Smoking cessation

BACKGROUND

Smoking cessation is an effort by a person who regularly uses tobacco products to establish a plan to reduce, and eventually eliminate, tobacco use. Tobacco contains nicotine, a highly addictive drug, in addition to the 69 chemicals known to cause cancer. All major medical institutions acknowledge that quitting smoking greatly increases a person's health prospects.

In the past few decades, the medical community has come to recognize the enormous health risks of smoking. Though governmental and health related organizations have conducted extensive campaigns to address the hazards of smoking, less information is available on strategies a smoker can use to quit.

Tobacco use is a major cause of death worldwide, according to the World Health Organization (WHO). Worldwide, tobacco use (including cigarettes, cigars, smokeless, and chewing tobacco) causes nearly five million deaths per year. Current trends show that tobacco use will cause more than ten million deaths annually by 2020.

Cigarette smoke contains over 4,800 chemicals, 69 of which are known to cause cancer.

Nicotine is the most abundant psychoactive drug in tobacco products that produces dependence. Nicotine can produce both excitation and stimulation along with relaxation at the same time, making it a very attractive drug for addictive personalities. Both smoking tobacco and smokeless tobacco (chewing, dipping) can lead to nicotine dependence. Chewing and dipping tobacco is placed between the lip and gums or in the cheek. Nicotine dependence is the most common form of chemical dependence in the United States. Research suggests that nicotine is as addictive as heroin, cocaine, or alcohol. Examples of nicotine withdrawal symptoms include irritability, anxiety, difficulty concentrating, and increased appetite.

An estimated 20.9% of all adults (age 18 or older), or approximately 44.5 million people, smoke cigarettes in the United States. Cigarette smoking is more common among men than women.

Cigarette and cigar smoking are the leading preventable cause of death in the United States. In the United States, cigarette smoking is responsible for about one in five deaths annually, or about 438,000 deaths per year. An estimated 38,000 of these deaths annually are the result of secondhand smoke exposure. On average, smokers die 13-14 years earlier than nonsmokers.

Smoking cessation benefits men and women at any age. Smokers who quit before age 50 have half the risk of dying in the next 16 years compared with people who continue to smoke. Older adults who quit smoking also have a reduced risk of dying from coronary heart disease and lung cancer.

According to the Centers for Disease Control (CDC), cigarette smoking costs more than $167 billion annually, based on lost productivity ($92 billion) and healthcare expenditures ($75.5 billion).

Smoking cessation (quitting tobacco) is difficult and may require multiple attempts, as users often relapse because of withdrawal symptoms. Tobacco dependence is a chronic (long-term) condition that often requires repeated intervention. As part of the wider tobacco control movement, there have been numerous advertising campaigns, smoking restriction policies, tobacco taxes, and other strategies to encourage people to quit smoking.

Smoking in pregnancy accounts for an estimated 20-30% of low-birth weight babies, up to 14% of preterm deliveries, and some 10% of all infant deaths. Even apparently healthy, full-term babies of smokers have been found to be born with narrowed airways and decreased lung function.

Smoking by parents is associated with a wide range of adverse effects in their children, including increased asthma symptoms, such as wheezing and shortness of breath, and an increased frequency of colds and ear infections. Smoking may also increase the chances of a newborn's death by sudden infant death syndrome (SIDS). The American Lung Association estimates that secondhand smoke causes 150,000 to 300,000 cases of lower respiratory tract infections in children less than 18 months of age, resulting in 7,500 to 15,000 annual hospitalizations.

Tobacco advertising, family smokers, and peer pressure play an important role in encouraging young people to begin a lifelong addiction to smoking before they are old enough to fully understand the long-term health risk. Approximately 90% of smokers begin smoking before the age of 21.

Among current adult smokers in the United States, 70% report that they want to quit completely. In 2004, an estimated 14.6 million, or 40.5% of adult smokers, had stopped smoking for at least one day during the preceding 12 months because they were trying to quit. Nearly 54% of current high school cigarette smokers in the United States tried to quit smoking within the preceding year.

Smoking low-tar, low-nicotine, or "light" cigarettes may actually make it harder for smokers to kick the habit. Studies have reported that individuals who smoke light cigarettes are more than 50% less likely to quit smoking than those who smoke regular cigarettes.

People who stop smoking greatly reduce their risk of dying prematurely. Benefits are greater for people who stop at earlier ages, but cessation is beneficial at all ages.

