European Respiratory Society
Smoking Cessation

This book offers a comprehensive review of the different aspects of smoking and smoking cessation in context with today's society. The following topics are discussed: epidemiology, tobacco/nicotine addiction, characteristics of patients who smoke, psychological and behavioural interventions, pharmacological treatment, organisational anchorage and education of the patient and clinician alike, as well as the current economics of smoking cessation.

  • European Respiratory Society Monographs
  1. Page vii
  2. Page ix
  3. Page 1
    Correspondence: G. Viegi, National Research Council Institute of Biomedicine and Molecular Immunology, Via U. La Malfa, 153, 90146 Palermo39 0916809122, Italy. E-mail:

    The ERS has contributed greatly to the dissemination of the awareness of the health risks of smoking, the need and possibility of doctors helping smokers to quit, and the need for a smoke-free Europe.

    Working Group 06.03 (Tobacco, Smoking Control & Health Education), devoted to the scientific coverage of smoking cessation and control, has been increasing in membership and scientific quantity and quality in recent years. The ad hoc committee created by the ERS Executive Committee (the Tobacco Control Committee) is involved in advocacy. The ERS directly managed a multicentric randomised study (CEASE), performed in 17 European countries, which permitted an important step to be taken towards the promotion of research and implementation of smoking cessation programmes in clinical practice. Working Group 06.03, along with the Tobacco Control Committee, organised an ERS Research Seminar on Tobacco Control: Harm Reduction Strategies in 2005; this is a controversial issue, important from a public health perspective. The ERS co-organised a Smoke-free Europe conference in Luxembourg during the meeting of the European Health Council.

    Relevant publications have been edited by the ERS: 1) the European Lung White Book. The First Comprehensive Survey on Respiratory Health in Europe (in collaboration with the ELF); 2) the report Tobacco or Health in the European Union. Past, Present and Future (in collaboration with the European Commission); 3) Lifting the Smokescreen, a report on passive smoking, presented to the European Parliament by the Smoke Free Partnership (ERS and other allies); 4) the updated recommendations on smoking cessation to be applied in pulmonary units in Europe (produced in collaboration with the Society for Research on Nicotine and Tobacco); and 5) the present issue of the European Respiratory Monograph on smoking cessation.

    Such ERS activity can help pulmonary doctors to implement smoking cessation programmes, one of the most cost-effective public health activities.

  4. Page 8
    Correspondence: P. Bartsch, University of Liège, CHU Dept of Pneumology, Bd de l’Hôpital, Bat. B35, Sart Tilman, 4000 Liège 132 43668846, Belgium. E-mail:

    The history of the evolving opinion of physicians regarding tobacco is briefly reviewed here.

    The position of chest physicians has been influenced more by the progressive expansion of specialised medicine than by a specific gift of chest physicians. Nevertheless, their professional associations, which dealt with a large public health challenge, namely tuberculosis, were prepared to be rapidly sensitised by the new challenge, again concerning mainly the lungs, represented by the tobacco smoking epidemics.

    The ERS itself urges chest physicians to be part of challenging the disease represented by nicotine dependence, by means of both a training including expertise in smoking cessation and being in close relationship with behaviour specialists if they do not want to improve their skills in that specific area.

    As regards what happens in schools, it is quite difficult to identify the chest physicians among the promoters of health education scenarios concerning smoking, but it can be stated that the Belgian Society of Pneumology officially encourages its members to use a slide kit developed by a chest physician in the schools in the vicinity of their practices.

    If what is happening in hospitals regarding smoking cessation during or before hospital stay is considered, it is clear that lung or heart and lung departments are most active in this field. Again chest physicians can be identified among the promoters in their own country, but most of these activities are not published or appear only in the grey literature.

  5. Page 23
    Correspondence: C. Lazzaro, Health economics office, Via Stefanardo da Vimercate, 19, I-20128 Milan39 226000516, Italy. E-mail:

    The economic burden of smoking-related diseases, such as cardiovascular disease, chronic obstructive pulmonary disease, stroke and lung cancer, borne by healthcare systems and society as a whole is relevant.

