However, acutely the amount of CO in tobacco smoke is too small to lead to hypoxia and the body produces increased numbers of red blood cells to compensate. The nicotine in tobacco smoke may cause a small part of the increase in cardiovascular disease but none or almost none of the increase in risk of respiratory disease or cancer Benowitz, , It is the other components of cigarette smoke that do almost all the damage.
It has been proposed on the basis of studies with other species that nicotine damages the adolescent brain but there is no evidence for clinically significant deficits in cognition or emotion in adults who smoked during adolescence and then stopped US Department of Health and Human Services, Exposure to second-hand smoke carries a significant risk for both children and adults.
Thus, non-smokers who are exposed to a smoky environment have an increased risk of cancer, heart disease and respiratory disease Action on Smoking and Health, a.
Stopping smoking has different effects on different smoking-related diseases. Smokers who stop show reduced levels of stress and mood disorder than those who continue Royal College of Physicians and Royal College of Psychiatrists, This suggests that smoking may harm mental health, though other explanations cannot be ruled out on the current evidence.
Cigarette smoking prevalence in Great Britain was estimated to be Smoking in Great Britain has declined by 0. In Australia, daily cigarette smoking has declined by 0. However, international comparisons are confused by different countries using a different definition of what counts as being a smoker, and different methods for assessing prevalence. Australia only counts daily smokers in their headline figures. The situation in the US is even more misleading. Most noteworthy is that smoking prevalence in men is more than four times that in women globally but that the difference is much less in most parts of Europe, and that Eastern Europe as a whole has the highest smoking prevalence of any region in the world.
Note: Current smoking of any tobacco product, adults aged 15 years and older, age-standardised rate, by gender. From Gowing et al. Average daily cigarette consumption among smokers in the US and UK has declined steadily since the s. Smokers take in an average of 1—1. The reduction in daily cigarette consumption has not been accompanied by a reduction in daily nicotine intake Jarvis et al.
This could be due to the use of other smoked tobacco products in the case of the US or smokers smoking their cigarettes more intensively taking more, deeper or longer puffs. Men and people in more deprived socio-economic groups are more likely to smoke hand-rolled cigarettes Action on Smoking and Health, c. In the UK, average daily cigarette consumption is higher for men than women, and higher in smokers in more deprived socio-economic groups and those with mental health problems Action on Smoking and Health, c.
The natural history of smoking can be modelled as states and factors that influence the transition between these. Factors associated with transitions in the natural history of smoking parentheses indicate negative associations. Important factors predicting initiation in western societies are: having friends who smoke, having parents who smoke, low social grade, tendency to mental health problems and impulsivity Action on Smoking and Health, b.
Important factors predicting transition to regular smoking are: having friends who smoke, weak academic orientation, low parental support, pro-smoking attitudes, drinking alcohol and low socio-economic status Action on Smoking and Health, b. This means that differences in genetic make-up account for almost half of the difference in likelihood of starting smoking between individuals.
This does not mean that environmental factors do not also play a crucial role as is evident from the very large decline in smoking initiation since the s in many western countries. Cigarette addiction here refers to the extent to which someone experiences a strong need to smoke.
Heritability of cigarette addiction, as indexed by failure of attempts to stop, is higher than the heritability for smoking and for initiation of smoking.
This suggests that differences in genetic inheritance play a larger role in being able to stop smoking than in starting to smoke.
Nicotine provided more slowly, for example by the nicotine transdermal patch, is much less addictive. It is possible that one or more mono-amine oxidase inhibitors in cigarette smoke add to, or synergise, the addictive properties of nicotine Hogg, The psychopharmacology of cigarette addiction is complex and far from fully understood. The following paragraphs summarise the current narrative. Nicotine resembles the naturally occurring neurotransmitter, acetylcholine, sufficiently to attach itself to a subset of neuronal receptors for this neurotransmitter in the brain.
When it does this with receptors in the ventral tegmental area in the midbrain, it causes an increased rate of firing of the nerves projecting forward from that area to another part of the brain called the nucleus accumbens.
