What Is Smoking Cessation?

Smoking can be addictive, called tobacco dependence. Tobacco dependence is a chronic disease. The International Classification of Diseases (ICD-10) is coded F17.2 and has corresponding clinical diagnostic criteria. The main substance that causes tobacco dependence in tobacco is nicotine. Its pharmacological and behavioral processes are similar to other addictive substances, such as heroin and cocaine. Tobacco addicts can stop smoking, a series of withdrawal symptoms such as craving for smoking, anxiety, depression, headache can occur. At the same time, tobacco dependence is highly recurrent, and its treatment often requires the assistance of professionals and scientific methods. ^[1]

Extensive research evidence shows that quitting smoking can reduce or eliminate the health hazards caused by smoking. Anyone can benefit from quitting smoking at any age, and the sooner and longer they quit, the greater the health benefits. There are effective treatments that can significantly increase the long-term quit rate, including brief advice on quitting, medications, counselling and quitlines.

Quit tobacco harmful ingredients

The smoke generated from the combustion of tobacco is a complex mixture of more than 7,000 compounds, of which 95% are gases such as carbon monoxide, hydrogen cyanide, and volatile nitrosamines, and particulate matter accounts for 5%, including semi-volatile and non-volatile , Such as tobacco tar, nicotine and so on. The vast majority of these compounds are harmful to the human body, at least 69 of which are known carcinogens, such as polycyclic aromatic hydrocarbons, nitrosamines, etc., and nicotine is an addictive substance.

Second-hand smoking (SHS) refers to smoke emitted from the burning end of cigarettes or other tobacco products, and is often mixed with smoke emitted by smokers. Second-hand smoke contains hundreds of known toxic or carcinogens, including formaldehyde, benzene, vinyl chloride, arsenic, ammonia, and hydrocyanic acid. Second-hand smoke has been identified as a Class A carcinogen by the US Environmental Protection Agency and the International Cancer Research Agency. Many second-hand smoke have higher levels of carcinogenic and toxic chemicals than the smoke inhaled by the smoker himself. ^[2]

Quit smoking and disease

Six of the world's top eight fatal diseases (ischemic heart disease, cerebrovascular disease, lower respiratory infections, chronic obstructive pulmonary disease, tuberculosis and lung cancer) are related to smoking. Smoking can cause tumors in the lungs, throat, kidneys, stomach, bladder, colon, mouth and esophagus, as well as chronic obstructive pulmonary disease (COPD), ischemic heart disease, stroke, abortion, premature birth, birth defects, impotence And other diseases. ^[3] In 1998, the results of a retrospective survey of 1 million deaths and a follow-up survey of 250,000 people in China showed that COPD and lung cancer accounted for about 60% of all deaths attributed to tobacco in China, and Among smoking-related diseases, COPD accounts for 45%, lung cancer accounts for 15%, and esophageal cancer, gastric cancer, liver cancer, stroke, coronary heart disease, and tuberculosis account for 5% -8% each.

Studies have shown that smoking is an important environmental risk factor for COPD, and at least 95% of COPD patients are smokers. Smoking increases the prevalence of coronary heart disease by 10 years, increases the risk of disease by 2 times, and increases the relative risk of sudden cardiac death by more than 3 times. Smoking increases the relative risk of stroke by 50%, among which the relative risk of ischemic stroke increases by 90%, and the risk of death from subarachnoid hemorrhage increases by 190%; smoking increases the risk of peripheral vascular disease by 10 Sixteen times, 70% of atherosclerotic vascular occlusions and almost all thromboocclusive vasculitis are related to smoking. The greater the amount of smoke, the longer the age of the smoker, and the earlier the age of smoking, the greater the risk of smoking-related diseases.

Evidence suggests that exposure to second-hand smoke can cause multiple illnesses in adults and children. Secondhand smoke exposure can increase the risk of lung cancer, cardiovascular disease and chronic obstructive pulmonary disease in adults, increase the risk of asthma, and damage lung function. The health hazards of second-hand smoke exposure to children involve all stages of child growth and development. Exposure to maternal or second-hand smoke during the fetal period and second-hand smoke exposure after birth can cause infants and young children to suffer from various diseases such as sudden infant death syndrome, acute and chronic Respiratory diseases, acute and chronic middle ear diseases, induce or exacerbate asthma, and can affect children's lung development. ^[4]

Quit Tobacco Dependence Assessment

The higher the cumulative score of the Tobacco Dependence Assessment Scale and the Heaviness of Smoking Index (HSI), the more serious the smoker s dependence on tobacco is, and the smoker benefits from intensive smoking cessation interventions, especially the treatment of smoking cessation drugs The greater the probability.

