smoking cessation smoking cessation smoking cessation, usually called quitting smoking or stopping smoking, is the process of discontinuing tobacco smoking. tobacco smoke contains nicotine, which is addictive and can cause dependence. as a result, nicotine withdrawal often makes the process of quitting difficult. part of a series onsmoking tobacco tobacco health effects advertising cessation industry politics prevalence of consumption cannabis cannabis plant effects legality medical use religious and spiritual use opium den opiate opioid papaver somniferum (opium poppy) psychoactive drug first opium war second opium war crack cocaine epidemic other dmt heroin meth narcotics pcp smoking is the leading cause of preventable death and a global public health concern. tobacco use leads most commonly to diseases affecting the heart and lungs, with smoking being a major risk factor for heart attacks, strokes, chronic obstructive pulmonary disease (copd), idiopathic pulmonary fibrosis (ipf), emphysema, and various types and subtypes of cancers (particularly lung cancer, cancers of the oropharynx, larynx, and mouth, esophageal and pancreatic cancer). smoking cessation significantly reduces the risk of dying from smoking-related diseases. from 2001 to 2010, about 70% of smokers in the united states expressed a desire to quit smoking, and 50% reported having attempted to do so in the past year. many strategies can be used for smoking cessation, including abruptly quitting without assistance ("cold turkey"), cutting down then quitting, behavioral counseling, and medications such as bupropion, cytisine, nicotine replacement therapy, or varenicline. in recent years, especially in canada and the united kingdom, many smokers have switched to using electronic cigarettes to quit smoking tobacco. most smokers who try to quit do so without assistance. however, only 3–6% of quit attempts without assistance are successful long-term. behavioral counseling and medications each increase the rate of successfully quitting smoking, and a combination of behavioral counseling with a medication such as bupropion is more effective than either intervention alone. a meta-analysis from 2018, conducted on 61 randomized controlled trials, showed that among people who quit smoking with a cessation medication (and some behavioral help), approximately 20% were still nonsmokers a year later, as compared to 12% who did not take medication. in nicotine-dependent smokers, quitting smoking can lead to nicotine withdrawal symptoms such as nicotine cravings, anxiety, irritability, depression, and weight gain.: 2298 professional smoking cessation support methods generally attempt to address nicotine withdrawal symptoms to help the person break free of nicotine addiction. smoking cessation methods unassisted it often takes several attempts, and potentially utilizing different approaches each time, before achieving long-term abstinence. over 74.7% of smokers attempt to quit without any assistance, otherwise known as "cold turkey", or with home remedies. previous smokers make between an estimated 6 to 30 attempts before successfully quitting. identifying which approach or technique is eventually most successful is difficult; it has been estimated, for example, that only about 4% to 7% of people are able to quit smoking on any given attempt without medicines or other help. the majority of quit attempts are still unassisted, though the trend seems to be shifting. in the u.s., for example, the rate of unassisted quitting fell from 91.8% in 1986 to 52.1% during 2006 to 2009. the most frequent unassisted methods were "cold turkey", a term that has been used to mean either unassisted quitting or abrupt quitting and "gradually decreased number" of cigarettes, or "cigarette reduction". cold turkey "cold turkey" is a colloquial term indicating abrupt withdrawal from an addictive drug. in this context it indicates sudden and complete cessation of all nicotine use. in three studies, it was the quitting method cited by 76%, 85%, or 88% of long-term successful quitters. in a large british study of ex-smokers in the 1980s, before the advent of pharmacotherapy, 53% of the ex-smokers said that it was "not at all difficult" to stop, 27% said it was "fairly difficult", and the remaining 20% found it very difficult. studies have found that two-thirds of recent quitters reported using the cold turkey method and found it helpful. cutting down to quit gradual reduction involves slowly reducing one's daily intake of nicotine. this method can theoretically be accomplished through repeated changes to cigarettes with lower nicotine levels, by gradually reducing the number of cigarettes smoked daily, or by smoking only a fraction of a cigarette on each occasion. a 2009 systematic review by researchers at the university of birmingham found that gradual nicotine replacement therapy could be effective in smoking cessation. there is no significant difference in quit rates between smokers who quit by gradual reduction or abrupt cessation as measured by abstinence from smoking of at least six months from the quit day. the same review also looked at five pharmacological aids for reduction. when reducing the number of smoked cigarettes, it found some evidence that additional varenicline or fast-acting nicotine replacement therapy can positively affect quitting for six months or longer. medications a 21mg dose nicotine patch applied to the left arm the american cancer society notes that "studies in medical journals have reported that about 25% of smokers who use medicines can stay smoke-free for over 6 months." single medications include: nicotine replacement therapy (nrt): five medications have been approved by the u.s. food and drug administration (fda) to deliver nicotine in a form that does not involve the risks of smoking: transdermal nicotine patches, nicotine gum, nicotine lozenges, nicotine inhalers, nicotine oral sprays, and nicotine nasal sprays. high-quality evidence indicates that these forms of nrt improve the success rate of people who attempt to stop smoking. nrts are meant to be used for a short period of time and should be tapered down to a low dose before stopping. nrts increase the chance of stopping smoking by 50 to 60% compared to placebo or to no treatment. some reported side effects are local slight irritation (inhalers and sprays) and non-ischemic chest pain (rare). others include mouth soreness and dyspepsia (gum), nausea or heartburn (lozenges), as well as sleep disturbances, insomnia, and a local skin reaction (patches). a study found that 93% of over-the-counter nrt users relapse and return to smoking within six months. there is weak evidence that adding mecamylamine to nicotine is more effective than nicotine alone.antidepressants: the antidepressant bupropion is