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ABSC-FM.qxd 21/6/04 2:38 PM Page i

ABC OF SMOKING CESSATION

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ABC OF SMOKING CESSATION

Edited by
JOHN BRITTON
Professor of Epidemiology at the University of Nottingham
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© 2004 by Blackwell Publishing Ltd

BMJ Books is an imprint of the BMJ Publishing Group Limited, used under licence

Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia

The right of the Author to be identified as the Author of this Work has been asserted in
accordance with the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988,
without the prior permission of the publisher.

First published 2004

ISBN 0 7279 1818 4

A catalogue record for this title is available from the British Library and the Library of Congress

The cover shows a No Smoking sign. With permission from Dennis Potokar/Science Photo Library

Set by BMJ Electronic Production

Printed and bound in Spain by GraphyCems, Navarra

Commissioning Editor: Eleanor Lines

Development Editor: Sally Carter/Nick Morgan
Production Controller: Mirjana Misina

For further information on Blackwell Publishing, visit our website:

http://www.blackwellpublishing.com

The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and
which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices.
Furthermore, the publisher ensures that the text paper and cover board used have met acceptable
environmental accreditation standards.
ABSC-FM.qxd 21/6/04 2:38 PM Page v

Contents

Contributors vii
Preface ix

1 The problem of tobacco smoking 1

Richard Edwards

2 Why people smoke 4

Martin J Jarvis

3 Assessment of dependence and motivation to stop smoking 7

Robert West

4 Use of simple advice and behavioural support 9

Tim Coleman

5 Nicotine replacement therapy 12

Andrew Molyneux

6 Bupropion and other non-nicotine pharmacotherapies 15

Elin Roddy

7 Special groups of smokers 18

Tim Coleman

8 Cessation interventions in routine health care 21

Tim Coleman

9 Setting up a cessation service 24

Penny Spice

10 Population strategies to prevent smoking 27

Konrad Jamrozik

11 Harm reduction 31
Ann McNeill

12 Economics of smoking cessation 34

Steve Parrott, Christine Godfrey

13 Policy priorities for tobacco control 37

Konrad Jamrozik

Index 41

v
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Contributors

John Britton Ann McNeill

Professor of Epidemiology at the University of Nottingham in Independent consultant in public health and Honorary Senior
the division of epidemiology and public health at City Hospital, Lecturer in the Psychology Department at St George’s Hospital
Nottingham Medical School, London

Tim Coleman Andrew Molyneux

Senior Lecturer in general practice at the School of Consultant respiratory physician at the Sherwood Forest
Community Health Sciences in the Division of Primary Care Hospitals Trust, Nottinghamshire
at University Hospital, Queen’s Medical Centre, Nottingham

Richard Edwards Steve Parrott

Senior Lecturer in public health in the Evidence for Research Fellow at the Centre for Health Economics at the
Population Health Unit at the Medical School, University University of York
of Manchester
Elin Roddy
Christine Godfrey Clinical Research Fellow at the University of Nottingham
Professor of Health Economics at the Department of Health in the Division of Respiratory Medicine at City Hospital,
Sciences and Centre for Health Economics at the University Nottingham
of York

Konrad Jamrozik Penny Spice

Professor of Primary Care Epidemiology, Imperial College, Head of Public Involvement at Rushcliffe Primary Care Trust
London, and Visiting Professor in Public Health, School of and formerly smoking cessation coordinator at Nottingham
Population Health, University of Western Australia, Perth Health Authority

Martin J Jarvis Robert West

Professor of Health Psychology in the Cancer Research UK Professor of Health Psychology in the Cancer Research UK
Health Behaviour Unit, Department of Epidemiology and Health Behaviour Unit, Department of Epidemiology and
Public Health at the University College London Public Health at the University College London

vii
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Preface

Smoking kills more people than any other avoidable factor in developed countries. Smoking cessation has a substantial positive
impact on quantity and quality of life expectancy in all smokers, and smoking cessation interventions are among the most cost
effective interventions available in medicine. It is therefore surprising that in many countries, smoking cessation measures are not
routinely available or are not widely used to help smokers to quit smoking. Most medical schools do not train doctors properly to
treat smoking, and many doctors and other health professionals are still unfamiliar with the basic underlying principles of smoking
as an addictive behaviour, and with methods of intervening to help smokers to quit.
This book is intended to provide the basic, simple information needed to equip all health professionals to intervene effectively,
efficiently, and constructively to help their patients to stop smoking. The book describes how and why people start smoking, why they
continue to smoke, and what to do to help them to stop. We describe methods of ensuring that identifying and treating smoking
becomes a routine component of health care, and because the best results are generally achieved by specialist smoking cessation
services we describe some of the challenges and difficulties of establishing these facilities. As prevention of smoking in populations
is such an important determinant of individual motivation to quit or avoid smoking, the authors summarise the population strategies
and political policies that can help drive down the prevalence of smoking. For our managers, this ABC covers the cost-effectiveness
of these initiatives.
One of the tragedies of modern clinical medicine is that treating smoking is so simple, has so much to offer, and so often is not
done. The methods are not difficult. This book explains them.

