Tobacco smoking is the practice of smoking tobacco and inhaling tobacco smoke. A broader definition may include simply taking tobacco smoke into the mouth, and then releasing it, as is done by some with tobacco pipes and cigars. The practice is believed to have begun as early as 5000–3000 BC in Mesoamerica and South America. Tobacco was introduced to Eurasia in the late 17th century by European colonists, where it followed common trade routes. The practice encountered criticism from its first import into the Western world onwards but embedded itself in certain strata of a number of societies before becoming widespread upon the introduction of automated cigarette-rolling apparatus.
Cigarette smoke is an aerosol produced by the incomplete combustion of tobacco during the smoking of cigarettes. Temperatures in burning cigarettes range from about 400 ℃ between puffs to about 900 ℃ during a puff. During the burning of the cigarette tobacco, thousands of chemical substances are generated by combustion, distillation, pyrolysis and pyrosynthesis. Tobacco smoke is used as a fumigant and inhalant.
Nicotine is a stimulant and potent parasympathomimetic alkaloid that is naturally produced in the nightshade family of plants. It is used for the treatment of tobacco use disorders as a smoking cessation aid and nicotine dependence for the relief of withdrawal symptoms. Nicotine acts as a receptor agonist at most nicotinic acetylcholine receptors (nAChRs), except at two nicotinic receptor subunits where it acts as a receptor antagonist.
Chronic obstructive pulmonary disease (COPD) is a type of obstructive lung disease characterized by long-term breathing problems and poor airflow. The main symptoms include shortness of breath and cough with sputum production. COPD is a progressive disease, meaning it typically worsens over time. Eventually, everyday activities such as walking or getting dressed become difficult. Chronic bronchitis and emphysema are older terms used for different types of COPD. The term "chronic bronchitis" is still used to define a productive cough that is present for at least three months each year for two years. Those with such a cough are at a greater risk of developing COPD. The term "emphysema" is also used for the abnormal presence of air or other gas within tissues.
Lung cancer, also known as lung carcinoma, is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. This growth can spread beyond the lung by the process of metastasis into nearby tissue or other parts of the body. Most cancers that start in the lung, known as primary lung cancers, are carcinomas. The two main types are small-cell lung carcinoma (SCLC) and non-small-cell lung carcinoma (NSCLC). The most common symptoms are coughing, weight loss, shortness of breath, and chest pains.
Many different strategies can be used for smoking cessation, including abruptly quitting without assistance ("cold turkey"), cutting down then quitting, behavioral counseling, and medications such as bupropion, cytisine, nicotine replacement therapy, or varenicline. Most smokers who try to quit do so without assistance. However, only 3-6% of quit attempts without assistance are successful long-term. Behavioral counseling and medications each increase the rate of successfully quitting smoking, and a combination of behavioral counseling with a medication such as bupropion is more effective than either intervention alone. A meta-analysis from 2018, conducted on 61 randomized controlled trials, showed among people who quit smoking with a cessation medication (and some behavioral help), approximately 20% were still quit a year later, as compared to 12% who did not take medication.
"Cold turkey" refers to the abrupt cessation of a substance dependence and the resulting unpleasant experience, as opposed to gradually easing the process through reduction over time or by using replacement medication. The term comes from the piloerection or "goose bumps" that occurs with abrupt withdrawal from opioids, which resembles the skin of a plucked refrigerated turkey.
Bupropion, sold under the brand names Wellbutrin and Zyban among others, is a medication primarily used to treat major depressive disorder and to support stopping smoking. It is an effective antidepressant on its own, but is also used as an add-on medication in cases of incomplete response to first-line SSRI antidepressants. Bupropion is taken in tablet form and is available only by prescription in most countries.
Cytisine, also known as baptitoxine and sophorine, is an alkaloid that occurs naturally in several plant genera, such as Laburnum and Cytisus of the family Fabaceae. It has been used medically to help with smoking cessation. Its molecular structure has some similarity to that of nicotine and it has similar pharmacological effects. Like varenicline, cytisine is a partial agonist of nicotinic acetylcholine receptors (nAChRs). Cytisine has a short half-life of 4.8 hours, and is rapidly eliminated from the body. The use of cytisine for smoking cessation remains relatively unknown outside Eastern Europe, however, it is currently being investigated in clinical trials in the United States, being conducted by Achieve Life Sciences.
In nicotine-dependent smokers, quitting smoking can lead to symptoms of nicotine withdrawal such as nicotine cravings, anxiety, irritability, depression, and weight gain.:2298 Professional smoking cessation support methods generally attempt to address nicotine withdrawal symptoms to help the person break free of nicotine addiction.
Nicotine withdrawal is a group of symptoms that occur in the first few weeks upon the abrupt discontinuation or decrease in intake of nicotine. Symptoms include intense cravings for nicotine, anger/irritability, anxiety, depression, impatience, trouble sleeping, restlessness, hunger or weight gain, and difficulty concentrating. A smoking cessation program may improve one’s chance for success in quitting nicotine. Nicotine withdrawal is recognized in both the American Psychiatric Association Diagnostic and Statistical Manual and the WHO International Classification of Diseases.
Anxiety is an emotion characterized by an unpleasant state of inner turmoil, often accompanied by nervous behaviour such as pacing back and forth, somatic complaints, and rumination. It is the subjectively unpleasant feelings of dread over anticipated events, such as the feeling of imminent death.
Depression is a state of low mood and aversion to activity. It can affect a person's thoughts, behavior, motivation, feelings, and sense of well-being. It may feature sadness, difficulty in thinking and concentration and a significant increase/decrease in appetite and time spent sleeping, and people experiencing depression may have feelings of dejection, hopelessness and, sometimes, suicidal thoughts. It can either be short term or long term. The core symptom of depression is said to be anhedonia, which refers to loss of interest or a loss of feeling of pleasure in certain activities that usually bring joy to people. Depressed mood is a symptom of some mood disorders such as major depressive disorder or dysthymia; it is a normal temporary reaction to life events, such as the loss of a loved one; and it is also a symptom of some physical diseases and a side effect of some drugs and medical treatments.