considered a first-line medication for smoking cessation and has been shown in many studies to increase long-term success rates. although bupropion increases the risk of getting adverse events, there is no clear evidence that the drug has more or less adverse effects when compared to a placebo. nortriptyline produces significant rates of abstinence versus placebo.other antidepressants such as selective serotonin reuptake inhibitors (ssris) and st. john's wort have not been consistently shown to be effective for smoking cessation.varenicline decreases the urge to smoke and reduces withdrawal symptoms and is therefore considered a first-line medication for smoking cessation. the number of people stopping smoking with varenicline is higher than with bupropion or nrt. varenicline more than doubled the chances of quitting compared to placebo, and was also as effective as combining two types of nrt. 2 mg/day of varenicline has been found to lead to the highest abstinence rate (33.2%) of any single therapy, while 1 mg/day leads to an abstinence rate of 25.4%. a 2016 systematic review and meta-analysis of randomized controlled trials concluded there is no evidence supporting a connection between varenicline and increased cardiovascular events. concerns arose that varenicline may cause neuropsychiatric side effects, including suicidal thoughts and behavior. however, more recent studies indicate less serious neuropsychiatric side effects. for example, a 2016 study involving 8,144 patients treated at 140 centers in 16 countries "did not show a significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo". no link between depressed moods, agitation or suicidal thinking in smokers taking varenicline to decrease the urge to smoke has been identified. for people who have pre-existing mental health difficulties, varenicline may slightly increase the risk of experiencing these neuropsychiatric adverse events.clonidine may reduce withdrawal symptoms and "approximately doubles abstinence rates when compared to a placebo," but its side effects include dry mouth and sedation, and abruptly stopping the drug can cause high blood pressure and other side effects.there is no good evidence anxiolytics are helpful.previously, rimonabant, which is a cannabinoid receptor type 1 antagonist, was used to help in quitting and moderate the expected weight gain. but it is important to know that the manufacturers of rimonabant and taranabant stopped production in 2008 due to serious cns side effects. the 2008 us guideline specifies that three combinations of medications are effective:: 118–120 long-term nicotine patch and ad libitum nrt gum or spray nicotine patch and nicotine inhaler nicotine patch and bupropion (the only combination that the us fda has approved for smoking cessation) a meta-analysis from 2018, conducted on 61 rcts, showed that during their first year of trying to quit, approximately 80% of the participants in the studies who got drug assistance (bupropion, nrt, or varenicline) returned to smoking, while 20% continued to not smoke for the entire year (i.e.: remained sustained abstinent). in comparison, 12% the people who got placebo kept from smoking for (at least) an entire year. this makes the net benefit of the drug treatment to be 8% after the first 12 months. in other words, out of 100 people who will take medication, approximately 8 of them would remain non-smoking after one year thanks to the treatment. during one year, the benefit from using smoking cessation medications (bupropion, nrt, or varenicline) decreases from 17% in 3 months, to 12% in 6 months to 8% in 12 months. community interventions community interventions using "multiple channels to provide reinforcement, support and norms for not smoking" may have an effect on smoking cessation outcomes among adults. specific methods used in the community to encourage smoking cessation among adults include: policies making workplaces and public places smoke-free. it is estimated that "comprehensive clean indoor laws" can increase smoking cessation rates by 12%–38%. in 2008, the new york state of alcoholism and substance abuse services banned smoking by patients, staff, and volunteers at 1,300 addiction treatment centers. voluntary rules making homes smoke-free, which are thought to promote smoking cessation. initiatives to educate the public regarding the health effects of second-hand smoke, including the significant dangers of secondhand smoke infiltration for residents of multi-unit housing. increasing the price of tobacco products, for example by taxation. the us task force on community preventive services found "strong scientific evidence" that this is effective in increasing tobacco use cessation : 28–30 it is estimated that an increase in price of 10% will increase smoking cessation rates by 3–5%. mass media campaigns. there is evidence to suggest that when combined with other types of interventions, mass media campaigns may of benefit.: 30–32 weak evidence suggests that imposing institutional level smoking bans in hospitals and prisons may reduce smoking rates and second hand smoke exposure. pharmacist interventions pharmacist-led interventions have proven to be effective in helping smoking cessation attempts. many systematic reviews have looked at the importance of pharmacist involvement. in malaysia, their study looked at how pharmacist intervention in patients' overall healthcare showed improvements in screening early stages of disease. this allowed for earlier treatment starts in smoking-caused copd. in addition, pharmacists in malaysia could prescribe nrt products, and when they led a smoking cessation service, it was more successful than other smoking cessation trials in malaysia. it was also shown that pharmacist counselling and nrt products were more effective in smoking cessation than using nrt alone. in pharmacist-led smoking cessation services in ethiopia, the study found statistically and clinically significant benefits favouring pharmacist intervention. they found that structured care, and regular visits, easy accessibility to pharmacists helped more people trying to quit than without. however, the study concluded that more research should be done in the area as they found an unknown risk of bias in the studies included another systematic review analyzed pharmacist intervention in smoking cessation and alcohol and weight interventions. they found that evidence suggests that the longer the duration of pharmacist-led intervention, the more influential the attempt at quitting was in addition, they found that community pharmacists were beneficial in delivering public health information. pharmacists have a great reach in the community to help with smoking cessation and have proven to help with lifestyle modifications and proper nrt use. digital interventions