RELATED HEALTH CONDITIONS

Emphysema: Emphysema is a chronic (long lasting) condition in which the walls between the alveoli (air sacs) within the lung lose their ability to stretch and recoil, causing shortness of breath.

Under normal conditions, air enters the nose or mouth and travels down the air tube (trachea) to the main air passages (bronchial tube). These passages allow air to go into the right and left lungs. Each bronchial tube branches into smaller passages (bronchioles) and eventually into tiny air sacs (alveoli). It is through the alveoli that oxygen enters the bloodstream when a person inhales; carbon dioxide is expelled upon exhaling.

In smoking, the air sacs become weakened and can break apart. Elasticity of the lung tissue is lost, causing air to be trapped in the air sacs and decreasing the amount of oxygen that is available for the body and also decreasing the amount of carbon dioxide (CO2) expelled from the lungs. Also, it is easier for the airways to be blocked, because normal respiratory function is lost.

Over 3.1 million Americans have emphysema, of which 91% are 45 years of age or older.

Emphysema damage is irreversible and in an individual who continues smoking with emphysema, the prognosis is most certainly death. Lung transplants or lung volume reduction surgeries can be performed with limited success. These are major invasive surgeries with many complications.

Chronic obstructive pulmonary disease (COPD) or chronic obstructive lung disease: Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease, is a general term for diseases that damage the lungs and includes emphysema and bronchitis (inflammation of the lungs). Smoking is the most common cause of COPD. In COPD, the airways and air sacs lose their elasticity (like an old rubber band) and the walls between many of the air sacs are destroyed. The walls of the airways become thick and inflamed (swollen), causing excess mucus to be produced that tends to clog the airways. COPD develops slowly, and it may be many years before a person notices symptoms such as feeling short of breath. Most of the time, COPD is diagnosed in middle-aged or older people. It is estimated that more than 16 million Americans have some form of COPD. COPD is the fourth leading cause of death in the United States, claiming the lives of more than 120,000 Americans.

RISK FACTORS

Emphysema: The single greatest risk factor for emphysema is smoking. Emphysema is most likely to develop in cigarette smokers, but cigar and pipe smokers and marijuana smokers also are susceptible, and the risk for all types of smokers increases with the number of years and amount smoked. Men are affected more often than women are, but this statistic is changing as more women take up smoking.

Connective tissue disorders: Some conditions that affect connective tissue (provides body framework and support) are associated with emphysema. These conditions include cutis laxa (a rare disease that causes premature aging) and Marfan syndrome (a disorder that affects many different organs, especially the heart, eyes, skeleton, and lungs).

Other disorders: Smoking can lead to chronic obstructive pulmonary disease (COPD, including emphysema and bronchitis), cancer of the lungs, kidney, pancreas, stomach, cervix, bladder, esophagus, mouth, and throat, bladder control problems, migraine headaches, allergies, acid reflux, cataracts, pneumonia, acute myeloid leukemia, abdominal aortic aneurysm, stomach cancer, pancreatic cancer, cervical cancer, kidney cancer, and periodontitis (gum disease). Smoking is also reported to produce long-lasting changes in the brains of smokers and former smokers alike, a new study suggests.

Smoking leads to wrinkles, bad breath, stained teeth, a bad smell on clothes, skin and hair, lower athletic ability, persistent cough and sore throat, faster heartbeat and raised blood pressure, and producing second-hand smoke for others.

Age: Although the lung damage that occurs during smoking develops gradually, most people with tobacco-related problems begin to experience symptoms between the ages of 50-60.

Exposure to secondhand smoke: Secondhand smoke, also known as passive or environmental tobacco smoke, is smoke that is inadvertently inhaled from someone else's cigarette, pipe, or cigar.

Pollution and chemical exposure: An individual breathing fumes from certain chemicals such as chlorine or pesticides, dust from grain, cotton, wood, or working around toxic fumes, is more likely to develop emphysema. The risk is even greater if the person smokes. Breathing indoor pollutants such as fumes from heating fuel as well as outdoor pollutants such as car exhaust increases the risk of emphysema.

Heredity: A rare, inherited deficiency of the protein alpha-1-antitrypsin (AAt) can cause emphysema, especially before age 50, and even earlier if the individual smokes.

