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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. </p></div><div class="iconblock clearfix whole_rhythm no_top_margin bk_noprnt"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/pdqcis/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-pdqcis-lrg.png" alt="Cover of PDQ Cancer Information Summaries" height="100px" width="80px" /></a><div class="icnblk_cntnt eight_col"><h2>PDQ Cancer Information Summaries [Internet].</h2><a data-jig="ncbitoggler" href="#__NBK66008_dtls__">Show details</a><div style="display:none" class="ui-widget" id="__NBK66008_dtls__"><div>Bethesda (MD): <a href="http://www.cancer.gov/" ref="pagearea=page-banner&targetsite=external&targetcat=link&targettype=publisher">National Cancer Institute (US)</a>; 2002-.</div></div><div class="half_rhythm"></div><div class="bk_noprnt"><form method="get" action="/books/n/pdqcis/" id="bk_srch"><div class="bk_search"><label for="bk_term" class="offscreen_noflow">Search term</label><input type="text" title="Search this book" id="bk_term" name="term" value="" data-jig="ncbiclearbutton" /> <input type="submit" class="jig-ncbibutton" value="Search this book" submit="false" style="padding: 0.1em 0.4em;" /></div></form></div></div></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK66008_"><span class="title" itemprop="name">Cigarette Smoking: Health Risks and How to Quit (PDQ®)</span></h1><div class="subtitle whole_rhythm">Health Professional Version</div><p class="contrib-group"><span itemprop="author">PDQ Screening and Prevention Editorial Board</span>.</p><p class="small">Published online: June 2, 2016.</p></div><div class="jig-ncbiinpagenav body-content whole_rhythm" data-jigconfig="allHeadingLevels: ['h2'],smoothScroll: false" itemprop="text"><div id="_abs_rndgid_" itemprop="description"><p id="CDR0000062879__308">This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the prevention and cessation of cigarette smoking and the control of tobacco use. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.</p><p id="CDR0000062879__309">This summary is reviewed regularly and updated as necessary by the PDQ Screening and Prevention Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).</p></div><div id="CDR0000062879__1"><h2 id="_CDR0000062879__1_">Overview</h2><p id="CDR0000062879__171">Note: A separate PDQ summary on <a href="/books/n/pdqcis/CDR0000304747/">Levels of Evidence for Cancer Screening and Prevention Studies</a> is also available.</p><p id="CDR0000062879__2">The cancer prevention summaries in PDQ refer to cancer
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prevention, defined as a reduction in the incidence of cancer. The PDQ
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includes summaries generally classified by histological type of cancer,
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especially when there are known risk factors for the specific types of cancer.
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This summary addresses a specific risk factor, tobacco use, which is associated
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with a large number of different cancers (and other chronic diseases) and
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unequivocally contains human carcinogens.[<a class="bk_pop" href="#CDR0000062879_rl_1_1">1</a>] The focus of this summary is on
|
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clinical interventions by health professionals that decrease the use of
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tobacco.</p><div id="CDR0000062879__134"><h3>Effects of Smoking Cessation</h3><p id="CDR0000062879__3">Based on solid evidence, cigarette smoking causes cancers of the lung, oral cavity and pharynx, larynx, esophagus, bladder, kidney, pancreas, stomach, uterine cervix, and acute myeloid leukemia.[<a class="bk_pop" href="#CDR0000062879_rl_1_2">2</a>] Smoking avoidance and smoking cessation result in decreased
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incidence and mortality from cancer.
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</p><h4><span class="title">Description of the Evidence</span></h4><ul id="CDR0000062879__176"><li class="half_rhythm"><div><b>Study Design</b>: Evidence obtained from a randomized controlled trial.</div></li><li class="half_rhythm"><div><b>Internal Validity</b>: Good.</div></li><li class="half_rhythm"><div><b>Consistency</b>: Good.</div></li><li class="half_rhythm"><div><b>Magnitude of Effects on Health Outcomes</b>: The relative risk (RR) of several cancers is much greater in cigarette smokers compared with nonsmokers (depending on the anatomical site of the cancer and the intensity and duration of smoking, the RR can range from twofold to tenfold or greater in smoking populations). A reduction of 15% is seen in the RR of all-cause mortality in heavy smokers subjected to intensive clinical cessation interventions.</div></li><li class="half_rhythm"><div><b>External Validity</b>: Good.</div></li></ul></div><div id="CDR0000062879__135"><h3>Counseling and Smoking Cessation</h3><p id="CDR0000062879__6">Based on solid evidence, counseling by a health professional improves smoking
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|
cessation rates.
|
|
</p><h4><span class="title">Description of the Evidence</span></h4><ul id="CDR0000062879__177"><li class="half_rhythm"><div><b>Study Design</b>: Evidence obtained from randomized controlled trials.</div></li><li class="half_rhythm"><div><b>Internal Validity</b>: Good.</div></li><li class="half_rhythm"><div><b>Consistency</b>: Good.</div></li><li class="half_rhythm"><div><b>Magnitude of Effects on Health Outcomes</b>: Counseling improves cessation rates (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.32–1.84).[<a class="bk_pop" href="#CDR0000062879_rl_1_3">3</a>,<a class="bk_pop" href="#CDR0000062879_rl_1_4">4</a>]</div></li><li class="half_rhythm"><div><b>External Validity</b>: Good.</div></li></ul></div><div id="CDR0000062879__249"><h3>Physician Advice and Smoking Cessation</h3><p id="CDR0000062879__250">Based on solid evidence, simple advice from a physician to stop smoking improves smoking cessation rates.</p><ul id="CDR0000062879__251"><li class="half_rhythm"><div><b>Study Design:</b> Evidence obtained from randomized controlled trials.</div></li><li class="half_rhythm"><div><b>Internal Validity</b>: Good.</div></li><li class="half_rhythm"><div><b>Consistency</b>: Good.</div></li><li class="half_rhythm"><div><b>Magnitude of Effects on Health Outcomes</b>: Physician advice improves cessation rates (relative risk [RR], 1.66; 95% CI, 1.42–1.94).[<a class="bk_pop" href="#CDR0000062879_rl_1_3">3</a>]</div></li><li class="half_rhythm"><div><b>External Validity</b>: Good.</div></li></ul></div><div id="CDR0000062879__136"><h3>Drug Treatment and Smoking Cessation</h3><p id="CDR0000062879__9">Based on solid evidence, drug treatments, including nicotine replacement
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|
therapies (gum, patch, spray, lozenge, and inhaler), selected antidepressant therapies (e.g.,
|
|
bupropion), and nicotinic receptor agonist therapy (varenicline), result in better smoking cessation rates than placebo.
|
|
</p><h4><span class="title">Description of the Evidence</span></h4><ul id="CDR0000062879__178"><li class="half_rhythm"><div><b>Study Design</b>: Evidence obtained from randomized controlled trials.</div></li><li class="half_rhythm"><div><b>Internal Validity</b>: Good.</div></li><li class="half_rhythm"><div><b>Consistency</b>: Good.</div></li><li class="half_rhythm"><div><b>Magnitude of Effects on Health Outcomes</b>: Nicotine replacement therapy treatments, alone or in combination, improve cessation rates over placebo after 6 months (RR, 1.58; 95% CI, 1.50–1.66).[<a class="bk_pop" href="#CDR0000062879_rl_1_5">5</a>] Treatment with bupropion improves cessation rates over placebo after 6 months (OR, 1.94; 95% CI, 1.72–2.19).[<a class="bk_pop" href="#CDR0000062879_rl_1_6">6</a>] Varenicline therapy treatment improves cessation rates over placebo after 6 months (RR, 2.33; 95% CI, 1.95–2.80).[<a class="bk_pop" href="#CDR0000062879_rl_1_7">7</a>]</div></li><li class="half_rhythm"><div><b>External Validity</b>: Good.</div></li></ul></div><div id="CDR0000062879_rl_1"><h3>References</h3><ol><li><div class="bk_ref" id="CDR0000062879_rl_1_1">IARC Working Group on the Evaluation of Carcinogenic Risks to Humans: Tobacco smoke and involuntary smoking. IARC Monogr Eval Carcinog Risks Hum 83: 1-1438, 2004. [<a href="/pmc/articles/PMC4781536/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4781536</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/15285078" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15285078</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_1_2">The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. <a href="http://www.cdc.gov/tobacco/data_statistics/sgr/2004/index.htm" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">Also available online</a>. Last accessed June 29, 2016.</div></li><li><div class="bk_ref" id="CDR0000062879_rl_1_3">Lancaster T, Stead L: Physician advice for smoking cessation. Cochrane Database Syst Rev (4): CD000165, 2004. [<a href="https://pubmed.ncbi.nlm.nih.gov/15494989" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15494989</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_1_4">Lemmens V, Oenema A, Knut IK, et al.: Effectiveness of smoking cessation interventions among adults: a systematic review of reviews. Eur J Cancer Prev 17 (6): 535-44, 2008. [<a href="https://pubmed.ncbi.nlm.nih.gov/18941375" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18941375</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_1_5">Silagy C, Lancaster T, Stead L, et al.: Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev (3): CD000146, 2004. [<a href="https://pubmed.ncbi.nlm.nih.gov/15266423" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15266423</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_1_6">Hughes JR, Stead LF, Lancaster T: Antidepressants for smoking cessation. Cochrane Database Syst Rev (1): CD000031, 2007. [<a href="https://pubmed.ncbi.nlm.nih.gov/17253443" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17253443</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_1_7">Cahill K, Stead LF, Lancaster T: Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev (3): CD006103, 2008. [<a href="https://pubmed.ncbi.nlm.nih.gov/18646137" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18646137</span></a>]</div></li></ol></div></div><div id="CDR0000062879__19"><h2 id="_CDR0000062879__19_">Evidence of Benefit</h2><div id="CDR0000062879__138"><h3>Background</h3><p id="CDR0000062879__322">In the United States, smoking-related illnesses accounted for an estimated
|
|
480,000 deaths each year.[<a class="bk_pop" href="#CDR0000062879_rl_19_1">1</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_2">2</a>] (<a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a4.htm" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Also available online.</a>) On average, these deaths occur 12 years earlier than would
|
|
be expected, so the aggregate annual loss exceeds 5 million life-years.[<a class="bk_pop" href="#CDR0000062879_rl_19_3">3</a>] These
|
|
deaths are primarily due to smoking’s role as a major cause of cancer, cardiovascular diseases,
|
|
and chronic lung diseases. The known adverse health effects also include other respiratory diseases and symptoms, nuclear cataract, hip fractures, reduced female fertility, and diminished health status. Maternal smoking during pregnancy is associated with fetal growth restriction, low birth weight, and complications of pregnancy.[<a class="bk_pop" href="#CDR0000062879_rl_19_4">4</a>] It has been estimated that about 32% of
|
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cancer deaths [<a class="bk_pop" href="#CDR0000062879_rl_19_1">1</a>] and 20% of all premature deaths in the United States are
|
|
attributable to smoking.[<a class="bk_pop" href="#CDR0000062879_rl_19_5">5</a>]</p><p id="CDR0000062879__323">Tobacco products are the single, major avoidable cause of cancer, causing more than
|
|
155,000 deaths among smokers in the United States annually due to various
|
|
cancers.[<a class="bk_pop" href="#CDR0000062879_rl_19_6">6</a>] The majority of cancers of the lung, trachea, bronchus, larynx,
|
|
pharynx, oral cavity, nasal cavity, and esophagus are attributable to tobacco products, particularly cigarettes. Smoking is also causally associated with cancers of the pancreas, kidney, bladder, stomach, and
|
|
cervix and with myeloid leukemia.[<a class="bk_pop" href="#CDR0000062879_rl_19_4">4</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_7">7</a>]</p><p id="CDR0000062879__324">Smoking also has substantial effects on the health of nonsmokers.