    Even when effective healthcare programmes aimed at the early detection of lung cancer in long-term heavy smokers are not cost effective compared to not screening, since the cost per quality-adjusted life year gained may reach >2,300,000 US dollars (USD), well over the threshold of USD50,000 reported in the literature. This poor result can be explained by the consideration that costs and consequences related to not screening become evident in the future and should be valued less highly than those accruing at the time of screening.

    All interventions aimed at stopping smoking are highly cost-effective compared to other healthcare programmes. In the UK, the cost per year of life saved following smoking cessation interventions ranged from 354 Euros (EUR; general practitioner's brief advice to stop smoking) to EUR1,458 (general practitioner's advice plus self-help plus advice to purchase nicotine replacement therapy with specialist services) when inflated to 1998 prices.

    However, a favourable incremental cost-effectiveness ratio is probably not the only relevant criterion to be considered whenever policies and strategies targeted at smoking cessation have to be implemented. Information on the clusters of the population that seem to have major problems with cigarette consumption compared to the rest of society (worse-off people, low-schooling persons and manual workers) should be taken into account, since they are usually poorly compliant with smoking cessation therapies. Enrolling such patients into ad hoc smoking cessation programmes may initially increase the cost per year of life (or per quality-adjusted life year) saved by these interventions, but will probably reduce the global prevalence of smokers in the future to a greater extent.

  6. Page 35
    Correspondence: C. Gratziou, Smoking Cessation Clinic, Pulmonary and Critical Care Dept, Evgenidio Hospital, Medical School, Athens University, 20 Papadiamantopoulou Street, 11528 Athens, Greece00 30 2107272785. E-mail:

    Healthcare providers should deliver state-of-the-art assistance to their smoking patients in order to help them to quit.

    Given that the health benefits of stopping smoking are enormous, and that significant morbidity, mortality and economic effects are attributed to smoking, a number of smoking cessation guidelines have been published, in recent years, that provide recommendations for interventions and strategies for promoting the treatment of tobacco dependence.

    These reviews and guidelines draw on hundreds of well-controlled trials, and emphasise not only that treatment for tobacco dependence is effective but also that it is extremely cost-effective.

    The various guidelines consistently recommend that physicians first identify smokers, then motivate them to make an attempt at stopping smoking and support them in quitting successfully through counselling, pharmacotherapy and follow-up.

    The following key points can be made regarding medication treatment in smoking cessation.

    1) Smokers attempting to quit should be encouraged to use medication to aid cessation, except in the presence of contraindications (evidence level A).

    2) NRT, bupropion SR and varenicline are first-line treatments for smoking cessation (evidence level A).

    3) Various NRTs (gum, patch, inhaler, nasal spray, lozenge and sublingual tablets) are equally effective as smoking cessation treatments (evidence level A).

    4) Combining the nicotine patch with a self-administered form of NRT can be more effective than a single form of NRT (evidence level B). 5) Combined treatment with bupropion SR and NRT might be more effective in heavy smokers (evidence level C), combined treatment with varenicline (no evidence).

    6) Both NRT and bupropion SR are effective and well tolerated in smokers with stable cardiovascular disease and in COPD patients (evidence level A). Varenicline might have an additional therapeutic effect as a smoking cessation treatment in these groups (evidence level B).

    7) Nortriptyline may be used as a second-line medication to treat tobacco dependence (evidence level B).

    8) Regular follow-up visits are important and are linked with a longer-term successful outcome (evidence level B).

  7. Page 44
    Correspondence: K.O. Fagerström, Smoker’s Information Centre, Berga Alle 1, 25452 Helsingborg46 42165760, Sweden. E-mail:

    Certain assessments of the smoker can be important to make in order to better diagnose and understand the smoker’s dependence and what sort of help might best fit the smoking patient. For that purpose, it is important to understand what motivation the patient has for changing the smoking behaviour, their degree of dependence upon tobacco and any possible comorbid condition that interacts with smoking cessation. The instantaneous measurement of carbon monoxide in exhaled air is another assessment that can be very helpful for increasing motivation and checking progress.

