Running Head: SMOKING CESSATION PROGRAMS

Success Rate of Smoking Cessation Programs

Lucy McCarty, Averi McCarthy, Michael Rusu, Alleya Wagner, and Emma Wukelich

Youngstown State University

NURS 3749: Nursing Research

Ms. Randi Heasley

5 April 2021
SMOKING CESSATION PROGRAMS 2

Abstract

The purpose of this research was to discover if pharmacological smoking cessation

therapy is more successful than non-pharmacological smoking cessation therapy. The smoking

cessation programs researched were nicotine patches and gum, Chantix, combination therapy,

and non-pharmacological interventions. It was found through our research that there was

significant evidence supporting the use of smoking cessation programs. All forms of smoking

cessation programs that were researched showed some success in either reducing cigarette

consumption or produced long-term smoking abstinence. Smoking cessation programs were

effective in helping smokers to reduce cravings and quit smoking. Even in smokers with no

desire to stop smoking, cessation programs effectively decreased their tobacco consumption.

This research included ten sources with qualitative studies, longitudinal studies, and a

literature review. There was no definite evidence regarding proof one individual smoking

cessation program was more successful than another. However, there was evidence that the use

of any combination of smoking cessation therapies lead to greater results than all types of

individual therapy. Overall, the research showed that smoking cessation programs effectively

helped people quit smoking regardless of therapy and the use of multiple therapies led to higher

success rates of smoking cessation.

SMOKING CESSATION PROGRAMS 3

Literature Review

Introduction

In order to discover the most effective smoking cessation methods in the medical

profession, information was acquired using the Maag Library’s nursing databases. Specifically,

MedLINE, Proquest, and CINAHL were used to find the ten sources used to examine and collect

data regarding the effectiveness of various smoking cessation programs, both pharmacological

and nonpharmacological.

Nicotine Patch

Smoking cessation has been a hot topic in research due to the number of people that want

to quit smoking, considering the lasting effects of smoking tobacco. Many, old and new, nicotine

replacement therapies (NRT) are available on the market today, including nicotine patches that

have long been used in smoking cessation treatments to ease the transition to becoming smoke-

free. Extensive research has been performed to evaluate the effectiveness of patches compared to

other therapies. The goal of NRT is to replace the nicotine that would otherwise come from

smoking to reduce symptoms of withdrawal. Nicotine patches have advantages over other forms

of NRT stated as, “Nicotine patches differ from the other products in that they deliver the

nicotine dose slowly and passively” (Hartmann, 2018, p. 5). Nicotine patches have been proven

to help an individual quit smoking longer than six months. However, there is no conclusive

evidence that solely using patches is more effective than solely using other forms of NRT. As

Lindson (2018, p.2) said, “High‐certainty evidence from eight studies suggests that using either a

form of fast‐acting NRT or a nicotine patch results in similar long‐term quit rates (RR 0.90, 95%

CI 0.77 to 1.05, 8 studies, 3319 participants; I2 = 0%)”. It has been shown that the choice to use

one therapy over another is affected by factors such as expense, availability, and personal
SMOKING CESSATION PROGRAMS 4

response to each therapy. Hartman (2018, p.2) stated, “Side effects from using NRT are related

to the type of product, and include skin irritation from patches and irritation to the inside of the

mouth from gum and tablets''.

Research has proven that combinations of NRT have led to greater results than individual

therapy. Again, no conclusive evidence has been provided over which therapies to use together

will bring the best results. It plays into the same factors as choosing an individual therapy.

Patches have not only been studied against other forms of NRT but also have been compared to

different patches based on dosing and duration. Nicotine patches were examined at higher doses

and longer durations to determine if there was more success in smoking cessation. The studies

concluded that participants did have a higher rate of smoking cessation with higher dosages and

durations. The concern with higher dosages and durations was the adverse effects on the

participant. “Results suggest that many smokers can tolerate much higher doses than those

offered by current NRT products and that the evaluation of such dosing is warranted” (Przulj,

2019, p.520).

Overall, nicotine patches do aid in the process of quitting smoking and lead to much

higher success rates long term. Further study will need to be conducted to determine the most

effective monotherapy form of NRT. “Overall evidence favored the combination of NRT over

single-type NRT for smoking cessation” (Lindson, 2019, p.26). Lindson went on to say, “Using

nicotine patch and another type of NRT (such as gum or lozenge) together made it 15% to 36%

more likely that a person would successfully stop smoking than if they used one type of NRT

alone”. However, it is unlikely that new results will change due to the number of individual

factors playing into the choice of therapy.