|
|
Environmental or secondhand tobacco smoke is implicated in causing lung
|
|
cancer and coronary heart disease.[<a class="bk_pop" href="#CDR0000062879_rl_19_8">8</a>] Among children, secondhand smoke exposure is causally associated with sudden infant death syndrome, lower respiratory tract illnesses, otitis media, middle ear effusion, exacerbated asthma, and respiratory effects such as cough, wheeze, and dyspnea.[<a class="bk_pop" href="#CDR0000062879_rl_19_8">8</a>]</p><p id="CDR0000062879__325">Environmental tobacco smoke has the
|
|
same components as inhaled mainstream smoke, although in lower absolute
|
|
concentrations, between 1% and 10%, depending on the constituent. Carcinogenic
|
|
compounds in tobacco smoke include the polycyclic aromatic hydrocarbons (PAHs),
|
|
including the carcinogen benzo[a]pyrene (BaP) and the nicotine-derived
|
|
tobacco-specific nitrosamine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone
|
|
(NNK).[<a class="bk_pop" href="#CDR0000062879_rl_19_9">9</a>]
|
|
Elevated biomarkers of tobacco exposure, including urinary cotinine,
|
|
tobacco-related carcinogen metabolites, and carcinogen-protein adducts, are
|
|
seen in passive or secondhand smokers.[<a class="bk_pop" href="#CDR0000062879_rl_19_8">8</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_10">10</a>-<a class="bk_pop" href="#CDR0000062879_rl_19_12">12</a>]</p><p id="CDR0000062879__326">In 2014, 18.8% of adult men and 14.8% of adult women in the United States were
|
|
current smokers.[<a class="bk_pop" href="#CDR0000062879_rl_19_13">13</a>] (<a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6444a2.htm" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Also available online.</a>) Cigarette smoking is particularly common among American
|
|
Indians and Alaska Natives. The prevalence of smoking also varies inversely
|
|
with education, and was highest among adults who had earned a General Educational Development diploma (43.0%) and generally decreased with increasing years of education.[<a class="bk_pop" href="#CDR0000062879_rl_19_13">13</a>] (<a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6444a2.htm" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Also available online.</a>) From 2011 to 2014, significant declines occurred in the use of cigarettes among middle school (4.3% to 2.5%) and high school (15.8% to 9.2%) students.[<a class="bk_pop" href="#CDR0000062879_rl_19_14">14</a>] Cigarette smoking prevalence among male and
|
|
female high school students increased substantially during the early 1990s in
|
|
all ethnic groups, but in 2014, it declined to 9%.[<a class="bk_pop" href="#CDR0000062879_rl_19_1">1</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_15">15</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_16">16</a>] (<a href="http://www.monitoringthefuture.org/pubs/monographs/vol1_2001.pdf" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Also available online.</a>) </p><p id="CDR0000062879__327">The effect of tobacco use on population-level health outcomes is illustrated
|
|
by the example of lung cancer mortality trends. Smoking by women increased
|
|
between 1940 and the early 1960s, resulting in a greater than 600% increase in
|
|
female lung cancer mortality since 1950. Lung cancer is now the leading cause
|
|
of cancer death in women.[<a class="bk_pop" href="#CDR0000062879_rl_19_15">15</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_17">17</a>] In the last 30 years, prevalence of current
|
|
cigarette use has generally decreased, though far more rapidly in males. Lung
|
|
cancer mortality in men peaked in the 1980s, and has been declining since then; this
|
|
decrease has occurred predominantly in squamous cell and small cell carcinomas,
|
|
the histologic types most strongly associated with smoking.[<a class="bk_pop" href="#CDR0000062879_rl_19_15">15</a>] Variations in
|
|
lung cancer mortality rates by state also more or less parallel long-standing
|
|
state-specific differences in tobacco use. Among men, the average
|
|
annual age-adjusted lung cancer death rates from 2008 to 2012 were highest in
|
|
Kentucky (92 per 100,000),[<a class="bk_pop" href="#CDR0000062879_rl_19_1">1</a>] where 29.1% of men were current smokers in 1997,
|
|
and lowest in Utah (26.4 per 100,000), where only 10.4% of men smoked. Among
|
|
women, lung cancer death rates were highest in Kentucky (55.2 per 100,000), where
|
|
28.0% of women were current smokers, and lowest in Utah (15.6 per 100,000),
|
|
where only 9.3% of women smoked.[<a class="bk_pop" href="#CDR0000062879_rl_19_1">1</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_15">15</a>]</p></div><div id="CDR0000062879__328"><h3>Smoking Cessation Interventions</h3><p id="CDR0000062879__329">Many health risks related to tobacco smoking can be reduced by smoking
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|
cessation. Smokers who quit smoking before age 50 years have up to half the
|
|
risk of dying within 15 years compared with people who continue to smoke, and the risk
|
|
of dying is reduced substantially even among persons who stop smoking after age
|
|
70 years.[<a class="bk_pop" href="#CDR0000062879_rl_19_18">18</a>] The risk of lung cancer is 30% to 50% lower than that of continuing
|
|
smokers after 10 years of abstinence, and the risk of oral and esophageal
|
|
cancer is halved within 5 years of cessation.[<a class="bk_pop" href="#CDR0000062879_rl_19_18">18</a>] Smokers who quit also lower
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|
their risk of cervical, gastric, and bladder cancer.[<a class="bk_pop" href="#CDR0000062879_rl_19_4">4</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_17">17</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_18">18</a>]</p><p id="CDR0000062879__330">A number of approaches at the policy, legislative, and regulatory levels have
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|
been attempted to effect widespread reduction in or prevention of commencement
|
|
of tobacco use. Various efforts at the community, state, and national level
|
|
have been credited with reducing the prevalence of smoking over time. These
|
|
efforts include, reducing minors’ access to tobacco products, disseminating effective
|
|
school-based prevention curricula together with media strategies, raising the
|
|
cost of tobacco products, using tobacco excise taxes to fund community-level
|
|
interventions including mass media, providing proven quitting strategies
|
|
through health care organizations, and adopting smoke-free laws and
|
|
policies.[<a class="bk_pop" href="#CDR0000062879_rl_19_19">19</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_20">20</a>]</p><div id="CDR0000062879__331"><h4>The Lung Health Study</h4><p id="CDR0000062879__332">In a randomized trial of heavy smokers, the long-term follow-up results demonstrated that compared with the nonintervention group (n = 1,964), those randomly assigned to a smoking cessation intervention (n = 3,923) experienced a 15% reduction in all-cause mortality rates (8.83 vs. 10.38 per 1,000 person-years; <i>P</i> = .03).[<a class="bk_pop" href="#CDR0000062879_rl_19_21">21</a>] The smoking cessation intervention consisted of a strong physician message plus 12 group sessions and nicotine gum administered during a 10-week period. Decreases in the risk of lung and other cancers, and coronary heart disease, cardiovascular disease, and respiratory disease contributed to the benefit in the group randomly assigned to the smoking cessation intervention.</p></div><div id="CDR0000062879__333"><h4>School-based interventions</h4><p id="CDR0000062879__334">School-based interventions alone have not demonstrated
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|
long-term impact for smoking prevention.[<a class="bk_pop" href="#CDR0000062879_rl_19_22">22</a>] One of the highest-quality studies was a large, randomized trial
|
|
in which children received a theory-based
|
|
program that incorporated various social-influence approaches from grade 3 through grade 12, with no
|
|
difference in smoking outcomes observed either at grade 12 or at 2 years after high school between school
|
|
districts receiving the intervention and those in the control arm.[<a class="bk_pop" href="#CDR0000062879_rl_19_23">23</a>]</p></div><div id="CDR0000062879__335"><h4>Minimum legal age of access to tobacco products</h4><p id="CDR0000062879__336">Raising the minimum legal age of access (MLA) to tobacco products is a tobacco control policy option that has gained momentum. Currently, the MLA set by the federal government is 18 years of age, but states and municipalities can raise the MLA to older ages. In 2015, Hawaii became the first state to raise the MLA to 21 years, and many municipalities, including Boston and New York City, have enacted MLA 21-years legislation. An Institute of Medicine report thoroughly evaluated public health implications of raising the MLA.[<a class="bk_pop" href="#CDR0000062879_rl_19_24">24</a>] In the absence of direct evidence on this topic, the report was based on a series of assumptions about the impact of raising the MLA on reducing and delaying initiation of smoking. These assumptions were entered into statistical models that forecast the impact of increasing the MLA on smoking prevalence and smoking-caused premature deaths during the 21st century. Even the results of the more conservative Cancer Intervention and Surveillance Modeling Network estimated that an increase of the MLA to 21 years in 2015 would avert 249,000 smoking-caused premature deaths in a hypothetical U.S. birth cohort by 2100.</p><p id="CDR0000062879__337">Despite the strong hypothetical evidence of benefit implied by the Institute of Medicine report, the dearth of direct evidence on raising the MLA makes it challenging to discern the actual impact of raising the MLA in real-world settings. Needham, Massachusetts became the first U.S. municipality to raise the MLA to 21 years in April of 2005. To evaluate the impact of raising the MLA, researchers used a post-intervention only time series approach to compare area-level smoking prevalence among high school students in Needham with 16 surrounding municipalities that had a constant MLA of 18 years.