs. The complexity of the problem is addressed by The Committee on Reducing Tobacco Use (2007):

Smoking initiation is influenced by peers, particularly peers’ rates of smoking. More generally, individuals’ decisions to start, stop, or restart smoking may be influenced by the smoking or nonsmoking of others. These feedbacks from current prevalence to various flow rates include personal interaction effects (e.g., when smoking teens encourage their friends to smoke), societal-level effects (e.g., if smoking is rare, it is more likely to be shunned, which might reduce relapse rates), and market-level effects (e.g., if there are fewer smokers, and hence less demand for tobacco, the market equilibrium price for cigarettes might be affected, which in turn can affect smoking rates).

Resources

Quit Lines

National Cancer Institute:

1-877-44U-QUIT ( 1-877-448-7848)

National Network of Tobacco Cessation:

1–800-QUITNOW ( 1-800-784-8669) and 1-800-332-8615

Professional Resources

The Cochrane Collaboration

http://www2.cochrane.org/reviews/en/subtopics/94.html
Cochrane Meta-studies, organized by topic.

Smoking Cessation Research Network

www.scsrn.org/research_reviews.html
Includes various sources of statistics and Cochrane Reviews.

Tobacco Control

http://tobaccocontrol.bmj.com/
"An international peer-reviewed journal for health professionals and others in tobacco control."

Clinical Trials

Some people may wish to participate in clinical trials because of the prospect of free medication and services.

Clinical Trials (NIH)

http://clinicaltrials.gov/search/open/condition=%22Smoking+Cessation%22

Online Information and Support for the General Public (May also have Professional Materials)

American Heart Association

Search on smoking cessation.
www.americanheart.org

American Cancer Society

Offers various smoking cessation materials. Search on "smoking cessation."
www.Cancer.org
Their Guide to Quitting Smoking
http://www.cancer.org/docroot/PED/content/PED_10_13X_Guide_for_Quitting_Smoking.asp

Centers for Disease Control: Smoking and Tobacco Use Resource Area

http://www.cdc.gov/tobacco/
http://www.cdc.gov/tobacco/quit_smoking/index.htm

DMOZ List of Smoking Cessation Sites

http://search.dmoz.org/cgi-bin/search?search=smoking+cessation

National Cancer Institute Live Help

You can chat online with a helpful person who will point you to resources. It may be easier for a lot of people than calling someone and talking directly.
https://cissecure.nci.nih.gov/livehelp/welcome.asp

Office of the Surgeon General

Various materials for the public (scroll down) and clinicians.
http://www.surgeongeneral.gov/tobacco/

Smoking-Cessation.org

Has a Quit Smoking Guide
www.smoking-cessation.org/

QuitSmokingSupport.com

Offers a wealth of materials.
http://www.quitsmokingsupport.com/intro.htm

Quitting Smoking (Medline Plus)

http://www.nlm.nih.gov/medlineplus/quittingsmoking.html
Well-categorized, for the general public.

Online Forums. Some have Additional Features

A search on terms such as "quit smoking" "online support" will yield sites of potential value. 

About.com Smoking Cessation Forum

A good general discussion forum.
http://forums.about.com/n/pfx/forum.aspx?webtag=ab-quitsmoking

The DMOZ List of Smoking Cessation Forums

www.DMOZ.org/Health/Support_Groups/Smoking_Cessation/

Experience Project

http://www.experienceproject.com/groups/Want-To-Quit-Smoking/1725

WhyQuit.com

http://whyquit.com/
This is just one of many online support systems and forums.

Face-to-Face Support Groups

American Cancer Society: Choosing a Support Group

http://www.cancer.org/docroot/ESN/ESN_1.asp
This organization has groups in many locations. This page provides information on groups and lists groups by zip code.

Nicotine Anonymous (NicA)

www.Nicotine-Anonymous.org
International group with local meetings. Find a local meeting via their site. They also have books, recordings, and other materials, including free materials online.

Books

The Easy Way to Stop Smoking: Join the Millions Who Have Become Non-Smokers Using Allen Carr's Easyway Method, by Allen Carr

How to Quit Smoking for Dummies by David Brizer.

There are many books and other materials to help people quit smoking. This one covers a lot of material.

Self-Help Techniques

Emotional Freedom Technique

Various websites offer information on this technique. Advocates claim that it can be used to reduce or eliminate cravings and responses to relapse triggers.
Smokers can target cravings, you can target emotional hooks and other issues. They offer a free manual. Some therapists, coaches, and trainings can help you learn and use the method.
www.EmoFree.com

Education

Anatomy of a Cigarette, PBS

http://www.pbs.org/wgbh/nova/cigarette/anatomy.html
Provides information to the public about cigarettes and alternative cigarette designs.

Tobacco Documents

http://tobaccodocuments.org/
This repository of documents liberated from the tobacco industry also provides analysis and other information. Not for the faint of heart, this site seems to have endless information.

Citations

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American Cancer Society. (2010). Detailed guide: Cancer (general information), Signs and symptoms of cancer. Accessed 6/16/2010 http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_What_are_the_signs_and_symptoms_of_cancer.asp

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Brunnhuber, K., Cummings, K. M., Feit, S., Sherman, S., and Woodcock, J. (2007). Putting evidence into practice: Smoking cessation. BMJ Publishing Group Limited.

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