Most smokers regret ever having taken up the habit, so how can pharmacists best support people to quit? Sheshtyn Paola explores the latest research and expert advice
Jessica* started smoking at the age of 16, giving up briefly while pregnant before starting up again when her son was about four years old.
“I smoked off and on for about 20 years,” she tells AJP.
“I justified my continuing to smoke because I didn’t think I smoked very much.”
However her cigarette count could often add up quickly, especially during social situations.
Jessica smoked about five cigarettes a day on average, but if she was out drinking “then it could be as much as 10 or more”.
Twenty years passed before she decided enough was enough: it was time to kick the habit for good.
“I decided to quit because everyone else was giving up and I didn’t want to be the last one still smoking—and smelling of smoke too,” she says.
“I couldn’t be bothered with the hassle of smoking and having to go outside or walk to the petrol station in the rain to buy cigarettes. My husband refused to buy them for me.”
Jessica says she “probably made about three quit attempts seriously other than when you have a cold and decide to give up but smoke the next day.”
However before she successfully using pharmacotherapy to quit, her fail attempts were simply going cold turkey.
Smoking cessation expert Emeritus Professor Simon Chapman, from Sydney Medical School at the University of Sydney, says any smokers who try to quit will have unsuccessful attempts before they have their final successful attempt.
“What we know about that is many of those ‘attempts’ are not really very serious attempts, they’re people who say ‘oh I really should quit, I think I better do something about it’. They might be getting advice or pressure from friends who quit or their family or partner, and so they go ‘oh yeah, I’m going to try and quit this weekend’.
“But they don’t really put their back into it, they don’t really do it with a lot of determination. And so understandably a lot of them fall over.”
Professor Chapman says it’s important for smokers who want to quit to know that “if you have failed using any particular method, you shouldn’t run a script in your head that you can’t quit.
“The most common way that people do quit is by having several attempts and then eventually succeeding.”
As for going cold turkey, Professor Chapman says it’s actually a surprisingly common way to successfully quit.
“If you look at any research from the last 40-50 years, looking at how people quit smoking, overwhelmingly the method used by people who used to smoke and no longer do was cold turkey,” he tells AJP.
“Between about two thirds and three quarters of all ex-smokers on their final, successful attempt, when you ask them how they quit, they’ll say that they ‘did it by myself’.
“That either means that they quit abruptly, or they cut down a bit and then finally quit, without any sort of aid at all.”
Professor Chapman supervised a PhD thesis for a Sydney researcher called Andrea Smith on the topic.1
“When she interviewed a lot of ex-smokers, her research showed the view that if you are serious when you are quitting smoking, you will try to do it by yourself.
“There’s absolutely no substitute for really, really wanting to do it.”
Head to head
While going cold turkey might be successful in some people, how does it stack up against pharmacotherapy and other quitting strategies?
Cochrane reviews give strong evidence that compare nicotine replacement therapy (NRT), varenicline and bupropion are all effective.2
However some have stronger evidence than others.
“Head to head, if you compare NRT with vaping, with cold turkey, with varenicline or bupropion – just comparing one to the other – the one which is most successful judging attempt by attempt is varenicline,” says Professor Chapman.
A person needs a prescription for varenicline so a pharmacist should advise patients to speak to a doctor about it, he says.
“But a lot of people do not persist with varenicline and a lot of people don’t want to take it – they’ve heard that it messes with your head a bit, things like that. Worries about side effects are very common.”
Champix (varenicline) is what Jessica eventually used to successfully quit smoking.
“Champix worked for me,” she tells AJP.
“My friend recommended it as she was working as a smoking cessation counsellor with lower socio-economic groups and she’d used it herself.
“It was extremely successful, so much so I didn’t need the second script.
“I was meant to have counselling or call the Quitline but I lied to the GP as I didn’t.”
(This is not surprising, as Professor Chapman confirms that only about 3% of smokers ever call the Quitline.)
