ABC OF SMOKING CESSATION

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ABC OF SMOKING CESSATION

Edited by

JOHN BRITTON

Professor of Epidemiology at the University of Nottingham

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© 2004 by Blackwell Publishing LtdBMJ Books is an imprint of the BMJ Publishing Group Limited, used under licence

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First published 2004

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Contents

Contributors vii

Preface ix

1 The problem of tobacco smoking 1Richard Edwards

2 Why people smoke 4Martin J Jarvis

3 Assessment of dependence and motivation to stop smoking 7Robert West

4 Use of simple advice and behavioural support 9Tim Coleman

5 Nicotine replacement therapy 12Andrew Molyneux

6 Bupropion and other non-nicotine pharmacotherapies 15Elin Roddy

7 Special groups of smokers 18Tim Coleman

8 Cessation interventions in routine health care 21Tim Coleman

9 Setting up a cessation service 24Penny Spice

10 Population strategies to prevent smoking 27Konrad Jamrozik

11 Harm reduction 31Ann McNeill

12 Economics of smoking cessation 34Steve Parrott, Christine Godfrey

13 Policy priorities for tobacco control 37Konrad Jamrozik

Index 41

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John BrittonProfessor of Epidemiology at the University of Nottingham inthe division of epidemiology and public health at City Hospital,Nottingham

Tim ColemanSenior Lecturer in general practice at the School of Community Health Sciences in the Division of Primary Care at University Hospital, Queen’s Medical Centre, Nottingham

Richard EdwardsSenior Lecturer in public health in the Evidence for Population Health Unit at the Medical School, University of Manchester

Christine GodfreyProfessor of Health Economics at the Department of HealthSciences and Centre for Health Economics at the University of York

Konrad JamrozikProfessor of Primary Care Epidemiology, Imperial College,London, and Visiting Professor in Public Health, School ofPopulation Health, University of Western Australia, Perth

Martin J JarvisProfessor of Health Psychology in the Cancer Research UKHealth Behaviour Unit, Department of Epidemiology andPublic Health at the University College London

Ann McNeillIndependent consultant in public health and Honorary SeniorLecturer in the Psychology Department at St George’s HospitalMedical School, London

Andrew MolyneuxConsultant respiratory physician at the Sherwood ForestHospitals Trust, Nottinghamshire

Steve ParrottResearch Fellow at the Centre for Health Economics at theUniversity of York

Elin RoddyClinical Research Fellow at the University of Nottingham in the Division of Respiratory Medicine at City Hospital,Nottingham

Penny SpiceHead of Public Involvement at Rushcliffe Primary Care Trustand formerly smoking cessation coordinator at NottinghamHealth Authority

Robert WestProfessor of Health Psychology in the Cancer Research UKHealth Behaviour Unit, Department of Epidemiology andPublic Health at the University College London

Contributors

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ix

Preface

Smoking kills more people than any other avoidable factor in developed countries. Smoking cessation has a substantial positiveimpact on quantity and quality of life expectancy in all smokers, and smoking cessation interventions are among the most costeffective interventions available in medicine. It is therefore surprising that in many countries, smoking cessation measures are notroutinely available or are not widely used to help smokers to quit smoking. Most medical schools do not train doctors properly totreat smoking, and many doctors and other health professionals are still unfamiliar with the basic underlying principles of smokingas an addictive behaviour, and with methods of intervening to help smokers to quit.

This book is intended to provide the basic, simple information needed to equip all health professionals to intervene effectively,efficiently, and constructively to help their patients to stop smoking. The book describes how and why people start smoking, why theycontinue to smoke, and what to do to help them to stop. We describe methods of ensuring that identifying and treating smokingbecomes a routine component of health care, and because the best results are generally achieved by specialist smoking cessationservices we describe some of the challenges and difficulties of establishing these facilities. As prevention of smoking in populationsis such an important determinant of individual motivation to quit or avoid smoking, the authors summarise the population strategiesand political policies that can help drive down the prevalence of smoking. For our managers, this ABC covers the cost-effectivenessof these initiatives.

One of the tragedies of modern clinical medicine is that treating smoking is so simple, has so much to offer, and so often is notdone. The methods are not difficult. This book explains them.

John Britton

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1 The problem of tobacco smokingRichard Edwards

Cigarette smoking is the single biggest avoidable cause of deathand disability in developed countries. Smoking is nowincreasing rapidly throughout the developing world and is oneof the biggest threats to current and future world health. Formost smokers, quitting smoking is the single most importantthing they can do to improve their health. Encouragingsmoking cessation is one of the most effective and cost effectivethings that doctors and other health professionals can do toimprove health and prolong their patients’ lives. This book willexplore the reasons why smokers smoke, how to help them toquit, and how to reduce the prevalence of smoking moregenerally.

Who smokes tobacco?Cigarette smoking first became a mass phenomenon in theUnited Kingdom and other more affluent countries in the early20th century after the introduction of cheap, mass produced,manufactured cigarettes. Typically, a “smoking epidemic” in apopulation develops in four stages: a rise and then decline insmoking prevalence, followed two to three decades later by asimilar trend in smoking related diseases. Usually, the uptakeand consequent adverse effects of smoking occur earlier and toa greater degree among men.

In the United Kingdom there are about 13 million smokers,and worldwide an estimated 1.2 billion. Half of these smokerswill die prematurely of a disease caused by their smoking, losingan average of eight years of life; this currently represents fourmillion smokers each year worldwide. Deaths from smoking areprojected to increase to more than 10 million a year by 2030, bywhich time 70% of deaths will be in developing countries.

The prevalence of smoking among adults in the UnitedKingdom has declined steadily from peaks in the 1940s in menand the late 1960s in women. However, this reduction in overallprevalence during stage 4 of the epidemic disguises relativelystatic levels of smoking among socioeconomicallydisadvantaged groups, making smoking one of the mostimportant determinants of social inequalities in health in thedeveloped world. Smoking has also declined much more slowlyamong young adults in the United Kingdom. The decline insmoking in the United Kingdom and some other developedcountries may now be coming to an end. For example, since1994 the prevalence of smoking in UK adults has remained atabout 28%.

Whereas countries in western Europe, Australasia, and theUnited States may be in stage 4 of the smoking epidemic, inmany developing countries the epidemic is just beginning.Smoking in low and middle income countries is increasingrapidly—for example, the prevalence of smoking among malesin populous Asian countries is now far higher than in Westerncountries—45% in India, 53% in Japan, 63% in China, 69% inIndonesia, and 73% in Vietnam.

Adverse health effectsThe adverse health effects of smoking are extensive, and havebeen exhaustively documented. There is a strong dose-response

Stage 1Sub-Saharan

Africa

Stage 4Western Europe,North America,

Australia

Stage 2China, Japan,

South East Asia,Latin America,

north Africa

Stage 3Eastern Europe,

southern Europe,Latin America

Stage 1 Stage 4Stage 2 Stage 3

% o

f sm

oker

s am

ong

adul

ts

0 10 20 30 40 50 60 70 80 90 100Years

0

20

30

40

50

60

70

10 % o

f dea

ths

caus

ed b

y sm

okin

g

0

20

30

40

10

Male smokers

Female smokers

Male deaths

Female deaths

Stages of worldwide tobacco epidemic. Adapted from Lopez et al. Adescriptive model of the cigarette epidemic in developed countries. TobaccoControl 1994;3:242-7

Year

% o

f UK

adul

ts s

mok

ing

man

ufac

ture

d ci

gare

ttes

1952 19561948 1960 1964 1968 1972 1976 1980 1984 1988 1992 1996 20000

20

30

40

50

60

70

10

Men

Women

Prevalence of smoking of manufactured cigarettes in Great Britain. Datafrom Tobacco Advisory Council (1948-70) and general household survey(1972-2001)

Deprivation score

Prev

alen

ce o

f sm

okin

g in

pop

ulat

ion

(%)

0

PoorestMost affluent

0

20

30

40

50

60

70

80

10

1973

1993

1 2 3 4 5

Cigarette smoking by deprivation level in Great Britain. Data from generalhousehold survey

1

relation with heavy smoking, duration of smoking, and earlyuptake associated with higher risks of smoking related diseaseand mortality. Data from 40 years of follow up of smokers in aprospective cohort study of male British doctors show theimpact of smoking on longevity at different levels of exposure.The strongest cause-specific associations are with respiratorycancers and chronic obstructive pulmonary disease; in numericterms, the greatest health impacts of smoking are on respiratoryand cardiovascular diseases.

Some of the increases in health risk associated with smokingare greater among younger smokers. The risk of heart attackamong smokers, for example, is at least double over the age of60 years, but those aged under 50 have a more than fivefoldincrease in risk. Smokers are also at greater risk of many othernon-fatal diseases, including osteoporosis, periodontal disease,impotence, male infertility, and cataracts. Smoking in pregnancyis associated with increased rates of fetal and perinatal deathand reduced birth weight for gestational age. Passive smokingafter birth is associated with cot death and respiratory disease inchildhood and lung cancer, heart disease, and stroke in adults.

The effect on health services is considerable—for example,an estimated 364 000 admissions and £1.5bn ($2.4bn; €2.1bn) ayear in health service costs are attributable to smoking in theUnited Kingdom alone.

Health benefits of smoking cessationStopping smoking has substantial immediate and long termhealth benefits for smokers of all ages. The excess risk of deathfrom smoking falls soon after cessation and continues to do sofor at least 10-15 years. Former smokers live longer thancontinuing smokers, no matter what age they stop smoking,though the impact of quitting on mortality is greatest atyounger ages. For smokers who stop before age 35, survival isabout the same as that for non-smokers.

The rate and extent of reduction of risk varies betweendiseases—for lung cancer the risk falls over 10 years to about30%-50% that of continuing smokers, but the risk remainsraised even after 20 years of abstinence. There is benefit fromquitting at all ages, but stopping before age 30 removes 90% ofthe lifelong risk of lung cancer. The excess risk of oral andoesophageal cancer caused by smoking is halved within fiveyears of cessation.

The risk of heart disease decreases much more quickly afterquitting smoking. Within a year the excess mortality due tosmoking is halved, and within 15 years the absolute risk isalmost the same as in people who have never smoked. In ameta-analysis by Wilson and colleagues in 2000, the odds ratiofor death for smokers who stopped smoking after myocardialinfarction was 0.54, a far higher protective effect than the0.75-0.88 odds ratio for death achieved by the conventionalstandard treatments for myocardial infarction, includingthrombolysis, aspirin, � blockers, and statins. Smoking cessationalso reduces the risk of death after a stroke and of death frompneumonia and influenza.

Smoking is associated with an accelerated rate of decline inlung function with age. Cessation results in a small increase inlung function and reverses the effect on subsequent rate ofdecline, which reverts to that in non-smokers.

Thus, early cessation is especially important in susceptibleindividuals to prevent or delay the onset of chronic obstructivepulmonary disease. In patients with this disease, mortality andsymptoms are reduced in former smokers compared withcontinuing smokers. Recent evidence shows that the benefits

Age

% o

f stu

dy d

octo

rs a

live

40 55 70 85 1000

20

40

60

80

100

Current cigarette smokers:

1-14 a day

15-24 a day

> 25 a day

Never smoked regularly

Survival by smoking status, according to study of male British doctors(follow up after 40 years, 1951-91). Adapted from Doll et al (see FurtherReading box)

No o

f dea

ths

(000

s) a

ttrib

utab

le to

sm

okin

g, 1

995

Rela

tive

risk

of d

eath

0

10

15

20

25

30

Lung

canc

er

Oesop

hage

al ca

ncer

Bladde

r can

cer

Throa

t and

mou

th ca

ncer

Ischa

emic

heart

dise

ase

Stroke

Aortic

aneu

rysm

Chronic

bron

chitis

and e

mphys

ema

Pneum

onia

5

0

10

15

20

25

30

5

Smoking attributable deaths Relative risk of death

Numbers and relative risk of death (by cause) due to smoking, UnitedKingdom. Data from Tobacco Advisory Group of the Royal College ofPhysicians and Doll et al (see Further Reading box)

FEV 1 (

litre

s)

2.0

2.2

2.4

2.6

2.8

3.0

Years of study

FEV 1 (

% o

f pre

dict

ed n

orm

al v

alue

)

0

FEV1 = forced expiratory volume in one second

1 2 3 4 5 6 7 8 9 10 1160

65

70

75

80

85

Sustained quitters

Intermittent smokers

Continuous smokers

Effect of smoking cessation on rate of decline in lung function in chronicobstructive pulmonary disease. Adapted from Anthonisen et al. Am J RespirCrit Care Med 2002;166:675-9

ABC of Smoking Cessation

2

occur even in older patients with severe chronic obstructivepulmonary disease.

At a population level, the importance of smoking cessationis paramount. Peto has estimated that current cigarette smokingwill cause about 450 million deaths worldwide in the next 50years. Reducing current smoking by 50% would prevent 20-30million premature deaths in the first quarter of this century andabout 150 million in the second quarter. Preventing youngpeople from starting smoking would have a more delayed butultimately even greater impact on mortality.

Effective prevention of cigarette smoking and help for thosewishing to quit can therefore yield enormous health benefits forpopulations and individuals. Promoting and supportingsmoking cessation should be an important health policypriority in all countries and for healthcare professionals in allclinical settings. However, this has not so far generally beenreflected at a policy level or in the practice of individualhealthcare professionals.

Competing interests: RE is chairman of North West ASH (Action onSmoking and Health); he receives no financial reward for this work. JB hasbeen reimbursed by GlaxoWellcome (now GlaxoSmithKline) for attendingtwo international conferences, has received a speaker’s honorarium fromGlaxoWellcome, and has been the principal investigator in a clinical trialof nicotine replacement therapy funded by Pharmacia. Both thesecompanies manufacture nicotine replacement products.

Further readingx Tobacco Advisory Group of the Royal College of Physicians.

Nicotine addiction in Britain. London: Royal College of Physicians ofLondon, 2000. www.rcplondon.ac.uk/pubs/books/nicotine/index.htm

x Jha P, Chaloupka F, eds. Tobacco control in developing countries.Oxford: Oxford University Press, 1999.

x Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality inrelation to smoking: 40 years’ observations on male British doctors.BMJ 1994;309:901-11.

x World Bank. Curbing the epidemic: governments and the economics oftobacco control. Washington, DC: World Bank, 1999.www1.worldbank.org/tobacco/reports.asp

x US Department of Health and Human Services. The health benefitsof smoking cessation: a report of the surgeon general. Rockville, MD: USGovernment Printing Office, 1990. (DHHS publication No (CDC)90-8416.)

x Wilson K, Willan A, Cook D. Effect of smoking cessation onmortality after myocardial infarction. Arch Intern Med2000;160:939-44.

Stopping smoking before or in the first three to fourmonths of pregnancy protects the fetus against thereduced birth weight associated with smoking.Preoperative cessation reduces perioperative mortalityand complications

Key pointsx Cigarette smoking is one of the greatest avoidable causes of

premature death and disability in the worldx Helping smokers to stop smoking is one of the most cost effective

interventions available in clinical practicex Promoting smoking cessation should therefore be a major priority

in all countries and for all health professionals in all clinical settings

The problem of tobacco smoking

3

2 Why people smokeMartin J Jarvis

For much of the 20th century, smoking was regarded as asocially learned habit and as a personal choice. It is only in thepast decade or so that the fundamental role of nicotine insustaining smoking behaviour has begun to be more widelyaccepted. It is now recognised that cigarette smoking isprimarily a manifestation of nicotine addiction and thatsmokers have individually characteristic preferences for theirlevel of nicotine intake. Smokers regulate the way they puff andinhale to achieve their desired nicotine dose.

The link with nicotine addiction does not imply thatpharmacological factors drive smoking behaviour in a simpleway and to the exclusion of other influences. Social, economic,personal, and political influences all play an important part indetermining patterns of smoking prevalence and cessation.Although drug effects underpin the behaviour, family and widersocial influences are often critical in determining who startssmoking, who gives up, and who continues.

Why do people start smoking?Experimenting with smoking usually occurs in the early teenageyears and is driven predominantly by psychosocial motives. Fora beginner, smoking a cigarette is a symbolic act conveyingmessages such as, in the words of the tobacco company PhilipMorris, “I am no longer my mother’s child,” and “I am tough.”Children who are attracted to this adolescent assertion ofperceived adulthood or rebelliousness tend to come frombackgrounds that favour smoking (for example, with high levelsof smoking in parents, siblings, and peers; relatively deprivedneighbourhoods; schools where smoking is common). Theyalso tend not to be succeeding according to their own orsociety’s terms (for example, they have low self esteem, haveimpaired psychological wellbeing, are overweight, or are poorachievers at school).

The desired image is sufficient for the novice smoker totolerate the aversion of the first few cigarettes, after whichpharmacological factors assume much greater importance.Again in the words of Philip Morris, “as the force from thepsychosocial symbolism subsides, the pharmacological effecttakes over to sustain the habit.” Within a year or so of starting tosmoke, children inhale the same amount of nicotine percigarette as adults, experience craving for cigarettes when theycannot smoke, make attempts to quit, and report experiencingthe whole range of nicotine withdrawal symptoms.

Physical and psychological effects ofnicotineAbsorption of cigarette smoke from the lung is rapid andcomplete, producing with each inhalation a high concentrationarterial bolus of nicotine that reaches the brain within 10-16seconds, faster than by intravenous injection. Nicotine has adistributional half life of 15-20 minutes and a terminal half lifein blood of two hours. Smokers therefore experience a patternof repetitive and transient high blood nicotine concentrationsfrom each cigarette, with regular hourly cigarettes needed tomaintain raised concentrations, and overnight blood levelsdropping to close to those of non-smokers.

Smoking a cigarette for a beginner is a symbolic act of rebellion

“If it were not for the nicotine in tobaccosmoke, people would be little moreinclined to smoke than they are to blowbubbles”

M A H Russell, tobacco researcher, 1974

By age 20, 80% of cigarette smokers regret that they everstarted, but as a result of their addiction to nicotine, manywill continue to smoke for a substantial proportion oftheir adult lives

Time (minutes)

Nico

tine

conc

entra

tion

(ng/

ml)

0 10 20 30

Cigarette smoked

40 50 600

10

20

30

40

50Venous levelsArterial levels

Arterial and venous levels of nicotine during cigarette smoking

4

Nicotine has pervasive effects on brain neurochemistry. Itactivates nicotinic acetylcholine receptors (nAChRs), which arewidely distributed in the brain, and induces the release ofdopamine in the nucleus accumbens. This effect is the same asthat produced by other drugs of misuse (such as amphetaminesand cocaine) and is thought to be a critical feature of brainaddiction mechanisms. Nicotine is a psychomotor stimulant,and in new users it speeds simple reaction time and improvesperformance on tasks of sustained attention. However, toleranceto many of these effects soon develops, and chronic usersprobably do not continue to obtain absolute improvements inperformance, cognitive processing, or mood. Smokers typicallyreport that cigarettes calm them down when they are stressedand help them to concentrate and work more effectively, butlittle evidence exists that nicotine provides effective selfmedication for adverse mood states or for coping with stress.

A plausible explanation for why smokers perceive cigarettesto be calming may come from a consideration of the effects ofnicotine withdrawal. Smokers start to experience impairment ofmood and performance within hours of their last cigarette, andcertainly overnight. These effects are completely alleviated bysmoking a cigarette. Smokers go through this processthousands of times over the course of their smoking career, andthis may lead them to identify cigarettes as effective selfmedication, even if the effect is the negative one of withdrawalrelief rather than any absolute improvement.

Symptoms of nicotine withdrawalMuch of the intractability of cigarette smoking is thought tostem from the problems of withdrawal symptoms—particularlyirritability, restlessness, feeling miserable, impairedconcentration, and increased appetite—as well as from cravingsfor cigarettes. These withdrawal symptoms begin within hoursof the last cigarette and are at maximal intensity for the firstweek. Most of the affective symptoms then resolve over three orfour weeks, but hunger can persist for several months. Cravings,sometimes intense, can also persist for many months, especiallyif triggered by situational cues.