John Britton

ix
ABSC-FM.qxd 21/6/04 2:38 PM Page x
1 The problem of tobacco smoking
Richard Edwards

Cigarette smoking is the single biggest avoidable cause of death

Male smokers Male deaths
and disability in developed countries. Smoking is now
Female smokers Female deaths
increasing rapidly throughout the developing world and is one 70 40

% of smokers among adults

% of deaths caused by smoking

Stage 1 Stage 2 Stage 3 Stage 4
of the biggest threats to current and future world health. For
60
most smokers, quitting smoking is the single most important
50 30
thing they can do to improve their health. Encouraging
smoking cessation is one of the most effective and cost effective 40
20
things that doctors and other health professionals can do to 30
improve health and prolong their patients’ lives. This book will 20
10
explore the reasons why smokers smoke, how to help them to
10
quit, and how to reduce the prevalence of smoking more
0 0
generally. 0 10 20 30 40 50 60 70 80 90 100
Years
Stage 1 Stage 2 Stage 3 Stage 4
Sub-Saharan China, Japan, Eastern Europe, Western Europe,
Africa South East Asia, southern Europe, North America,
Who smokes tobacco? Latin America,
north Africa
Latin America Australia

Cigarette smoking first became a mass phenomenon in the

Stages of worldwide tobacco epidemic. Adapted from Lopez et al. A
United Kingdom and other more affluent countries in the early
descriptive model of the cigarette epidemic in developed countries. Tobacco
20th century after the introduction of cheap, mass produced, Control 1994;3:242-7
manufactured cigarettes. Typically, a “smoking epidemic” in a
population develops in four stages: a rise and then decline in
smoking prevalence, followed two to three decades later by a
similar trend in smoking related diseases. Usually, the uptake
% of UK adults smoking manufactured cigarettes

70
and consequent adverse effects of smoking occur earlier and to Men
a greater degree among men. 60
In the United Kingdom there are about 13 million smokers, Women
and worldwide an estimated 1.2 billion. Half of these smokers 50

will die prematurely of a disease caused by their smoking, losing 40

an average of eight years of life; this currently represents four
million smokers each year worldwide. Deaths from smoking are 30
projected to increase to more than 10 million a year by 2030, by
20
which time 70% of deaths will be in developing countries.
The prevalence of smoking among adults in the United 10
Kingdom has declined steadily from peaks in the 1940s in men
and the late 1960s in women. However, this reduction in overall 0
1948 1952 1956 1960 1964 1968 1972 1976 1980 1984 1988 1992 1996 2000
prevalence during stage 4 of the epidemic disguises relatively
static levels of smoking among socioeconomically Year
disadvantaged groups, making smoking one of the most
important determinants of social inequalities in health in the Prevalence of smoking of manufactured cigarettes in Great Britain. Data
developed world. Smoking has also declined much more slowly from Tobacco Advisory Council (1948-70) and general household survey
(1972-2001)
among young adults in the United Kingdom. The decline in
smoking in the United Kingdom and some other developed
countries may now be coming to an end. For example, since
1994 the prevalence of smoking in UK adults has remained at 80
Prevalence of smoking in population (%)

1973
about 28%. 70
Whereas countries in western Europe, Australasia, and the 1993
60
United States may be in stage 4 of the smoking epidemic, in
many developing countries the epidemic is just beginning. 50
Smoking in low and middle income countries is increasing 40
rapidly—for example, the prevalence of smoking among males
in populous Asian countries is now far higher than in Western 30

countries—45% in India, 53% in Japan, 63% in China, 69% in 20

Indonesia, and 73% in Vietnam.
10

0
0 1 2 3 4 5
Most affluent Poorest
Adverse health effects Deprivation score

The adverse health effects of smoking are extensive, and have Cigarette smoking by deprivation level in Great Britain. Data from general
been exhaustively documented. There is a strong dose-response household survey

1
ABC of Smoking Cessation

relation with heavy smoking, duration of smoking, and early

uptake associated with higher risks of smoking related disease 100

% of study doctors alive

and mortality. Data from 40 years of follow up of smokers in a
prospective cohort study of male British doctors show the
80
impact of smoking on longevity at different levels of exposure.
The strongest cause-specific associations are with respiratory
cancers and chronic obstructive pulmonary disease; in numeric 60
terms, the greatest health impacts of smoking are on respiratory
Current cigarette smokers:
and cardiovascular diseases. 40
Never smoked regularly
Some of the increases in health risk associated with smoking
are greater among younger smokers. The risk of heart attack 1-14 a day
20
among smokers, for example, is at least double over the age of 15-24 a day
60 years, but those aged under 50 have a more than fivefold > 25 a day
0
increase in risk. Smokers are also at greater risk of many other 40 55 70 85 100
non-fatal diseases, including osteoporosis, periodontal disease,
impotence, male infertility, and cataracts. Smoking in pregnancy Age
is associated with increased rates of fetal and perinatal death
and reduced birth weight for gestational age. Passive smoking Survival by smoking status, according to study of male British doctors
(follow up after 40 years, 1951-91). Adapted from Doll et al (see Further
after birth is associated with cot death and respiratory disease in Reading box)
childhood and lung cancer, heart disease, and stroke in adults.
The effect on health services is considerable—for example,
an estimated 364 000 admissions and £1.5bn ($2.4bn; €2.1bn) a
No of deaths (000s) attributable to smoking, 1995
30 30