[<a class="bk_pop" href="#CDR0000062879_rl_19_25">25</a>] The source of smoking prevalence data was a biennial survey administered to students in grades 9 through 12; data from 2006, 2008, 2010, and 2012 were presented. During this 6-year period, the decrease in prevalence of current smoking in Needham (7.4%) was only slightly larger than the 16 surrounding municipalities (6.3%). Numerous limitations weaken the evidence provided by this study, including the assessment of evidence only more than a year after the MLA 21 years was enacted; this is especially important in the Needham example because the MLA had been gradually increased to MLA 19 years in 2003 and MLA 20 years in 2004 and ignoring these previous MLA increases would bias the findings toward the null. The lack of high-quality direct evidence evaluating the public health impact of raising the MLA accentuates the future need for stronger direct evidence on this topic.</p></div><div id="CDR0000062879__338"><h4>Community Intervention Trial for Smoking Cessation (COMMIT) </h4><p id="CDR0000062879__339">The Community Intervention Trial for Smoking Cessation (COMMIT) was a National Cancer Institute-funded large-scale study to assess a combination of community-based
|
|
interventions designed to help smokers cease using tobacco. COMMIT involved 11
|
|
matched pairs of communities in North America, which were randomly assigned to
|
|
an arm offering an active community-wide intervention or a control arm (no
|
|
active intervention).[<a class="bk_pop" href="#CDR0000062879_rl_19_26">26</a>] The 4-year intervention included messaging through
|
|
existing media channels, major community organizations, and social institutions
|
|
capable of influencing smoking behavior in large groups of people. The
|
|
interventions were implemented in each community through a local community
|
|
board that provided oversight and management of COMMIT activities.</p><p id="CDR0000062879__340">In COMMIT, there was no difference in the mean quit rate
|
|
of heavy-smokers in the intervention communities (18.0%) compared with the
|
|
control communities (18.7%). The light-to-moderate smoker quit rates were
|
|
statistically significantly different: averages of 30.6% and 27.5% for the
|
|
intervention and control communities, respectively (<i>P</i> = .004). Although no
|
|
significant differences in quit rates between the sexes were observed,
|
|
less-educated light-to-moderate smokers were more responsive to the
|
|
intervention than were college-educated smokers with a light-to-moderate
|
|
habit.[<a class="bk_pop" href="#CDR0000062879_rl_19_27">27</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_28">28</a>]</p><p id="CDR0000062879__341"> Clinical interventions targeted at individuals have shown more promising results. A meta-analysis of randomized controlled trials shows that 6-month cessation rates are significantly improved with use of nicotine replacement therapy (NRT) products compared with placebo or no intervention (summary relative risk [RR], 1.58; 95% confidence interval [CI], 1.50–1.66).[<a class="bk_pop" href="#CDR0000062879_rl_19_29">29</a>] The benefits of NRT product use have been consistently observed regardless of whether the product used was the patch, gum, nasal spray, inhaler, or lozenge.[<a class="bk_pop" href="#CDR0000062879_rl_19_29">29</a>] Smoking cessation counseling alone is also effective;[<a class="bk_pop" href="#CDR0000062879_rl_19_30">30</a>] even a brief
|
|
intervention by a health care professional significantly increases the smoking
|
|
cessation rate.[<a class="bk_pop" href="#CDR0000062879_rl_19_31">31</a>]</p><p id="CDR0000062879__342">An important issue is whether pharmacotherapies are more effective in the presence of counseling. A randomized trial compared the following three levels of intervention that combined free pharmacotherapy (nicotine patch or bupropion) with or without counseling: 1) pharmacotherapy alone; 2) pharmacotherapy plus up to two counseling sessions every 6 months; and 3) pharmacotherapy plus up to six counseling sessions every 6 months. During the 24-month study, each group was offered a randomly assigned intervention at baseline, 6 months, 12 months, and 18 months later. For the primary study endpoint of 7-day point prevalence of smoking abstinence after 24 months of follow-up, no statistically significant differences were observed among the interventions.[<a class="bk_pop" href="#CDR0000062879_rl_19_32">32</a>] The results of this study suggest that the combination of pharmacotherapy plus counseling is no better than intervention alone.</p><p id="CDR0000062879__343">Promoting smoking cessation among cancer survivors is essential because the deleterious health effects of cigarette smoking may impact prognosis in both the short term and long term. In a randomized controlled trial of a peer-delivered smoking cessation intervention among childhood cancer survivors, a significantly higher 12-month quit rate was observed in the intervention group (15% vs. 9%; <i>P</i> < .01).[<a class="bk_pop" href="#CDR0000062879_rl_19_33">33</a>]</p></div></div><div id="CDR0000062879__137"><h3>Tobacco Cessation Guidelines</h3><p id="CDR0000062879__26">In 1996, the Agency for Health Care Policy and Research (AHCPR), now the Agency
|
|
for Healthcare Research and Quality released a landmark set of clinical
|
|
smoking-cessation guidelines for helping nicotine-dependent patients and
|
|
health care providers. Now sponsored by the Public Health Service, the updated 2008 guidelines, "<a href="http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Treating Tobacco Use and Dependence</a>" are available online.[<a class="bk_pop" href="#CDR0000062879_rl_19_34">34</a>] The broad elements of these guidelines are:</p><ol id="CDR0000062879__97"><li class="half_rhythm"><div>Clinicians should document the tobacco-use status of every patient.
|
|
</div></li><li class="half_rhythm"><div>Clinicians should assess the readiness to quit of patients who use
|
|
tobacco and assist those who wish to quit in setting a quit date.
|
|
</div></li><li class="half_rhythm"><div>Patients using tobacco should be provided with at least one of the
|
|
effective brief cessation interventions that are available.
|
|
</div></li><li class="half_rhythm"><div>In general, more intense interventions are more effective than less
|
|
intense interventions in producing long-term tobacco abstinence,
|
|
reflecting the dose-response relationship between the intervention and
|
|
its outcome.
|
|
</div></li><li class="half_rhythm"><div>One or more of the three treatment elements identified as being particularly
|
|
effective should be included in smoking-cessation treatment:<ol id="CDR0000062879__98" class="lower-alpha"><li class="half_rhythm"><div>Social support from clinicians in the form of encouragement,
|
|
assistance.</div></li><li class="half_rhythm"><div>Skills training/problem solving (cessation/abstinence techniques).</div></li><li class="half_rhythm"><div>Pharmacotherapy, such as nicotine-replacement (e.g., patches, gum).</div></li></ol></div></li><li class="half_rhythm"><div>To be effective, health care systems must make institutional changes
|
|
resulting in systematic identification of tobacco users and intervention
|
|
with these patients at every visit.</div></li></ol><p id="CDR0000062879__42">For individual interventions, the guidelines [<a class="bk_pop" href="#CDR0000062879_rl_19_34">34</a>] suggest a model based on
|
|
outcomes from six major clinical trials of physician-delivered smoking
|
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intervention conducted in the late 1980s:[<a class="bk_pop" href="#CDR0000062879_rl_19_35">35</a>] the ASK, ADVISE, ASSESS, ASSIST,
|
|
and ARRANGE model. The physician provides a brief intervention that entails
|
|
asking about smoking status at every visit, advising abstinence, assisting by
|
|
setting a quit date, providing self-help materials and recommending use of
|
|
NRT, and arranging for a follow-up visit. See below
|
|
for brief and expanded intervention outlines. The recommendations also
|
|
strongly support the value of referral to more intensive counseling.
|
|
</p><h4><span class="title">Ask, Advise, Assess, Assist, Arrange: Key Elements
|
|
</span></h4><ol id="CDR0000062879__102" class="upper-alpha"><li class="half_rhythm"><div>Ask <ul id="CDR0000062879__103"><li class="half_rhythm"><div>Screen for smoking status at every visit or admission.</div></li></ul></div></li><li class="half_rhythm"><div>Advise<ul id="CDR0000062879__104"><li class="half_rhythm"><div>Minimal Advice: “As your physician, I must advise you that smoking is bad
|
|
for your health, and it would be important for you to stop.”</div></li><li class="half_rhythm"><div>Augmented Advice: “Because of your (__________) condition, it is
|
|
particularly important for you to stop. If you stop now, (briefly educate
|
|
patient about basic health benefits from quitting).”</div></li></ul></div></li><li class="half_rhythm"><div>Assess<ul id="CDR0000062879__105"><li class="half_rhythm"><div>Minimal Assessment: Ask every tobacco user if he/she is willing to make a
|
|
quit attempt at this time.</div></li><li class="half_rhythm"><div>Augmented Assessment: Assess characteristics of smoking history and
|
|
patterns.<dl id="CDR0000062879__106" class="temp-labeled-list"><dt>-</dt><dd><p class="no_top_margin">Amount smoked.
|
|
</p></dd><dt>-</dt><dd><p class="no_top_margin">Quit history.</p></dd><dt>-</dt><dd><p class="no_top_margin">Stage of Change:<ul id="CDR0000062879__107"><li class="half_rhythm"><div>Precontemplator: Is not seriously considering stopping smoking.