Social and behavioural aspectsThe primary reinforcing properties of nicotine ultimatelysustain smoking behaviour: in experimental models, if nicotineis removed from cigarette smoke, or nicotine’s effects on thecentral nervous system are blocked pharmacologically, smokingeventually ceases. However, under normal conditions, theintimate coupling of behavioural rituals and sensory aspects ofsmoking with nicotine uptake gives ample opportunities forsecondary conditioning. For a 20 a day smoker, “puff by puff”delivery of nicotine to the brain is linked to the sight of thepacket, the smell of the smoke, and the scratch in the throatsome 70 000 times each year. This no doubt accounts forsmokers’ widespread concern that if they stopped smoking theywould not know what to do with their hands, and for the abilityof smoking related cues to evoke strong cravings.

Social influences also operate to modulate nicotine’s effects.The direction of this influence can be to discouragesmoking—as, for example, with the cultural disapproval ofsmoking in some communities, the expectation of non-smokingthat has become the norm in professional groups, or the effectsof smoke-free policies in workplaces. Other factors encouragesmoking, such as being married to a smoker or being part ofsocial networks in socially disadvantaged groups, among whomprevalence is so high as to constitute a norm.

Effects of nicotine withdrawal

Symptom Duration Incidence (%)Lightheadedness < 48 hours 10Sleep disturbance < 1 week 25Poor concentration < 2 weeks 60Craving for nicotine < 2 weeks 70Irritability or aggression < 4 weeks 50Depression < 4 weeks 60Restlessness < 4 weeks 60Increased appetite < 10 weeks 70

Behavioural rituals are closely coupledwith sensory aspects of smoking

Many experimental and clinical studieshave shown that withdrawal symptomsare attributable to nicotine, as nicotinereplacement (by gum, patch, spray, orlozenge) reliably attenuates the severity ofwithdrawal

nAChR= nicotinic acetylcholine receptorNAcc= nucleus accumbensVTA= ventral tegmental areaNMDA= N-methyl-D-aspartate

Nicotine

Nicotine

NAccshell VTA

Raphénuclei

Pedunculopontinenucleus

DA

nAChR

nAChR

Nicotine

Nicotine

nAChR

nAChR

NMDA receptor

Glutamatergic efferents

Cholinergicefferents

NicotinenAChR

Pathways of nicotine reinforcement and addiction. Adapted from Watkinset al. Nicotine and Tobacco Research 2000;2:19-37

Why people smoke

5

Regulation of nicotine intakeSmokers show a strong tendency to regulate their nicotineintakes from cigarettes within quite narrow limits. They avoidintakes that are either too low (provoking withdrawal) or toohigh (leading to unpleasant effects of nicotine overdose). Withinindividuals, nicotine preferences emerge early in the smokingcareer and seem to be stable over time. The phenomenon ofnicotine titration is responsible for the failure of intakes todecline after switching to cigarettes with low tar and nicotineyields. Compensatory puffing and inhalation, operating at asubconscious level, ensure that nicotine intakes are maintained.As nicotine and tar delivery in smoke are closely coupled,compensatory smoking likewise maintains tar intake anddefeats any potential health gain from lower tar cigarettes.Similar compensatory behaviour occurs after cutting down onthe number of cigarettes smoked each day; hence this popularstrategy fails to deliver any meaningful health benefits.

Socioeconomic status and nicotineaddictionAn emerging phenomenon of the utmost significance over thepast two decades has been the increasing association ofcontinued smoking with markers of social disadvantage. Amongaffluent men and women in the United Kingdom, theproportion of ever smokers who have quit has more thandoubled since the early 1970s, from about 25% to nearly 60%,whereas in the poorest groups the proportion has remained ataround 10%. Part of the explanation for this phenomenon maybe found in the growing evidence that poorer smokers tend tohave higher levels of nicotine intake and are substantially moredependent on nicotine. It is evident that future progress inreducing smoking is increasingly going to have to tackle theproblems posed by poverty.

Smoking as a chronic diseaseCigarette dependence is a chronic relapsing condition that formany users entails a struggle to achieve long term abstinencethat extends over years or decades. Successful interventionsneed to tackle the interacting constellation of factors—personal,family, socioeconomic, and pharmacological—that sustain useand can act as major barriers to cessation.

The photo of children smoking is with permission from Ralph Mortimer/Rex, and the photo of the man smoking is with permission fromAlexandra Murphy/Photonica.

Cigarette nicotine yield (mg)

Nico

tine

inta

ke p

er c

igar

ette

(mg)

<0.1 0.1- 0.2- 0.4- 0.5- 0.6- 0.7- 0.8- 0.9- >1.00

0.4

0.6

0.8

1.0

1.2

1.4

1.6

0.2

Actual Predicted

Regulation of nicotine intake: actual and predicted intake per cigarette fromlow tar cigarettes. Data from health survey for England, 1998

Deprivation score

Mea

n pl

asm

a co

tinin

e (n

g/m

l)

0 1 4 5Most affluent Poorest

2 30

250

300

350

200

Nicotine intake and social deprivation. Data from health survey for England(1993, 1994, 1996)

Smoking behaviour and cessationx The natural course of cigarette smoking is typically characterised by

the onset of regular smoking in adolescence, followed by repeatedattempts to quit

x Each year about a third of adult smokers in the United Kingdomtry to quit, usually unaided and typically relapsing within days

x In general, less than 3% of attempts to quit result in sustained (12months’) cessation, though the chances of success are slightlyhigher in women of childbearing age, parents of young children,and spouses of non-smokers

Key pointsx Smoking usually starts as a symbolic act of rebellion or maturityx By age 20, 80% of smokers regret having started to smokex Nicotine from cigarettes is highly addictive—probably because it is

delivered so rapidly to the brainx Smoking a cigarette, especially the first of the day, feels good

mainly because it reverses the symptoms of nicotine withdrawalx Most smokers who switch to low tar cigarettes or reduce the

number of cigarettes they smoke continue to inhale the sameamount of nicotine, and hence tar, from the cigarettes they smoke

x Heavy dependence on nicotine is strongly related to socioeconomicdisadvantage

x Smoking is a chronic relapsing addictive disease

Further readingx Royal College of Physicians. Nicotine addiction in Britain. London:

RCP, 2000.x Benowitz NL. Pharmacologic aspects of cigarette smoking and

nicotine addiction. N Engl J Med 1988;319:1318-30.x National Institutes of Health. Risks associated with smoking cigarettes

with low machine-measured yields of tar and nicotine. Bethesda, MD:Department of Health and Human Services, National Institutes ofHealth, National Cancer Institute, 2001. (NIH publication No02-5074.)

x Jarvis MJ. Patterns and predictors of unaided smoking cessation inthe general population. In: Bolliger CT, Fagerstrom KO, eds. Thetobacco epidemic. Basle: Karger, 1997:151-64.

Competing interests: MJJ has received speaker’s honorariums fromGlaxoSmithKline and Pharmacia. He is also director of an NHS fundedsmoking cessation clinic. See chapter 1 for the series editor’s competinginterests.

ABC of Smoking Cessation

6

3 Assessment of dependence and motivation to stopsmokingRobert West

Whether a smoker succeeds in stopping smoking depends onthe balance between that individual’s motivation to stopsmoking and his or her degree of dependence on cigarettes.Clinicians must be able to assess both of these characteristics.Motivation is important because “treatments” to assist withsmoking cessation will not work in smokers who are not highlymotivated. Dependence is especially important in smokers whodo want to stop smoking, as it influences the choice ofintervention. It is also important to bear in mind that:x Motivation to stop and dependence are often related to eachother: heavy smokers may show low motivation because theylack confidence in their ability to quit; lighter smokers mayshow low motivation because they believe they can stop in thefuture if they wishx Motivation to stop can vary considerably with time and bestrongly influenced by the immediate environmentx What smokers say about their wish to stop, especially in aclinical interview, may not accurately reflect their genuinefeelings.

Measuring dependence in smokersQualitative methodsThe simplest approach to measuring dependence on cigarettesis a basic qualitative approach that uses questions to find outwhether the smoker has difficulty in refraining from smoking incircumstances when he or she would normally smoke orwhether the smoker has made a serious attempt to stop in thepast but failed.

Quantitative methodsThe most commonly used quantitative measure of dependence isthe Fagerstrom test for nicotine dependence, which has provedsuccessful in predicting the outcome of attempts to stop. Thehigher the score on this questionnaire, the higher the level ofdependence: smokers in the general population score an averageof about 4 on this scale. Of all the items in the questionnaire,cigarettes per day and time to first cigarette of the day seem to bethe most important indicators of dependence.

Objective methodsThe concentration of nicotine or its metabolite, cotinine, inblood, urine, or saliva is often used in research as an objectiveindex of dependence because it provides an accurate measureof the quantity of nicotine consumed, which is itself a marker ofdependence. Carbon monoxide concentration of expired air isa measure of smoke intake over preceding hours; it is not asaccurate an intake measure as nicotine based measures, but it ismuch less expensive and gives immediate feedback to thesmoker.

How should dependence influence choice of treatment?The main value of measuring dependence in tailoring cessationinterventions to individual smokers is in the choice ofpharmacotherapy. The manufacturers of smoking cessationdrug products (principally nicotine replacement therapy andbupropion—see later chapters in this book) recommend that

• Likely to stop with minimal help• Primary intervention goal is to trigger a quit attempt

• Unlikely to stop but could do so without help• Primary intervention goal is to increase motivation

High

Motivation

Dependence

Low

Low

• Unlikely to stop without help but would benefit from treatment• Primary intervention goal is to engage smoker in treatment

• Unlikely to stop• Primary intervention goal is initially to increase motivation to make smoker receptive to treatment for dependence

High

Clinical intervention goals for smoking according to dependence andmotivation to quit

No/YesDo you find it difficult not to smoke in situations where you wouldnormally do so?

No/YesHave you tried to stop smoking for good in the past but found that youcould not?

A “yes” response to either of these questions would suggest that the smokermight benefit from help with stopping

10 or less11 to 2021 to 30

31 or more

0123

Q1. How many cigarettes per day do you usually smoke? (Write a number in the box and circle one response)

Within 5 minutes6-30 minutes31 or more

320

Q2. How soon after you wake up do you smoke your first cigarette? (Circle one response)

NoYes

01

Q3. Do you find it difficult to stop smoking in non-smoking areas? (Circle one response)

First of the morningOther

10

Q4. Which cigarette would you most hate to give up? (Circle one response)

NoYes

01

Q5. Do you smoke more frequently in the first hours after waking than the rest of the day? (Circle one response)

NoYes

01

Q4. Do you smoke if you are so ill that you are in bed most of the day? (Circle one response)

The Fagerstrom test for nicotine dependence: a quantitative index ofdependence. The numbers in the pink shaded column corresponding to thesmoker’s responses are added together to produce a single score on scale of0 (low dependence) to 10 (high dependence). Adapted from Heatherton etal. Br J Addict 1991;86:1119-27

This article reviews some simple methods to assessdependence and motivation in smokers

7

only smokers of 10 or more cigarettes a day should use theirproducts. However, the UK National Institute for ClinicalExcellence has recently recognised this cut off to be arbitraryand has not specified any particular lower limit for dailycigarette consumption.

Measuring motivation to stop smokingSurvey evidence in the United Kingdom shows that about twothirds of smokers declare that they want to stop smoking andthat in any year almost a third make an attempt to stop. Youngsmokers are widely believed to be less motivated to stop thanolder smokers, but in fact the reverse is true: older smokers aretypically less motivated.

However, only a minority of smokers attempting to stopcurrently use smoking cessation medications or attend aspecialist cessation service. This may reflect a lack of confidenceamong smokers that these treatments will help.

Direct questioningMotivation to stop can be assessed qualitatively by means ofsimple direct questions about their interest and intentions toquit. This simple approach is probably sufficient for mostclinical practice, although slightly more complex,semiquantitative measures (asking the smoker to rate degree ofdesire to stop on a scale from “not at all” to “very much”) canalso be used.

Stages of changeOne model of the process of behaviour change has becomepopular: the “transtheoretical model.” In this model, smokersare assigned to one of five stages of motivation:precontemplation (not wishing to stop), contemplation(thinking about stopping but not in the near future),preparation (planning to stop in the near future), action (tryingto stop), and maintenance (have stopped for some time).Smokers may cycle through the contemplation to action stagesmany times before stopping for good. This model has beenwidely adopted, though no evidence exists that the ratherelaborate questionnaires for assigning smokers to particularstages predict smoking cessation better than the simple directquestions outlined above.

Some clinicians use a smoker’s degree of motivation to stopas a prognostic indicator of likely success once the quit attempthas been decided. In fact, degree of motivation seems to play afairly small role in success; once a quit attempt is made, markersof dependence are far stronger determinants of success. Theultimate practical objective of assessing motivation is thereforeto identify smokers who are ready to make a quit attempt. Afterthat, it is the success of the intervention in overcomingdependence that matters.

Dependence and dose of nicotine in treatmentx The nicotine dose should be guided by measures of dependencex The higher strength forms of nicotine replacement are particularly

recommended for high dependence smokersx For nicotine therapy, high dependence smoking is typically

considered to be at least 15-20 cigarettes a day and/or smokingwithin 30 minutes of waking

Nicotine therapy will be covered in a later article in this series

Estimated prevalence of selected indices of motivation tostop smokingIndex % of

smokersWould like to stop smoking for good 70Intend to stop smoking in next 12 months 46Made an attempt to stop in a given year 30Used medication to aid cessation in a given year* 8Attended smokers clinic or followed behaviouralsupport programme†

2

*Based on surveys showing that 30% of smokers make a quit attempt each yearand that in 25% of quit attempts medication is used.†Based on figures from attendance in 2001 at NHS cessation clinics.

No/YesDo you want to stop smoking for good?

No/YesAre you interested in making a serious attempt to stop in the near future?

No/YesAre you interested in receiving help with your quit attempt?

Simple qualitative test of motivation to stop smoking. A “yes” response to allquestions suggests that behavioural support and/or medication should beoffered

Smoking

Not smoking

Not thinkingabout stopping

Contemplatingstopping

Stayingstopped

Attemptingto stop

Preparingto stop

Relaspingback to

smoking

Stages of change in process of stopping smoking. Adapted from Prochaskaet al. Clin Chest Med 1991;12:727-35

Key pointsx Motivation to stop smoking can be assessed with simple questionsx Once a decision to quit is made, success is determined more by the

degree of dependence than the level of motivationx Simple questions can identify heavily dependent smokersx For high dependence, higher strength nicotine products may help

Further readingx Kozlowski LT, Porter CQ, Orleans CT, Pope MA, Heatherton T.

Predicting smoking cessation with self-reported measures ofnicotine dependence: FTQ, FTND, and HSI. Drug Alcohol Depend1994;34:211-6.

x National Institute for Clinical Excellence. Technology appraisalguidance No 38. Nicotine replacement therapy (NRT) and bupropion forsmoking cessation. London: NICE, 2002.

x Sutton S. Back to the drawing board? A review of applications ofthe transtheoretical model to substance use. Addiction2001;96:175-86.

Competing interests: RW has done paid research and consultancy for,and received travel funds and hospitality from, manufacturers ofsmoking cessation products, including nicotine replacement therapiesand Zyban. See chapter 1 for the series editor’s competing interests.

ABC of Smoking Cessation

8

4 Use of simple advice and behavioural supportTim Coleman

The most effective methods of helping smokers to quit smokingcombine pharmacotherapy (such as nicotine or bupropion)with advice and behavioural support. These two componentscontribute about equally to the success of the intervention.Doctors and other health professionals should therefore befamiliar with what these strategies offer, encourage smokers touse them, and be able at least to provide simple advice andbehavioural support to smokers. They also need to be familiarwith other sources of support, such as written materials,telephone helplines, and strategies for preventing relapses. Thischapter focuses on non-pharmacological interventions.

Brief adviceThe Cochrane Tobacco Addiction Group defines brief adviceagainst smoking as “verbal instructions to stop smoking with orwithout added information about the harmful effects ofsmoking.” All the published guidelines on managing smokingcessation recommend that all health professionals should givesimple brief advice routinely to all smokers whom theyencounter. The success rate of brief advice is modest, achievingcessation in about 1 in 40 smokers, but brief advice is one of themost cost effective interventions in medicine. The previousarticle in this series gave tips on how to take account ofsmokers’ motivation to stop, but the key point is that only oneor two minutes are needed for effective brief advice to bedelivered in routine consultations.

Advice along these lines is probably most effective insmokers with established smoking related disease. It is alsomore effective if more time is spent discussing smoking andcessation and if a follow up visit is arranged to review progress.More intensive advice (taking more than 20 minutes at theinitial consultation), inclusion of additional methods ofreinforcing advice (such as self help manuals, videos, or CDRoms and showing smokers’ their exhaled carbon monoxidelevels), and follow up can increase success rates by a factor of1.4. Again, the cost effectiveness of these more intensiveinterventions is extremely high—higher than many of theinterventions provided routinely in primary or secondary care.The case is therefore strong to integrate simple advice into allhealth consultations with smokers and to offer more intensiveadvice and follow up to smokers who are motivated to quit.

Behavioural supportIntensive behavioural support provided outside routine clinicalcare by appropriately trained smoking cessation counsellors isthe most effective non-pharmacological intervention forsmokers who are strongly motivated to quit. Meta-analyses oftrials have shown that about 1 in 13 smokers who are motivatedenough to attend individual counselling from a smokingcessation counsellor are likely to quit as a result of this. Differentapproaches to counselling based on various psychologicalmodels have been studied, but no one type of intensivebehavioural support is clearly more effective than any other.Behavioural support usually involves a review of patients’smoking histories and their motivation to quit, with smokersbeing helped to identify situations where they might have a

Suggested phrasing for giving brief advice to smokersx “The best thing you can do for your health is to stop smoking, and I

would advise you to stop as soon as possible.”x “Tobacco is very addictive, so it can be very difficult to give up, and

many people have to try several times before they succeed. Yourchances of succeeding are much greater if you make use ofcounselling support, which I can arrange for you, and eithernicotine replacement therapy or the antismoking drug Zyban[bupropion], which I can prescribe for you if you wish.”

x “If you are ready to try to give up smoking now, then the best thingis to see a counsellor as soon as possible, and I can arrange that foryou. If not, then I’d like you to take home this leaflet and read it, orring the NHS smokers’ helpline, to get further information.”

x “The best thing is to get counselling from experts, but if this isn’tpossible, you should make sure that you have good information onthe health effects of smoking and some tips on ways of stoppingsmoking and that you know where to turn for further help andsupport.”

x “How do you feel about your smoking?”x “How do you feel about tackling your smoking now?”

Disc

ount

ed c

ost p

er y

ear o

f life

sav

ed (£

)

Pravast

atin i

n

primary

preve

ntion

of

cardio

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sease

Aspirin

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ary

preven

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5000

10 000

15 000

20 000

25 000

Cost effectiveness of brief advice versus common medical interventions

Measuring the level of carbon monoxide in smokers’exhaled air can motivate them to quit or be a usefultool in monitoring their progress with cessation

9

high risk of relapsing during a quit attempt; counsellors alsoencourage smokers to develop problem based strategies fordealing with these situations.

Intensive behavioural support is equally effective whetherfor an individual or on a group basis, but the latter is more costeffective (although not all smokers are willing to take part in agroup). Moreover, in a group, smokers gain mutual supportfrom other smokers who are trying to quit. Sessions aregenerally smoker oriented, and group facilitators, who manage20 to 25 smokers simultaneously, ensure that smokers’ keyconcerns about quitting are tackled.