Relative risk of death

year in health service costs are attributable to smoking in the Smoking attributable deaths Relative risk of death
United Kingdom alone. 25 25

20 20

Health benefits of smoking cessation 15 15

Stopping smoking has substantial immediate and long term 10 10

health benefits for smokers of all ages. The excess risk of death
from smoking falls soon after cessation and continues to do so 5 5

for at least 10-15 years. Former smokers live longer than

0 0
continuing smokers, no matter what age they stop smoking,
er

er

ke

Pn ema s

ia
ce

ce

as

i
ys hit

on
nc

nc

ys
ro
an

an

ise

though the impact of quitting on mortality is greatest at

ur

ph nc

m
ca

ca

St
lc

rc

td

eu
ne

em ro
ng

th
ea

de

ca

d cb
ar
ou
Lu

younger ages. For smokers who stop before age 35, survival is
ag

ad

he

rti
m

an oni
ph

Bl

Ao
ic
d

r
so

m
an

about the same as that for non-smokers. Ch

Oe

ae
at

ch
ro

Is

The rate and extent of reduction of risk varies between

Th

diseases—for lung cancer the risk falls over 10 years to about

Numbers and relative risk of death (by cause) due to smoking, United
30%-50% that of continuing smokers, but the risk remains
Kingdom. Data from Tobacco Advisory Group of the Royal College of
raised even after 20 years of abstinence. There is benefit from Physicians and Doll et al (see Further Reading box)
quitting at all ages, but stopping before age 30 removes 90% of
the lifelong risk of lung cancer. The excess risk of oral and
oesophageal cancer caused by smoking is halved within five
3.0
FEV1 (litres)

years of cessation.
The risk of heart disease decreases much more quickly after 2.8
quitting smoking. Within a year the excess mortality due to 2.6
smoking is halved, and within 15 years the absolute risk is
almost the same as in people who have never smoked. In a 2.4

meta-analysis by Wilson and colleagues in 2000, the odds ratio 2.2

for death for smokers who stopped smoking after myocardial
2.0
infarction was 0.54, a far higher protective effect than the
0.75-0.88 odds ratio for death achieved by the conventional 85
FEV1 (% of predicted normal value)

standard treatments for myocardial infarction, including

thrombolysis, aspirin,
blockers, and statins. Smoking cessation 80

also reduces the risk of death after a stroke and of death from 75
pneumonia and influenza. Sustained quitters
70
Smoking is associated with an accelerated rate of decline in
Intermittent smokers
lung function with age. Cessation results in a small increase in 65
lung function and reverses the effect on subsequent rate of Continuous smokers
60
decline, which reverts to that in non-smokers. 0 1 2 3 4 5 6 7 8 9 10 11
Thus, early cessation is especially important in susceptible
FEV1 = forced expiratory volume in one second Years of study
individuals to prevent or delay the onset of chronic obstructive
pulmonary disease. In patients with this disease, mortality and
Effect of smoking cessation on rate of decline in lung function in chronic
symptoms are reduced in former smokers compared with obstructive pulmonary disease. Adapted from Anthonisen et al. Am J Respir
continuing smokers. Recent evidence shows that the benefits Crit Care Med 2002;166:675-9

2
 The problem of tobacco smoking

Key points
x Cigarette smoking is one of the greatest avoidable causes of Stopping smoking before or in the first three to four
premature death and disability in the world months of pregnancy protects the fetus against the
x Helping smokers to stop smoking is one of the most cost effective reduced birth weight associated with smoking.
interventions available in clinical practice Preoperative cessation reduces perioperative mortality
x Promoting smoking cessation should therefore be a major priority and complications
in all countries and for all health professionals in all clinical settings

occur even in older patients with severe chronic obstructive

pulmonary disease.
At a population level, the importance of smoking cessation
is paramount. Peto has estimated that current cigarette smoking
will cause about 450 million deaths worldwide in the next 50
years. Reducing current smoking by 50% would prevent 20-30 Further reading
million premature deaths in the first quarter of this century and x Tobacco Advisory Group of the Royal College of Physicians.
about 150 million in the second quarter. Preventing young Nicotine addiction in Britain. London: Royal College of Physicians of
people from starting smoking would have a more delayed but London, 2000. www.rcplondon.ac.uk/pubs/books/nicotine/
ultimately even greater impact on mortality. index.htm
x Jha P, Chaloupka F, eds. Tobacco control in developing countries.
Effective prevention of cigarette smoking and help for those Oxford: Oxford University Press, 1999.
wishing to quit can therefore yield enormous health benefits for x Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in
populations and individuals. Promoting and supporting relation to smoking: 40 years’ observations on male British doctors.
smoking cessation should be an important health policy BMJ 1994;309:901-11.
priority in all countries and for healthcare professionals in all x World Bank. Curbing the epidemic: governments and the economics of
clinical settings. However, this has not so far generally been tobacco control. Washington, DC: World Bank, 1999.
www1.worldbank.org/tobacco/reports.asp
reflected at a policy level or in the practice of individual
x US Department of Health and Human Services. The health benefits
healthcare professionals. of smoking cessation: a report of the surgeon general. Rockville, MD: US
Government Printing Office, 1990. (DHHS publication No (CDC)
Competing interests: RE is chairman of North West ASH (Action on
90-8416.)
Smoking and Health); he receives no financial reward for this work. JB has
x Wilson K, Willan A, Cook D. Effect of smoking cessation on
been reimbursed by GlaxoWellcome (now GlaxoSmithKline) for attending
two international conferences, has received a speaker’s honorarium from
mortality after myocardial infarction. Arch Intern Med
GlaxoWellcome, and has been the principal investigator in a clinical trial 2000;160:939-44.
of nicotine replacement therapy funded by Pharmacia. Both these
companies manufacture nicotine replacement products.