“With Champix you count down to the quit day and I did also continue to light up for a few days after the quit day,” Jessica continues.
“However, I did find Champix remarkable in that it was as if a switch had been turned off in my brain—smoking was merely a memory, not a craving I had to fight.
“I was also not bothered by other people’s smoke—it didn’t spark up a craving or desire to smoke as all urges to smoke had completely gone!”
Despite the resounding success, Jessica suffered from some side effects on the treatment.
“I had nausea—big time! I was throwing up everywhere until my friend told me not take Champix on an empty stomach and that worked completely. Some people report weird dreams although I wasn’t affected in that way.”
A 2016 Cochrane review on varenicline found that the most commonly reported adverse effect was nausea, which was mostly at mild to moderate levels and usually subsided over time.3
Based on 27 trials with 12,625 people (high-quality evidence), varenicline at standard dosage for continuous or sustained abstinence at six months or longer versus placebo was found to be effective (pooled relative risk [RR] 2.24; 95% confidence interval [CI] 2.06 to 2.43).
We know is that 90% of smokers regret having ever taken up smoking. So you’ve got a lot of people who are what I like to call very disloyal smokers.—Professor Chapman
It was found to be more effective than both bupropion and NRT.
High-quality evidence shows that pooled RR for varenicline versus bupropion at six months is 1.39 (95% CI, 1.25 to 1.54). 3
Compared to placebo, relative risk of abstinence for bupropion is 1.62 (95% CI 1.49 to 1.76).2
Meanwhile in a 2018 Cochrane review including 136 trials of NRT, with 64,640 people in the main analysis, researchers found evidence that all forms of NRT made it more likely that a person’s attempt to quit smoking would succeed—improving chances of a successful quit attempt by 50-60%.4
NRT is available as patches, lozenges, chewing gum or nasal sprays.
Relative risk of abstinence for any form of NRT relative to control is 1.55 (95% CI 1.49 to 1.61).
Moderate-quality evidence shows the RR for varenicline versus NRT for abstinence at 24 weeks is 1.25 (95% CI 1.14 to 1.37). 3
The Cochrane review found NRT worked with or without additional counselling and did not need to be prescribed by a doctor.
However Professor Chapman says NRT should ideally be combined with behavioural support.
“That means with support of a Quitline counsellor or a GP or a pharmacist – not a cashier, just someone across the counter – because these days you can go and take your NRT off the supermarket shelf or off the shelf in a pharmacy and you don’t even speak to a pharmacist or a doctor,” he says.
Vaping: not a silver bullet
Use of e-cigarettes has been heralded by some as a safe way to reduce cigarette smoking.
E-cigarettes don’t involve burning tobacco, rather they are filled with a liquid that contains flavouring agents, propylene glycol and potentially nicotine.
A small heating element inside the device turns the liquid into vapor that is then inhaled through a mouthpiece and into the lungs – a practice known as vaping.
Vaping devices come in a variety of forms, from systems that look like imitation cigarettes, to tank systems that can be quite large, and even devices that look like USBs and plug into your computer to charge.
While the popularity of vaping has skyrocketed – despite e-cigarettes not being approved either in Australia or America for smoking cessation – debate continues about whether they are really a safe avenue to quit.
Critics suggest vaping has health risks of its own or can even act as a ‘gateway drug’—drawing people, particularly vulnerable young people, into eventually moving onto smoking cigarettes.
So are e-cigarettes an effective avenue for smoking cessation?
A January 2019 randomised trial including 886 participants, published in the New England Journal of Medicine (NEJM), found that one-year abstinence in the e-cigarette group was 18%, compared with 9.9% in the NRT group (RR 1.83; 95% CI 1.30 to 2.58, p<0.001).5
However the study also found that among participants with sustained abstinence at one year, 63 out of 79 (80%) in the e-cigarette group were still using e-cigarettes, whereas only four of 44 (9%) in the NRT group were still using nicotine replacement.