SMOKING CESSATION PROGRAMS 5

Secondly, higher dosages and durations of nicotine patches did prove to have higher

success rates of smoking cessation due to individuals controlling their nicotine intake while

smoking. Lindson (2019, p.2) continued to state, “People were also more likely to quit

successfully if they used higher dose nicotine patches (containing 25 mg (worn over 16 hours) or

21 mg (worn over 24 hours) of nicotine compared to 15 mg (worn over 16 hours) or 14 mg of

nicotine (worn over 24 hours)) or higher-dose nicotine gum (containing 4 mg of nicotine

compared to 2 mg of nicotine)”. Research has shown that NRT is highly individualized, but there

is not enough evidence to accurately state that the sole use of nicotine patches offers a higher rate

of cessation compared to other forms of NRT.

Nicotine Gum

According to Hansson et al. (2019, p. 5), nicotine replacement therapy increases the

chances of stopping smoking by 50% regardless of the type of nicotine replacement therapy.

“Relief of cravings and withdrawal symptoms represents the primary intended use of nicotine

replacement therapy (NRT) and relief of these symptoms is also the principal mechanism of

action of NRT in the support of smoking cessation” (Hansson et al., 2019, p.1). In a randomized,

two-way crossover study conducted on 240 healthy adult smokers given either one dose of 6 mg

or 4 mg nicotine gum, it was discovered that the dose of nicotine gum is an essential factor for

the efficacy of NRT in the treatment of tobacco dependence. Healthy adult volunteers were

recruited for this study and then were randomly allocated in equal proportion to one of two

treatments using a random number generator. Each participant was given a piece of gum; they

were to place the gum in their mouth without looking at it and chew slowly for 30 minutes.

Subjects were then sent home with electronic diaries to record how strong their urge to smoke

was on a 100 mm visual analog scale (VAS) at various time intervals. On the VAS, 100
SMOKING CESSATION PROGRAMS 6

represented an extreme urge to smoke, and zero represented no urge to smoke. In the first 60

minutes, the average urge to smoke was 44 mm with 6 mg gum and 39 mm with 4 mg gum. The

study discovered that the mean reduction in urges to smoke was statistically greater with 6 mg

than 4 mg gum for all examined time intervals (Hannson et al., 2019, p. 1-6).

“For those smokers who, despite numerous quit attempts, are unable to stop or smokers

with low motivation to quit, the concept of smoking reduction, i.e. decreased number of daily

cigarettes smoked, maybe an alternative approach to controlling their smoking” (Wennike et al.,

2003, p. 1). A study was completed on volunteer participants who were 18 years or older, were

either unwilling or unable to stop smoking but interested in reducing their smoking. A total of

411 smokers were randomized to receive active gum or the placebo for up to 1 year. “Subjects

who scored 5 or less in the Fagerström Test for Nicotine Dependence (FTND) were allocated to

the low‐dose group and randomized to either nicotine 2 mg gum or placebo whereas those who

scored 6–10 were allocated to the high‐dose group and randomized to nicotine 4 mg gum or

placebo” (Wennike et al., 2003, p. 2).

The study found that a linear relationship was present between a decrease in smoking and

a decrease in plasma thiocyanate and exhaled carbon that was greater in the nicotine gum group

than the placebo group after 4 and 12 months (Wennike et al., 2003, p. 1). “In the active group

at month 12, while still using nicotine gum, mean cigarette consumption was 46% of baseline

value, while mean CO was reduced to 62%; plasma cotinine to 93% and plasma thiocyanate to

75% of baseline” (Wennike et al., 2003, p. 4). This study implies that smokers who are not

interested in smoking cessation can be given nicotine gum to help reduce the number of

cigarettes that they smoke daily, helping to reduce the levels of carbon monoxide and other

harmful cigarette toxins in their bodies (Wennike et al., 2003, p. 7).

SMOKING CESSATION PROGRAMS 7

Chantix

Along with the use of over-the-counter nicotine replacement therapies, physicians can

also prescribe medications that block the pleasant effects of nicotine on the brain. The United

States Food and Drug Administration (FDA) has provided approval for practitioners to prescribe

varenicline for individuals to use for nicotine addiction. It is one of the seven pharmaceutical

interventions that the FDA has permitted approval for smoking cessation (Burke, 2016, p. 435).

Varenicline is not used as frequently due to the concerns of prescribing practitioners regarding

the risk versus the benefit (Burke, 2016, p.436).

A literature review was completed, which provides insight on the effectiveness of

varenicline for smoking cessation (Burke, 2016, p. 436). The review was completed for PubMed

abstracts with the dates between January 1966 and December 2015. Varenicline was the key

primary word used for the literature search and evaluation. The authors of the literature review

provide disclosure of providing training for medical education credits for Phizer and research

with grants provided by Phizer (Burke, 2016, p. 440).