3
2 Why people smoke
Martin J Jarvis

For much of the 20th century, smoking was regarded as a

socially learned habit and as a personal choice. It is only in the
past decade or so that the fundamental role of nicotine in “If it were not for the nicotine in tobacco
sustaining smoking behaviour has begun to be more widely smoke, people would be little more
inclined to smoke than they are to blow
accepted. It is now recognised that cigarette smoking is
bubbles”
primarily a manifestation of nicotine addiction and that
smokers have individually characteristic preferences for their M A H Russell, tobacco researcher, 1974
level of nicotine intake. Smokers regulate the way they puff and
inhale to achieve their desired nicotine dose.
The link with nicotine addiction does not imply that
pharmacological factors drive smoking behaviour in a simple
way and to the exclusion of other influences. Social, economic,
personal, and political influences all play an important part in
determining patterns of smoking prevalence and cessation.
Although drug effects underpin the behaviour, family and wider
social influences are often critical in determining who starts
smoking, who gives up, and who continues.

Why do people start smoking?

Experimenting with smoking usually occurs in the early teenage
years and is driven predominantly by psychosocial motives. For
a beginner, smoking a cigarette is a symbolic act conveying
messages such as, in the words of the tobacco company Philip
Morris, “I am no longer my mother’s child,” and “I am tough.”
Children who are attracted to this adolescent assertion of
perceived adulthood or rebelliousness tend to come from
backgrounds that favour smoking (for example, with high levels Smoking a cigarette for a beginner is a symbolic act of rebellion
of smoking in parents, siblings, and peers; relatively deprived
neighbourhoods; schools where smoking is common). They
also tend not to be succeeding according to their own or
society’s terms (for example, they have low self esteem, have
impaired psychological wellbeing, are overweight, or are poor
achievers at school). By age 20, 80% of cigarette smokers regret that they ever
The desired image is sufficient for the novice smoker to started, but as a result of their addiction to nicotine, many
tolerate the aversion of the first few cigarettes, after which will continue to smoke for a substantial proportion of
their adult lives
pharmacological factors assume much greater importance.
Again in the words of Philip Morris, “as the force from the
psychosocial symbolism subsides, the pharmacological effect
takes over to sustain the habit.” Within a year or so of starting to
smoke, children inhale the same amount of nicotine per
cigarette as adults, experience craving for cigarettes when they
cannot smoke, make attempts to quit, and report experiencing
50
Nicotine concentration (ng/ml)

the whole range of nicotine withdrawal symptoms. Venous levels

Arterial levels
40

Physical and psychological effects of

30
nicotine
Absorption of cigarette smoke from the lung is rapid and 20
complete, producing with each inhalation a high concentration
arterial bolus of nicotine that reaches the brain within 10-16
10
seconds, faster than by intravenous injection. Nicotine has a
distributional half life of 15-20 minutes and a terminal half life
in blood of two hours. Smokers therefore experience a pattern 0
0 10 20 30 40 50 60
of repetitive and transient high blood nicotine concentrations
from each cigarette, with regular hourly cigarettes needed to Cigarette smoked Time (minutes)
maintain raised concentrations, and overnight blood levels
dropping to close to those of non-smokers. Arterial and venous levels of nicotine during cigarette smoking

4
 Why people smoke

Nicotine has pervasive effects on brain neurochemistry. It

Glutamatergic
activates nicotinic acetylcholine receptors (nAChRs), which are efferents
widely distributed in the brain, and induces the release of nAChR
dopamine in the nucleus accumbens. This effect is the same as Nicotine
that produced by other drugs of misuse (such as amphetamines nAChR NMDA receptor
and cocaine) and is thought to be a critical feature of brain
NAcc
addiction mechanisms. Nicotine is a psychomotor stimulant, Nicotine shell VTA
and in new users it speeds simple reaction time and improves DA Nicotine
nAChR
performance on tasks of sustained attention. However, tolerance
to many of these effects soon develops, and chronic users Cholinergic
probably do not continue to obtain absolute improvements in efferents
performance, cognitive processing, or mood. Smokers typically
report that cigarettes calm them down when they are stressed Raphé Pedunculopontine
nuclei nucleus
and help them to concentrate and work more effectively, but
little evidence exists that nicotine provides effective self nAChR nAChR
medication for adverse mood states or for coping with stress. Nicotine Nicotine
A plausible explanation for why smokers perceive cigarettes
to be calming may come from a consideration of the effects of
nicotine withdrawal. Smokers start to experience impairment of nAChR= nicotinic acetylcholine receptor
mood and performance within hours of their last cigarette, and NAcc= nucleus accumbens
VTA= ventral tegmental area
certainly overnight. These effects are completely alleviated by NMDA= N-methyl-D-aspartate
smoking a cigarette. Smokers go through this process
thousands of times over the course of their smoking career, and
Pathways of nicotine reinforcement and addiction. Adapted from Watkins
this may lead them to identify cigarettes as effective self et al. Nicotine and Tobacco Research 2000;2:19-37
medication, even if the effect is the negative one of withdrawal
relief rather than any absolute improvement.

