Smoking Cessation

Background

Tobacco use is the leading preventable cause of premature death in Canada, with an estimated 45,000 Canadian deaths per year. This is more than car accidents, suicides, AIDs and other substance abuse issues combined. Smokers generally die on average 10 to 17 years younger than their non-smoking peers, with 50% of long-term smokers dying prematurely from diseases such as cancer, heart disease, stroke and lung disease. 

Outcomes of smoking include (not exhaustive): 

• Cancer (lung, pancreas, kidney, bladder, lip, throat) 
  • Smoking accounts for ~30% of all cancer-related deaths
• Cardiovascular disease 
  • smoking can activate coagulation pathways in the body to promote blood clot formation and increase the risk of a heart attack
  • Nicotine can increase heart rate and blood pressure
• Delayed wound healing
• Diabetes (chronic smokers develop insulin resistance)
• Eye diseases (increased risk of cataracts, age-related macular degeneration) 
• Mouth diseases (gum disease, tooth stains)
• Peptic ulcer disease (increased incidence)
• Respiratory disease (chronic obstructive pulmonary disease (COPD), asthma exacerbations)
• Impotence (twice as likely to occur in smokers compared to nonsmokers), decreased fertility, pregnancy-related disorders
• Musculoskeletal disease (osteoporosis, rheumatoid arthritis)
• Premature skin aging and wrinkling
• Poor birth outcomes (sudden infant death syndrome (SIDS), low birth weight, preterm births, and long-term effects)

All forms of tobacco have harmful effects, including smokeless tobacco (chewing tobacco and “snuff”), pipe tobacco, cigars, hookahs and other nicotine delivery systems. Light and ultralight cigarettes may deliver the same amount of nicotine as regular cigarettes and aren’t considered safer. Each cigarette contains around 1 mg to 3 mg of nicotine and around 7000 chemicals, of which 70 are considered carcinogenic. Health risks are associated with at least 50 of the known carcinogens such as tar, arsenic, formaldehyde, ammonia and nickel. 

Smoking not only affects you but everyone around you as well. It can cause cancer and heart disease in nonsmokers, accounting for more than one thousand lung cancer or cardiac deaths per year. It is also associated with eye and throat irritation, cough and headaches in non-smokers. Childhood exposure is associated with asthma, recurrent ear infections and sudden infant death syndrome. 

Nicotine addiction is regarded as a chronic medical condition with tobacco dependence being defined as the inability to discontinue tobacco despite knowing the damaging things it does to your health. Cigarettes are highly addictive due to the rapid delivery of nicotine to the mesolimbic pathways (sometimes referred to as the reward pathway), combined with activity in the motivational and learning circuitry of the brain. Because of nicotine’s short half-life (60 to 90 minutes), it forces repeated administration to maintain nicotine levels. Many patients require multiple attempts (sometimes ten) before quitting successfully.

Thinking about quitting?

Quitting is not easy. Withdrawal symptoms can include:

• Depressed mood
• Insomnia
• Irritability, anxiety, restlessness
• Frustration or anger
• Difficulty concentrating
• Decreased heart rate
• Stomach discomfort, constipation
• Headache
• Weight gain

Thankfully, some withdrawal symptoms improve in 1 to 3 weeks, with symptoms peaking around 24 to 72 hours after the last cigarette. Unfortunately, cravings can continue for years. These are likely related to behavioural and psychological aspects of nicotine addiction.

A big concern among those considering quitting is the weight gain that may occur. Quitting is associated with an average increase of around 5kg in body weight after 12 months of cessation. Most of the weight increase occurs within the first three months of quitting. However, the variation is large. About ~16% of those who quit may lose weight and ~13% of those may gain more than 10kg. The use of pharmacotherapy may help delay weight gain. Of importance, the benefits of quitting persist despite the weight gain. Having a healthy lifestyle which involves increased exercise and low-calorie snacks (carrots, celery sticks, sugar-free candy and gum) will help manage the weight changes.

