Combination NRT gets higher quit rates: new study

A new study published this month in the journal “Archives of General Psychiatry” aimed to compare the effectiveness of some of the main medicines for stopping smoking and their combinations. The study, by Dr Megan Piper and colleagues at University of Wisconsin, recruited just over 1500 smokers seeking help to quit, and randomly allocated them to use either, placebo nicotine replacement, the nicotine patch, nicotine lozenge, bupropion tablets, buproion plus nicotine lozenges ,or the patch plus nicotine lozenges.

This was one of the biggest and most ambitious placebo-controlled trials of smoking cessation medicines ever published. Each participant was provided with medication to last a normal course of treatment, as indicated on the product label, plus 6 brief face-to-face counseling sessions. The key questions were:
1. Do each of the individual medicines (patch, lozenge, bupropion) produce higher quit rates than placebo?
2. Do combination medicines produced higher quit rates then individual medicines?


This was a “double-blind” study, meaning that both the participants and the researchers didn’t know who had active medicine and who had placebo, until the study was completed. Most of the medicines were provided for 8 weeks, but the lozenge could be used for 12 weeks after the planned quit date (as is normal according the labeling).

The researchers looked at the proportions of smokers who were quit (no smoking in previous week) at 2 and 6 months after the target quit rate. The quit rates at the 2 month follow-up were as follows:

Placebo : 30%
Patch: 45%
Lozenge: 40%
Bupropion : 40%
Bupropion plus lozenge: 50%
Patch plus lozenge: 54%

At 6 month follow-up the quit rates were:
Placebo : 22%
Patch: 34%
Lozenge: 34%
Bupropion : 32%
Buoropion plus lozenge: 33%
Patch plus lozenge: 40%

Each of the individual medicines achieved higher quit rates than placebo, but the patch plus lozenge combination had higher quit rate again. So these results add to the growing evidence suggesting that combining the nicotine patch plus another NRT is significantly better than either medicine alone.

This study was embedded in a larger 3-year study of factors influencing health, and this may explain the unusually high quit rate in the placebo group. To get into this study all the participants had to be willing to attend numerous appointments over a 3 year period, implying that they were (a) very highly motivated to improve their health and (b) relatively confident in the stability of their life over the coming 3 years.

One other noteworthy aspect of these results was that they appear to confirm the recent trend of results finding bupropion to be equivalent to but no better than NRT for smoking cessation. In the early bupropion trials it looked like bupropion may get slightly higher quit rates than the patch, but more recent studies (including this one) have found bupropion to give very similar outcomes to NRT. Perhaps the most disappointing result in this study was that of bupropion plus lozenge (no better than lozenge alone at 6 months). However, I suspect that this was a fluke poor outcome, caused by a few more participants relapsing after coming off their meds. Although the trial overall is relatively large, each “arm” has only around 250 participants, and so the quit rate is substantially influenced by just a few more people quitting or relapsing.

So this study confirms that the nicotine patch remains a pretty good basic smoking cessation aid, but that adding on another NRT on top of the patch helps more smokers to quit. Other studies suggest that quit rates could be boosted even further by (a) allowing participants to use the patch for a few weeks prior to their target quit date and (b) encouraging those doing well at two months to continue using their NRT for up to 6 months (or as log as needed). This trial did not provide a direct comparison with varenicline (Chantix/Champix) but other studies suggest that varenicline produces quit rates in the same ball park as patch plus another NRT.

We have now been consistently seeing research studies showing that combination NRT is more effective than single NRT for over a decade, and yet the labeling on all of these NRT products continues to warn patients not to combine them. Maybe its time the labeling on these medicines was changed so as not to warn smokers away from using them in the most effective way?

Reference:
Piper ME, Smith SS, Schlam TR, Fiore MC, Jorenby DE, Fraser D, Baker TB. A randomized placebo-controlled clinical trial of 5 smoking cessation pharmacotherapies.Arch Gen Psychiatry. 2009 Nov;66(11):1253-62.

This link should take you to the full report on the study:
http://archpsyc.ama-assn.org/cgi/content/full/66/11/1253

Labels: bupropion, combination, jonathan foulds, lozenge, Megan Piper, nicotine patch, nicotine replacement therapy, NRT, Smoking, smoking cessation, trial

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Menthol: it helps the poison go down easier

I’m writing from the second conference on menthol and cigarettes, in Washington DC. This conference was organized to review the evidence on the effects of menthol in cigarettes and to discuss what further research is necessary and what actions should be taken.

To me, the presentations appeared to suggest that right now the evidence that menthol cigarettes are more harmful to health is weak. However, the evidence that menthol cigarettes are a starter product for youth and that menthol cigarettes can (under certain circumstances) be more addictive and harder to quit, is quite strong and getting stronger all the time.

My own presentation focused on data we have previously published (and that I’ve already discussed on this blog) showing that menthol cigarettes are harder to quit for African Americans, Latinos and for people on a low income. It was very fortunate that just yesterday a new study by colleagues at UMDNJ-School of Public Health came into the public domain and so I was able to discuss its findings.

I think that study, by Drs Dan Gundersen, Cris Delnevo and Olivia Wackowski, is a very important one. The paper, which will be published in the journal “Preventive Medicine” and appeared online yesterday, was based on the 2005 National Health Interview Survey. It focused on a representative sample of U.S. adult ever exclusive cigarette smokers who had ever tried to quit (n=7,815). It aimed to assess whether people who were primarily menthol smokers had a lower quit rate than people who were regular cigarette smokers (after adjusting for other characteristics of those groups). The study found that among African American and Hispanic smokers, those who smoke menthols have a significantly lower rate of quitting. Interestingly it found that among whites, there was an opposite effect, with white menthol smokers having a slightly higher quit rate than white regular cigarette smokers.

One of the pleasing parts for me about this study was that the results, in a representative sample of smokers who had tried to quit, were almost perfectly consistent with the results we had previously published based on people trying to quit at our smokers clinic (Gandhi et al, 2009). Like our clinic study, this new paper found that the effect of menthol on inhibiting smoking cessation is a sizeable one. For example, among African Americans, while 62% of regular cigarette smokers successfully quit, only 44% of menthol smokers were able to quit. Also like our clinic study, the effect remained significant after controlling for differences in the relevant characteristics of those who smoke regulars and menthols. Also like our clinic study, the menthol effect differed between white (non-Hispanic) smokers and minority smokers. But one thing that was different was that Dr Gundersen’s study found that white menthol smokers were actually MORE likely to quit than white non-menthol smokers. So the question remains, why the difference of effect of menthol on quitting smoking between whites and minorities?