Effects of nicotine withdrawal

Symptoms of nicotine withdrawal Symptom Duration Incidence (%)
Much of the intractability of cigarette smoking is thought to Lightheadedness < 48 hours 10
stem from the problems of withdrawal symptoms—particularly Sleep disturbance < 1 week 25
irritability, restlessness, feeling miserable, impaired Poor concentration < 2 weeks 60
concentration, and increased appetite—as well as from cravings Craving for nicotine < 2 weeks 70
for cigarettes. These withdrawal symptoms begin within hours Irritability or aggression < 4 weeks 50
of the last cigarette and are at maximal intensity for the first Depression < 4 weeks 60
week. Most of the affective symptoms then resolve over three or Restlessness < 4 weeks 60
four weeks, but hunger can persist for several months. Cravings, Increased appetite < 10 weeks 70
sometimes intense, can also persist for many months, especially
if triggered by situational cues.

Many experimental and clinical studies

Social and behavioural aspects have shown that withdrawal symptoms
are attributable to nicotine, as nicotine
The primary reinforcing properties of nicotine ultimately replacement (by gum, patch, spray, or
sustain smoking behaviour: in experimental models, if nicotine lozenge) reliably attenuates the severity of
is removed from cigarette smoke, or nicotine’s effects on the withdrawal
central nervous system are blocked pharmacologically, smoking
eventually ceases. However, under normal conditions, the
intimate coupling of behavioural rituals and sensory aspects of
smoking with nicotine uptake gives ample opportunities for
secondary conditioning. For a 20 a day smoker, “puff by puff”
delivery of nicotine to the brain is linked to the sight of the
packet, the smell of the smoke, and the scratch in the throat
some 70 000 times each year. This no doubt accounts for
smokers’ widespread concern that if they stopped smoking they
would not know what to do with their hands, and for the ability
of smoking related cues to evoke strong cravings.
Social influences also operate to modulate nicotine’s effects.
The direction of this influence can be to discourage
smoking—as, for example, with the cultural disapproval of
smoking in some communities, the expectation of non-smoking
that has become the norm in professional groups, or the effects
of smoke-free policies in workplaces. Other factors encourage
smoking, such as being married to a smoker or being part of
social networks in socially disadvantaged groups, among whom Behavioural rituals are closely coupled
prevalence is so high as to constitute a norm. with sensory aspects of smoking

5
ABC of Smoking Cessation

Regulation of nicotine intake

Nicotine intake per cigarette (mg)

1.6
Smokers show a strong tendency to regulate their nicotine Actual Predicted
intakes from cigarettes within quite narrow limits. They avoid 1.4
intakes that are either too low (provoking withdrawal) or too 1.2
high (leading to unpleasant effects of nicotine overdose). Within
individuals, nicotine preferences emerge early in the smoking 1.0
career and seem to be stable over time. The phenomenon of 0.8
nicotine titration is responsible for the failure of intakes to
decline after switching to cigarettes with low tar and nicotine 0.6

yields. Compensatory puffing and inhalation, operating at a 0.4

subconscious level, ensure that nicotine intakes are maintained.
0.2
As nicotine and tar delivery in smoke are closely coupled,
compensatory smoking likewise maintains tar intake and 0
<0.1 0.1- 0.2- 0.4- 0.5- 0.6- 0.7- 0.8- 0.9- >1.0
defeats any potential health gain from lower tar cigarettes.
Similar compensatory behaviour occurs after cutting down on Cigarette nicotine yield (mg)
the number of cigarettes smoked each day; hence this popular
strategy fails to deliver any meaningful health benefits. Regulation of nicotine intake: actual and predicted intake per cigarette from
low tar cigarettes. Data from health survey for England, 1998

Socioeconomic status and nicotine

addiction
Mean plasma cotinine (ng/ml)
350
An emerging phenomenon of the utmost significance over the
past two decades has been the increasing association of
continued smoking with markers of social disadvantage. Among 300
affluent men and women in the United Kingdom, the
proportion of ever smokers who have quit has more than
doubled since the early 1970s, from about 25% to nearly 60%, 250
whereas in the poorest groups the proportion has remained at
around 10%. Part of the explanation for this phenomenon may
200
be found in the growing evidence that poorer smokers tend to
have higher levels of nicotine intake and are substantially more
dependent on nicotine. It is evident that future progress in 0
reducing smoking is increasingly going to have to tackle the 0 1 2 3 4 5
Most affluent Poorest
problems posed by poverty.
Deprivation score

