Factsheet 6. Smoking cessation

Key Facts

• Most smokers want to quit but few succeed.
• Cessation brings immediate and long-term health benefits.
• Cessation advice, quit lines, pharmacological and behavioural therapies are effective interventions.
• Smoking cessation services are fully available to only 5% of people worldwide.
• Cessation services should be part of a comprehensive tobacco control programme.

The need for smoking cessation programmes
Tobacco is the second biggest cause of death worldwide. Unless urgent action is taken, the number of annual deaths is expected to increase to 8 million by 2030.⁽¹⁾ Active smoking causes a wide range of health conditions and fatal diseases, including cancer, respiratory disease and heart disease.⁽²⁾

Smoking is highly addictive, and tobacco dependency is recognised as a medical condition.⁽³⁾ When smokers quit, they are very likely to start again.⁽⁴⁾ So providing assistance for smoking cessation and tobacco dependency treatment are key tobacco control measures. The introduction of tobacco control legislation around the world has encouraged many smokers to quit.

Health benefits of smoking cessation
Smoking cessation brings immediate health benefits for smokers, whether or not they have a smoking-related disease. For example, the decline in lung function stops within 48 hours of smoking cessation. Former smokers live longer than continuing smokers. Cessation reduces the risk of cancer, heart disease, stroke and respiratory diseases. It also brings reproductive health benefits in women.⁽⁵⁾

People who quit smoking before developing a smoking-related illness can reduce most of the associated risks within a few years of quitting. These smokers, if they quit before the age of 35, have a life expectancy that is not significantly different from non-smokers. Smokers quitting after the age of 35 will substantially reduce the risk of smoking-related disease compared with continuing smokers.⁽⁶⁾

Difficulties in quitting smoking
Most smokers want to quit but few succeed. A poll of US smokers found that three quarters of them want to quit. However, the success rate among attempted quitters is very low.^{(7) (8)} Cigarettes are addictive, primarily because they deliver nicotine rapidly to the brain. Powerful
to smoke, and adverse mood and physical symptoms that occur during abstinence from nicotine are relieved by smoking a cigarette.⁽⁹⁾


Interventions
There are several types of intervention for smokers wanting to quit: (1) smoking cessation advice; (2) free telephone quit lines; (3) pharmacological therapies; and (4) behavioural interventions.⁽¹⁾

Smoking cessation advice
This involves integrating cessation advice into primary healthcare services. Smokers are reminded at every medical visit that smoking harms their health and the health of those around them. Repeated advice reinforces the need to quit. It is a relatively inexpensive intervention.⁽¹⁾

Quit lines and internet-based support
Telephone quit lines are inexpensive to run, easy to access and can operate beyond normal business hours. They can reach people in remote areas, can introduce smokers to other therapies, and can be tailored to target groups. Quit lines linked to counselling services are more effective. Continuous support for smoking cessation can also be provided via the internet,⁽¹⁾ and four recent studies have shown that internet-based support can be effective.^{(10) (11) (12) (13)}

Pharmacological interventions
The main categories of medical intervention are as follows:

• Nicotine replacement therapy (NRT) – low levels of nicotine are
  delivered to the body (in the form of skin patches, chewing gum, lozenges/sublingual tablets, nasal sprays and inhalers) in order to help with withdrawal symptoms. NRT can increase a smoker’s chances of quitting by 1.5 to 2 times.⁽¹⁴⁾
• Sustained-release bupropion tablet - an antidepressant medication that reduces withdrawal symptoms and increases the smoker’s chance of quitting twofold.⁽¹⁵⁾ Another antidepressant, nortryptiline, has also been shown to double the chances of quitting.
• Varenicline tablet – it reduces the need to smoke and also makes cigarettes less satisfying. A recent study found that varenicline increases the likelihood of a smoker quitting threefold.⁽¹⁶⁾
  Combinations of different NRTs are effective, and no side effects of toxicity have been reported.^{(17) (18) (19)} NRT is usually available without prescription, but the other medications require one.

Behavioural interventions
Behavioural interventions for smoking cessation can be effective.^{(20) (21)} A combination of structured behavioural support and one of the medication options described above is believed to be the most effective way of helping smokers to quit.⁽²²⁾

Additional support can help to further increase the smoker’s chances of successfully quitting. It includes supervision of medication use, psychological support over the telephone or face-to-face, and group counselling. For young people the focus is largely on preventing them from starting smoking.⁽²³⁾ Interventions to treat tobacco dependence should be adapted to local conditions and cultures, and tailored to individual preferences and needs.1

Availability of smoking cessation services
Cessation therapies are not available in all parts of the world.⁽²⁴⁾ Services to treat tobacco dependence are fully available in only nine countries, 5% of the world’s population. Of the 173 countries who responded to a World Health Organization (WHO) questionnaire, 22 do not offer any basic services such as counselling or pharmacotherapy. Nicotine replacement therapy is not available in 39 countries, even for people with the means to pay for it. Only 44 countries, or 40% of the world’s population, have access to telephone quit lines.⁽¹⁾


FCTC requirements
FCTC requirements
Under Article 14 of The WHO Framework Convention on Tobacco Control, parties must⁽²⁵⁾ :

• develop comprehensive guidelines based on evidence and best practice.
• adopt measures to promote smoking cessation and treatment of tobacco dependence.