This causes release of another neurotransmitter called dopamine in the nucleus accumbens. Dopamine release and uptake by neurones in the nucleus accumbens is believed to be central to all addictive behaviours. In the case of smoking, this creates an urge to smoke in situations in which smoking frequently occurs. This explains why even non-daily smokers often find it difficult to stop smoking altogether. Repeated ingestion of nicotine from cigarettes causes changes to the functioning of the ventral tegmental area and nucleus accumbens such that when brain concentrations of nicotine are lower than usual, there is an abnormally low level of neural activity in these regions.
This leads to feelings of need for behaviours that have in the past restored normal functioning, typically smoking. When smokers abstain from cigarettes, within a few hours many of them start to experience nicotine withdrawal symptoms. Withdrawal symptoms from a drug are temporary symptoms that arise when the drug dose is reduced or use is terminated. They arise from neural adaptation to the presence of the drug in the central nervous system. For smoking, the most common early onset symptoms are: irritability, restlessness and difficult concentrating.
Depression and anxiety have also been observed in some smokers. After a day or two of stopping smoking, many smokers experience other symptoms: increased appetite, constipation, mouth ulcers, cough, and weight gain.
Increased appetite tends to last for at least 3 months; weight gain averaging around 6 kg tends to be permanent; other symptoms tend to last a few weeks. Many smokers report that smoking helps them cope with stress and increases their ability to concentrate. However, this appears to be because when they go for a period without smoking they experience nicotine withdrawal symptoms that are relieved by smoking. However, the evidence indicates that neither nicotine nor smoking improves psychological symptoms, and people with serious mental health disorders who stop smoking do not experience a worsening of mental health.
For most smokers, cessation requires a determined attempt to stop and then sufficient resolve in the following weeks and months to overcome what are often powerful urges to smoke.
Factors that predict quit attempts differ from those that predict the success of those attempts Vangeli et al. The most common self-reported reasons for smoking are stress relief and enjoyment, with around half of smokers reporting these smoking motives. No clear association has been found between the number of times smokers have tried to stop in the past and their chances of success the next time they try Vangeli et al.
However, having tried to stop in the past few months is predictive of failure of the next quit attempt Zhou et al. Belief in the harm caused by smoking is predictive of smokers making quit attempts but not the success of those attempts Vangeli et al.
Some clinical studies have found that women were less likely to succeed in quit attempts than men but large population studies have found no difference in success rates between the genders Vangeli et al. Number of cigarettes smoked per day, time between waking and the first cigarette of the day and rated strength of urges to smoke prior to a quit attempt have been found to predict success of quit attempts Vangeli et al. Quit attempts that involve gradual reduction are less likely to succeed than those that involve quitting abruptly, even after controlling statistically for measures of cigarette addiction, confidence in quitting, other methods used to quit e.
There is extensive evidence on interventions that can reduce smoking prevalence, either by reducing initiation or promoting cessation. Increasing the financial cost of smoking through tax increases and control of illicit supply on average reduces overall consumption with a typical price elasticity globally of 0.
Social marketing campaigns e. TV advertising can prevent smoking uptake, increase the rate at which smokers try to quit and improve the chances of success. This can lead to a reduction in smoking prevalence. Legislating to ban smoking in all indoor public areas may have a one-off effect on reducing smoking prevalence but findings are inconsistent across different countries Bala et al. For example, in countries such as France it was not possible to detect an effect while in England, there did appear to be a decline in prevalence following the ban.
Brief advice to stop smoking from a physician and offer of support to all smokers, regardless of motivation to quit, has been found in randomised trials to increase rate of quitting by an average of 2 percentage points of all those receiving it, whether or not they were initially interested in quitting Stead et al. Using a form of nicotine replacement therapy NRT: transdermal patch, chewing gum, nasal spray, mouth spray, lozenge, inhalator, dissolvable strip for at least 6 weeks from the start of a quit attempt increases the chances of long-term success of that quit attempt by about 3—7 percentage points if the user is under the care of a health professional or provided as part of a structured support programme Stead et al.
