Nicotine withdrawal symptoms associated with smoking cessation and the intense feelings of craving make it very difficult to stop smoking. Approximately 70% of adults who smoke in the United States say they want to quit (1), but only a small percentage are successful.
(See also Tobacco and Vaping.)
Reference
1. Babb S, Malarcher A, Schauer G, Asman K, Jamal A: Quitting Smoking Among Adults - United States, 2000-2015. MMWR Morb Mortal Wkly Rep 65(52):1457-1464, 2017. Published 2017 Jan 6. doi:10.15585/mmwr.mm6552a1
Nicotine Withdrawal
Withdrawal symptoms are often powerful enough that even with knowledge of the health risks, many people who smoke are unable to sustain a quit attempt. Smoking cessation can cause intense symptoms, including strong cravings for nicotine in cigarettes, anxiety, depressed mood, inability to concentrate, irritability, restlessness, insomnia, hunger, headaches, gastrointestinal disturbances, and sleep disruption. These symptoms are the worst in the first 3 days (when most people trying to quit smoking relapse) and most subside within 2 to 4 weeks in most people, but some symptoms, such as craving, may continue for months or even years. Weight gain is common; quitters gain an average of 4 to 5 kg, and weight gain is another reason for relapse. Temporary cough, headaches, and constipation may develop after quitting.
Interventions for Smoking Cessation
Evidence-based counseling and medications are both effective for treating tobacco use and addiction; combining counseling and medications is more effective than either intervention alone (1). Medications reduce the discomfort of quitting while the person learns to "re-engineer" their life to support a tobacco-free lifestyle (2nicotine withdrawal; and reducing the rewarding effects of nicotine if someone lapses and smokes, by blocking or desensitizing nicotinic receptors.
Smoking is a chronic disorder. Thus, the optimal evidence-based approach for treating people who smoke, particularly those not ready to quit or those who have not yet considered quitting, should be guided by the same principles that guide chronic disease management, namely:
Continually assessing and monitoring smoking status
Using different evidence-based interventions (or combinations) for different patients and building on their prior experiences and treatment preferences
Encouraging temporary abstinence and reduction in consumption for patients who fall short of total smoking cessation while emphasizing that abstinence is the ultimate goal
Although reduction in consumption can increase motivation to quit (particularly when combined with nicotine replacement therapy), people who smoke should be reminded that reducing the number of cigarettes smoked may not improve health because it is common to inhale more smoke (and thus more toxins) per cigarette to maintain nicotine intake when someone reduces the number of cigarettes smoked per day.
Alternative approaches to smoking cessation, such as acupuncture, lasers, and herbs have not proved to be effective and cannot be recommended for routine use. A review of 14 studies of hypnosis for quitting smoking concluded that rates of smoking cessation after hypnotherapy were comparable to rates after other behavioral interventions, such as counseling (3). Five of the studies evaluated hypnotherapy as an adjunct to other treatments, and the pooled results showed a statistically significant benefit for hypnotherapy; however, the findings were limited by risk of bias among the studies, and additional high-quality evidence is needed.
Evidence-based counseling
Counseling efforts follow the 5 A’s:
Ask at every visit whether a patient uses tobacco and document the response.
Advise all patients who use tobacco to quit in clear, strong, personalized, and nonjudgmental language.
Assess patients' willingness to quit tobacco within the next 30 days, emphasize the benefits of quitting for patients not intending to quit in the next 30 days.
Assist patients willing to make a quit attempt by providing brief counseling and cessation medication.
Arrange a follow-up, preferably within the first week of the quit date and again later on to prevent relapse.
For patients willing to quit, clinicians should work with the patient to establish a quit date, preferably within 2 weeks, and stress that total abstinence is better than reduction. Past quitting experiences can be reviewed to identify what helped and what did not, and tobacco use triggers or challenges to quitting should be planned for in advance. For example, alcohol use is associated with relapse, so alcohol restriction or abstinence should be discussed. In addition, quitting is more difficult when others smoke in the home; spouses and housemates who also smoke should be encouraged to smoke outside of the home or to quit all together. Clinicians should reinforce their availability and assistance in support of the quit attempt.
