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Smoking cessation and replacement

Key learning points:

 - The most successful method of quitting is the use of behavioural support together with a combination of two nicotine replacement therapy (NRT) products, or varenicline with NRT

 - Smokers may use NRT to cut down, which will have negligible immediate health benefits, but it may prompt a successful future quit attempt 

 - Use of e-cigarettes is increasing, but evidence of their safety and effectiveness in cessation is still only preliminary

Smoking cessation in the UK

Among many other factors, smoking increases risks of cancers, cardiovascular diseases (CVDs)  and dementias, and it negatively impacts on wound healing, as well as treatment, surgery, and pregnancy outcomes. Therefore, smokers of all ages, including patients with and without smoking-related diseases, should be advised to quit and assisted in this process, regardless their readiness or motivation to quit.1 

Every year, more than a third of UK smokers make an attempt to quit.2 Most of them try without any assistance (with willpower alone, or 'cold turkey') and as a result, only about 4% of them are still abstinent a year on.3 Behavioural support, such as NHS Stop Smoking Services or the Smoking Helpline, together with appropriate medications, can increase chances of quitting successfully threefold.4 

Primary care nurses can play a vital role in helping smokers quit by offering brief advice, information about cessation aids, and behavioural support.5 The National Centre for Smoking Cessation and Training (NCSCT) offers online courses on best practice in smoking cessation for UK health professionals.

Smoking Cessation Medications 

Three classes of medications are licensed for smoking cessation and are available on the NHS  - nicotine replacement therapy (NRT) that is offered both on prescription and over the counter, and two prescription-only medications that do not contain nicotine: bupropion and varenicline.2 Only NRT has been approved for use among adolescents, pregnant women, and smokers with heart disease.6 

NRT includes a wide range of different products: transdermal patch, gum, tablet, lozenge, inhaler and nasal spray (which is the strongest), all of which deliver less nicotine and at slower pace than cigarettes, but without the many harmful substances. They work immediately, and can help smokers manage nicotine cravings (including urges to smoke) and withdrawal symptoms (such as irritability) which may appear as soon as two to three hours after smoking the last cigarette. All NRT products are similarly effective, and increase success rates by 50-70%, even without the additional behavioural support.7 

Bupropion (marketed as Zyban) is a monocyclic antidepressant that can also be used by non-depressed smokers. It inhibits nicotine receptors, thus reducing cravings, withdrawal symptoms and pleasure from smoking. Its effectiveness is comparable to NRT8, but it may be particularly suitable for smokers with a previous history of depression, chronic obstructive pulmonary disorder (COPD) and high nicotine dependence.9

Varenicline (marketed as Champix) is a selective nicotine receptor partial agonist (a 'synthetic' nicotine) that stimulates dopamine release, relieves withdrawal symptoms, and reduces the rewards from smoking cigarettes. It is normally prescribed as part of a structured behavioural support programme, and could even double the quit rates in comparison to NRT at one-year follow-up.10

Treatment selection and adherence

There is strong evidence that all three medications are effective as single treatments, but varenicline or a combination of two NRT products, such as a slow-working patch and a fast acting gum or lozenges, leads to highest success rates.8 Given their different roles in cessation, a combination of NRT with either varenicline or bupropion may be most effective, particularly among more dependent smokers.11 The choice of pharmacotherapy and treatment regime for any given quit attempt should be consulted with a GP or a Stop Smoking Advisor, and consider the smoker's profile, including dependency levels and any existing health conditions, and possible medication side effects. Importantly, smokers trying to quit smoking were shown not to use the cessation medications according to guidelines, including not taking enough of them, or discontinuing their use long before it is recommended, which may decrease their effectiveness.12 To maximize the benefits and minimize any side effects (particularly in case of NRT products), smokers should be advised to carefully follow manufacturer's instructions.13

However, pharmacotherapy does not address the many behavioural aspects of smoking addiction, such as having one's hands occupied, and associating smoking with alcohol consumption or certain social situations, all of which may need to be addressed separately by behavioural support. 

Using NRT for harm reduction 

Many smokers are unable to quit smoking, especially when quitting for the first time. As part of a “harm reduction” strategy, the Medicines and Healthcare products Regulatory Agency (MHRA) has approved the use of some NRT products for smoking reduction and temporary abstinence (eg. when travelling or at home), even if smokers are not intending to quit. Use of NRT for harm reduction among adolescents and pregnant women is not recommended, however.14 In the UK up to 20% of smokers are currently using NRT for these purposes.15

Using NRT for smoking reduction can increase smokers' motivation to quit, thus leading to a successful quit attempt in the near future.16 However, smokers may not be reducing the immediate harms from smoking through the use of NRT to cut down. First, the decrease in the number of cigarettes smoked is often minimal, and even lower than when NRT is not used.15 Additionally, any reduction in cigarettes smoked tends to be short-lived, and when it is successful, it does not lower the levels of smoking biomarkers: saliva cotinine or carbon monoxide.17 This may be because smokers smoke their remaining cigarettes more intensely. 