I remain convinced that the underlying mechanism of action of menthol is to enable smokers to inhale more nicotine (and smoke) under circumstances that require it. The main circumstance requiring the smoker to inhale more nicotine per cigarette is a situation forcing the smoker to reduce their daily cigarette consumption. There are various forces requiring smokers to reduce their cigarette consumption, but a major one is money. In recent times as cigarettes have become more expensive across the United States, many smokers can no longer afford to smoke a pack a day. So they have to reduce to 5 or 10 cigarettes per day or try to quit. Of course we know that as smokers reduce, they rend to inhale more nicotine per cigarette (an effect often referred to as “nicotine compensation”). But inhaling more smoke per cigarette can cause harsh sensations in the throat. Menthol cools that effect, making it easier for larger doses of the poison to go down (Williams et al, 2007). But one of the effects of inhaling a higher dose of nicotine per cigarette is that each cigarette becomes more reinforcing and addictive. Although there is always more than one explanation for any effect, I believe that facilitation of increased nicotine inhalation is one of the main effects of menthol. But people who have plenty of money don’t need to smoke fewer each day, and inhale more from each one. So there is a socioeconomic difference in the effect. This is part of the reason for the difference of effect of menthol in whites and minorities. In our clinic study we found a similar menthol effect in unemployed whites that we did in employed African Americans (with no effect of menthol on quitting at all in employed whites).

I suspect that if national data is analyzed focusing on unemployed white smokers living in the north east of the U.S. (the highest cigarette cost area), who tried to quit in recent times (when high cigarette taxes kicked in), we would find a lower quit rate among the menthol than the non-menthol smokers in that group.

In terms of harms to health, we’d more easily find these in the short term by looking, for example, at pregnancy outcomes in menthol versus non-menthol smokers. I’m suggesting greater study of the effects of menthol in pregnancy because it’s a situation when many smokers try to cut down or quit, but many remain smoking, and in which the health impact can be measured in the short term (e.g. birth weight and complications).

I’m leaving this conference with a greater clarity that menthol added to cigarettes make it easier for young people to start smoking and harder for smokers to quit, because menthol helps the poison go down easier.


References

Gundersen D, Delnevo C, Wackowski O. Exploring the relationship between race/ethnicity, menthol smoking, and cessation, in a nationally representative sample of adults. Preventive Medicine (2009), doi:10.1016/j.ypmed.2009.10.003

Gandhi KK, Foulds J, Steinberg MB, Lou SE, Williams J. Lower quit rates among menthol cigarette smokers at a tobacco treatment clinic. International Journal of Clinical Practice 2009 Mar;63(3):360-7.

Williams JM, Gandhi KK, Steinberg ML, Foulds J, Ziedonis DM, Benowitz NL. Higher nicotine and carbon monoxide levels in menthol cigarette smokers with and without schizophrenia. Nicotine Tob Res. 2007 Aug;9(8):873-81.

Labels: African American, cessation, cigarette, ethnicity, Gundersen, Hispanic, jonathan foulds, latino, menthol, NHIS, race, Smoking, white

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Mortality risks of smoking and obesity.

Both smoking and obesity cause increased health problems, but it is unusual to find an analysis of their separate and combined effects in a single study. One such study was published by Dr Freedman and colleagues of the National Cancer Institute in 2006. They analyzed a nationwide, prospective mortality study of U.S. radiologic technologists (64,000 women and 18,000 men) who were recruited 1983-89 and followed up to 2002. As in many studies of obesity the main measure was the Body Mass Index (BMI) which is a measure of body fat based on height and weight that applies to both adult men and women. The “normal weight” BMI comprises the range of 18.5 to 24.8. For example, the upper boundary for “normal weight” for someone who is 5 feet 10 is 173 pounds (bmi=24.8), and a person of that height would be classified as obese at a weight of 209 pounds (bmi=30) and “very obese” at a weight of 244 pounds (bmi=35).

For women aged under 65 who never smoked, there was no excess risk of death due to being obese, but for those in the “very obese” range the mortality risk relative to normal weight people was 1.87 (ie increased by 87%). However, compared to a normal weight never smoker, the relative risk for a normal weight smoker was 2.22 (i.e. increased by 122%, I.e more than doubled). This shows that the mortality risk caused by smoking is greater even than the risk due to being “very obese”. In fact this means that for a normal weight individual, the excess mortality risk due to smoking is greater than the risks due to putting on over 70 pounds!

Of course the mortality risks are larger still (RR=5.2) for someone who is very obese AND smokes. The mortality risk patterns for men were similar to those of women

The mortality risks from circulatory diseases were particularly affected by smoking and BMI, with combined smoking and obesity producing a 6-11-fold increase in cardiovascular mortality risks.

Overall, the study found that, “in all gender/age groups, both obesity and smoking, particularly current smoking, contributed substantially to all-cause mortality, with 3.5- to 5-fold risks for very obese, current smokers compared to normal weight, never smokers. Current smoking was the predominant risk factor for cancer mortality. Combining obesity with current smoking increased circulatory disease mortality by 6- to 11-fold for people aged less than 65 years, compared to normal weight, never smokers. Obese former smokers (less than 65 years) had notably lower risks.”
The authors of the study concluded that:
“Obese smokers (aged less than 65 years) had strikingly high mortality risks, particularly from circulatory disease mortality.”
It is clear from this study that smoking poses much larger health risks than obesity, but that combining these risk factors produces marked increases in health risks. Smokers planning to quit, or ex-smokers who may have put on some weight should know that the health benefits of quitting smoking far outweigh the health risks of putting on a few pounds (e.g. 10 pounds).

Reference:
Freedman DM, Sigurdson AJ, Rajaraman P, Doody MM, Linet MS, Ron E. The mortality risk of smoking and obesity combined. Am J Prev Med. 2006 Nov;31(5):355-62.

Labels: BMI, jonathan foulds, mortality, obesity, risks, Smoking, weight

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Debunking myths about self-quitting (1989): a classic study.

Every now and again I’d like to pick a classic research study from the past which shaped our understanding of smoking cessation. Today I’m going to focus on a paper by Dr Sheldon Cohen and 16 other researchers (recognized experts in the field 20 years later) entitled “Debunking myths about self-quitting. Evidence from 10 prospective studies of persons who attempt to quit smoking by themselves.”