Major reviews of the scientific literature on smoking cessation include:
Systematic reviews of the Cochrane Tobacco Addiction Group of the Cochrane Collaboration. As of 2016, this independent, international, not-for-profit organization has published over 91 systematic reviews "on interventions to prevent and treat tobacco addiction" which will be referred to as "Cochrane reviews" in this article.
Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update of the United States Department of Health and Human Services, which will be referred to as the "2008 Guideline." The Guideline was originally published in 1996 and revised in 2000. For the 2008 Guideline, experts screened over 8,700 research articles published between 1975 and 2007.:13–14 More than 300 studies were used in meta-analyses of relevant treatments; an additional 600 reports were not included in meta-analyses, but helped formulate the recommendations.:22 Limitations of the 2008 Guideline include not evaluating studies of "cold turkey" methods ("unaided quit attempts") and its focus on studies that followed up subjects only to about 6 months after the "quit date" in order to capture the greatest number of studies for analyses. Most relapses occur early in a quit attempt, though some relapses can occur later - even years later.
Systematic reviews are a type of literature review that uses systematic methods to collect secondary data, critically appraise research studies, and synthesize findings qualitatively or quantitatively. Systematic reviews formulate research questions that are broad or narrow in scope, and identify and synthesize studies that directly relate to the systematic review question. They are designed to provide a complete, exhaustive summary of current evidence relevant to a research question. For example, systematic reviews of randomized controlled trials are key to the practice of evidence-based medicine, and a review of existing studies is often quicker and cheaper than embarking on a new study.
The United States Department of Health & Human Services (HHS), also known as the Health Department, is a cabinet-level department of the U.S. federal government with the goal of protecting the health of all Americans and providing essential human services. Its motto is "Improving the health, safety, and well-being of America". Before the separate federal Department of Education was created in 1979, it was called the Department of Health, Education, and Welfare (HEW).
A meta-analysis is a statistical analysis that combines the results of multiple scientific studies. Meta-analysis can be performed when there are multiple scientific studies addressing the same question, with each individual study reporting measurements that are expected to have some degree of error. The aim then is to use approaches from statistics to derive a pooled estimate closest to the unknown common truth based on how this error is perceived. Existing methods for meta-analysis yield a weighted average from the results of the individual studies, and what differs is the manner in which these weights are allocated and also the manner in which the uncertainty is computed around the point estimate thus generated. In addition to providing an estimate of the unknown common truth, meta-analysis has the capacity to contrast results from different studies and identify patterns among study results, sources of disagreement among those results, or other interesting relationships that may come to light in the context of multiple studies.
It is common for ex-smokers to have made a number of attempts (often using different approaches on each occasion) to stop smoking before achieving long-term abstinence. According to a recent survey from UNC over 74.7% of smokers attempt to quit without any assistance, otherwise known as "Cold Turkey", or with home remedies. A recent study estimated that ex-smokers make between 6 and 30 attempts before successfully quitting. Identifying which approach or technique is eventually most successful is difficult; it has been estimated, for example, that only about 4% to 7% of people are able to quit smoking on any given attempt without medicines or other help. A recent review of unassisted quit attempts in 9 countries found that the majority of quit attempts are still unassisted, though the trend seems to be shifting. In the U.S., for example, the rate of unassisted quitting fell from 91.8% in 1986 to 52.1% during 2006 to 2009. The most frequent unassisted methods were "cold turkey", a term that has been used to mean either unassisted quitting or abrupt quitting and "gradually decreased number" of cigarettes, or "cigarette reduction".
"Cold turkey" is a colloquial term indicating abrupt withdrawal from an addictive drug, and in this context indicates sudden and complete cessation of all nicotine use. In three studies, it was the quitting method cited by 76%, 85%, or 88% of long-term successful quitters. In a large British study of ex-smokers in the 1980s, before the advent of pharmacotherapy, 53% of the ex-smokers said that it was "not at all difficult" to stop, 27% said it was "fairly difficult", and the remaining 20% found it very difficult. Studies have found that two-thirds of recent quitters reported using the cold turkey method and found it helpful.
The American Cancer Society notes that "Studies in medical journals have reported that about 25% of smokers who use medicines can stay smoke-free for over 6 months." Single medications include:
Nicotine replacement therapy (NRT): Five medications have been approved by the U.S. Food and Drug Administration (FDA) deliver nicotine in a form that does not involve the risks of smoking: transdermal nicotine patches, nicotine gum, nicotine lozenges, nicotine spray, and nicotine inhalers. High quality evidence indicates that these forms of NRT improve the success rate for people who attempt to stop smoking. NRTs are meant to be used for a short period of time and should be tapered down to a low dose before stopping. NRTs increase the chance of stopping smoking by 50 to 60% compared to placebo or to no treatment. There are no side effects reported other than local slight irritation and rarely non-ischemic chest pain.
Further increased chance of success was found when a combination of the nicotine patch and a faster acting form was used.[needs update] A study found that 93% of over-the-counter NRT users relapse and return to smoking within six months.
There is weak evidence that adding mecamylamine to nicotine is more effective than nicotine alone.
Antidepressants: The antidepressant bupropion is considered a first-line medication for smoking cessation and has been shown in many studies to increase long-term success rates. People who take bupropion should be monitored for any unusual mood changes; bupropion also increases the risk of seizures and should not be used in people with a seizure disorder. Nortriptyline has also been shown to increase smoking cessation success rates. In a recent Cochrane update, nortriptyline did not produce significant rates of abstinence versus placebo, nor evidence of additional benefit when combined with NRT, although only four trials were included in the analysis.
