Ten guidelines for a healthy life: Korean Medical Association statement (2017).
December 15, 2017 148 p (in English)

doi: https://doi.org/10.26604/979-11-5590-078-9-93510-1

Quitting Smoking

Quitting Smoking

Smoking shortens your life. Quit now!

Summary

◆ Background

Smoking is the cause of a wide range of diseases. Quitting smoking is essential for a healthy life.

◆ Purpose

These guidelines suggest effective methods that can help smokers quit successfully.

◆ Contents

1. Quit smoking! If you decide to quit, tell people around you about your resolution right away

When quitting smoking, your willpower matters. However, your surroundings and people around you play a major role as well. Therefore, if you decide to quit smoking, tell as many people around you as possible that you’re quitting and ask for their support. Support from others will reliably and effectively help you quit smoking.

2. Looking for a shortcut to quit smoking? Consult with medical specialists

The rates of successful quitting increase in proportion to the amount of time spent on smoking cessation counseling. Even brief counseling sessions lasting less than 5 minutes each can increase cessation rates. Moreover, for smokers with nicotine dependence, counseling combined with medication is most effective.

3. The best treatments for withdrawal symptoms are exercise, diet, and stress management!

After quitting, you may experience weight gain. An increase in weight may cause you to relapse and cause or aggravate cardiovascular diseases. Engaging in regular exercise, eating a healthy diet, and utilizing effective stress management techniques can alleviate withdrawal symptoms and help you control your weight.

◆ Expected impact

These guidelines will raise awareness of the importance of smoking cessation and increase quit rates by suggesting evidence-based smoking cessation methods and programs.

Keywords: Tobacco use, Smoking cessation, Varenicline, Bupropion, Counselling

Best practices to follow

1. Quit smoking! If you decide to quit, tell people around you about your resolution right away

2. Looking for a shortcut to quit smoking? Consult with medical specialists

3. The best treatments for withdrawal symptoms are exercise, diet, and stress management!

Smoking causes cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer, thereby leading to premature deaths. Smoking not only causes firsthand damage via the smoke inhaled by the smoker, but also harms nonsmokers through exposure to secondhand smoke, which refers to smoke that has been exhaled and that comes from the burning end of a cigarette. Moreover, smoking has serious ramifications on the well-being of newborns, toddlers, and children, as smoking makes them more likely to develop respiratory diseases, otitis media, asthma, and decreased pulmonary function [1].

More than 70% of smokers wish to stop smoking and attempt to quit. Nonetheless, due to nicotine dependence, it is very difficult for smokers to quit of their own free will. The success rates of smokers who try quitting on their own are as low as 3%-5% [2]. For smoking cessation to be effective, we need to understand that smoking is not a mere habit, but is a chronic relapsing disease requiring repeated interventions [2]. In addition, smoking cessation counseling and medications increase the successful quit rate when used together. Smokers who desire to quit should be provided with smoking cessation aids by medical professionals, and those who do not should be provided with counseling to enhance their motivation to quit.

Fact Sheet ➊

Quit smoking! If you have decided to quit, tell people around you about your resolution right away

When quitting smoking, your willpower matters. However, your surroundings and people close to you play a major role as well. Therefore, if you have decided to quit smoking, tell as many people around you as possible that you’re quitting and ask for their support. Even if you are determined to quit, challenges will appear, such as severe withdrawal symptoms in the early stages and the temptations posed by smokers around you who do not offer support. However, if you do not keep cigarettes at home, inside the car, or near your work environment during the first month of smoking cessation, or if none of your family members or colleagues smoke, success rates are higher.

Among the major health-related lifestyle habits, such as smoking, physical activity, and weight management, smoking is known to be the most heavily influenced by people around you [3]. If people close to you at work or at home smoke, quitting smoking can be difficult. In contrast, if those close to you are nonsmokers, your chances of quitting can increase to 84%. It has been reported that if your spouse is a smoker, your chance of quitting decreases to 67%; if your sibling is a smoker, your chance of quitting decreases to 25%; and if your friends are smokers, your chance of quitting becomes as low as 36% [4].