Tobacco Dependence Assessment Scale *

Evaluation content	0 points	1 point	2 points	3 points
How long do you smoke your first cigarette after waking up in the morning?	> 60 minutes	31 to 60 minutes	6 to 30 minutes	5 minutes
Do you have difficulty controlling smoking in many non-smoking places?	no	Yes
Which cigarette do you think is the least willing to give up?	other time	The first one in the morning
How many cigarettes do you smoke daily?	10 sticks	11-20	21 30 sticks	> 30
Do you smoke more in the first hour after waking up in the morning than at any other time?	no	Yes
Do you still smoke when you are sick?	no	Yes

0 to 3 points: mild tobacco dependence; 4 to 6 points: moderate tobacco dependence; 7 points: severe tobacco dependence

* Fagerstrm test for nicotine dependence (FTND)

Smoking severity index

Evaluation content	0 points	1 point	2 points	3 points
How long do you smoke your first cigarette after waking up in the morning?	> 60 minutes	31 to 60 minutes	6 to 30 minutes	5 minutes
How many cigarettes do you smoke daily?	10 sticks	11-20	21 30 sticks	> 30

4 points for severe tobacco dependence

Quit smoking treatment

For smokers who are not addicted or less dependent on tobacco, they can quit smoking with perseverance, but often need to give brief advice and motivate them to quit; for those who are more dependent on tobacco, often need to give stronger interventions In order to finally successfully quit smoking.

Quit smoking

Studies have shown that the average percentage of untreated smokers quitting smoking is about 2% per year, and brief recommendations from clinicians can increase smoking cessation by 6% or more.

Smoking cessation medication

In May 2008, based on more than 8,000 references, the US Public Health Agency issued a new version of clinical practice guidelines on tobacco use and dependence treatment. This guideline recommends 7 first-line clinical quit drugs that can effectively increase the long-term quitting effect, including 5 nicotine replacement therapy (NRT) quit drugs (nicotine chewing gum, nicotine inhalants, nicotine buccal tablets, nicotine nose Sprays and nicotine patches) and two non-nicotine smoking cessation drugs (valericlan tartrate tablets and bupropion hydrochloride sustained-release tablets). The guidelines also recommend two second-line smoking cessation drugs, clonidine and nortriptyline, which are currently rarely used clinically.

At present, the smoking cessation drugs that have been approved for use in China are:

Prescription drugs: vaniklan (valniklan tartrate), bupropion hydrochloride
Over-the-counter drugs: nicotine patches, nicotine chewing gum

Nicotine replacement therapy reduces the symptoms of nicotine withdrawal, such as inattention, anxiety, irritability, and depression, by providing nicotine to the body in place of or in place of nicotine obtained from tobacco. NRT drugs are safe and effective in assisting smoking cessation, which can double the possibility of long-term smoking cessation. Although it does not completely eliminate the symptoms of withdrawal, it can reduce the discomfort of smoking cessation to varying degrees.

Vavaniklan (Vavaniklan tartrate) is a new type of non-nicotine smoking cessation drug, which has been approved by the US FDA for marketing in 2006 for smoking cessation in adults. The level of evidence recommended for smokers is A. In a clinical study published in 2009 involving 15 centers in China, Singapore, and Thailand, varnaclan had a significantly better smoking cessation effect than placebo. The main efficacy endpoint was 9-12 weeks (including 12 weeks) after CO The rate of sustained smoking cessation confirmed by the measurement at 4 weeks was significantly higher in the valnickelan-treated group (50.3%) than in the placebo group (31.6%) ( P = 0.0003). There were statistically significant differences in key and other secondary efficacy indicators between the valnickelan group and the placebo group. ^[4]

Bupropion hydrochloride (sustained-release tablets) is the first non-nicotine smoking cessation drug that can effectively help smokers quit smoking. It was used to quit smoking in 1997. The level of evidence recommended for smokers is A. Bupropion hydrochloride is a dopaminergic and noradrenergic antidepressant. The mechanism of action may include inhibiting the reuptake of dopamine and norepinephrine and blocking the nicotine acetylcholine receptor. Bupropion hydrochloride is an oral medicine with a dose of 150 mg / tablet. It should be taken at least 1 week before quitting smoking, and the course of treatment is 7-12 weeks. Side effects include dry mouth, irritability, insomnia, headache and dizziness. Patients with epilepsy, anorexia or abnormal appetite, those who are taking drugs containing bupropion or those who have taken monoamine oxidase inhibitors in the past 14 days are contraindicated. For smokers who are heavily dependent on nicotine, the combined use of NRT drugs can increase the effect of smoking cessation. Bupropion hydrochloride is a prescription drug, and the long-term (> May) smoking cessation rate is twice that of the placebo group.

