This Monograph provides a comprehensive overview of tobacco cessation, from health policy to patient care. Broad in scope, this state-of-the art collection is broken down into four sections: the changing landscape of the tobacco epidemic and challenges to curb it; treatment of tobacco dependence (pharmacotherapy, behavioural support); improving the care of patients with particular conditions who smoke (asthma, COPD, TB, cardiovascular diseases, etc.); and prevention. It also deals with some of the more controversial topics such as e-cigarettes and web applications. Readers will gain an understanding of how to implement smoking cessation into their everyday practice, but will also expand their knowledge about the policy and systems changes needed for population-wide smoking cessation.
- Page 1AbstractLinnea Hedman, The OLIN studies, Norrbotten County Council, Robertsviksgatan 9, 971 89 Luleå, Sweden. E-mail: linnea.hedman@norrbotten.se
Tobacco use and exposure to ETS remain the main causes of respiratory diseases, both in adults and children. It places significant burden on both individual and public health, particularly in vulnerable groups such as children and people of lower socioeconomic status. Tobacco smoking is still the most preventable cause of premature death and respiratory diseases and it interferes with most of the sustainable development goals. Moreover, tobacco smoking is a chronic dependence disorder that needs a systematic diagnostic approach and treatment. Most smokers want to quit, but although safe, evidence-based nicotine-dependence treatments exist, they remain poorly implemented in medical education and practice. The content and emissions of cigarettes and their impact on health are well known. By stronger enforcement of existing tobacco control measures, the tobacco epidemic can be curbed.
Cite as: Hedman L, Ashley D, Filippidis F, et al. Tobacco is still the most important preventable cause of respiratory diseases. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 1–17 [https://doi.org/10.1183/2312508X.10001920].
- Page 18AbstractSakire Pogun, Ege University Center for Brain Research, Dekanlik Binasi, Bornova, 35100 Izmir, Turkey. E-mail: sakire.pogun@ege.edu.tr
Tobacco use is not a free choice or lifestyle but a chronic relapsing disorder. Nicotine is the psychoactive component of tobacco. Inhaled nicotine reaches the brain rapidly, is highly addictive and poses challenges to treatment interventions. Nicotine exerts its effects through nicotinic acetylcholine receptors, which also mediate in reward, motivation, attention, learning and memory. Despite worldwide efforts for a tobacco-free world, hard-core smokers remain. Individual differences in tobacco/nicotine addiction are due to genetic background, sex, age, psychiatric comorbidities, endocrine status and environmental factors. Nicotine use has detrimental effects on brain development and function, especially during pre-natal and early childhood exposure. Currently, there is growing evidence that nicotine is a neural teratogen and damages brain structure and development. Even infrequent experimental smoking in adolescence significantly increases the risk of adult smoking. Once initiated, cessation is difficult: smoking is a long-term addiction. Prevention of adolescent smoking is essential to reduce overall smoking prevalence and its attendant morbidity and mortality.
Cite as: Pogun S, Rodopman Arman A. Understanding nicotine addiction and the health effects of nicotine use. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 18–32 [https://doi.org/10.1183/2312508X.10002020].
- Page 33AbstractJørgen Vestbo, North West Lung Centre, 2nd Floor, ERC Building, Wythenshawe Hospital, Southmoor Road, M23 9LT, Manchester, UK. E-mail: jorgen.vestbo@manchester.ac.uk
EC, heated tobacco and other novel nicotine-containing products cover a wide array of products manufactured to deliver nicotine to the user. Nicotine is delivered along with a number of other substances, some of them are also found in burnt tobacco but most are different and with varying toxicity. They are marketed extensively, often by companies owned by the tobacco industry, and their use is increasing in most countries. They are offered as aids to smoking cessation; however, when discussing the role of ECs on smoking cessation, the effectiveness, safety and public health impact of EC use should be evaluated together. The current evidence is inconclusive to recommend ECs over approved first-line pharmacotherapy or as safe smoking-cessation tools. Importantly, their safety is unproven and as they are increasingly used by young people and people not previously addicted to cigarette smoking, they may prove to be a significant future health burden. The European Respiratory Society warns against seeing these devices as part of a harm reduction strategy and advocates against using them instead of evidence-based smoking cessation tools and treatments.
Cite as: Pisinger C, Katsaounou P, Belo Ravara S, et al. E-cigarettes, heated tobacco and other novel nicotine-containing products: a help to smokers or a public health threat? In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 33–55 [https://doi.org/10.1183/2312508X.10002120].