A small proportion of people who use NRT to stop smoking continue to use it for months or even years after stopping smoking, but NRT appears to carry minimal risk to long-term users Royal College of Physicians, ; Stead et al. Data are sparse but at present, using an electronic cigarette in a quit attempt appears to increase the chances of success at stopping on average by an amount broadly similar to that from NRT; the variety of products available and the greater similarity to smoking appear to make them more attractive to many smokers as a means of stopping than NRT McNeill et al.
Electronic cigarettes deliver nicotine to users by heating a liquid containing nicotine, propylene glycol or glycerol and usually flavourings to create a vapour that is inhaled. They appear to carry minimal acute risk to users. If they are used long-term, their risk is almost certainly much less than that of smoking based on concentrations of chemicals in the vapour McNeill et al. Starting to use a nicotine transdermal patch several weeks before the target quit date may improve the chances of success at quitting compared with starting on the quit date Stead et al.
Bupropion often leads to sleep disturbance and carries a very small risk of seizure. Bupropion probably works by reducing urges to smoke rather than any effect on depressed mood, but how it does this is not known. It is contra-indicated in pregnant smokers and people with an elevated seizure risk or history of eating disorder Hughes et al, Taking the tricyclic anti-depressant, nortriptyline also improves the chances of success of quit attempts, probably by about the same amount as bupropion and NRT Hughes et al.
Its mechanism of action is not known. Nortriptyline often leads to dry mouth and sleep disorder and can be fatal in overdose Hughes et al. This is true for smokers with or without a psychiatric disorder Anthenelli et al. Varenicline often leads to sleep disturbance and nausea. Serious neuropsychiatric and cardiovascular adverse reactions have been reported, but in comparative studies these have not been found to be more common than placebo or NRT Anthenelli et al. Taking the nicotinic-acetylcholine receptor partial agonist, cytisine, appears to improve the chances of success at least as much as single-form NRT and probably more Cahill et al.
Cytisine often causes nausea. No serious adverse reactions have been reported to date Cahill et al. There is good evidence that behavioural interventions of many kinds, delivered though several modalities can help smokers to stop.
There is still relatively limited evidence on the effectiveness of digital support interventions for smoking cessation. Thus, while there is evidence that tailored, interactive websites can improve the chances of success at stopping smoking compared with no support, brief written materials or static information websites, many of those tested have not been found to be effective and it is not clear what differentiates those that are effective from those that are not Graham et al.
There is currently insufficient evidence to know whether smartphone applications can improve success rates of quit attempts, although preliminary data suggest that they might Whittaker et al. Evidence on alternative and complementary therapies is not sufficient to make confident statements about their effectiveness as aids to smoking cessation Barnes et al. Overall, the highest smoking cessation rates appear to be achieved using specialist face-to-face behavioural support together with either varenicline or dual form NRT.
In pregnant smokers, there is some evidence that NRT can help promote smoking cessation but evidence for an effect sustained to end of pregnancy is not conclusive Sterling et al. Almost half of women who stop smoking during pregnancy as a result of a clinical intervention relapse to smoking within 6 months of the birth Jones et al. Smokers who report that they are reducing their cigarette consumption smoke only 1—2 fewer cigarettes per day on average than when they say they are not Beard et al.
Clinical trials have found that use of NRT while smoking can substantially reduce cigarette consumption compared with placebo Royal College of Physicians, but national surveys show very little reduction in cigarette consumption when smokers take up use of NRT in real-world settings Beard et al.
The benefit from using NRT while continuing to smoke appears to be in promoting subsequent smoking cessation. The follow-up period in this study was 3 months, which is the follow-up period for smoking cessation support specified in the public health guidance by physicians and public health nurses in Japan.