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|
</div></li><li class="half_rhythm"><div>Contemplator: Is seriously considering stopping within 3 to 6 months.
|
|
</div></li><li class="half_rhythm"><div>Preparation: Is seriously considering stopping within the next week
|
|
to month and has already made changes such as cutting back.
|
|
</div></li><li class="half_rhythm"><div>Action: Has recently stopped smoking (within last 6 months).
|
|
</div></li><li class="half_rhythm"><div>Relapse: Has quit for at least 48 hours but is smoking again.
|
|
</div></li><li class="half_rhythm"><div>Maintenance: Has quit for at least 6 months but may still be
|
|
vulnerable to a relapse up to 1 year.
|
|
</div></li></ul></p></dd></dl><dl id="CDR0000062879__223" class="temp-labeled-list"><dt>-</dt><dd><p class="no_top_margin">Nicotine Addiction: <a href="http://www.aafp.org/afp/2000/0801/p579.html" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Fagerstrom Test</a> for nicotine dependency.</p></dd><dt>-</dt><dd><p class="no_top_margin">Behavioral Patterns: "Why Do You Smoke?" Scale.</p></dd></dl></div></li></ul></div></li><li class="half_rhythm"><div>Assist/Counsel<ul id="CDR0000062879__108"><li class="half_rhythm"><div>Minimal Assistance: Provide self-help materials; assess interest in
|
|
quitting; and assess interest in and appropriateness of pharmacological aids.
|
|
</div></li><li class="half_rhythm"><div>Augmented Assistance: Provide brief 5- to 7-minute patient-centered counseling.
|
|
See below for an outline of the counseling content.
|
|
</div></li></ul></div></li><li class="half_rhythm"><div>Arrange Follow-up Support<ul id="CDR0000062879__109"><li class="half_rhythm"><div>Minimal Follow-up Support: Arrange for single follow-up contact by visit or
|
|
by telephone in about 2 weeks; provide referral to a smoking counselor or
|
|
group.
|
|
</div></li><li class="half_rhythm"><div>Extended Follow-up Support: Establish “quit smoking” contract with quit
|
|
date. Arrange three or more follow-up contacts by visit or by telephone.</div></li></ul></div></li></ol><h4><span class="title">Patient-Centered Counseling: Key Elements</span></h4><ul id="CDR0000062879__59"><li class="half_rhythm"><div>Motivation<dl id="CDR0000062879__110" class="temp-labeled-list"><dt>-</dt><dd><p class="no_top_margin">Basic Question:<ul id="CDR0000062879__111"><li class="half_rhythm"><div>“How do you feel about smoking?”</div></li></ul>
|
|
</p></dd><dt>-</dt><dd><p class="no_top_margin">Follow-up Questions:<ul id="CDR0000062879__112"><li class="half_rhythm"><div>“How do you feel about stopping smoking?”</div></li><li class="half_rhythm"><div>“Have you ever tried to stop before?” “What happened?”</div></li><li class="half_rhythm"><div>“What do you like about smoking?”</div></li><li class="half_rhythm"><div>“What do you not like about smoking?”</div></li></ul></p></dd></dl></div></li><li class="half_rhythm"><div>Anticipated Problems<dl id="CDR0000062879__113" class="temp-labeled-list"><dt>-</dt><dd><p class="no_top_margin">Basic Question:
|
|
<ul id="CDR0000062879__114"><li class="half_rhythm"><div>“What problems will you have if you stop smoking?”
|
|
</div></li></ul></p></dd><dt>-</dt><dd><p class="no_top_margin">Follow-up Questions:<ul id="CDR0000062879__115"><li class="half_rhythm"><div>“Anything else?”
|
|
</div></li><li class="half_rhythm"><div>“On the ‘Why Do You Smoke?’ questionnaire, you scored high on (_______). How do you think you can handle that type of situation?”
|
|
</div></li></ul></p></dd></dl></div></li><li class="half_rhythm"><div>Resources for Coping with Problems<dl id="CDR0000062879__116" class="temp-labeled-list"><dt>-</dt><dd><p class="no_top_margin">Basic Question:<ul id="CDR0000062879__117"><li class="half_rhythm"><div>“How do you think you can handle that?”
|
|
</div></li></ul></p></dd><dt>-</dt><dd><p class="no_top_margin">Follow-up Questions:<ul id="CDR0000062879__118"><li class="half_rhythm"><div>“What else could you do?”
|
|
</div></li><li class="half_rhythm"><div>“How do you expect your (family/spouse/friends) to help you?”
|
|
</div></li></ul></p></dd></dl></div></li></ul></div><div id="CDR0000062879__119"><h3>Pharmacotherapy for Smoking Cessation</h3><p id="CDR0000062879__72">Pharmacological agents have been used successfully to aid in the cessation of
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|
smoking in the general population.[<a class="bk_pop" href="#CDR0000062879_rl_19_36">36</a>] Since the original AHCPR guidelines [<a class="bk_pop" href="#CDR0000062879_rl_19_37">37</a>]
|
|
were published in 1996, various nicotine replacement products have been
|
|
approved for over-the-counter sale, and additional evidence of the
|
|
effectiveness of therapies for smoking cessation has been published.[<a class="bk_pop" href="#CDR0000062879_rl_19_38">38</a>-<a class="bk_pop" href="#CDR0000062879_rl_19_41">41</a>]
|
|
Pharmacotherapy of smoking cessation, including NRTs (gum,
|
|
patch, spray, lozenge, and inhaler) and nonnicotine medications (e.g., bupropion and varenicline), results
|
|
in statistically significant increases in smoking cessation rates over those of a placebo. Based on a synthesis of the results of 110 randomized trials, the researchers found that NRT treatments, alone or in combination, improved cessation rates over placebos after 6 months (RR, 1.58; 95% CI, 1.50–1.66).[<a class="bk_pop" href="#CDR0000062879_rl_19_29">29</a>] The results of a meta-analysis of three randomized controlled trials that tested combination NRT versus single NRT interventions suggested that combining another type of NRT, such as nicotine lozenges, with the nicotine patch was more efficacious than the nicotine patch alone (odds ratio [OR], 1.43; 95% CI, 1.08–1.91).[<a class="bk_pop" href="#CDR0000062879_rl_19_42">42</a>] However, this result was not confirmed in a subsequent randomized trial that compared an intervention of nicotine patch plus nicotine lozenge to nicotine patch alone.[<a class="bk_pop" href="#CDR0000062879_rl_19_43">43</a>] There was little difference in 7-day point-prevalence abstinence after 26 weeks of follow-up (27% vs. 23%; <i>P</i> = .25) and no added benefit after 52 weeks of follow-up (20% vs. 21%; <i>P</i> = .86) between participants in the combination NRT intervention and those in the nicotine patch–alone intervention.</p><p id="CDR0000062879__253">There are also nonnicotine pharmacotherapies that have been efficacious for smoking cessation, including bupropion and varenicline. Based on the results of 31 randomized trials that compared the antidepressant bupropion to placebo, after 6 months of follow-up, bupropion was associated with a statistically significant increase in the likelihood of quitting smoking (summary OR, 1.94; 95% CI, 1.72–2.19).[<a class="bk_pop" href="#CDR0000062879_rl_19_44">44</a>] There is insufficient evidence to support the idea that combining bupropion plus NRT increases smoking cessation rates over those of NRT alone (summary OR, 1.37; 95% CI, 0.65–2.91).[<a class="bk_pop" href="#CDR0000062879_rl_19_44">44</a>] </p><p id="CDR0000062879__254">Varenicline is a selective alpha-4-beta-2 nicotinic acetylcholine receptor partial agonist. In two randomized controlled trials for smoking cessation, varenicline titrated to a dose of 1.0 mg twice a day and was compared with bupropion sustained-release (SR) 150 mg twice a day and with a placebo group.[<a class="bk_pop" href="#CDR0000062879_rl_19_45">45</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_46">46</a>] Treatment lasted for 12 weeks, with an additional 40 weeks of posttreatment follow-up. In both studies, varenicline was more efficacious than bupropion and placebo for continuous abstinence from smoking at 9 to 12 weeks and at 9 to 24 weeks of follow-up. For 9 to 52 weeks of follow-up, varenicline was more efficacious than placebo in both studies.[<a class="bk_pop" href="#CDR0000062879_rl_19_45">45</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_46">46</a>] At 52 weeks of follow-up, the 7-day point prevalence of smoking abstinence was 46% higher in the varenicline group than in the bupropion SR group (OR, 1.46; 95% CI, 1.04–2.06).[<a class="bk_pop" href="#CDR0000062879_rl_19_45">45</a>] The other study also showed a 46% higher continuous abstinence in the varenicline group (OR, 1.46; 95% CI, 0.99–2.17).[<a class="bk_pop" href="#CDR0000062879_rl_19_46">46</a>] Approximately 30% of the participants who were randomly assigned to receive varenicline reported nausea, more than double that in the bupropion groups, and triple that seen in the placebo groups. In a randomized trial comparing varenicline with transdermal nicotine, continuous abstinence was greater in the varenicline group than in the transdermal nicotine group at the end of treatment (56% vs. 43%; <i>P</i> < .001) and during posttreatment follow-up (26% vs. 20%; <i>P</i> = .06).[<a class="bk_pop" href="#CDR0000062879_rl_19_47">47</a>] The prevalence of nausea in the varenicline group (37%) was more than triple that in the transdermal nicotine group (10%). However, this result was not confirmed in a subsequent randomized trial that compared varenicline with the nicotine patch.[<a class="bk_pop" href="#CDR0000062879_rl_19_43">43</a>] There was little difference in 7-day point-prevalence abstinence after 26 weeks (24% vs. 23%; <i>P</i> = .82) or 52 weeks (19% vs. 21%; <i>P</i> = .61) between those randomly assigned to the varenicline intervention and those assigned to the nicotine patch intervention.</p><p id="CDR0000062879__255">Based on postmarketing surveillance, on July 1, 2009, the U.S. Food and Drug Administration (FDA) required additions to the Boxed Warnings for both bupropion and varenicline to describe the risk of serious neuropsychiatric symptoms associated with these products. Symptoms include: “changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide.”[<a class="bk_pop" href="#CDR0000062879_rl_19_48">48</a>] The FDA goes on to advise that the important health benefits of quitting smoking “should be weighed against the small, but real, risk of serious adverse events with the use of varenicline or bupropion.”[<a class="bk_pop" href="#CDR0000062879_rl_19_48">48</a>] A meta-analysis of double-blind, placebo-controlled, randomized trials of varenicline administered for at least 1 week (N = 14 trials) indicated that varenicline was associated with an increased risk of serious adverse cardiovascular events (RR, 1.72; 95% CI, 1.09–2.71).[<a class="bk_pop" href="#CDR0000062879_rl_19_49">49</a>] This finding is particularly noteworthy because almost all of the randomized trials included in the meta-analysis had the following in common: they excluded patients with cardiovascular disease (CVD) at baseline; the usual average age of the patient populations (early 40s) was young for CVD; varenicline was usually administered for only 12 weeks or less; and, varenicline is efficacious for smoking cessation, which would act to decrease CVD risk.</p><p id="CDR0000062879__73">There is a growing number of smoking cessation pharmacotherapies that have been shown to be efficacious in significantly increasing rates of smoking cessation. The choice of therapy should be individualized based on a number
|
|
of factors, including past experience, patient and/or physician preference, and
|
|
potential agent side effects.
|
|
As more is learned about specific genetic variants that influence a smoker's response to smoking cessation pharmacotherapies—such as polymorphisms in genes encoding enzymes involved in nicotine metabolism—this information could eventually be integrated into smoking cessation treatment planning.[<a class="bk_pop" href="#CDR0000062879_rl_19_50">50</a>] Presently, the evidence is not yet sufficient to be integrated into clinical practice.</p><p id="CDR0000062879__74">The following sections summarize available pharmacologic interventions to assist
|
|
in tobacco cessation. More comprehensive information is available from product package inserts.
