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Smoking cessation

A guide for smoking cessation

There are currently in excess of 1 billion smokers worldwide and this means  significant cardiovascular risk with an annual cost of $500 billion in the US alone. Promoting smoking cessation with appropriate and sustained actions is essential to allow the reduction of smoking and its related adverse effects.

Currently, there are more than 1 billion smokers worldwide with 80% of them living in low and middle income countries.  Each year five million deaths are directly related to smoking with 600,000 additional deaths caused by passive smoking. Furthermore, the amount of healthcare expenditure due to smoking-attributable diseases is similarly significant and increasing, approaching $500 annually in the USA [1].

Despite the huge reduction in cardiovascular disease (CVD) in the last 30 years, CVD still remains the most common cause of death worldwide. Although the risk factor modification has improved significantly thanks to appropriate public awareness campaigns/programmes, including successful anti-smoking legislation, it is still anticipated that a healthy lifestyle can further prevent in excess of 80% of CVD [2].

Mechanism by which smoking leads to CVD

Smoking can increase the development of atherosclerosis and superimposed thrombotic phenomena by affecting platelet function, fibrinolysis, endothelial function, oxidative processes, inflammation, lipid oxidation and vasomotor function. In both experimental and human studies, several of these are reversible, even after a short period (a few weeks) of smoking cessation [3]. Atherosclerotic plaque formation however, is not thought to be fully reversible and in terms of CVD, smokers would never be expected to reach the risk level of those who have never smoked , especially if they continue to smoke after the age of 30 [2].

Life expectancy and smoking

There is ample evidence documenting the risk associated with smoking, and it is well accepted that on average a life-long smoker will die 10 years earlier than a non-smoker, a risk that is halved if smoking is given up at the age of 50 and almost normalised if given up before the age of 30 [4]. This risk is much higher even when compared to patients with severe hypertension, who, on average, die ~3 years younger than people without hypertension [5]. Despite this, many smokers (up to 25% in countries like China) still remain unaware of the cardiovascular risk associated with tobacco use [6] and hence are unaware of the harm.

Do smokers want to give up?

Certainly more than two thirds of smokers are keen to give up smoking, but, less than 1 in 20 are successful [2]. This is an area where we can help by promoting smoking cessation and supporting the smokers throughout the entire process. Furthermore, the benefit and health of passive smokers should also be reminded in all healthcare promotion campaigns.

Time and ways to give up smoking

It is also known that stopping smoking altogether is the most cost-effective strategy to prevent CVD, and there is strong evidence that short pharmacotherapeutic treatment, with, for example, nicotine replacement therapy, bupropion, varenicline plus ongoing support are very effective. At the moment, it is anticipated that electronic cigarettes might also assist significantly in reducing smoking, but in the absence of long-term data for the time being, they should be covered with the same marketing restrictions as cigarettes.

The first step in facilitating smoking cessation

The very first step is identifying who the smokers are in a community or hospital setting and how dependent on nicotine they are (using the Fagerstrom Test).

Fagerstrom test

The Fagerstrom Test for Nicotine Dependence. [9]


Your results
1-2= Low dependence
3-4= low to mod dependence
5-7= moderate dependence
8+= high dependence

The "five As" for a smoking cessation strategy for routine practice

By considering the “Five As” as shown in the table below, it is important to consider who would be a suitable candidate for smoking cessation.

A-ASK Systematically inquire about smoking status at every oppotunity.
A-ADVISE Unequivocally urge all smokers to quit.
A-ASSESS Determine the person's degree of addiction and readiness to quit.
A-ASSIST  Agree on a smoking cessation strategy, including setting a quit date, behavioural counselling
and pharmacological support.
A-ARRANGE Arrange a schedule of follow-up.

Table taken from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice detailing the first steps, the “Five As” in smoking cessation [2].


Having identified a candidate willing to attempt smoking cessation, in addition to the pharmacotherapeutic and other actions by health professionals (doctors, nurses, councillors) it is also important to look for help from the person’s family (with their consent) as support from the partner and family can be instrumental. The following table details the recommendations for smoking intervention strategies.

Recommendations for smoking intervention strategies

Recommendations Classa Levelb Refc
It is recommended to identify smokers and provide repeated advice on stopping with offers to help, by the use of follow up support, nicotine replacement therapies, varenicline, and bupropion individually or in combination.  I  A  289-  286
It is recommended to stop all smoking of tobacco or herbal products, as this is strongly and independently causal of CVD.   I  B 287-291
 It is recommended to avoid passive smoking.  I 292- 293

CVD: cardiovascular disease

aClass of recommendation

bLevel of evidence

cReference(s) supporting recommendations


Table taken from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice showing the recommendations for smoking cessation intervention [2].

