A Review of Smoking Cessation Interventions

Conclusion

The "5A strategy" is a multicomponent evidence-based approach that includes behavioral therapy and pharmacotherapy; "Ask, Advise, Assess, Assist, and Arrange" is now recommended for planning all smoking cessation programs.^[18]

Pairing smokers together to make the quit attempt improves success rates,^[53] while women do better when some physical activity is incorporated in the cessation program.^[100] Patients should be aware that relapses are quite common and that it takes on average of 4-5 quit-attempts before eventually succeeding. Patients should be encouraged to quit as soon as possible after a failed attempt. Factors that should guide the selection of drug include efficacy, cost, ease of use, adverse effect profile, and patient characteristics (eg, past experience or personal preference).^[4]

Most people who stop smoking gain weight, and few smokers will ever return to their precessation weight.^[7] Smokers should be informed that weight gain is common but that the associated health risks are far outweighed by the benefits of stopping smoking.^[27,101] Nicotine replacement therapy and bupropion can delay but not prevent weight gain, until smokers feel ready to follow a weight control strategy.^[83,102]

Pharmacotherapy should be made available to all smokers, and because concomitant behavioral and supportive therapy improves efficacy, these drugs should be encouraged. Regardless of the modality, intensity, or duration of any given intervention to be used to affect smoking cessation, what is evident is that some form of treatment offers a higher probability of quitting than unassisted cessation attempts.

Comparison of the Different Preparations Available for Nicotine Replacement Therapy
Drug	Dosage	Duration	Side Effects	Precautions	Advantages	Disadvantages	Efficacy
Nicotine gum 2 mg (<25 cig/day) 4 mg (≥25 cig/day)	1 piece/hour up to a maximum of 24 pieces/day	8 12 weeks	Irritation in mouth, mouth ulcers, sore jaw, dyspepsia, nausea, hiccups, (?) breathing difficulties	Contraindicated if gastric ulcers. Avoid in pregnancy and lactation	User controls dose, substitute ritual*, rapid absorption, available OTC	Complex chewing technique, difficulty for denture users, cannot eat/drink, acute withdrawal on abrupt discontinuation	≈ 1.5 to 2 times that of placebo
Nicotine patch 7, 14, 21 mg (24 hours) 15 mg (16 hours)	Worn for 16 24 hours, depending upon the patch	21 mg/day X 4 weeks then 14 mg/day X 2 weeks then 7 mg/day X 2 weeks (total 8 weeks) or 15 mg/16 hours/day X 8 weeks	Local skin reaction/irritation, insomnia, (?) cardiovascular side effects	Avoid in pregnancy/lactation. Caution advised if coexistent cardiovascular disease	Steady plasma levels, simple to use (? therefore better compliance), can be used by patients of PUD/those with denture, OTC, low habituation, (?) improved cognitive decrements, discreet	Slow release preparation, no control over dose (therefore not useful for acute craving), effects wane over time therefore high relapse rate	As above
Nasal spray 1 dose = 1 spray (0.5 mg) in each nostril	1 to 2 doses/hour (up to 40 mg/day)	3 to 6 months	Nasal irritation, sneezing, watering of eyes **	Cautious use in patients with perennial rhinitis, rhinosinusitis, recurrent epistaxis, recent MI or worsening angina. Avoid in pregnancy and lactation	Fastest delivery & highest levels of nicotine among all products, user controls dose	Embarrassing, high incidence of local side effect may decrease compliance	As above
Nicotine inhaler 4 mg/cartridge (also 1 mg of menthol/ cartridge)	6 to 16 cartridges/day	3 to 6 months	Irritation in mouth and throat, cough	Avoid in pregnancy and lactation, Cautious use in patients with recent MI or worsening angina	User controls dose, substitute ritual, rapid delivery of nicotine compared to patch	Embarrassing, compliance less than patch, frequent puffing required	As above
Nicotine lozenges 2 and 4 mg	9 to 20 per day	12 weeks	Dyspepsia, irritation in mouth	Avoid in pregnancy/lactation. Caution advised if coexistent cardiovascular disease	Easy to use, no complex techniques for administration, user controls dose, discreet	Acute withdrawal on abrupt discontinuation cannot eat/drink, safety in geriatric patients and PUD unclear

Comparison of the Different Preparations Available for Nicotine Replacement Therapy

Drug

Dosage

Duration

Side Effects

Precautions

Advantages

Disadvantages

Efficacy

Nicotine gum
2 mg (<25 cig/day)
4 mg (≥25 cig/day)

1 piece/hour up to a maximum of 24 pieces/day

8 12 weeks

Irritation in mouth, mouth ulcers, sore jaw, dyspepsia, nausea, hiccups, (?) breathing difficulties

Contraindicated if gastric ulcers. Avoid in pregnancy and lactation

User controls dose, substitute ritual*, rapid absorption, available OTC

Complex chewing technique, difficulty for denture users, cannot eat/drink, acute withdrawal on abrupt discontinuation

≈ 1.5 to 2 times that of placebo

Nicotine patch
7, 14, 21 mg (24 hours)
15 mg (16 hours)

Worn for 16 24 hours, depending upon the patch

21 mg/day X 4 weeks then 14 mg/day X 2 weeks then 7 mg/day X 2 weeks (total 8 weeks) or 15 mg/16 hours/day X 8 weeks

Local skin reaction/irritation, insomnia, (?) cardiovascular side effects

Avoid in pregnancy/lactation. Caution advised if coexistent cardiovascular disease

Steady plasma levels, simple to use (? therefore better compliance), can be used by patients of PUD/those with denture, OTC, low habituation, (?) improved cognitive decrements, discreet

Slow release preparation, no control over dose (therefore not useful for acute craving), effects wane over time therefore high relapse rate

As above

Nasal spray
1 dose = 1 spray (0.5 mg) in each nostril

1 to 2 doses/hour (up to 40 mg/day)

3 to 6 months

Nasal irritation, sneezing, watering of eyes **

Cautious use in patients with perennial rhinitis, rhinosinusitis, recurrent epistaxis, recent MI or worsening angina. Avoid in pregnancy and lactation

Fastest delivery & highest levels of nicotine among all products, user controls dose

Embarrassing, high incidence of local side effect may decrease compliance

As above

Nicotine inhaler
4 mg/cartridge (also 1 mg of menthol/ cartridge)

6 to 16 cartridges/day

3 to 6 months

Irritation in mouth and throat, cough

Avoid in pregnancy and lactation, Cautious use in patients with recent MI or worsening angina

User controls dose, substitute ritual, rapid delivery of nicotine compared to patch

Embarrassing, compliance less than patch, frequent puffing required

As above

Nicotine lozenges
2 and 4 mg