In addition to the brief counseling provided by the clinician, counseling programs can help. They usually use cognitive-behavioral techniques and are offered by various health programs. Success rates are higher than with self-help programs. All states in the United States have telephone quit lines that can provide tobacco cessation counseling support (and sometimes nicotine replacement therapy). People can call 1-800-QUIT-NOW (1-800-784-8669) toll-free anywhere in the United States. Quit lines appear to be at least as effective as in-person counseling. Mobile smoking cessation applications (apps) may be also be helpful tools. The National Cancer Institute's smokefree.gov web site provides information, a tailored quit plan, text-based support, and "quit" apps.
Medications for smoking cessation
nicotine addiction.
Nicotine replacement products are designed to reduce withdrawal when quitting smoking. Four nicotine replacement therapies (in the form of gum, lozenges, transdermal patch, and nasal spray—see table ) are approved for use in the United States. Previously available by prescription, the nicotine inhaler was discontinued in the United States in 2023. The nicotine mouth spray is available in many countries outside of the United States,but is not yet approved for sales in the United States.
nicotine. The effect of varenicline is to mitigate nicotine withdrawal symptoms and decrease the pleasurable effects of smoking if the patient has a lapse. Varenicline is the most effective monotherapy available for smoking cessation (4).
Varenicline or bupropion can be used in conjunction with nicotine replacement products. Additionally, combinations of different nicotine replacement products are more effective than single products and are comparable in efficacy to varenicline (5). For example, combining the nicotine patch with a shorter-acting nicotine replacement drug (eg, lozenge, gum, nasal spray) is more effective than monotherapy. When used in combination, the patch helps maintain continuous levels of nicotine, and use of gum, lozenge, or nasal spray enables the patient to rapidly increase nicotine levels in response to immediate cravings. Nicotine replacement therapy is dosed at about 1 mg of nicotine replacement per cigarette smoked per day. Patients using the nicotine patch should continue wearing the patch even if they have a lapse and smoke.
People may worry that they may remain dependent on nicotine after using nicotine products for smoking cessation; however, such dependence rarely persists. An important point is that the addiction potential of a drug is related to its speed of delivery to the brain. Because none of the nicotine replacement products deliver nicotine to the brain anywhere close to the speed that smoking does (8 to 10 seconds), the replacement products are far less addictive. Medication choice is guided by the clinician’s familiarity with the medication, patient preference and previous experience (positive or negative), and contraindications.
Despite their proven efficacy, smoking cessation medications are used by < 25% of people attempting to quit smoking. Reasons for people not using cessation medications in a quit attempt include cost, low rates of insurance coverage, concerns about adverse effects and the safety of simultaneous smoking and nicotine replacement, and patient discouragement because of past unsuccessful quit attempts.