Varenicline decreases the urge to smoke and reduces withdrawal symptoms and is therefore considered a first-line medication for smoking cessation. A 2016 Cochrane review of 27 studies also found that the number of people stopping smoking with varenicline was higher than with bupropion or NRT. Varenicline more than doubled the chances of quitting compared to placebo, and was also as effective as combining two types of NRT. 2mg/day of varenicline has been found to lead to the highest abstinence rate (33.2%) of any single therapy, while 1mg/day leads to an abstinence rate of 25.4%. A 2016 systematic review and meta-analysis of randomized controlled trials concluded there is no evidence supporting a connection between varenicline and increased cardiovascular events. Concerns arose that varenicline may cause neuropsychiatric side effects, including suicidal thoughts and behavior. However, more recent studies indicate less serious neuropsychiatric side effects. For example, a 2016 study involving 8,144 patients treated at 140 centers in 16 countries "did not show a significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo". A 2016 Cochrane review concluded that the most recent evidence does not indicate that there is a link between depressed moods, agitation or suicidal thinking in smokers taking varenicline to decrease the urge to smoke. For people who have pre-existing mental health difficulties, varenicline may slightly increase the risk of experiencing these neuropsychiatric adverse events.
Clonidine may reduce withdrawal symptoms and "approximately doubles abstinence rates when compared to a placebo," but its side effects include dry mouth and sedation, and abruptly stopping the drug can cause high blood pressure and other side effects.
Previously, rimonabant which is a cannabinoid type 1 receptor antagonist was used to help in quitting and to moderate the expected weight gain. But it is important to know that the manufacturers of rimonabant and taranabant stopped production in 2008 due to its serious side effects.
The 2008 US Guideline specifies that three combinations of medications are effective::118–120
Long-term nicotine patch and ad libitum NRT gum or spray
Nicotine patch and nicotine inhaler
Nicotine patch and bupropion (the only combination that the US FDA has approved for smoking cessation)
A meta-analysis from 2018, conducted on 61 RCTs, showed that during their first year of trying to quit, approximately 80% of the participants in the studies who got drug assistance (bupropion, NRT, or varenicline) returned to smoking while 20% continued to not smoke for the entire year (i.e.: remained sustained abstinent). In comparison, 12% the people who got placebo kept from smoking for (at least) an entire year. This makes the net benefit of the drug treatment to be 8% after the first 12 months. In other words, out of 100 people who will take medication, approximately 8 of them would remain non-smoking after one year thanks to the treatment. During the course of one year, the benefit from using smoking cessation medications (Bupropion, NRT, or Varenicline) decreases from 17% in 3 months, to 12% in 6 months to 8% in 12 months.
Cut down to quit
Gradual reduction involves slowly reducing one's daily intake of nicotine. This can theoretically be accomplished through repeated changes to cigarettes with lower levels of nicotine, by gradually reducing the number of cigarettes smoked each day, or by smoking only a fraction of a cigarette on each occasion. A 2009 systematic review by researchers at the University of Birmingham found that gradual nicotine replacement therapy could be effective in smoking cessation. There is no significant difference in quit rates between smokers who quit by gradual reduction or abrupt cessation as measured by abstinence from smoking of at least six months from the quit day, suggesting that people who want to quit can choose between these two methods.[needs update]
Set a Quit Plan and Quit Date
Most smoking cessation resources such as the Centers for Disease Control and Prevention (CDC) and The Mayo Clinic encourage smokers to create a quit plan, including setting a quit date, which helps them anticipate and plan ahead for smoking challenges. A quit plan can improve a smoker’s chance of a successful quit as can setting Monday as the quit date, given that research has shown that Monday more than any other day is when smokers are seeking information online to quit smoking and calling state quit lines.
A Cochrane review found evidence that community interventions using "multiple channels to provide reinforcement, support and norms for not smoking" had an effect on smoking cessation outcomes among adults. Specific methods used in the community to encourage smoking cessation among adults include:
Policies making workplaces and public places smoke-free. It is estimated that "comprehensive clean indoor laws" can increase smoking cessation rates by 12%–38%. In 2008, the New York State of Alcoholism and Substance Abuse Services banned smoking by patients, staff and volunteers at 1,300 addiction treatment centers.
Voluntary rules making homes smoke-free, which are thought to promote smoking cessation.
Initiatives to educate the public regarding the health effects of second-hand smoke, including the significant dangers of secondhand smoke infiltration for residents of multi-unit housing.
Increasing the price of tobacco products, for example by taxation. The US Task Force on Community Preventive Services found "strong scientific evidence" that this is effective in increasing tobacco use cessation :28–30 It is estimated that an increase in price of 10% will increase smoking cessation rates by 3–5%.
Mass media campaigns. The US Task Force on Community Preventive Services declared that "strong scientific evidence" existed for these when "combined with other interventions",:30–32 and a Cochrane review suggested their benefits with paying attention to their intensty and duration.
Institutional level smoking bans. A recent Cochrane Review found evidence that imposing bans at the institutional level (i.e. hospitals and prisons) reduced smoking rates and secondhand exposure, although the evidence base was rated as poor quality.
Great American Smokeout is an annual event that invites smokers to quit for one day, hoping they will be able to extend this forever.
Smoking-cessation support is often offered over the telephone quitlines (e.g., the US toll-free number 1-800-QUIT-NOW), or in person. Three meta-analyses have concluded that telephone cessation support is effective when compared with minimal or no counselling or self-help, and that telephone cessation support with medication is more effective than medication alone.,:91–92:40–42[needs update] and the intensive individual counselling is more effective than the brief individual counselling intervention. There is about 10% to 25% increase of the chance of smoking cessation success with the more behavioral support provided in person or via telephone when used as an adjunct to pharmacotherapy .[needs update]
Online social cessation networks attempt to emulate offline group cessation models using purpose built web applications. They are designed to promote online social support and encouragement for smokers when (usually automatically calculated) milestones are reached. Early studies have shown social cessation to be especially effective with smokers aged 19–29.
