####Background Cigarette smoking is the single largest preventable cause of death and illness in the industrialised world.[1] Each year more than 100,000 people in the UK[2] and 4.9 million people worldwide die due to smoking-related causes.[3] Tobacco contributes to a wide range of diseases that cause death and disability. One in two regular smokers will die prematurely because of their habit.[4] Without effective intervention, it is estimated that cigarette smoking will have caused the deaths of more than 520 million people worldwide by 2050. #####Smoking prevalence In the UK, approximately 9.4 million adults are smokers, 21% of the total population. Rates among men are slightly higher than among women (22% and 20% respectively).[5] Prevalence is higher in less affluent groups and communities; smoking prevalence is currently 29% in routine and manual occupations, compared with 15% in managerial and professional groups.[5] #####Smoking cessation Around 70% of smokers want to stop smoking.[6] A recent survey in England suggested that 30% of smokers endorsed the statement ‘I want to stop smoking’ and 25% endorsed the statement ‘I intend to stop smoking soon’. It also found that 43% of smokers reported having tried to quit in the past year and 56% of smokers reported trying to cut down.[7] Approximately 50% of quit attempts involve the use of smoking cessation aids, usually consisting of nicotine replacement therapy (NRT) bought over the counter. Varenicline is used by approximately 5% of quitters and only 3% of smokers access National Health Service (NHS) stop smoking services when trying to quit. Additionally, 19% of smokers reported using medication without behavioural support and a further 19% reported trying to quit without using any treatment.[7] #####Unaided quit attempts Most smokers attempt to quit without using medication or behavioural support. However, most unaided quit attempts are unsuccessful. A systematic review of the effectiveness of unaided quit attempts[8] suggested that most relapse occurs very early on in the quit attempt, with the majority of smokers relapsing within eight days of cessation. This review concluded that the main challenge posed by unaided cessation is not late relapse but initiating a period of abstinence. The authors concluded that ‘front loaded’ therapies that provide structured support to a smoker immediately prior to their quit attempt should be promoted.[8] The long-term prolonged abstinence rate of an unaided smoker ranges from 3–5%, considerably below that of a supported cessation attempt of 10–15%.[9] ####Interventions The UK is the only country in the world with a national, free at the point of use smoking treatment service. NHS stop smoking services were established from 1999 and are available in all parts of the UK, providing structured behavioural support and stop smoking medications (pharmacotherapy) to smokers who are motivated to stop smoking. #####Pharmacotherapy There are currently three main licensed medications for smoking cessation in the UK: NRT, bupropion (Zyban) and varenicline (Champix). Evidence from clinical trials suggests that, when used as directed, these medications can significantly increase a smoker’s chance of stopping smoking and remaining abstinent.[10] #####Nicotine replacement therapy Nicotine replacement therapy is the most common and widely available medication for smoking cessation. It is available on prescription and also sold over the counter. Nicotine replacement therapy use is normally initiated on the quit date and used for a further 8--12 weeks, depending upon the product. Nicotine replacement therapy is now licensed for use in the UK with pregnant women, people with cardiovascular disease and young people aged 12 years and over.[11,12] There are six types of NRT products: **Nicotine patch** The patch is applied to a hair-free, non-sensitive area of the body, usually the upper arm or leg. Nicotine is absorbed through the skin and a constant supply is received for 16 or 24 hours, depending upon the type of patch used. Nicotine levels rise very slowly, peaking at 4--8 hours. The patch is changed daily. Minimal side effects include skin irritation, sleep disturbance or a mild itch. **Nicotine gum** The gum is chewed following a ‘chew-rest-chew’ technique, different to normal chewing gum. Nicotine is slowly absorbed through the mouth, and nicotine levels peak after approximately 30 minutes. An estimated 10--15 pieces should be used daily. Minimal side effects include hiccups, gastric problems or jaw ache. **Lozenge** The lozenge is sucked slowly, dissolving in about 20 minutes, and the nicotine is absorbed through the mouth. Nicotine levels peak after about 20--30 minutes. A new lozenge can be sucked about every 1--2 hours, with a maximum of 25 per day. Mild side effects may include a stinging sensation in mouth with first use, gastric irritation and hiccups. **Microtab** The microtab is placed under the tongue and dissolves after approximately 20 minutes. Nicotine levels peak after 20--30 minutes. Approximately 15--30 tabs should be used per day. Side effects may include stinging or burning under the tongue with first use, gastric irritation or hiccups. **Inhalator** The inhalator is ‘smoked’ in a similar way to a cigarette, via shallow or deep puffing for about 20 minutes every hour. Nicotine is absorbed through the mouth and peak nicotine levels occur after about 20--30 minutes. This method of NRT provides a high sensory and behavioural replacement, e.g. the hand-to-mouth sensation. Side effects may include coughing and throat irritation; these, however, will disappear with continued use. **Nasal spray** The nasal spray is the fastest-acting NRT product, providing rapid relief from cravings. It is squirted into each nostril, about once per hour. Nicotine levels peak after about 5--10 minutes. Side effects may include nasal and throat irritation, stinging and a runny nose. The six products can be used individually or, alternatively, products can be used in combination (e.g. using the patch regularly, and supplementing this with the gum as and when needed). Recent evidence suggests that combination therapy is more effective than using a single product.