The study was conducted because a prior paper, based on a small number of people (161) had suggested that people who quit on their own are generally quite successful (more so than people who go for professional treatment) and that heavy smokers were just as likely to quit successfully on their own as light smokers. The researchers decided to pool together the data from 10 larger studies of “self-quitters” (smokers making a quit attempt without receiving any formal treatment), in order to get to the truth on these questions.

They picked 10 “prospective” self-quitting studies that followed people up for at least 6 months (most were at least 12 months) and that provided biochemical or other verification of people’s claim to have quit. Using prospective studies avoids the self-selection and recall biases you get when you simply recruit a group of people and ask them what it was like for them when they tried to quit. The 10 studies had taken place all over the country and included over 5,000 smokers and so this was thought more likely to provide results that would be generalizable to the population of smokers trying to quit on their own in the United States. One other good aspect of this study was that it included different measures of quitting, and assessed outcomes at numerous time points, enabling an analysis of both continuous “not a puff” quitting after a single attempt, as well as long term “point prevalence” abstinence, that may be the result of repeated quits and relapses over time.

The median “not a puff” continuous quit rate a year later was 4.2% and the median “point prevalence, not smoked in the past week” quit rate at 12 months was 14%. Those who tried to quit completely on their own, and those who had a manual to help them had similar quit rates. The study also found that heavy smokers (those smoking over a pack a day) were less than half as likely to quit for a year as less heavy smokers (a pack per day or less).

The study examined whether the number of previous quit attempts predicted the likelihood of successful quitting on this quit attempt. It found that although those who had never tried to quit before had slightly lower quit rates, there was no significant relationship between the number of prior quit attempts and success this time. A substantial proportion (24%) of those who had quit at 6 months had relapsed back to smoking by 12 months.

So this study was successful in debunking a number of myths about quitting smoking that were prevalent at the time. It showed that smokers who simply try to quit on their own with no assistance, do not (as had been claimed, and is still sometimes claimed) have surprisingly high quit rate. In this study the one year quit rates were in the range 4-14% depending on your definition. It also showed that quit rates vary by simple measures of baseline ‘dependence,” with heavier smokers having lower quit rates than less heavy smokers. It also found that the number of previous quit attempts has relatively little influence on a smoker’s chances of successfully quitting on the next quit attempt. Finally the study showed that a substantial proportion of smokers (around a quarter) who quit for 6 months, are likely to relapse in the next 6 months. One of the main conclusions of the study was that, “quitting smoking (by oneself or with the aid of a program) should be viewed as a process and not as a discrete event.” Wise words.

20 years later, even although the core findings from this study have been replicated many times, we still hear some of the myths about quitting smoking being repeated. The classic mistake (which resulted in the small study that prompted this one) is to try to figure out how people quit by asking a handful of successful self-quitters what it was like for them. Don’t be surprised if they tell you that the last time (i.e. the successful one, so far) wasn’t too hard. But that would be missing out on data from the other 95% of quit attempts that were not successful.

Reference
Cohen S, Lichtenstein E, Prochaska JO, Rossi JS, Gritz ER, Carr CR, Orleans CT, Schoenbach VJ, Biener L, Abrams D, et al. Debunking myths about self-quitting. Evidence from 10 prospective studies of persons who attempt to quit smoking by themselves. Am Psychol. 1989 Nov;44(11):1355-65.

Labels: cessation, classic, jonathan foulds, myths, self-quitting, Sheldon Cohen, Smoking, unassisted

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Smoking after cancer diagnosis: Comment by Patrick Swayze’s doctor on CNN’s Larry King

Many people were saddened to hear of the recent death of the actor Patrick Swayze, after an almost two year battle with pancreatic cancer. Patrick Swayze was a very successful actor, most noted for his leading roles in the hit movies, Ghost and Dirty Dancing.

Within the past week, one of Patrick Swayze’s oncologists, Dr George Fisher, was interviewed on the CNN “Larry King Live” show and made the following comments:

LARRY KING: “He continued to smoke. Was that a bad idea?”

DR. GEORGE A. FISHER, ONCOLOGIST, STANFORD HOSPITAL & CLINICS: “I think at the point that one is already diagnosed with cancer, there's little additional harm in it. And if it -- it seems to provide him some comfort or partly identity of who he is, I certainly have no objections to that. But he would be the first to say that if you don't smoke, don't start. And if you do smoke, quit before you develop cancer.”

I suspect that Dr Fisher’s comments were referring to the specific context of someone suffering from a severe type of terminal cancer where the estimated life expectancy is in months rather than years, and not referring to all cancer diagnoses. So I think it is important that people, and particularly those people with a recent cancer diagnosis who are still smoking or recently quit, don’t take this comment out of context. Nowadays many types of cancer can be cured or effectively managed over a period of many years, and it is very clear that for many of these cancer diagnoses, the prognosis is much better if the patient quits smoking.

Below is a quote from a published review by an expert on this subject, Professor Ellen Gritz, of MD Anderson Cancer Center:
“The detrimental effect of smoking on cancer survival rates has been consistently demonstrated. Continued smoking after diagnosis has been found to negatively affect overall survival in patients with lung, head and neck, prostate, and cervical cancers. However, stopping smoking before diagnosis and treatment can have a positive influence on survival rates. Studies have generally indicated that the longer the interval between smoking cessation and initiation of cancer treatment, the better the prognosis.“

(Gritz ER, Fingeret MC, Vidrine DJ, Lazev AB, Mehta NV, Reece GP. Successes and failures of the teachable moment: smoking cessation in cancer patients. Cancer. 2006;106:17–27.)

Just last month the results of a very large study were published showing better outcomes for smokers who quit sooner after lung cancer diagnosis. I’ve copied the study summary below. Just to be clear, the research evidence shows that in the vast majority of cancer diagnoses, health outcomes will be improved by quitting smoking.


Impact of smoking cessation before resection of lung cancer: a Society of
Thoracic Surgeons General Thoracic Surgery Database study.
Mason DP, Subramanian S, Nowicki ER, Grab JD, Murthy SC, Rice TW, Blackstone EH. Ann Thorac Surg. 2009 Aug;88(2):362-70; discussion 370-1.