Group or individual psychological support can help people who want to quit. Recently, group therapy has been found to be more helpful than self-help and some other individual intervention. The psychological support form of counselling can be effective alone; combining it with medication is more effective, and the number of sessions of support with medication correlates with effectiveness.:89–90,101–103[needs update][needs update] The counselling styles that have been effective in smoking cessation activities include motivational interviewing,cognitive behavioural therapy and Acceptance and Commitment Therapy, methods based on Cognitive Behavioral Therapy, as well as the CBQ (Cognitive Behavioral Quitting) method focusing on the psychological dependence on smoking.
The Freedom From Smoking group clinic includes eight sessions and features a step-by-step plan for quitting smoking. Each session is designed to help smokers gain control over their behavior. The clinic format encourages participants to work on the process and problems of quitting both individually and as part of a group.
Multiple formats of psychosocial interventions increase quit rates: 10.8% for no intervention, 15.1% for one format, 18.5% for 2 formats, and 23.2% for three or four formats.:91
The Transtheoretical Model including "stages of change" has been used in tailoring smoking cessation methods to individuals. However, a 2010 Cochrane review concluded that "stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents."
According to the most recent Cochrane review in 2019, self-help materials may produce a small increase in quit rates specially when there is no other supporting intervention form. In the 2008 Guideline, "the effect of self-help was weak," and the number of types of self-help did not produce higher abstinence rates.:89–91 Nevertheless, self-help modalities for smoking cessation include:
WebMD: a resource providing health information, tools for managing health, and support.
Interactive web-based and stand-alone computer programs and online communities which assist participants in quitting. For example, "quit meters" keep track of statistics such as how long a person has remained abstinent. In the 2008 US Guideline, there was no meta-analysis of computerised interventions, but they were described as "highly promising.":93–94 A meta-analysis published in 2009, a Cochrane review updated in 2017, and a 2011 systematic review found the evidence base for such interventions weak, although interactive and tailored interventions show some promise.
Mobile phone-based interventions: A 2016 updated Cochrane review stated that "the current evidence supports a beneficial impact of mobile phone-based cessation interventions on six-month cessation outcomes. A 2011 randomized trial of mobile phone-based smoking cessation support in the UK found that a Txt2Stop cessation program significantly improved cessation rates at 6 months. A 2013 meta-analysis also noted "modest benefits" of mobile health interventions.
Interactive web-based programs combined with a Mobile phone: Two RCTs documented long-term treatment effects (abstinence rate: 20-22 %) of such interventions,.
Spirituality: In one survey of adult smokers, 88% reported a history of spiritual practice or belief, and of those more than three-quarters were of the opinion that using spiritual resources may help them quit smoking.
A review of mindfulness training as a treatment for addiction showed reduction in craving and smoking following training.
Physical activities help in the maintenance of smoking cessation even if there is no conclusive evidence of the most appropriate exercise intensity.
Various methods exist which allow a smoker to see the impact of their tobacco use, and the immediate effects of quitting. Using biochemical feedback methods can allow tobacco-users to be identified and assessed, and the use of monitoring throughout an effort to quit can increase motivation to quit. A recent Cochrane Review found "little evidence about the effects of most types of biomedical tests for risk assessment on smoking cessation." 
Breath carbon monoxide (CO) monitoring: Because carbon monoxide is a significant component of cigarette smoke, a breath carbon monoxide monitor can be used to detect recent cigarette use. Carbon monoxide concentration in breath has been shown to be directly correlated with the CO concentration in blood, known as percent carboxyhemoglobin. The value of demonstrating blood CO concentration to a smoker through a non-invasive breath sample is that it links the smoking habit with the physiological harm associated with smoking. Within hours of quitting, CO concentrations show a noticeable decrease, and this can be encouraging for someone working to quit. Breath CO monitoring has been utilized in smoking cessation as a tool to provide patients with biomarker feedback, similar to the way in which other diagnostic tools such as the stethoscope, the blood pressure cuff, and the cholesterol test have been used by treatment professionals in medicine.
Cotinine: A metabolite of nicotine, cotinine is present in smokers. Like carbon monoxide, a cotinine test can serve as a reliable biomarker to determine smoking status. Cotinine levels can be tested through urine, saliva, blood, or hair samples, with one of the main concerns of cotinine testing being the invasiveness of typical sampling methods.
While both measures offer high sensitivity and specificity, they differ in usage method and cost. As an example, breath CO monitoring is non-invasive, while cotinine testing relies on a bodily fluid. These two methods can be used either alone or together, for example, in a situation where abstinence verification needs additional confirmation.
Competitions and incentives
Financial or material incentives to entice people to quit smoking improves smoking cessation while the incentive is in place.[needs update] Competitions that require participants to deposit their own money, "betting" that they will succeed in their efforts to quit smoking, appear to be an effective incentive. However, in head to head comparisons with other incentive models such as giving participants NRT or placing them in a more typical rewards program, it is more difficult to recruit participants for this type of contest. There is evidence that incentive programs may be effective for pregnant mothers who smoke.
A different 2008 Cochrane review found that one type of competition, "Quit and Win," did increase quit rates among participants.
Interventions delivered via healthcare providers and healthcare systems have been shown to improve smoking cessation among people who visit those services.