Who should deliver theseinterventions?All doctors and other health professionals should provide briefadvice as a low intensity but routine intervention to all smokerswho use their services. For smokers who do not wish to take upintensive behavioural support, doctors or other professionalsshould, where possible, also provide advice and follow up inprimary and secondary care services; this should be providedeither directly by the primary or secondary care clinician or byarrangement with another healthcare professional. Intensivesupport services need to be available to all smokers by referral.How to organise and deliver these services is discussed later inthis series.

In the United Kingdom, smoking cessation services havenow been established as part of a national initiative, and allhealth professionals should be able to refer smokers forbehavioural support from a person who has specifically trainedfor this role. Any interested, trained health professional can bean effective smoking cessation counsellor, and those workingfor smoking cessation services in England come from variedclinical and non-clinical backgrounds.

Written self help materials andhelplinesSelf help materials that aim to promote smoking cessation aredefined by the Cochrane Collaboration as “structuredprogramming for smokers trying to quit without intensivecontact from a therapist.” This definition includes writtenleaflets, videos, and CD Roms. Giving smokers self helpmaterials is more effective than doing nothing but is not aseffective as simple advice. The effectiveness of self helpmaterials may be improved by tailoring them to individualsmokers’ needs. Telephone helplines are widely available andprovide a simple alternative means of providing low costcounselling or advice to motivated smokers, although they arealso less effective than face to face advice from a healthprofessional.

Complementary therapiesComplementary therapies have been advocated by some aseffective cessation interventions, but little evidence exists tosupport their use. Acupuncture and related therapies such asacupressure have been found to be no more effective thanplacebo therapies. Similarly, although hypnotherapy is alsoprovided in the belief that it can weaken the desire to smoke orcan strengthen the will to stop, no convincing evidence existsthat it works. Designing placebo care for randomised, controlledtrials of complementary therapies is challenging, but withoutsuch trials no conclusions can be reached about the utility ofcomplementary therapies in smoking cessation.

Strategies used in intensive behavioural supportx Review smoking history—number smoked per day, time of first

cigarette in the day. Ask smoker to keep diary of activities thatcoincide with smoking

x Review smoking behaviour—past quit attempts, what helped, andreasons for failure

x Emphasise need for total abstinencex Emphasise need to combat psychological and physical nicotine

addiction, where appropriatex Identify triggers to smoking and encourage smoker to develop

strategies for countering these (for example, avoid places oractivities associated with smoking)

x If relevant, encourage smoker to develop strategies for avoidingrelapse when drinking alcohol

x Encourage appropriate action: set quit date, inform or enlistsupport of peer group or family, and prescribe nicotine addictiontreatment

x Follow up to review progress and prescribe or issue nicotineaddiction treatment

Written leaflets can also help people to stop smoking

Websites giving quitline informationx http://cancercontrol.cancer.gov/tcrb/quitlines.html (United States)x www.ash.org.uk/html/quit/givingup.html (for guide to UK quitlines)x www.asianquitline.org (UK, for Asians)x www.quitnow.info.au/quitlineinfo.html (Australia)x www.quit.org.nz (New Zealand)

Adequate training in smoking cessationcounselling is much more importantthan the discipline of the healthprofessional providing that support

The challenge for those who advocate complementarytherapies in smoking cessation is to provide evidence fortheir effectiveness

ABC of Smoking Cessation

10

Prevention of relapseMost smokers who are trying to stop make several quit attemptsbefore they succeed. Consequently, smokers have frequentlybeen provided with treatments that health professionals believewill help smokers to sustain quit attempts and will help toprevent relapse. Recent American guidelines on smokingcessation recommended that when clinicians encounter apatient who has recently quit smoking they should reinforce thepatient’s decision to quit and help the patient to resolve anyresidual problems.

Combination with pharmacotherapyAll the evidence on the combination of non-pharmacologicaland pharmacological interventions indicates that the effectsmultiply rather than add together. Therefore the effectiveness ofall non-pharmacological therapy is increased substantially bypharmacotherapy, and the more intensive thenon-pharmacological support, the greater the extent of thatincrease. It is therefore important that non-pharmacologicalinterventions are recognised as equal contributors to the overallsuccess of smoking cessation interventions, which can achieveup to 20% success with any quit attempt, and that they are notdiscarded as inferior or irrelevant alternatives to drugtreatment. The provision of non-pharmacological interventions,ranging from simple advice to intensive behavioural support,needs to become a routine component of healthcare delivery tosmokers.

Competing interests: TC has been paid for speaking at a conference byGlaxoSmithKline, a drug company that manufactures treatments fornicotine addiction; he has also done consultancy work on one occasion forPharmacia. See chapter 1 for the series editor’s competing interests.

% o

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Inten

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6

9

12

15

Comparison of effective smoking cessation interventions: percentage ofsmokers who quit as a result of the intervention. Adapted from Raw et al.Thorax. 1998;53(suppl 5, part 1):S1-19

Key pointsx Simple advice to give up smoking is one of the most cost effective

interventions in medicinex Doctors and other health professionals should routinely give brief,

non-judgmental advice to stop smoking to all smokers they seex Self help materials such as leaflets, videos, or helplines provide

additional supportx Intensive behavioural support from a trained counsellor is the most

effective non-drug treatment for smokersx Behavioural support is equally effective for groups and individualsx The most effective interventions combine behavioural support with

drug treatmentx Therapy that combines drug treatment with the level of behavioural

support most acceptable to the smoker should be routinelyavailable to all smokers

Further readingx Silagy C, Stead LF. Physician advice for smoking cessation. Cochrane

Database Syst Rev 2003;(2):CD000165.x Lancaster T, Stead LF. Individual behavioural counselling for

smoking cessation. Cochrane Database Syst Rev 2003;(2):CD001292.x Lancaster T, Stead LF. Self-help interventions for smoking

cessation. Cochrane Database Syst Rev 2003;(2):CD001118.x Stead LF, Lancaster T. Group behaviour therapy programmes for

smoking cessation. Cochrane Database Syst Rev 2003;(2):CD001007.x Stead LF, Lancaster T, Perera R. Telephone counselling for smoking

cessation. Cochrane Database Syst Rev 2003;(2):CD002850.

Use of simple advice and behavioural support

11

5 Nicotine replacement therapyAndrew Molyneux

Although products for nicotine replacement therapy (NRT)have been available for over 20 years, they have been excludeduntil recently from state or insurance based health serviceprovision in the United Kingdom and many other countries.They have therefore not been widely prescribed by doctors whohelp smokers wanting to quit. Recent changes in funding policyin the United Kingdom and new guidance from the NationalInstitute for Clinical Excellence (which covers England andWales) mean that NRT products can and should now be madeavailable to all smokers who want to stop smoking.Like other pharmacological interventions for helping smokersto quit (see the next chapter), NRT is most effective when usedin conjunction with behavioural and other types ofnon-pharmacological cessation interventions.

Mechanism of actionThe main mode of action of NRT is thought to be thestimulation of nicotinic receptors in the ventral tegmental areaof the brain and the consequent release of dopamine in thenucleus accumbens. This and other peripheral actions ofnicotine lead to a reduction in nicotine withdrawal symptoms inregular smokers who abstain from smoking.

NRT may also provide a coping mechanism, makingcigarettes less rewarding to smoke. It does not completelyeliminate the symptoms of withdrawal, however, possibly becausenone of the available nicotine delivery systems reproduce therapid and high levels of arterial nicotine achieved when cigarettesmoke is inhaled.

All the available medicinal nicotine products rely onsystemic venous absorption and do not therefore achieve suchrapid systemic arterial delivery. It takes a few seconds for highdoses of nicotine from a cigarette to reach the brain; medicinalproducts achieve lower levels over a period of minutes (for nasalspray or oral products such as gum, inhalator, sublingual tablet,or lozenge) and hours (for transdermal patches).

Evidence for effectivenessThe most recent Cochrane reviews suggest that NRT leads to anear doubling of cessation rates achieved bynon-pharmacological intervention, irrespective of the level ofthat intervention.

NRT will therefore increase the chance of success with anyquit attempt but is most effective when combined with intensivebehavioural support.

No evidence exists that NRT is any more or less effective inany specific subgroups of smokers, such as those in hospital orpresenting with a smoking related disease. The effectiveness ofNRT in adolescents and children who smoke has not beenestablished, though studies are in progress.

Who should receive NRT?Nicotine replacement therapy, preferably in conjunction withbehavioural support (see the previous chapter), shouldgenerally be offered to any regular cigarette smoker

Plas

ma

nico

tine

conc

entra

tion

(ng/

ml)

0

10

15

20

5

0

20

40

60

80

100

Cigarette(nicotine delivery, 1-2 mg)

Cigarette(nicotine delivery, 1-2 mg), arterial

Plas

ma

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conc

entra

tion

(ng/

ml)

0

10

15

20

5

Oral snuff

Minutes

Plas

ma

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conc

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tion

(ng/

ml)

0 30 60 90 1200

10

15

20

5

Gum(nicotine delivery, 4 mg)

0Spray

0

10

15

20

5

Nasal spray(nicotine delivery, 1 mg)

Minutes

0 30 60 90 120 1600

10

15

20

5

Transdermal patch(nicotine delivery, 15 mg)

Rise in blood nicotine concentrations after smoking a cigarette and afterusing different NRT products (after overnight abstinence from cigarettes).Values are for venous blood, except where shown. Adapted fromHenningfield JE. N Engl J Med 1995;333:1196-203

Proportion of smokers abstaining from smoking long term,by cessation intervention. Adapted from West et al, 2000*

InterventionLong term

abstinence (%)No intervention (willpower alone) 3Brief, opportunistic advice from doctor to stop 5

Plus NRT 10Intensive support from specialist 10

Plus NRT 18

*See Further Reading box

This article outlines the mechanism of action of nicotinereplacement therapy (NRT), the evidence for itseffectiveness, and how and when NRT products canbe used

12

prepared to make a quit attempt. NRT is relatively unlikely tohelp smokers who are not motivated to quit or do notexperience or expect to experience nicotine withdrawalsymptoms. Any healthcare professionals can assess thesecharacteristics in the following ways:x Motivation to quit: smokers should be asked whether theywould like to stop smoking. Those willing to stop within thenext 30 days should set a quit date and their dependenceshould be assessed.x Dependence: smokers should be asked whether they havetried to quit smoking before, whether they experiencedsymptoms of nicotine withdrawal, and whether they anticipatethese symptoms in a future quit attempt.

Formulations and use of NRTSix NRT formulations are currently available. In the UnitedKingdom, all of these are now available on prescription throughthe NHS and most can also be bought over the counter atpharmacies. In addition, patch, gum, and lozenge formulationsare on general sale in supermarkets and other outlets. As littleevidence exists that any one of these formulations is moreeffective than any other or that any is more effective inparticular subgroups of smokers, the choice of product shouldgenerally be guided by the smoker’s preference and clinicalconsiderations relating to duration of action.

Evidence exists, however, that higher dose gum is moreeffective than lower dose gum in those smoking 20 or morecigarettes a day, that higher dose patches are more effectivethan low dose patches in those smoking more than 10cigarettes a day, and that combining products (such as patchand nasal spray, or patch and inhalator) is more effective thanusing single agents alone. NRT, and nicotine gum in particular,has also been shown to help to control the weight gaincommonly experienced after cessation.

NRT should be prescribed in blocks, usually of two weeks, becontinued in those maintaining abstinence from cigarettes for atotal of six to eight weeks, and then discontinued. If possible,NRT prescriptions should be linked to the delivery of follow upbehavioural support. The prescriptions can be issued throughdelegated prescribing by nurses or other health professionals.

No evidence shows that gradual withdrawal of NRT is betterthan abrupt withdrawal. The risk of dependence on NRT issmall, and only a small minority of patients (about 5%) who quitsuccessfully continue to use medicinal nicotine regularly in thelonger term.

Studies investigating the use of NRT to help smokers toabstain from smoking for certain periods (for example, at workor in a public place) or to reduce the number of cigarettes theysmoke each day are in progress.

Safety of NRTObtaining nicotine from NRT is considerably safer than doingso from cigarettes, as the patient is not exposed to any of themany harmful products of tobacco combustion.

Long term use of NRT is not thought to be associated withany serious harmful effects. Concerns over the safety of NRT incircumstances in which nicotine might be harmful—such as inpregnancy, cardiovascular disease, or in adolescents—thereforeneed to be considered in relation to the safety of the likelyalternative, which is continued intake of nicotine fromcigarettes.

Offer nicotine replacement therapy

No

No

Yes

Yes

Assess motivation to quit:is smoker willing to stop in next 30 days?

Give clear adviceto stop smoking

Assess dependency on nicotine: past or anticipatedwithdrawal symptoms (craving for cigarettes, irritability,aggression, anxiety, depression, poor concentration)?

Help smoker tostop smoking

Decision pathway for giving nicotine replacement therapy

NRT formulations and their availabilityTransdermal patch—On general sale,* at pharmacies, and on

prescriptionGum—On general sale,* at pharmacies, and on prescriptionNasal spray—At pharmacies and on prescriptionInhaler—At pharmacies and on prescriptionSublingual tablet—At pharmacies and on prescriptionLozenge—On general sale,* at pharmacies, and on prescription*In supermarkets and other outlets

Nicotine gum products

Prescribing details for NRT formulations

Formulation (dose) UsePatch (16 h patch: 15, 10, or 5 mg;24 patch: 21, 14, or 7 mg)

One daily on clean, unbrokenskin; remove before bed (16 hpatch) or next morning (24 h);new patch, fresh site

Gum (2 or 4 mg per piece) Chew gum until taste is strong,then rest gum between gum andcheek; chew again when taste hasfaded

Inhalator (10 mg per cartridge) Inhale as requiredSublingual tablet (2 or 4 mgper piece)

Rest under tongue until dissolved

Lozenge (1, 2, or 4 mg per piece) Place between gum and cheekand allow to dissolve

Nasal spray (10 mg/ml, 0.5 mgper spray)

One spray each nostril asrequired

Side effects for all formulations: sore throat, hiccups, indigestion, nausea,headache, palpitations (but without hiccups for the inhalator and plus itching,erythma, and rash for patches).

Smokers should be advised not to smoke while usingNRT products

Nicotine replacement therapy

13

Pregnancy and breast feedingSmoking during and after pregnancy poses a serious risk to thehealth of both mother and baby. NRT may also have adverseeffects on placental function and fetal development, butalthough the magnitude of these pure nicotine effects inhumans is uncertain, the likelihood is that obtaining nicotinefrom cigarette smoke is far more harmful.

Complete avoidance of all nicotine should therefore be theobjective in pregnancy and breast feeding, and 30% of pregnantwomen succeed in stopping smoking during pregnancy withoutpharmacological support. However, for those who do notsucceed, or have previously failed in an attempt to quit, the useof NRT to support smoking cessation in pregnancy is justifiablein relation to the risk of continued smoking. Pregnant or breastfeeding women who make an informed choice to try NRTshould probably be advised to use shorter acting products tominimise fetal exposure to nicotine overnight.

Cardiovascular diseaseNicotine replacement therapy is safe in smokers with stablecardiovascular disease. In acute cardiovascular conditions, suchas unstable angina, acute myocardial infarction, or stroke, NRTshould be used with caution because nicotine is avasoconstrictor. However, as medicinal nicotine is unlikely to bemore harmful in this context than continued intake of nicotine(and the associated tar, carbon monoxide, and other products)from cigarettes, it is appropriate to offer NRT to help insmoking cessation in patients with acute cardiovascular diseasewho continue to smoke. In these circumstances it is probablyadvisable to use rapidly reversible preparations—such as gum,inhalator, nasal spray, or lozenge—as absorption of nicotineceases when the product is withdrawn; after removal of atransdermal patch, however, the skin can continue to absorbnicotine slowly from the skin for some time.

Young smokersMost adult smokers established their smoking habit as children.Even in adolescence, many smokers are addicted to nicotine andwould like to stop smoking. Over two thirds of adolescentsmokers have tried to stop, and failed. Although no randomisedcontrolled trials of the effectiveness of NRT in young smokershave been published, several NRT products are licensed for use insmokers aged under 18, on medical advice. In addition, the recentNational Institute for Clinical Excellence guidance on NRTsuggests that smokers under 18 who want to quit using NRTshould discuss this with a relevant healthcare professional. Untilfurther evidence arises to the contrary, it therefore seemsreasonable to use NRT in adolescent smokers who are motivatedto quit and show evidence of nicotine dependence.

Competing interests: AM has received research funding and beenreimbursed for attending conferences by Pharmacia, a manufacturer ofNRT. He has also received speaking fees and been reimbursed forattending a conference by GlaxoSmithKline, which manufacturesbupropion and NRT. See chapter 1 for the series editor’s competinginterests.

Key pointsx Nicotine replacement therapy is an effective aid to smoking

cessationx Smokers who are motivated to quit and are dependent on nicotine

should be offered NRTx The choice of NRT product should normally be guided by the

patient’s preferencex NRT should be prescribed for six to eight weeks, in blocks of up to

two weeks, contingent on continued abstinencex Obtaining nicotine from NRT is considerably safer than smokingx NRT is safe in stable cardiac disease, but caution is needed in

unstable, acute cardiovascular disease, pregnancy, or breast feeding,or in those aged under 18

Further readingx Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement

therapy for smoking cessation. Cochrane Database Syst Rev2000;CD000146.

x Tobacco Advisory Group of the Royal College of Physicians.Nicotine addiction in Britain. RCP: London, 2000.

x West R, McNeill A, Raw M. Smoking cessation guidelines for healthprofessionals: an update. Thorax 2000;55:987-99.

x Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Fox BJ, GoldsteinMG, et al. A clinical practice guideline for treating tobacco use anddependence. JAMA 2000;283:3244-54.

The photo of the pregnant woman is with permission fromFaye Norman/SPL.

ABC of Smoking Cessation

14

6 Bupropion and other non-nicotinepharmacotherapiesElin Roddy

Although nicotine replacement has been the first line drugtreatment for smoking cessation for many years, other drugs ofproved efficacy are also now available. Foremost among these isbupropion (marketed as Zyban). Bupropion was developed andinitially introduced in the United States as an antidepressant butwas subsequently noted to reduce the desire to smoke cigarettesand shown in clinical trials to be effective in smoking cessation.

Mechanism of actionBupropion is an atypical antidepressant structurally similar todiethylpropion, an appetite suppressant. The mechanism of theantidepressant effect of bupropion is not fully understood, butbupropion inhibits reuptake of dopamine, noradrenaline, andserotonin in the central nervous system, is a non-competitivenicotine receptor antagonist, and at high concentrations inhibitsthe firing of noradrenergic neurons in the locus caeruleus.

It is not clear which of these effects accounts for theantismoking activity of the drug, but inhibition of the reductionsin levels of dopamine and noradrenaline levels in the centralnervous system that occur in nicotine withdrawal is likely to beimportant. The antismoking effect of bupropion does not seemto be related to the antidepressant effect as bupropion is equallyeffective as a smoking cessation therapy in smokers with andwithout depression.

Evidence for effectivenessWhen given in association with intensive behavioural support,bupropion is as effective as nicotine replacement therapy(NRT), and like NRT, leads to a near doubling of the smokingcessation rate, achieving long term abstinence in 19% ofsmokers who use it to quit.

The effectiveness of bupropion in conjunction with lessintensive levels of behavioural support has not been tested inclinical trials. Like NRT, however, bupropion therapy probablyincreases the chance of success with any quit attempt but ismost effective when combined with intensive behaviouralsupport. No evidence suggests that bupropion is any more orless effective in any specific subgroups of smokers, such as thosein hospital or those with a smoking related disease.

Bupropion also seems to attenuate the weight gain thatoften occurs after quitting. More prolonged use of bupropion(beyond the recommended eight weeks) seems to confer furtherprotection against relapse.

Using bupropionDoseBupropion is marketed in the United Kingdom as an oralprolonged release 150 mg tablet. An eight week course oftreatment is recommended and costs about £86 ($143; €123).Smokers should start taking bupropion one week before theirintended quit date. A reduced dose—that is, one tablet daily—isrecommended in elderly people and those with liver or renalimpairment.