Smoking affects how drugs are processed in the body so certain drugs will require dosing adjustments (including caffeine). It is recommended to decrease caffeine intake by 50% when quitting. Other common medications that will need to be monitored include insulin (monitor for low-sugar episodes), warfarin (monitor INR in 3 to 5 days and adjust the dose as needed), antipsychotics (clozapine, olanzapine), antidepressants (fluvoxamine), and opioids (codeine, oxycodone, methadone). 

What are the benefits to quitting?

After 20 minutes	Your blood pressure and heart rate return to normal
After 24 hours	Your risk of heart attack starts to drop
After 14 days	Your circulation increases and the airways in your lungs relax
After 3 months	Your lung function increases by 30% and you cough less
After 1 year	Your added risk of smoking-related heart disease or stroke is decreased by 50%
Within 2 to 5 years	Your risk of stroke returns to baseline
After 5 years	Your risk of oral, esophageal, lung and bladder cancers decrease by 50%
After 10 years	Your cancer death rate is similar to that of a non-smoker
After 15 years	Your risk of heart disease is similar to that of a nonsmoker

By quitting, not only do your physical health benefits improve, there are improvements in depression, anxiety and stress. Quitting before age 50 results in a 50% reduction in the risk of death in the next 15 years. The younger you are when quitting, the better the overall quality of life. Those who quit between ages 25 and 34 lived 10 years longer compared to those who continued to smoke. It is never too late to quit smoking!

When should I see the doctor?

• When over the counter medications haven’t helped sufficiently
• If any of the smoking cessation medications are causing abnormal behavioural changes or feelings
• Pregnancy or breastfeeding (important to initiate within the first 16 weeks)
• Under 18 years old (counselling is the most effective approach)
• Have unstable cardiovascular disease (heart attack within 14 days, persistent unexplained chest pain)
• Have unstable psychiatric illness
• Have a history of suicidal ideation or attempts
• Have a history of anorexia or bulimia
• Have end-stage kidney disease
• Have signs or symptoms of undiagnosed or inadequately controlled smoking-related diseases (COPD, lung cancer)

What treatments are available?

Treatment plans will vary based on your preference and the severity of the addiction. For those who smoke 10 cigarettes or less daily, behavioural therapy is the first line option. This includes understanding that quitting is a process, ensuring that all environments (home, work, car) are smoke free, documenting every cigarette smoked, setting a quit date within 30 days, enlisting social support and planning for how to deal with cravings as well as trigger avoidance.

For those where medication may be helpful, the combination with counseling is much more effective than either alone. 

What can I do about triggers and modifying behaviour?

Avoid triggering situations by modifying your routine. These can include drinking water or tea instead of coffee (if coffee is a triggering event), or avoiding parties and being around people who smoke. Remove ashtrays from the home, lighters from the home and cars, and remove the smell of smoke from the house and other common areas. Make sure you have strategies to deal with cravings. 

Exercise helps relax the mind and body. Employ relaxation techniques including deep breathing, meditation, yoga, listening to music, or taking a bath or shower. Refer to your list of benefits for quitting and have it handy to pull out whenever you need to remind yourself. Reward yourself every time you avoid smoking, just don’t use food as a reward. If you need to keep your mouth in motion, use sugar-free gum or candy, carrots or celery sticks. Be involved in a counseling and support group. Let your family and friends know about your plan to quit and engage them in how they can help and support you. 