Medications and Nicotine Replacement Products for Smoking Cessation
Medication | Duration | Selected Adverse Effects* | Comments |
|---|---|---|---|
7–12 weeks initially (may continue up to 6 months) | Insomnia Dry mouth Neuropsychiatric symptoms | Prescription only Contraindicated by history of seizure, eating disorder, or monoamine oxidase inhibitor (MAOI) use within the past 2 weeks | |
Up to 6 months | Mouth soreness Dyspepsia | Over-the-counter only Slow chewing and parking between cheek and gum recommended to maximize blood levels and minimize gastric and esophageal irritation; can be a challenge to use enough gum to adequately address withdrawal; available in different flavors | |
Up to 6 months | Nausea Insomnia Mouth sores | Over-the-counter only; available in different flavors and in a mini version; need for frequent dosing can compromise adherence | |
14 weeks | Nasal and pharyngeal irritation | Prescription only Reaches peak blood levels earlier (in 10 minutes) than other nicotine replacement products | |
10 weeks | Local skin reaction Insomnia Vivid dreams | Over-the-counter and prescription Local skin reactions possibly less likely if location of patch is rotated; can be removed at night if bothered by vivid dreams | |
12–24 weeks‡ | Most commonly, nausea and sleep disturbances Neuropsychiatric symptoms | Prescription only | |
*Refer to a drug information resource for more detailed information regarding dosing, adverse reactions, and other safety considerations. †There have been neuropsychiatric symptoms reported post-marketing, but clinical trial data have not confirmed a causal relationship. A US Food and Drug Administration boxed warning has been removed. | |||
Medication safety
Postmarketing reports of serious or clinically significant neuropsychiatric adverse events when taking bupropionvarenicline or bupropion SR for the occurrence of such symptoms and advise them to stop taking varenicline or bupropion SR and contact a healthcare provider immediately if they experience such adverse events. If treatment is stopped due to neuropsychiatric symptoms, patients should be monitored until the symptoms resolve. Most experts nonetheless recommend varenicline for most people who smoke because the risks of smoking substantially exceed the risks of taking the medication. However, it would be reasonable to avoid varenicline in people with active suicidal risk.
Some patients taking varenicline report increased effects of alcohol. Instruct patients to reduce the amount of alcohol they consume until they know whether varenicline affects them.
Nicotine replacement should be used cautiously in people with certain cardiovascular risks (those within 2 weeks of a myocardial infarction, with serious arrhythmias, or with serious angina); however, most data suggest that such use is safe. Nicotine gum is contraindicated in people with temporomandibular joint syndrome, and nicotine patches are contraindicated in people with severe topical sensitization.
Because of safety concerns, inadequate efficacy data, or both, cessation medications are not routinely recommended fort people who are:
Pregnant
Smoking nondaily or smoking only a few cigarettes a day
Adolescents (< age 18)
Using smokeless tobacco
E-cigarettes and smoking cessation
E-cigarettes are another form of nicotine delivery, and some devices deliver nicotine to the brain as quickly as combusted cigarettes.
Some clinicians suggest that e-cigarettes be considered for use in smoking cessation as another type of nicotine replacement product. The National Academies of Sciences, however, concluded there is insufficient evidence on the effectiveness of e-cigarettes as cessation devices (6). An additional concern is that, because nicotine inhaled from some e-cigarette devices is delivered to the brain as rapidly as nicotine from smoked cigarettes, patients might remain similarly addicted to e-cigarettes though with less harmful exposures than are associated with combusted cigarettes. Dual use (continued use of combustibles while using e-cigarettes) also is common and the health benefits of e-cigarettes in the context of dual use are unproven. In contrast, US Food and Drug Administration-approved nicotine replacement therapies have demonstrated effectiveness in helping people quit smoking with several additional benefits:
Few and mild side-effects
Low likelihood of inducing dependence
No potential for abuse among youth or evidence that youth will transition to using combustible tobacco products
If patients have been unsuccessful with evidence-based approaches to quitting smoking in the recent past and are intent on trying e-cigarettes, clinicians ought to provide support and encourage their efforts with a focus on switching completely from combustible to electronic cigarettes.
Cessation in children
The counseling approach for children is similar to that for adults; however, cessation medications are not recommended for people under the age of 18. (See also Centers for Disease Control and Prevention — Youth Tobacco Prevention.)
Children should be screened for tobacco use by age 10. Parents should be advised to maintain smoke-free households and to communicate the expectation to their children that the children will not smoke. Movies and youth video games that incorporate smoking should be avoided.
For children who smoke, cognitive-behavioral therapy that involves establishing awareness of tobacco use, providing motivations to quit, preparing to quit, and providing strategies to maintain abstinence after cessation are effective in treating nicotine dependence.
Cessation of non-cigarette tobacco products
Cessation counseling for people who use smokeless tobacco has been shown to be effective. However, medications have not proved effective for treating smokeless tobacco use.