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute,
Cleveland Clinic, Cleveland, Ohio 44195, USA. masond2@ccf.org

BACKGROUND: Smoking cessation is presumed to be beneficial before resection of
lung cancer. The effect of smoking cessation on outcome was investigated.
METHODS: From January 1999 to July 2007, in-hospital outcomes for 7990 primary
resections for lung cancer in adults were reported to the Society of Thoracic
Surgeons General Thoracic Surgery Database. Risk of hospital death and
respiratory complications was assessed according to timing of smoking cessation,
adjusted for clinical confounders. RESULTS: Hospital mortality was 1.4% (n =
109), but 1.5% in patients who had smoked (105 of 6965) vs 0.39% in those who had
not (4 of 1025). Compared with the latter, risk-adjusted odds ratios were 3.5 (p
= 0.03), 4.6 (p = 0.03), 2.6 (p = 0.7), and 2.5 (p = 0.11) for those whose timing
of smoking cessation was categorized as current smoker, quit from 14 days to 1
month, 1 to 12 months, or more than 12 months preoperatively, respectively.
Prevalence of major pulmonary complications was 5.7% (456 of 7965) overall, but
6.2% in patients who had smoked (429 of 6941) vs 2.5%% in those who had not (27
of 1024). Compared with the latter, risk-adjusted odds ratios were 1.80 (p =
0.03), 1.62 (p = 0.14), 1.51 (p = 0.20), and 1.29 (p = 0.3) for those whose
timing of smoking cessation was categorized as above. CONCLUSIONS: Risks of
hospital death and pulmonary complications after lung cancer resection were
increased by smoking and mitigated slowly by preoperative cessation. No optimal
interval of smoking cessation was identifiable. Patients should be counseled to
stop smoking irrespective of surgical timing.

The CNN interview transcript is at:
http://transcripts.cnn.com/TRANSCRIPTS/0909/19/lkl.01.html

Labels: cancer, cessation, cigarette, CNN, diagnosis, George Fisher, jonathan foulds, Larry King, Patrick Swayze, Smoking, survival

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Concerned you might relapse to smoking?

Most ex-smokers who have succeeded in quitting for many months or years, have occasional periods where they feel at risk of relapsing to smoking. There are many potential triggers, but the most common include (a) after having an isolated “lapse” cigarette, e.g. at a party (b) when in a different kind of environment and feel you “deserve” a break…e.g. on vacation (c) while under a lot of psychological stress. In all of these situations, the presence of accessible cigarettes is a major risk factor for relapse. That is why we always advise smokers who are trying to quit to make sure there are no cigarettes, tobacco or other smoking materials (e.g. lighters) in the house.

Of course, this means that living with a smoker can be a major relapse risk itself.

Right now, many people in the United States are experiencing the stress associated with the very bad economic situation. Many have lost their jobs or are concerned that they might. Many have lost their homes or are concerned that they might. This is precisely the kind of stress that may cause some people to start craving cigarettes again.

Here in my home state of New Jersey we were particularly impacted by the terrorist attack on September 11th, 2001. Many people living in New Jersey either worked in Manhattan at the twin towers or knew people who did. The data on smoking rates within the state appear to show a slight increase in smoking among middle-aged people. Although we don’t know this for sure, I suspect that was due to a significant number of ex-smokers relapsing to smoking after the events of 9/11. I remember hearing the story of one man who had quit smoking for a long period at our clinic. On 9/11 he found himself over a thousand miles from home on business. Because of the disruption to flights at that time, he decided to rent a car and drive home. He relapsed to smoking on the journey.

So what should an ex-smoker who feels at risk of relapsing do to prevent it?

One thing to note is that if you have quit for years and had either no tobacco or a few lapses, then you are not currently nicotine dependent in the same sense as a current smoker. You would not have any nicotine withdrawal symptoms just now. It is therefore very important to avoid becoming highly dependent again. But having not smoked for a long time, it is not appropriate to use a medicine (NRT, bupropion or vareniclene) to help you stay stopped.

One of the most obvious things to do is to make sure there is no tobacco around that is easily accessible. If there is any tobacco in the house, car or garage, get rid of it properly. If a family member or person sharing your accommodation smokes, make sure they don’t smoke in the building and don’t leave their cigarettes laying around.

The other main thing I recommend is to take some time to reconsider the reasons you quit smoking in the first place, and the reasons why it is important not to go back to smoking now. You may have quit before you had kids, but they provide a good additional reason to stay quit now. You may have hated being addicted and struggled really hard to quit. The desire not to become addicted and have to go through all that again, may strengthen your motivation. You might have quit partly because of the expense of smoking….well the expense is even higher nowadays. But really it is best for you to bring to your mind and maybe even write down the reasons you don’t want to smoke again. From that list, pick your top 2 or 3 reasons, and bring them back to your mind whenever you have a thought of smoking.

Below are links to a couple of previous posts that may be particularly relevant to ex-smokers feeling vulnerable to relapse.

Quitting smoking while living with a smoker. 3/25/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/quitting-smoking-while-living-with.html

One cigarette wouldn’t do any harm, would it? 11/05/07
http://www.healthline.com/blogs/smoking_cessation/2007/11/one-cigarette-wouldnt-do-any-harm-would.html

Labels: jonathan foulds, relapse, Smoking

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Lung Cancer

November is lung cancer awareness month – aiming to increase awareness of lung cancer, and its causes and to stimulate activities aimed at preventing and treating lung cancer.

Most people are aware that by far the biggest cause of lung cancer is tobacco smoke, whether it be via active smoking of cigarettes or cigars, or exposure to environmental tobacco smoke pollution (secondhand smoke). Many people are still surprised to learn that lung cancer kills more women than breast cancer. The risks of lung cancer increase dramatically with age and years of tobacco smoking. Men who continue to smoke are over 20 times more likely to die of lung cancer compared with men who have never smoked. At age 75, never smokers have a cumulative risk of lung cancer of less than one percent. Those who smoked but quit at age 50 have a cumulative risk of lung cancer by age 75 of 6%. Those who continue smoking have a cumulative risk of lung cancer by age 75 of over 16%. So it is clear that quitting smoking reduces the risks of lung cancer, even if you have smoked for decades. However, the risks do not return to those of a never smoker and it takes about 15 years without smoking for the increased risks to be cut in half.

Environmental tobacco smoke pollution also causes lung cancer. This cause accounts for a significant proportion of the never smokers who get lung cancer. So living with someone who smokes in the home, or working in an environment where people smoke (e.g. a bar, restaurant or casino) will significantly increase your lung cancer risks even if you never smoked yourself. This is part of the reason why many countries and states have passed laws to prevent smoking in workplaces (and remember, bars, restaurants and casinos are workplaces too). Its also part of the reason that many homes have also become smoke-free – requiring family, friends and guests who smoke to take it outside rather than pollute the air inside the home with carcinogens.

