Clinical Review

Managing smoking cessation

BMJ 2007; 335 doi: http://dx.doi.org/10.1136/bmj.39252.591806.47 (Published 05 July 2007) Cite this as: BMJ 2007;335:37
  1. Paul Aveyard, National Institute of Health research career scientist1,
  2. Robert West, professor of health psychology and director of tobacco studies2
  1. 1Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT
  2. 2Cancer Research UK Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, London WC1E 6BT
  1. Correspondence to: P Aveyardp.n.aveyard{at}bham.ac.uk
  • Accepted 18 June 2007

Cross sectional studies show that most smokers in countries such as the United Kingdom and the United States report that they want to stop and intend to stop at some point.1 The rate of attempts to stop is high—78 attempts per 100 smokers per year in the UK—with many smokers making several attempts in a year.2 Nearly half of all smokers expect not to be smoking in a year's time,3 but only 2-3% actually stop permanently each year.3

The most common reasons smokers give for smoking are stress relief and enjoyment,4 but the main reason is nicotine dependence. Nicotine acts in the midbrain, creating impulses to smoke in the face of stimuli associated with smoking.5 Consequent changes in brain chemistry also produce “nicotine hunger” when a smoker goes without nicotine. A third mechanism underlying nicotine dependence is nicotine withdrawal: unpleasant mood and physical symptoms that occur on abstinence and are relieved by smoking.6 7 Nicotine dependence is the main reason that most unassisted quit attempts fail within a week.8 We give evidence based recommendations and new treatment options for healthcare professionals to increase the success rate of these attempts. Most evidence for treatment comes from randomised controlled trials summarised in the Cochrane reviews for tobacco dependence.

Summary points

  • Stopping smoking before the age of 40 is crucial to improve health—beyond 40, people lose three months of life expectancy for every further year smoking

  • The most important factor leading to failure of attempts to stop is nicotine dependence

  • Nicotine dependence is most effectively treated with a combination of drugs and specialist behavioural support, such as provided by the NHS Stop Smoking Service

  • Varenicline, bupropion, nortriptyline, and nicotine replacement are all effective

  • Relapse during or after treatment is common, and treatment is usually needed several times …

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