COMPLICATIONS

Shortness of breath: Shortness of breath (also known as dyspnea), especially during activity, is one of the earliest symptoms of emphysema and is common in smokers. As emphysema progresses, shortness of breath becomes constant, even during rest.

Fatigue: Shortness of breath causes a reduced capacity for physical activity, becoming worse as the disease progresses. An individual who smokes is likely to feel tired both because it is more difficult to breathe and because the body is getting less oxygen.

Lowered immunity: In addition, individuals who smoke may suffer from frequent colds accompanied by coughing. They may also catch the "flu" more often than non-smokers.

Disease complications: Smoking is a major factor in coronary heart disease (lack of blood and oxygen to the heart) and stroke (lack of blood and oxygen to the brain). Smoking leads to atherosclerosis (fatty buildups in arteries), thrombosis (blood clots), coronary artery spasm and cardiac arrhythmia (heart rhythm problems).

Smoking during pregnancy can have adverse effects on the unborn child, such as premature delivery and low birth weight.

Withdrawal complications: The common symptoms of nicotine withdrawal include an intense craving for nicotine, tension, irritability, headaches, difficulty in concentrating, drowsiness, trouble sleeping, increased appetite, and weight gain. A milder form of nicotine withdrawal involving some or all of these symptoms can occur when a smoker switches from regular to low-nicotine cigarettes or significantly cuts down. These symptoms often start just a few hours after the last cigarette. The first 72 hours of quitting are the hardest, but symptoms may persist for weeks. Smokers have learned that a cigarette will relieve these symptoms in a few moments. But taking nicotine in another form, such as a patch or gum, can suppress withdrawal.

BENEFITS OF SMOKING CESSATION

The health benefits of smoking cessation (quitting) are substantial. An individual's blood circulation begins to improve and the level of carbon monoxide in the blood begins to decline. Carbon monoxide (CO), a colorless, odorless gas found in cigarette smoke, reduces the blood's ability to carry oxygen. An individual's heart rate and blood pressure, which may be abnormally high while smoking, begins to return to normal. Within a few days of quitting, the individual's sense of taste and smell return, and breathing becomes increasingly easier.

Smoking cessation lowers the risk for lung and other types of cancer, including those of the bladder, throat, stomach, pancreas, and mouth. The risk for developing cancer continues to decline with the number of years smoking has been stopped.

Risk for coronary heart disease, stroke, heart attack, and peripheral vascular disease is reduced within one to two years of cessation.

Cessation reduces respiratory symptoms, such as coughing, wheezing, and shortness of breath. The rate of decline in lung function is slower among persons who quit smoking than those who smoke.

Women who stop smoking before or during pregnancy reduce their risk for adverse reproductive outcomes such as infertility or having a low-birth-weight baby.

Additional, immediate benefits (such as improved circulation and increased energy and breathing capacity) are other good reasons for older adults to quit smoking.

TREATMENT

Quitting smoking has immediate as well as long-term benefits, reducing risks for lung and heart diseases caused by smoking and improving health in general.

Self treatment:

Abrupt cessation of all nicotine use as opposed to tapering or gradual stepped-down nicotine weaning (called "cold turkey") is the quitting method used by 80-90% of all successful long-term quitters.

Commitment: Once a smoker has committed to stopping, it must be followed through. Healthcare professionals recommend setting a quit date, changing environments that are associated with smoking (such as being in a bar or nightclub and around others that smoke), and getting rid of all tobacco products in the home, car, and workplace. Not letting others smoke in the home where an individual is stopping is also important. Washing the clothes that smell of smoke of someone who is going to stop smoking can help decrease the desire to smoke. Also, the individual's friends and family should be told so they can help support the commitment to smoking cessation.

Support and counseling: Individuals tell family, friends, and co-workers of the choice to stop smoking for support. Talking to a healthcare provider (such as doctor, dentist, nurse, pharmacist, psychologist, or smoking cessation coach or counselor) can help.

Person to person contact with a counselor can help some individuals in smoking cessation. Individual, group, or telephone counseling are all effective. Counseling increases the chances of success.

The more help one has, the better the chances are of quitting. Free programs are available at local hospitals and health centers. Individuals using structured treatment programs offered by hospitals or other caregivers my dramatically increase the success of smoking cessation.

Telephone counseling is available at 1-800-QUIT-NOW. The website that hosts this number also now has a chat feature so that the individual trying to stop smoking can discuss the process and find support with others struggling with the addiction. The website is: http://www.smokefree.gov.

