Smoking Cessation

Cigarette smoking is the leading preventable cause of disease and death in the United States, and results in enormous medical costs. The health benefits of quitting are substantial, even if smoking-related health problems already exist (U.S. Department of Health and Human Services [USDHHS], 1990). As the dangers associated with smoking and the benefits of quitting became more widely known, the prevalence of smoking among adults in the United States dropped from 40% in 1965 to 29% in 1987; most recent data indicate that approximately 23.3% of U.S. adults are current smokers (Centers for Disease Control [CDC], 1996; CDC, 2002; USDHHS, 1990). Smoking prevalence continues to decline, but not quickly enough to reach the target of 12% set in the Healthy People 2010 objectives (USDHHS, 2000). Interest in smoking cessation remains high among the majority of regular smokers: 70% of current smokers report that they want to quit smoking, and 41 % have made an attempt to quit in the preceding year (CDC, 2002). Despite the high level of interest in quitting smoking, long-term abstinence is extremely difficult to achieve.

Factors Contributing to Continued Smoking

Smoking cigarettes is extremely reinforcing. This is the result of both the physical addiction to nicotine and the habitual/psychological component of smoking. The physical addiction begins with the repeated administration of nicotine in cigarettes. Nicotine addiction follows the typical developmental pattern of any addiction: with repeated exposure to nicotine, tolerance develops, requiring increased levels of nicotine to achieve the physical effects experienced during early administrations. If nicotine is withheld, a set of negative physical effects known as withdrawal begins, and the person experiences increasingly stronger urges for the substance. Withdrawal symptoms and cravings can be relieved by administering more of the substance. Although dependence can develop to nicotine in any form, nicotine is delivered to the brain quickly when administered through cigarettes, which results in a particularly strong pattern of addiction.

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There is also an extremely strong habitual component to smoking cigarettes, which creates a pattern of behavior that can be difficult to alter. Individuals tend to smoke in predictable settings associated with specific events, times of day, feelings, places, and other persons. When smoking is frequently repeated in a particular set of circumstances, smokers experience cravings and urges when presented with those contextual cues despite their physiological state. For example, smoking cigarettes is commonly paired with drinking alcohol and coffee. These events or settings become strongly associated with smoking, which results in a conditioned habit that can be difficult to change.

Another substantial influence on the addictive nature of cigarette smoking is the strong social influence on urges and cravings to smoke. One factor that adds difficulty to a quit attempt is the number of smokers in the environment. The more a person is exposed to cigarette smoking, the greater the difficulty that person will have with quitting. There may be many reasons this is true, including additional exposure to smoking cures, greater availability of cigarettes (increasing the probability of slips and relapse), less pressure to quit smoking, and less support for quitting efforts.

In addition, there is ample evidence to suggest that cigarette smoking has a host of positive psychological effects including mood regulation (smokers might smoke to help manage depression and anxiety) and increased attention and concentration. Given the strong physical addiction to nicotine, the habitual component of smoking cigarettes, and the psychological/social reasons for continued smoking, treatments used to stop smoking have been developed targeting these specific influences.

Methods Used to Stop Smoking

Most smokers who have quit smoking have done so on their own or with minimal assistance. There are several types of minimal interventions that can be effective for quitting smoking. Brief cessation advice and counseling by health professionals during routine and other health care visits is an effective method of motivating smokers to quit and facilitating cessation. Success can be enhanced if health care professionals arrange for follow-up support. The largest problem with this type of cessation strategy is with health care providers consistently implementing the recommended treatment guidelines in real-world facilities.

There are many self-help cessation interventions aimed at reaching large populations of smokers. The formats of these programs include workbooks, pamphlets, video- or audiotapes, Internet sites, and hotlines that can provide assistance in planning and coping with a quit effort. Most smokers who wish to quit are not interested in attending formal treatment groups and would prefer to make their quit attempt on their own. Most self-help programs take the successful components from intensive cessation interventions and modify them for a minimal treatment paradigm. Recent research indicates that the success rates from these types of programs have been relatively modest, between 5% and 15% 12 months after the intervention; however, because these types of programs can be easily distributed to a large proportion of the population of smokers at a low cost, they can potentially result in a substantial number of individuals quitting.

Behavioral and cognitive skill building can enhance quit rates substantially. These types of programs are typically intensive, multisession interventions led by a health professional and presented to small groups of smokers who have voluntarily enrolled themselves in the program. These programs focus on teaching smokers the skills they need to prepare for quitting and cope with withdrawal and temptations to smoke. Formal programs typically include many different components including relaxation training, stress and mood management, strategies for harnessing social support, and addressing concerns regarding weight gain. Intensive clinical interventions result in relatively high quit rates, ranging from 20% to 40% 12 months after the end of the intervention. Whereas these types of interventions are very successful, relatively few smokers make use of these programs and prefer trying to quit smoking on their own.

There are a variety of pharmacologic aids to quit smoking. The most popular are the nicotine replacement therapies (NRT), which can be administered in many forms including patch, gum, spray, and inhaler. In the United States, patch and gum are sold over the counter, whereas spray and inhaler require a physician’s prescription. NRT theoretically works by providing the smoker with stable levels of nicotine in the blood and therefore minimizing withdrawal symptoms and cravings for cigarettes. There is data to suggest that adding NRT to a more intensive behavioral cessation program roughly doubles quit rates; however, other data suggest that use of NRT products alone does not increase quit rates. There is one non-nicotine pharmacotherapy approved by the Federal Drug Administration for smoking cessation: bupropion SR, an atypical antidepressant. The mechanism of action of this medication is unknown, but the research evidence does not support the hypothesis that its effectiveness in smoking cessation is related to reducing depressive symptomatology. The data on the pharmacotherapies clearly illustrate that there is no silver bullet when it comes to quitting smoking.

Maintenance and Relapse Issues

Regardless of the type of intervention utilized, the majority of initial cessation successes result in a relapse back to smoking within the first 3 months after quitting. Although high relapse rates after an intensive and expensive intervention can be disappointing, some individuals are able to recycle their efforts into another quit attempt. For most smokers, it will take multiple serious efforts to achieve a period of prolonged abstinence. Given the high rates of relapse, many of the formal clinical interventions for smoking cessation include a treatment component to teach people how to recover from a slip during a quit attempt in order to avoid a relapse.

Health Benefits of Quitting Smoking

Smoking contributes to death from cardiovascular and respiratory diseases as well as a number of different types of cancers. The health benefits of quitting smoking are enormous and cover most of the major systems in the body. Some of the health benefits that occur rather quickly after quitting include increased lung function and improved circulation. The most important long-term health improvement resulting from cessation is that individuals who quit smoking live longer than those who continue to smoke. Other important health benefits of cessation include a decreased risk of developing lung cancer and a number of other types of cancer and a lowered risk of experiencing heart attacks, strokes, and other respiratory ailments. For women who quit smoking before getting pregnant or early in their pregnancy, their risk of having a low-birth-weight infant is significantly reduced (USDHHS, 1990). It is important to note that individuals who have already developed smoking-related health problems benefit from quitting smoking. Research indicates that for some conditions, quitting may improve the course of the physical ailment and in some cases increase overall survival.

In conclusion, although quitting smoking for prolonged periods of time is frequently difficult for individuals to accomplish, there are many effective intervention options to select from. The health benefits from quitting are substantial; thus, smokers should be strongly encouraged to continue putting forth strong efforts to quit smoking.


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