The reviews were broken down into three samples: dosing studies, Phase II studies, and

Phase III studies. The sample for the dosing study was 320 random smokers. There were two

studies of 638 random smokers and 647 random smokers in the Phase II studies. Two trials were

included in the Phase III study with 1,927 smokers.

The measurement of the trials was based on two factors. The first was the check-in

points of the participants at 7, 12, 24, and 52 weeks. The confirmations of the trial ending were

the verification of nicotine abstinence by biochemical testing and validation. The trial

participants were provided written education and counseling for smoking cessation (Burke, 2016,

p. 437).
SMOKING CESSATION PROGRAMS 8

Burke (2016, p. 438) reported that varenicline is a successful intervention for persons

who are seeking to stop smoking. The patients who can utilize this technique safely include

those with such diagnoses, including mental health and diseases of the heart and lungs.

Practitioners need to assess the hazards and advantages of using varenicline before determining

if the patient will be started on the medication. The dosage needs to be adjusted to manage

potential side effects of the medication. Self-titrated dosing by the participants had the highest

smoking cessation highest efficacy. Adjusting doses demonstrated improved side effect

management (Burke, 2016, p. 440).

Ebbert (2010) completed a literature review to identify the efficacy of varenicline for

smoking cessation. The authors report no conflicts of interest in the article's completion. The

review identifies how to avoid negative side effects of the treatment. Two double-blind Phase III

trials were reviewed. Of the 377 adult smokers in the studies, half were provided a placebo, and

half were provided varenicline. The meta-analysis Ebbert (2010, p. 357) included in the

literature review included six clinical trials.

The meta-analysis contained 2583 individuals who received either varenicline or a

placebo (Ebbert, 2010, p. 357). The study participants checked in throughout the study. The

dosage of varenicline was 1 milligram twice a day versus the placebo dosage. The results of this

study were participants who received varenicline had higher smoking cessation success

compared to those receiving a placebo. The results were 44% for medication versus 37% for

placebo. A study to verify the safety and effectiveness of long-term varenicline treatment was

reviewed by Ebbert (2010, p. 358). There were 377 smokers in the study divided into

varenicline or placebo administration. After one year, the cohort receiving varenicline was 37%,

while the cohort receiving placebo was 8% for smoking cessation. Ebbert concluded that when
SMOKING CESSATION PROGRAMS 9

smoking adults take varenicline, they have the highest level of smoking cessation attainment

(2010, p. 361). The comparison group is individuals who take other first-line pharmaceutical

treatments for eliminating tobacco dependence. Obstacles to a client's success include such items

as previous smoking cessation failures and unfavorable side effects. Recommendations for

success by Ebbert (2010, p. 361) incorporate fluctuating the medication dosage to minimize the

side effects the client experiences.

Nonpharmacological

Smoking cessation can be largely attributed to pharmacologic intervention, but other

influences can also aid smokers in reduction and quitting. Smoking cessation is a “social event,”

and those smokers with more social support have a better chance of quitting, as noted by

O’Keefe et al. (2018). In a study, 46 participants between the ages of 33-56 were selected based

on the criteria that they had attended any phase of CEASE (Clinical Effort Against Secondhand

Smoke Exposure) cessation classes. The participants were then split into two groups, based on

their self-reported smoking status; 11 “doers” (quitters) and 35 “non-doers” (smokers). These 46

individuals were given in-depth interviews (IDI) and placed into exploratory focus group

discussions (FGD), which were led by Peer Motivators. “Medical personnel are not as effective

in leading cessation classes as are Peer Motivators (PMs)” (O’Keefe et al., 2018, p. 3).

The 46 individuals completed 8 FGDs, which were recorded and transcribed. “The codes,

themes and subthemes from the FGDs were compared and contrasted to identify similarities and

differences between doers and non-doers” (O’Keefe et al., 2018, p. 3). Most of the non-doers

(smokers) had more reasons for why they smoked cigarettes and were also more apt to place

blame on external triggers for their smoking, such as stress, family, etc. Most of the doers

(quitters) credited their ability to quit on support from their PMs. Doers were also motivated by
SMOKING CESSATION PROGRAMS 10

the well-being of others and their family support systems. The study found that the feedback

most commonly reported by all participants was the appreciation they had to be a participant in a

community-cessation effort and the desire for the program to reach more smokers (O’Keefe et

al., 2018, p. 7). “For many of these smokers, CEASE became the social capital they needed to

conquer the most addictive drug we know” (O’Keefe et al., 2018, p. 7).