Dopaminereuptakeinhibition

Corpuscallosum

Non-competitivenicotine

antagonist

Noradrenergicinhibition

Serotoninreuptakeinhibition

Ventraltegmentalarea

Raphénuclei

Pedunculo-pontinenucleus

Central nucleusof the amygdala

Hippocampus

Bed nucleus ofstria terminalis

Nucleusaccumbens

shell

Prefrontalcortex

Effects of bupropion on the central nervous system

Week

Abst

inen

ce ra

te (%

of p

atie

nts)

1 2

Quit day (day 8 of treatment)

3 4 5 6 7 8 9

End oftreatment

10 11 12 26 520

20

40

60

80

100Placebo (n=160)

Nicotine patch (n=244)

Bupropion (n=244)

Bupropion and nicotine patch (n=245)

Abstinence from smoking in relation to sustained release bupropion ornicotine patch, or both. Adapted from Jorenby et al. N Engl J Med1999;340:685-91

Week 1

Weeks 2-8

Days 6-7: 150 mg twice daily

150 mg twice daily

Days 1-6: 150 mg once daily

Quit smoking between day 7and day 14 of treatment

Dose regimen for bupropion

Bupropion is the only non-nicotine drug licensed for usein smoking cessation in the United Kingdom and theEuropean Union; it became available for use in 2000

15

Unwanted effectsThe most serious adverse effect of bupropion is seizure, whichaffects an estimated 1 in 1000 users. More common side effectsinclude dry mouth, insomnia, skin rash, pruritus, andhypersensitivity. Rarely the drug may cause a reactionresembling serum sickness.

Contraindications and precautionsBupropion is contraindicated in patients with current or pastepilepsy. It should also be used with extreme caution in patientswith conditions predisposing to a low threshold for seizure—history of head trauma, alcohol misuse, diabetes treated withhypoglycaemic agents or insulin—and in patients taking drugsthat lower the seizure threshold (for example, theophylline,antipsychotics, antidepressants, and systemic corticosteroids).

Bupropion is also contraindicated in patients with a historyof anorexia nervosa and bulimia, severe hepatic necrosis, orbipolar disorder.

Pharmacokinetics and interactionsBupropion reaches a peak plasma concentration three hoursafter oral administration, with steady state concentrationreached within eight days. It has a half life of 20 hours and ismetabolised in the liver by cytochrome p450.

Use with NRTOne study has suggested that combined nicotine patch therapyand bupropion may produce higher quit rates than nicotinepatches alone. Combination therapy may therefore berecommended to patients attending specialist cessation clinicswho find it difficult to quit using a single pharmacotherapy.Monitoring for hypertension is recommended when combinedtherapy is used.

Special groupsChronic obstructive pulmonary disease—Smoking cessation is

the most important intervention in this disease. Bupropion hasbeen shown to be effective and well tolerated in this group ofpatients.

Ischaemic heart disease—Smoking cessation is one of the mostimportant interventions in this disease. Bupropion is notcontraindicated or subject to caution except in diabetic patientstreated with hypoglycaemic agents or insulin (caution) or inpatients taking propafenone or flecainide (dose reduction ofantiarrhythmics advised).

Power of the pressx The use of bupropion has been inhibited in the United Kingdom

by a series of articles in national newspapers soon after the drugwas launched

x These implicated bupropion in some serious adverse effects,including death, in a number of cases

x Post-marketing surveillance has since shown that serious adverseevents are rare with bupropion, occurring at about half the averagereported rate for new drugs in Britain

Study week

% o

f pat

ient

s ab

stai

ning

5 6 7 10 12 260

10

15

20

25

30

35

5Bupropion

Placebo

Long term abstinence from smoking in patients with chronic obstructivepulmonary disease, after treatment with bupropion. Adapted from Tashkinet al. Lancet 2001;357:1571-5

Bupropion should not be used with a monoamine oxidaseinhibitor, and at least 14 days should elapse betweenstopping such treatment and starting bupropion

Bupropion interacts with a number of commonly useddrugs, including some antidepressants, type 1cantiarrhythmics, and antipsychotics

Interactions of bupropion

Drug Mechanism of interaction Action requiredAntidepressants (desipramine, fluoxetine)

Prolongs action of drugs metabolised bycytochrome p450 (CTP2D6)

Start these drugs at low end of dose range in patientsalready taking bupropion. Decrease dose of ongoingtreatment with these drugs if patient starts bupropion

Antipsychotics (risperidone, thioridazine)Type 1c antiarrhythmics (propafenone,flecainide)� blockers (metoprolol)Antiepileptics (carbamazepine,phenobarbitone, phenytoin) Metabolism of bupropion induced Bupropion dose increase not recommended*

Levodopa Limited clinical data suggest higherincidence of adverse events

Give bupropion with caution to patients receivinglevodopa

MAOIs (including moclobemide) Avoid using bupropion for two weeks after MAOIs

Ritonavir Increased plasma bupropionconcentration; risk of increased toxicity Avoid concomitant use

MAOI = mono amine oxidase inhibitor.*Bupropion contraindicated in epilepsy.

ABC of Smoking Cessation

16

Pregnant women—No trials of bupropion have been done inpregnant women. Bupropion is therefore not recommended foruse in pregnancy.

Other antidepressantsNortriptyline, a tricyclic antidepressant with mostlynoradrenergic properties and a small amount of dopaminergicactivity, is also effective in cessation therapy, and although fewclinical trials have been done, these suggest an effect of similarmagnitude to that of bupropion. Again, this effect seems to beindependent of the presence of depressive symptoms.

Several other antidepressants have been used in smokingcessation including imipramine, doxepin, venlafaxine,fluoxetine, and the reversible monoamine oxidase inhibitormoclobemide. The latter may be effective in some patients, butthe effectiveness of other therapies is unproved.

Other pharmacotherapiesClonidine is an � noradrenergic agonist that suppresses

sympathetic activity and has been used for hypertension and toreduce withdrawal symptoms associated with misuse of alcoholand opiates. Both in its oral and low dose patch formulation,clonidine increased smoking cessation in eight out of nine trials,but the drug is associated with serious side effects, includingsedation and postural hypotension. Clonidine is thereforeprobably best reserved for smokers who cannot or do not wishto use NRT, bupropion, or nortriptyline.

Mecamylamine is a nicotinic antagonist originally used todecrease cholinergic activity and thus reduce blood pressure. Itblocks the effects of nicotine but does not precipitatewithdrawal symptoms. Two trials have suggested that a low dosemecamylamine patch combined with a nicotine patch wassuperior to placebo, but a recent multicentre trial has failed toshow efficacy.

Sensory replacement therapy could be useful for the manysmokers who report missing the sensory aspects of smoking.Sensory effects of smoking are important in reinforcingsmoking behaviour, and loss of these effects may contribute torelapse. Two inhalers containing ascorbic acid or citric acid havebeen tested, and both increased rates of short term cessation.Further testing of these adjuncts to NRT or other non-nicotinetherapies is warranted, but neither of these treatments iscurrently used routinely in specialist cessation clinics.Competing interests: ER has been reimbursed by GlaxoSmithKline, themanufacturer of bupropion, for attending one international meeting andhas attended educational events sponsored by Pharmacia, themanufacturer of Nicorette. See chapter 1 for the series editor’s competinginterests.

Non-nicotine therapies for smoking cessationProved effective—Bupropion, clonidine, nortriptylinePossibly effective—Noradrenergic antidepressants, monoamine oxidase

inhibitors, mecamylamine plus nicotine replacement therapy,sensory replacement

Ineffective or insufficient evidence—Anorectics, benzodiazepines,� blockers, buspirone, caffeine, ephedrine, cimetidine, dextrose,lobeline, naltrexone, ondansetron, phenylpropanolamine, silveracetate, stimulants, selective serotonin reuptake inhibitors

Key pointsx NRT is the treatment of choice, but non-nicotine drugs are also

available as an alternativex Bupropion is the most commonly used non-nicotine treatmentx Bupropion is generally safe and well toleratedx Bupropion is as effective as NRT and doubles quit rates when given

alongside intensive behavioural supportx Bupropion must not be given to patients at increased risk of

seizuresx Nortriptyline has been less widely studied, but its effectiveness

seems similar to that of bupropionx Any risks associated with these therapies are likely to be much less

serious than the risks from continued smoking

Further readingx Antidepressants for smoking cessation. Cochrane Database Syst Rev

2003;(3):CD000031x Royal College of Physicians of London. Nicotine addiction in Britain.

London: RCP, 2000.x Hurt RD, Sachs DPL, Glover ED, Offord KP, Johnston JA, Dale LC,

et al. A comparison of sustained-release bupropion and placebo forsmoking cessation. N Engl J Med 1997;337:1195-202.

No trials of bupropion have been done in smokers agedunder 18, and the drug is not licensed or recommendedfor smoking cessation in this age group

Elin Roddy is clinical research fellow at the University of Nottinghamin the division of respiratory medicine at City Hospital, Nottingham.

Bupropion and other non-nicotine pharmacotherapies

17

7 Special groups of smokersTim Coleman

Earlier articles in this series have provided general guidance ondelivering smoking cessation interventions. This chapterinvestigates issues relevant to several special groups of smokers.

Pregnant womenIn the United Kingdom over a quarter of pregnant women whosmoke continue to do so during pregnancy. These women tendto be young, single, of lower educational achievement, and inmanual occupations. If they have a partner, their partner is alsomore likely to smoke. Smoking has substantial adverse effectson the unborn child, including growth retardation, pretermbirth, miscarriage, and perinatal mortality. Most of this harm isprobably caused by toxins in cigarette smoke, such as carbonmonoxide, nicotine, cyanide, cadmium, and lead. Nicotine itselfmay cause harm, however, through placental vasoconstrictionand possible developmental effects on the fetus.

Ideally, women should stop smoking before gettingpregnant. In practice, however, few do, and it is pregnancy itselfthat seems to be the key motivator to stop. About a quarter ofwomen who smoke manage to stop for at least part of theirpregnancy, mostly within the first trimester, but most of thesestart smoking again after their child is born.

Most pregnant women (80% in UK surveys) accept thatstopping smoking is the most important lifestyle change thatthey can make during pregnancy, and consequently mostwomen will be receptive to discussion of their smoking and thepossibility of stopping. Those who continue to smoke, however,tend to hold rather different views from those who give up—forexample, only about 30% of those who continue to smokebelieve that smoking during pregnancy is “very dangerous” totheir baby, compared with 80% of those who quit. It is,therefore, particularly important that health professionals tailortheir message to the perceptions and beliefs of smokers indifferent stages of pregnancy.

Evidence based cessation interventions

Behavioural interventionsThe effectiveness of brief interventions by different healthprofessionals is not as clearly established for pregnant smokersas for non-pregnant smokers, but some form of intervention isclearly necessary to prompt cessation. However, intensivecessation programmes delivered to pregnant women byspecially trained staff outside routine antenatal care are ofproved effectiveness in promoting cessation and in reducinglow birth weight and preterm birth.

For every 100 pregnant women who are still smoking at thetime of their booking an antenatal visit, about 10 will stopsmoking with “usual care” and a further six or seven can beencouraged to stop as a result of formal cessation programmes.As the available trials have investigated the effects of variedprogrammes—with few common elements—it is difficult to drawconclusions about which facets of these are effective.

PharmacotherapyIdeally, to minimise potential adverse effects on the fetus,pregnant smokers should give up smoking without resort topharmacotherapy. In practice, however, many do not. Thus, the

Year

% o

f wom

en s

mok

ing

in 1

2 m

onth

sbe

fore

thei

r pre

gnan

cy

1992 1993 1994 1995 1996 1997 1998 19990

10

20

30

40

50

% o

f wom

en w

ho c

ontin

ue to

sm

oke

durin

g pr

egna

ncy

0

10

20

30

40

50

Prevalence of smoking in women before and during pregnancy, 1992-9.Adapted from Owen and Penn, 1999 (see Further Reading box)

Clinical issues to highlight or be aware of in relation topregnant women who smoke*

Clinical issue ReasonWomen should stop smokingearly in pregnancy if possible

Early quitting provides thegreatest benefit to the fetus

Women can stop smoking anytime during pregnancy

Fetus benefits even when womenquit later in pregnancy

Emphasise the immediate benefitsof stopping smoking

Both mother and baby willbenefit very soon after stopping

Provide pregnancy related,motivational messages

These messages are associatedwith higher quit rates

Be alert to patients minimising ordenying their smoking

Minimising or denying smokingis common among pregnantwomen who smoke

*Adapted from Fiore MC et al. Smoking cessation. Clinical practice guideline No 18.Rockville, MD: Department of Health and Human Services, Pubic HealthService, Agency for Health Care Policy and Research., 1998. (US AHCPRpublication No 96-0692.)

Possible evidence based approach tocessation intervention in pregnancyx Doctors and midwives should use their

consultations to identify women who aremotivated to try to stop

x They should then refer them for individual,intensive smoking cessation interventions

x These interventions can be delivered by specialistcessation services or any health professional withadequate time and training (see earlier chapter)

Generally the more intensive the intervention the moreeffective it is; however, group based intensiveinterventions for pregnant women have tended to bepoorly attended

18

relative risks and benefits of pharmacotherapy need to beconsidered. As bupropion is specifically contraindicated inpregnancy, and other antidepressants are subject to specialcaution, the treatment of choice is nicotine replacement therapy(NRT). Any safety concerns about this treatment can bediscounted by the fact that the alternative for most women iscontinued smoking and hence continued fetal exposure tonicotine and other toxins. To avoid unnecessary exposure of thefetus to nicotine it is probably advisable to avoid the longeracting NRT formulations, such as 24 hour transdermal patches.

However, although the only published placebo controlledtrial of NRT in pregnancy showed a significant increase in birthweight in babies born to women who used NRT, it showed noeffect on cessation. This is an area of high priority for furtherresearch.

AdolescentsIn Britain, the proportion of young people starting to smokehas remained fairly stable over the past 20 years. In 1988, 8% of11 to 15 year olds in England were regular smokers; by 1996the proportion had increased to 13%, but since 1998 the figurehas remained around 10%. As 80% of smokers start smoking asteenagers, the prevalence of smoking among teenagers hasserious implications for public health. Young smokers are awareof the health risks of smoking and most would like to stop, buttheir attitudes towards their habit are more changeable thanthose of adult smokers. Although young smokers reportsmoking few cigarettes, many consider themselves to beaddicted to tobacco and believe that stopping would be difficult.Young smokers are also more likely to drink alcohol or takeillicit drugs.

Reducing smoking among young people presents achallenge for health professionals. Preventing uptake ofsmoking would result in the greatest population health gain,but the reasons why adolescents start smoking are many andcomplex (see chapter 2). Young people who have friends andfamily members who smoke are more likely to start themselves,and, for many young people, smoking is a social activity, withthe first cigarette being provided by friends.

Many school based education campaigns aimed atpreventing children from starting smoking have been studied,but the studies have shown mixed results. And as most of thiswork has been conducted in North America, the findings mightnot be completely generalisable to education systems in othercountries. No evidence exists that campaigns involving givinginformation alone are effective, but where educationalcampaigns train young people to resist the social influences thatencourage them to smoke, they can be effective.

“Social influence training” introduces young people to skillsthat, if used, reduce their likelihood of becoming regularsmokers—for example, skills for refusing cigarettes whenoffered by peers. The best methods for preventing uptake ofsmoking by young people have yet to be discovered, and broadbased prevention programmes that tackle the many factorsinvolved in this have been advocated. One possible role forhealth professionals in such a universal strategy is to give briefadvice reinforcing the health risks posed by smoking wheneveryoung people present for health care.

Information is lacking about which smoking cessationinterventions are effective for young people. Brief advice orbehavioural counselling is likely to be effective, but this has yetto be proved. No randomised placebo controlled trials of NRThave been conducted among young smokers, and neither NRTnor bupropion is currently licensed for use in Britain in theunder 16s. The best methods for delivering antismoking

Cessation interventions in pregnancy: recommendations andevidence*

RecommendationStrength ofevidence

Pregnant smokers should be strongly encouraged tostop throughout pregnancy; pregnant smokersshould be offered intensive counselling treatment ABrief interventions (for example, brief advice fromhealth professionals) should be used if more intensiveinterventions are not feasible CMotivational messages on the impact of smokingboth on the pregnant woman and on the fetus shouldbe given CNicotine replacement therapy should be used duringpregnancy if the benefits of using this (increasedlikelihood of cessation) outweigh the risks (from extranicotine if women use the therapy and continue tosmoke)

C

A = many well designed randomised controlled trials with a consistent patternof findings. C = recommendation based on panel consensus in the absence ofevidence from randomised controlled trials.*Adapted from Fiore MC et al (details as for table, previous page).

Year

% o

f reg

ular

sm

oker

s

19820

4

6

8

10

12

14

16

2

84 86 88 90 92 94 96 98 99 2000 01 02

Boys

Girls

Total

Prevalence of regular cigarette smoking in schoolchildren aged 11-15 inEngland, 1982-2002. Data from the Department of Health Statistics

Preventing uptake of smoking by young people

Factor to be tackled InterventionInfluence of family members(parental smoking, siblingsmoking, and family attitudesto smoking)

Local, community based initiativesrunning concurrently with schoolcampaigns and media campaignsproviding consistent messages

Peer influence Social influence training(community or school based);media campaigns

School influence School based social influencetraining; media campaigns

Relevance of media campaigns Piloting or developmental workto refine messages for localpopulations

Changing young people’sattitudes to smoking beforethey experiment with cigarettes

Develop campaigns aimed atchildren aged 4 to 8 years

Health professionals could consider becoming involvedin school based, anti-tobacco education programmes thatpromote acquisition of social influence skills for youngpeople

Special groups of smokers

19

interventions to young people have also yet to be determined, asservices designed for adults may not appeal to young smokers.

People with low incomeAlthough the overall prevalence of smoking in the UnitedKingdom has decreased markedly over the past 30 years, littlechange has occurred among those living on low incomes. In themost deprived groups, smoking prevalence can be very high,reaching 90% among the homeless. The disparity in smokingprevalence between the most and least advantaged members ofsociety is the single most important factor contributing to thegap in “healthy life expectancy” (amount of time that someoneis expected to live in a healthy state) between these groups. Asmotivation to quit is fairly similar across social groups, poorersmokers cannot be blamed for failing to quit because they havelower motivation. As disadvantaged smokers tend to be moreseriously addicted, however, there may be even greaterjustification for using pharmacotherapy in this group.

Ethnic minority groupsThe prevalence of smoking varies greatly among differentethnic communities living in Britain. Bangladeshi, BlackCaribbean, and Irish men and women have a higher thanaverage prevalence of smoking, whereas fewer women fromSouth Asian ethnic minority groups smoke compared with thegeneral population. In the Bangladeshi population, the use ofchewing tobacco is also common, with 19% of men and 26% ofwomen using oral tobacco products.

Antismoking interventions described in earlier articles canall be used with smokers from ethnic minority groups. Theseinterventions are probably all effective, but little research in theUnited Kingdom has specifically investigated whether theinterventions differ in their effectiveness across ethnic groups.This has been investigated in the United States, however, whereantismoking interventions were found to be of equaleffectiveness across all racial groups. Health professionals needto bear in mind that some ethnic groups, especiallyBangladeshis, may use tobacco in other harmful ways (forexample, chewing) in addition to smoking it.

The data for the last three graphs are from www.doh.gov.uk/public/mainreport-smokingdrinkinganddruguse2002.pdf andwww.statistics.gov.uk/lib2001/viewerchart5041.html andwww.archive.official-documents.co.uk/document/doh/survey99/hses-02.htm[gen19 respectively (accessed 15 December 2003).