Recommendations for pharmacotherapy for smoking cessation

The table below illustrates the evidence-based recommendations for pharmacotherapy for smoking cessation [7].

Nicotine-replacement therapy
  • Gum: 2 mg od or 4 mg od, according to level of patient’s nicotine dependence.
  • Patch: For heavy smokers: 25 mg patch for 8 weeks, followed by 15 mg for 2 weeks, followed by 10 mg for 2 weeks.; Light smokers: 15 mg patch for 8 weeks, followed by 10 mg for 4 weeks.
Advantages Many years of experience. High safety. Dose and combination of several different products can be adapted individually
Disadvantages High risk of under-dosing (i.e. no effect)
Side effects Common: palpitations, chest pain, nausea and vomiting, gastrointestinal complaints, insomnia, skin irritation, mouth and throat soreness, mouth ulcers, hiccups and coughing
  • Patch: allergic reactions (caution).
  • Gum: temporomandibular joint disease, ulcers
Dosage Bupropion Starting dose is 150 mg od for 6 days; followed by 150 mg bd for 7 to 9 weeks.
Advantages Easy to dose. Well-known safety profile as the drug has previously been used in psychiatric patients for decades
Disadvantages Many interactions with other types of medicine, e.g. antidepressants, antipsychotics, and type 1c anti-arrhythmics
Side effects Insomnia, headache, dry mouth, dizziness, and nausea are common. Risk exists for serious adverse effects such as seizures
Contraindications History of hypersensitivity to bupropion. Concurrent use of MAO inhibitors. Current or past epilepsy, bulimia, or anorexia nervosa. Alcohol withdrawal or withdrawal from benzodiazepines. Bipolar disorder. Severe liver cirrhosis. Know CNS tumour. Pregnancy
Dosage Varenicline Starting dose is 0.5 mg od for 3 days, followed by 0.5 mg bd for 3 to 4 days, followed by 1 mg bd.
Advantages Highest quit rates. Easy to dose
Disadvantages Neuropsychiatric cautions. Expensive
Side effects Common: nausea, insomnia, headache, abnormal dreams, constipation, flatulence, and abdominal pain. Severe: neuropsychiatric and cardiac adverse events have been reported
Contraindications History of serious hypersensitivity or skin reactions to varenicline. Pregnancy

Addressing overall cardiovascular risk

In addition to promoting smoking cessation at every opportunity and supporting smokers with this throughout, it should also be remembered that smokers do have a significantly higher CVD risk. Therefore, this should be reviewed and other conditions such as hypertension and hypercholesterolemia should be appropriately managed alongside the smoking cessation strategy.

Patient info - Tips to stop smoking:

Cravings for a cigarette usually last 3 to 5 minutes. If you can get over those few minutes, you are well on the way to not having that cigarette. The 4 D's can help you do that. [8]

  • Delay: wait at least 3 minutes; the urge will pass
  • Drink: water or juice
  • Distract yourself: move away from the situation, and do something different
  • Take deep breaths: breathe slowly and deeply, in through your nose and out through your mouth.


Smoking still results in significant morbidity and mortality in both smokers and passive smokers. With appropriate identification of smokers, education and successful actions for smoking cessation and a healthy lifestyle, the advantages associated with giving up smoking can be seen both at an individual level, but also at a population level.


[1] Goodchild M, Nargis N, Tursan d’Espaignet E. Global economic cost of smoking-attributable diseases. Tob Control 2017;:tobaccocontrol-2016-053305. doi:10.1136/tobaccocontrol-2016-053305

[2] Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2016;37:2315–81. doi:10.1093/eurheartj/ehw106

[3] Eliasson B, Hjalmarson A, Kruse E, et al. Effect of smoking reduction and cessation on cardiovascular risk factors. Nicotine Tob Res 2001;3:249–55. doi:10.1080/14622200110050510

[4] Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004;328:1519. doi:10.1136/bmj.38142.554479.AE

[5] Kiiskinen U, Vartiainen E, Puska P, et al. Long-term cost and life-expectancy consequences of hypertension. J Hypertens 1998;16:1103–12.

[6] World Health Organisation Tobacco Fact Sheet. 2016.

[7] Pisinger C and Tonstad S. Chapter 10 Smoking. In: Gielen S, De Backer G, Piepoli MF, Wood D, editors. The ESC Textbook of Preventive Cardiology. 2nd ed. United Kingdom: Oxford University Press, 2016


[9] Fagerström K, "Determinants of tobacco use and renaming the FTND to the Fagerstrom Test for Cigarette Dependence", Nicotine and Tobacco Research, 2012, vol. 14(1), p. 75-8

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The ESC Prevention of Cardiovascular Disease programme is supported by AMGEN, AstraZeneca, Ferrer, and Sanofi and Regeneron in the form of educational grants.

Related link

Report on unmet prevention needs: Smoking