The combination of first-line drugs has proven to be an effective smoking cessation treatment that can increase withdrawal rates. Effective combination medications include: (1) long-range nicotine patches (> 14 weeks) + other NRT drugs (such as chewing gum and nasal sprays); (2) nicotine patches + nicotine inhalants; (3) nicotine patches Tablets + bupropion hydrochloride (level of evidence A).

In the course of smoking cessation treatment, NRT drugs, vaniklan (valvaline tartrate), and bupropion hydrochloride are frequently used drugs. In terms of the health benefits of smoking cessation, these drugs are effective treatments that can save lives. In combination with behavioral interventions, the success rate of smoking cessation will be improved, but smoking cessation drugs alone are still effective. Smoking is often mistaken as a purely personal choice, but this is not the case. After fully realizing the health hazards of smoking, most smokers are willing to quit smoking, but it is often difficult to quit because of the addictive nature of nicotine. Where possible, smoking cessation medications and smoking cessation counselling and counselling measures should be used simultaneously.

Quit smoking cessation counseling and quit hotline

Quit smoking counseling (whether used alone or in combination) is an effective method of quitting smoking. The use of smoking cessation drugs at the same time as the patient's counselling or drug adjuvant treatment during the consultation will significantly improve the smoking cessation effect. ^[5] Therefore, if conditions permit, smokers who are willing to quit smoking should try to combine smoking cessation counseling and drug treatment as much as possible. Shown are some common counselling techniques: problem-solving / skill training and ways to support them during treatment. These methods are mainly used for short smoking cessation interventions and are the basis of intensive smoking cessation treatment. The smoking cessation hotline is an effective smoking cessation treatment method.

Specific implementation of clinical smoking cessation

Tobacco dependence is chronic and highly recurrent, and physicians need to work hard to encourage patients to quit smoking. Before giving up smoking cessation treatment, doctors should first understand the usual patterns of smoking cessation, including thinking, preparation, action, maintenance, and relapse. Prochaska and Diclemente use this model to describe a series of stages in the process of quitting. Smokers have different views and cognitions on quitting at different stages, so different interventions should be adopted for smokers at different stages. ^[6]

In this model, smokers who are in the early stages of thinking do not want to quit; as the awareness of the dangers of smoking increases, smokers will enter the thinking stage. Smokers at this stage are often in a dilemma. On the one hand, they should realize that they should quit smoking. On the other hand, it is still difficult to give up with smoke; after long-term thinking, smokers will enter the preparation stage, and smokers in the preparation stage begin to plan to quit smoking; then they put quitting into practice and enter the action period; immediately follow the action period It is the maintenance period, during which the behavior of quitting smoking is consolidated; if this consolidation cannot be maintained, the smoker will enter the relapse period and return to the thinking period or the earlier period of thinking. If the maintenance period continues, they will quit smoking successfully.

Foreign studies have shown that even intervention as short as 3 minutes can significantly increase the success rate of smoking cessation. ^{[7] The} brief intervention is effective for the following three types of patients: current smokers who are willing to quit, current smokers who do not plan to quit this time, and former smokers who have recently quit, as detailed in the following points.

1. For smokers who are willing to quit

5A's programs can be used for short interventions for smokers who want to quit, including: (1) asking patients if they smoke; (2) recommending that they quit; (3) assessing their willingness to quit; (4) helping smokers who want to quit Try to quit smoking; (5) arrange follow-up to prevent relapse. These steps are simple and generally take less than 3 minutes. The 5A's program is consistent with the smoking cessation strategies recommended by the National Cancer Center, the American Medical Association, and other institutions. These interventions can be implemented according to actual conditions.

2. For smokers who have not yet quit

For patients who are not ready to quit this time, the doctor should give a brief intervention to make them think of quitting. For patients who do not want to quit but have a willingness to quit after a doctor's intervention, the reasons may be: lack of knowledge about the health risks and benefits of quitting; lack of financial resources; fear or concern about quitting; lack of confidence due to previous failures. Motivation interviews are a direct counseling intervention that focuses on patients and is effective for these patients. There is evidence that this method is effective in enabling patients to make future attempts to quit smoking. However, for smokers who already have a willingness to quit, it is unclear whether motivational interviews increase their chances of successful quitting.

The focus of doctors 'motivational interview strategies is to explore smokers' feelings, confidence, ideas, and values in an effort to reveal the ambivalence of smokers. Once ambivalence is identified, doctors should selectively guide, support, and strengthen patients to help them change (such as reasons, ideas, significance, etc.) and make commitments (change smoking behaviors, such as not smoking at home) Wait). Studies have found that patients making their own promises to quit smoking are more effective than doctors' advice and arguments, which can increase rather than lessen patient resistance to smoking cessation.

There are four main principles of motivational interviews: (1) empathy; (2) development differences; (3) dealing with impedance; and (4) supporting self-efficacy. Because this is a professional skill, professional training in motivational interviews with relevant medical staff is required. The 5R's method can be used in the consultation process: table 8 for relevance, risk, reward, roadblocks, and repetition. Studies have shown that applying 5R's can increase smokers' future attempts to quit.