- Page 56AbstractLynne Johnston, Halley Johnston Associates Ltd, 28 Queens Drive, Whitley Bay, Tyne and Wear, NE26 2JU, UK. E-mail: LynneJohnston@halleyjohnstonassociates.co.uk
Motivational interviewing is essentially a client-centred conversation about change and is a useful, pragmatic approach to use within a tobacco-dependence context. A brief comparison between traditional advice-giving and motivational interviewing is followed by a short review of the background to motivational interviewing, together with examples of its use in smoking cessation. We describe the underpinning spirit of the method, the importance of the concept of psychological ambivalence and the need to view change as a psychological process linked to core client-centred values. We discuss how to work with the language of change, highlighting the concepts of “change talk”, “sustain talk” and “discord”, and introduce the four key processes in motivational interviewing: engaging, focusing, eliciting and planning. Examples of motivational interviewing-specific strategies are provided that can be used to help engage clients, focus on a target behaviour for change, resolve their ambivalence, increase their internal motivation and move into planning for change. A critique of appropriate training pathways to develop proficiency in motivational interviewing is provided. Examples of clinical dialogue are included to aid the reader in the application of key concepts.
Cite as: Johnston L, Hilton C, Dempsey F. Practical guidance on the use of motivational interviewing to support behaviour change. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 56–75 [https://doi.org/10.1183/2312508X.10002320].
- Page 76AbstractCristina Martínez, Tobacco Control Unit, Institut Català d'Oncologia. Av. Gran Via de L'Hospitalet, 199-203, E-08908 L'Hospitalet de Llobregat, Spain. E-mail: cmartinez@iconcologia.net
Tobacco addiction relies on physiological and psychological dependence, as well as social determinants. Consequently, smoking cessation guidelines recommend that HCPs identify smokers at the first opportunity, record smoking status in the subject's clinical notes, and offer advice to help them quit, as well as intensive behavioural support and pharmacotherapy. To easily incorporate smoking cessation intervention into the HCP's daily routine, several models have been developed: the 5 As (ask, advise, assess, assist and arrange), the 5 Rs (relevance, risks, rewards, roadblocks and repetition), Very Brief Advice (VBA) and the Brief Support and Treatment (BST) models. This chapter will: 1) present the evidence on the types and effectiveness of psychosocial interventions to aid smoking abstinence; 2) describe how to approach smokers and assess their readiness to quit using the 5 As and 5 Rs models, and the shortened 2 As/3 As version; 3) discuss two pragmatic tobacco cessation interventions for smokers that can be used during routine consultations (VBA and BST); and 4) describe what is important to patients in helping them quit.
Cite as: Martínez C, Schoretsaniti S, Bobak A, et al. Behaviour counselling and psychosocial interventions. The role of patient involvement. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 76–96 [https://doi.org/10.1183/2312508X.10013220].
- Page 97AbstractNeal L. Benowitz, Zuckerberg San Francisco General Hospital, Building 30, Room 3316, 1001 Potrero Avenue, San Francisco, CA 94110, USA. E-mail: neal.benowitz@ucsf.edu
Based on the research of recent decades, there is robust evidence that all licensed first-line smoking cessation pharmacotherapies (i.e. varenicline, bupropion and NRT) can help motivated smokers quit. Varenicline appears to be equally effective as combined NRT and more effective than bupropion or single NRT. None of the treatments appear to cause adverse events that would justify avoiding their use and, although monitoring is still recommended, initial concerns for varenicline (and bupropion) about a possible causal link with serious psychiatric or cardiovascular adverse events could not be confirmed in recent meta-analyses. A combination of pharmacotherapy with smoking cessation counselling is recommended where possible. Genetic and environmental factors related to the rate of nicotine metabolism, as well as racial and sex differences, might influence smoking behaviour and rates of quitting. More data are needed before personalised recommendations can be made for specific subgroups.
Cite as: Liakoni E, Benowitz NL. Evidence of the effectiveness and safety of first-line smoking cessation pharmacotherapy. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 97–117 [https://doi.org/10.1183/2312508X.10002420].