Smoking as a chronic disease Nicotine intake and social deprivation. Data from health survey for England
(1993, 1994, 1996)
Cigarette dependence is a chronic relapsing condition that for
many users entails a struggle to achieve long term abstinence
that extends over years or decades. Successful interventions
need to tackle the interacting constellation of factors—personal, Smoking behaviour and cessation
family, socioeconomic, and pharmacological—that sustain use x The natural course of cigarette smoking is typically characterised by
and can act as major barriers to cessation. the onset of regular smoking in adolescence, followed by repeated
attempts to quit
x Each year about a third of adult smokers in the United Kingdom
Further reading try to quit, usually unaided and typically relapsing within days
x Royal College of Physicians. Nicotine addiction in Britain. London: x In general, less than 3% of attempts to quit result in sustained (12
RCP, 2000. months’) cessation, though the chances of success are slightly
x Benowitz NL. Pharmacologic aspects of cigarette smoking and higher in women of childbearing age, parents of young children,
nicotine addiction. N Engl J Med 1988;319:1318-30. and spouses of non-smokers
x National Institutes of Health. Risks associated with smoking cigarettes
with low machine-measured yields of tar and nicotine. Bethesda, MD:
Department of Health and Human Services, National Institutes of
Health, National Cancer Institute, 2001. (NIH publication No
02-5074.)
Key points
x Jarvis MJ. Patterns and predictors of unaided smoking cessation in x Smoking usually starts as a symbolic act of rebellion or maturity
the general population. In: Bolliger CT, Fagerstrom KO, eds. The x By age 20, 80% of smokers regret having started to smoke
tobacco epidemic. Basle: Karger, 1997:151-64. x Nicotine from cigarettes is highly addictive—probably because it is
delivered so rapidly to the brain
x Smoking a cigarette, especially the first of the day, feels good
mainly because it reverses the symptoms of nicotine withdrawal
The photo of children smoking is with permission from Ralph Mortimer/ x Most smokers who switch to low tar cigarettes or reduce the
Rex, and the photo of the man smoking is with permission from number of cigarettes they smoke continue to inhale the same
Alexandra Murphy/Photonica. amount of nicotine, and hence tar, from the cigarettes they smoke
Competing interests: MJJ has received speaker’s honorariums from x Heavy dependence on nicotine is strongly related to socioeconomic
GlaxoSmithKline and Pharmacia. He is also director of an NHS funded disadvantage
smoking cessation clinic. See chapter 1 for the series editor’s competing x Smoking is a chronic relapsing addictive disease
interests.

6
3 Assessment of dependence and motivation to stop
smoking
Robert West

Whether a smoker succeeds in stopping smoking depends on

the balance between that individual’s motivation to stop This article reviews some simple methods to assess
dependence and motivation in smokers
smoking and his or her degree of dependence on cigarettes.
Clinicians must be able to assess both of these characteristics.
Motivation is important because “treatments” to assist with
smoking cessation will not work in smokers who are not highly Motivation
motivated. Dependence is especially important in smokers who Low High
do want to stop smoking, as it influences the choice of
• Unlikely to stop but could do so • Likely to stop with minimal help
intervention. It is also important to bear in mind that: without help • Primary intervention goal is to
x Motivation to stop and dependence are often related to each Low
• Primary intervention goal is to trigger a quit attempt
other: heavy smokers may show low motivation because they increase motivation
Dependence
lack confidence in their ability to quit; lighter smokers may • Unlikely to stop • Unlikely to stop without help but
show low motivation because they believe they can stop in the • Primary intervention goal is would benefit from treatment
future if they wish High initially to increase motivation • Primary intervention goal is to
to make smoker receptive to engage smoker in treatment
x Motivation to stop can vary considerably with time and be
treatment for dependence
strongly influenced by the immediate environment
x What smokers say about their wish to stop, especially in a
clinical interview, may not accurately reflect their genuine Clinical intervention goals for smoking according to dependence and
feelings. motivation to quit