The difference in the smoking cessation rate between the two groups was Compared to these results, our study suggests that the FINE program may enable community pharmacists to efficiently provide advice to smokers who have decided to quit.
The results also suggest that the FINE program could play an important role in the application of motivational interviewing to support smoking cessation in patients affected by chronic diseases such as diabetes, dyslipidemia, and respiratory diseases. However, there are limitations to the current study.
First, we were unable to reliably test our hypotheses due to a low recruitment rate and an insufficient number of participants. This clearly shows that it is difficult to recruit patients to smoking cessation programs in community pharmacies under the current situation in Japan. Specifically, we found that the reasons for the small sample size were that the expected effect size was too large, and the number of pharmacies was insufficient due to a high estimate of the expected number of patients that each pharmacy could recruit.
Therefore, in the future, we will need to reexamine our recruitment methods, understand the level of interest in smoking cessation in advance, and train pharmacists to respond accordingly, as well as reduce the number of recruits per pharmacy and increase the number of pharmacies. Third, the study was conducted unblinded because it would be difficult to blind behavioral interactions between patients and pharmacists. The issues pertaining to recruitment methods in Japanese community pharmacies that were clarified in the current study need to be further considered from the perspectives of both patients and pharmacists.
According to a survey on effective ways to recruit smokers and reasons for smokers who are not interested in quitting to participate in smoking cessation support research, common recruitment methods include word of mouth, posters, and referrals to outpatient clinics for smoking cessation. Further, the most common reasons for participating in such research were, in order of frequency, financial incentives Therefore, to increase the recruitment rate in the future, we believe that it would be useful to add more specific information about the content of the smoking cessation support program and the benefits of smoking cessation to the explanatory document in an easy-to-understand manner before obtaining consent [ 23 ].
Many pharmacies have not incorporated smoking cessation support into their daily operations is that it takes time and effort to recruit patients under tight time constraints [ 24 ]. Additionally, community pharmacists may feel they lack the counseling skills needed to help smokers quit [ 25 ].
For community pharmacies to proactively reach out to smokers, a simplified approach to smoking cessation support is needed, and its effectiveness needs to be objectively evaluated [ 25 ]. A study among Canadian pharmacists found that smoking cessation training in undergraduate and postgraduate education was associated with an increased belief that the role of a pharmacist includes providing effective counseling for smoking cessation.
Therefore, the training program developed may need to be modified further to address this issue [ 26 ]. Based on the effect size values, the FINE program may be effective to some extent; however, the difference was not significant. We speculate that this is related to the small sample size due to the low recruitment rate. Therefore, further studies with an effective recruitment method and larger sample sizes are needed to accurately verify the effectiveness of this program.
We would like to express my sincere gratitude to Dr. Masakazu Nakamura and Dr. Shizuko Masui for their valuable advice on this research. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Article of the Year Award: Outstanding research contributions of , as selected by our Chief Editors.
Read the winning articles. Journal overview. Academic Editor: Haniki Mohamed. Received 11 Mar Accepted 17 Nov Published 03 Dec Abstract Objectives. Introduction Each year, more than 8 million people worldwide die from diseases linked to smoking tobacco products.
Materials and Methods 2. Participants Community pharmacies were directly recruited via explanatory meetings, resulting in the participation of 11 pharmacies in Osaka Prefecture. Randomization Pharmacies were considered to be clusters and divided into categories according to size stratified by the number of prescriptions per month: small, ; medium, 1,,; and large, more than 2, Recruitment The pharmacists who participated in the study displayed posters and introduced the program to those visiting the pharmacies.