Unfortunately the 5-year survival rate for lung cancer remains very low – around 15%, and so far there has not been very convincing evidence that going for CT scans is particularly effective in detecting curable lung tumors at an early stage (without giving false-positives causing unnecessary treatment).

On the positive side, lung cancer is largely preventable on an individual level by not smoking and by avoiding smoky places. On a national level too, we know how to prevent most lung cancer, by implementing comprehensive tobacco control policies including smoke-free workplace legislation, increasing cigarette taxes, hard-hitting mass media educational campaigns, and providing effective smoking cessation treatments. For reasons not entirely unrelated to political campaign contributions from tobacco companies, successive governments have chosen not to adequately fund these effective lung cancer prevention efforts – even though they happen to prevent heart disease, respiratory disease and numerous other illnesses at the same time.

At this moment the President of the United States has promised to veto legislation that has been approved by both the Senate and Congress to increase cigarette taxes to pay for health insurance for poor families. Protecting the tobacco industry in this way leads directly to many more cases of lung cancer.

The symbol for lung cancer awareness is a clear ribbon – symbolic of the “invisible cancer” that receives far fewer dollars for prevention and treatment or public attention than other types of cancer.

For those wishing to learn more about the ways that tobacco harms health, some colleagues and I have just published a fairly detailed review of the health effects of tobacco as a chapter in a new book . You can access the pdf of this chapter via the following link:
http://www.tobaccoprogram.org/staffarticles.htm

Labels: lung cancer, Smoking

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Smoking, smokeless tobacco and cancer (2)

My previous post discussed toxin delivery from different tobacco products. Now what is the evidence relating use of these products to health problems? Unfortunately most studies don’t collect data on different brands or even categories of smokeless tobacco being used, and few compare directly the risks from smokeless with those from smoking. However, we can get a sense of the risks by examining studies based in different parts of the world where different types of tobacco are used. When we look at it this way we can find very clear evidence that the types of smokeless tobacco used in Sudan and India increase the risk of oral cancer. There is also toxicological evidence showing that Sudanese smokeless tobacco has very high concentrations of TSNAs (carcinogenic toxins), as do some forms of smokeless tobacco used in India. In Asia the picture is complicated by the tradition of adding other ingredients, especially areca nut which is highly carcinogenic on its own.

Then when we look at studies of smokeless tobacco use from the U.S. we see mixed results. One particular study published in the 1980s found very high risks of oral cancer. That study by Professor Deborah Winn and colleagues focused on women in southern United States and found that white never-smoking women (who tend to use oral dry snuff powder) had a relative risk of over 4.2 (2.6-6.7), for developing oral and pharyngeal cancer. Women who had used smokeless tobacco for 50 years had a 50-fold increase in risk for some oral cancers. It should be noted that only a tiny minority of smokeless users use the type of dry snuff tobacco that is commonly used by women in these rural parts of North Carolina. It should also be noted that the type of smokeless tobacco with the extremely high concentration of toxins mentioned in my previous post was also a type of dry snuff. So it begins to look like it’s the smokeless tobacco with very high toxin levels that has evidence of a causal effect on oral cancer. In fact, one of the largest studies on the effects of smokeless tobacco use in the United States (by the American Cancer Society) found no significant increase in the risk for oral cancer among smokeless tobacco users. One of these studies examined a population of 2488 smokeless tobacco users with a median age of 57 at enrolment (i.e. they'd used smokeless for decades) and followed them up 18 years later (i.e. mean age 75). This study found only one death from oral cancer in exclusive smokeless tobacco users, and none in former users, which was a slightly lower rate than occurred in people who had never used any tobacco in their life. These findings from the American Cancer Society suggest that any effect of commonly used brands of smokeless tobacco in the United States on oral cancer, if present, is relatively small.

Finally, we can examine the studies conducted in Sweden where the use of a form of low-toxin moist snuff (called snus) is more common than smoking in men. These studies consistently find no increased risk of oral cancer for snus users. One of the best of these studies was published in the Lancet recently and found that snus users have no increased risk of oral or lung cancer, but they have twice the risk of pancreatic cancer of never tobacco users. That same study found higher risks of all these cancers in smokers (e.g. smokers were about 10 times more likely to get lung cancer than either snus users or never tobacco users, who both had similar risks).

So now lets come back the recent report by Hecht and colleagues. It found similar concentrations of a specific carcinogen in smokeless users and smokers. But we have excellent data showing that smokers have much higher risks of lung cancer than smokeless users, and also higher risks of oral cancer than users of some forms of smokeless tobacco. The lung cancer pattern suggests that deposition of carcinogens directly into the lungs is relevant to the causal mechanism as smokeless tobacco has generally not been found to cause lung cancer in humans. But then we also have a higher risk of oral cancer for smokers. This causes one to consider whether the biomarker being measured in the urine in Hecht and colleague's study is very closely linked to the mechanism wherbye tobacco causes cancer in humans. Perhaps there are other toxins (e.g. benzo(a)pyrene) that are important in triggering cancer in smokers, but are found in lower levels in smokeless users? Whatever, the explanation, it seems that urine NNAL levels do not relate very closely to cancer risks in tobacco users.

But when discussing health risks from tobacco we need to be clear that these involve much more than lung or oral cancer, but also other cancers, and also other serious respiratory and cardiovascular diseases. For most of these, the health risks from smoking greatly outweigh the risks from smokeless tobacco. Chronic respiratory diseases are extremely common among smokers but there is neither good evidence nor a plausible rationale linking use of smokeless tobacco to these respiratory diseases.

So although it is clear that smokeless tobacco contains carcinogens and is not harmless, it is significantly less harmful than smoking cigarettes. I agree with Hecht and colleagues that we should not encourage anyone to use smokeless tobacco, when we have safe and effective medicines to help them quit smoking. However, I think we need to be able to give an honest answer to the question, “Are there forms of smokeless tobacco that are much less likely to kill me than smoking cigarettes?”. The honest answer is,”yes”. Similarly, of we are asked whether some types of smokeless tobacco may be less harmful than others, it seems prudent to suggest that some types of tobacco that have higher concentrations of toxins than others, and that the type of smokeless tobacco used in Sweden (snus) appears to be lower in toxins and health risks than much of the tobacco used in the rest of the world. It is far from risk-free (as are many things that people choose to do on a regular basis, like driving a car, eating donuts, drinking beer, mountain-climbing, or having sex), but experts agree that it is about 90% less harmful than smoking:
http://cebp.aacrjournals.org/cgi/content/full/13/12/2035
Similarly, given the relationship between toxin delivery and health effects from smokeless tobacco, it would seem to be sensible to regulate tobacco products in a manner that requires manufacturers to minimize the concentrations of toxins delivered as much as is technically possible.