Effectiveness of cessation treatments for quitting pipe and cigar smoking is not well documented. Also, cessation may be affected by whether the person inhales the smoke and whether they also smoke cigarettes (eg, dual or poly-tobacco use).
Interventions references
1. US Preventive Services Task Force, Krist AH, Davidson KW, et al: Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons: US Preventive Services Task Force Recommendation Statement. JAMA. 325(3):265-279, 2021. doi:10.1001/jama.2020.25019
2. Hartmann-Boyce J, Hong B, Livingstone-Banks J, et al: Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation. Cochrane Database Syst Rev 6(6):CD009670, 2019. Published 2019 Jun 5. doi:10.1002/14651858.CD009670.pub4
3. Barnes J, McRobbie H, Dong CY, Walker N, Hartmann-Boyce J: Hypnotherapy for smoking cessation. Cochrane Database Syst Rev 6(6):CD001008, 2019. Published 2019 Jun 14. doi:10.1002/14651858.CD001008.pub3
4. Guo K, Zhou L, Shang X, et al: Varenicline and related interventions on smoking cessation: A systematic review and network meta-analysis. Drug Alcohol Depend 241:109672, 2022. doi:10.1016/j.drugalcdep.2022.109672
5. Baker TB, Piper ME, Stein JH, et alJAMA 315(4):371-379, 2016. doi:10.1001/jama.2015.19284
6. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Eaton DL, Kwan LY, Stratton K, et al: Public Health Consequences of E-Cigarettes. Washington (DC): National Academies Press (US); January 23, 2018.
Prognosis for Smoking Cessation
Most adults who smoke in the United States try to quit each year, without the use of cessation medication or counseling and relapse within days, weeks, or months. Many cycle through multiple periods of relapse and remission. The long-term success rate for unassisted quitting is approximately 5% (1). In contrast, higher 1-year success rates are achieved with evidence-based cessation counseling and medications.
Among adolescents who smoke, most believe they will not be smoking in 5 years, and 60% report having tried to quit in the previous year (2). However, most high school students smoking daily continue to smoke 5 years later.
Prognosis references
1. Méndez D, Le TTT, Warner KE: Monitoring the Increase in the U.S. Smoking Cessation Rate and Its Implication for Future Smoking Prevalence. 24(11):1727-1731, 2022. doi:10.1093/ntr/ntac115
2. Gentzke AS, Wang TW, Cornelius M, et al: Tobacco Product Use and Associated Factors Among Middle and High School Students - National Youth Tobacco Survey, United States, 2021. MMWR Surveill Summ 71(5):1-29, 2022. Published 2022 Mar 11. doi:10.15585/mmwr.ss7105a1
Key Points
Most people who smoke want to quit and most make a quit attempt each year, but few remain smoke-free at 1 year.
Evidence-based methods of smoking cessation increase the 1-year success rate.
Evidence-based counseling methods include physician counseling and referral to support programs.
nicotine replacement products) is recommended for all patients interested in quitting, unless there is a contraindication (eg, pregnancy, < age 18, nondaily smoking, smoke-less tobacco use).
More Information
The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.
Centers for Disease Control and Prevention — Youth Tobacco Prevention: Fact sheets, infographics, and other resources for teachers, coaches, parents, and others involved in anti-smoking, youth education
Smokefree.gov: The National Cancer Institute (NCI) resource to help reduce smoking rates in the US, particularly among certain populations, by providing cessation information, a tailored quit plan, and text-based support
The National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division: Public health consequences of e-cigarettes: A 2018 review of the evidence of the health effects related to the use of electronic nicotine delivery systems
Rx for Change Clinician-Assisted Tobacco Cessation: A tobacco cessation training program for health professional students and providers for assisting patients with quitting
World Health Organization: WHO launches Quit Tobacco App: Information about the WHO "Quit Tobacco App" that targets all forms of tobacco, helps users to identify the triggers, set their targets, manage cravings, and stay focused to quit tobacco