A clinic screening system (e.g., computer prompts) to identify whether or not a person smokes doubled abstinence rates, from 3.1% to 6.4%.:78–79 Similarly, the Task Force on Community Preventive Services determined that provider reminders alone or with provider education are effective in promoting smoking cessation.:33–38
A 2008 Guideline meta-analysis estimated that physician advice to quit smoking led to a quit rate of 10.2%, as opposed to a quit rate of 7.9% among patients who did not receive physician advice to quit smoking.:82–83 A Cochrane review found that even brief advice from physicians had "a small effect on cessation rates,". However, one study from Ireland involving vignettes found that physicians' probability of giving smoking cessation advice declines with the patient's age, and another study from the U.S. found that only 81% of smokers age 50 or greater received advice on quitting from their physicians in the preceding year.
For one-to-one or person-to-person counselling sessions, the duration of each session, the total amount of contact time, and the number of sessions all correlated with the effectiveness of smoking cessation. For example, "Higher intensity" interventions (>10 minutes) produced a quit rate of 22.1% as opposed to 10.9% for "no contact" over 300 minutes of contact time produced a quit rate of 25.5% as opposed to 11.0% for "no minutes" and more than 8 sessions produced a quit rate of 24.7% as opposed to 12.4% for 0–1 sessions.:83–86
Both physicians and non-physicians increased abstinence rates compared with self-help or no clinicians.:87–88 For example, a Cochrane review of 58 studies found that nursing interventions increased the likelihood of quitting. Another review found some positive effects when trained community pharmacists support the customers in their smoking cessation trials.
Dental professionals also provide a key component in increasing tobacco abstinence rates in the community through counseling patients on the effects of tobacco on oral health in conjunction with an oral exam.
According to the 2008 Guideline, based on two studies the training of clinicians in smoking cessation methods may increase abstinence rates;:130 however, a Cochrane review found and measured that such training decreased smoking in patients.
Reducing or eliminating the costs of cessation therapies for smokers increased quit rates in three meta-analyses.:139–140:38–40[needs update]
In one systematic review and meta-analysis, multi-component interventions increased quit rates in primary care settings. "Multi-component" interventions were defined as those that combined two or more of the following strategies known as the "5 A's"::38–43
Ask — Systematically identify all tobacco users at every visit
Advise — Strongly urge all tobacco users to quit
Assess — Determine willingness to make a quit attempt
Assist — Aid the patient in quitting (provide counselling-style support and medication)
Electronic cigarette: There is limited supporting evidence in helping people quit smoking. The available evidence for their effectiveness in abstaining from smoking is inconclusive. A 2018 review stated for people who are only willing to vape to quit smoking, they recommended that these people be told that little is known regarding the long-term harms related to vaping. A 2016 UK Royal College of Physicians report supports the use of e-cigarettes as a smoking cessation tool. A 2015 Public Health England report stated that "Smokers who have tried other methods of quitting without success could be encouraged to try e-cigarettes (EC) to stop smoking and stop smoking services should support smokers using EC to quit by offering them behavioural support."
Acupuncture: Acupuncture has been explored as an adjunct treatment method for smoking cessation. A 2014 Cochrane review was unable to make conclusions regarding acupuncture as the evidence is poor. A 2008 guideline found no difference between acupuncture and placebo, found no scientific studies supporting laser therapy based on acupuncture principles but without the needles.:99
Chewing cinnamon sticks or gum has been recommended when trying to quit the use of tobacco.
Hypnosis: Hypnosis often involves the hypnotherapist suggesting to the patient the unpleasant outcomes of smoking. Clinical trials studying hypnosis and hypnotherapy as a method for smoking cessation have been inconclusive.:100[needs update] A Cochrane review was unable to find evidence of benefit of hypnosis in smoking cessation, and suggested if there is a beneficial effect, it is small at best. However, a randomized trial published in 2008 found that hypnosis and nicotine patches "compares favorably" with standard behavioral counseling and nicotine patches in 12-month quit rates.
Herbs: Many herbs have been studied as a method for smoking cessation, including lobelia and St John's wort. The results are inconclusive, but St. Johns Wort shows few adverse events. Lobelia has been used to treat respiratory diseases like asthma and bronchitis, and has been used for smoking cessation because of chemical similarities to tobacco; lobelia is now listed in the FDA's Poisonous Plant Database. Lobelia can still be found in many products sold for smoking cessation and should be used with caution.
Smokeless tobacco: There is little smoking in Sweden, which is reflected in the very low cancer rates for Swedish men. Use of snus (a form of steam-pasteurized, rather than heat-pasteurized, air-cured smokeless tobacco) is an observed cessation method for Swedish men and even recommended by some Swedish doctors. However, the report by the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) concludes "STP (smokeless tobacco products) are addictive and their use is hazardous to health. Evidence on the effectiveness of STP as a smoking cessation aid is insufficient,". A recent national study on the use of alternative tobacco products, including snus, did not show that these products promote cessation.
Aversion therapy: It is a method of treatment works by pairing the pleasurable stimulus of smoking with other unpleasant stimului. A Cochrane review reported that there is insufficient evidence of its efficacy.
Nicotine vaccines: Nicotine vaccines (e.g., NicVAX and TA-NIC) work by reducing the amount of nicotine reaching the brain, however, this method of therapy needs more investigations to establish its role and determine its side effects.
Technology and machine learning: Research studies using machine learning or artificial intelligence tools to provide feedback and communication with those who are trying to quit smoking are increasing, yet the findings are so far inconclusive.
Although smoking prevalence has declined in recent years leading up to 2016, certain subpopulations continue to smoke at disproportionately high rates and show resistance to cessation treatments.
Children and adolescents
Methods used with children and adolescents include:
Cochrane reviews, mainly of studies combining motivational enhancement and psychological support, concluded that "complex approaches" for smoking cessation among young people show promise. The 2008 US Guideline recommends counselling-style support for adolescent smokers on the basis of a meta-analysis of seven studies.:159–161 Neither the Cochrane review nor the 2008 Guideline recommends medications for adolescents who smoke.
