McClain 1

Melinda McClain

Dr. Cassel

ENG 1201

1 May 2021

Combining Medication with Counseling is a Safe and Effective Way Quit Smoking

Tobacco use is the cause of 7 million deaths per year globally and costs the health

industry $300 billion a year to care for those who suffer from smoking related illness. Of the

34.2 million people in the United States that are current cigarette smokers, more than half have

attempted to quit in the past year with only 7.5% of them succeeding in their attempt to kick the

habit. (CDC) Nicotine is one of the most addictive substances on the planet and withdrawal

from nicotine makes the process of quitting smoking extremely difficult. There are prescription

and over the counter medications on the market that can lessen the effects of nicotine withdrawal

and have proven effective in helping smokers kick the habit when combined with behavioral and

Quitline-counselling. There has been some controversy surrounding the safety and effectiveness

of Nicotine Replacement Therapy (NRT), Chantix, and Zyban, but the addictive quality of

nicotine coupled with the health risks and social taboo of smoking have spurred more smokers to

consider these medications to assist in their quest to quit smoking and when combined with

behavioral and Quitline-counselling these medications have proven to be safe and effective in

helping smokers kick the habit.

People have been smoking some form of tobacco for over 2,000 years and before the

medical health risks of smoking where know, it was common to see people smoking in

restaurants, school building, hospitals, planes, and offices. Smoking was socially acceptable, and

it was permitted nearly everywhere. Doctors smoked in exam rooms, nurses smoked at their
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stations, teachers smoked at their desks, and actors smoked on screen. Cummings and Proctor

state that smoking was encouraged by medical professional as a weight loss aid and

recommended for reducing anxiety. Cummings and Proctor estimate that in 1953 almost half of

American adults were smoking cigarettes.

The first health warnings appeared on cigarette packs in 1966. This warning was

prescribed by Congress and was a caution that smoking may be hazardous. This warning was

upgraded in 1984 from the soft cautionary words of may be hazardous to harder language that

included a warning from the Surgeon General that stated smoking caused lung cancer, heart

disease, emphysema, and pregnancy complications, but the cigarette companies were still

spending millions to advertise and market cigarettes to all ages. There was the Marlboro Man

and cartoon character Joe Camel in magazines and on billboards. That trumpet player with the

cool Jazz sound in the Kool commercials on television and NASCAR’s car driver competed in

televised races on Sunday afternoons to win the Winston Cup.

In 2003 the World Health Organization sponsored an international treaty with a goal of

decreasing tobacco consumption worldwide and 170 countries signed on to reduce tobacco

production and curb distribution, advertisement, and production of tobacco products. (Mishra,

Aseem et al) These sale, production, distribution, promotion, and advertising restrictions placed

on the tobacco products were slow to come, but they eventually took effect and were

instrumental in making smoking less socially acceptable. Strict guidelines were instituted on

where tobacco companies could advertise, programs were developed to get the work out of the

health risks associated with smoking, and smoking bans were put in place in most public areas.

Taxes were levied on tobacco companies’ production and tobacco product purchase to offset the

cost that smoking has on the healthcare system. (Mishra, Aseem et al)
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As people become aware of the health risks of cigarette smoking and dangers of

secondhand smoke, the public’s attitudes toward smoking and smokers began to change and

smoking became taboo, causing people who smoked to feel like second class citizens. Smoking

cigarettes was no longer socially acceptable and the battle over where people could smoke and

how people should quit smoking began. The addiction associated with nicotine makes the

struggle to quit smoking extremely difficult and most people make many attempts to kick the

habit before they are successful.

The health risks associated with smoking cigarettes and inhaling secondhand smoke is

well known today and many people who have smoked for many years have experienced health

problems such COPD, lung cancer, heart disease, stroke, and diabetes. Smoking is also linked to

types of other cancers such as colon, pancreatic, cervix, liver, breast, and stomach. (Mishra, et al)

Current health problems and concerns of future health problems are added incentives for many

people to choose to quit smoking.

Nicotine is quickly ingested by the body and is one of the most addictive substances on

the planet. Nicotine has a negative effect on many organs in the body and is an

immunosuppressant. It increases heart rate and blood pressure, while reducing blood flow to the

heart. It stimulates cells in the body that are involved in the initiation and progression of cancer.

Nicotine reduces blood glucose and increasing the body’s resistance to insulin which can cause

diabetes. Nicotine’s effect on dopamine in the brain and central nervous system reinforces

addiction and induces cravings. (Mishra, et al) Nicotine withdrawal and the cravings associated

with nicotine addictions are a stumbling block for many people who attempt to quit smoking.

Medications that help to manage nicotine withdrawal and cravings can increase smoking

cessation success for many people.

One of the first products to hit the market as a smoking cessation aid was Nicorette and it

was a nicotine replacement treatment (NRT). Nicorette hit the market in 1984 and today there

are several different forms of NRTs. These gums, lozenges, patches, e cigarettes, and

inhalational agents are sold over the counter and supply the body with small amounts of nicotine

and are effective in reducing the symptoms of withdrawal associated with smoking cessation.

