Running head: SMOKING CESSATION

Smoking Cessation
Ardy Emile
University of South Florida

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Abstract
Clinical Problem: Cigarette smoking is an extremely toxic habit that is very dangerous to
patients. It can have huge implications on their health and on clinical care. Smoking is an
addictive habit that is one of the leading causes of numerous diseases and health complications
like COPD, heart disease, and stroke. Nicotine reduction therapy (NRT) by the use of patches,
gums, and etc. are commonly used to help patients quit smoking, but this method alone may not
be as effective.
Objective: The purpose is to determine if there are other intervention programs that can help
facilitate smoking cessation other than NRT. Also, to evaluate how much more effective these
interventions are for abstinence/smoking cessation in comparison to NRT/NRT alone. CINAHL
and the National Guideline Clearinghouse were accessed to obtain clinical trials and guidelines
about smoking cessation. The key terms used were smoking cessation, nicotine replacement
therapy, NRT, hypnotherapy, cigarette smoking, effects of cigarette smoking on health, and
interventions.
Results: The Tobacco Use and Dependence Guideline Panel (2008) provides ten strategies and
recommendations to aid in smoking cessation. These guidelines essentially highlight that one
method/intervention can be somewhat effective, but when used in combination; there is a higher
rate of effectiveness. The literature demonstrated an increased rate of abstinence and smoking
cessation rates by using other interventions besides NRT or interventions in combination with
NRT.
Conclusion: In a population of cigarette smokers, other comprehensive intervention methods are
more effective than NRT. Alone, NRT is somewhat effective, but it can be even more beneficial
in combination. Statistically significant data was found to suggest that other interventions alone
or with a combination of NRT have higher rates of abstinence and smoking cessation.
Smoking Cessation

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Cigarette smoking is the primary source of tobacco exposure worldwide (Morris et al.,
2015). Although there has been a decline in cigarette use in adolescents and a decline of daily
cigarette smoking per day by both women and men between the years of 1980 and 2012; the
amount of smokers globally continues to elevate due to population growth. The statistic from this
period jumped extremely from approximately 721 million to 967 million (Morris et al., 2015).
Tobacco products are engineered in numerous fashions and due to their low prices, high
availability, pleasurableness, rapid delivery of nicotine, toxins and carcinogens; they are highly
addictive and dangerous. These products also contain tar packed with free radicals in their
particulate and gaseous phases that cause extreme oxidative stress. The nicotine and all these
byproducts are the reasons why tobacco is so addictive and so unsafe. There is no safe amount of
tobacco exposure according to a 2014 report by the U.S. Surgeon General (Morris et al., 2015).
As tobacco is burned, over 7,000 compounds of chemical mixtures known to potentiate
premature deaths and diseases that affect almost every organ system in the body are released
(Morris et al., 2015). Smoking is one of the biggest risk factors for several diseases and their
complications. Compared to high blood pressure globally, cigarette smoke exposure (CSE) and
secondhand smoke (SHS) are known to be the primary risk factors for comorbidity and mortality
in Western Europe and high-income North America. Diseases attributed to CSE and SHS are
extremely substantial. So much that they cause 6.3 million deaths annually and 6.3% of
disability-adjusted life-years (Morris et al., 2015). These reasons are why it is so important for
clinicians to help patients in their cessation attempts by applying the most effective interventions
possible. Nicotine Replacement Therapy (NRT) is part of one of the guidelines for smoking
cessation and is commonly used to help patients quit. It is found to be effective, but how
effective (Tobacco Use and Dependence Guideline Panel, 2008)? This paper evaluates the

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effectiveness of other cessation intervention programs in comparison to NRT alone. In a

