Tobacco use will kill as many as I billion people in the 21st century unless its use is curtailed. Smoking cessation is associated with several health and personal benefits; however, smoking cessation is difficult because of the highly addictive nature of nicotine. Successful smoking cessation strategies can generally be divided into two groups: nicotine replacement therapy (NRT) and behavioral modification. The National Cancer Institute in the US advocates the use of the 'Ask-Assess-Advise-Assist-Arrange' approach to strengthen the role of the healthcare provider in initiating and sustaining smoking cessation. The 'stages of change' model is also useful in tailoring the physician's approach to smoking cessation to the patient's attitude to this change. There are several approved types of NRT. These include nicotine polacrilex gum, transdermal nicotine patches, nicotine lozenges, nicotine nasal sprays, nicotine inhalers, and nicotine lollipops. Nicotine polacrilex gum, nicotine transdermal patches, and nicotine lozenges are available both on prescription and over the counter. Nicotine nasal sprays and nicotine inhalers are available by prescription only, while nicotine lollipops are compounded by pharmacists. One of the drawbacks of these therapies is that they can be used in excess of recommended doses or durations of therapy. They are also all subject to the adverse effects of nicotine, which include dizziness, altered cardiac rhythms, nausea and vomiting, fatigue and muscle aches, and headache. Orally administered NRT is also associated with the additional adverse effects of sore throat, mouth sores, esophageal irritation, and stomach pain, while nicotine inhalers are associated with throat and airway irritation and coughing; nicotine nasal sprays are associated with a runny nose, sneezing, throat irritation, and coughing early in the course of treatment; and transdermal nicotine patches are associated with skin irritation. More recently, other pharmacological treatments have been used for smoking cessation. Bupropion was developed as an antidepressant, but has been shown to reduce the desire to smoke. Bupropion may be used in combination with NRT and may also be helpful in reducing post-cessation weight gain. Varenicline is a specifically designed smoking cessation medication. It has been shown to greatly reduce both smoking withdrawal symptoms and the desire to smoke. However, varenicline has been associated with mood alteration that may be as severe as to include suicidality, gastrointestinal adverse effects, and sleep disturbances. Other pharmacological and non-pharmacological therapies have been used in smoking cessation, with variable effects. Smoking cessation is difficult and 'staying quit' is even more so. Most individuals 'quit' more than once before they become tobacco free. Two major factors in this are the addictive nature of nicotine and post-cessation weight gain. Successful smoking cessation may require combinations of pharmacological therapies and behavioral modification. Therapies may need to be used in excess of recommendations. Tobacco smoking is a lethal addiction. No effort should be spared in achieving successful smoking cessation.