Since these products deliver nicotine into the body the unhealth side effects of nicotine are also

experienced such as increased heart rate and blood pressure.

Drug companies have developed two prescription medications that help control nicotine

withdrawal as well. Zyban is an antidepressant that acts on the chemicals in the brain associated

with nicotine cravings. Chantix is a partial agonist that stops nicotine from attaching to nicotine

receptors in your brain and lessens the feel-good effect caused by nicotine. Both medications

lessen the effects of nicotine withdrawal and have proven effective in assisting smokers to kick

the habit.

There has been some controversy about the safety and effectiveness of NRT’s, Zyban,

and Chantix when used for smoking cessation. There were reports that NRT’s were associated

with increased coronary events and Zyban and Chantix were linked to psychiatric side effects

that included suicidal thoughts, hostility, and agitation.

In 2009 the FDA mandated that the manufactures place a black box warning in the

packaging of Zyban and Chantix, the figure below from the article written by Brian Orelli and

published in 2014 gives an example of this black box warning and demonstrates the controversy

regarding the use of Chantix to control nicotine cravings during smoking cessation treatment.

This warning explains that Chantix is effective but neuropsychiatric events have been reported
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and physicians should weight the risks of side effects of this medication and the benefits of

smoking cessation.

Fig. 1 Image obtained from the Motley Fool website that demonstrates the mixed message of the

Black Box Warning that the FDA required that Pfizer place in the information sheet included in

the packaging of the prescription medication Chantix advising physicians to weigh the

neuropsychiatric risks of the medication against the health benefits of smoking cessation.

In 2016, after 7 years of studies with mixed results, the FDA removed the black box

warning from Zyban and Chantix. Even though, this warning was worded in such a way as to

send a mixed message, the damage was already done. Doctors were hesitant to prescribe these

medications to their patients for smoking cessation and many people were leery of taking these

medications to quit smoking.

It became common for physicians to recommend support counseling for smoking

cessation and reserve these medications, that were effective in controlling nicotine withdrawal

symptoms, for patients that were already ill from smoking. (New Smoking Cessation Agents
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Study) This type of best practice approach for the treatment for smoking cessation skewed the

statistics and added to the negative medical information about the physical and psychological

health risk associated with NRTs, Chantix, and Zyban. The case crossover studies, and statistical

analysis of the FDA’s Averse Events Reporting System were only looking at a set window of

time, which was immediately before these incidents occurred. These case crossover studies and

statistics did not take the patient’s health or medical condition into account. Since these

medications were only prescribed to patients who were already sick from smoking, it is

understandable that there would be an increase of adverse events for these patients. It is

reasonable to conclude that these adverse events may have been a result of the health conditions

of these ill patients not the medications that had been prescribed.

The best practices set by physicians for smoking cessation therapy was based on

information obtain from patients that were ill from smoking and did not include NRTs, Zyban,

and Chantix as the first line treatment for quitting smoking. Healthy individuals who were

interested in quitting smoking were not offered medication to assist with their nicotine cravings.

Healthy smokers, who wished to quit, were advised to seek cognitive behavior therapies and

motivational interventions which address their smoking behaviors but not their addiction. The

absence of NRTs, Zyban, and Chantix hampered their attempts to quit smoking and the medical

information on side effects of these medications on health patients were not studied until later.

The most extensive study preformed on smoking cessation medications was known as the

EAGLES study and was published in The Lancet in 2016. This study touch all the bases because

it involved patients of many nationalities, some ill from smoking, others healthy. It also included

patients that had no previously diagnosed psychological issues and patients with a history of

psychological disorders. This clinical trial looked at the safety and effectiveness of NRTs,
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Zyban, and Chantix in patient for smoking cessation treatment. This study found that smokers

were more successful in quitting when NRTs, Zyban, and Chantix were used and that there was

no significant increase with the use of these medications and coronary incidents, suicidal

thoughts, hostility, or agitation. (Anthenelli, et al)

The EAGLES study was the first to look how effective NRTs, Zyban, and Chantix were

when used for smoking cessation and monitor the physical and psychological effects these

medications on healthy and ill patients both with and without psychological disorders. This

study did not indicate that there was any correlation with the use of NRTs, Zyban, and Chantix

for smoking cessation therapy and sever adverse events such as coronary incidents, depression,

suicidal ideation, or aggression. (Anthenelli, et al) Even though it put to rest these concerns, it

has not changed the way physicians chose to treat smoking cessation.

The EAGLES study was funded by Pfizer, the maker of Chantix, and the issue that Pfizer

had an interest in the positive outcome of the research may have caused some people to doubt the

viability of the results. This doubt from the findings of the Pfizer funded study was alleviated

once the data from this study was reviewed and recreated, on a smaller scale, by other

researchers in several different countries that obtained similar results.