Year

% o

f reg

ular

sm

oker

s

19880

10

15

20

25

30

35

40

5

1990 1992 1994 1996 1998 2000

Manual

Non-manual

Prevalence of regular smoking in England by occupational socioeconomicgroup, 1988-2000. Data from general household survey

% o

f reg

ular

sm

oker

s

Ethnic group

0General

populationBangladeshi Irish Black

CaribbeanPakistani Indian Chinese

20

30

40

50

10

Men Women

Prevalence of smoking in England, by ethnic minority group, 1999. Datafrom health survey for England

Key pointsx Two thirds of women who stop smoking while pregnant restart

afterwardsx Cessation programmes for pregnant women are effective; where

these are available, health professionals must refer women to themx Eighty per cent of adult smokers started smoking as teenagers, but

effective methods of prevention or cessation for young peopleremain unknown

x Smoking is most common among poorer people, explaining muchof the disparity in healthy life expectancy between the richest andpoorest groups in Britain

x Patients from some ethnic groups are more likely to smoke thanothers; tobacco may also be chewed, especially among Bangladeshipeople

Competing interests: TC has been paid for speaking at a conference byGlaxoSmithKline, a drug company that manufactures treatments fornicotine addiction; he has also done consultancy work on one occasion forPharmacia. See chapter 1 for the series editor’s competing interests.

Further readingx Preventing the uptake of smoking in young people. Effective Health

Care 5(5). www.york.ac.uk/inst/crd/ehcb.htmx Fiore MC. US public health service clinical practice guideline:

treating tobacco use and dependence. Respir Care 2000;45:1200-62.x Lumley J, Oliver S, Waters E. Interventions for promoting smoking

cessation during pregnancy. Cochrane Database Syst Rev 2003;(3):CD001055.

x Owen L, Penn G. Smoking and pregnancy: a survey of knowledge,attitudes and behaviour, 1992-9. London: Health DevelopmentAgency, 1999.

x Wisborg K, Henriksen TB, Jespersen LB, Secher NJ. Nicotinepatches for pregnant smokers: a randomized controlled study.Obstet Gynecol 2000;96:967-71.

ABC of Smoking Cessation

20

8 Cessation interventions in routine health careTim Coleman

Smoking cessation interventions are widely underused inprimary and secondary care despite being effective and easy todeliver (see earlier articles in this series). Smoking causes muchgreater harm than, say, hypertension (which is generallyidentified and managed entirely in primary care by healthprofessionals working to agreed routine, systematic, andstructured protocols), yet few primary healthcare teams managesmoking as methodically as they approach hypertension.

Maximising the delivery of cessation interventions tosmokers wanting to quit can probably achieve more in terms ofyears of life saved and provide better value for money (see laterchapter) than almost any other simple medical intervention.

Smoking as a vital signThe first step towards developing a systematic approach for themanagement of smoking is to treat smoking as a “vital sign.” Todo this, health professionals must regularly inquire aboutpatients’ smoking status and have a methodical approachtowards documenting and updating this in medical records.This information needs to be recorded in a prominent place sothat it can be seen whenever medical records are accessedduring consultations. In paper records, a summary card can beused, and, in electronic records, smoking status data should belodged with other important summary information on apatient’s health. Recording information where it is easilynoticed prompts health professionals to raise the topic ofsmoking more frequently with patients.

The minimum information to record is whether the patientsmokes and the date on which this was ascertained. It is alsouseful to record the average number of cigarettes smoked eachday, not least because those who smoke more heavily are morelikely to benefit from nicotine replacement therapy orbupropion therapy. Recording whether the smoker is interestedin or motivated to try stopping smoking is also helpful: whenhealth professionals raise the topic of smoking in futureconsultations, they can then tailor their messages to smokers’levels of motivation (see below).

Smokers’ medical records should also be indexed so thatthey are readily identifiable and easy to retrieve. Without easyaccess to smokers’ medical records, health professionals cannoteffectively monitor their management of smoking. The simplestmethod for indexing smokers’ medical records is to tagelectronic records with one of the smoking status Read codes,but non-computerised general practices could use a simple cardindex. Monitoring longitudinal changes in patients’ smokingbehaviour and health professionals’ delivery of cessationinterventions is most appropriate in primary care because thereis repeated contact between patients and primary healthcareteams. Health professionals can therefore treat smoking as achronic disease, like asthma or diabetes.

The five “A”s approachThe five “A”s (ask, assess, advise, assist, arrange) summarise therole of health professionals in managing smoking. Healthprofessionals are urged to ask all smokers about their smoking.Once smokers have been identified, it is important to assess

Date.............................

Number smoked per day........................cigarettes/cigars

Smoker? Yes No

Motivated to stop

Brief advice given

NRT prescribed/recommended

Bupropion prescribed/recommended

Referred for intensive advice/to cessation service

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

Uncertain

Not applicable

Not applicable

Not applicable

Example of record sheet for noting information on smoking status andintervention. The sheet can be inserted into paper records; computertemplates enable a similar electronic record to be kept

Documentation of smoking in secondary carex Smoking status, number of cigarettes smoked, and motivation to

stop should be ascertained at all visitsx Electronic and paper records should be adapted to facilitate and

promote the recording of this information

The five “A”s for antismoking interventions in routine carex Ask about smoking at every opportunityx Assess smokers’ interest in stoppingx Advise against smokingx Assist smokers to stopx Arrange follow up

Managing smoking cessation needs tobecome a key part of routine practice forall clinicians. This article discussesstrategies for incorporating effectiveantismoking interventions into routineclinical care

Cessation interventions in routine health care

21

their interest in stopping smoking with an open question suchas “how do you feel about your smoking?” It is important to asksensitively as some smokers feel defensive when doctors raisethe issue, and this can make it difficult to ascertain patients’ trueviews.

All smokers, irrespective of their motivation to stop, need tobe advised against smoking in a clear, personalised, andnon-judgmental way. When smokers are clearly interested instopping, health professionals should assist them to do so.Specific action will depend on the individual’s circumstances,but, where appropriate, smokers should be encouraged to set adate for stopping completely, to plan for likely problems, and toenlist the support of family and friends. Health professionalsshould discuss the use of nicotine replacement therapy orbupropion with heavier smokers and prescribe either treatmentif this is appropriate (see earlier chapter).

For smokers who want counselling and behaviouralsupport, health professionals should also arrange for this to beprovided, if possible from a specialist cessation service.

Implementing the approachSuccess in integrating the five “A”s approach into routineclinical care will vary. In primary care, for example, patients visitdoctors for a wide variety of reasons and general practitionersare, perhaps understandably, reluctant to raise the issue ofsmoking in all consultations..

Conversely, cardiologists and respiratory physicians willprobably ask about smoking status in the vast majority of firstconsultations. Health professionals, therefore, should beencouraged to raise the issue of smoking with patients as oftenthey believe is possible while recognising that discussingsmoking is sometimes better left for subsequent consultations.

One way is to ensure that inquiring about smoking statusand updating medical records is routine and systematic. Ifclinicians consider it inappropriate to raise the issue of smokingat all consultations, they should inquire and update records ofsmoking status at least annually. This gives clinicians theopportunity to select consultations in which to discuss smoking,taking into account patients’ expectations of whether the issueshould be tackled.

Health professionals often cite pressure of time, amongother things, as a reason for not intervening against smokingmore frequently. Smoking can be one of several importanthealth issues that need tackling in a single, short consultation.The crucial difference between individual smokers is theirmotivation to stop. Smokers vary greatly in their motivationand, to make best use of limited time, health professionalsshould tailor their approach to the motivational level of theindividual smoker (see chapter 3). As only about a fifth ofsmokers who attend general practitioners intend to try tostop smoking, it makes no sense for general practitioners togive all smokers they meet detailed information about how tostop. Non-motivated smokers need to be encouraged to changetheir attitudes to smoking before being urged to take action toquit.

Tailoring advice to motivationHealth professionals in both primary and secondary care canbe encouraged to advise and assist smokers in a mannerappropriate to their motivation to stop.

Primary care“Help 2 Quit” (H2Q) is a smoking cessation service thatencourages general practitioners to use their routine

General practitioners’ reasons for not giving smoking advicex Patients are often not motivated to stopx Patients often don’t listen to advicex Stopping smoking is often not a priority for smokersx Lack of timex Unwanted advice can annoy patientsx Difficult to impress on patients the importance of not smokingx Do not know how to deal with smokers who are not motivated

to stop

Does the patient smoke?

Never smokedSmoker Former smoker(smoked for >1 year)

Thinking about itReady to quit Not interested

Ask: "How do you feel about your smoking?"

Trigger quit attemptAssist patient inquit attempt

Increase patient'sdesire to stop• Provide H2Q leaflet

and brief motivational advice

• Assess nicotine dependence• Refer to H2Q nurse

• If appropriate, try to influence smoker's attitude to smoking• Advise that help is available if they change their mind

Opportunistic assessment of smokers’ motivation: Help 2 Quit approach.Adapted from the Help 2 Quit cessation service, Shropshire County PrimaryCare Trust

Where counselling and behavioural support is notavailable, health professionals should consider providingfollow up themselves or through another member of theirteam; this may be particularly convenient for smokers ifpharmacotherapy for nicotine addiction is beingprescribed and they cannot attend a specialist service

General practitioners tend to prefer to discuss smokingwhen patients present with smoking related problems,and they would generally avoid discussing smoking at allwith some patients (for example, bereaved patients)

ABC of Smoking Cessation

22

consultations opportunistically to intervene against smoking.They are encouraged to identify each smoker’s level ofmotivation for trying to quit as soon as possible after raising theissue of smoking with them, and to use this as a base forsubsequent discussions on smoking. The primary objective ofthis method is to offer support to those who are ready to quitand improve their chances of success. H2Q uses a simplifiedversion of the “stages of change” (see chapter 3) to tailor theintervention to the smoker. Although little empirical evidenceexists to support the use of this approach, it fits well with clinicalpractice, including patients’ expectations of how doctors shouldrespond to their smoking.

Secondary careIn the H2Q approach, general practitioners are urged to treatmore motivated and less motivated smokers differently:motivated smokers are given specific advice about quitting thatwould be inappropriate for those not interested in stopping.In Nottingham, midwives have developed a mechanism forincorporating inquiry and intervention into their routine work.When pregnant women attend their booking appointment forantenatal care, midwives use an algorithm to ask a series ofquestions about smoking.

As 80% of pregnant women believe that stopping smokingis the most important lifestyle change they can make toimprove their babies’ health, inquiring about smoking at allbooking appointments is unlikely to upset many pregnantwomen. Midwives ask the women about smoking status, whetherthey live with smokers (including partners), and finally whetherthey or other smokers they live with are interested in quitting.

All smoking related data from manual records are enteredinto an electronic database for monitoring purposes. Midwivesthen respond to women in an appropriate way for theirmotivation level, and those who are interested in receiving extrasupport in quitting are referred to the local cessation service forbehavioural counselling.

Monitoring management of smokingAll medical care systems sometimes experience some inertia orresistance to change. The fact that effective smoking cessationinterventions have not been adopted into routine care despitetheir availability for over 20 years shows that this is especiallytrue in relation to smoking cessation.

It is therefore important to monitor and audit theimplementation and delivery of these services. This can berelatively simple when information about smoking is recordedelectronically. For example, most general practice computersystems in the United Kingdom use Read codes, which allowclinicians to record data on smoking status simply and accurately.

Recently, new Read codes describing the three categories ofsmokers’ motivation (and used by H2Q) have been approved,and these can now be used by any general practice computersystem to record individual smokers’ motivation to quit inmedical records. Use of these Read codes and information onpatient management from medical records provides a meansfor monitoring how primary care health professionals respondto smokers with differing levels of motivation.

(Start here - circle/complete responses) Do you, or does anyone in your household smoke?

No

NoNoYes

Yes No

Yes

Have you ever smoked?Who?

Patient?

Have you ever smoked?How many cigarettes a daywere you smoking beforeyou became pregnant?

........./day

Discuss importance ofnot exposing baby to

any smoky environmentAdvice given? Yes/No

Discuss risks to baby ofpassive smoking andimportance of smoke-free zone for baby

Suggested leaflet: "Helpyour partner give up for life"Discuss referral to New Leaf

if appropriateAdvice given? Yes/NoLeaflet given? Yes/No

Referred to New Leaf ? Yes/No

Discuss risks of smoking,benefits of stopping and

importance of smoke -freezone for baby

Suggested leaflets: "Smoking:giving up for life" (booklet)

"Give up smoking and give yourbaby a head start" (leaflet)

Discuss referral to NewLeaf if appropriate

Advice given? Yes/NoLeaflet given? Yes/No

Referred to New Leaf ? Yes/No

No

Were you smokingwhen you found outyou were pregnant?

Were you smokingwhen you found outyou were pregnant?

How long before youbecame pregnant didyou stop smoking?

.......years .......months

Discuss importance of notexposing baby to anysmoky environment

Advice given? Yes/No

How long before youbecame pregnant didyou stop smoking?

.......years .......months

YesHow many cigarettes aday were you smoking?

........./day

How many cigarettes aday were you smoking?

........./day

How many cigarettes aday are you smoking now?

........./day

How many cigarettesdoes he/she smoke a day?

........./day

Do you think you mightbe tempted to start

smoking again? Yes/No

If answered Yes to partner,relative or friend smoking,

go to red box

Are you interested instopping smoking?

Partner? Yes/NoRelative? Yes/NoFriend? Yes/No

Offer support as appropriate. Discuss importance ofnot exposing baby to any smoky environmentSuggested leaflet: "Smoking: giving up for life"

Discuss referral to New Leaf if appropriateAdvice given? Yes/No Leaflet given? Yes/No

Referred to New Leaf ? Yes/No

SmokeScreen

Phone Quitline 0800 002 200 for advice,information and Quitpack

Name..................................................................

Hospital No.........................................................

Do you think youmight be temptedto start smokingagain? Yes/No

Offer support as appropriate. Discuss importance ofnot exposing baby to any smoky environment

Suggested leaflet if tempted: "Smoking: giving upfor life". Discuss referral to New Leaf if appropriate

Advice given? Yes/No Leaflet given? Yes/NoReferred to New Leaf ? Yes/No

Yes

Yes

Do you think he/shewould consider

stopping smoking?

NoYes

NoYes

Yes

No

No

Yes

© Nottingham City Hospital (NHS Trust)Maternity Unit, 1994, 1998, 2003

Flow chart for midwives inquiring about smoking at booking. FromNottingham City Hospital NHS Trust (see bmj.com for larger version)

Key pointsx Smoking cessation interventions are simple, cheap, and effective

but are not yet widely part of routine carex Clinicians must develop and use routine and systematic approaches

to inquiring about and recording patients’ smoking statusx Cessation interventions need to be adapted to smokers’ levels of

motivationx Cessation interventions need to be audited and monitored

Further readingx Butler CC, Pill R, Stott NC. Qualitative study of patients’

perceptions of doctors’ advice to quit smoking: implications foropportunistic health promotion. BMJ 1998;316:1878-81.

x Coleman T, Murphy E, Cheater FC. Factors influencing discussionsabout smoking between general practitioners and patients whosmoke: a qualitative study. Br J Gen Pract 2000;50:207-10.

x Rollnick SR, Mason P, Butler C. Health behaviour change: a guide forpractitioners. London: Churchill Livingstone, 1999.

x West R, McNeill A, Raw M. Smoking cessation guidelines for healthprofessionals: an update. Thorax 2000;55:987-99.

In the Help 2 Quit approach, general practitioners areurged to treat more motivated and less motivated smokersdifferently: motivated smokers are given specific adviceabout quitting that would be inappropriate for those notinterested in stopping

The adapted figure showing the “Help 2 Quit” approach is published withpermission from K Lewis, and the flow chart for midwives with permissionof Nottingham City Hospital (NHS Trust).

Competing interests: TC has been paid for speaking at a conference byGlaxoSmithKline, a drug company that manufactures treatments fornicotine addiction; he has also done consultancy work on one occasion forPharmacia. See chapter 1 for the series editor’s competing interests.

Cessation interventions in routine health care

23

9 Setting up a cessation servicePenny Spice

In 1998, when the UK government announced the introductionof smoking cessation services throughout the NHS, few suchservices already existed. In most areas, therefore, the serviceshad to be set up quickly and from scratch. This chapter reflectson some of the difficulties and challenges experienced inestablishing and maintaining a cessation service, theNottingham “New Leaf” service.

What is the likely demand?Nottingham has a population of about 650 000—andtherefore about 200 000 smokers. If (as expected from nationaldata) 30% of these were to make a quit attempt in the sameyear, and all sought help from the cessation service, thedemand would be overwhelming. In the event, however, initialdemand rose fairly slowly. Some of the reasons for this slowstart were:x Smokers were initially suspicious of the new service. Manyremarked that they expected to be “told off” about theirsmoking but were pleasantly surprised when encouragedinstead to decide if the time was right for them to quitx Health professionals were sceptical about the likelyeffectiveness of the service and had little understanding of whatwas offeredx There was also general suspicion, in an NHS based largelyon a medical model, of services that relied on a healthpromotion approach, including client empowerment andbehaviour change.

As a result, one of the major pressures in the early monthswas not the level of demand but the political pressure to meethigh quit rate targets set by government.

Demand soon rose, however, as a result of variousinfluences, such as the service’s feedback of performance resultsto primary care teams. Although variable, the service currentlydeals each month with about 200 smokers who agree to set aquit date, of whom half are not smoking four weeks later.

Recruiting staffInterest in joining the service was relatively low at first, thoughthis changed considerably once New Leaf began to be knownand respected.

It has since recruited staff from a wide range ofbackgrounds, including nursing, health promotion, communitywork, and counselling. Staff joining from a non-healthbackground, however, have had to learn very quickly aboutworking practices in the NHS and have at times been veryfrustrated over seemingly unnecessary hurdles of protocol andapproval.

Although staff recruitment has become easier over time,retention has become increasingly difficult because the initialfunding allocated by government expired after three years.Guarantees of continued salary support have subsequentlytended to be short term and be delayed well into the financialyear. Many staff move to other jobs because of the financialinsecurity this causes.

Reasons for increasing use of New Leaf servicex Recommendations to others by smokers who have used the servicex Increasing familiarity, trust, and use of the service by health

professionalsx Feedback of performance results to primary care teamx Spread of publicity through other partners, such as pharmacistsx Gradual incorporation of referral to cessation services into routine

pathways and protocolsx Return of former clients who quit but started smoking again

Quarter

No o

f sm

oker

s

02

400

600

800

1000

1200

200

3 4 1 2 3 4 1 2

2000 2001 2002

3 4

Set quit date

Quit at four weeks

Numbers of smokers seen by New Leaf, by quarter, since launch of servicein April 2000

Recruitment of staff from a wide range of backgroundsbrings a rich mix of skills, experience, and perceptionsinto the service, with no established culture of “customand practice”

24

Model of service provisionWithin smoking cessation models there are three keyapproaches: high intensity with low coverage; medium intensitywith medium coverage; and low intensity with high coverage.

Each of these has its relative advantages and disadvantages,and will reach different populations of smokers. New Leaf ’spolicy from the outset was to try to provide services across thefull range of these approaches, and to plan and recruit staffaccordingly. Currently, 10 smoking cessation specialists and 15sessional workers provide an intensive service, seeing about4000 smokers a year. In addition, a network of 16 associateadvisers based in primary and secondary care (many workingpart time for New Leaf) provide brief interventions as part oftheir normal work and offer support for former smokers whohave completed the cessation programme. Overall, the serviceachieves an average quit rate, at four weeks, of 56%. In line withgovernment guidance, it monitors the exhaled carbonmonoxide levels of all clients.

LocationTwo of the guiding principles for the service were that it shouldbe accessible and that it should target smokers fromdisadvantaged areas.

To achieve these goals, New Leaf tried to ensure that itsservices were available at locations in the centres of localcommunities. It used deprivation indicators to identifydisadvantaged areas of the city and the staff spent much timeand effort finding venues in the right place, for the rightamount of money, where staff would feel safe, that wereaccessible for people who used wheelchairs, and were on busroutes.