In the mean time (and also after regulation is in place), manufacturers who produce and market products containing and delivering unnecessarily high quantities of toxins should be legally liable for the effects of their defective products.

Labels: cancer, smokeless, Smoking, tobacco

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Chantix and mental illness - what are the facts?

The August issue of the American Journal of Psychiatry included two letters reporting single cases of worsening of symptoms of schizophrenia and mania, while they were taking the new smoking cessation medication, Chantix (varenicline). Links to those case reports can be found below. It was also noticeable that some readers of my previous article on Chantix who were also taking medications for psychiatric problems wrote online comments about unpleasant side effects.
http://www.healthline.com/blogs/smoking_cessation/2007/04/chantix-how-does-this-new-quit-smoking.html

People suffering from major mental illnesses were excluded from the initial placebo-controlled trials of varenicline (Chantix), which showed that it is both safe and effective in helping smokers to quit. It is normal practice to exclude certain categories of patient from trials of new medicines, prior to the drug being approved for sale to the public. Often the reason is that patients with certain diagnoses are more likely to be taking medications that may affect the condition being treated (e.g. antidepressants could theoretically affect smoking cessation, as at least 2 antidepressants are effective for smoking cessation). Sometimes it is partly to protect those considered “at risk”, from taking an unlicensed experimental medicine. What we end up with is that many new medicines have mainly been studied in people who are relatively healthy, apart from having the condition the new medicine is designed to treat. Chantix is like many new drugs in this respect. It is also very common, especially for new medicines that are very widely used, for reports to appear of unusual side-effects occurring in some patients. I’ve published a few such reports myself.

However, it is not until fairly thorough additional placebo-controlled studies have been published in more patient groups, that we can tell with any confidence whether the new drug really does cause problematic side effects in certain patient groups or not. Sometimes such studies are never carried out and in that case we need to rely on the reported experiences of clinicians treating those patient groups over a period of time.

One thing we have to bear in mind is that when a person starts using Chantix, that’s not the only thing that’s changing. That person will also be trying to quit smoking. Quitting smoking itself causes a number of changes, including the increases in nicotine withdrawal symptoms I’ve talked about before (see link below), and also a slowing in metabolism of some medications, that could cause an increase in the blood levels of the drugs contained in those medicines (I’ll discuss this in a future post). So some symptoms may be related to quitting smoking, rather than Chantix per se.

So if I had a relative who smoked and suffered from a mental illness (like schizophrenia, bipolar disorder or depression) and was taking medicine for that illness but wanted help to quit smoking, what would I suggest?

As with all the people I see who want to quit smoking, I’d describe all the available forms of help, including counseling, internet support and medicines. I’d recommend that they use these. With regards to medicines, I’d point out one advantage of nicotine replacement therapy, which is that it does not involve taking a “new” drug, - as they have been taking nicotine in a much more harmful form every day, for years. When discussing Chantix I’d point out that it had not been studied in many people with a serious mental health problem, and so it would be particularly important to discuss that option with their doctor and to allow the doctor to monitor their progress on that medicine fairly closely if the doctor decided to prescribe it. But if my family member had already tried nicotine replacement therapy and wanted to try something different, I wouldn’t discourage it. I’ve heard from many clinicians who have treated patients with mental health problems successfully with Chantix, and so I am not convinced yet that there is a markedly increased risk of adverse events caused by Chantix in such patients.

It would be helpful to hear peoples’ experiences of using Chantix, particularly if you have also had a mental health problem. If you feel that any medicine has caused a harmful effect, then you should tell your doctor, and particularly in the case of a new medicine, it may be appropriate to report this to the FDA. For further information on that procedure, visit: http://www.fda.gov/medwatch/

Here are the links to the recent case reports:
http://ajp.psychiatryonline.org/cgi/content/full/164/8/1269
http://ajp.psychiatryonline.org/cgi/content/full/164/8/1269-a

Here is the link to my previous article on nicotine withdrawal:http://www.healthline.com/blogs/smoking_cessation/2007/03/what-is-nicotine-withdrawal-syndrome.html

Labels: Chantix, mental illness, quit smoking cessation tobacco advice cigarettes, Smoking, tobacco, varenicline

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Sidestream cigarette smoke more toxic than mainstream smoke

In my last post about tobacco smoke pollution I mentioned the puzzling fact that although exposure to tobacco smoke pollution (TSP or ETS or SHS) gives about 1-5% of the smoke dose of active smoking, it gives a proportionately bigger increase in some disease risks. This fact has caused some to be rather skeptical about the evidence on tobacco smoke pollution and health. But just this month a new paper has been published by Drs Suzaynn Schick and Stan Glanz at University of California at San Francisco, that sheds some new light on this.

One of the main carcinogens in cigarette smoke is known as NNK (as its long chemical name is almost unpronounceable!). Previous studies have shown that there is a 3-4 times higher concentration of NNK in sidestream smoke (the smoke released from a burning cigarette into the air between puffs) than in mainstream smoke (the smoke inhaled by the smoker). But the new paper by Drs Schick and Glanz went further. They analyzed tobacco industry documents dating back to the 1980s that showed that Philip Morris tobacco company (which was, at that time, denying the harmfulness of exposure to environmental tobacco smoke) had conducted studies that not only measured these effects, but uncovered the mechanism behind it (continued reaction of nicotine, nitrogen oxides and other smoke chemicals). These studies also showed that while the smoke ages as it hangs in the air in a room where someone has smoked, the concentration of NNK actually increases another 2-4 times! So the net effect is that the concentration of NNK per unit of sidestream smoke hanging around in the air in a room hours after the smoker has left, may be 10 times greater than the concentration per unit of smoke the smoker inhaled directly from the cigarette. This type of finding may be a part of the explanation of why exposure to tobacco smoke pollution is more harmful than we might expect from the simple amount of smoke being inhaled.

Of course the tobacco company that discovered these results (Philip Morris, makers of Marlboro) did not expend much effort to share them with the public. Rather, it has taken painstaking research by public health scientists to piece together the evidence from tobacco industry documents and publish them in a peer-reviewed journal.