Switching to other tobacco products

There are no safe levels of tobacco use, and tobacco consumption in any form is carcinogenic and increases CVD mortality, although certain diseases tend to be more strongly associated with different tobacco forms, such as mouth cancers with smoking cigars or chewing smokeless tobacco. Similarly, snus - popular in Sweden but banned in other European Union countries - is often considered to be less harmful than smoking as it is linked to fewer cancers, but may nevertheless increase risks of major CVD events.18  Smokers will not benefit from switching to cigars, pipes or water pipes (also known as shishas or hookas). Shisha smoking, which is becoming more popular among many different groups in cities across UK, can be addictive and may be particularly harmful - an hour of its use may be equivalent to smoking more than a pack of cigarettes.19 

Electronic cigarettes - new replacement products?

Electronic cigarettes (e-cigarettes) are novel nicotine-containing products (NCP) that do not contain tobacco, but instead use a battery to vaporise liquid nicotine (flavoured or not), hence their use has been referred to as 'vaping'. Dozens of different brands and types are available on the market, many of which do not resemble cigarettes. E-cigarettes are becoming increasingly popular, with approximately 20% of both smokers and ex-smokers currently using them. Using e-cigarettes reproduces many of the behavioural components of smoking, such as drawing on smoke and manipulating the device with hands, which may make them particularly appealing and potentially effective cigarette replacements. 

Preliminary evidence suggests that e-cigarettes can help smokers quit,20 but more rigorous studies are still needed. In June 2013 MHRA decided that from 2016 e-cigarettes, together with other NCPs, will be regulated as medications. Until then they are not undergoing strict assessments of quality, safety and efficacy. Nevertheless, it is likely that they are much less harmful than cigarettes and might be used for harm reduction, but smokers should be advised to first try quitting smoking using licensed products and without e-cigarettes.20

Long-term use of nicotine-containing products 

Long-term use of NCP by ex-smokers, although not completely safe, will outweigh the harms associated with continued smoking. Nevertheless, smokers may be concerned about becoming addicted to new forms of nicotine. The content of nicotine in both NRT and e-cigarettes can be controlled, however, thus allowing the users for its gradual reduction until complete abstinence is achieved. Additionally, except for the nasal spray, long-term NRT use by ex-smokers is relatively rare, and may not pose harm to health even when used up to five years.2 However, it is possible that smokers who use e-cigarettes to quit smoking may be more likely to still use them months after being abstinent from cigarette smoking, but no data exists yet on the impact and safety of their long-term use.21 

Other cessation treatments and aids 

Evidence-based websites, smartphone applications and text-based support for smoking cessation can aid quit attempts.22 Several unconventional treatment that have limited or mixed evidence for effectiveness are homeopathy, hypnotherapy, acupuncture.23 The 'Allen Carr method' has not yet been evaluated in a randomised controlled trial. Several additional medications have been investigated as potential cessation treatments. Some were shown to be effective, but are not licensed for cessation in the UK, including nortriptyline (antidepressant), and cytisine (nicotine receptor partial agonists). Many other pharmacological treatments were not shown to be effective, such as anxiolytics, lobeline, and dianicline.8 

Conclusion

All smokers should be offered behavioural support and consider using and adhering to a choice of pharmacotherapy to increase their chances of being successful ex-smokers still in a year's time. All tobacco-containing products are harmful, while long-term use of nicotine replacement is likely to outweigh any risks associated with continued smoking. Some smokers may use NRT to reduce cigarettes smoked, which may lead to them quitting smoking in the near future.  Increasing numbers of smokers are using e-cigarettes. They can potentially aid quitting and be less harmful than cigarettes, but limited data exists on their long-term use, effectiveness and safety. 

 

Resources

National Centre for Smoking Cessation Training (NCSCT)

Smokefree UK 

NHS Choices: Map of Medicine. Smoking Cessation - Assistance

Smoking in England: Providing the latest information on smoking and smoking cessation in England

 

References

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2. Action on Smoking and Health (ASH). Stopping smoking. The benefits and aids to quitting. 2013. Available at: http://ash.org.uk/files/documents/ASH_116.pdf 

3. Hughes L, Keely J, Naud Sh. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004;99:29-38

4. Stead LF, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database of Sys Rev 2012;10:CD008286. 

5. Rice VH, Hartmann-Boyce J, Stead LF. Nursing interventions for smoking cessation. Cochrane Database of Sys Rev 2013;8:CD001188. 

6. MHRA. Report of the committee on safety of medicines working group on nicotine 

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11. NICE. Public Health Guidance, No 10. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. 2008. Available at: http://www.nice.org.uk/nicemedia/pdf/ph010guidance.pdf

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19. British Heart Foundation. Shisha. Available at:  http://www.bhf.org.uk/heart-health/prevention/smoking/shisha.aspx

20. NICE Tobacco: harm-reduction approaches to smoking. June 2013. Available at: guidance.nice.org.uk/ph45 

21. Bullen C, Howe C,  Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. The Lancet 2013 [Epub before print]

22. Whittaker R, Borland R, Bullen C, et al. Mobile phone-based interventions for smoking cessation. 

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23. Tahiri M, Mottillo S, Joseph L, et al. Alternative smoking cessation aids: a meta-analysis of randomized controlled trials. Am J Med 2012; 125:576-84