- Page 118AbstractKeir Lewis, Swansea University Medical School, Institute of Life Science 2, Swansea University, Singleton Park, Swansea, SA2 8PP, UK. E-mail: k.e.lewis@swansea.ac.uk
While HCPs lack training in smoking cessation, health systems lack engagement with preventive care; few offer a system-level intervention or a full package of best practice cessation services. There is a need to incorporate innovative and system-level cessation interventions into healthcare and community settings, as part of wider tobacco action plans. This chapter describes successful examples of system-level tobacco cessation interventions from primary care to secondary care, community programmes and internet support in the UK and Canada. We describe national models, such as in Denmark where these separate services can be incorporated into a unified service, and finally look at international collaborations where different aspects of each system can be adapted across countries.
Cite as: Lewis KE, Belo Ravara S, Papadakis S, et al. Optimising health systems to deliver tobacco-dependence treatment. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 118–135 [https://doi.org/10.1183/2312508X.10002520].
- Page 136AbstractParaskevi Katsaounou, Pulmonary Dept, First ICU, Evangelismos Hospital, Ipsilandou Str 45-7, 10676, Athens, Greece. E-mail: paraskevikatsaounou@gmail.com
Active and passive smoking are well recognised as worsening asthma control and increasing the need for therapy. The combination of tobacco smoking and asthma increases the possibility of acute exacerbations and absenteeism from work/school; worsens asthma control, QoL and therapeutic outcomes; accelerates respiratory decline, enhancing morbidity and mortality. However, the prevalence of smoke exposure amongst asthmatic patients is still high, approximately the same as in the general population; 20% of asthmatics in Europe are smokers. Smoking cessation in asthmatic patients regardless of age at cessation can improve symptoms and QoL, reduce the use of rescue medications, airway hyperresponsiveness, steroid-resistance, emergency visits and hospitalisation, asthma acute exacerbations and mortality rates, and result in better asthma control and improved lung function within weeks of quitting. Smoking cessation should be a central component of the management of current smokers with asthma. Asthmatics should be informed about the impact of smoking and given appropriate medical support, both behavioural and pharmaceutical, in their quitting efforts. Barriers such as depression, anxiety and high levels of addiction should be taken into account. Respiratory physicians should incorporate smoking cessation and relapse prevention in the asthma plan of their patients.
Cite as: Barnes PJ, Adcock IM, Mumby S, et al. Asthmatic patients. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 136–153 [https://doi.org/10.1183/2312508X.10002620].
- Page 154AbstractCarlos A. Jiménez-Ruiz, Smoking Cessation Service, Hospital Cliníco San Carlos, Calle del Prof Martín Lagos, Madrid 28040, Spain. E-mail: victorina@separ.es
The global burden of COPD continues to rise because of continued exposure to smoking, and the majority of COPD cases are caused by tobacco smoke exposure, yet many COPD patients continue to smoke, despite knowing that it will make their condition worse. As a group, COPD patients face particular difficulties in quitting, as well as barriers within the healthcare profession. However, smoking cessation is the only measure that has been shown to be effective in halting the progression of COPD, so proper diagnostic and therapeutic interventions for smoking are essential in these patients. A combination of psychological counselling and pharmacological treatment (NRT, bupropion or varenicline) is the most effective method to help COPD smokers quit, which will improve their QoL and prolong their life expectancy.
Cite as: Jiménez-Ruiz CA, Lewis KE. COPD patients. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 154–164 [https://doi.org/10.1183/2312508X.10002720].
- Page 165AbstractRachel E. Gemine, Research and Development, Hywel Dda University Health Board, Llanelli, SA14 8QF, UK. E-mail: rachel.e.gemine@wales.nhs.uk
Smoking is the leading cause of lung cancer worldwide but despite advances in radiology and chemotherapy, the 5-year survival for lung cancer remains poor. Almost half of patients are smokers at the time of lung cancer diagnosis, despite this little is known about the effects of continuing to smoke on outcomes. There is growing evidence that cessation following a diagnosis results in fewer treatment complication, improved response, fewer recurrences and metastatic disease leading to improved survival. Clinicians should be strongly recommending smoking cessation programmes. Smoking cessation should be offered at the earliest opportunity, including at screening or at time of diagnosis. Patients should be supported through behaviour support and pharmacotherapy, with patients demonstrating higher levels of nicotine dependency being offered intensive support. It is recommended that smoking cessation is incorporated into patients treatment plans.
Cite as: Gemine RE, Haider SA, Belo Ravara S, et al. Lung cancer patients. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 165–180 [https://doi.org/10.1183/2312508X.10012220].