This gives yet more reason to ensure that people (and pets) in public spaces should not be exposed to tobacco smoke pollution, and to make sure your home environment is smoke-free.

This link takes you to the original journal report:
http://cebp.aacrjournals.org/cgi/content/abstract/16/8/1547

Labels: ETS, pollution, SHS, Smoking, tobaco

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How many medical doctors smoke?

In many countries medical doctors have been at the forefront of attempts to reduce the number of people who smoke. The medical doctor is one of the most highly respected professionals and patients place a large amount of faith in their doctor’s advice. However, concerns have been expressed about the willingness of doctors who smoke themselves to advise their patients to quit, and about the likelihood of patients taking such advice seriously if they are aware that the doctor is a smoker him/herself. So what proportion of medical doctors smoke?

In the past month Drs Derek Smith and Peter Leggat published a comprehensive international review of tobacco smoking in the medical profession from 1974-2004. The study showed that in countries like the United States, UK, Canada, Australia and New Zealand, smoking rates have dropped dramatically among doctors, from 15-20% in the 1970’s to around 5% at the end of the 20th century. However, such low smoking rates are not uniform among doctors across the world. In China, 32% of male doctors smoke (but 0% of females doctors smoke), in Italy 28% of doctors smoke (32% among men), and in Turkey or Bosnia & Herzegovina around 40% of doctors smoke.

Some may be surprised to hear that as many as 5% of US doctors smoke. But remember that doctors are human beings like the rest of us, and not immune to either infections or addictions. Many smoking doctors report that they (like most smokers) started in their teen years and so were likely addicted even prior to the decision to study medicine at college. I prefer to look at the low (and still falling) smoking rates among doctors in some countries as a very positive sign. It provides an indication of how low it is possible for smoking prevalence to go in a population that is well informed of the health risks, has relatively good access to treatment, and generally works in a smoke-free environment where smoking is not considered to be socially acceptable. It suggests that 5% may be a reasonable target for the rest of the population as well.

The full report on smoking among doctors can be found at:
http://www.biomedcentral.com/1471-2458/7/115

Labels: doctors, medical, profession, Smoking, tobacco

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Wearing the patch prior to quitting may help

If you buy a box of nicotine patches, you will notice that the instructions for use and warnings advise against wearing the patch while taking nicotine from any other source. Many smokers interpret this as implying that something terrible will happen if they kept the patch on while smoking, and consequently when they have a lapse cigarette then often decide to take the patch off (and so obey the instructions on the box).

However, numerous studies have shown that nothing terrible happens when you smoke while wearing the patch. 15 years ago I published a study in which 30 smokers smoked normally for 2 weeks, and wore full strength nicotine patches for one of those weeks and placebo patches for the other. The smokers generally couldn’t tell which week was the week with the nicotine patches and the single participant who vomited did so while wearing placebo patches! So it appears to be very unlikely for smokers to experience adverse events caused by wearing the patch while smoking.

However, some recent studies have actually suggested that wearing the patch for a few weeks prior to the target quit date may actually increase the chances of a successful quit. One such study was carried out by Dr Schuurmans and colleagues in South Africa. They found that people who wore nicotine patches for two weeks prior to their quit day had better long term quit rates than smokers who wore placebo patches for two weeks prior to their quit date (22% vs 12% quit, 6 months later).

Interestingly, studies of the use of other forms of nicotine replacement therapy by smokers not intending to quit have also found that not only does the NRT help them to reduce their cigarette consumption, but that a significant proportion of them go on and quit completely. One such study was carried out by Dr Batra and colleagues in Germany. They recruited over 300 smokers who were interested in cutting down but not quitting. They were provided with either 4mg nicotine gum or placebo gum for a year. As well as helping with smoking reduction, the group receiving the nicotine gum had significantly more people who were quit 13 months later (12% versus 5%).

We are not clear on the mechanism whereby combining NRT with smoking prior to quitting may help subsequent cessation. It may simply be that it loosens the associations between smoking and reinforcement (by providing nicotine separately from smoking). Just to be clear, the use of NRT prior to the quit date is not yet normal practice, and may never become so. My current practice is to advise patients using the patch to put their first patch on the morning of their quit day and not before (as suggested on the box). However, as more evidence is gathered on the safety and effectiveness of NRT pre-treatment, I may have to reconsider.

Labels: cessation, nicotine, pre-treatment, replacement, Smoking

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Reductions in teen smoking.

One of the most fascinating and unexplained changes in smoking habits that has taken place in the United States was the dramatic reduction of cigarette smoking among African American youth since the 1970s. The “Monitoring the Future” study has documented clearly that in 1975, smoking prevalence was very similar across ethnic/racial groups of teenagers, with 38% of white teens smoking, 37% of African American teens smoking and 36% of Latino youth smoking cigarettes in 1977. However, by 1985, smoking prevalence had halved among African American teens (18%) but remained high in whites (31%) and Latino youth (26%). By 1992 the differences had become even more marked, with only 9% of African American youth smoking, compared with 32% of white youth and 25% of Latino youth. Although smoking declined in young people of all backgrounds since 1998, these ethnic/racial differences largely persist. So the proportion of African American teens who smoke was cut by more than three quarters over 15 years, and yet no-one appears to know how it happened. Suggestions have ranged from increased price-responsiveness among African American teens (during a period involving increases in price of cigarettes), the possibility that African American youth could be using other substances instead. However, this last idea is based more on stereotypes than data: illegal drug use has also fallen in African American youth over the same time frame, and in 2006 a smaller proportion of African American high school seniors had used an illicit substance in the past year, as compared with whites or Latinos.

So this rather dramatic reduction in smoking by African American youth occurred prior to the major funded campaigns that followed the master Settlement Agreement in 1998, and is largely unexplained. If you think you have an explanation, please tell me!

Labels: ethnicity, nicotine addiction cigarette, race, Smoking, teen, tobacco, youth

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Which nicotine replacement therapy?

Nicotine replacement therapy (NRT) is the name given to FDA-approved medicines containing nicotine that are used to reduce nicotine withdrawal symptoms and cravings and to help smokers quit. Currently there are 5 main types: patch, gum, lozenge, nasal spray and inhaler. These latter two (nasal spray and inhaler) are only available via prescription in the United States, although they are available over-the-counter in many other countries (e.g. UK).