The following are counseling and psychosocial support programs:

Telehealth Ontario (for support to help quit smoking)	1-866-797-0000 (toll-free)
Smokers’ Helpline (to register for online programs and text-message support)	https://www.smokershelpline.ca/
Centre for Addiction and Mental Health’s Prevention of Gestational and Neonatal Exposure to Tobacco Smoke (PREGNETS) network for pregnancy and postpartum care	https://www.nicotinedependenceclinic.com/en/pregnets
Break It Off (free mobile app to help young people quit)	https://breakitoff.ca/
The Lung Association (tips for quitting and listings of local support groups)	https://www.lung.ca/lung-health/smoking-and-tobacco/how-quit-smoking/choose-support
Centre for Addiction and Mental Health’s website with listings of nicotine dependence clinics and treatment programs	http://smokingcessation.camh.ca/
Health Canada (40 pages self-help guide and online program to assist smokers with the quitting process)	https://www.canada.ca/en/health-canada/services/publications/healthy-living/road-quitting-guide-becoming-non-smoker.html

Nicotine Replacement Therapy (NRT)

Nicotine replacement therapy increases the rate of smoking cessation by 50-70% and increases abstinence 1.5 to 2 fold when compared to placebo. It has a long safety record and is widely available. It is commonly considered the first line option for most patients. Experts believe short-term NRT is safer than smoking despite risks, and is generally safe in stable cardiovascular disease. In heart disease, the patch may be a more preferable option because of its constant consistent release of nicotine. Common side effects include: nausea, indigestion, taste alteration, and headaches. The standard duration typically lasts 8 to 12 weeks but can be extended to 24 weeks. Durations lasting greater than 24 weeks present no additional benefit. Doses should be individualized. Speak with your pharmacist about what options may be best for you.