New behaviors: Individuals smoke due to emotional reasons such as anxiety and stress. Decreasing stress can help the individual to stop smoking. Reducing stress by taking a hot bath, exercising, listening to music or reading a book can help. There are several integrative therapies that have been reported to be effective in helping support smoking cessation, including guided imagery, hypnotherapy, and yoga. Distraction also helps turn the individual's attention from smoking to another task. Talking to someone, going for a walk, or working on a hobby can help distract the attention from smoking.

Drug therapies:

Several pharmacological or drug therapies exist to help the individual stop smoking. Nicotine replacement therapy (NRT) and medications for decreasing the side effects of nicotine withdrawal, such as chemical imbalances in the brain and labored (difficulty) breathing, are available.

Nicotine replacement therapy (NRT): Nicotine is the chemical in cigarettes and other forms of tobacco that causes addiction. Nicotine replacement therapies deliver small, steady doses (amounts) of nicotine into the body that help to relieve the withdrawal symptoms often felt by people trying to quit smoking, such as depression, cravings, nervousness, and irritability. These products, which are available in four forms (patches, gum, nasal spray, and inhaler), appear to be equally effective in smoking cessation. The consistent use of one of these products doubles an individual's chances of quitting smoking.

Nicotine patch: A nicotine patch looks like an oversized adhesive bandage (band-aid). The outer part of the patch sticks to the skin, while the inner portion presses against and slowly releases nicotine into the skin. Nicotine patches are usually sold in "boxes" or kits that contain enough patches to get most people through the quitting process. Brands come with different-sized patches containing different strengths of nicotine. An individual may use patches containing more nicotine for the first few weeks, then step down to patches that contain less nicotine for the remaining weeks. With other brands, the individual should simply stop using the patch. There is no evidence that slowly decreasing the use of the patch (tapering off) is more effective than abruptly stopping use. Choosing the right patch strength is important in the success in quitting smoking. Nicotine patches are available without a prescription.

Use of nicotine patches usually lasts eight to ten weeks, but this can vary with the individual and the brand of patch. There appears to be little benefit in using the patch for more than eight weeks.

Applying the nicotine patch: The patch is used on a clean, dry, non-hairy area of skin on the upper body or the outer part of the arm. Skin that is very oily, burned, broken out, cut or irritated in any way may cause the patch not to stick. Men with excess hair can apply the patches on the underside of the arms or clip excess hair from the back or chest. The patch may stay in place if it is placed over joints, such as the shoulder. Most individuals prefer the patch placed on an area that is not visible to others. The patch should not be removed from the sealed, protective pouch until it is ready to be used. There are instructions in the package regarding opening, such as where to cut the package so as not to cut the patch. After opening the package, the patch is immediately applied to the skin, pressing firmly against the skin with the palm of the hand for about 10 seconds.

Nicotine patches are available in forms that supply a constant dose of nicotine for either 16 or 24 hours (depending on how long the patch is worn). There is no evidence that wearing the patch 24 hours is more effective than the 16 hours. Leaving a patch on for 24 hours may cause sleep disturbance, such as difficulty sleeping or vivid dreams. Removing the patch in the evening around 8 p.m. may stop sleep problems.

Healthcare professions recommend rotating the site of patch application. Apply the patch on a different place on the skin daily. The nicotine patch may not be a good choice for individuals with skin problems or allergies to adhesive tape. It should not be worn for more than 24 hours because it may irritate the skin.

A box or kit of patches (usually 14) may cost between $30 and $50 U.S. dollars, depending on the product chosen. A healthcare professional can help a patient decide which kit is right for the individual. Some health insurance policies may pay for smoking cessation programs prescribed by a licensed healthcare professional.

Nicotine gum: Chewing nicotine gum releases nicotine into the bloodstream through the lining of the mouth. Nicotine gum (Nicorette©) is available over the counter in 2 milligram and 4 milligram strengths. Nicorette© 2 milligram gum is for those who smoke fewer than 25 cigarettes daily, and Nicorette© 4 milligram gum is for those who smoke 25 or more cigarettes daily. Nicotine gum might not be appropriate for people with temporomandibular joint disease (TMJ, or popping of the jaw) or for those with dentures or other dental work such as bridges. Side effects of the gum include a bad taste in the mouth, a tingling feeling on the tongue while chewing the gum, hiccups, upset stomach (nausea) or heartburn. Nicotine gum is generally used for 12 weeks.