Measuring dependence in smokers

Do you find it difficult not to smoke in situations where you would No/Yes
Qualitative methods
normally do so?
The simplest approach to measuring dependence on cigarettes
is a basic qualitative approach that uses questions to find out Have you tried to stop smoking for good in the past but found that you No/Yes
whether the smoker has difficulty in refraining from smoking in could not?
circumstances when he or she would normally smoke or
whether the smoker has made a serious attempt to stop in the
past but failed. A “yes” response to either of these questions would suggest that the smoker
might benefit from help with stopping
Quantitative methods
The most commonly used quantitative measure of dependence is
the Fagerstrom test for nicotine dependence, which has proved
successful in predicting the outcome of attempts to stop. The Q1. How many cigarettes per day do you usually smoke?
(Write a number in the box and circle one response) 10 or less 0
higher the score on this questionnaire, the higher the level of 11 to 20 1
dependence: smokers in the general population score an average 21 to 30 2
of about 4 on this scale. Of all the items in the questionnaire, 31 or more 3
cigarettes per day and time to first cigarette of the day seem to be
the most important indicators of dependence. Q2. How soon after you wake up do you smoke your Within 5 minutes 3
first cigarette? (Circle one response) 6-30 minutes 2
31 or more 0
Objective methods
The concentration of nicotine or its metabolite, cotinine, in Q3. Do you find it difficult to stop smoking in No 0
blood, urine, or saliva is often used in research as an objective non-smoking areas? (Circle one response) Yes 1
index of dependence because it provides an accurate measure
of the quantity of nicotine consumed, which is itself a marker of Q4. Which cigarette would you most hate to give up? First of the morning 1
dependence. Carbon monoxide concentration of expired air is (Circle one response) Other 0
a measure of smoke intake over preceding hours; it is not as
accurate an intake measure as nicotine based measures, but it is Q5. Do you smoke more frequently in the first hours after No 0
waking than the rest of the day? (Circle one response) Yes 1
much less expensive and gives immediate feedback to the
smoker.
Q4. Do you smoke if you are so ill that you are in bed No 0
most of the day? (Circle one response) Yes 1
How should dependence influence choice of treatment?
The main value of measuring dependence in tailoring cessation
interventions to individual smokers is in the choice of The Fagerstrom test for nicotine dependence: a quantitative index of
dependence. The numbers in the pink shaded column corresponding to the
pharmacotherapy. The manufacturers of smoking cessation smoker’s responses are added together to produce a single score on scale of
drug products (principally nicotine replacement therapy and 0 (low dependence) to 10 (high dependence). Adapted from Heatherton et
bupropion—see later chapters in this book) recommend that al. Br J Addict 1991;86:1119-27

7
ABC of Smoking Cessation

only smokers of 10 or more cigarettes a day should use their

Dependence and dose of nicotine in treatment
products. However, the UK National Institute for Clinical
Excellence has recently recognised this cut off to be arbitrary x The nicotine dose should be guided by measures of dependence
x The higher strength forms of nicotine replacement are particularly
and has not specified any particular lower limit for daily
recommended for high dependence smokers
cigarette consumption. x For nicotine therapy, high dependence smoking is typically
considered to be at least 15-20 cigarettes a day and/or smoking
within 30 minutes of waking
Measuring motivation to stop smoking Nicotine therapy will be covered in a later article in this series
Survey evidence in the United Kingdom shows that about two
thirds of smokers declare that they want to stop smoking and
that in any year almost a third make an attempt to stop. Young Estimated prevalence of selected indices of motivation to
smokers are widely believed to be less motivated to stop than stop smoking
older smokers, but in fact the reverse is true: older smokers are Index % of
typically less motivated. smokers
However, only a minority of smokers attempting to stop Would like to stop smoking for good 70
currently use smoking cessation medications or attend a Intend to stop smoking in next 12 months 46
specialist cessation service. This may reflect a lack of confidence Made an attempt to stop in a given year 30
among smokers that these treatments will help. Used medication to aid cessation in a given year* 8
Attended smokers clinic or followed behavioural 2
Direct questioning support programme†
Motivation to stop can be assessed qualitatively by means of *Based on surveys showing that 30% of smokers make a quit attempt each year
simple direct questions about their interest and intentions to and that in 25% of quit attempts medication is used.
†Based on figures from attendance in 2001 at NHS cessation clinics.
quit. This simple approach is probably sufficient for most
clinical practice, although slightly more complex,
semiquantitative measures (asking the smoker to rate degree of
desire to stop on a scale from “not at all” to “very much”) can
also be used. Do you want to stop smoking for good? No/Yes

Stages of change Are you interested in making a serious attempt to stop in the near future? No/Yes

One model of the process of behaviour change has become

Are you interested in receiving help with your quit attempt? No/Yes
popular: the “transtheoretical model.” In this model, smokers
are assigned to one of five stages of motivation:
precontemplation (not wishing to stop), contemplation
Simple qualitative test of motivation to stop smoking. A “yes” response to all
(thinking about stopping but not in the near future), questions suggests that behavioural support and/or medication should be
preparation (planning to stop in the near future), action (trying offered
to stop), and maintenance (have stopped for some time).
Smokers may cycle through the contemplation to action stages
many times before stopping for good. This model has been
widely adopted, though no evidence exists that the rather Smoking
Not thinking Contemplating
elaborate questionnaires for assigning smokers to particular about stopping stopping
stages predict smoking cessation better than the simple direct
Relasping Preparing
questions outlined above.
back to to stop
Some clinicians use a smoker’s degree of motivation to stop smoking
as a prognostic indicator of likely success once the quit attempt
has been decided. In fact, degree of motivation seems to play a Not smoking
fairly small role in success; once a quit attempt is made, markers Staying Attempting
of dependence are far stronger determinants of success. The stopped to stop

ultimate practical objective of assessing motivation is therefore

to identify smokers who are ready to make a quit attempt. After
that, it is the success of the intervention in overcoming Stages of change in process of stopping smoking. Adapted from Prochaska
dependence that matters. et al. Clin Chest Med 1991;12:727-35