Harm reduction aimed at promoting e-cigarettes and vaping among tobacco users is a

topic that has come under much speculation. “Public Health England recommends the use of e-

cigarette for smokers who do not succeed in quitting smoking with other methods or who do not

want to stop smoking” (Pasquereau et al., 2017, p.1). A study was conducted on 2,057 cigarette

users. Of those, 1,805 were conventional smokers, and 252 were dual users (e-cigarettes and

conventional cigarettes). Participants were given a baseline survey. “Intention to quit smoking

during the next 6 months, attempt to stop at least 24 hours during the last 30 days and use of

nicotine replacement therapy (NRT) during the last 30 days were asked at baseline” (Pasquereau

et al., 2017, p.2).

These outcomes were again measured at a six-month follow-up. “The three outcomes

assessed at 6 months were: a minimum 50% reduction in the number of cigarettes smoked per

day, quit attempts of at least 7 days and smoking cessation of at least 7 days at the time of

follow-up” (Pasquereau et al., 2017, p. 1). The study found that dual users were more likely than

exclusive cigarette users to have halved their cigarette consumption. Dual users were also more

likely to have made a quit attempt of at least a week. “Among people who smoke, those also

using an e-cigarette regularly are more likely to try to quit smoking and reduce their cigarette

consumption during the next 6 months” (Pasquereau et al., 2017, p.1).

Combination Therapy
SMOKING CESSATION PROGRAMS 11

In many instances, pharmacological therapy has a much higher success rate when used in

combination with other forms of therapy. This can be seen in a study Vogeler, McClain, and

Evoy conducted in 2016 on whether varenicline, also known as Chantix, worked better as a

single drug therapy for smoking cessation, or if combining varenicline with bupropion, also

known as Wellbutrin, had a higher success rate with smoking cessation. The study had 1,320

with 4 different research groups.

The first group consisted of patients who received a

prescription for varenicline from a cardiovascular smoking

cessation service at the study site, and the sample size for this

group was 427. The results for this group showed, “A significantly

higher amount of combination treatment patients in the success

group. Success rates: varenicline monotherapy (32.1%); varenicline +

bupropion (55.0%); varenicline + bupropion + SSRI (57.7%).” (Volger,

McClain, Evoy, 2016, p.4). The next two groups that were studied

included those older than eighteen years old who were smoking at

least ten cigarettes a day for more than six months and had expired-

air CO level ≥ 10 ppm (recent exposure to high levels of CO2). The sample size for

these groups combined was 387. This study concluded, “Results showed a significant difference

in the primary endpoint of 4-week smoking abstinence for weeks 8–11 with combination

treatment (39.8%) versus varenicline plus placebo (25.9%)” (Volger, McClain, Evoy, 2016, p.3).

The last group observed in the study were those greater than the age of 18, who were smoking

more than ten cigarettes a day, for more than six months, who also were in good health. This

group showed, “Results displayed significantly higher prolonged abstinence rate at 12 weeks
SMOKING CESSATION PROGRAMS 12

(OR = 1.49; 95% CI = 1.05–2.12; p value 0.03) and 26 weeks (OR = 1.52; 95% CI = 1.04–2.22;

p value 0.03)” (Volger, McClain, Evoy, 2016, p.4). Overall, the results from each group of the

study concluded that taking varenicline alone yielded less success than if the patient took

varenicline with bupropion or varenicline with bupropion with an SSRI. The success rates from

taking polytherapy were much higher than taking a monotherapy drug by at least ten percent

with each group studied.

The next study researched, examined data on medication use and abstinence or cessation

from smoking cigarettes using a randomized comparative effectiveness trial of nicotine patch

monotherapy, varenicline, and combination nicotine patch and lozenge therapy. 241 patients

were given a nicotine patch, 424 patients were given varenicline, 421 patients were given a

nicotine patch and lozenge, and all 1,086 patients received cessation counseling along with their

pharmacologic therapy. Adherence to the cessation therapy was evaluated at the twenty-seventh

day, and data was then compared between all three groups.

The outcome of the study states,

“This secondary analysis of adherence and abstinence in a comparative effectiveness trial

shows that adherence is highest for the nicotine patch, and next highest for varenicline,

and lowest for combination nicotine patch and lozenge therapy, due to low lozenge use.”

(McCarthy, Versella, 2019, p. 1).

These results show that physically taking medication and having to remember to take medication

shows to be less effective than placing a transdermal patch on your skin once every few days

because it requires less energy and effort in remembering to place the patch.