Nicotine nasal spray: Nicotine nasal spray was approved by the U.S. Food and Drug Administration (FDA) in 1996 for use by prescription only. The spray comes in a pump bottle containing nicotine that tobacco users can inhale when they have an urge to smoke. One or two sprays into each nostril every hour may be used. The dose is then adjusted based on the number of cigarettes smoked each day before beginning treatment, and on the side effects the nasal spray may cause, including nervousness, insomnia, or shortness of breath. This product is not generally used in people with nasal or sinus conditions, allergies, asthma, or in young tobacco users. This product is used for no more than three months.

Nicotine lozenge: Commit© lozenge is an over the counter (OTC) nicotine lozenge meant to help individuals stop smoking. Nicotine lozenge comes in the form of a hard candy, and releases nicotine as it slowly dissolves in the mouth. Eventually, the quitter will use fewer and fewer lozenges during the 12 week program until he or she is completely nicotine-free.

Nicotine lozenge is available in two or four milligram doses. There is no eating or drinking within 15 minutes before using or while the lozenge is in the mouth. Each lozenge will last about 20-30 minutes and nicotine will continue to leach through the lining of the mouth for a short time after the lozenge has disappeared. No more than five lozenges in six hours, or more than 20 lozenges total per day are used. One lozenge after another is not used, since this may cause hiccups, heartburn, nausea, or nervousness. Biting or chewing the lozenge will cause more nicotine to be swallowed quickly and may result in indigestion and/or heartburn.

The most common side effects of lozenge use are soreness of the teeth and gums, indigestion, and throat irritation.

Nicotine inhaler: A nicotine inhaler, also available only by prescription, was approved by the FDA in 1997. This device delivers a vaporized form of nicotine to the mouth through a mouthpiece attached to a plastic cartridge. Even though it is called an inhaler, the device does not deliver nicotine to the lungs the way a cigarette does. Most of the nicotine only travels to the mouth and throat, where it is absorbed through the mucous membranes. Common side effects include throat and mouth irritation and coughing. Anyone with a bronchial condition such as asthma or bronchitis (inflammation of the bronchial tubes) should use the inhaler with caution. Each Nicotrol© inhaler package includes a mouthpiece and 42 cartridges of nicotine. Treatment takes place in two stages. Each cartridge is puffed on frequently for about 20 minutes, and then discarded. During the first stage (up to 12 weeks), as many Nicotrol© cartridges as needed are used (no more than 16 daily) to quell the craving for cigarettes. During the second stage (6-12 weeks), there is a gradual reduction in the daily use of the inhaler until the individual is nicotine-free. Side effects may include acid indigestion, allergies, coughing, gas, headache, hiccups, jaw and neck pain, mouth and throat irritation, nasal inflammation, nausea, sinus inflammation, taste disturbances, and a tingling skin sensation. If any develop or change in intensity, inform a doctor as soon as possible.

Combinations: There is evidence that combining the nicotine patch with nicotine gum or nicotine nasal spray increases long-term quit rates compared with using a single type of nicotine replacement therapy. Nicotine gum, in combination with nicotine patch therapy, may also reduce withdrawal symptoms better than either medication alone. A doctor or pharmacist can provide more information.

NRT and pregnancy: While the use of nicotine replacement therapy (NRT) during pregnancy is not risk-free, it is much less dangerous to the individual and their baby than smoking. If an individual is pregnant or planning to become pregnant and wanting to stop smoking, healthcare professionals are available for counseling.

NRT and heart disease: NRT has been reported to be safe in most people with heart disease. However, if the individual has recently had heart problems, such as an irregular or rapid heartbeat, or chest pain (angina), a healthcare professional such as a doctor or pharmacist is available for advice on smoking cessation alternatives.

Tobacco products, including cigarettes, cigars, or smokeless, are not used along with nicotine replacement therapy due to an increase in side effects, such as nervousness, stomach upset, nausea, heart palpitations, and chest pain.