Smoking during pregnancy can cause adverse health effects in both the woman and the fetus. The 2008 US Guideline determined that "person-to-person psychosocial interventions" (typically including "intensive counseling") increased abstinence rates in pregnant women who smoke to 13.3%, compared with 7.6% in usual care.:165–167 Mothers who smoke during pregnancy have a greater tendency towards premature births. Their babies are often underdeveloped, have smaller organs, and weigh much less than the normal baby. In addition, these babies have weaker immune systems, making them more susceptible to many diseases such as middle ear inflammations and asthmatic bronchitis, which can bring significant morbidity. There is also an increased chance that the child will be a smoker in adulthood. A systematic review showed that psychosocial interventions help women to stop smoking in late pregnancy and can reduce the incidence of low birthweight infants.
It is a myth that a female smoker can cause harm to a fetus by quitting immediately upon discovering she is pregnant. This idea is not based on any medical study or fact.
Studies across 20 countries show a strong association between patients with schizophrenia and smoking. People with schizophrenia are much more likely to smoke than those without the disease. For example, in the United States, 80% or more of people with schizophrenia smoke, compared to 20% of the general population in 2006.
A 2008 Cochrane review of smoking cessation activities in work-places concluded that "interventions directed towards individual smokers increase the likelihood of quitting smoking". A 2010 systematic review determined that worksite incentives and competitions needed to be combined with additional interventions to produce significant increases in smoking cessation rates.
Smokers who are hospitalised may be particularly motivated to quit.:149–150 A 2012 Cochrane review found that interventions beginning during a hospital stay and continuing for one month or more after discharge were effective in producing abstinence.
Patients undergoing elective surgery may get benefits of preoperative smoking cessation interventions, when starting 4–8 weeks before surgery with weekly counselling intervention for behavioral support and use of nicotine replacement therapy. It is found to reduce the complications and the number of postoperative morbidity.
Homelessness doubles the likelihood of an individual currently being a smoker. This is independent of other socioeconomic factors and behavioral health conditions. Homeless individuals have the same rates of the desire to quit smoking but are less likely than the general population to be successful in their attempt to quit.
In the United States, 60-80% of homeless adults are current smokers. This is a considerably higher rate than that of the general adult population of 19%. Many current smokers who are homeless report smoking as a means of coping with "all the pressure of being homeless." The perception that homeless people smoking is "socially acceptable" can also reinforce these trends.
Americans under the poverty line have higher rates of smoking and lower rates of quitting than those over the poverty line. While the homeless population as a whole is concerned about short-term effects of smoking, such as shortness of breath of recurrent bronchitis, they are not as concerned with long-term consequences. The homeless population has unique barriers to quit smoking such as unstructured days, the stress of finding a job, and immediate survival needs that supersede the desire to quit smoking.
These unique barriers can be combated through pharmacotherapy and behavioral counseling for high levels of nicotine dependence, emphasis of immediate financial benefits to those who concern themselves with the short-term over the long-term, partnering with shelters to reduce the social acceptability of smoking in this population, and increased taxes on cigarettes and on alternative tobacco products to further make the addiction more difficult to fund.
People living with HIV/AIDS
Smoking is very common among people living with HIV/AIDS and it impacts morbidity and mortality substantially. Combined smoking cessation interventions provide good long-term control.
Comparison of success rates
Comparison of success rates across interventions can be difficult because of different definitions of "success" across studies. Robert West and Saul Shiffman, authorities in this field recognized by government health departments in a number of countries,:73,76,80 have concluded that, used together, "behavioral support" and "medication" can quadruple the chances that a quit attempt will be successful.
A 2008 systematic review in the European Journal of Cancer Prevention found that group behavioural therapy was the most effective intervention strategy for smoking cessation, followed by bupropion, intensive physician advice, nicotine replacement therapy, individual counselling, telephone counselling, nursing interventions, and tailored self-help interventions; the study did not discuss varenicline.
Factors affecting success
Quitting can be harder for individuals with dark pigmented skin compared to individuals with pale skin since nicotine has an affinity for melanin-containing tissues. Studies suggest this can cause the phenomenon of increased nicotine dependence and lower smoking cessation rate in darker pigmented individuals.
There is an important social component to smoking. The spread of smoking cessation from person to person contributes to the decrease in smoking these years. A 2008 study of a densely interconnected network of over 12,000 individuals found that smoking cessation by any given individual reduced the chances of others around them lighting up by the following amounts: a spouse by 67%, a sibling by 25%, a friend by 36%, and a coworker by 34%. Nevertheless, a Cochrane review determined that interventions to increase social support for a smoker's cessation attempt did not increase long-term quit rates.
Smokers who are trying to quit are faced with social influences that may persuade them to conform and continue smoking. Cravings are easier to detain when one's environment does not provoke the habit. If a person who stopped smoking has close relationships with active smokers, he or she is often put into situations that make the urge to conform more tempting. However, in a small group with at least one other not smoking, the likelihood of conformity decreases. The social influence to smoke cigarettes has been proven to rely on simple variables. One researched variable depends on whether the influence is from a friend or non-friend. The research shows that individuals are 77% more likely to conform to non-friends, while close friendships decrease conformity. Therefore, if an acquaintance offers a cigarette as a polite gesture, the person who has stopped smoking will be more likely to break his commitment than if a friend had offered. Recent research from the International Tobacco Control (ITC) Four Country Survey of over 6,000 smokers found that smokers with fewer smoking friends were more likely to intend to quit and to succeed in their quit attempt.
Expectations and attitude are significant factors. A self-perpetuating cycle occurs when a person feels bad for smoking yet smokes to alleviate feeling bad. Breaking that cycle can be a key in changing the sabotaging attitude.