3. Prevention of relapse among smokers

Patients who have recently quit smoking will face a higher risk of relapse. Although most relapses occur early in smoking cessation, they may occur months or even years after quitting. The current method to increase the long-term success rate of smoking cessation is to use the most effective smoking cessation treatment, that is, to provide patients with proven smoking cessation drugs and relatively intensive smoking cessation counselling when they are willing to quit smoking (such as giving 4 or more Consultations, each lasting 10 minutes or longer).

For patients who have recently quit smoking, doctors should affirm the patient's success, review the benefits of quitting, and help patients solve their problems. Doctors' attention to patients can make them actively seek help when relapses occur. For patients who have successfully quit smoking and no longer need treatment, the doctor can discuss with them the experience of successful smoking cessation. These patients who have quit smoking may also experience problems related to quitting, and doctors should intervene in these problems. Table 9 shows some common problems and solutions.

4. The concept and implementation of intensive treatment for smoking cessation

Intensive treatment is a smoking cessation treatment method that extends the duration of each treatment, arranges multiple visits, involves multiple doctors, or performs comprehensive treatment. It is suitable for smokers who are willing to perform such treatment. Intensive smoking cessation treatment can be provided by any trained clinician. Foreign studies have shown that intensive treatment to quit smoking is more effective than short treatment. In addition, even those who are not prepared to quit think that their satisfaction with health care will increase as the intensity of cessation counselling increases. ^[8]

The benefits of quitting smoking

Tobacco can damage almost all organs of the human body, and quitting smoking can effectively prevent or delay the progression of smoking-related diseases. The study found that the risk of death of coronary heart disease patients can be reduced by about half after 1 year of smoking cessation, and will continue to decrease with the cessation of smoking. After 15 years, the absolute risk of death of coronary heart disease patients will be similar to that of never-smokers Preventing secondhand smoke exposure is the most important means of preventing and treating COPD. Quitting smoking is the only method that has been proven to effectively delay the progressive decline of lung function. Quitting smoking can also reduce stroke, peripheral vascular disease, pneumonia, and stomach, twelve fingers. Incidence and mortality of bowel ulcers. Therefore, quitting smoking is an important part of treating various smoking-related diseases. Quitting smoking can also reduce the risk of second-hand smoke exposure to surrounding people, especially family and colleagues.

Quitting smoking is beneficial for all ages, and "it is better to quit early than to quit, and it is better to quit than not to quit." Whenever you quit, you can earn a longer life expectancy after you quit. A 50-year prospective follow-up cohort study of male doctors in the UK found that smokers had about 10 years less life expectancy than non-smokers, and quitting at 60, 50, 40 or 30 years of age could earn about 3 , 6, 9 or 10 years life expectancy. In addition, the number of years of life increased after smoking cessation is "healthy years of life". Quitting smokers is less associated with illness and disability than continuing smokers.

Quit smoking has significant economic benefits, which can greatly reduce various medical and insurance costs caused by smoking. Studies have shown that in 2005, the direct economic loss caused by smoking in China was 166.560 billion yuan, the indirect economic loss was 86.111 billion to 120.501 billion yuan, and the total economic loss was nearly 300 billion yuan, which accounted for about 2005 GDP. 1.5%.

In addition, the smoking cessation behavior of smokers will also serve as a model for family members, friends, and colleagues, especially affecting the attitude of young people to smoking.

Myths about quitting smoking

1. Tobacco "low tar" harm is low

Smokers have "smoke compensation behaviors" in the process of smoking "low-tar cigarettes", including blocking the ventilation holes on the filter with their fingers and lips, increasing the amount of tobacco smoke inhaled, and increasing the number of cigarettes smoked. The existence of "compensating smoking behavior" has not reduced harmful components such as tar and nicotine inhaled by smokers. ^[9]

2. "Chinese herbal cigarettes" have low harm

Because the original aroma of tobacco leaves is affected after the amount of tar is reduced, the tobacco industry additionally adds various spices, additives or Chinese herbs to cigarettes. But so far there is no evidence that these are safe.

There are no harmless tobacco products, as long as smoking is harmful to health. The purpose of the tobacco industry to add additives such as Chinese herbal medicine is to increase the attractiveness of cigarettes, thereby inducing smoking or weakening the willingness of smokers to quit.

3. Limit law to quit smoking

Many people say that quitting smoking needs to be taken slowly, but it will often awaken the withdrawal response for each "limited amount" of cigarettes, making you always yearn for that "limited cigarette".

4. Snack replacement law can quit smoking

If snacks could replace nicotine, there would not be so many smokers in the world.