|
|
</p><div id="CDR0000062879__120"><h4>Pharmacologic interventions to assist in tobacco cessation
|
|
</h4><div id="CDR0000062879__121"><h5> Nicotine replacement therapy</h5><p id="CDR0000062879__79">These products are designed to aid in the withdrawal
|
|
symptoms associated with nicotine. Several precautions are warranted
|
|
before initiating therapy, but it should be noted that these precautions do
|
|
not constitute absolute contraindications. In particular, special
|
|
considerations are necessary in some patient groups (e.g., those with
|
|
medical conditions such as arrhythmias, uncontrolled hypertension,
|
|
esophagitis, peptic ulcer disease, insulin-treated diabetes, or asthma,
|
|
pregnant or breast-feeding women, and adolescent smokers).[<a class="bk_pop" href="#CDR0000062879_rl_19_51">51</a>]</p><div id="CDR0000062879__122" class="table"><h3><span class="title">Table 1. Nicotine Patches</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK66008.6/table/CDR0000062879__122/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__CDR0000062879__122_lrgtbl__"><table class="no_margin"><thead><tr><th colspan="1" rowspan="1" style="vertical-align:top;"></th><th colspan="1" rowspan="1" style="vertical-align:top;">Brand</th><th colspan="1" rowspan="1" style="vertical-align:top;"> Dose </th><th colspan="1" rowspan="1" style="vertical-align:top;">Side Effects </th><th colspan="1" rowspan="1" style="vertical-align:top;">Comments</th></tr></thead><tbody><tr><td colspan="1" rowspan="1" style="vertical-align:top;">Rx</td><td colspan="1" rowspan="1" style="vertical-align:top;">Habitrol</td><td colspan="1" rowspan="1" style="vertical-align:top;">7–21 mg/d</td><td colspan="1" rowspan="1" style="vertical-align:top;"> Erythema </td><td colspan="1" rowspan="1" style="vertical-align:top;">Use for 6–12 wk</td></tr><tr><td colspan="1" rowspan="1" style="vertical-align:top;">OTC</td><td colspan="1" rowspan="1" style="vertical-align:top;"> Nicoderm CQ </td><td colspan="1" rowspan="1" style="vertical-align:top;">7–21 mg/d</td><td colspan="1" rowspan="1" style="vertical-align:top;"> Pruritus </td><td colspan="1" rowspan="1" style="vertical-align:top;">Use for 6–12 wk</td></tr><tr><td colspan="1" rowspan="1" style="vertical-align:top;">OTC</td><td colspan="1" rowspan="1" style="vertical-align:top;">Nicotrol</td><td colspan="1" rowspan="1" style="vertical-align:top;">5–15 mg/d</td><td colspan="1" rowspan="1" style="vertical-align:top;"> Burning at site </td><td colspan="1" rowspan="1" style="vertical-align:top;">Use for 14–20 wk</td></tr><tr><td colspan="1" rowspan="1" style="vertical-align:top;">Rx</td><td colspan="1" rowspan="1" style="vertical-align:top;">ProStep </td><td colspan="1" rowspan="1" style="vertical-align:top;"> 11–22 mg/d </td><td colspan="1" rowspan="1" style="vertical-align:top;">Local irritation </td><td colspan="1" rowspan="1" style="vertical-align:top;">Use for 6–12 wk</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">d = day; OTC = over the counter; Rx = prescription; wk = week.</p></div></dd></dl></div></div></div><p id="CDR0000062879__279">Current guidelines recommend 8 weeks of transdermal nicotine therapy. Findings from two randomized placebo-controlled trials of transdermal therapy are divergent in their findings as to whether extended therapy (22–24 weeks vs. 8 weeks) improves quit rates.[<a class="bk_pop" href="#CDR0000062879_rl_19_52">52</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_53">53</a>]</p><div id="CDR0000062879__123" class="table"><h3><span class="title">Table 2. Nicotine Polacrilex Gums</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK66008.6/table/CDR0000062879__123/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__CDR0000062879__123_lrgtbl__"><table class="no_margin"><thead><tr><th colspan="1" rowspan="1" style="vertical-align:top;"></th><th colspan="1" rowspan="1" style="vertical-align:top;"> Brand</th><th colspan="1" rowspan="1" style="vertical-align:top;">Dose</th><th colspan="1" rowspan="1" style="vertical-align:top;"> Side Effects </th><th colspan="1" rowspan="1" style="vertical-align:top;">Comments</th></tr></thead><tbody><tr><td colspan="1" rowspan="1" style="vertical-align:top;"> OTC</td><td colspan="1" rowspan="1" style="vertical-align:top;">Nicorette</td><td colspan="1" rowspan="1" style="vertical-align:top;">18–24 mg/d </td><td colspan="1" rowspan="1" style="vertical-align:top;">Stomatitis, sore throat </td><td colspan="1" rowspan="1" style="vertical-align:top;">Max 30 pieces/d; decrease 1 piece every 4–7 d</td></tr><tr><td colspan="1" rowspan="1" style="vertical-align:top;">OTC</td><td colspan="1" rowspan="1" style="vertical-align:top;">Nicorette DS</td><td colspan="1" rowspan="1" style="vertical-align:top;"> 36–48 mg/d </td><td colspan="1" rowspan="1" style="vertical-align:top;">Jaw ache </td><td colspan="1" rowspan="1" style="vertical-align:top;">Max 20 pieces/d; decrease 1 piece every 4–7 d</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin"> d = day; OTC = over the counter.</p></div></dd></dl></div></div></div><div id="CDR0000062879__144" class="table"><h3><span class="title"> Table 3. Nicotine Lozenges</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK66008.6/table/CDR0000062879__144/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__CDR0000062879__144_lrgtbl__"><table class="no_margin"><thead><tr><th colspan="1" rowspan="1" style="vertical-align:top;"></th><th colspan="1" rowspan="1" style="vertical-align:top;">Brand</th><th colspan="1" rowspan="1" style="vertical-align:top;">Dose</th><th colspan="1" rowspan="1" style="vertical-align:top;">Side Effects</th><th colspan="1" rowspan="1" style="vertical-align:top;">Comments</th></tr></thead><tbody><tr><td colspan="1" rowspan="1" style="vertical-align:top;">OTC</td><td colspan="1" rowspan="1" style="vertical-align:top;">Commit</td><td colspan="1" rowspan="1" style="vertical-align:top;">40–80 mg/d</td><td colspan="1" rowspan="1" style="vertical-align:top;">Local irritation (warmth and tingling)</td><td colspan="1" rowspan="1" style="vertical-align:top;">Use for 12 wk; max 20 pieces/d. Wk 1–6: 1–2 lozenges every 1–2 h; wk 7–9: 1 lozenge every 2–4 h; wk 10–12: 1 lozenge every 4–8 h</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">d = day; h = hour; OTC = over the counter; wk = week.</p></div></dd></dl></div></div></div><div id="CDR0000062879__124" class="table"><h3><span class="title">Table 4. Nicotine Inhalers</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK66008.6/table/CDR0000062879__124/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__CDR0000062879__124_lrgtbl__"><table class="no_margin"><thead><tr><th colspan="1" rowspan="1" style="vertical-align:top;"></th><th colspan="1" rowspan="1" style="vertical-align:top;">Brand</th><th colspan="1" rowspan="1" style="vertical-align:top;">Dose</th><th colspan="1" rowspan="1" style="vertical-align:top;">Side Effects</th><th colspan="1" rowspan="1" style="vertical-align:top;">Comments</th></tr></thead><tbody><tr><td colspan="1" rowspan="1" style="vertical-align:top;">Rx</td><td colspan="1" rowspan="1" style="vertical-align:top;">Nicotrol Inhaler </td><td colspan="1" rowspan="1" style="vertical-align:top;">Individualized </td><td colspan="1" rowspan="1" style="vertical-align:top;">Local irritation </td><td colspan="1" rowspan="1" style="vertical-align:top;">Use up to 24 wk</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">Rx = prescription; wk = week.</p></div></dd></dl></div></div></div><div id="CDR0000062879__125" class="table"><h3><span class="title">Table 5. Nicotine Nasal Sprays</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK66008.6/table/CDR0000062879__125/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__CDR0000062879__125_lrgtbl__"><table class="no_margin"><thead><tr><th colspan="1" rowspan="1" style="vertical-align:top;"></th><th colspan="1" rowspan="1" style="vertical-align:top;">Brand</th><th colspan="1" rowspan="1" style="vertical-align:top;">Dose </th><th colspan="1" rowspan="1" style="vertical-align:top;">Side Effects</th><th colspan="1" rowspan="1" style="vertical-align:top;">Comments</th></tr></thead><tbody><tr><td colspan="1" rowspan="1" style="vertical-align:top;">Rx</td><td colspan="1" rowspan="1" style="vertical-align:top;">Nicotrol NS</td><td colspan="1" rowspan="1" style="vertical-align:top;"> Max 40 mg/d </td><td colspan="1" rowspan="1" style="vertical-align:top;"> Nasal irritation </td><td colspan="1" rowspan="1" style="vertical-align:top;"> Max use 3 mo</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">d = day; mo = month; Rx = prescription. </p></div></dd></dl></div></div></div></div><div id="CDR0000062879__208"><h5>Nonnicotine products</h5><div id="CDR0000062879__213"><h5>Bupropion HCl</h5><p id="CDR0000062879__214">Also used as an antidepressant, bupropion HCl is a
|
|
nonnicotine aid to smoking cessation. It is a relatively weak inhibitor of
|
|
the neuronal uptake of norepinephrine, serotonin, and dopamine, and does not
|
|
inhibit monoamine oxidase. The exact mechanism by which bupropion HCl
|
|
enhances the ability of patients to abstain from smoking is unknown;
|
|
however, it is presumed that this action is mediated by noradrenergic or
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dopaminergic mechanisms.</p><div id="CDR0000062879__215" class="table"><h3><span class="title">Table 6. Bupropion Hydrochloride</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK66008.6/table/CDR0000062879__215/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__CDR0000062879__215_lrgtbl__"><table class="no_margin"><thead><tr><th colspan="1" rowspan="1" style="vertical-align:top;"></th><th colspan="1" rowspan="1" style="vertical-align:top;">Brand</th><th colspan="1" rowspan="1" style="vertical-align:top;">Dose</th><th colspan="1" rowspan="1" style="vertical-align:top;">Side Effects</th><th colspan="1" rowspan="1" style="vertical-align:top;">Warning/Precaution </th></tr></thead><tbody><tr><td colspan="1" rowspan="3" style="vertical-align:top;">Rx</td><td colspan="1" rowspan="3" style="vertical-align:top;"> Zyban </td><td colspan="1" rowspan="3" style="vertical-align:top;">150 mg/d × 3 d then increase to 300 mg/d × 7–12 wk</td><td colspan="1" rowspan="3" style="vertical-align:top;">Insomnia, dry mouth, dizziness, rhinitis</td><td colspan="1" rowspan="1" style="vertical-align:top;"> Do not take with Wellbutrin or Wellbutrin SR</td></tr><tr><td colspan="1" rowspan="1" style="vertical-align:top;">Higher incidence of seizures in patients treated for bulimia, anorexia </td></tr><tr><td colspan="1" rowspan="1" style="vertical-align:top;">Do not prescribe >300 mg/d for patients being treated for bulimia </td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin"> d = day; Rx = prescription; wk = week.</p></div></dd></dl></div></div></div><div id="CDR0000062879__210" class="table"><h3><span class="title"><div class="milestone-start" id="CDR0000062879__209"></div>Table 7. Varenicline</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK66008.6/table/CDR0000062879__210/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__CDR0000062879__210_lrgtbl__"><table class="no_margin"><thead><tr><th colspan="1" rowspan="1" style="vertical-align:top;"></th><th colspan="1" rowspan="1" style="vertical-align:top;">Brand</th><th colspan="1" rowspan="1" style="vertical-align:top;">Dose</th><th colspan="1" rowspan="1" style="vertical-align:top;">Side Effects</th><th colspan="1" rowspan="1" style="vertical-align:top;">Warning/Precaution</th></tr></thead><tbody><tr><td colspan="1" rowspan="2" style="vertical-align:top;">Rx</td><td colspan="1" rowspan="2" style="vertical-align:top;">Chantix</td><td colspan="1" rowspan="2" style="vertical-align:top;">0.5 mg/d, d 1–3; 0.5 mg twice a d, d 4–7; then 1.0 mg twice a d through wk 12</td><td colspan="1" rowspan="2" style="vertical-align:top;">Nausea, insomnia</td><td colspan="1" rowspan="1" style="vertical-align:top;">Risk of toxicity greater in patients with impaired renal function </td></tr><tr><td colspan="1" rowspan="1" style="vertical-align:top;">Not tested in children and pregnant women <div class="milestone-end"></div></td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">d = day; Rx = prescription; wk = week.</p></div></dd></dl></div></div></div></div><div id="CDR0000062879__216"><h5> Fluoxetine</h5><p id="CDR0000062879__217">Although Zyban (bupropion HCl) is the only