Therefore, if you have decided to quit smoking, tell others around you about your resolution. If you have smokers around you, encourage them to quit with you. Doing so will increase your chances of quitting.

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Fact Sheet ➋

2.1 Smoking cessation counseling

Smoking cessation counseling is a simple and effective smoking cessation method. A typically recommended set of guidelines for smoking cessation, known as the 5 A’s, is as follows:

  • 1. Ask about his or her history of tobacco use (Ask)

  • 2. Assess if he or she is willing to quit smoking (Assess)

  • 3. Advise on quitting smoking (Advise)

  • 4. Assist in quitting (Assist)

  • 5. Arrange follow-up appointments to check on his or her smoking status (Arrange)

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For smokers who do not intend to quit, medical specialists use the 5 R’s, providing a guidance on:

  • 1. The relevance and necessity of smoking cessation (Relevance)

  • 2. The risks caused by smoking (Risks)

  • 3. The rewards following smoking cessation (Rewards)

  • 4. Methods to overcome roadblocks that may lead to failure (Roadblocks)

  • 5. Repeating this counseling so that the patient is motivated to quit smoking (Repetition)

The rates of successful quitting increase in proportion to the amount of time spent on smoking cessation counseling. Even brief counseling sessions lasting less than 5 minutes each can increase cessation rates. For smokers with nicotine dependence, providing counseling along with medication is most effective. A short smoking cessation counseling session of 3 minutes or less has been shown to result in a 1.66 times higher success rate, and the effect of counseling tends to increase relative to the duration of the counseling. It is recommended that smokers trying to quit should receive smoking cessation counseling at least 4 times over a period of 3 months, for a minimum of 10 to 15 minutes. Including group counseling along with individual counseling has also been reported to be effective [5].

2.2 Pharmacotherapy for smoking cessation

Smoking is a symptom of the disease of nicotine addiction. Medication is recommended, as counseling alone is generally not enough for successful smoking cessation. Pharmacotherapy for smoking cessation is recommended for all smokers who desire to quit, even for smokers who do not wish to use medications. The first-line agents for tobacco cessation that have been approved by the Food and Drug Administration (FDA) and recommended for their usage in the U.S. and Europe include nicotine replacement therapies (NRTs; the patch, nicotine gum, lozenge, sprays, and inhaler) and oral medications, sustained-release bupropion and varenicline [6].

1. Nicotine replacement therapy

NRTs were developed in the 1970s and have been widely used in many countries. NRTs are used to reduce physiological and psychiatric withdrawal symptoms caused by tobacco cessation. NRTs come in 5 different forms: patch, gum, lozenge, spray, and inhaler. In Korea, only patches, gum, and lozenges are available. Even smokers with cardiocerebrovascular diseases can use NRTs if they are in a stable condition (except for those who are hospitalized for acute cardio-cerebrovascular symptoms) [2]. Nicotine patches are the most commonly used NRT product. Smokers who smoke more than 10 cigarettes a day use 21 mg in the first 4 weeks, and gradually decrease to 14 mg for the following 2 weeks, and 7 mg for the next 2 weeks. Those who smoke 10 or fewer cigarettes a day are recommended to use 14 mg in the first 6 weeks, and then to decrease to 7 mg. The most common side effect is skin irritation. In clinical settings, users complain about patches because they easily fall off. Some users may experience tachycardia, chest pain, nausea and vomiting, or insomnia. Nicotine gum comes in 2 mg and 4 mg dosages. Those who smoke fewer than 25 cigarettes per day should use 2 mg, and those who smoke 25 or more cigarettes per day should use 4 mg. To reduce the risks of smoking for those who find it hard to quit entirely, medical specialists may recommend smoking less and using NRT products as supplements. Although the safety of NRTs for pregnant women, nursing women, or young adults has not yet been proven, some studies have reported that there were no serious adverse effects. However, for pregnant women, common NRTs do not affect smoking cessation, as the increase in metabolism during pregnancy speeds up nicotine decomposition [1].