Formulation	Dosage	Instructions/Side effects	Comments
Nicotine Patch Habitrol – How to apply the Habitrol nicotine patch  Nicoderm – How To Quit Smoking With NICODERM® Patch	If smoke <10 cigarettes/day, <45kg or heart disease – start with 14mg/24h patch If smoke 10 or more cigarettes/day – start with 21mg/24h patch	Apply to dry, hairless area on upper arm or hip in the morning,  change daily and rotate the site to minimize skin irritation (avoid using the same site more than once weekly) Apply pressure to patch for 10 seconds when first putting it on Side effects include skin irritation, insomnia, nightmares If insomnia or vivid dreams, remove patch at bedtime Don’t apply on eczema areas	Use for 8 to 12 weeks, but may need longer Habitrol takes longer to reach peak levels than Nicoderm More tolerable side effects and safer for heart disease  Avoid strenuous exercise, may increase absorption and side effects. Place patch on after exercise. Dispose of patch by folding sticky sides inwards and discard safely away from children or pets Do not cut patches
Nicotine Gum Thrive Nicorette – How To Quit Smoking With NICORETTE® Gum	If smoke <25 cigarettes/day – start with 2mg gum (max 20 pieces/day) If smoke 25 or more cigarettes/day, or smoke within 30 minutes of waking – start with 4mg gum (max 20 pieces/day)  Consider chewing on a fixed schedule for the first month – those who smoke a pack-a-day could chew one piece of gum per hour Can also be used on an as needed basis or to top-off cravings in those who use the patch  To taper: reduce by 1 piece/day each week as withdrawal symptoms allow	2mg gum = 1 mg of nicotine 4mg gum = 1.5-2mg of nicotine Bite down on gum to release nicotine tingle, then park between cheek and gums. Once tingle subsides, repeat. Gum lasts ~30 minutes. Side effects include cough, mild throat irritation, hiccups, jaw or mouth pain	Use for 1 to 3 months – as needed use beyond 3 months may be needed Do not use if dental problems, temporomandibular joint syndrome (TMJ) Absorbed through the buccal mucosa (lining of the mouth/cheeks) Avoid acidic beverages (juice, pop, coffee, alcohol) or food (tomatoes) 15 minutes beforehand and while chewing
Nicotine Lozenge Thrive Nicorette Mini Lozenge – How To Quit Smoking With NICORETTE® Mini Lozenge	Thrive: If smoke <20 cigarettes/day – start with 1mg lozenge (max: 25 loz/day) If smoke 20 or more cigarettes/day – start with 2mg lozenge (max: 15 loz/day) Nicorette: If smoke within 30 minutes of waking – start with 4mg lozenge (max 15 loz/day) If smoke after 30 minutes of waking – start with 2mg lozenge  Sample schedule: Weeks 1-6: 1 lozenge every 1-2 hours as needed Weeks 7-9: 1 lozenge every 2-4 hours as needed Weeks 10-12: 1 lozenge every 4-8 hours as needed Discontinue when reduced to 1-2 loz/day	Suck on the lozenge until there’s a strong taste then place lozenge between cheek and gum until the taste is gone, then repeat above steps while periodically moving lozenge from one side of the mouth to the other, until dissolved. Lozenge lasts ~30 minutes. Do not chew or swallow Useful for those with dentures or jaw problems Side effects: hiccups, throat soreness, jaw pain	Avoid food and drink for 15 minutes beforehand and while in mouth  Mini lozenges dissolve faster (~10 minutes instead of 20 minutes)
Nicotine Spray Nicorette QuickMist – How To Quit Smoking With NICORETTE® QuickMist®	Use when one would normally smoke a cigarette, can use a second spray if cravings don’t disappear within a few minutes Generally need 1-2 sprays every ½-1 hour when initially started  Max: 2 sprays/dose Max: 4 sprays/hour Max: 64 sprays/day Suggested schedule: Weeks 1-6: use 1-2 sprays every ½ hour Weeks 7-9: reduce number of sprays per day by half Weeks 10-12: use 2-4 sprays/day and discontinue (consider a flexible dosing schedule)	Each spray = 1mg of nicotine Prime device (waste sprays until fine mist appears) and cartridge before first use and if not used for 2 days Spray on or under the tongue (not inhaled or into the throat). Wait a few seconds before swallowing.  Side effects include throat irritation, cough, burning lips, dry mouth, hiccups	Use for 1 to 3 months – as needed use beyond 3 months may be necessary  Avoid acidic beverages (juice, pop, coffee, alcohol) or foods (tomatoes) 15 minutes beforehand or afterwards Although still absorbed via the buccal mucosa (lining of the mouth/cheek) which is slower absorption than with a cigarette, quick delivery is convenient for cravings
Nicotine Inhaler Nicorette – How To Quit Smoking With NICORETTE® Inhaler	Each 10mg cartridge = 4mg of nicotine (~2mg is systemically absorbed) 10 inhaler puffs ~ 1 cigarette puff Each cartridge lasts 20 minutes of puffing Once the cartridge is puncture, it is good for only 24 hours Suggested schedule: Weeks 1-12: use 6-12 cartridges a day (max 12 cart/day) Weeks 12-24: gradually reduce use until able to discontinue when down to 1-2 cart/day (consider a flexible dosing schedule)	Line up the markers and pull each end in the opposite direction. Insert cartridge into mouthpiece and twist to close securely. Bring mouthpiece to mouth and inhale as you would a cigarette (~5-10 minutes at a time) Useful in those with hand-to-mouth trigger, and those with poor oral health or dentures Wash mouthpiece daily with soap and water Side effects include throat irritation, cough	Use for 12 to 24 weeks Avoid acidic beverages (juice, pop, coffee, alcohol) and foods (tomatoes) 15 minutes beforehand and during use Cold temperatures can decrease the absorption rate (therefore, in cold environments, store in warmer place like inner clothing pocket) Although still absorbed via the buccal mucosa (lining of the mouth/cheek) which is slower absorption than with a cigarette, quick delivery is convenient for cravings

Prescription Products (speak to your doctor)

Varenicline (also known as Champix) has improved cessation rate compared to placebo and higher rates compared to bupropion (Zyban) and NRT. It works by providing some stimulation of nicotine receptors while blocking nicotine from smoking. A typical course lasts 12 weeks, but may be extended to 24 weeks in total. There are no significant drug interactions. Side effects include nausea (take with meal), insomnia (avoid taking the second dose too close to bedtime), vivid dreams, and possible mood and behaviour changes. 