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antidepressant approved by the FDA for smoking cessation, Prozac (fluoxetine
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HCl) has been shown to be effective.[<a class="bk_pop" href="#CDR0000062879_rl_19_54">54</a>]</p><div id="CDR0000062879__218" class="table"><h3><span class="title"> Table 8. Fluoxetine</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK66008.6/table/CDR0000062879__218/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__CDR0000062879__218_lrgtbl__"><table class="no_margin"><thead><tr><th colspan="1" rowspan="1" style="vertical-align:top;"></th><th colspan="1" rowspan="1" style="vertical-align:top;">Brand</th><th colspan="1" rowspan="1" style="vertical-align:top;">Dose </th><th colspan="1" rowspan="1" style="vertical-align:top;">Side Effects</th><th colspan="1" rowspan="1" style="vertical-align:top;">Comments</th></tr></thead><tbody><tr><td colspan="1" rowspan="1" style="vertical-align:top;">Rx</td><td colspan="1" rowspan="1" style="vertical-align:top;">Prozac </td><td colspan="1" rowspan="1" style="vertical-align:top;">30–60 mg/d </td><td colspan="1" rowspan="1" style="vertical-align:top;"> Insomnia, dizziness, anorexia, sexual dysfunction, confusion</td><td colspan="1" rowspan="1" style="vertical-align:top;"> Limited data available on its use in combination with cognitive-behavioral therapy </td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">d = day; Rx = prescription.</p></div></dd></dl></div></div></div></div><div id="CDR0000062879__300"><h5>Cytisine</h5><p id="CDR0000062879__301">Cytisine is a naturally occurring compound isolated more than 50 years ago from the plant <i>Cytisus laburnum</i>, a partial nicotinic acetylcholine receptor agonist.[<a class="bk_pop" href="#CDR0000062879_rl_19_55">55</a>] It has a long history of use for smoking cessation in Bulgaria and other eastern European nations, including clinical trials published in the 1970s. As this older evidence has been uncovered, it has led to more recent trials in western nations; a systematic review and meta-analysis showed clear benefit for cytisine compared with placebo.[<a class="bk_pop" href="#CDR0000062879_rl_19_55">55</a>] For all trials combined (n = 9 trials; 2,141 cytisine participants, 1,879 placebo participants), the pooled relative risk for abstinence from smoking at the longest follow-up for cytisine was 1.59 (95% CI, 1.43–1.75), compared with placebo. When the analyses were limited to two high-quality trials published since 2008, the pooled relative risk for smoking abstinence was 3.29 (95% CI, 1.84–5.90).[<a class="bk_pop" href="#CDR0000062879_rl_19_55">55</a>] There has been no evidence of serious adverse events, but gastrointestinal symptoms have been more common in the cytisine (12%) group compared with the placebo (7%) group.[<a class="bk_pop" href="#CDR0000062879_rl_19_55">55</a>]</p><p id="CDR0000062879__302">A randomized trial in New Zealand compared cytisine (n = 655) with NRT (n = 655).[<a class="bk_pop" href="#CDR0000062879_rl_19_56">56</a>] Compared with the group who received NRT, the cytisine group had higher continued abstinence at 1 month (40% vs. 31%; risk difference 9%; 95% CI, 4%–15%), 2 months (31% vs. 22%; risk difference 9%; 95% CI, 4%–14%), and 6 months (22% vs. 15%; risk difference 7%; 95% CI, 2%–11%).[<a class="bk_pop" href="#CDR0000062879_rl_19_56">56</a>] With respect to adverse events, there was no difference between groups for serious adverse events, but comparing the cytisine group with the NRT group, nausea and vomiting (28 events vs. 2 events) and sleep disorders (28 events vs. 2 events) were more common in the cytisine group.[<a class="bk_pop" href="#CDR0000062879_rl_19_56">56</a>] This trial is noteworthy because of the following results:</p><ol id="CDR0000062879__304"><li class="half_rhythm"><div>It considerably strengthened an already substantial body of evidence indicating that cytisine is an efficacious smoking cessation pharmacotherapy.</div></li><li class="half_rhythm"><div>It showed that cytisine is more efficacious than NRT products that are known to be effective.</div></li></ol><div id="CDR0000062879__303" class="table"><h3><span class="title">Table 9. Cytisine</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK66008.6/table/CDR0000062879__303/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__CDR0000062879__303_lrgtbl__"><table class="no_margin"><thead><tr><th colspan="1" rowspan="1" style="vertical-align:top;"></th><th colspan="1" rowspan="1" style="vertical-align:top;">Brand</th><th colspan="1" rowspan="1" style="vertical-align:top;">Dose</th><th colspan="1" rowspan="1" style="vertical-align:top;">Side Effects</th><th colspan="1" rowspan="1" style="vertical-align:top;">Comments</th></tr></thead><tbody><tr><td colspan="1" rowspan="1" style="vertical-align:top;">Cytisine
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(Rx and OTC)
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</td><td colspan="1" rowspan="1" style="vertical-align:top;">Tabex,
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Desmoxan
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</td><td colspan="1" rowspan="1" style="vertical-align:top;">1.5–9.0 mg/d</td><td colspan="1" rowspan="1" style="vertical-align:top;">Nausea, vomiting, sleep disturbances</td><td colspan="1" rowspan="1" style="vertical-align:top;">Use for 3–4 wk,
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d 1–3: 1 tablet every 2 h;
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d 4–12: 1 tablet every 2.5 h;
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d 13–16: 1 tablet every 3 h;
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d 17–20: 1 tablet every 4 h;
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d 21–25: 1 tablet every 6 h
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</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">d = day; h = hour; mg = milligram; OTC = over the counter; Rx = prescription; wk = week.</p></div></dd></dl></div></div></div></div><div id="CDR0000062879__219"><h5>Lobeline</h5><p id="CDR0000062879__220">Lobeline (Bantron) is classified as a category III agent by the FDA, safe but no proven effectiveness. This product is not recommended for use in any smoking cessation program due to its lack of efficacy.[<a class="bk_pop" href="#CDR0000062879_rl_19_57">57</a>]</p></div><div id="CDR0000062879__221"><h5>Other agents</h5><p id="CDR0000062879__222">Clonidine and nortriptyline have been suggested as possibly useful second-line pharmacotherapies, but are not approved for smoking cessation by the FDA. Nortriptyline is an antidepressant that does not contain nicotine. A meta-analysis of five randomized controlled trials found that smokers who received nortriptyline were 2.4 times more likely (95% CI, 1.7–3.6) than smokers who received a placebo to remain abstinent from smoking after 6 months.[<a class="bk_pop" href="#CDR0000062879_rl_19_58">58</a>]</p></div></div></div></div><div id="CDR0000062879__211"><h3>Smoking Reduction</h3><p id="CDR0000062879__212">Among dependent smokers, complete abstinence from smoking is the ultimate goal. Even in instances when complete abstinence from smoking is not achieved, smoking cessation pharmacotherapies may benefit individual health—and ultimately the public’s health—if the smoker reduces the number of cigarettes smoked. The relationship between cigarette smoking and lung cancer, and other smoking-associated malignancies, is strongly dose-dependent. Thus, an individual smoker who is unable to achieve abstinence or who is not motivated to quit smoking may benefit by using pharmacotherapies (or other means) to reduce the number of cigarettes smoked per day. NRT has thus generated attention as a viable means of “harm reduction.” In studies that randomly assigned smokers who were not trying to quit to NRT or placebo, a greater proportion of those randomly assigned to NRT compared with placebo reduced the number of cigarettes per day.[<a class="bk_pop" href="#CDR0000062879_rl_19_59">59</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_60">60</a>] However, the impact of NRT on smoking reduction appears not to be sustained in the long run.[<a class="bk_pop" href="#CDR0000062879_rl_19_61">61</a>] Less evidence is available for bupropion, varenicline, and psychosocial interventions as a means of harm reduction. A potential problem with such a harm reduction strategy would be if it prevented cessation among smokers who would have otherwise quit smoking. Evidence shows that smoking reduction is actually associated with increased likelihood of future cessation.[<a class="bk_pop" href="#CDR0000062879_rl_19_60">60</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_62">62</a>] Another potential negative aspect of harm reduction would be if smokers reduced the number of cigarettes smoked per day but modified the way the cigarettes were smoked in such a way that exposure to tobacco toxins was not actually reduced (e.g., by inhaling more deeply). Compensatory behaviors such as inhaling more deeply or smoking more of a cigarette are attempts by the smoker to try to maintain nicotine levels, so the use of supplemental NRT presumably safeguards against this. Evidence from studies of smoking reduction with NRT that measured smoking biomarkers indicates that compensation occurs, but not to such an extent that it would be expected to outweigh the reduction in exposure from the reduced number of cigarettes per day.[<a class="bk_pop" href="#CDR0000062879_rl_19_59">59</a>]</p><p id="CDR0000062879__299">Among smokers who are interested in quitting but not ready to make an immediate quit attempt, gradually decreasing the number of cigarettes smoked per day leading up to a quit attempt may prove to be a viable intervention strategy. This “reduce to quit” approach was tested in the context of a randomized controlled trial. In this study, both the intervention group and control group received counseling with the goals of reducing the number of cigarettes smoked per day by 75% or greater by week 8 and to quit smoking entirely by week 12.[<a class="bk_pop" href="#CDR0000062879_rl_19_63">63</a>] The intervention group (n = 760) also received smoking cessation pharmacotherapy (varenicline at a maintenance dose of 1 mg twice per day for 24 weeks), whereas the control group (n = 750) received placebo tablets. For the primary endpoint of self-reported smoking abstinence during weeks 15 through 24, a statistically significant risk difference of 25.2% (varenicline group, 32.1% vs. placebo group, 6.9%; 95% CI, 21.4%–29.0%) was observed. The clinical significance of this finding is that it provides evidence of benefit for a pharmacotherapy-enhanced intervention aimed to motivate smokers who are interested in quitting, but not yet ready to quit, to start by cutting down on the number of cigarettes per day as a lead-in to a subsequent quit attempt.</p></div><div id="CDR0000062879__310"><h3>Financial Incentive Programs for Smoking Cessation</h3><p id="CDR0000062879__311">Financial incentive programs can offer additional support for smoking cessation efforts. Results from a recent randomized trial suggest that the efficacy of such programs may be influenced greatly by the way rewards are disbursed.