  8. Page 51
  9. Page 57
    Correspondence: K.O. Fagerström, Smoker’s Information Centre, Berga Alle 1, 25452 Helsingborg46 42165760, Sweden. E-mail:

    Physicians are normally constrained for time and may need to be very effective in their communication with patients. This often results in directive one-way communication. Such a communication style does not work so well when the objective is behaviour change, especially not with a drug addiction that the patient may like and identify with. One of the goals of motivational communication is to establish a good rapport. This is more likely to occur if the communication does not take the form of direct orders and the use of guilt and blame is avoided. It is important that the physician be understanding and empathic. It is preferable that the patients do most of the talking and that the physicians steer the conversation into relevant areas, with open questions and reinforcing remarks. This style of communication is often referred to as motivational interviewing. An algorithm showing how a smoker can be managed using this style is included.

  10. Page 61
    Correspondence: C.A. Jiménez-Ruiz, C/Santa Cruz del Marcenado, 9 Piso 2, 28015 Madrid, Spain34 912044972. E-mail:

    Combining behavioural interventions with pharmacological treatment significantly increases smoking cessation success rates. Smokers who want to make a serious attempt at quitting should be encouraged to use both. Self-help programmes, brief advice, counselling, behavioural advice, biomedicinal risk assessments and other complementary interventions can be included as psychological interventions to help smokers to quit.

    Self-help programmes provide no intensive contact between the therapist and the smoker. Their efficacy is low.

    Brief advice provides smokers with brief information to help them quit smoking. This information should be delivered opportunistically during routine consultations with smokers whether or not they are seeking help with stopping smoking. It can be calculated that, following brief advice to 50 patients, there will be one extra quitter after 6–12 months.

    Regarding the manner of providing counselling and the time consumed, there are four types of counselling: individual, group, telephone, and Internet interventions. However, all of these counselling interventions have proved to be efficacious.

    Systematic reviews on the effect of exercise and aversive smoking on smoking cessation suggest that there is insufficient evidence to support these interventions for smoking cessation

    Hypnotherapy, acupuncture, acupressure, laser therapy and electrostimulation could be considered complementary interventions. There is no evidence that these interventions can help smokers to quit.

    A Cochrane meta-analysis did not find evidence that biomedicinal risk assessments increase smoking cessation.

    A behavioural programme to help smokers to quit should be provided during various clinic visits: clinic visit for preparation to quit, clinic visit around quit date, and some follow-up clinic visits. Doctors should consider that the number of visits can influence the success rate: the greater the number of visits the higher the success rate. It is recommended that smokers attend the office weekly during the first month, and then that the number of visits diminish progressively.

  11. Page 74
    Correspondence: C.A. Jiménez-Ruiz, C/Santa Cruz del Marcenado, 9 Piso 2, 28015 Madrid34 912044972, Spain. E-mail:

    The main objective of using pharmacotherapies during the smoking cessation process is to alleviate withdrawal syndrome and thus to facilitate smoking abstinence.

    Three medications are in common use: NRT, for which there are six different products, bupropion and varenicline. Other medications have been proven efficacious for smoking cessation but are used less frequently: nortriptyline, and clonidine. There are some other medications not currently recommended for smoking cessation: some antidepressants, mecamylamine, monoamine oxidase inhibitors, some anxiolytics, naltrexone, lobeline, silver acetate, nicobrevin, and rimonabant. Nicotine vaccine is being studied in several randomised clinical trials and is the most promising new treatment aimed at aiding smokers to quit.

    NRT is the most well-studied and well-documented pharmacological approach to helping smokers to quit. This treatment acts by replacing some of the nicotine smokers would have received from their cigarettes, and, in doing so, reducing the severity of withdrawal syndrome. The last meta-analysis carried out demonstrated that the OR for abstinence with the different types of NRT compared with controls was 1.77 (95% CI 1.66–1.88).

    Bupropion was the first non-nicotine medication to be licensed for smoking cessation. It is presumed that it acts on the nucleus accumbens, inhibiting neuronal reuptake of dopamine. It also inhibits neuronal reuptake of noradrenalin in the nucleus ceruleus. In 31 trials, bupropion was used as the sole pharmacotherapy and was found to double the odds of cessation (OR 1.94; 95% CI 1.72–2.19).

