Tobacco use remains the leading preventable cause of disease, disability, and death in the United States. Due to the well-established dangers of smoking, more than two-thirds of smokers express a desire to quit. Most attempt to do so at least once a year. However, quitting smoking is notoriously difficult. Many individuals need multiple attempts before achieving long-term smoking cessation.
Related CE for pharmacists: Pharmacotherapy to Assist with Smoking Cessation
The far-reaching impact of tobacco use
The consequences of smoking are far-reaching, affecting nearly every organ system in the body and contributing to a range of chronic diseases. Smokers are nearly three times more likely to die prematurely from cardiovascular disease than non-smokers. The risk is especially high among those who began smoking at an early age. While cancer, cardiovascular disease, and respiratory disorders are the most commonly associated conditions, smoking has been linked to an expanding list of diseases.
The life-saving benefits of quitting
The good news is that smoking cessation offers substantial health benefits, both in the short and long term. Within 24 hours of quitting, nicotine levels in the blood drop to zero. Several days later, carbon monoxide levels return to those typical of non-smokers. Over time, the body begins to repair itself.
- 1 year after quitting: Coughing and shortness of breath decrease.
- 1-2 years: Risk of heart attack significantly drops.
- 3-6 years: Risk of coronary heart disease is reduced to about half that of a current smoker.
- 5-10 years: The risk of stroke and cancers of the mouth, throat, and voice box decreases to levels comparable to non-smokers.
- 10 years: The risk of lung cancer is cut by half, and the risks of bladder, esophagus, and kidney cancers also decrease.
- 15 years: Risk of coronary heart disease is reduced to that of a non-smoker.
These statistics underscore the dramatic positive changes that occur following smoking cessation, reinforcing the importance of supporting patients in their quit attempts.
The 5 A’s of tobacco cessation counseling
Clinical practice guidelines emphasize the critical role of healthcare providers in facilitating smoking cessation. Even brief interventions (as short as 3 minutes) can significantly increase quit rates. The 5 A’s provide a simple and effective framework for integrating smoking cessation into routine healthcare interactions.
- Ask: At every patient encounter, inquire about tobacco use.
- Advise: Provide clear, strong, and personalized advice to quit. For example, “As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future.”
- Assess: Evaluate the patient’s readiness to quit.
- Assist: Offer appropriate resources, including behavioral therapy and pharmacotherapy.
- Arrange: Follow up with the patient to monitor progress and offer additional support.
By using this approach, healthcare professionals can significantly enhance the likelihood of successful smoking cessation.
Behavioral therapy
Behavioral approaches to cessation typically involve multiple behavioral counseling sessions (≥4), with total contact time ranging from 90 to 300 minutes. Interventions with 8 or more sessions showed the greatest effect, though the difference in effectiveness based on session number was not significant.
Various behavioral counseling methods, including physician advice, nurse counseling, individual or group therapy, telephone counseling, and mobile phone-based support, can be delivered in both primary care and community settings. These interventions are most effective when targeting individuals motivated to quit smoking.
The role of pharmacotherapy
Pharmacotherapy is frequently recommended for many smokers attempting to quit. Medications can nearly double the chances of success, with nicotine replacement therapy (NRT) being the most common option. However, special considerations must be taken for certain populations, including pregnant women, light smokers, and adolescents, where data on pharmacotherapy is less definitive.
Nicotine Replacement Therapy (NRT)
NRT is effective in increasing the likelihood of quitting by approximately 50-60%, but long-term success often requires multiple quit attempts. NRT should be used cautiously in patients with certain cardiovascular conditions, such as recent myocardial infarction or unstable angina, as nicotine can increase heart rate and blood pressure. The decision to use NRT should always weigh the risks of continued smoking against the potential benefits of treatment, as smoking itself poses far greater risks.
Non-nicotine medications
In addition to NRT, there are other pharmacological options:
- Bupropion: This non-nicotine medication works by blocking the reuptake of dopamine and norepinephrine in the brain. Although its exact mechanism for smoking cessation is not fully understood, studies show that bupropion increases quit rates, whether or not the patient has depression.
- Varenicline: Varenicline is a partial agonist at the α4β2 nicotinic acetylcholine receptor, which plays a central role in nicotine addiction. This medication relieves withdrawal symptoms while also blocking the pleasurable effects of nicotine from cigarettes, reducing the likelihood of relapse. Varenicline has been shown to be more effective than both NRT and bupropion in multiple studies.
Combination therapy, including both pharmacotherapy and behavioral counseling, has consistently been shown to provide the best outcomes for sustained smoking cessation. Healthcare professionals should tailor treatment plans to the individual, considering factors such as patient preference, previous experiences, comorbid conditions, and potential drug interactions.
The chronic nature of tobacco dependence
It’s essential to approach smoking cessation as a process rather than a one-time event. Tobacco dependence is a chronic condition that often requires multiple interventions and repeated attempts before long-term cessation is achieved. Relapse should not be viewed as failure but as a normal part of the journey toward quitting. Patients should be encouraged to continue their efforts and to see each attempt as an opportunity to learn and improve.
Making a difference in tobacco cessation
Tobacco use continues to be a leading cause of preventable death and disease, but healthcare professionals have the tools and strategies to help patients quit. By incorporating brief interventions, offering pharmacotherapy, and providing continuous support, clinicians can significantly increase smoking cessation rates. With the right approach, the health benefits of quitting smoking are vast and life-changing, both for individuals and for public health as a whole.
Written by Katie Blair, PharmD
Resources
- American Heart Association. (2020). Smokers, especially those who begin young, are three times more likely to die prematurely. Journal of the American Heart Association Report. https://newsroom.heart.org/news/smokers-especially-those-who-begin-young-are-three-times-more-likely-to-die-prematurely
- Cahill, K., Lindson-Hawley, N., Thomas, K. H., Fanshawe, T.
- R., & Lancaster, T. (2016). Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews, (5), CD006103. doi:10.1002/14651858.CD006103. pub7
- Centers for Disease Control and Prevention (CDC). (2024). Benefits of quitting smoking. https://www.cdc.gov/tobacco/about/benefits-of-quitting.html
- Hughes, J. R., Stead, L. F., Hartmann-Boyce, J., Cahill, K., &
- Lancaster, T. (2014). Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews, (1), CD000031. doi:10.1002/14651858.CD000031.pub4.
- U.S. Department of Health & Human Services [USDHHS]. (2020). Smoking Cessation: A report of the Surgeon General. US Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General. Rockville, MD. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf
- US Preventative Services Task Force. (2021). Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Recommendation Statement. American family physician, 103(12).