Best practice

• Integrate smoking cessation services into government healthcare services.
• Make NRT products available without prescription.
• Adopt tax/price policies that make cessation products affordable.
• Require that cessation products and counselling are covered by private and government health
  insurance.
• Make available funding for smoking cessation programmes.
• Make smoking cessation services part of a comprehensive tobacco
  control programme.

For more information visit http://www.iuatld.org http://www.tobaccofreeunion.org
tobaccofreeunion@iuatld.org

⁽¹⁾ WHO report on the global tobacco epidemic, 2008. The MPOWER packgage. Geneva, World Health Organization, 2008. http://www.who.int/tobacco/mpower/en/index.html
⁽²⁾ The health consequences of smoking: a report of the Surgeon General. Atlanta, GA: Dept of Health and Human Services, Centers for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health; Washington, DC: 2004.http://www.cdc.gov/tobacco/data_statistics/sgr/index.htm and http://www.surgeongeneral.gov
⁽³⁾ World Health Organization. International statistical classification of diseases and related health problems, 10th revision. Geneva: World Health Organization, 1992.
⁽⁴⁾ Nicotine addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians of London. London: Royal College of Physicians of London, 2000:10. http://www.rcplondon.ac.uk/pubs/books/nicotine/
⁽⁵⁾ The health benefits of smoking cessation: a report of the Surgeon General. Atlanta, GA: Dept of Health and Human Services, Centers for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health; Washington, DC: 1990. http://profiles.nlm.nih.gov/NN/B/B/C/T/
⁽⁶⁾ Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years’ observations on male British doctors. BMJ 1994;309:901-911. http://www.bmj.com/cgi/content/abstract/309/6959/901
⁽⁷⁾ Lader D, Goddard E. Smoking-related behaviour and attitudes, 2003. Office for National Statistics, London 2004. http://www.rcplondon.ac.uk/pubs/books/nicotine/
⁽⁸⁾ Stopping smoking: the benefits and aids to quitting smoking. Factsheet No. 11. Action on Smoking and Health, London. 2007. http://www.ash.org.uk
⁽⁹⁾ West R, Shiffman S. Smoking cessation: Fast Facts. Oxford: Health Press, 2007
⁽¹⁰⁾ Strecher VJ, Shiffman S, West R. Randomized controlled trial of a web-based computer-tailored smoking cessation program as a supplement to nicotine patch therapy. Addiction 2005;100:682-8.
⁽¹¹⁾ Swartz LH, Noell JW, Schroeder SW, Ary DV. A randomised control study of a fully automated internet based smoking cessation programme. Tob Control 2006;15:7-12.
⁽¹²⁾ Brendryen H, Kraft P. Happy ending: a randomized controlled trial of a digital multi-media smoking cessation intervention. Addiction 2008;103:478-84
⁽¹³⁾ Strecher VJ, McClure JB, Alexander GL, Chakraborty B, Nair VN, Konkel JM et al. Web-based smoking-cessation programs results of a randomized trial. Am J Prev Med 2008;34:373-81.
⁽¹⁴⁾ Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD000146. DOI: 10.1002/14651858
CD000146.pub2
⁽¹⁵⁾ Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database System Rev 2007 (1): CD000031. doi: 10.1002/14651858.CD000031.pub3
⁽¹⁶⁾ Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2007 Jan 24;(1): CD006103.
⁽¹⁷⁾ Sweeny C, Fant R, Fagerstrom K, McGovern J, Henningfield J. Combination nicotine replacement therapy for smoking cessation: rationale, efficacy and tolerability, CNS Drugs 2001;15:453-67
⁽¹⁸⁾ Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004 (3): CD000146.
⁽¹⁹⁾ Fiore M. Treating tobacco use and dependence: an introduction to the US Public Health Service Clinical Practice Guideline. Respir Care 2000;45:1196-9.
⁽²⁰⁾ Soria R, Legido A, Escolano C, López Yeste A, Montoya J. A randomised controlled trial of motivational interviewing for smoking cessation. Br J Gen Pract 2006;56:768-74
⁽²¹⁾ Ranney L, Melvin C, Lux L, McClain E, Lohr K. Smoking cessation intervention strategies for adults and adults in special populations. Ann Int Med 2006 145;845-56
⁽²²⁾ West R. Helping patients in hospital to quit smoking. BMJ 2002;324:64. http://www.bmj.com/cgi/reprint/324/7329/64
⁽²³⁾ Grimshaw GM, Stanton A. Tobacco cessation interventions for young people. Cochrane Database System Rev 2006 (4): CD003289. doi: 10.1002/14651858. CD003289.pub4
⁽²⁴⁾ McKay J, Eriksen M, Shafey O. The tobacco atlas (2nd Ed.) Atlanta, GA: American Cancer Society, 2006. http://www.cancer.org/docroot/AA/content/AA_2_5_9x_Tobacco_Atlas.asp
⁽²⁵⁾ The Framework Convention Alliance for Tobacco Control.http://www.fctc.org