While the patch had an overall success in cessation, the study concludes, “Varenicline

and combination NRT did not promote abstinence among adherent latent classes but did promote
SMOKING CESSATION PROGRAMS 13

abstinence among those partially adherent, relative to patch alone.” (McCarthy, Varsella, 2019,

p.1). Meaning for those who only took the varenicline medication part of the time, had better

success in smoking abstinence, than those who only partly adhered to using the nicotine patch.

Conclusion

Overall, the research showed that smoking cessation programs did effectively help people

quit smoking regardless of the type of therapy used. However, it was discovered that the

combination of any of these therapies proved to be more effective than the use of only one of the

therapies. While some smokers were able to achieve full abstinence from tobacco with these

programs, other smokers benefited from harm reduction by simply reducing their cigarette

consumption. According to the CDC, 480,000 Americans die every year due to smoking-related

illnesses. Smoking cessation programs, therefore, could be responsible for saving countless lives

if implemented by the individuals who suffer from tobacco addiction.

SMOKING CESSATION PROGRAMS 14

References

Burke, M. V., Hays, J. T., & Ebbert, J. O. (2016). Varenicline for smoking cessation: A

narrative review of efficacy, adverse effects, use in at-risk populations, and

adherence. Patient Preference and Adherence, 10, 435–441. doi:10.2147/PPA.S83469

Ebbert, J. O., Wyatt, D. W., Klee, E. W., & Hurt, R. D. (2010. Varenicline for smoking

cessation: Efficacy, safety, and treatment recommendations. Patient Preference and

Adherence 2010, 4, 355-362. doi:10.2147/ppa.s10620

Hansson, A., Rasmussen, T., Perfekt, R., Hall, E., & Kraiczi, H. (2019). Effect of nicotine 6 mg

gum on urges to smoke, a randomized clinical trial. BMC pharmacology & toxicology, 20(1),

69. https://doi.org/10.1186/s40360-019-0368-9

Hartmann-Boyce, J., Chepkin, S. C., Ye, W., Bullen, C., & Lancaster, T. (2018). Nicotine

replacement therapy versus control for smoking cessation. The Cochrane database of

systematic reviews, 5(5), CD000146. https://doi.org/10.1002/14651858.CD000146.pub5

Lindson, N., Chepkin, S. C., Ye, W., Fanshawe, T. R., Bullen, C., & Hartmann-Boyce, J.

(2019). Different doses, durations and modes of delivery of nicotine replacement therapy

for smoking cessation. The Cochrane database of systematic reviews, 4(4), CD013308.

https://doi.org/10.1002/14651858.CD013308

McCarthy, D. E., & Versella, M. V. (2019). Quitting Failure and Success With and Without

Using Medication: Latent Classes of Abstinence and Adherence to Nicotine

SMOKING CESSATION PROGRAMS 15

Monotherapy, Combination Therapy, and Varenicline. Nicotine & Tobacco Research :

Official Journal of the Society for Research on Nicotine and Tobacco, 21(11), 1488–

1495. https://doi-org.eps.cc.ysu.edu/10.1093/ntr/nty157

O’Keefe, A. M., Bustad, K., Apata, J., Sheikhattari, P., Abrams, N. R., & Mahmud, A.

(2019). What Differentiates Underserved Smokers Who Successfully Quit From Those

Who Do Not. Journal of Community Health, 44(1), 44–51. https://doi-

org.eps.cc.ysu.edu/10.1007/s10900-018-0551-8

Pasquereau, A., Guignard, R., Andler, R., & Nguyen, T. V. (2017). Electronic cigarettes,

quit attempts and smoking cessation: a 6-month follow-up. Addiction, 112(9), 1620–

1628. https://doi-org.eps.cc.ysu.edu/10.1111/add.13869

Przulj, D., Wehbe, L., McRobbie, H., & Hajek, P. (2019). Progressive nicotine patch

dosing prior to quitting smoking: feasibility, safety and effects during the pre‐quit and

post‐quit periods. Addiction, 114(3), 515–522.

https://doi-org.eps.cc.ysu.edu/10.1111/add.14483

Vogeler, T., McClain, C., & Evoy, K. E. (2016). Combination bupropion SR and varenicline for

smoking cessation: a systematic review. The American Journal of Drug and Alcohol

Abuse, 42(2), 129–139. https://doi-org.eps.cc.ysu.edu/10.3109/00952990.2015.1117480

Wennike P, Danielsson T, Landfeldt B, Westin Å, & Tønnesen P. (2003). Smoking reduction

promotes smoking cessation: results from a double blind, randomized, placebo-controlled

trial of nicotine gum with 2-year follow-up. Addiction, 98(10), 1395–1402. https://doi-

org.eps.cc.ysu.edu/10.1046/j.1360-0443.2003.00489.x