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2. Sustained-release bupropion

Bupropion, a norepinephrine dopamine reuptake inhibitor (NDRI), was initially developed as an antidepressant, but it was also found to help smokers quit smoking. In terms of its mechanism, bupropion can be considered as a top choice for smokers with depression, but clinical evidence is lacking. As the medication controls weight gain to some extent when administered, smokers who fear gaining weight in the early stages of smoking cessation may desire to try bupropion. Nonetheless, the weight gain control effect disappears 1 year after the therapy. Serious side effects include seizure (1 in 1,000 chances). As the risk of this side effect is dosage-dependent, a daily limit of 300 mg should not be exceeded: One tablet (150 mg) both in the morning and evening is recommended. Additionally, bupropion tablets should not be crushed because the medication comes in a sustained-release form. Moreover, to reduce the risk of seizure, it should not be taken more than once in 8 hours. As heavy drinking during administration of this medication increases the risk of seizure, drinking should be minimized or completely avoided. Other side effects include insomnia, headache, and dry mouth. The standard regimen is 150 mg a day for the first 3 days orally every morning and then 150 mg twice a day for the rest of the course of treatment, for a total duration of 8 to 12 weeks. Sustained-release bupropion can be used for up to 6 months [1].

3. Varenicline

Varenicline is a smoking cessation treatment medication approved in the U.S. in 2006 and in the U.K. in 2007. It works in a manner similar to nicotine, releasing dopamine constantly to reduce withdrawal symptoms. At the same time, it reduces the reward effects of nicotine. Through this double effect, smokers can quit smoking more easily. In a study that examined the smoking cessation effectiveness and safety of bupropion, the first-line agent for tobacco cessation, and varenicline, 1,027 smokers took these medications for 3 weeks and were followed up for 52 weeks. The subjects who took varenicline demonstrated a 2.7 times higher rate of maintaining abstinence for up to 52 weeks than the group given a placebo. In comparison, the subjects who took bupropion showed a 1.8 times higher rate of maintaining abstinence than those who received a placebo treatment [7].

During the first week before smoking cessation, the dosage should be increased gradually (0.5 mg a day from day 1 to 3; 0.5 mg twice a day from day 4 to 7). Then, 1 mg should be taken twice a day for 11 weeks. The duration may be extended for another 12 weeks, as necessary. The most common side effect is nausea, which has been reported in 17%-52% of cases. However, this symptom is generally mild and improves over time. Other side effects include insomnia, nightmares, and headache. Contraindications include suicide attempts or suicidal impulses. However, in a large-scale study conducted on more than 8,000 mokers, varenicline was not reported to lead to any higher of a risk for developing psychiatric symptoms such as suicidal impulses than NRTs, bupropion, or placebo. Currently, varenicline can be prescribed to all smokers except for pregnant women and those under 18 years old [8].

In March 2015, the U.S. FDA warned that varenicline can alter one’s response to alcohol. This medication lowers alcohol tolerance and a drinker may become more easily intoxicated, possibly leading them to exhibit abnormal or violent behaviors [9]. In addition, the substance inhibits a person’s ability to form memories while under the influence of alcohol. Therefore, those who take varenicline are advised to decrease their alcohol intake. Furthermore, although rarely, risks of seizure associated with varenicline have been suggested. The seizures associated with varenicline occurred mainly during the first month of its administration.

4. Electronic nicotine delivery systems: electronic cigarettes

Electronic cigarettes, or e-cigarettes, have increasingly been used in the U.S. since 2006. Their use is surging dramatically, particularly among adolescents.

According to a recent report by the U.S. FDA, the aerosol and liquid from an e-cigarette cartridge contain various toxic or cancer-causing chemical substances and ultrafine particles that can eventually lead to respiratory or cardiovascular diseases. E-cigarettes are mainly used by past smokers or current smokers, and as they tend to use regular cigarettes and e-cigarettes together, it is highly likely that users of e-cigarettes may progress to become smokers of regular cigarettes. Since insufficient studies have been conducted on the safety and usefulness of e-cigarettes, it is not recommended to use them as smoking cessation aids [10].

Fact Sheet ➌

The best treatments for withdrawal symptoms are exercise, diet, and stress management!