Thus New Leaf uses libraries, community centres, familycentres, church halls, scout huts, a drop-in centre for homelesspeople, schools, prisons, colleges, and young people’s centres.These are in addition to conventional healthcare sites, such ashealth centres, antenatal clinics, general practice surgeries, andhospitals.

AdvertisingIn the health community and the relevant statutory andvoluntary sectors, New Leaf used briefings, presentations,reports, newsletters, and any other suitable internal means topromote the service wherever possible. It also ensured that theservice was included in various “patient pathways,” protocols,and policies.

For the general public, it organised an intensive publicitycampaign around the launch and to advertise early successes ofNew Leaf. The campaign had various elements, includingarticles in local newspapers (including the free press); manyradio appearances; flyers, posters, and credit cards; a New Leaflogo and phone number painted on a local bus; and displaysand attendance at local health and community fairs.

IndependenceIt has proved important in Nottingham that the New Leafcessation service was closely integrated into primary andsecondary care while maintaining financial independence. Thishas ensured that funding allocated for smoking cessation hasindeed been spent on the service and also encourages expertiseand innovative ways of working. This autonomy also means thatrisks can be taken more easily and changes made more quicklythan in larger administrations.

Three key approachesHigh intensity with low coverage—“Closed” smoking cessation groups

(usually for six to eight weeks), with follow upMedium intensity with medium coverage—“Open” smoking cessation

groups or clinics for smokers, usually on a one to one basis or withcouples or families. This model allows the client to negotiate thelength of time of the contact with the service, which may beshorter than the usual eight weeks

Low intensity with high coverage—Brief interventions, usually as part ofanother consultation or intervention

Groups or one-to-one services?x The initial guidance on service development from the UK

government focused primarily on group based, high intensityservices

x This later changed to include “intermediate” services (interpretedto mean one to one sessions of shorter duration)

x New Leaf offered both services from the outset

In poor areas, smoking prevalence can be high, although people’s motivationto quit is no lower than in more affluent areas

An effective way to advertise a new cessation service

Setting up a cessation service

25

FundingFunding for cessation services is especially vulnerable todiversion into other services, but some measures can be takento help to protect the service.

Funding must be “ring-fenced” or allocated specifically forcessation services. Cessation services must have challenging andauditable targets. The funding allocated for services must allowfor the provision of more than just the bare minimum—therehas to be capacity to develop and offer tailor made services forparticular client groups with special needs. Funding also needsto be committed for the medium rather than short term toprovide reasonable job security for staff.

It is important to give fundholders, through accurate andregular updates about the successes of the services, evidenceabout the services’ effectiveness and efficiency, and to prove thatthey provide added value to what existed before or what wouldexist if they disappeared. Quantitative information aboutthroughput, quit rates, relapse, loss to follow up, anddevelopments to support smokers with special needs (such aspregnant women, young smokers, and hard to reach groups) isalso important.

The annual budget for New Leaf in Nottingham for 2002-3was £465 000 ($790 000; €677 000), serving a population ofabout 650 000. This level of funding has been adequate for thedelivery of basic needs and to provide some support fordevelopment of new and special initiatives. Less than this wouldprovide a basic service—that is, for well motivated and mobilesmokers—but little more.

How long to establish a service?In Nottingham it took over two years to establish an effectiveand efficient core service, and there is still a long way to go tomeet the diverse range of smokers’ needs. As the servicedevelops, there are new discoveries and different ways ofstreamlining the existing systems, and a high quality service willalways learn from mistakes, its staff, other services, and, mostimportantly, its clients.

The photograph showing a run-down block of flats is published withpermission from Matthew Butler/Rex.

Competing interests: See chapter 1 for the series editor’s competinginterests.

Why funding may be diverted from smoking cessationservicesx Smoking cessation is a preventive intervention; other more

immediate demands may be perceived to be more deserving orimportant

x Perception that smokers “choose” to smoke, so their addiction tosmoking (and consequent disease) is not a medical problem andshould not compete for medical funds

x Belief that smokers should pay for their own services, offsetting thecost against long term savings on cigarette purchase

x Smoking cessation therapy is behavioural so is not medical

Challenges for smoking cessation servicesx Strategy with employer and partnersx Staff recruitmentx Accommodation for offices and clinicsx Policies and protocolsx Evaluation methodsx Purchase of furniture, office equipmentx Design and printing of paperwork for administration, evaluation,

information for clientsx Engagement and joint working with partners in primary and

secondary carex Full partnership with local pharmacistsx Publicity strategyx Training programme for cessation staffx Awareness raising and training programme for existing health,

statutory, and voluntary sector workersx Financial planningx User feedbackx Follow up systemsx Joint working with health professionals and the voluntary sector to

ensure continued support of former clientsx Synthesis within wider tobacco control agenda—for example,

tobacco control strategyx Regular reports and communication with the Department of

Health, primary care trusts, local health services, colleagues in thestatutory and voluntary sector

x Training for health professionals and workers from the statutoryand voluntary sectors in how to give brief opportunistic smokingcessation advice

x Establishment of “special” services—for example, for pregnancy andfamily service, young people, smokers from deprived communitiesand excluded groups, ethnic minority communities, people withlearning disabilities, homeless people, people with mental healthproblems

x Programme of monitoring and evaluationx Supporting former clients

Key pointsx Setting up a smoking cessation service is challenging but can be

done quickly and effectivelyx A service needs to be autonomous in terms of funding and overall

administrationx There will be a substantial demand once it is establishedx A service needs to be accessible, responsive, and adaptablex Funding and autonomy need to be guaranteed for the medium

term to ensure efficient staff recruitment and service development

Persuading fundholders to prioritise cessation services isvital to ensuring the future of the services

Further readingx Department of Health. Smoking kills. A white paper on tobacco.

London: DoH, 1998.x West R, McNeill A, Raw M. Smoking cessation guidelines for health

professionals: an update. Thorax 2000;55:987-99.x Department of Health. NHS smoking cessation services: service and

monitoring guidance 2001/2. London: DoH, 2001.x Department of Health. National cancer plan. London: DoH, 2000.x Department of Health. National service framework for coronary heart

disease. London: DoH, 2000.x Department of Health. The NHS plan. London: DoH, 2000.

ABC of Smoking Cessation

26

10 Population strategies to prevent smokingKonrad Jamrozik

Interventions targeted at individual smokers are only part of themuch broader spectrum of strategies to reduce the prevalenceof smoking. This article summarises the population strategiesthat can make substantial contributions to smoking cessationand help to prevent people from taking up smoking. Tenimportant initiatives are used or have been proposed forreducing tobacco use at population level. Nine initiatives arediscussed here; the tenth (the use of proved treatments) iscovered in previous articles in this series.

Public places and workplacesPolicies that ban smoking in public places are effective inreducing passive smoking among non-smokers generally. Theyalso protect vulnerable groups such as children and infants,adults with cardiac or respiratory disease, and pregnant womenagainst the adverse effects of environmental tobacco smoke.Smoke-free policies in public places also send a clear messageto young people about non-smoking being the norm, and theyreduce the numbers of adults that young people see smoking.

In the workplace, smoke-free policies lead to some staffquitting—typically about 4% of the workforce—and reduce dailyconsumption among continuing smokers. Each extension of asmoke-free policy to a setting in which smoking was previouslypermitted requires both careful consideration of public opinionand systematic planning for the change. It is good practice tooffer existing smokers in an organisation help in quittingduring the lead-up to the introduction of a smoke-free policy,but most of those who quit in response to the change do sowithout special help.

Support for smoke-free policies typically increases amongsmokers and non-smokers alike once the policies areintroduced, and in the state of South Australia, for example,the introduction of smoke-free policies in restaurants andcafes indicates that such policies have no adverse economicimpact.

Ten point plan for tobacco control

Issue and initiative ImportancePublic places and workplaces:comprehensive smoke-freepolicies

Reduces passive smoking,increases cessation, lowersconsumption, removes rolemodels from children’s view

Price: regular increases in thereal (adjusted for inflation) priceof tobacco products

Reduces consumption andprevalence; especially effectiveamong adolescents

Public education: adequatefunding for general and schooleducation on tobacco

Sophisticated, intensive massmedia campaigns increasequitting

Promotion: end to exemptionsfor sporting events and of“product placement”

Important in re-establishingnon-smoking as the norm

Proved treatments: subsidies forcessation clinics and provendrug therapies

Counselling, nicotinereplacement therapy, andbupropion at least double thesuccess of attempts to quit; costshould not act as barrier toproved cessation aids

Prosecution: increase andpublicise efforts to enforcelegislation

Publicity has important“knock-on” effect—for example, inreducing sales to minors

Point of sale: tobacco productsmade an under the counter item

Closes further channel ofpromotion of tobacco products

Products and their production:remove the exemption fornicotine in tobacco frommedicines, food, or otherconsumer protection legislation

Comprehensive and unifiedapproach needed for regulationof nicotine (and othercomponents in tobacco andtobacco smoke)

Packaging: move to genericpackaging

Reduces appeal of tobaccoproducts as symbols of lifestyle,sophistication, and wealth

Probity in publicpronouncements: proscribe andpenalise misleading publicstatements about tobacco andthe tobacco industry

Reduces misleading informationand confusion about tobacco

Good evidence exists that at least the first six of these initiatives are effective

Year

% o

f the

pub

lic

Late 1997 Late 1998 Late 19990

20

40

60

80

100

Non-smokers

Smokers

Total

Support for smoke-free restaurants in South Australia (smoke-free policyintroduced in January 1999). Adapted from Miller et al (Aust N Z J PublicHealth 2002;26:38-44)

Year

Ratio

April1991

0

0.02

0.04

0.06

0.08

0.1Smoke-free law1 January 1999

April1992

April1993

April1994

April1995

April1996

April1997

April1998

April1999

April2000

April2001

Economics of smoke-free policies in restaurants: ratio of South Australia’srestaurant sales to its retail sales, 1991 to 2001. Adapted from Wakefield et al(see Further Reading box)

27

PricePrice is one of the strongest influences on tobacco consumption.Typically, an increase in price of tobacco products of 10% causesa fall in smoking of 4% in adults and 6% in children, thusreducing prevalence while increasing revenue. Progressive andregular increases in the price of tobacco products throughtaxation, at least in line with the cost of living and preferablymore, can therefore have a considerable impact on smokingprevalence. A price rise should be accompanied by clear publicityabout the reasons for it—to reinforce the message that smoking isbad for the pocket as well as for health. A price rise also needs tobe associated with appropriate investment to deter and detectsmuggling of tobacco products into higher price areas.

Public educationMass media campaigns have a direct impact on the prevalenceof smoking and are most effective when they are sustained anddelivered as part of a comprehensive tobacco controlprogramme. Most of the reduction is the result of establishedsmokers quitting, but campaigns also reduce the proportion ofchildren taking up smoking.

Mass media campaigns are expensive but not in relation tolevels of tax revenue raised from tobacco products. Effectivecampaigns need careful coordination and a blend of medicaland marketing expertise to ensure that their content isscientifically accurate and their presentation effective.

They also need to be bold and to take some risks,challenging public and personal opinions and feelings so thatthe issue of tobacco remains “alive” in the minds of individualsand communities. Such activities therefore need to haveadequate funds not only for production and dissemination ofmaterials but also for associated programmes of marketresearch.

Strongly enforced non-smoking policies in schools seem toresult in a lower prevalence of smoking in schoolchildren,though little evidence exists to date on the longer termeffectiveness of this and other school based strategies inpreventing smoking.

Evidence is mounting from communities with intensive,population-wide education strategies that the best way ofreducing smoking in young people is to reset prevailing normsabout smoking and to reduce greatly the prevalence of smokingin adults.

PromotionAn increasing proportion of governments in Western countrieshave moved to ban all promotion of cigarettes and smoking viathe electronic and print media; outdoor advertising such asbillboards; competitions; or via direct “giveaways” to passers by.The Norwegian government was the first to commit itself tosuch a policy, and the announcement of this decision, in 1970,was followed by an immediate end to the upward trend intobacco consumption in that country.

This shows the importance of a government giving a clearmessage to the public that it is serious about taking action onsmoking. The passing of the legislation and its implementationare further landmark events that lend themselves to morepublicity about changing norms in regard to smoking and thereasons for them.

Banning indirect tobacco advertising through sponsorshipin sport and other public areas is as important as ending directadvertising. Other forms of tobacco promotion, such as product

Year

Real

pric

e pe

r pac

k ($

US)

Annu

al c

igar

ette

con

sum

ptio

n pe

r cap

ita (i

n pa

cks)

19890

2

3

4

5

6

7

1

0

20

30

40

50

60

70

80

90

10

1990 1991 1992 1993 1994 1995

Price

Consumption

Inverse relation between real price of cigarettes and consumption, Canada,1989-95. Adapted from Jha et al (Curbing the epidemic: governments and theeconomics of tobacco control. Washington, DC: World Bank, 1999)

Year

Smok

ing

prev

alen

ce in

adu

lts (%

)

19890

19

20

21

22

23

24

25

26

18

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Massachusetts

Remaining US states (except California)

Effectiveness of sustained public education campaigns in reducing smokingin US state of Massachusetts. Adapted from Biener et al (BMJ2000;321:351-4)

Year

Thou

sand

s of

gra

ms

of to

bacc

o

0

1.6

1.8

2.0

2.2

2.4

1.4

1954-5 1959-601950-1 1964-5 1969-70 1974-5 1979-80

Impact of political commitment to tobacco control—tobacco consumption inNorway before and after the 1975 tobacco act (first discussed 1970), whichincluded a ban on cigarette advertising. Adapted from Health or Smoking?(Royal College of Physicians, 1983)

Educating children in schools about tobacco is animportant component of a comprehensive tobaccocontrol programme

ABC of Smoking Cessation

28

placement (deliberate or otherwise) in films and via the internet,also must be dealt with. This requires coordinatedintergovernmental action because these activities transcendnational boundaries.

Point of saleAs the advertising of their products in the mass media andoutdoor venues has come to an end in some countries, tobaccocompanies have increased the volume and sophistication oftheir promotional activities indoors in shops selling theirproducts. Anecdotal reports speak of specially designeddispensing racks that obscure health warnings on cigarettepackets, and some companies will refit entire display areas ofshops in return for a guaranteed share of the space to show offtheir products. In Western Australia the introduction of arequirement that 50% of the area of promotional posters shownat the point of sale should contain a health warning wasfollowed by a sharp reduction in the use of such posters. Anunambiguous law that requires tobacco products to be storedout of sight under the counter (so that customers have to askfor them by name) is much better than governments having tomake piecemeal regulatory responses to the industry’s attemptsto circumvent advertising restrictions.

Regulation of tobacco productsCigarettes are highly toxic, but in most countries they havegenerally remained exempt from the food, drug, or consumerprotection legislation that applies to other consumer products.Smokeless tobacco products (see chapter 11) are much saferthan cigarettes but are not permitted in many countries onhealth grounds. Medicinal nicotine is even safer, but is generallysubject to drug legislation that prevents or inhibits use as analternative regular nicotine supply. The result is that regulatorysystems tend to favour the most dangerous products, and, if so,need to be reformed.

PackagingAs one Australian tobacco company’s annual report said, “Ourproducts are their own best advertisement.” This statementshows the importance to manufacturers of establishing andmaintaining a physical image for each brand, preferably onethat makes it symbolic of a desirable lifestyle, sophistication, andwealth. This has led to serious discussion of a move to genericpackaging—with tobacco products all being presented indeliberately unappealing packets, with a substantial proportion

Smoking in films helps to promote a positive image of smoking to youngpeople

Prosecutionx Regulatory measures to control tobacco need to be seen to be

enforcedx Successful prosecutions of tobacco and advertising companies are

an embarrassment to industries whose public images are critical totheir business

x Prosecutions and large fines for small players in the industry—suchas shopkeepers who repeatedly break the law on selling cigarettesto children or sellers of cut price smuggled tobacco—are alsoimportant in signalling that communities and their governmentsare serious about tobacco control

x Publicising such cases spreads and strengthens that perception andhas been effective in persuading proprietors of tobacco outlets totake greater care in instructing their staff not to sell cigarettes tounder-age customers

Further readingx Fichtenberg CM,Glantz SA. Effect of smoke-free workplaces on

smoking behaviour: systematic review. BMJ 2002;325:188-91.x Wakefield M, Siahpush M, Scollo M, Lal A, Hyland A, McCaul K, et

al. The effect of a smoke-free law on restaurant business in SouthAustralia. Aust N Z J Public Health 2002;26:375-82.

x Glantz SA, Slade L, Bero LA, Hanauer P, Barnes DE. The cigarettepapers. Berkeley: University of California Press, 1996.

x Royal College of Physicians. Nicotine addiction in Britain: a report ofthe Tobacco Advisory Group of the Royal College of Physicians. London:RCP, 2001.

The Irish government has recently started to look at theissue of legislation surrounding medicinal nicotine as analternative regular supply. It has established and isfunding an Office for Tobacco Control with a remit toadvise the government on tobacco related issues

Population strategies to prevent smoking

29

of each packet displaying strong written and visual warningsabout the hazards of smoking.

Probity in public pronouncementsThe tobacco companies have an increasingly long record ofbeing successfully prosecuted for misleading and deceptivebehaviour under trade practices and consumer protectionlegislation. The Australian state of Tasmania has recognised thatdealing with an entrenched pattern of such behaviour by caselaw and usually civil prosecution is an unsatisfactory way ofcurbing it. Instead, it has proscribed—and provided penaltiesfor—issuing misleading public statements about either tobaccoor the tobacco industry.

The film shot (from Die Another Day) is from the Kobal Collection.

Key pointsx Effective tobacco control programmes should tackle smoking at the

population levelx Health staff working in smoking cessation should know about the

main population strategiesx All tobacco advertising, sponsorship, and product placement

should be bannedx Smoke-free policies should operate in all public places and

workplacesx Governments should introduce progressive price increases through

taxx Mass media public education programmes are an important

strategyx Effective policing of tobacco laws and smuggling is neededx Appropriate cessation services should be available to all smokers

wanting to quitx Current inconsistent legislation on tobacco products and medicinal

nicotine needs to be reformedCompeting interests: KJ received costs for travel and accommodationfrom SmithKlineBeecham to attend a meeting of the Australian SmokingCessation Consortium that was convened by the drug company.See chapter 1 for the series editor’s competing interests.

ABC of Smoking Cessation

30

11 Harm reductionAnn McNeill

Although the ideal for all smokers is to quit completely, asubstantial proportion of smokers either do not want to stopsmoking or have been unable to do so despite many attempts.Harm reduction strategies are aimed at reducing the adversehealth effects of tobacco use in these individuals.

Cutting downCutting down on the number of cigarettes smoked each day is acommon strategy used by smokers to reduce harm, to movetowards quitting, or to save money. Some health professionalsalso advocate cutting down if smokers cannot or will not stop.No evidence exists, however, that major health risks are reducedby this strategy. The likely explanation for this is that smoking isprimarily a nicotine seeking behaviour, and smokers who cutdown tend to compensate by taking more and deeper puffsfrom each cigarette, and smoking more of it. This results in amuch smaller proportional reduction in intake of nicotine (andin associated tar and other toxins) than the reduction innumber of cigarettes smoked suggests resulting in little nethealth benefit.

Cutting down on cigarettes in conjunction with the use ofnicotine replacement therapy (NRT) to maintain nicotine levelsis a more promising strategy, although NRT is not currentlylicensed in the United Kingdom or in many other countries foruse in this way. Preliminary studies have suggested that thisapproach may help with sustained cigarette reduction andreduce intake of toxins, but no strong evidence exists yet ofhealth benefit from this strategy.

Switching to “low tar” cigarettesMany smokers who are concerned about the health effects ofsmoking switch to “low tar” cigarettes, in the belief that these areless dangerous than ordinary cigarettes. This perception hasbeen encouraged by the tobacco industry and, in manycountries, also by government policies seeking a progressivereduction in the tar yields of cigarettes.