In a 2007 review of the effects of abstinence from tobacco, Hughes concluded that "anger, anxiety, depression, difficulty concentrating, impatience, insomnia, and restlessness are valid withdrawal symptoms that peak within the first week and last 2–4 weeks."[needs update] In contrast, "constipation, cough, dizziness, increased dreaming, and mouth ulcers" may or may not be symptoms of withdrawal, while drowsiness, fatigue, and certain physical symptoms ("dry mouth, flu symptoms, headaches, heart racing, skin rash, sweating, tremor") were not symptoms of withdrawal.
Giving up smoking is associated with an average weight gain of 4–5 kilograms (8.8–11.0lb) after 12 months, most of which occurs within the first three months of quitting.
The possible causes of the weight gain include:
Smoking over-expresses the gene AZGP1 which stimulates lipolysis, so smoking cessation may decrease lipolysis.
Heavy smokers are reported to burn 200 calories per day more than non-smokers eating the same diet. Possible reasons for this phenomenon include nicotine's ability to increase energy metabolism or nicotine's effect on peripheral neurons.
The 2008 Guideline suggests that sustained-release bupropion, nicotine gum, and nicotine lozenge be used "to delay weight gain after quitting.":173–176 A 2012 Cochrane review concluded that there is not sufficient evidence to recommend a particular program for preventing weight gain.
Like other physically addictive drugs, nicotine addiction causes a down-regulation of the production of dopamine and other stimulatory neurotransmitters as the brain attempts to compensate for the artificial stimulation caused by smoking. Therefore, when people stop smoking, depressive symptoms such as suicidal tendencies or actual depression may result, although a recent international study comparing smokers who had stopped for 3 months with continuing smokers found that stopping smoking did not appear to increase anxiety or depression. This side effect of smoking cessation may be particularly common in women, as depression is more common among women than among men.
A recent study by The British Journal of Psychiatry has found that smokers who successfully quit feel less anxious afterward with the effect being greater among those who had mood and anxiety disorders than those that smoked for pleasure.
Many of tobacco's detrimental health effects can be reduced or largely removed through smoking cessation. The health benefits over time of stopping smoking include:
Within 5 years, the risk of stroke falls to the same as a non-smoker, and the risks of many cancers (mouth, throat, esophagus, bladder, cervix) decrease significantly
Within 10 years, the risk of dying from lung cancer is cut in half, and the risks of larynx and pancreas cancers decrease
Within 15 years, the risk of coronary heart disease drops to the level of a non-smoker; lowered risk for developing COPD (chronic obstructive pulmonary disease)
The British Doctors Study showed that those who stopped smoking before they reached 30 years of age lived almost as long as those who never smoked. Stopping in one's sixties can still add three years of healthy life. A randomized trial from the U.S. and Canada showed that a smoking cessation program lasting 10 weeks decreased mortality from all causes over 14 years later. A recent article on mortality in a cohort of 8,645 smokers who were followed-up after 43 years determined that “current smoking and lifetime persistent smoking were associated with an increased risk of all-cause, CVD [cardiovascular disease], COPD [chronic obstructive pulmonary disease], and any cancer, and lung cancer mortality.
Another published study, "Smoking Cessation Reduces Postoperative Complications: A Systematic Review and Meta-analysis," examined six randomized trials and 15 observational studies to look at the effects of preoperative smoking cessation on postoperative complications. The findings were: 1) taken together, the studies demonstrated decreased the likelihood of postoperative complications in patients who ceased smoking prior to surgery; 2) overall, each week of cessation prior to surgery increased the magnitude of the effect by 19%. A significant positive effect was noted in trials where smoking cessation occurred at least four weeks prior to surgery; 3) For the six randomized trials, they demonstrated on average a relative risk reduction of 41% for postoperative complications.
In a 1997 U.S. analysis, the estimated cost per QALY varied by the type of cessation approach, ranging from group intensive counselling without nicotine replacement at $1108 per QALY to minimal counselling with nicotine gum at $4542 per QALY.
Among National Health Service smoking cessation clients in Glasgow, pharmacy one-to-one counselling cost £2,600 per QALY gained and group support cost £4,800 per QALY gained.
The frequency of smoking cessation among smokers varies across countries. Smoking cessation increased in Spain between 1965 and 2000, in Scotland between 1998 and 2007, and in Italy after 2000. In contrast, in the U.S. the cessation rate was "stable (or varied little)" between 1998 and 2008, and in China smoking cessation rates declined between 1998 and 2003.
Nevertheless, in a growing number of countries there are now more ex-smokers than smokers  For example, in the U.S. as of 2010, there were 47 million ex-smokers and 46 million smokers. In 2014, the Centers for Disease Control and Prevention reports that the number of adult smokers, 18 years and older, in the U.S. has fallen to 40 million current smokers.
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A cigarette is a narrow cylinder containing psychoactive material, usually tobacco, that is rolled into thin paper for smoking. Most cigarettes contain a "reconstituted tobacco" product known as "sheet", which consists of "recycled [tobacco] stems, stalks, scraps, collected dust, and floor sweepings", to which are added glue, chemicals and fillers; the product is then sprayed with nicotine that was extracted from the tobacco scraps, and shaped into curls. The cigarette is ignited at one end, causing it to smolder; the resulting smoke is orally inhaled via the opposite end. Most modern cigarettes are filtered, although this does not make them safer. Cigarette manufacturers have described cigarettes as a drug administration system for the delivery of nicotine in acceptable and attractive form. Cigarettes are addictive and cause cancer, chronic obstructive pulmonary disease, heart disease, and other health problems.
