BMJ  2003;327:1394-1395 (13 December), doi:10.1136/bmj.327.7428.1394

Clinical review

Extracts from "BestTreatments"

Treating nicotine addiction

¹ BestTreatments, BMJ Publishing Group, London WC1H 9JR ajain{at}bmjgroup.com

Introduction

Key messages—Nicotine is extremely addictive; it is comparable to cocaine, opiates, and amphetamines. In one study, even heroin users rated cigarettes as their most needed drug. Quitting is possible, and almost half of smokers have quit for at least some time. Half of smokers quit eventually. People who quit decrease their rates of death and illness, including heart disease and cancer, even if they quit late in life. The benefits of quitting late in life are less than quitting when young. Helping patients quit typically involves helping them through many attempts (five to seven, on average). Because most relapses occur within three months of quitting, and half within the first two days, patients need follow up within days, not weeks, of starting treatment.

It is important to warn patients about what they are likely to experience when they try to quit. In particular, they can expect a weight gain of 8-13 pounds (4-6 kg)—and dieting seems to interfere with quitting smoking successfully. Quitters also describe anxiety, insomnia, depressed mood, and inability to concentrate, in addition to severe cravings for cigarettes.

Most smokers say they want to quit on their own—but only 5-10% of these attempts are successful. Assistance can more than double the chance of success. Quitting gradually is as successful as quitting abruptly ("cold turkey").

Treatment

Treatments that work
Advice to quit smoking
Giving patients advice to quit, even just once, helps to increase quit rates. More intensive advice may be even more helpful. Advice works equally well whether given by doctors, counsellors, or nurses. Advice to quit is likely to be less effective if it is given by staff who are told to take on this task along with their regular workload. Setting aside time in staff schedules specially for counselling patients, or employing new staff for the task, is likely to increase the effectiveness. Telephone counselling and written self help materials may also improve rates of quitting compared to no advice. Overall, brief advice versus no advice improves rates of quitting by about 2% at one year.

Nicotine replacement therapy
In trials, 17% of patients who received nicotine replacement therapy had abstained from smoking at 6 months, or longer, compared to 10% of those without treatment. A variety of delivery methods are available (chewing gum, patches, inhalers, nasal sprays, lozenges, sublingual tablets) but the method did not seem to affect the outcome—they all worked. Allowing patients to choose the method may be best. Nicotine replacement works even without counselling or other medication, but it is more effective in combination with other treatments.

Bupropion
This antidepressant helps smokers quit whether or not they are depressed. In trials, the drug increased the odds of quitting successfully at 6-12 months, although it did not help prevent relapse at one year. One study found that when bupropion was used with a nicotine patch, the combination worked better than the patch alone, although not better than bupropion alone. The most common side effects are insomnia, dry mouth, and nausea. The drug can provoke seizures and is contraindicated in at-risk patients (see www.besttreatments.org/nicotine). It should not be prescribed with monoamine oxidase inhibitors.

Treatments that need further study
Physical exercise to aid smoking cessation
Exercise, including lifestyle activity or more structured programmes of aerobic exercise, may help patients to stop smoking, but the evidence for this is limited. Most exercise programmes in trials involved 30 minutes of aerobic exercise three times a week, and behavioural techniques were used to reinforce and increase adherence to exercise.

Training health professionals to give advice
Training health practitioners to counsel smokers leads to them offering antismoking interventions more often, but this has not yet been shown to improve quitting rates.

Treatments that are likely to be ineffective or harmful
Acupuncture
Acupuncture and related techniques (including acupressure, laser acupuncture, and electrostimulation of acupuncture points or acupuncture needles) are not helpful for stopping smoking compared to sham acupuncture treatment (in which needles do not penetrate the skin). But acupuncture seems to work better initially than no treatment at all.

Anxiolytics
In trials, drugs for anxiety (buspirone, diazepam, doxepin, meprobamat, and ondansetron) did not improve rates of abstinence from smoking. But the studies included smokers who did not have anxiety disorders. Smokers with a high level of anxiety symptoms could possibly benefit from anxiolytics as a smoking cessation intervention.

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This extract will remain available on bmj.com but the rest of the BestTreatments website is currently available only to US doctors and patients who are members of United Healthcare Group health plans in the United States.

This extract is from www.besttreatments.org, a shared information resource for US patients and doctors that is based on ClinicalEvidence (www.clinicalevidence.com). More information, including references for this BMJ article, is at www.besttreatments.org/nicotine

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Rapid Responses:

Read all Rapid Responses

Nicotine addiction

edward housley
bmj.com, 12 Dec 2003 [Full text]

A few more puffs on nicotine dependence

G Sivagnanam
bmj.com, 12 Dec 2003 [Full text]

Absence of proof is no proof of abscence

FEMI BADA
bmj.com, 14 Dec 2003 [Full text]

Training doctors may improve quit rates

Jean-Francois ETTER
bmj.com, 15 Dec 2003 [Full text]

Easing Physician Cessation Frustration

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Don't forget the generic antidepressant nortryptiline as an effective smoking cessation aid

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Individual difference, a critical factor in determining the effect of acupuncture.

Hi Joon Park, et al.
bmj.com, 18 Jan 2004 [Full text]

Quitting Smoking - and then what?

Bob Dunkley
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