population of cigarette smokers, how do intervention programs compared to nicotine
replacement therapy influence abstinence and smoking cessation in a 6-month period?
Literature Search
CINAHL and the National Guideline Clearinghouse were accessed to obtain clinical trials
and guidelines about smoking cessation. The key terms used were smoking cessation, nicotine
replacement therapy, NRT, hypnotherapy, cigarette smoking, effects of cigarette smoking on
health, and interventions.
Literature Review
Three randomized controlled trials and one guideline were used to evaluate the efficacy
of NRT and other cessation intervention programs on smoking cessation. These trials and
guideline further evaluated how much more effective these other cessation programs were in
comparison to just NRT. Using a randomized controlled trial, Chan et al. (2011) investigated the
effectiveness of smoking reduction counseling plus NRT in smokers unwilling to quit. There
were a total of 1154 Chinese American smokers who were randomly allocated to prospective
control and intervention groups. This randomization entailed two intervention groups and one
control group. The first intervention group (Group A1) had a sample of 479 participants and
received in-person counseling on smoking reduction and NRT adherence, receiving 4 weeks of
NRT. The following intervention group (Group A2) consisted of 449 participants and received
the exact intervention as Group A1 minus the free NRT. Lastly, the control group consisted of
226 participants and received basic cessation advice only. Statistically significant data was found
to suggest higher tobacco abstinence (p= 0.01) and higher reduction (p= 0.001) rates within the
intervention groups after six months in comparison to the control group. Group A1 also obtained
substantially higher abstinence rates than Group A2 within a six-month period (p= 0.01). The
major weakness of this study was that the smoking cessation counselors were not blind to the

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intervention and control groups. The strengths of this study include the randomization of
subjects, appropriate control group, large population of subjects, similar groups considering
baseline variables, and adequate duration (six months) until follow-up assessments.
Haas et al. (2015) designed a randomized controlled trial that examines the effectiveness
of a proactive smoking cessation strategy for low social economic status (SES) smokers that
brings the socio-contextual mediators of tobacco to the forefront. This trial consisted of low SES
white, black, and Hispanic, adult smokers in the greater Boston area. These 707 participants were
randomly assigned to prospective intervention (n= 399) and control groups (n= 308). The major
outcome of this study is that the intervention group (Consisting of phone-based motivational
counseling, six weeks of free NRT, access to community based referrals to address sociocontextual mediators of tobacco use, and an integration of all these components in normal
healthcare.) had higher quit rates than the control group who only received usual care. There was
no difference in patients who used NRT only, but those who utilized telephone counseling were
more likely to quit than those who didnt (p< 0.001) and those who used their referrals were
more likely to quit than those who didnt (p< .001). The only weakness to this trial was that the
researchers were not blind to the control and intervention groups. The strengths of this trial were
that the subjects were randomized, the control group was appropriate, the participants in all
groups were similar at baseline, and follow up assessments were long enough to adequately
study the effects of the interventions.
Hasan et al. (2014) conducted a randomized controlled trial to determine effectiveness of
smoking cessation in hospitalized cardiac/pulmonary patients within three intervention groups
and a control group. At total of 164 patients were randomized into three intervention groups: 30
days of NRT (n= 41), 90-minute hypnotherapy sessions (n= 39), and a combination of NRT and
hypnotherapy (n= 37). The control group (n= 35) were patients who self-quit and refused

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hypnotherapy. The results highlighted significant data that suggested that the hypnotherapy
group and the hypnotherapy/NRT combination group had a more than three times likeliness to
abstain 26 weeks post discharge than the NRT group (p= 0.04). One weakness of this study was
that the researchers were not blind to the test subjects intervention and control groups. Another
weakness was that the statistics/sample groups convey inconsistent information. The paper
mentioned that the 35 patients in the control group were the ones who refused hypnotherapy and
mentioned that some patients refused NRT as well. It can only be assumed that the missing 12
patients were the ones who refused NRT and were just not documented properly. The strengths of
this trial were that the subjects were randomized, the control group was appropriate, participants
in each group were similar at baseline, and the duration until the follow-up assessments was long
enough to properly study the effects of the interventions.
The guideline for smoking cessation by the Tobacco Use and Dependence Guideline
Panel (2008) utilize evidence-based practice and was received from the National Guidelines
Clearinghouse. This guideline consists of ten recommendations of various strategies and
interventions to potentiate smoking cessation. The overarching message was to help clinicians,
insurers, and health systems to have effective treatments available that combine both dependence
treatment and medication treatment. Using one intervention can be somewhat beneficial, but
when combined together can be even more efficacious.
Synthesis
Chan et al. (2011) studied smokers unwilling to quit. They were able to demonstrate that
NRT and cessation programs with behavioral therapy were more effective in abstinence (p=
0.01) and reduction (p< 0.001) than simple advice to quit after six months. The combination of
reduction counseling and NRT was also more effective than the reduction counseling alone (p=
0.001). Haas et al. (2015) displayed that using interactive voice response (IVR) and a
comprehensive set of interventions that addressed the socio-contextual mediators in low SES