    Varenicline is the first drug specifically developed to aid smokers quitting smoking. It acts as a selective partial agonist for the nicotinic receptor. A meta-analysis that reviewed four clinical trials found that this drug was significantly more effective than placebo for achieving continuous abstinence at the end of 1 yr of follow-up (OR 2.96; 95% CI 2.12–4.12).

  12. Page 98
  13. Page 100
    Correspondence: G. Invernizzi, Tobacco Control Unit, National Cancer Institute/Italian College of General Practitioners, Milan39 034334315, Italy. E-mail:

    It has been demonstrated that ICSs are much less effective in asthmatic smokers. Most smokers are believed to take their asthma medications in the place in which they smoke, and some of them report delivering the inhaled drug just after the last cigarette puff. This behaviour raises the possibility that drug particles might interact with particulate matter present in smokers’ airways due to ETS or residual tobacco smoke (mainstream tobacco smoke polluting the lung after the last puff). The conglomeration of aerosol particles is a well-known physical phenomenon that takes place very quickly and results in an increase in particle diameter. In order to verify such a possibility, the fluticasone dry powder aerodynamic profile was studied in the presence of clean air or ETS; when delivered in the presence of cigarette smoke, a 15% increase in particles sized ≥3.00 μm was observed compared to the aerodynamic profile of the drug in clean air. The results of the survey concerning place and timing of smoking/inhaled drug actuation showed that most smokers smoke at home, and actuate the inhaler in the room in which they have smoked. Moreover, 50% of smokers deliver the drug during the first 20 min after smoking, and 22% within 5 min after the last cigarette. None of the smokers had received suggestions from their doctor regarding smoking/inhaler timing and place. These results indicate that ICSs delivered in the presence of tobacco smoke undergo changes in aerodynamic profile, leading to a possible decrease in the percentage of respirable particles. This phenomenon could be one of the explanations for the steroid resistance demonstrated in asthmatic smokers. Smokers should be advised to actuate their ICSs after a reasonable time from their last cigarette puff, and should take care to avoid drug inhalation in environments polluted by ETS.

  14. Page 106
    Correspondence: P. Tønnesen, Dept of Pulmonary Medicine, Gentofte Hospital, Nlels Andersensvej 65, 2900 Hellerup, Denmark, 45 39777693. E-mail:

    The present review is based on nonrandomised lung cancer CT studies without control groups since such studies are lacking. Overall, the quit rates in the CT studies seem to be in the same range as in the general population, and probably a little higher due to a subset of more motivated smokers enrolled.

    The subset with interim abnormal lung CT scan results seems to receive an enhanced drive to quit smoking due to fear of contracting lung cancer, and are probably also driven by the wish to normalise their lung CT scan. It appears that an abnormal lung CT scan has a greater impact upon quit rates than abnormal spirometric results, probably because the latter are perceived as much less of a hazard and threat to health. In one study, 20% of smokers with three normal annual lung CT scans quit smoking.

    There was no evidence that normal findings on scans might give the smoker the impression that it is safe to continue smoking.

  15. Page 113
    Correspondence: P. Tønnesen, Dept of Pulmonary Medicine, Gentofte Hospital, Nlels Andersensvej 65, 2900 Hellerup, Denmark, 45 39777693. E-mail:

    The present chapter discusses the evidence regarding the efficacy of pre-operative smoking cessation as regards quit rates, post-operative complications and smoking habits in lung cancer patients in relation to diagnosis and radiotherapy and chemotherapy. Surprisingly few controlled studies have been published in this area, and several of the studies are underpowered and contain various methodological problems. Despite these flaws, there is evidence that adequate pre-operative smoking cessation increases quit rates peri-operatively and post-operatively, with up to 60% abstinence 3–6 months following surgery.

    Smoking abstinence 6–8 weeks before surgery seems to reduce post-operative complications by up to 50%. Up to 80% of patients with lung cancer quit during the time of diagnosis, but more than half subsequently relapse. As lung cancer patients might be more nicotine-dependent and have more difficulty in stopping smoking, a more aggressive therapeutic approach should be used, i.e. higher doses of nicotine replacement therapy (NRT), combination of two NRT formulations, varenicline, sustained-release bupropion plus NRT, longer duration of therapy (6–12 months) and more support visits. Lower complication rates are reported in abstinent patients following radiotherapy and chemotherapy.