“This differential pattern of long-term use raises concerns about the health consequences of long-term e-cigarette use,” say Dr Belinda Borrelli and Dr George O’Connor from the Boston University School of Medicine, in an accompanying NEJM editorial.6
Comprehensive research by the National Academies of Sciences, Engineering, and Medicine (NASEM) published in January 2018 found there is conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances.7
Additionally NASEM found substantial evidence that e-cigarette aerosol contains metals.
But evidence also showed that except for nicotine, under typical conditions of use, exposure to potentially toxic substances from e-cigarettes is significantly lower compared with combustible tobacco cigarettes.
Professor Chapman says we need to look at vaping with a balanced view of the evidence.
“You will read all sorts of wild and wonderful claims about how successful vaping is, and a lot of them are really, really overhyped and from very, very dodgy studies,” he tells AJP.
“A lot of that hype is driven by people who’ve got a commercial interest in it taking off,” he says.
For example, all the major tobacco companies now have investments in e-cigarettes—what they call ‘heat-not-burn’ products.
Philip Morris, which is the second biggest tobacco company in the world after the China National Tobacco Corporation, recently invested US$12.8 billion dollars in a vaping product called Juul, which growing in popularity among young people in the US.
“The business model for these companies is not to quit smoking and vape instead, it’s to keep smoking and to vape when you can’t smoke,” says Professor Chapman.
He explains that longitudinal studies are currently the best form of evidence, particularly those that measure persistent abstinence—usually meaning a person hasn’t smoked for 30 days.
In a June 2018 study published in the American Journal of Epidemiology, data looked at people who were using e-cigarettes at the beginning of the study, those who took it up during the 12 months, those using NRT, varenicline and bupropion, and people who weren’t using anything.8
Altogether examining 3,093 American quit attempters, those who weren’t using anything did the best – 12.5% had persistent abstinence.
Meanwhile vaping was down the other end with persistent abstinence at 5.6%.
“Vaping advocates try to say, ‘oh this is too important to regulate, we need to cut red tape, this is going to save a billion lives this century, it’s as big a breakthrough as antibiotics’—you hear all these kinds of wild exaggerations,” says Professor Chapman.
“If [e-cigarettes] are as good as vaping advocates say, then they can provide that evidence to the TGA.”
Time to quit? How pharmacy can help
For smoking cessation treatments that already have strong evidence behind them and are regulated by the TGA, pharmacists can assist with choosing the right one for each patient while supporting them through the process.
Bill Suen, former community pharmacy owner and immediate past State Manager of the PSA (Mr Suen moved onto a new role shortly after this article was written), points out that pharmacists are knowledgeable about nicotine addiction.
“Pharmacists have a lot of counselling skills, as well as a lot of knowledge about pharmacotherapy treatment for smoking cessation,” he tells AJP.
“The other very important part is that pharmacists are the most accessible health professionals in Australia. Nowadays most pharmacies are available seven days a week, 12 hours a day or more, and the general public can actually see a pharmacist without making an appointment. That’s the fantastic infrastructure that we have in community pharmacy.”
Mr Suen says pharmacists can extend their influence by:
- Identifying potential candidates for smoking cessation;
- Supporting them with advice and treatment;
- If required, referring them to appropriate organisations.
“Pharmacists should equip themselves with the most up-to-date knowledge, because addiction and harm minimisation concepts evolve, new research provides new information and new approaches all the time, so you must keep up to date,” he says.
“Secondly you also need to educate your staff to help them identify potential candidates and make appropriate referral back to a pharmacist.
“Thirdly you have to equip your pharmacies with appropriate treatment and also referral tools.”
PSA is leading the way in this area, particularly in Victoria.
The organisation has collaborated with Quit Victoria over the last 12 months to run a series of professional development training for pharmacists to update them with best practice for smoking cessation.
Mr Suen explains that the PSA set up referrals to go to Quit Victoria, so pharmacists can identify the appropriate candidates.
“What we do is we train our pharmacists to identify the right people, provide counselling and recommend appropriate treatment. And at the same time refer them to Quit Victoria for ongoing support and counselling,” he tells AJP.