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smokers were more effective for abstinence than usual care (17.8% vs 8.1%; odds ratio, 2.5; 95%
CI, 1.5-4.0; number needed to treat, 10). Those who participated in telephone counseling (p<
0.001) and those who used their referrals (p< 0.001) were even more likely to quit. Hasan et al.
(2014) highlighted that NRT is not as effective for abstinence as hypnotherapy. In fact, both
hypnotherapy related interventions were three times as effective in improving tobacco smoking
abstinence than NRT (p= 0.04) after 26 weeks. Finally, the Tobacco Use and Dependence
Guideline Panel (2008) guideline proposes many recommendations, but supports the use of
multiple interventions together than separately to increase effectiveness.
These studies are similar because they all investigate the effectiveness of intervention
strategies other than NRT. One difference is that the third study made direct comparisons with
NRT alone whereas we can make these comparisons using critical thinking and context in the
other two studies. These findings impact patient care because when we have accurate data, we
can implement more effective interventions in and out of the clinical setting that will help
patients quit smoking and maintain abstinence. These alternative interventions/strategies are
great assets for hospitalized and post-discharge patients.
Clinical Recommendations
The Tobacco Use and Dependence Guideline Panel (2008) provides a guideline designed
to help clinicians and health professionals with the treatment of tobacco use and dependence.
This guideline provides many recommendations. To begin with, repeated interventions are
emphasized because tobacco dependence is a chronic disease. Repetition is found to increase
rates of long term abstinence. It is important to identify and document tobacco use in every
patient and encourage counseling and medication treatments. Interventions such as
individual/group/telephone counseling, telephone quit lines, and medications are found to be
effective. It is interesting to find that counseling and medications alone are effective, but when

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combined, the effectiveness is increased. Many of these medications include: nicotine patches,
nicotine lozenges, nicotine gum, bupropion SR, etc. Overall, these treatments are found to be
highly effective and cost-effective in comparison to other disorders. It would be imperative for
clinicians to continually be identifying and documenting tobacco use and dependence as well as
offering/administering these interventions. Likewise, it would be very beneficial for insurers and
healthcare facilities to provide coverage for counseling, medications, or any alternative
intervention found in this guideline on all insurances as added benefits. These steps should be
taken because the treatments in this guideline are found to increase quit rates. In turn, this will
increase the health status of our patients and prevent complications and the onset of new disease
processes.

References
Chan, S. C., Leung, D. P., Abdullah, A. M., Wong, V. T., Hedley, A. J., & Lam, T. (2011). A
randomized controlled trial of a smoking reduction plus nicotine replacement therapy
intervention for smokers not willing to quit smoking. Addiction, 106(6), 1155-1163.
doi:10.1111/j.1360-0443.2011.03363.x
Haas, J. S., Linder, J. A., Park, E. R., Gonzalez, I., Rigotti, N. A., Klinger, E. V., ... Williams, D.
R. (2015). Proactive tobacco cessation outreach to smokers of low socioeconomic status:
A randomized clinical trial. JAMA Internal Medicine, 175(2), 218-226.
doi:10.1001/jamainternmed.2014.6674
Hasan, F. M., Zagarins, S. E., Pischke, K. M., Saiyed, S., Bettencourt, A. M., Beal, L., ...
McCleary, N. (2014). Hypnotherapy is more effective than nicotine replacement therapy
for smoking cessation: Results of a randomized controlled trial. Complementary
Therapies in Medicine, 22(1), 1-8. doi:10.1016/j.ctim.2013.12.012

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Morris, P. B., Ference, B. A., Jahangir, E., Feldman, D. N., Ryan, J. J., Bahrami, H., ... Benowitz,
N. L. (2015). Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic
Cigarettes: Clinical Perspectives from the Prevention of Cardiovascular Disease Section
Leadership Council and Early Career Councils of the American College of Cardiology.
Journal of the American College of Cardiology, 66(12), 1378-1391.
doi:10.1016/j.jacc.2015.07.037
Tobacco Use and Dependence Guideline Panel (2008). Treating tobacco use and dependence.
Retrieved February 28, 2016, from http://www.ncbi.nlm.nih.gov/books/NBK63952/