[10,13] With NRT the numbers needed to treat (i.e. the number of smokers who smoke 15 or more per day who need to be treated in order to achieve one long-term (six months or more) quitter) is 13--20.[14] It is preferable for smokers to set a quit date and stop smoking completely. However, for some smokers, for a variety of reasons, this is not possible. In response, the product licence for NRT has recently been modified to allow it to be used while cutting down cigarette consumption with a view to quitting, usually over a two-week period.[10] #####Bupropion (Zyban) Bupropion was originally developed as an antidepressant. Early trials identified that, as an unexpected effect of the medication, it helped patients to stop smoking. When bupropion is used as an aid to smoking cessation, the dosage is lower and treatment does not rely on the medication's antidepressant action. The medication is started one week before the quit date to allow steady state levels to be reached in the blood. During this time the smoker is encouraged to continue smoking as normal. One tablet is taken per day for the first week, followed by two tables per day from the quit date for 7--11 weeks. After this time it is likely that individuals will have changed their habits and the behaviours they previously linked to smoking and the majority of withdrawal symptoms will have stopped. They should then be able to stop taking bupropion without starting to smoke again. Side effects of bupropion may include a dry mouth, sleeping difficulties and headache. Seizures have been reported, but they are rare (one in 1,000). Bupropion is thought to work by increasing the activity in the dopamine and noradrenaline pathways in the central nervous system; this reduces the severity of withdrawal symptoms and the motivation to smoke.[11,15] With bupropion the numbers needed to treat (i.e. the number of smokers who smoke 15 or more per day who need to be treated in order to achieve one long-term (six months or more) quitter) is 10--17.[14] #####Varenicline (Champix) Varenicline, known as Champix in the UK, was launched in December 2006 and is available only on prescription. It is a new medication, developed specifically for smoking cessation. Published trials report that varenicline is superior to placebo and to bupropion in supporting a smoker to stop.[16] Varenicline has a different mechanism of action from the other smoking cessation medications. It is a partial nicotine agonist, meaning that it binds to and triggers the ACh (nicotinic) receptors in the brain. It works by reducing the urge to smoke and by relieving craving and withdrawal symptoms. As with bupropion, smokers start by taking one varenicline tablet per day for a week before the quit date to build up the levels of the drug in the body. On the quit date they stop smoking and increase the dosage to two per day. When the course of treatment ends it is anticipated that the ex-smoker will be able to stop taking the medication, coming down to one tablet per day for the last week, without initiating smoking again. Side effects of varenicline may include nausea, abnormal dreams, headache and insomnia. Several stories appeared both in the US and the UK media at the end of 2007 and beginning of 2008 suggesting that varenicline was associated with suicidal ideation and suicide. However, there is no scientific evidence to support this link.[17] The varenicline summary of product characteristics currently states that depressed mood may be a symptom of nicotine withdrawal. Depression, rarely including suicidal ideation and suicide attempt, has been reported in patients undergoing a smoking cessation attempt, including those with varenicline. Treatment should be discontinued if agitation, depressed mood or changes in behaviour are a concern, or if the patient develops suicidal ideation or suicidal behaviour. With varenicline the numbers needed to treat (i.e. the number of smokers who smoke 15 or more per day who need to be treated in order to achieve one long-term (six months or more) quitter) is 5--11.[14] #####Behavioural interventions Behavioural interventions include brief advice and more intensive support. Brief advice lasts for up to five minutes and can be delivered by any health professional as part of regular consultation or patient interaction. Health professionals should ask about patients' smoking, advise them to stop, assess whether they are willing to stop, assist them with medication, provide a referral to specialist treatment if necessary and arrange a follow-up to check on their progress. Brief interventions can also include discussion, provision of self-help material and encouragement to quit or maintain abstinence.[10] In comparison, more intensive structured behavioural support is usually provided on a one-to-one basis, or as part of a group. In the UK, this type of support is provided by NHS stop smoking service staff or other professionals who have been trained as smoking cessation advisers. A pattern is often followed of one or two pre-quit sessions, followed by regular weekly post-quit sessions for four to six weeks. During these sessions discussion includes how smokers can prepare for the quit date, situations that they may find challenging, how to overcome these and how to deal with craving to avoid relapse. This behavioural support is usually combined with pharmacotherapy.