There is high-quality evidence that individually delivered smoking cessation counselling can assist smokers to quit, according to a 2018 Cochrane review. 9
Individual counselling has been found to be more effective than minimal contact control (brief advice, usual care, or provision of self-help materials) when pharmacotherapy is not offered (RR 1.57, 95% CI 1.40 to 1.77).
There is also moderate-quality evidence of benefit of counselling with NRT (RR 1.24 95% CI 1.01 to 1.51).
“Any counselling should be done in a way where the privacy of the patient is maintained,” says Mr Suen.
“Part of training is to identify the right people, often when they come in to ask for recommendations for other medical conditions like asthma, COPD – part of this should be asking questions about smoking behaviour.
“You need to have a really tactful way of raising the discussion otherwise you’ll make people feel like they are under threat or alienated because they are smokers.
“That’s an approach that we can actually teach pharmacists and pharmacy assistants to actually raise the subject matter in a non-threatening and supportive way. And that’s part of training that’s run by Quit Victoria, which PSA is rolling out to pharmacists.”
Professor Chapman says the appetite to quit is certainly there if pharmacists want to play a role.
“We know is that 90% of smokers regret having ever taken up smoking. So you’ve got a lot of people who are what I like to call very disloyal smokers—I can’t think of any other consumer product where 90% of people say for example, yes I drive a particular brand of car and I hate it, I wish I had never gotten it. Or I eat chocolate and I wish I didn’t.
“But 90% of people who smoke are not happy smokers, they’re people who are bothered by it, wish they’d never taken it up and they’re always talking about, ‘I’m going to give this up one day’,” he says.
“So there’s a big appetite for quitting and around about 40% of smokers make some sort of attempt during the course of a year.”
Jessica is certainly glad she kept persisting until she finally gave up smoking for good.
As a former smoker, she feels “relief, really”.
“I don’t have the shame and hassle of smoking!” she says.
“I sort of joked that I thought I’d be able to run a four-minute mile but of course that didn’t happen!
“To be honest I don’t feel any healthier as smoking didn’t make me feel specifically ill—really just cleaner and definitely more free.”
*name has been changed.
- Smith A, Carter S, Chapman S, Dunlop S, et al. Why do smokers try to quit without medication or counselling? A qualitative study with ex-smokers. BMJ Open. 2015.
- Hartmann-Boyce J, Aveyard P. Drugs for smoking cessation. BMJ. 2016 Feb 23;352:i571. doi: 10.1136/bmj.i571.
- Cahill K, Lindson‐Hawley N, Thomas KH, Fanshawe TR, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2016, Issue 5. doi: 10.1002/14651858.CD006103.pub7.
- Hartmann‐Boyce J, Chepkin SC, Ye W, Bullen C, et al. Nicotine replacement therapy versus control for smoking cessation. Cochrane Database of Systematic Reviews 2018, Issue 5. doi: 10.1002/14651858.CD000146.pub5.
- Hajek P, Phillips-Waller A, Przulj D, Pesola F, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med. 2019 Feb 14;380(7):629-637. doi: 10.1056/NEJMoa1808779. Epub 2019 Jan 30.
- Borrelli B, O’Connor G. E-Cigarettes to Assist with Smoking Cessation. N Engl J Med. 2019 Feb 14;380(7):678-679. doi: 10.1056/NEJMe1816406. Epub 2019 Jan 30.
- National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. doi: 10.17226/24952.
- Benmarhnia T, Pierce JP, Leas E, White MM, et al. Can E-cigarettes and pharmaceutical aids increase smoking cessation and reduce cigarette consumption? Findings from a nationally representative cohort of American smokers. Am J Epidemiol. 2018 Nov 1; 187(11):2397–2404. doi: 10.1093/aje/kwy129
- Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database of Systematic Reviews 2017, Issue 3. doi: 10.1002/14651858.CD001292.pub3.