[<a class="bk_pop" href="#CDR0000062879_rl_19_64">64</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_65">65</a>]</p><p id="CDR0000062879__312">The trial randomly assigned 2,538 participants to either one of four incentive programs or usual care. The four programs were combinations of scope (two programs targeted individuals, and two targeted groups of six participants) and incentive structure (one of the individual-focused programs and one of the group-focused programs provided rewards of approximately $800 to participants who achieved cessation at 6 months; the others required an initial refundable deposit of $150, supplemented with $650 in reward payments for successful cessation). The rationale for the four intervention arms was based on behavioral observations that 1) people are more loss averse than gain seeking and 2) collaboration/competition with others can bolster intervention efficacy.[<a class="bk_pop" href="#CDR0000062879_rl_19_64">64</a>]</p><p id="CDR0000062879__316">Two main dimensions of the intervention effects were explored:</p><ol id="CDR0000062879__317"><li class="half_rhythm"><div>Acceptance of the intervention.</div></li><li class="half_rhythm"><div>Efficacy of the intervention. </div></li></ol><p id="CDR0000062879__313">Both intent-to-treat and per-protocol analyses were performed, with an in-depth sensitivity analysis for potential biases accompanying the latter. In the intent-to-treat analyses (which evaluated the overall efficacy of the interventions), all of the financial incentive arms demonstrated significantly higher 6-month abstinence rates than did usual care (9.4%–16%, compared with 6% for usual care). The 6 month abstinence rates were similar between the group-focused and individual-focused arms (13.7% and 12.1%, respectively; <i>P</i> = .29), but the reward-based programs were associated with higher abstinence rates than were the deposit-based ones (15.7% vs. 10.2%; <i>P</i> < .001).[<a class="bk_pop" href="#CDR0000062879_rl_19_64">64</a>]</p><p id="CDR0000062879__314">However, per-protocol analyses that accounted for the dramatically lower acceptance rate for the deposit-based interventions than for the reward-based interventions (14% vs. 90%) estimated that 6-month abstinence rates could be 13.2 percentage points (95% CI, 3.1–22.8) higher in the deposit-based programs than in the reward-based programs among the estimated 13.7% of participants who would participate in either type of program. That is, deposit-based interventions may be more efficacious than reward-based interventions but harder to get people to commit to.[<a class="bk_pop" href="#CDR0000062879_rl_19_64">64</a>]</p></div><div id="CDR0000062879__290"><h3>A Changing Marketplace for Tobacco Products and Nicotine-Delivery Devices</h3><p id="CDR0000062879__291">The expansion in the marketplace of tobacco products and devices that deliver nicotine poses new challenges to tobacco control.[<a class="bk_pop" href="#CDR0000062879_rl_19_66">66</a>-<a class="bk_pop" href="#CDR0000062879_rl_19_70">70</a>] Examples of nontraditional tobacco products in the U.S. market include small cigars, water pipe tobacco smoking (“hookah”), and new types of flavored, smokeless tobacco products modeled after Swedish snus. Prominent among non–tobacco-containing nicotine delivery devices are electronic cigarettes (or “e-cigarettes”) that have experienced a rapid upsurge in use and are now marketed by the major U.S. tobacco companies.[<a class="bk_pop" href="#CDR0000062879_rl_19_66">66</a>,<a class="bk_pop" href="#CDR0000062879_rl_19_67">67</a>] Monitoring this expansion in products, how the products are used (e.g., product switching, multiple use, and use for tobacco cigarette smoking cessation), and the harms and benefits associated with their use compared with the use of tobacco cigarettes is critical to the development of more effective tobacco control strategies.</p><p id="CDR0000062879__292">Research to determine the potential risks and benefits of these new products is just beginning to emerge. In a three-arm trial in New Zealand, 657 adult tobacco cigarette smokers who wanted to quit smoking were all referred to a smoking cessation quit line and randomly assigned to receive nicotine e-cigarettes, nicotine patches, or placebo e-cigarettes.[<a class="bk_pop" href="#CDR0000062879_rl_19_71">71</a>] After 3 months of intervention and 3 additional months of follow-up, the primary outcome of 6-month continuous abstinence was 7.3%, 5.8%, and 4.1%, respectively. These quit rates were low in all three arms of the study, and the differences were not statistically significant but provide preliminary evidence that e-cigarettes resulted in rates of smoking cessation comparable to those of the nicotine patch, a smoking cessation pharmacotherapy of established efficacy. The trial results also suggested that nicotine e-cigarettes could expand the reach of smoking cessation interventions. Compared with the group assigned to the nicotine patch, the group assigned to e-cigarettes had higher adherence to treatment (78% vs. 46%; <i>P</i> < .0001) and were more likely to report that they would recommend their assigned product to a friend wanting to quit (88% vs. 56%; no <i>P</i>-value reported).[<a class="bk_pop" href="#CDR0000062879_rl_19_71">71</a>]</p></div><div id="CDR0000062879_rl_19"><h3>References</h3><ol><li><div class="bk_ref" id="CDR0000062879_rl_19_1">American Cancer Society: Cancer Facts and Figures 2016. Atlanta, Ga: American Cancer Society, 2016. <a href="http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">Available online.</a> Last accessed July 11, 2016.</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_2">Jamal A, Agaku IT, O'Connor E, et al.: Current cigarette smoking among adults--United States, 2005-2013. MMWR Morb Mortal Wkly Rep 63 (47): 1108-12, 2014. [<a href="/pmc/articles/PMC5779518/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5779518</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25426653" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25426653</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_3">Nelson DE, Kirkendall RS, Lawton RL, et al.: Surveillance for smoking-attributable mortality and years of potential life lost, by state--United States, 1990. Mor Mortal Wkly Rep CDC Surveill Summ 43 (1): 1-8, 1994. [<a href="https://pubmed.ncbi.nlm.nih.gov/8208238" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 8208238</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_4">The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. <a href="http://www.cdc.gov/tobacco/data_statistics/sgr/2004/index.htm" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">Also available online</a>. Last accessed June 29, 2016.</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_5">American Cancer Society: Cancer Facts and Figures 2015. Atlanta, Ga: American Cancer Society, 2015. <a href="http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">Available online</a>. Last accessed June 28, 2016.</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_6">Centers for Disease Control and Prevention: Targeting Tobacco Use: The Nation's Leading Cause of Death 2005. Atlanta, Ga: CDC, 2005.</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_7">Ontario Task Force on the Primary Prevention of Cancer: Recommendations for the Primary Prevention of Cancer. Toronto, Canada: Queen's Printer for Ontario, 1995.</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_8">U.S. Department of Health and Human Services: The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, Centers for Disease Control and
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Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. <a href="/books/NBK44324/" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">Also available online</a>. Last accessed June 29, 2016. [<a href="https://pubmed.ncbi.nlm.nih.gov/20669524" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20669524</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_9">Cinciripini PM, Hecht SS, Henningfield JE, et al.: Tobacco addiction: implications for treatment and cancer prevention. J Natl Cancer Inst 89 (24): 1852-67, 1997. [<a href="https://pubmed.ncbi.nlm.nih.gov/9414173" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 9414173</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_10">Finette BA, O'Neill JP, Vacek PM, et al.: Gene mutations with characteristic deletions in cord blood T lymphocytes associated with passive maternal exposure to tobacco smoke. Nat Med 4 (10): 1144-51, 1998. [<a href="https://pubmed.ncbi.nlm.nih.gov/9771747" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 9771747</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_11">Benowitz NL: Cotinine as a biomarker of environmental tobacco smoke exposure. Epidemiol Rev 18 (2): 188-204, 1996. [<a href="https://pubmed.ncbi.nlm.nih.gov/9021312" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 9021312</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_12">Hecht SS: Human urinary carcinogen metabolites: biomarkers for investigating tobacco and cancer. Carcinogenesis 23 (6): 907-22, 2002. [<a href="https://pubmed.ncbi.nlm.nih.gov/12082012" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12082012</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_13">Jamal A, Homa DM, O'Connor E, et al.: Current cigarette smoking among adults - United States, 2005-2014. MMWR Morb Mortal Wkly Rep 64 (44): 1233-40, 2015. [<a href="https://pubmed.ncbi.nlm.nih.gov/26562061" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26562061</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_14">Youth and Tobacco Use. Atlanta, Ga: Centers for Disease Control and Prevention, 2015. <a href="http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">Available online</a>. Last accessed February 17, 2016.</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_15">Jemal A, Thun MJ, Ries LA, et al.: Annual report to the nation on the status of cancer, 1975-2005, featuring trends in lung cancer, tobacco use, and tobacco control. J Natl Cancer Inst 100 (23): 1672-94, 2008. 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[<a href="/pmc/articles/PMC4471993/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4471993</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25970009" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25970009</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_65">Sunstein CR: Nudging smokers. N Engl J Med 372 (22): 2150-1, 2015. [<a href="https://pubmed.ncbi.nlm.nih.gov/25970008" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25970008</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_66">Popova L, Ling PM: Alternative tobacco product use and smoking cessation: a national study. Am J Public Health 103 (5): 923-30, 2013. [<a href="/pmc/articles/PMC3661190/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3661190</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/23488521" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23488521</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_67">Kamerow D: Big Tobacco lights up e-cigarettes. BMJ 346: f3418, 2013. [<a href="https://pubmed.ncbi.nlm.nih.gov/23709584" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23709584</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_68">Schuster RM, Hertel AW, Mermelstein R: Cigar, cigarillo, and little cigar use among current cigarette-smoking adolescents. Nicotine Tob Res 15 (5): 925-31, 2013. [<a href="/pmc/articles/PMC3621583/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3621583</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/23072873" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23072873</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_69">Jawad M, McEwen A, McNeill A, et al.: To what extent should waterpipe tobacco smoking become a public health priority? Addiction 108 (11): 1873-84, 2013. [<a href="https://pubmed.ncbi.nlm.nih.gov/23863044" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23863044</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_70">Centers for Disease Control and Prevention (CDC): Consumption of cigarettes and combustible tobacco--United States, 2000-2011. MMWR Morb Mortal Wkly Rep 61 (30): 565-9, 2012. [<a href="https://pubmed.ncbi.nlm.nih.gov/22854624" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22854624</span></a>]</div></li><li><div class="bk_ref" id="CDR0000062879_rl_19_71">Bullen C, Howe C, Laugesen M, et al.: Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 382 (9905): 1629-37, 2013. [<a href="https://pubmed.ncbi.nlm.nih.gov/24029165" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24029165</span></a>]</div></li></ol></div></div><div id="CDR0000062879__139"><h2 id="_CDR0000062879__139_">Changes to This Summary (06/02/2016)</h2><p id="CDR0000062879__141">The PDQ cancer information summaries are reviewed regularly and updated as