Each type of NRT has its own advantages and disadvantages. The patch is by far the most commonly used NRT, largely because it is the easiest to use, requiring only a single patch application per day. Another advantage of the patch is that its side effects are usually mild – primarily mild skin irritation and itching. The main disadvantage is that there is nothing one can do with the patch to increase the dose when you feel the need for more nicotine.

The gum and the lozenge are broadly similar in terms of dose (each available in 2mg and 4mg formats) and route of administration. The main challenge facing the gum chewer is to adopt a “chew and park” style, such that you chew the gum a few times to release a peppery taste (nicotine) and then park it in the side of your mouth for a few minutes before chewing again. The labeling on the gum suggests that people who smoke less than 25 cigarettes per day should use 2mg (rather than 4mg) and the labeling on the lozenge states that those who don’t smoke within 30 minutes of waking in the morning should use the 2mg lozenge. In practice many clinicians have learned that this labeling (especially the gum) is a recipe for under-dosing and advise all but the lightest smokers to use the 4mg formulation of each product. To get a real benefit from these products you need to use enough. Most users only take 3 or 4 per day in response to cravings. You can get a far greater benefit by taking one per hour (to prevent cravings and withdrawal symptoms) plus another whenever you have a breakthrough craving.

I described the nicotine nasal spray in some detail a few days ago. It appears to be particularly helpful for heavy addicted smokers who are willing to persevere despite the initial nasal irritation. Make sure you have some Kleenex handy when you first try the spray. The initial doses sting and will make you sneeze. But, just as with smoking, you will get used to it within a few days, and within a week will probably like it!

The inhaler‘s main advantage is that it enables the smoker to continue with a similar hand/mouth habit, but it helps to gradually wean them off nicotine. The main thing to note is that one puff on a cigarette delivers a similar amount of nicotine to ten puffs on the inhaler. This means that in order to obtain a therapeutic dose, the ex-smoker has to be puffing on the nicotine inhaler almost all the time. We recommend puffing on the inhaler for 20 minutes out of ever waking hour. Again, people who get into that regular use habit early on tend to do very well with the inhaler.

Some years ago Professor Peter Hajek and colleagues at the University of London conducted a randomized trial comparing the nicotine patch, gum, nasal spray and inhaler. In practice they all had similar quit rates (around 20-25% complete abstinence 3 months later), although women did better on the inhaler than the gum and men were the opposite. Prior to their quit attempt, participants were shown videos describing each NRT and were then allowed to rate their preferences. They were each then randomly allocated to one product. This meant that some people were allocated the product that was their first preference, whereas most were not. However, at the end of the study the smoking cessation outcomes were similar for those receiving their preferred NRT versus those being randomly allocated to a less preferred NRT. Also, people came to prefer the product they were given after they had used it for a week.

One final thing to consider is that the products differ in the risk of inducing dependence. It is extremely rare for someone to have any difficulty coming off the patch (which typically have a built-in reduction plan, involving using smaller sized patches over 4 weeks). However, some people (about 5-10%) find themselves using the gum, inhaler or lozenge long term (i.e. over 3 months and possibly continuing for years). The nicotine nasal spray has the highest dependence potential, with around 10-15% of those who use it continuing use after 3 months. The risk of becoming dependent is related to the speed of nicotine delivery from the product (spray fastest, but still slower and lower dose than a cigarette, whereas the patch delivers nicotine very slowly). It also seems to be related to how addicted the person was to their cigarettes. Thus people who smoked over a pack a day and smoke within 30 minutes of waking in the morning (or wake at night to smoke) are more likely to become a long term user of their NRT product. However, in the placebo-controlled trials these were precisely the people who were much less likely to succeed in quitting if they received the placebo. The thing to remember here is that it is much better to be a long term user of an NRT product delivering only nicotine, than a continuing user of a product that delivers a higher dose of nicotine plus 4000 other toxic chemicals (i.e. a cigarette).

Recently a group of experts in the treatment of tobacco addiction got together to produce a consensus statement guiding consumers on the most effective ways to use NRT to help them quit smoking. You can find a copy of the paper and the summary (in both English and Spanish) at: http://proyectovidanofume.org/publication.htm

Labels: addiction, cigarette, nicotine, NRT, replacement, Smoking, therapy, tobacco

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Can Smoking Cessation Internet Sites Help You Quit?

Many smokers use the internet to seek help in stopping smoking. Thousands of websites (including this one) provide basic information and advice on stopping smoking, and over 30 focus on providing direct smoking cessation assistance (e.g. a tailored quit plan) rather than just information and advice. So do these smoking cessation websites actually help smokers to quit?

When one considers some of the advantages of the internet (easy access, anonymity, lack of face-to-face contact etc), one can immediately also see some of the challenges in evaluating smoking cessation websites. For example, how do you follow-up on people who visited a website anonymously, in order to find out if they quit smoking? Research on this topic has only recently started, but there are already some promising studies suggesting that some smoking cessation websites boost the smokers’ chances of quitting. A recent study by Dr Lynn Swartz at the Oregon Center for Applied Science compared one particular internet site with no intervention. They found that smokers given access to the smoking cessation internet site were roughly twice as likely to have quit smoking three months later. Another recent study by Dr Joanne Pike at University of Texas Health Science Center compared utilization and quit rates at 5 interactive websites and one static website, all of which aimed to help smokers quit. They found that some of the interactive websites had much higher participation rates than others, and that this was associated with the amount of interactivity available on the site. Sites containing a lot of interactive functions also tended to have more participants succeed in quitting smoking.

Many of the websites offer the chance to view some of the basic information pages immediately but require visitors to complete an online registration process (and possibly pay a fee) before being given full access to the more useful interactive features on the site. One of the top smoking cessation websites can be found at: www.quitnet.com . This site offers a range of interactive features including “chat rooms”, and “ask-the-expert” functions, as well as online “wizards” that automatically calculate how much money you have saved since you quit smoking. This site is widely used around the world, so that at any given moment there will be hundreds or thousands of people visiting the site for help to quit.

The advantages of these interactive smoking cessation websites are that they are available 24/7, from the comfort of your own home, are generally free or low cost, and can put you in touch with a whole community of people going through the same process. Website assistance can also be used in addition to other methods (e.g. counseling and/or medication). Generally the more help and support you can get, the more likely you are to succeed in quitting. If you found any websites particularly helpful (or unhelpful), let me know, so I can pass it on to others. Best of luck.

Labels: cessation, online, Smoking, website

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