A vaporizer or vaporiser, colloquially known as a vape, is a device used to vaporize substances for inhalation. Plant substances can be used, commonly cannabis, tobacco, or other herbs or blends of essential oil. However, they can also be filled with a combination propylene glycol, glycerin, and drugs such as nicotine or tetrahydrocannabinol as a liquid solution.
Nicotine replacement therapy (NRT) is a medically-approved way to take nicotine by means other than tobacco. It is used to help with quitting smoking or stopping chewing tobacco. It increases the chance of quitting smoking by about 55%. Often it is used along with other behavioral techniques. NRT has also been used to treat ulcerative colitis. Types of NRT include the adhesive patch, chewing gum, lozenges, nose spray, and inhaler. The use of more than one type of NRT at a time may increase effectiveness.
Nicotine marketing is the marketing of nicotine-containing products or use. Traditionally, the tobacco industry markets cigarette smoking, but it is increasingly marketing other products, such as electronic cigarettes and heat-not-burn products. Products are marketed through social media, stealth marketing, mass media, and sponsorship. Expenditures on nicotine marketing are in the tens of billions a year; in the US alone, spending was over US$ 1million per hour in 2016; in 2003, per-capita marketing spending was $290 per adult smoker, or $45 per inhabitant. Nicotine marketing is increasingly regulated; some forms of nicotine advertising are banned in many countries. The World Health Organization recommends a complete tobacco advertising ban.
Tobacco use has predominantly negative effects on human health and concern about health effects of tobacco has a long history. Research has focused primarily on cigarette tobacco smoking.
Smokeless tobacco is a tobacco product that is used by means other than smoking. Their use involves chewing, sniffing, or placing the product between gum and the cheek or lip. Smokeless tobacco products are produced in various forms, such as chewing tobacco, snuff, snus, and dissolvable tobacco products. Smokeless tobacco products typically contain over 3000 constituents. All smokeless tobacco products contain nicotine and are therefore highly addictive. Quitting smokeless tobacco use is as challenging as smoking cessation.
Varenicline is a prescription medication used to treat nicotine addiction. It reduces both craving for and decreases the pleasurable effects of cigarettes and other tobacco products.
NicVAX is an experimental conjugate vaccine intended to reduce or eliminate physical dependence to nicotine. According to the U.S. National Institute of Drug Abuse, NicVAX can potentially be used to inoculate against nicotine addiction. This proprietary vaccine is being developed by Nabi Biopharmaceuticals of Rockville, MD. with the support from the U.S. National Institute on Drug Abuse. NicVAX consists of the hapten 3'-aminomethylnicotine which has been conjugated (attached) to Pseudomonas aeruginosa exoprotein A.
Tobacco harm reduction (THR) is a public health strategy to lower the health risks to individuals and wider society associated with using tobacco products. It is an example of the concept of harm reduction, a strategy for dealing with the abuse of other drugs. Tobacco smoking is widely acknowledged as a leading cause of illness and death, and reducing smoking is vital to public health.
An electronic cigarette or e-cigarette is a handheld battery-powered vaporizer that simulates smoking and provides some of the behavioral aspects of smoking, including the hand-to-mouth action of smoking, but without burning tobacco. Using an e-cigarette is known as "vaping" and the user is referred to as a "vaper." Instead of cigarette smoke, the user inhales an aerosol, commonly called vapor. E-cigarettes typically have a heating element that atomizes a liquid solution called e-liquid. E-cigarettes are automatically activated by taking a puff; others turn on manually by pressing a button. Some e-cigarettes look like traditional cigarettes, but they come in many variations. Most versions are reusable, though some are disposable. There are first-generation, second-generation, third-generation, and fourth-generation devices. E-liquids usually contain propylene glycol, glycerin, nicotine, flavorings, additives, and differing amounts of contaminants. E-liquids are also sold without propylene glycol, nicotine, or flavors.
Nicotine dependence is a state of dependence upon nicotine. Nicotine dependence is a chronic, relapsing disease defined as a compulsive craving to use the drug, despite harmful social consequences. Tolerance is another component of drug dependence. Nicotine dependence develops over time as a person continues to use nicotine. Nicotine dependence is a serious public health concern due to it being one of the leading causes of avoidable deaths worldwide.
Ventilated cigarettes are considered to have a milder flavor than regular cigarettes. These cigarette brands may be listed as having lower levels of tar ("low-tar"), nicotine, or other chemicals as "inhaled" by a "smoking machine". However, the scientific evidence is that switching from regular to light or low-tar cigarettes does not reduce the health risks of smoking or lower the smoker's exposure to the nicotine, tar, and carcinogens present in cigarette smoke.
Studies across 20 countries show a strong association between schizophrenia and tobacco smoking, whereby people with schizophrenia are much more likely to smoke than those without the disease. For example, in the United States, 80% or more of people with schizophrenia smoke, compared to 20% of the general population in 2006.
The scientific community in United States and Europe are primarily concerned with the possible effect of electronic cigarette use on public health. There is concern among public health experts that e-cigarettes could renormalize smoking, weaken measures to control tobacco, and serve as a gateway for smoking among youth. The public health community is divided over whether to support e-cigarettes, because their safety and efficacy for quitting smoking is unclear. Many in the public health community acknowledge the potential for their quitting smoking and decreasing harm benefits, but there remains a concern over their long-term safety and potential for a new era of users to get addicted to nicotine and then tobacco. There is concern among tobacco control academics and advocates that prevalent universal vaping "will bring its own distinct but as yet unknown health risks in the same way tobacco smoking did, as a result of chronic exposure", among other things.
Jed Eugene Rose, Ph.D. is an American academic professor, inventor and researcher in the field of nicotine and smoking cessation. Rose is presently the President and CEO of the Rose Research Center, LLC in Raleigh, North Carolina. Additionally, he is the Director of the Duke Center for Smoking Cessation at Duke University Medical Center.
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