The EAGLES study and the corroborating studies found that at 6 months NRT had a

15.7% success rate, Zyban had a 16.2% success rate, and Chantix had a 21.8% success rate when

used for smoking cessation. (Chang, et al.) These results provide concrete evidence that NRTs,

Chantix, and Zyban are far more effective when used for smoking cessation than attempting to

quit smoking cold turkey.

Smoking, as with any other addiction, has a behavior component that goes hand-in-hand

with the bodies physical dependance of the drug. There are triggers, habits and thought patterns
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associated with addiction and these issues must be included in smoking cessation treatment plans

for a successful outcome. It is not enough to lessen the effects of the bodies dependance on

nicotine with Zyban or Chantix or the nicotine cravings with NRTs, for any attempt to quit

smoking to be successful the behaviors involved with the habit must be addressed.

Cognitive behavior therapy can help a person who is trying to quit smoking retrain their

brain by redirecting the negative thoughts and behaviors that their brain generates about quitting

smoking when they are craving a cigarette. Cognitive behavior therapy is based in the belief that

thoughts create feeling, feeling, create behaviors, behaviors reinforce thoughts. (Soltysiak 369)

This therapy is a 12-to-16-week process that teaches people to change the negative thoughts that

trigger their behavioral need to smoke and reduces the anxiety they experience while attempting

to break their habit. (Soltysiak 370) Cognitive behavior therapy teaches an individual who is

attempting to quit smoking to focus more on the positive outcome of their goal and less on their

current discomfort of the difficulties they experience while attempting to break their addiction to

smoking and nicotine. Avoiding triggers and changing daily routines can break smoking

patterns. By changing the person’s smoking-related behaviors they reduce their urges to smoke

and increase their chances of quitting.

Quitline-counselling can assist a person who has decided to quit develop a plan to quit

smoking. Mapping out a plan helps to identify problems and solutions before they become

roadblocks that derail the smoking cessation attempt. Quitline-counseling is structured to

provide assistance with developing a smoking cessation plan. Picking a date and circling that

date on the calendar is a daily visual reminder of the goal that mentally prepare the person for the

journey to become smoke free. Planning for alternate activities to use as a distraction during

peak craving symptoms such as keeping chewing gum in the car or talking a short walk after
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meals could help individuals that smoke while diving or smoke after meals. Setting short- and

long-term goals can help people visualize the smoking cessation process. Quitline-counselling

helps people find the information and resources they need to stock their emotional toolbox so

they can build the skills needed to successfully quit.

Government imposed motivational interventions such as media campaigns, taxes levied

on cigarettes, and smoking bans in public areas are effective deterrent to smoking cigarettes.

Inspirational motivations interventions accessed through a mobile app, support groups, or

through family and friends are effective in improving success rates of smoking cessation. These

inspirational interventions provide the positive feedback needed to support individuals who are

attempting to quit smoking as well as help them celebrate the successes on the long journey of

breaking the addiction. The recognition and celebration of short-term goals is a boost to the

moral of the person who is struggling to quit smoking.

When combined with cognitive behavior therapy, Quitline-counselling, and motivational

interventions, smoking cessation medications become even more effective. The first long term

study on the efficacy of medication for use in smoking cessation, not funded by Pfizer, was a 2-

year study published in 2020 and combined the use of Chantix with Quitline-counselling as a

randomized controlled clinical trial for patients with smoking related illness. This clinical trial

had the highest success rate with Chantix plus Quitline-counselling as the most effective with a

29.2% success rate at the end of 2 years. (Carson-Chahhoud) In this study the patients were

selected from people who were hospitalized with a tobacco related illness and the smoking

cessation medication were administer and monitored by medical staff which may explain this

high success rate.

The escalating physical, financial, and social cost of smoking cigarettes has increased the

need to quit smoking for many people. Smoking bans in most public places and the negative

connotation associated with smoking has made many smokers feel like social outcast. The

escalating financial cost of maintaining a smoking habit, with current health problems or

concerns of future health issues have motivated people to choose to quit smoking. The struggle

with nicotine withdrawal and addiction complicates the difficult journey to smoking cessation

causing many to people to fail in their attempts to kick the habit. A common misconception

with smoking cessation is if a person wants to quit smoking bad enough, they will be able to kick

the habit cold turkey. While quitting cold turkey may work for some ex-smokers it is not the

best choice for most people who want to quit smoking. The statistics given each year on the

number of people who attempted to quit smoking but failed would indicate that most people

would benefit from medications that can lessen the effects of nicotine withdrawal and addiction.

Studies indicate that NRTs, Zyban, and Chantix are safe medications to use for smoking

cessation and are effective in controlling nicotine cravings. When these medications are

combined with cognitive behavioral therapy, Quitline-counseling, and motivational incentive the

success rates of smoking cessation increase substantially. Studies indicate that combining

multiple smoking cessation treatments is the most effective to quit smoking and has the highest

long-term success of kicking the smoking habit.

Works Cited

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