- Page 181AbstractRaquel Duarte, Instituto de Saúde Pública, Universidade do Porto (ISPUP), Rua das Taipas no.135, 4050-600 Porto, Portugal. E-mail: raquel.duarte@chvng.min-saude.pt
Both active smoking and SHS increases the risk of infection and reactivation of tuberculosis (TB). Tobacco smoke is an independent risk factor for TB severity; delaying sputum smear and culture conversion can lead to treatment failure and can increase mortality. Patients are more likely to change their smoking behaviours during treatment, rendering this period a crucial opportunity for health professionals to deliver brief cessation advice and counselling. Smoking cessation interventions are cost-effective and can be successfully incorporated into TB programmes. The level of intervention should be tailored to the health services’ capacity. All healthcare providers involved with TB care should be trained in tobacco-cessation brief advice. The World Health Organization has proposed that tobacco control should be integrated into TB programmes. Smoking cessation: reduces infection and disease caused by Mycobacterium tuberculosis; improves treatment outcomes; and reduces and/or ameliorates other pulmonary and cardiovascular diseases, thereby benefiting society.
Cite as: Magis-Escurra C, Tiberi S, Akkerman O, et al. Tuberculosis patients. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 181–192 [https://doi.org/10.1183/2312508X.10002920].
- Page 193AbstractArwel Wyn Jones, Dept of Allergy, Immunology and Respiratory Medicine, Central Clinical School, Monash University, Melbourne VIC 3004, Australia. E-mail: arwel.jones@monash.edu
Smoking is implicated in the pathogenesis of interstitial lung disease (ILD), including respiratory bronchiolitis-associated ILD, desquamative interstitial pneumonitis, pulmonary Langerhans cell histiocytosis and acute eosinophilic pneumonia, and is a risk factor for the development of idiopathic pulmonary fibrosis. Smoking-related mechanisms in these ILDs remain unclear but their low prevalence suggests they occur in those with genetic predispositions. Case series and cohort studies report the benefits of smoking cessation in preventing the progression of ILD. Smoking exposure is a risk factor for first or recurrent pneumothorax, and worsens outcomes in cystic fibrosis. Lung transplantation may be a treatment option for respiratory diseases at an advanced stage. Smoking in transplant donors or recipients is associated with poor outcomes. Definitive randomised controlled trials of smoking cessation interventions in these respiratory diseases and settings are lacking. With appropriate consideration of any contraindications and comorbid conditions, these patients should receive specialist evidence-based support to quit smoking.
Cite as: Jones AW, Gemine RE, Haider SA. Patients who suffer from other respiratory diseases. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 193–207 [https://doi.org/10.1183/2312508X.10003020].
- Page 208AbstractSophia Papadakis, Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON K1Y 4W7, Canada. E-mail: spapadakis@ottawaheart.ca
Stopping smoking is possibly the most powerful intervention for improving prognosis after a cardiac event, proven to reduce the risk of future myocardial infarction, repeat revascularisation and death. Unfortunately, a significant number of patients continue to smoke following a cardiac event, and those who do quit return to smoking. There is strong evidence regarding the efficacy of behavioural counselling and pharmacotherapy in supporting cessation among patients with cardiovascular disease (CVD). Evidence continues to accrue that the implementation of systematic approaches to cessation in both hospital and primary care settings can substantially improve clinician effectiveness and efficiency in enhanced rates of cessation. Best practices for the delivery of smoking-cessation support in the inpatient setting include: documentation of the smoking status of all patients, appropriate bedside behavioural counselling by a trained clinician, initiation of NRT during hospitalisation to manage acute nicotine withdrawal and support cessation, and follow-up support post-discharge. All HCPs and organisations that treat patients with CVD should make tobacco cessation a priority.
Cite as: Papadakis S, Pipe A, Vlachopoulos C, et al. Cardiovascular patients. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 208–228 [https://doi.org/10.1183/2312508X.10003020].