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new information becomes available. This section describes the latest
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changes made to this summary as of the date above.</p><p id="CDR0000062879__345"><b><a href="#CDR0000062879__19">Evidence of Benefit</a></b></p><p id="CDR0000062879__347">Added <a href="#CDR0000062879__72">text</a> about the results of a meta-analysis of three randomized controlled trials that tested combination nicotine replacement therapy (NRT) versus single NRT interventions (cited Cahill et al. as reference 42); also added that this result (combining another type of NRT with the nicotine patch was more efficacious than the nicotine patch alone) was not confirmed in a subsequent randomized trial (cited Baker et al. as reference 43). Also added that there was little difference in 7-day point-prevalence abstinence after 26 weeks or 52 weeks of follow-up between the two groups.</p><p id="CDR0000062879__348">Added <a href="#CDR0000062879__254">text</a> to state that the result about the prevalence of nausea (in the varenicline group and in the transdermal nicotine group) was not confirmed in a subsequent randomized trial. Also added that there was little difference in 7-day point-prevalence abstinence after 26 weeks or 52 weeks between the two groups.</p><p id="CDR0000062879__disclaimerHP_3">This summary is written and maintained by the <a href="http://www.cancer.gov/publications/pdq/editorial-boards/screening-prevention" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">PDQ Screening and Prevention Editorial Board</a>, which is
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editorially independent of NCI. The summary reflects an independent review of
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the literature and does not represent a policy statement of NCI or NIH. More
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information about summary policies and the role of the PDQ Editorial Boards in
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maintaining the PDQ summaries can be found on the <a href="#CDR0000062879__AboutThis_1">About This PDQ Summary</a> and <a href="http://www.cancer.gov/publications/pdq" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">PDQ® - NCI's Comprehensive Cancer Database</a> pages.
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</p></div><div id="CDR0000062879__AboutThis_1"><h2 id="_CDR0000062879__AboutThis_1_">About This PDQ Summary</h2><div id="CDR0000062879__AboutThis_2"><h3>Purpose of This Summary</h3><p id="CDR0000062879__AboutThis_3">This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the prevention and cessation of cigarette smoking and the control of tobacco use. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.</p></div><div id="CDR0000062879__AboutThis_4"><h3>Reviewers and Updates</h3><p id="CDR0000062879__AboutThis_5">This summary is reviewed regularly and updated as necessary by the <a href="http://www.cancer.gov/publications/pdq/editorial-boards/screening-prevention" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">PDQ Screening and Prevention Editorial Board</a>, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).</p><p id="CDR0000062879__AboutThis_22"> Board members review recently published articles each month to determine whether an article should:</p><ul id="CDR0000062879__AboutThis_6"><li class="half_rhythm"><div>be discussed at a meeting,</div></li><li class="half_rhythm"><div>be cited with text, or</div></li><li class="half_rhythm"><div>replace or update an existing article that is already cited.</div></li></ul><p id="CDR0000062879__AboutThis_7">Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.</p><p id="CDR0000062879__AboutThis_9">Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's <a href="http://www.cancer.gov/contact/email-us" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Email Us</a>. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.</p></div><div id="CDR0000062879__AboutThis_10"><h3>Levels of Evidence</h3><p id="CDR0000062879__AboutThis_11">Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Screening and Prevention Editorial Board uses a <a href="/books/n/pdqcis/CDR0000304747/">formal evidence ranking system</a> in developing its level-of-evidence designations.</p></div><div id="CDR0000062879__AboutThis_12"><h3>Permission to Use This Summary</h3><p id="CDR0000062879__AboutThis_13">PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”</p><p id="CDR0000062879__AboutThis_14">The preferred citation for this PDQ summary is:</p><p id="CDR0000062879__AboutThis_15">PDQ® Screening and Prevention Editorial Board. PDQ Cigarette Smoking. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: <a href="http://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/quit-smoking-hp-pdq" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">http://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/quit-smoking-hp-pdq</a>. Accessed <MM/DD/YYYY>. [PMID: 26389444]</p><p id="CDR0000062879__AboutThis_16">Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in <a href="http://visualsonline.cancer.gov/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Visuals Online</a>, a collection of over 2,000 scientific images.
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</p></div><div id="CDR0000062879__AboutThis_17"><h3>Disclaimer</h3><p id="CDR0000062879__AboutThis_19">The information in these summaries should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the <a href="http://www.cancer.gov/about-cancer/managing-care" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Managing Cancer Care</a> page.</p></div><div id="CDR0000062879__AboutThis_20"><h3>Contact Us</h3><p id="CDR0000062879__AboutThis_21">More information about contacting us or receiving help with the Cancer.gov website can be found on our <a href="http://www.cancer.gov/contact" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Contact Us for Help</a> page. Questions can also be submitted to Cancer.gov through the website’s <a href="http://www.cancer.gov/contact/email-us" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Email Us</a>.</p></div></div></div></div>
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<div xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Views</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="PDF_download" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="/books/NBK66008.6/?report=reader">PubReader</a></li><li><a href="/books/NBK66008.6/?report=printable">Print View</a></li><li><a data-jig="ncbidialog" href="#_ncbi_dlg_citbx_NBK66008" data-jigconfig="width:400,modal:true">Cite this Page</a><div id="_ncbi_dlg_citbx_NBK66008" style="display:none" title="Cite this Page"><div class="bk_tt">PDQ Screening and Prevention Editorial Board. Cigarette Smoking: Health Risks and How to Quit (PDQ®): Health Professional Version. 2016 Jun 2. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. <span class="bk_cite_avail"></span></div></div></li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Version History</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter shutter_closed" title="Show/hide content" remembercollapsed="true" pgsec_name="version_history" id="Shutter"></a></div><div class="portlet_content" style="display: none;"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><span class="bk_col_itm"><a href="/books/NBK66008.22/">NBK66008.22</a></span> October 10, 2024</li><li><span class="bk_col_itm"><a href="/books/NBK66008.21/">NBK66008.21</a></span> August 14, 2024</li><li><span class="bk_col_itm"><a href="/books/NBK66008.20/">NBK66008.20</a></span> June 21, 2024</li><li><span class="bk_col_itm"><a href="/books/NBK66008.19/">NBK66008.19</a></span> May 24, 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class="brieflinkpop offscreen_noflow">Links to PubMed</div></li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Similar articles in PubMed</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="PBooksDiscovery_RA" id="Shutter"></a></div><div class="portlet_content"><ul><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/26389451" ref="ordinalpos=1&linkpos=1&log$=relatedreviews&logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Cancer Prevention Overview (PDQ®): Health Professional Version.</a><span class="source">[PDQ Cancer Information Summari...]</span><div class="brieflinkpop offscreen_noflow"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Cancer Prevention Overview (PDQ®): Health Professional Version.<div class="brieflinkpopdesc"><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="author">PDQ Screening and Prevention Editorial Board. </em><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="cit">PDQ Cancer Information Summaries. 2002</em></div></div></li><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/26389477" ref="ordinalpos=1&linkpos=2&log$=relatedreviews&logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Endometrial Cancer Prevention (PDQ®): Health Professional Version.</a><span class="source">[PDQ Cancer Information Summari...]</span><div class="brieflinkpop offscreen_noflow"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Endometrial Cancer Prevention (PDQ®): Health Professional Version.<div class="brieflinkpopdesc"><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="author">PDQ Screening and Prevention Editorial Board. </em><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="cit">PDQ Cancer Information Summaries. 2002</em></div></div></li><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/26389433" ref="ordinalpos=1&linkpos=3&log$=relatedreviews&logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Cervical Cancer Prevention (PDQ®): Health Professional Version.</a><span class="source">[PDQ Cancer Information Summari...]</span><div class="brieflinkpop offscreen_noflow"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Cervical Cancer Prevention (PDQ®): Health Professional Version.<div class="brieflinkpopdesc"><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="author">PDQ Screening and Prevention Editorial Board. </em><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="cit">PDQ Cancer Information Summaries. 2002</em></div></div></li><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/26389511" ref="ordinalpos=1&linkpos=4&log$=relatedreviews&logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Anal Cancer Prevention (PDQ®): Health Professional Version.</a><span class="source">[PDQ Cancer 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<a class="text-white" href="https://www.hhs.gov/">HHS</a>
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