Blinding The intervention was assumed to be behavioral, and the pharmacists were not blinded. Intervention Group 2. Pharmacist Training All participating pharmacists were required to complete training prior to study commencement [ 15 ]. Table 1. Training program and follow-up during the study citation from reference [ 15 ]. Timing Action The first visit Set of the start date of smoking cessation Measurement of CO concentration in exhaled air voluntary Delivery of the guidebook Explanation of how to use the guidebook Selection of the course that would be used to quit smoking The introduction of a smoking cessation aid if necessary Day 3 Check whether or not participants had been smoking Follow-up on the telephone Check for nicotine withdrawal symptoms Words of encouragement Check for side effects of the smoking cessation aid if necessary Weeks 2, 4, 6, and 8 Check whether or not participants had been smoking Follow-up at the pharmacy or over the telephone Check whether or not participants had been filling in their smoking diaries and give advice Words of encouragement Check for side effects of the smoking cessation aid if necessary Assessment Check whether or not participants had been smoking Measurement of CO concentration in breath at week Table 2.
The flow of the FINE program citation from reference [ 15 ]. Figure 1. Recruitment, allocation, and 3-month follow-up of study subjects. Table 3. Johnson and T. Mdege and S. Carson-Chahhoud, J.
Livingstone-Banks, and K. View at: Google Scholar L. Steed, R. Sohanpal, W. James et al. Caponnetto, J. DiPiazza, M. Aiello, and P. El Hajj, N. Kheir, A. Al Mulla, R. Shami, N.
Fanous, and Z. Maguire, J. Although many African countries have policies regarding tobacco control, very few have programmes to support smokers who wish to quit, and even fewer have active training programmes to equip healthcare practitioners to assist active smokers in breaking their addiction to nicotine.
We present a perspective from several countries across the African continent, highlighting the challenges and opportunities to work together to build capacity for smoking cessation services throughout Africa. These range and the MPOWER strategy, instituted in , have assisted from lack of training for healthcare providers, competing disease governments in tobacco control efforts.
HIV and TB, lack of access to affordable medications via Monitoring tobacco use, Protecting people from tobacco use, and lack of data and locally applicable tobacco cessation guidelines. Additionally, to cultivate a group of clinicians around across continents and countries, but a striking discrepancy is seen Africa gathering local data to support locally appropriate cessation in low- vs. Although each country faces its own unique The MPOWER strategy that is reported to be the most underutilised challenges, many of the factors are likely to be similar across low- is that of offering help to quit tobacco use.
Article 14 of the FCTC and middle-income countries. Likewise, each country will afford promotes tobacco cessation awareness and support for tobacco different opportunities to support and lead tobacco cessation based dependence, including that nicotine replacement therapy NRT is on their size, location and experience.
The WHO report on the global tobacco high-income countries offer complete cessation support, as do fewer epidemic is missing any data on a third of countries on the continent, than one in 10 middle-income countries, with only one low-income as well as missing complete data for many other countries.
Zimbabwe has small or no warnings on some of the issues and information gaps across the continent relating tobacco products and no ban on advertising tobacco products.
There are currently no services for smoking cessation in the To our knowledge, South Africa is the only country with specific Zimbabwean public sector, including a telephone quit line or coverage smoking cessation guidelines in Africa. There are no 2. This ranges from Medical schools do not actively teach smoking of female youths were current smokers.
However, there are some initiatives to discourage tobacco use. Selling tobacco products to minors with Quit lines National Council Against Smoking , and web-based is legally prohibited. Control Act, which was passed into law in Despite this, there Smoking cessation is largely integrated with clinical work in general, is very limited availability of smoking cessation clinics in Nigeria focusing on patients with conditions that are caused or worsened and most tertiary hospitals do not have smoking cessation clinics.
Smoking cessation has also been integrated into the any form of smoking cessation advice. Pharmacotherapy for smoking cessation is scarce as these markets decline. The best estimates for smoking tobacco prevalence and available resources admixture.
It is also among men and women are 1. Despite this, the capacity to undertake effective been effectively implemented. Currently there are no smoking cessation services available Effective treatment strategies for nicotine addiction without policies nor access to NRT. There are currently designated effective and stringent tobacco control along with effective options to smoking rooms in healthcare facilities, educational facilities, including assist smokers in overcoming their addiction to nicotine is likely to universities, and in public transport but no such facilities in restaurants, be more effective for overall tobacco control.
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