- Page 229AbstractSerena Tonstad, Dept of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Box 4956 Nydalen, N-0424 Oslo, Norway. E-mail: serton@ous-hf.no
Cigarette smoking, even light smoking, increases the risks of metabolic syndrome, type 2 diabetes and certain forms of thyroid dysfunction, in particular thyroid eye disease. Stopping smoking entirely lowers the vascular risks associated with diabetes, despite even large amounts of weight gain. Smoking cessation among persons with type 2 diabetes may cause a deterioration in glycaemic control, but this effect is temporary. While guidelines for the care of people with diabetes or thyroid eye disease universally recommend help for smokers to quit, there is a dearth of studies. Clearly, trials of specific and supported cessation programmes are required. Given our knowledge to date, people with these disorders should be offered personalised support including, for example, the 5 As (ask, advise, assess, assist and arrange), consideration of the 5 Rs (relevance, risks, rewards, roadblocks and repetition) for unmotivated smokers, medications and follow-up, as recommended for smokers with other medical conditions, as a routine component of their care. Medications should be considered early, including NRT, bupropion or varenicline. When possible, weight management education including personalised support may minimise post-cessation weight gain without sabotaging abstinence.
Cite as: Rice S, Sharaf GM, Kyriakakis N, et al. Patients with common endocrine disorders. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 229–247 [https://doi.org/10.1183/2312508X.10003220].
- Page 248AbstractEmily Stockings, The National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, 22–32 King Street, Randwick, Sydney, New South Wales 2031, Australia. E-mail: e.stockings@unsw.edu.au
People with mental disorders are twice as likely to smoke compared with the general population and are more likely to die from tobacco-related disease. There are unique factors that contribute to the elevated smoking rate in this group and that act as barriers to cessation, including higher nicotine-dependence levels, reduced receipt of cessation support, perceived negative impacts on mental health functioning, and social and cultural influences. Despite this, a number of effective smoking-cessation treatments are available, including pharmacological support such as NRT, varenicline and bupropion, and psychological strategies such as behavioural support and CBT. Evidence suggests that smokers with a mental disorder are able and willing to quit, but long-term cessation rates are low. Improving routine delivery of nicotine-dependence treatment within mental health treatment settings may prove to be an effective method for achieving sustained smoking cessation in this group, given the strong interconnectedness between smoking and mental health treatment.
Cite as: Stockings E, Metse A, Taylor G. “It's the one thing they have left”: smoking, smoking cessation and mental health. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 248–272 [https://doi.org/10.1183/2312508X.10003420].
- Page 273AbstractFusun Yildiz, Kyrenia University Dr Suat Günsel Hospital, Şht. Yahya Bakır Sokak, Karakum, Kyrenia, Turkish Republic of Northern Cyprus. E-mail: fusun.yildiz@gmail.com
There is strong evidence that the effects of maternal tobacco use and exposure to SHS result in adverse pregnancy outcomes. Tobacco use is the leading preventable cause of miscarriage, stillbirth and neonatal deaths, and evidence has shown that the health effects extend into childhood and adult life. Thus, the changes caused in the developing fetus may have long-lasting consequences. The common barriers to a tobacco-free pregnancy include deficient knowledge about the negative effects on the health of the child and about the health benefits of quitting, a lack of social support, having a smoking partner and high-level dependence on nicotine. However, there is evidence that behavioural support and NRT are effective in enhancing tobacco abstinence. This preventable condition must be a priority for the physicians involved.
Cite as: Karadag B, Dağlı E, Yildiz F. Preventing tobacco use and exposure to second-hand tobacco smoke in pregnancy. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 273–286 [https://doi.org/10.1183/2312508X.10003520].
- Page 287AbstractElif Dağli, Cemil Topuzlu Cad, 16/1 Selamiçeşme, Kadıköy, Istanbul 34724, Turkey. E-mail: elifzdagli@gmail.com
The youth population, a critical target for the tobacco industry, is highly susceptible to nicotine addiction. The use of ECs among the youth has expanded dramatically in many countries in the last decade. From the public health perspective, growing evidence shows that ECs may serve as a gateway for maintenance of nicotine addiction. The health hazards of nicotine dependence and ECs, especially for the youth, are now better described. Countries can protect children from starting smoking and becoming addicted to nicotine by implementing strict tobacco-control laws and by modernisation of evidence-based tobacco-control strategies to include vaping products. There are promising smoking-cessation programmes, but better evidence is still needed for youth cessation. The best practice to prevent tobacco use among the youth is achieved when interventions are comprehensive, coordinated and combined with many partners at several levels.
Cite as: Dağli E, Dilektaşlı AG, Pisinger C. Preventing the initiation of tobacco and e-cigarette use among the youth. In: Belo Ravara S, Dağli E, Katsaounou P, et al., eds. Supporting Tobacco Cessation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 287–307 [https://doi.org/10.1183/2312508X.10003620].