Chantix©: There are receptors for nicotine in the brain. When smoke is inhaled, nicotine attaches to these receptors. This sends a message to a different part of the brain to release a chemical called dopamine. Dopamine gives a feeling of pleasure. But it only lasts for a short time. The body wants to repeat this feeling. Based on research, it is believed that Chantix© works by activating these receptors and blocking nicotine from attaching to them. However, Chantix© does not contain nicotine. Chantix© (varenicline) is approved for smoking cessation by the U.S. Food and Drug Administration (FDA) a 12 weeks treatment course. Usually, Chantix© is started one week before the planned quit date. The individuals who successfully quit smoking during Chantix© treatment may continue with an additional 12 weeks of Chantix© treatment to further increase the likelihood of long-term smoking cessation. Side effects of Chantix© include changes in taste, nausea, vomiting, gas, and insomnia (inability to sleep).

Zyban©: Zyban© (bupropion) is an antidepressant that is approved by the FDA for smoking cessation. It does not contain nicotine, unlike the nicotine replacement therapies. Zyban© helps reduce the side effects associated with nicotine withdrawal, including irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, and depressed mood. Zyban© is not used in those individuals with seizure disorders, or individuals taking other antidepressant medications such as Wellbutrin© (bupropion). The normal dosage for smoking cessation is 150 milligrams, two times daily. Side effects include insomnia (trouble sleeping), nervousness, and dry mouth.

Other drugs: If an individual has a complication from smoking, such as shortness of breath, bronchitis (inflammation of the bronchial tubes), or a lung infection, other medications may be used. Drugs that open airways include albuterol (Ventolin©, Proventil©), metaproterenol (Alupent©), terbutaline (Brethine©), theophylline (Theo-Dur© or Slo-bid©), and perbuterol (Maxair©). Corticosteroids (steroids) may also help with decreasing inflammation, including the inhaled beclomethasone (Beclovent© and Vanceril©), budesonide (Pulmicort Respules©), flunisolide (Aerobid©), fluticasone (Flovent©), and triamcinolone (Azmacort©). Oral steroids can be used including prednisone (Decadron©) or methyprednisolone (Medrol©). Oral and inhaled steroids can cause side effects including many drug interactions and severe swelling (edema), which can lead to dangerously high blood pressure.

Supportive measures, such as oxygen, antibiotics, vaccines for influenza, and surgery, may also be used for smokers who have developed a chronic (long term) lung disease such as emphysema.

INTEGRATIVE THERAPIES

Unclear or conflicting scientific evidence:

Acupressure: The practice of applying finger pressure to specific acupoints throughout the body has been used in China since 2000 BC, prior to the use of acupuncture. Acupressure techniques are widely practiced internationally for relaxation, wellness promotion, and the treatment of various health conditions. Shiatsu means finger (Shi) pressure (Atsu) in Japanese. Shiatsu can incorporate palm pressure, stretching, massaging and other manual techniques. Early study indicates that auricular acupressure (pressure to points on the ear) may help with smoking cessation. Also, preliminary evidence suggests that acupressure may be a helpful adjunct therapy to assist with the prevention of relapse, withdrawal, or dependence.

Astragalus: Astragalus (Astragalus membranaceus) is commonly used in traditional Chinese medicine (TCM). Limited available study has reported positive benefits in smoking cessation. However, more human studies are needed.

Avoid if allergic to astragalus, peas, or any related plants or with a history of Quillaja bark-induced asthma. Avoid with aspirin or aspirin products or herbs or supplements with similar effects. Avoid with inflammation (swelling) or fever, stroke, transplants, or autoimmune diseases (like HIV/AIDS). Stop use two weeks before surgery/dental/diagnostic procedures with a risk of bleeding and avoid use immediately after these procedures. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders, or kidney disorders. Use cautiously with blood-thinners, blood sugar drugs, or diuretics or herbs and supplements with similar effects. Avoid if pregnant or breastfeeding.

Black pepper: Sensory cues associated with cigarette smoking can suppress certain smoking withdrawal symptoms, including the craving for cigarettes. Inhalation of black pepper essential oil may reduce cravings and physical symptoms associated with cigarette smoking cessation.

Avoid if allergic or hypersensitive to black pepper (Piper nigrum), its constituents, or members of the Piperaceae family. Use cautiously if taking anti-asthmatic drugs, cholinergic agonists, cyclosporine A or digoxin, cytochrome P450 metabolized agents, oral herbs or drugs, phenytoin, propranolol, rifamipicin (rifampin), or theophylline. Use cautiously with gastrointestinal disorders. Avoid if pregnant or breastfeeding.