Key points
Further reading
x Motivation to stop smoking can be assessed with simple questions
x Once a decision to quit is made, success is determined more by the x Kozlowski LT, Porter CQ, Orleans CT, Pope MA, Heatherton T.
degree of dependence than the level of motivation Predicting smoking cessation with self-reported measures of
x Simple questions can identify heavily dependent smokers nicotine dependence: FTQ, FTND, and HSI. Drug Alcohol Depend
x For high dependence, higher strength nicotine products may help 1994;34:211-6.
x National Institute for Clinical Excellence. Technology appraisal
guidance No 38. Nicotine replacement therapy (NRT) and bupropion for
smoking cessation. London: NICE, 2002.
Competing interests: RW has done paid research and consultancy for, x Sutton S. Back to the drawing board? A review of applications of
and received travel funds and hospitality from, manufacturers of the transtheoretical model to substance use. Addiction
smoking cessation products, including nicotine replacement therapies 2001;96:175-86.
and Zyban. See chapter 1 for the series editor’s competing interests.

8
4 Use of simple advice and behavioural support
Tim Coleman

The most effective methods of helping smokers to quit smoking

combine pharmacotherapy (such as nicotine or bupropion) Suggested phrasing for giving brief advice to smokers
with advice and behavioural support. These two components x “The best thing you can do for your health is to stop smoking, and I
contribute about equally to the success of the intervention. would advise you to stop as soon as possible.”
x “Tobacco is very addictive, so it can be very difficult to give up, and
Doctors and other health professionals should therefore be
many people have to try several times before they succeed. Your
familiar with what these strategies offer, encourage smokers to chances of succeeding are much greater if you make use of
use them, and be able at least to provide simple advice and counselling support, which I can arrange for you, and either
behavioural support to smokers. They also need to be familiar nicotine replacement therapy or the antismoking drug Zyban
with other sources of support, such as written materials, [bupropion], which I can prescribe for you if you wish.”
telephone helplines, and strategies for preventing relapses. This x “If you are ready to try to give up smoking now, then the best thing
is to see a counsellor as soon as possible, and I can arrange that for
chapter focuses on non-pharmacological interventions.
you. If not, then I’d like you to take home this leaflet and read it, or
ring the NHS smokers’ helpline, to get further information.”
x “The best thing is to get counselling from experts, but if this isn’t
Brief advice possible, you should make sure that you have good information on
the health effects of smoking and some tips on ways of stopping
The Cochrane Tobacco Addiction Group defines brief advice smoking and that you know where to turn for further help and
support.”
against smoking as “verbal instructions to stop smoking with or
x “How do you feel about your smoking?”
without added information about the harmful effects of x “How do you feel about tackling your smoking now?”
smoking.” All the published guidelines on managing smoking
cessation recommend that all health professionals should give
simple brief advice routinely to all smokers whom they
encounter. The success rate of brief advice is modest, achieving 25 000
Discounted cost per year of life saved (£)

cessation in about 1 in 40 smokers, but brief advice is one of the

most cost effective interventions in medicine. The previous 20 000
article in this series gave tips on how to take account of
smokers’ motivation to stop, but the key point is that only one 15 000
or two minutes are needed for effective brief advice to be
delivered in routine consultations. 10 000
Advice along these lines is probably most effective in
smokers with established smoking related disease. It is also 5000
more effective if more time is spent discussing smoking and
212
cessation and if a follow up visit is arranged to review progress. 0
More intensive advice (taking more than 20 minutes at the
dis ion in

ise ar y

ar tio r

e
inf ven n fo
t d on ar

vic
lar nt tin
ea of

as y

cti n
ar or nd

ad
ial re ti
cu ve ta

initial consultation), inclusion of additional methods of

se

on
he of c eco

rd p sta
as pre vas

ief
ca ary va
n s

Br
iov y ra

tio or

yo d m

reinforcing advice (such as self help manuals, videos, or CD

rd ar P

en n f

m on Si
ev iri

Roms and showing smokers’ their exhaled carbon monoxide

pr sp
ca prim

of sec

levels), and follow up can increase success rates by a factor of

1.4. Again, the cost effectiveness of these more intensive
interventions is extremely high—higher than many of the Cost effectiveness of brief advice versus common medical interventions
interventions provided routinely in primary or secondary care.
The case is therefore strong to integrate simple advice into all
health consultations with smokers and to offer more intensive
advice and follow up to smokers who are motivated to quit.

Behavioural support
Intensive behavioural support provided outside routine clinical
care by appropriately trained smoking cessation counsellors is
the most effective non-pharmacological intervention for
smokers who are strongly motivated to quit. Meta-analyses of
trials have shown that about 1 in 13 smokers who are motivated
enough to attend individual counselling from a smoking
cessation counsellor are likely to quit as a result of this. Different
approaches to counselling based on various psychological
models have been studied, but no one type of intensive
behavioural support is clearly more effective than any other.
Behavioural support usually involves a review of patients’
Measuring the level of carbon monoxide in smokers’
smoking histories and their motivation to quit, with smokers exhaled air can motivate them to quit or be a useful
being helped to identify situations where they might have a tool in monitoring their progress with cessation

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