However, tar yields from cigarettes are measured bymachines that artificially “smoke” the cigarettes, and much ofthe reduction in the tar yield of low tar cigarettes, as measuredby a smoking machine, results from ventilation holesintroduced in the filter to dilute the smoke drawn in by themachine. The ratio of tar to nicotine produced in the tobaccosmoke of low tar cigarettes is in fact closely similar to that ofconventional cigarettes. Low tar therefore also means lownicotine.

Equating low tar with “healthy”: market research for Silk Cut(manufactured by Gallaher)“Who are we talking to? The core low tar (and Silk Cut) smoker isfemale . . . upmarket, aged 25 plus, a smart health consciousprofessional who feels guilty about smoking but either doesn’t want togive it up or can’t. Although racked with guilt they feel reassured thatin smoking low tar they are making a smart choice and will jump atany chance to make themselves feel better about their habit”“. . . white signals the low tar category . . . low tar (‘healthy’) quality”Source: House of Commons Health Committee. The tobacco industry andthe health risks of smoking. London: Stationery Office, 2000; para 87 (session1991-200). www.parliament.uk/commons/selcom/hlthhome.htm

Enabling smokers to take control of their cigaretteconsumption—by using NRT at the same time as cuttingdown on smoking—may also increase smokers’ confidenceand ability to quit subsequently

Nicotine yield (mg)

Tar y

ield

(mg)

0 0.2 0.4 0.6 0.8 1 1.2 1.40

10

15

5

Tar and nicotine yields for 187 cigarette brands tested by UK Laboratory ofthe Government Chemist (data from www.open.gov.uk/doh/dhhome.htm)

Prospective hazard ratios for death for smokers who cutdown or quit compared with continuing heavy smokers

Cause ofdeath

No ofdeaths

Adjustedhazard ratio*

95% confidenceinterval

All causesCutting down 434 1.02 0.89 to 1.17Quitting 577 0.65 0.56 to 0.74Cardiovascular diseases†

Cutting down 138 1.01 0.76 to 1.35Quitting 171 0.88 0.68 to 1.15Tobacco related cancerCutting down 70 0.91 0.63 to 1.31Quitting 51 0.36 0.22 to 0.59Respiratory diseaseCutting down 28 1.20 0.70 to 2.07Quitting 23 0.77 0.44 to 1.35

*Results were obtained from a stratified Cox proportional hazards regressionmodel, with data adjusted for age (underlying), sex, cohort of origin, body massindex, educational level, duration of smoking, and inhalation habits†These analyses included adjustment for systolic blood pressure (per 10 mmHgincrease)Adapted from Godtfredsen et al

“Low tar” cigarettes showingventilation holes in the filters

31

As with cutting down, smokers who switch to lower yieldbrands tend to compensate for the reduction in nicotinedelivery by changing their smoking pattern. With low tarcigarettes smokers do this in two main ways—they smoke thecigarettes more “strongly” by taking more or deeper puffs orthey occlude the filter ventilation holes with fingers or lips toprevent or reduce smoke dilution. This results in very little, ifany, change in actual intake of nicotine—and consequently oftar—and ultimately therefore, in little reduction in harm.

Switching to cigars or pipesSome cigarette smokers, particularly men, switch to smokingcigars or pipes as a means of giving up cigarettes. The risks ofsmoking cigars or pipes for smokers who have never beenregular cigarette smokers are indeed much lower than informer cigarette smokers, principally because they tend not toinhale the smoke but rely on nicotine absorption from thebuccal mucosa. Cigarette smokers who switch to cigars or pipestend, however, to continue to inhale the smoke and aretherefore likely to gain little or no health benefit.

Alternative cigarettesSeveral tobacco companies have designed and in some casesmarketed alternative smoking products that heat rather thanburn tobacco or tobacco products. An example is the Eclipsebrand of cigarettes, now marketed in the United States with theclaim of being a safer alternative to conventional cigarettes.Eclipse delivers less tar than conventional cigarettes, but morecarbon monoxide, so any harm reduction is likely to be limited.No studies have yet shown health benefits associated withswitching to Eclipse or similar alternative smoking products.

Switching to smokeless tobaccoSmokeless tobacco comes in two main forms—snuff andchewing tobacco. The types of smokeless tobacco product usedaround the world vary considerably, as do the health risksacross the products used. For example, in India, use ofsmokeless tobacco is a major cause of oral cancer. Neverthelessthe health risks associated with smokeless tobacco areconsiderably smaller than those associated with cigarettes.

In Sweden the use of oral moist snuff (known as snus) hasbeen common among men for several decades. The health risksof this product seem to be extremely low, in absolute terms aswell as in relation to cigarette smoking. Snus seems to be widelyused by smokers as an alternative to cigarettes, contributing tothe low overall prevalence of smoking and smoking relateddisease in Sweden.

Snus and other smokeless oral tobacco products currentlybeing developed by some tobacco companies could thereforeprovide a viable alternative to smoking for many smokers inother countries, and thus deliver substantial health gains.However, these products are currently prohibited throughoutthe European Union (except in Sweden) on the grounds thatthey are unsafe.

Some experts have argued that even if smokeless tobacco isa less harmful form of nicotine intake than smoking, itsavailability might have unintended undesirable consequences,such as causing harm to people who might have otherwise quitsmoking completely or attracting young people to tobacco use.Other experts recommend that smokers should be able tochoose less harmful forms of nicotine delivery. They argue thatthe ban on the less harmful smokeless tobacco products

Seru

m c

otin

ine

(ng/

ml)

Nico

tine

yiel

d (m

g)

1 2 3Control group

4 5 1 2 3Fast reduction group

4 5 1 2 3Slow reduction group

4 50

100

150

200

250

300

350

50

0

2

3

4

5

6

7

1

Effect of compensation by smokers when smoking low tar cigarettes, asshown by mean blood levels of cotinine (with 95% confidence intervals) andrelated nicotine yield over time. 1=run-in to study; 2=entry; 3=at 2 months;4=at 4 months; 5=at 6 months. Adapted from Frost et al (Thorax1995;50:1038-43)

Cigarette paper/foil

Hollowfilter

Heatinsulator

Premiumtobaccoblend

High purity carbon tip

According to the manufacturer,R J Reynolds (RJR), Eclipsecigarettes are “designed to burnonly about 3% as much tobacco asother cigarettes.” RJR also explainsthat they “create smoke primarilyby heating tobacco rather thanburning it” (www.eclipse.rjrt.com)

Swedish snus, with pound coins for scale

Some experts say that if smokers switched to the leastharmful forms of smokeless tobacco it wouldsubstantially reduce their harm

ABC of Smoking Cessation

32

should be lifted—within an evidence based regulatoryframework that favours the least harmful forms of smokelesstobacco—and that smokers should be encouraged to use them.

Switching to pharmaceutical nicotineproductsSwitching from cigarettes to pharmaceutical nicotineproducts—that is, NRT—is standard practice in managingsmoking cessation, but these products are not currently licensedfor long term use as an alternative to smoking. Given that therisks associated with NRT are much lower than those associatedwith smoking, long term use of NRT products is a rationalharm reduction strategy.

However, as most smokers do not find the current NRTproducts to be as satisfying as cigarettes, the viability of theseproducts as a long term substitute is limited. The technology todevelop safe, inhaled forms of nicotine that could provide amore satisfactory alternative to cigarette smoking is available inthe pharmaceutical industry, but in the context of the currentregulatory framework in the United Kingdom and many othercountries, such products would not be licensed and aretherefore not commercially viable. As discussed above and inthe previous article in this series, this imbalance in theregulation of nicotine needs to be redressed urgently in favourof public health.

The table showing prospective hazard ratios for death for smokers who cutdown or quit is adapted from Godfredsen et al (Am J Epidemiol2002;156:994-1001).

Competing interests: Ann McNeill has received two honorariums andhospitality from manufacturers of tobacco dependence treatments. Seechapter 1 for the series editor’s competing interests.

Key pointsx Many smokers try to reduce the harm from smoking by cutting

down or switching to “low tar” productsx No evidence exists that cutting down or switching to low tar

products substantially reduces health risksx Cutting down on cigarettes with concomitant use of NRT could be

a more promising strategyx Switching to smokeless tobacco should substantially reduce adverse

effects from tobacco use, but in many countries its use is illegalx Switching to pharmaceutical nicotine would substantially reduce

harm, but NRT products are licensed as cessation aids, not assubstitutes, and smokers tend to find them less satisfying thancigarettes

x The regulatory framework in many countries, including Britain,discourages the development of nicotine products that are lessharmful than cigarettes

Further readingx Tobacco Advisory Group of the Royal College of Physicians.

Regulation of nicotine intake by smokers, and implications forhealth. In: Nicotine addiction in Britain. London: RCP, 2000. (Areport of the Tobacco Advisory Group of the Royal College ofPhysicians, Chapter 6.)

x Stratton K, Shetty P, Wallace R, Bondurant S, eds. Clearing the smoke:assessing the science base for tobacco harm reduction. Washington, DC:National Academy Press, 2001.

x Ferrence R, Slade J, Room R, Pope M, eds. Nicotine and public health.Washington, DC: American Public Health Association, 2000.

x Tobacco Advisory Group of the Royal College of Physicians.Protecting smokers, saving lives. The case for a tobacco and nicotineregulation authority. London: RCP, 2002.

x National Cancer Institute. Risks associated with smoking cigarettes andlow machine-measured yields of tar and nicotine. Bethesda, MD: USDepartment of Health and Human Services, National Institutes ofHealth, National Cancer Institute, 2001. (Smoking and tobaccocontrol monograph No 13; NIH publication No 02-5074.)

Harm reduction

33

12 Economics of smoking cessationSteve Parrott, Christine Godfrey

Smoking imposes a huge economic burden on society—currently up to 15% of total healthcare costs in developedcountries. Smoking cessation can save years of life, at a very lowcost compared with alternative interventions. This chapterreviews some of the economic aspects of smoking cessation.

Who benefits from cessation?The most obvious benefits of smoking cessation areimprovements in life expectancy and prevention of disease.However, cessation also improves individuals’ quality of life assmokers tend to have a lower self reported health status thannon-smokers, and this improves after stopping smoking.

There are also wider economic benefits to individuals andsociety, arising from reductions in the effects of passive smokingin non-smokers and savings to the health service and theemployer. These wider benefits are often omitted fromeconomic evaluations of cessation interventions, whichconsequently tend to underestimate the true value for moneyafforded by such programmes.

Economic burden of smokingMany estimates have been made of the economic cost ofsmoking in terms of health resources. For the United Statesthey typically range from about 0.6% to 0.85% of grossdomestic product. In absolute terms, the US public healthservice estimates a total cost of $50bn (£29bn; €42bn) a year forthe treatment of smoking related diseases, in addition to anannual $47bn in lost earnings and productivity. Estimated totalcosts in Australia and Canada, as a proportion of their grossdomestic product, are 0.4% and 0.56% respectively. In theUnited Kingdom, the treatment of smoking related disease hasbeen estimated to cost the NHS £1.4bn-£1.5bn a year (about0.16% of the gross domestic product)—including £127m to treatlung cancer alone.

When expressed as a percentage of gross domestic product,the economic burden of smoking seems to be rising. In reality,however, the burden may not be increasing, but instead, as morediseases are known to be attributable to smoking, the burdenattributed to smoking increases. Earlier estimates may simplyhave underestimated the true cost.

Passive smokingIn the United States, passive smoking has been estimated tobe responsible for 19% of total expenditure on childhoodrespiratory conditions, and maternal smoking has been shownto increase healthcare expenditure by $120 a year for childrenunder age 5 years and $175 for children under age 2 years.

In the United Kingdom an estimated £410m a year is spenttreating childhood illness related to passive smoking; in adults,passive smoking accounts for at least 1000 deaths innon-smokers, at an estimated cost of about £12.8m a year at2002 prices.

Age group

Self

rate

d sc

ore

18-24 25-34 35-44 45-54 55-64 65-74 >750

20

40

60

80

100Non-smoker<20 cigarettes/day>20 cigarettes/day

Self rated health status (100 = best imaginable health state), by age andsmoking status. Data from Kind et al. UK population norms for EQ-5D. York:Centre for Health Economics (Discussion paper 172)

Benefits of smoking cessationSmokers and their families• Improved quality and quantity of life for those stopping smoking• Improved quality and quantity of life for those living with smokers

through a reduction in the harm from passive smoking

Society• Lower healthcare expenditure on treatment of smoking induced

disease• Less workplace absenteeism due to smoking related disease• Less harm from passive smoking in public places• Reduction in costs related to cleaning up after smokers (cigarette

ends, ash, etc and damage from these to floors and furnishings)

In Puerto Rico, China (above), and Venezuela, the cost of smoking has beenestimated as 0.3%-0.43% of the gross domestic product

Passive smoking causes illness and premature loss of life,at all ages from the prenatal period to late adult life

34

Cost of absenteeismAbsenteeism arising from smoking related disease is also a majorcause of lost productivity, a cost incurred by employers. Anannual estimated 34 million days are lost in England and Walesthrough sickness absence resulting from smoking related illness,and in Scotland the cost of this productivity loss is about £400m.

Cost effectiveness of cessationprogrammesClear evidence exists that smoking cessation interventions areeffective. However, to show value for money, the costs as well asthe effectiveness of such programmes have to be examined. Theoverwhelming evidence is that face to face cessationinterventions provide excellent value for money compared withthe great majority of other medical interventions.

Several complex factors influence cost effectiveness. Forexample, although a cessation programme tends to be moreeffective as its intensity increases, increased intensity isassociated with increased costs, therefore increasing both sidesof the cost effectiveness ratio. This was illustrated in a study byParrott et al (1998) of the range of intensities of smokingcessation interventions in the United Kingdom. The researchersexamined these interventions using local cost data and life yearssaved as predicted from the PREVENT simulation model. Theylooked at four interventions: a basic intervention of threeminutes of opportunistic brief advice; brief advice plus self helpmaterial; brief advice plus self help material and nicotinereplacement products; and brief advice plus self help material,nicotine replacement products, and a recommendation toattend a smoking cessation clinic. The most cost effectiveintervention was the brief advice alone (cost £159 per life yearsaved, £248 when discounted at 6%), although the mostintensive clinical interventions still represent good value formoney at £1002 per life year saved when discounted at 6%.

The cost effectiveness of putting the US Agency forHealthcare Research and Quality’s clinical guidelines onsmoking cessation into practice has also been estimated, forcombined interventions based on smokers’ preferences fordifferent types of the five basic recommended interventions.The cost of implementation was estimated at $6.3bn in the firstyear, as a result of which society would gain 1.7 million newquitters at an average cost of $3779 per quitter, $2587 per lifeyear saved, and $1915 per quality adjusted life year (QALY). Inthis study the most intensive interventions were calculated to bemore cost effective than the briefer therapies.

Care should be taken when extrapolating the results ofthese evaluations, as cost effectiveness estimates are likely to betime and country specific and highly dependent on thehealthcare system in question. In a system of fee for service, asin the United States, monetary rewards may be necessary toencourage provision. On the other hand, if patients who stopsmoking place a reduced burden on the primary care budget infuture years, the incentives to provide such services may beinherent in the system.

Pharmacological interventionsThe National Institute for Clinical Excellence (NICE) hasrecently estimated the cost effectiveness of using nicotinereplacement therapy (NRT) or bupropion therapy. Theseestimates projected life years saved over a shorter period thanthe PREVENT model and hence produced generally higherfigures: £1000-£2400 per life year saved for advice and NRT,

Cost effectiveness estimates for healthcare providers

Type of interventionCosts per life year saved (£)Undiscounted Discounted

Face to faceBrief advice 159 248Brief advice plus self help 195 303Brief advice plus self help plus NRT 524 815Brief advice plus self help plus NRTplus specialist cessation service

658 1022

Community“Quit and win” programme:

Medium intensity 634 986“No smoking” day 26 40

Broader community healthpromotion interventions(medium intensity)

192 295

NRT = nicotine replacement therapy. Data from Parrott et al, 1998 (see FurtherReading box), revised to reflect 2001-2 prices.

Cost per year of life saved (£000s)

0.1 1 10 100

Aspirin after myocardial infarctionGaspoz et al (N Engl J Med 2002;346:1800)

Simvastatin after myocardial infarctionJonsson et al (Eur Heart J 1996;17:1001)

Brief advice + self help + NRT +specialist support

Brief advice + self help + NRT

Brief advice + self help

Brief advice

Pravastatin primary preventionCaro et al (BMJ 1997;315:1577)

Cost effectiveness of smoking cessation interventions compared with that ofroutine strategies for preventing myocardial infarction

Smoking related fires cause about £151m of damage eachyear in England and Wales

The National Institute for Clinical Excellence is part ofthe NHS in England and Wales; it issues guidance oncurrent “best practice”

Discounting is a method of adjusting for the fact thatindividuals prefer to incur costs in later periods andenjoy benefits in the current period. Applying a discountrate transforms future values into current values, takingthis preference into account

Economics of smoking cessation

35

£645-£1500 for advice plus bupropion, and £890-£1970 foradvice, nicotine replacement, and bupropion. When QALYs areused, the ranges are £741-£1780, £473-£1100, and £660-£1460respectively. These costs again compare favourably with a rangeof other healthcare interventions. Bupropion does seem morecost effective than NRT, although the evidence base for theeffectiveness of bupropion is much less extensive than for NRT,and results should therefore be treated with caution.

The cost effectiveness of bupropion has been investigated inSpain with a decision model (Musin et al, eighth meeting of theSociety for Research on Nicotine and Tobacco, Savannah,2002). The model presents results in an incremental analysisover and above opportunistic advice in primary care. Thefindings show that if all motivated smokers in Spain were to usethe therapy, over a 20 year period 44 235 smoking relateddeaths would be averted at a saving to the healthcare system of€1.25bn. In the United States, studies have predicted savings ofbetween $8.8m and $14m over 20 years when bupropion isadded to an insurance plan. In a UK study, Stapleton et al(1999) used data from a randomised placebo controlled trial ofnicotine patches and a survey of resource use to show that ifgeneral practitioners were allowed to prescribe transdermalnicotine patches on the NHS for 12 weeks, the cost per life yearsaved would be £398 for people aged under 35, £345 for thoseaged 35-44, £432 for those aged 45-54, and £785 for those aged55-65. Since Stapleton’s study was published, NRT has beenmade available in Britain through NHS prescription. However,studies have tended to exclude potential side effects ofbupropion and are again based on a more limited effectivenessdatabase then the evidence for the effectiveness of NRTproducts.

The means by which the provision is financed is a crucialdeterminant of the effectiveness of smoking cessation products.Evidence shows that smokers are more likely to take upsmoking cessation interventions if they are provided by theirinsurance scheme or health service than if they have to pay forthem themselves. In the United Kingdom, NHS provision canreduce costs through bulk buying and discounts frompharmaceutical manufacturers. The price for a packet of seven15 mg Nicorette patches, for example, costs £15.99 throughretail outlets, compared with an NHS purchase price of only£9.07, a reduction of about 43%. It is also clear that decreases inthe price of NRT products and increases in the price ofcigarettes would lead to substantial increases in per capita salesof NRT products.

The photograph of the Marlboro advertisement in China is publishedwith permission from Mark Henley/Panos.

Competing interests: See chapter 1 for the series editor’s competinginterests.