Eucalyptus oil: Nicobrevin is a proprietary product marketed as an aid for smoking cessation that contains quinine, menthyl valerate, camphor, and eucalyptus oil. Despite use of this product, there is currently a lack of evidence suggesting benefit for smoking cessation.

Avoid if allergic to eucalyptus oil or with a history of seizure, diabetes, asthma, heart disease, abnormal heart rhythms, intestinal disorders, liver disease, kidney disease, or lung disease. Use caution if driving or operating machinery. Avoid with a history of acute intermittent porphyria. Avoid if pregnant or breastfeeding. A strain of bacteria found on eucalyptus may cause infection. Toxicity has been reported with oral and inhaled use.

Guided imagery: In contemporary times, the term "guided imagery" may be used to refer to a number of techniques, including metaphor, story telling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, or direct suggestion using imagery. Therapeutic guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Based on early study, guided imagery in addition to education and counseling sessions may be helpful for long-term smoking cessation and abstinence in adult smokers. Further study is needed to confirm these results.

Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified healthcare provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety, or emotional upset because imagery may trigger these symptoms. If feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse, speak with a qualified healthcare provider before practicing guided imagery.

Meditation: Available evidence does not indicate whether meditation can help with smoking cessation. More studies are needed.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.

Melatonin: Melatonin is a hormone produced in the brain and is involved in the sleep wake cycle during light and darkness. Levels of melatonin in the blood are highest prior to bedtime. A small amount of research has examined the use of melatonin to reduce symptoms associated with smoking cessation, such as anxiousness, restlessness, irritability, and cigarette craving. Although preliminary results are promising, due to weaknesses in the design and reporting of this research, further study is necessary before a firm conclusion can be reached.

Melatonin is not to be used for extended periods of time. Melatonin can cause drug interactions, and healthcare professionals recommend not using in pregnancy or breastfeeding.

Prayer: Traditional forms of prayer in the treatment of addiction and smoking cessation are widely used. However, initial research does not report effects of prayer on smoking dependency.

Prayer is not recommended as the sole treatment approach for potentially serious medical conditions and should not delay the time it takes to consult with a healthcare professional or receive established therapies.

Psychotherapy: Several studies suggest that group therapy may be more effective than self-help for smoking cessation. However, there is not enough evidence to show that group therapy is as effective or cost-effective as intensive individual counseling. More research is needed to determine effectiveness.

Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire about the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.

Relaxation therapy: Early research reports that relaxation with imagery may reduce relapse rates in people who successfully completed smoking cessation programs. Better study is needed in this area before a firm conclusion can be reached.

Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.

Fair negative scientific evidence:

Acupuncture: Numerous studies of acupuncture for smoking cessation have been conducted, and the quality of studies has varied widely. There may, however, be some benefit in reducing side effects of withdrawal such as irritation, cigarette craving, and headache. Additional research is needed.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers because therapy may interfere with the device.

Hypnotherapy: Hypnotherapy involves suggestion by therapists during periods of deep relaxation. Although used for smoking cessation with some positive results, there is currently a lack of scientific evidence for hypnotherapy as a valid treatment for this indication.

Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.

Traditional or theoretical uses lacking sufficient evidence:

Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Preliminary research suggests that yoga may be beneficial when added to standard therapies for the treatment of drug abuse, including smoking cessation. Additional studies are needed.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

RELAPSE PREVENTION

Relapse: A relapse in smoking cessation is the return to smoking. Most relapses occur within the first three months after quitting. An individual should not be discouraged if they start smoking again, as most people try several times before they finally quit.

Triggers: Triggers include people the smoker hangs around with, places they smoke, or events that may relate thoughts to smoking, such as eating, riding in a car, or watching television. Drinking alcohol may trigger some individuals, especially if they are considered "social smokers."

Distractions: Using other items, such as toothpicks, straws, sunflower seeds (unsalted), apples, celery, raisins, or sugar free gum, to occupy the individual instead of cigarettes and tobacco when the urge to smoke arises is a useful tool. Completing a task can help distract from the thoughts of needing tobacco, such as washing the dishes, yard work, playing with the kids, or taking a shower.

Regular exercise: Regular exercise can help decrease the urge to smoke. Healthcare professionals recommend at least 30 minutes of exercise, such as a brisk walk, at least five days a week.

AUTHOR INFORMATION

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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