When a person quits smoking, the metabolism rates that had increased above ordinary levels due to nicotine intake return to normal. As a result, the heart rate slows down by 10 to 20 beats and weight increases. Usually, weight gain occurs within 6 months after quitting, and ranges from 3 to 5 kg on average, up to more than 10 kg in some cases. Together with such weight gains, one may experience withdrawal symptoms such as depression, anxiety, excitement, or impaired attention. The combination of weight gain and withdrawal symptoms can trigger a past smoker to relapse and can cause or worsen cardiovascular diseases. Regular exercise strengthens physical fitness and controls the weight gain that comes with smoking cessation. Moreover, it reduces the withdrawal symptoms caused by nicotine addiction, increasing the success rate of quitting and helping former smokers to maintain abstinence. One study reported that those who exercised consistently for 12 months after quitting smoking maintained significantly higher quit rates [11]. When quitting smoking, the satisfaction that came from smoking is often replaced with eating. Therefore, adjusting one’s diet by dividing a meal into small portions and eating it throughout the day or choosing nuts and low-calorie vegetables and fruits such as beans, dried fruits, celery, and carrots over high-calorie foods like candy, crackers, and potato chips may provide higher satisfaction and help control weight.

Furthermore, stress in everyday life may trigger a relapse of smoking and negatively affect the probability of maintaining abstinence from smoking. Therefore, understanding one’s own emotions, thoughts, behaviors, and physical changes that arise in stressful situations and developing coping skills to properly manage them are helpful for maintaining smoking cessation.

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References

1 

European Network for Smoking and Tobacco Prevention aisbl (ENSP) ENSP Guidelines for treating tobacco dependence 2016 Available from URL: http://elearning-ensp.eu/assets/English%20version.pdf

2 

S Shiffman SE Brockwell JL Pillitteri JG Gitchell Use of smoking cessation treatments in the United States Am J Prev Med 2008 34 102 111

3 

SE Jackson Steptoe J Wardle The influence of partner’s behavior on health behavior change: the English longitudinal study of aging JAMA Intern Med 2015 175 385 392

4 

NA Christakis JH Fowler The collective dynamics of smoking in a large social network N Engl J Med 2008 358 2249 2258

5 

LF Stead D Buitrugo N Preciado G Sanchez J Hartmann-Boyce T Lancaster Physician advice for smoking cessation Cochrane Database Syst Rev 2013 5 CD000165

6 

MC Fiore CR Jaén TB Baker Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline Rockville, MD U.S. Department of Health and Human Services. Public Health Service 2008 Available from URL: https://bphc.hrsa.gov/buckets/treatingtobacco.pdf (accessed 2 May, 2017)

7 

DE Jorenby JT Hays NA Rigotti Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial JAMA 2006 296 56 63

8 

RM Anthenelli NL Benowitz R West Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial Lancet 2016 387 2507 2520

9 

RM Van der Meer MC Willemsen F Smit P Cuijpers Smoking cessation interventions for smokers with current or past depression Cochrane Database Syst Rev 2013 8 CD006102

10 

SE Adkison RJ O’Connor M Barsal-Travers Electronic nicotine delivery systems: international tobacco control four-country survey Am J Prev Med 2013 44 207 215

11 

AC Farley P Hajek D Lycett P Aveyard Interventions for preventing weight gain after smoking cessation Cochrane Database Syst Rev 2012 1 CD006219

Notes

[1] Contributing associations:

Korean Academy of Addiction Psychiatry

The Korean Academy of Tuberculosis and Respiratory Diseases

Korean Medical Practitioners Association

Korean Neuropsychiatric Association

The Korean Society for Research on Nicotine and Tobacco

Korean Society of Cancer Prevention

Contributing experts:

Bossng Kang, Department of Emergency Medicine, Hanyang University Guri Hospital

Hee Man Kim, Department of Internal Medicine, Yonsei University Wonju College of Medicine and Wonju Severance Christian Hospital

Yu Jin Paek, Department of Family Medicine, Hallym University Sacred Heart Hospital