[10] #####Self-help materials Self-help materials are an effective way of communicating sizable amounts of information to large audiences, at relatively low cost. There is evidence that smoking cessation self-help materials can help smokers to quit.[18] Materials that are individually tailored and aimed at specific groups have proved successful at aiding a quit attempt. The use of self help materials are recommended in the National Institute for Health and Clinical Excellence (NICE) smoking cessation guidelines.[10] #####Telephone counselling Telephone counselling, delivered by services such as the NHS smoking quit-line is also recommended in NICE smoking cessation guidance. Counsellors working for the quit-line provide encouragement and support to anyone who wants to quit, or who has recently quit and requires ongoing support. Quit-lines provide behavioural support over the phone rather than face to face, and counsellors have usually received similar training to NHS stop smoking service advisers.[10] ####Combined interventions Pharmacotherapy alone increases the likelihood of a successful quit attempt, as does behavioural support alone. However, it is the combination of the two that is most effective in helping smokers quit. Table 1 shows that a combination of medication and behavioural support can result in an increase in abstinence of 10--20% at six months, compared with unaided cessation, or a 5--10% increase in permanent abstinence.[9] West and Stapleton used previously collected data to estimate that for every 100,000 smokers, using only medication would save 3,750 life years, while using behavioural support and medication together would save between 7,500--15,000 life years.[9] #####Cost-effectiveness of behavioural support and medication It is estimated that smoking annually costs the NHS £2.7 billion. This figure covers the treatment of diseases caused by smoking, including the cost of hospital admissions, general practitioner consultations and prescription charges.[19] Effective smoking cessation aids and stop smoking services are highly cost-effective.[10] NICE guidelines conclude that brief advice, individual and group behavioural support, pharmacotherapy, self-help materials, telephone counselling and quit-lines are all cost-effective compared with no intervention.[10] While all stop smoking interventions are cost-effective, some are more cost-effective than others: * Group counselling is more cost-effective than individual counselling; * Brief advice and more intensive counselling, when combined with NRT or bupropion, are more cost-effective than when these types of behavioural support are provided alone; * NRT and bupropion, combined with counselling, are more cost-effective than NRT or bupropion alone; * Varenicline is cost-effective compared with bupropion, NRT or placebo.[10] ####Alternative interventions In addition to the effective smoking cessation treatments described above, other interventions are available. Many of these claim to be successful; however, the evidence to support these claims is limited. McRobbie et al. conducted a rapid review of alternative treatments for smoking cessation. They found inadequate evidence to recommend that any of the following interventions be offered by the NHS.[20] **Acupuncture** Evidence suggests that acupuncture does not improve long-term abstinence more than placebo; similarly this is true for acupressure, laser therapy and electro stimulation.[10,20] **Hypnotherapy** Evidence suggests that hypnotherapy does not improve long-term abstinence rates more than any other intervention which is as participant-intensive, such as individual counselling.[10,20] **St John’s wort** At the time of the review, there was no evidence of the effectiveness of St John's wort on long-term smoking cessation. **‘Rapid smoking’** Rapid smoking is a form of aversion therapy that involves a client smoking a large number of cigarettes in quick succession. There is some evidence that this method can improve abstinence rates, but it is not recommended in NICE guidance for smoking cessation, as it conflicts with smoke-free legislation regulations and can expose the practitioner to secondhand smoke.[10,20] McRobbie and colleagues also examined a number of other products, including NicoBloc, Nicobrevin and glucose, and concluded that these were not effective in increasing long-term abstinence rates, although glucose may increase the efficacy of other smoking cessation medications when used in combination.[20] ####Conclusion Stopping smoking is the single most important action smokers can take to improve their current and future health.[21] While most smokers try to stop unaided, using a combination of pharmacotherapy and behavioural support is what works best. Health professionals should ensure that smokers are aware of the effects of smoking, of the different types of support available and of the efficacy of different treatments. Smokers who are motivated to quit should be referred to local NHS stop smoking services to maximise their chances of becoming non-smokers. ####Further resources * National Institute for Health and Clinical Excellence. [Smoking cessation services.](http://guidance.nice.org.uk/PH10) * [NHS smoking cessation support](http://smokefree.nhs.uk/) * [Action on Smoking and Health (ASH)](http://www.ash.org.uk/) * [UK Centre for Tobacco Control Studies](http://www.ukctcs.org) 2009-09-08T14:22:49Z None declared. 112 2009-09-08T00:00:00Z 2009-09-16T12:07:41Z smoking-cessation 2009-09-16T12:07:41Z

Stopping smoking is the single most important action smokers can take to improve their health. In this article, Professor Linda Bauld and Ms Lucy Hackshaw from the UK Centre for Tobacco Control Studies review the available treatment options and their efficacy.

2009-09-16T12:07:41Z