Bupropion (also known as Zyban) improves smoking cessation rates compared to placebo and similar rates to NRT. It has a slower onset (of 1 to 2 weeks). Bupropion may help patients minimize the weight gain experienced with smoking cessation. Side effects include insomnia, dry mouth, agitation and decreased appetite. A typical course lasts 12 weeks, there is no added benefit from extending the duration of therapy. This medication should be avoided in patients with a seizure disorder, eating disorder, severe liver disease and on medications in the class of monoamine oxidase inhibitors (MAOI) within 14 days. Medication interactions are common with this medication. 

What about other methods?

Cystine (Cravv) is a natural health product derived from Golden Rain or Golden Chain acacia, with demonstrated efficacy over placebo. Evidence possibly suggests similar or better efficacy than NRT; however, it has a complex dosing regimen with multiple daily doses (starting with up to 6 capsules daily). Side effects include nausea, stomach discomfort, vomiting, sleep disorders, and possible mood or/and behaviour changes. 

Although widely promoted, there is no clear evidence for the long-term efficacy of therapies like hypnosis, acupuncture, acupressure or laser therapy.

Clove and herbal cigarettes may contain up to 70% tobacco and other ingredients such as tar, carbon monoxide and various other toxins. They are not recommended.

Electronic cigarettes (e-cigs) contain a battery-powered mechanism that heats and vaporizes a liquid chemical mixture composed of various amounts of nicotine, propylene glycol (a known irritant with unknown long-term effects) and other chemicals. Products legally imported and sold in Canada are without nicotine or health claims. Current evidence doesn’t support the use of e-cigs for smoking cessation. 

Some patients attempt to quit cold turkey; it might not be for everyone. Others may try quitting gradually, extending periods between smoking, especially the time to the first cigarette. Methods include using matches instead of a lighter since they run out faster and are less convenient. Likewise, putting cigarettes in a difficult spot may make you less inclined to go get them, or trying to butt out after half a cigarette. 

Speak to your pharmacist or doctor about which treatment options may be best for you. 

References

1. Swidrovich J, Bell C, Burgess J, Damm T, Jensen K, Taylor J. Tobacco Cessation. College of Pharmacy and Nutrition (University of Saskatchewan). Feb 2019. Available from: https://medsask.usask.ca/tobacco-cessation.php/. Accessed July 22, 2020.
2. Support to quit smoking. Ontario Health and Wellness. Oct 2019. Available from: https://www.ontario.ca/page/support-quit-smoking#:~:text=Counselling%20and%20support%20groups,-Talk%20to%20your&text=call%20Telehealth%20Ontario%20(toll%2Dfree,programs%20and%20text%2Dmessage%20support/. Accessed July 22, 2020.
3. Regier L, Jensen B, Chan W, Taylor J. Tobacco Use Disorder Smoking Cessation. Rxfiles (online). Nov 2019. Available from: https://www.rxfiles.ca/RxFiles/uploads/documents/members/CHT-Smoking-Cessation.pdf/. Accessed July 23, 2020.
4. Quitting Smoking for Teens and Young Adults (Patient Education – Disease and Procedure). Lexicomp (online). Mar 2020. Available from: https://online.lexi.com/lco/action/doc/retrieve/docid/disandproc/3746525?cesid=0LtM4SvHurX&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dsmoking%2520cessation%26t%3Dname%26va%3Dsmoking%2520cessation/. Accessed July 23, 2020.
5. Selby P, deRuiter W. Tobacco Use Disorder: Smoking Cessation. E-therapeutics. May 2018. Available from: https://www.e-therapeutics.ca/search/. Accessed July 23, 2020.
6. Petrasko K, Reeve C. Smoking Cessation. E-therapeutics. May 2018. Available from: https://www.e-therapeutics.ca/search/. Accessed July 23, 2020.
7. Nicorette QuickMist. Nicorette. Dec 2016. Available from: https://www.nicorette.ca/products/quickmist?upcean=062600960351/. Accessed July 24, 2020.
8. Nicorette Inhaler. Nicorette. Dec 2016. Available from: https://www.nicorette.ca/products/inhaler/. Accessed July 24, 2020.