Comparative costs of other common healthcare treatments(analysis of guidance of the National Institute for ClinicalExcellence)

Intervention

Incremental cost (£)Per qualityadjustedlife year

Per lifeyear gained

Zanamivir in managing influenza 9300-31 500Taxanes for ovarian cancer 6500-10 000Taxanes for breast cancer 7000-24 000Implantable cardioverterdefibrillators for arrhythmias

26 000-31 000

Glycoprotein IIb/IIIa inhibitors foracute coronary syndromes

7000-12 000

Methylphenidate forattention-deficit/hyperactivitydisorder in children

10 000-15 000

Tribavirin and interferon alfa for hepatitis C:First six months’ treatment 3000-7000Second six months’ treatment 5000-36 000

Laparoscopic surgery for inguinalhernias

50 000

Riluzole for motor neurone disease 34 000-43 000Orlistat for obesity in adults 20 000-30 000

Adapted from Raftery (BMJ 2001;323:1300-3).

Key points• Savings to the healthcare system, a reduction in the harm caused

by passive smoking, and savings to employers are all relevant inevaluations of cessation interventions

• The economic cost of smoking in the United States may be as highas 1.15% of gross domestic product in terms of healthcare costsalone

• The estimated cost to the NHS is £1.4bn-£1.5bn• Cessation interventions offer excellent value for money when

compared with some other healthcare interventions• Some studies have quantified outcomes in life years saved, not

allowing for changes in quality of life, thereby underestimating thecost effectiveness of smoking cessation by almost half

Further reading• Action on Smoking and Heath. Smoking and disease. Basic facts No 2.

London: ASH, 2002. www.ash.org.uk (accessed 15 Dec 2003).• Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T.

Cost-effectiveness of the clinical practice recommendations in theAHCPR guideline for smoking cessation. JAMA 1997;278:1759-66.

• Nielsen K, Fiore MC. Cost-benefit analysis of sustained-releasebupropion, nicotine patch, or both for smoking cessation. Prev Med2000;30:209-16.

• Parrott S, Godfrey C, Raw M, West R, McNeill, A. Guidance forcommissioners on the cost effectiveness of smoking cessationinterventions. Thorax 1998;53(suppl 5, part 2):S1-38.

• Stapleton JA, Lowin A, Russell MAH. Prescription of transdermalnicotine patches for smoking cessation in general practice:evaluation of cost-effectiveness. Lancet 1999;354:210-5.

ABC of Smoking Cessation

36

13 Policy priorities for tobacco controlKonrad Jamrozik

Although many countries have implemented strategies forreducing tobacco use at individual and population level, nocountry to date has adopted a truly comprehensive controlprogramme. In addition, the tobacco industry and the strategiesit uses to counteract policies on tobacco control and therebymaintain and develop its commercial markets have bothcontinued to evolve. All communities therefore face at leastsome “unfinished business” in relation to tobacco control, andthose working in smoking cessation need to be familiar with thenecessary policy responses.

The healthcare industryIndividuals and institutions in the healthcare industry havean important exemplar role. In many countries theprevalence of smoking among doctors differs little from thatin the wider community. This considerably underminesindividual practitioners’ credibility in advising patients notto smoke and denies the profession as a whole the influenceit might wield on public and political opinion and policyon tobacco.

Institutions that train health professionals need to makemore time available in both undergraduate and postgraduatecurriculums for teaching about smoking and especially abouteffective cessation interventions. Coverage of these topics iscurrently, for the most part, inadequate. As assessment shapeslearning, these topics also need to feature prominently andregularly in major examinations.

All healthcare facilities, including schools of medicine,nursing, and dentistry, should adopt and enforcecomprehensive smoke-free policies across their entire campusesand not just in buildings. Where smoking rooms are providedfor inpatients, these should have separate, externally ventilatedair conditioning systems so that tobacco smoke is notrecirculated into the rest of the building.

Policies on smoke-free placesThe smoking of tobacco should eventually become an activityundertaken only by consenting adults in private. Although sucha goal seems unattainable now, many current smoke-freepolicies were at one time viewed in the same way.

In several countries, virtually all workplaces and publicbuildings (and other enclosed public places) are nowsmoke-free zones, with equivalent policies spreading steadilyinto venues such as outdoor sports arenas, as well as intoprivate homes. An important omission has been schools,where smoke-free policies should cover not only buildingsbut also playgrounds. They should also extend to all schoolrelated events, including parents’ meetings, excursions, andfield trips. Several countries are seriously consideringlegislation to ban smoking in private cars carrying infantsor children.

Overall, it is now possible to conceive of communitieswhere incremental changes will result in all public placesbecoming smoke free—and free also of all of the littergenerated by smokers.

% of doctors who smoke

0

AustraliaBangladesh

Bosnia-HercegovinaChile

ChinaColombiaDenmark

IcelandIndia

IndonesiaLaos

MoroccoRepublic of Korea

Russian FederationSaudi Arabia

SpainSweden

SyriaUnited Kingdom

20 30 40 50 60 70 80 90 10010

Men

Women

Prevalence of smoking among doctors around the world, according to datacollected from 493 medical schools in 93 countries (36% response rate) in1995. Data from Mackay et al (The tobacco atlas. Geneva: World HealthOrganization, 2002)

Examples of stickers available in Australia to show visitors that privatehomes and cars are smoke-free environments

One of the most simple and cost effective of all medicalinterventions is for doctors to tell every smoker theyencounter in their work that giving up the habit is one ofthe most important things they can do for their health.Ascertaining smoking status and intervening asappropriate must become a routine component of allhealth care

37

The tobacco industryThe tobacco industry operates as a global entity whilesimultaneously maintaining notable sensitivity andresponsiveness to local regulatory and other conditions. Itsstandard tactics are to debate almost endlessly the scientificevidence on the harm caused by its products, to cultivate (andregularly pay) spokespeople in other industries and inacademia, and to purchase influence by making substantialdonations to any political party that will accept them. Many ofthese strategies are designed to foster uncertainty in the mindsof the public and governments, and all serve ultimately to delayeffective action on tobacco control.

The industry has responded to the growing number ofstronger initiatives by Western governments, however, byshifting its primary focus to developing countries. Severalfactors in these countries conspire to cause needless repetitionin this century of the sad experience of tobacco use in theWestern world in the last: a lack of information; the long leadtime between an increase in the prevalence of smoking and theconsequent increase in the incidence of death and disease; andthe appeal to farmers of a cash crop and to governments ofconsiderable taxation revenues. Unless effective action is takenglobally, more than a billion people will be killed by tobacco thiscentury.

The Framework Convention onTobacco ControlSuch calculations prompted the World Health Organization toconvene, in 1999, the first of a series of meetings to draw up aninternational treaty on tobacco control—that is, an effectiveglobal response to a problem already of global scale.

The Framework Convention on Tobacco Control comprisesa core statement complemented by several separate instrumentsthat individual governments may or may not adopt. Progress ondrafting the document was slowed by considerable resistancefrom governments of countries that are home to major tobaccocompanies or that run state tobacco monopolies. The coredocument was adopted unanimously, however, by the 192member countries of the World Health Assembly on 21 May2003, just six days short of the 53rd anniversary of thepublication of the first case-control study on smoking and lungcancer. Health professionals everywhere must now press theirown governments to ensure that the convention is ratified andenacted in their own countries with minimum delay.

The campaign stickers are from ACOSH (Australia Council on Smokingand Health, www.acosh.org/); the letter from Sylvester Stallone is from theLegacy Tobacco Documents Library at the University of California at SanFrancisco (http://legacy.library.ucsf.edu); and the photograph above ispublished with permission from Chris Stowers/Panos.

The tobacco industry is now targeting its products increasingly atdeveloping countries

Key pointsx No country has adopted a truly comprehensive programme on

tobacco control, so all nations have some “unfinished business”x Health professionals should set an example by not smokingx All public places and workplaces should become smoke freex Adequate funding and political support should be available for

sustained and sophisticated public education campaignsx Traditional and emerging forms of tobacco advertising should be

eliminatedx Effective action is needed on tobacco smugglingx Legislation on production, packaging, sale, and use of tobacco

products should be integratedx International action—via the Framework Convention on Tobacco

Control—is vital in countering the tobacco industry’s activities

Further readingx Richmond R, ed. Educating medical students about tobacco: planning

and implementation. Paris: International Union Against Tobacco andLung Disease, 1996.

x Jha P, Chaloupka FJ. Curbing the epidemic: governments and theeconomics of tobacco control. Washington, DC: World Bank, 1999.

x Glantz SA, Slade L, Bero LA, Hanauer P, Barnes DE. The cigarettepapers. Berkeley: University of California Press, 1996.

Despite the strategies and tactics of the tobacco industry,smoking is firmly on the wane in most of the developedworld, with the scope and momentum of governmentalinitiatives growing steadily

Competing interests: KJ received costs for travel and accommodationfrom SmithKlineBeecham to attend a meeting of the Australian SmokingCessation Consortium that was convened by the drug company. Seechapter 1 for the series editor’s competing interests.

Policy priorities for tobacco control

39

Advertising and sponsorshipThe tobacco industry has proved adept in identifying andexploiting loopholes in legislation designed to restrict how itadvertises its products. Recent examples include the industry’sexpansion of in-store advertising—as advertising outdoors andin the mass media becomes illegal. Ultimately, tobacco productsshould become “under the counter” items that are not displayedand must be requested by name. Such an arrangement isentirely appropriate to the harm they do and their proper“adults only” status.

Given their danger—half of cigarette smokers who continueto smoke are killed prematurely by the habit—legislation onpromotion of tobacco needs to cover all kinds of products anddefine promotional activities widely. Governments have beenslow, for example, to deal with “same name” advertising (that is,advertising of other products carrying the cigarette’s brandname, such as Marlboro clothing) and “product placement”(whereby celebrities or producers of entertainment are paid touse and display particular tobacco products prominently).

The internet is already becoming a vehicle for unsoliciteddirect advertising of tobacco to children as well as to adults,making it even worse than sponsorship of international sport.Solving each of these problems requires a coordinatedinternational response.

Young people and smoking?Rather than targeting children and teenagers, the best methodof helping them not to start smoking is highly likely to be apolicy of systematically driving down the prevalence of smokingamong adults. Already evidence shows that young people incommunities with active and prominent general programmes oftobacco control are beginning to realise that saying “no thanks,I’ve given up” is more “adult” than accepting the offer of acigarette.

“Quit” campaigns directed specifically at teenagers have notreceived much attention to date, despite the fact that in manypopulations two thirds of those who ever try smoking abandonthe habit before their mid-20s.

Nicotine and tobacco regulationA comprehensive approach to tobacco control must alsoinclude systematic attention to the tobacco products themselvesand to their presentation to the public. Tobacco companies,including those run as government monopolies, have to beflushed out from behind their “commercial and sensitive”smokescreen and be required to declare fully what they add totheir products during manufacture, just as the makers ofvirtually all other products intended for human consumptionare obliged to do.

Many governments have already abandoned voluntaryagreements with tobacco companies on health warnings to bedisplayed on their products because the manufacturersregularly resist using those warnings that independent fieldtesting show to be most arresting.

Governments are under pressure to move on frommandating warnings of proved effectiveness by requiring plain“generic” packaging that is far less eye catching. Such regulationneeds to be complemented by “probity” clauses that make it anoffence to make misleading or untrue public pronouncementsabout tobacco products, their effects, and the activities of thetobacco industry in general.

Public and school educationx The international benchmark in this area has been set by the US

state of California, where the budget for tobacco control has beenabout $5 (£2.70; €3.90)—over 1.5 times the average retail price of apacket of 20 cigarettes—per head of population per year

x This kind of investment makes sustained, sophisticated, public andschool based education campaigns eminently feasible

x Doctors and other health professionals must press their owngovernments to match California’s commitment

Letter from US actor Sylvester Stallone agreeing in 1983 to smokeBrown & Williamson products in five feature films in exchange for$500 000. From the Legacy Tobacco Documents Library at Universityof California, San Francisco (http://legacy.library.ucsf.edu)

Price, taxation, and smugglingx Studies have clearly shown that all smokers—and particularly young

smokers—are sensitive to the price of tobacco productsx Geographic variations in the “real” or absolute prices of tobacco

products, however, soon lead to the emergence of considerablesmuggling

x Ample evidence shows that organised crime is deeply involved insmuggling, and detailed studies of international movements oftobacco products have led to questions about possible connivancein these activities by major tobacco manufacturers

x Local detection and enforcement activities can never hope to dealadequately with such problems

x Technical solutions such as unambiguous, tamper-proof marking ofpackets of tobacco products to indicate their origin and tax paidstatus will form only part of the answer

x Coordinated international action is needed to tackle smuggling

“Quit” campaigns need to be targeted at teenage smokers,not just older smokers

Strong arguments exist for consolidating into a singlestatutory instrument all legislation covering tobacco andnicotine and for imposing price and marketingrestrictions on products in direct and consistent relationto their potential risk

ABC of Smoking Cessation

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key approaches 25pregnancy see pregnancy see also individual interventions

cessation services 24–6challenges 26

chewing tobacco 32–3children see adolescentschronic obstructive pulmonary disease (COPD)

bupropion 16, 16cessation benefits 2–3smoking status 2

cigar/pipe smoking, harm reduction 32clonidine 17complementary therapies 10contemplation stage 8cost-effectiveness

advice 9bupropion 36cessation interventions 35, 35, 35–6comparative of healthcare treatments 36nicotine replacement therapy 35–6PREVENT simulation model 35

costs (of smoking) 34cravings, nicotine withdrawal 5“cutting down” 31

dependencebupropion 7nicotine replacement therapy 13treatment choice 7–8, 8

diabetes mellitus, bupropion 16direct questioning, motivation assessments 8dopamine

bupropion effects 15nicotine replacement therapy 12during smoking 5

doxepin 17

economicshealth services 2passive smoking 34population strategies 27smoking cessation 34–6

education 28, 28emphysema 2epidemiology (of smoking) 1, 1ethnicity 20

smoking prevalence 20, 20

Fagerstrom test, dependence measurement 7, 7fetus, passive smoking effects 18

absenteeism 34action stage 8acupressure 10acupuncture 10adolescents 19–20

nicotine replacement therapy 13, 14smoking prevalence 19, 19, 38uptake (smoking) prevention 19

adverse health effects (of smoking) 1–2on fetus 18

advertising (of tobacco) 28–9, 38advertising, cessation services 25advice 9, 9, 22

personnel used 10pharmacotherapy combination 11

“alternative” cigarettes 32, 32antidepressant drugs, in cessation 17aortic aneurysms 2

bans (on smoking) 27, 37behaviour (of smoking) 5, 6

“cutting down” 31“low tar” cigarettes 6, 6, 31, 31–2, 32, 32

behavioural support 9–10, 10pharmacotherapy combination 11in pregnancy 18

benefits of smoking cessation 34, 34bladder cancer 2bronchitis 2budgets, cessation services 26bupropion 15–17

central nervous system effects 15, 15chronic obstructive pulmonary disease 16, 16contraindications/precautions 16cost-effectiveness 36dependence levels 7dose regimen 15, 15nicotine replacement therapy combination 16pharmacokinetics/interactions 16, 16side effects 16success rates 15, 15, 16

carbon monoxide measurements, in dependence 7cardiovascular disease, nicotine replacement therapy 13, 14cataracts 2central nervous system, bupropion effects 15, 15cessation, effects of 2, 2–3, 3

benefits 34, 34cessation interventions 21–3

comparisons 11cost effectiveness 35, 35, 35–6

Index

As smoking cessation is the subject of this book, all index entries refer to this unless otherwise indicated. Page references in italicsrefer to tables or boxed material; page numbers in bold refer to figures.

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five “A”s approach 21, 21–2fluoxetine 17Framework Convention on Tobacco Control 39funding, cessation services 26, 26

general practitionersreasons for not giving smoking advice 22, 22

generic packaging 29–30, 38group service

one-to-one service vs. 25gum 13, 13, 13

half life, nicotine 4harm reduction 31–3health benefits (cessation) 2–3, 3

see also individual diseases/disordershealthcare industry, tobacco control policies 37health effects

passive smoking 2smoking status 1–2, 2see also adverse health effects (of smoking)

health services, financial effects of smoking 2health warnings 38heart disease, cessation benefits 2“Help 2 Quit” (H2Q) 22, 22–3, 23

pregnancy 23helplines 10hunger, nicotine withdrawal 5

imipramine 17implementation, cessation services 24–6, 27impotence 2indirect advertising (of tobacco) 28–9infertility 2inhalators 13ischaemic heart disease 2

location, cessation services 25“low tar” cigarettes 31–2

smoking behaviour 6, 6, 31, 31–2, 32, 32lozenges 13, 13lung function 2, 2

maintenance stage 8management (of smoking), monitoring 23mecamylamine 17medical records 21, 21, 22moclobemide 17monoamine oxidase inhibitors (MAOIs) 17motivation 22–3motivation assessments 8, 22

indices 8nicotine replacement therapy supply 13

myocardial infarction, smoking status 2

nasal sprays 13National Institute for Clinical Evidence (NICE) 8“New Leaf” service 24, 24–6nicotine

addiction pathways 5half life 4intake regulation 6, 6levels during smoking 4physical/psychological effects 4–5as psychomotor stimulant 5

nicotine replacement therapy (NRT) 12–14

bupropion combination 16cost-effectiveness 35–6“cutting down” combination 31, 33decision pathway 13dependence 7, 13formulations 13, 13in pregnancy 13, 14, 19prescribing details 13, 13smoking vs. 12success rates 12

nicotine withdrawal 5effects 5, 5symptom reduction, nicotine replacement therapy 12

nicotinic acetylcholine receptors (nAChRs) 5non-nicotine therapies 17, 17nortriptyline 17Nottingham “New Leaf” service 24, 24–6

objective tests, dependence 7oesophageal cancer, cessation benefits 2oral cancer

cessation benefits 2chewing tobacco 32

osteoporosis 2

packaging 29–30, 38passive smoking

economics 34health effects 2reduction 27–8

patches, transdermal 13, 13periodontal disease 2pharmaceutical nicotine products 32–3pharmacotherapy

behavioural support combination 11in pregnancy 18–19see also individual drugs

pneumonia 2point of sale advertising 29, 38policy priorities 37–8political commitment 28political independence, cessation services 25population strategies 27, 27–30

economics 27education 28, 28packaging 29–30point of sale advertising 29political commitment 28pricing 28, 28product regulation 29prosecution 29public areas 27support for 27tobacco promotion/advertising 28–9workplaces 27

poverty see socioeconomic statusprecontemplation stage 8pregnancy 18–19, 19, 19

bupropion 17health effects 2“Help 2 Quit” 23nicotine replacement therapy 13, 14, 19smoking prevalence 18

preparation stage 8prevalence (of smoking) 1, 1

adolescents 19, 19, 38

Index

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ethnicity 20, 20pregnancy 18socioeconomic status 6, 6, 20, 20

prevention of smoking, young people 19PREVENT simulation model 35pricing 28, 28product regulation 29, 37–8, 38prosecution 29public places, smoking bans 27

qualitative measurements, dependence 7quantitative measurements, dependence 7

Read codes 23reasons (for smoking) 4–6regulation 29, 37–8, 38relapse prevention 11respiratory cancers 2

“same name” advertising 38seizures, bupropion 16self help materials 10, 10sensory replacement therapy 17serotonin, bupropion effects 15service provision models, cessation services 25smokeless tobacco 32, 32–3smoking

dopamine release 5nicotine levels 4nicotine replacement therapy vs. 12

smoking statuschronic obstructive pulmonary disease 2

health effects 1–2, 2myocardial infarction 2

snuff 32–3snus (moist snuff) 32–3social aspects (of smoking) 5“social influence training” 19socioeconomic status 1, 1, 6, 6, 20, 20specialist groups (of smokers) 18–20specialist services 22sponsorship 28–9staff recruitment, cessation services 24stages of change, motivation assessments 8stroke 2sublingual tablets 13success rates

advice 9bupropion 15, 15, 16nicotine replacement therapy 12

ten point plan, tobacco control 27tobacco industry 39transdermal patches 13, 13

uptake (of smoking) 4prevention 19, 28

venlafaxine 17

websites 10weight gain prevention

bupropion 15nicotine replacement therapy 13

workplaces, smoking bans 27

Index

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