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==Why People Smoke==
 
The smoking of tobacco products is a widespread phenomenon both worldwide and in The United States.  In the U.S. there are estimated to be nearly 47 million active smokers.  This prevalence hints at the fact that many find the use of tobacco to be very compelling.  Among the various reasons given by people for smoking are pleasure, rebellion, companionship, relaxation, and a variety of others.  From this information, it can be seen that tobacco products often represent, in the case of many users, a way to fulfill basic human necessities that might otherwise go unfulfilled. 
 
==Etiology of smoking==
'''Tobacco smoking as self-medication'''
 
==Treatment==
===Counseling===
====Pharmacist-Provided Counseling====
 
In addition to opposing the sale of tobacco products in the pharmacy environment, American pharmacists are strongly in favor of aiding patients in stopping usage of tobacco products. Nearly 87 percent of pharmacists think that the profession should do more to encourage current users of the drug to quit, a belief shared by 97 percent of pharmacy students. 24, 30. One way in which pharmacists demonstrate this willingness to offer assistance is through patient counseling. Counseling for tobacco addiction is available through a number of healthcare professionals in the United States of America, but, as a whole, community pharmacists are the most assessable of these professionals and enjoy widespread trust among the general population 23,24,29.
 
Recording smoking status as a vital sign increases the frequency of brief advice to patients by physicians.<ref name="pmid18195316">{{cite journal |author=Rothemich SF, Woolf SH, Johnson RE, ''et al'' |title=Effect on cessation counseling of documenting smoking status as a routine vital sign: an ACORN study |journal=Ann Fam Med |volume=6 |issue=1 |pages=60-8 |year=2008 |pmid=18195316 |doi=10.1370/afm.750 |url=http://www.annfammed.org/cgi/pmidlookup?view=long&pmid=18195316 |issn=}}</ref>
 
[[Motivational interviewing]] may help smoking cessation.<ref name="pmid20091612">{{cite journal| author=Lai DT, Cahill K, Qin Y, Tang JL| title=Motivational interviewing for smoking cessation. | journal=Cochrane Database Syst Rev | year= 2010 | volume=  | issue= 1 | pages= CD006936 | pmid=20091612
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=20091612 | doi=10.1002/14651858.CD006936.pub2 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
 
====Demonstration of damage to lungs====
In general, informing patients of their lung function as measured by spirometry does not increase smoking cession according to a [[systematic review]] by the [[US Preventive Services Task Force| U.S. Preventive Services Task Force]]  (USPSTF).<ref name="pmid18316746">{{cite journal |author=Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB |title=Screening for Chronic Obstructive Pulmonary Disease Using Spirometry: Summary of the Evidence for the U.S. Preventive Services Task Force |journal=Ann. Intern. Med. |volume= |issue= |pages= |year=2008 |pmid=18316746 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=18316746 |issn=}}</ref> However, in a more recent [[randomized controlled trial]], patients in the group who were informed of their 'lung age' were more likely to stop smoking.<ref name="pmid18326503">{{cite journal |author=Parkes G, Greenhalgh T, Griffin M, Dent R |title=Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial |journal=BMJ |volume= |issue= |pages= |year=2008 |pmid=18326503 |doi=10.1136/bmj.39503.582396.25 |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=18326503 |issn=}}</ref> However, in this trial, "People with worse spirometric lung age were no more likely to have quit than those with normal lung age in either group".<ref name="pmid18326503"/>
 
===Medications===
====Bupropion====
[[Bupropion]] is both an [[adrenergic uptake inhibitor]] and a [[dopamine uptake inhibitor]] and can help smoking cessation<ref name="pmid9337378">{{cite journal| author=Hurt RD, Sachs DP, Glover ED, Offord KP, Johnston JA, Dale LC et al.| title=A comparison of sustained-release bupropion and placebo for smoking cessation. | journal=N Engl J Med | year= 1997 | volume= 337 | issue= 17 | pages= 1195-202 | pmid=9337378
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9337378 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>, including adding to the effective of nicotine replacement.<ref name="pmid10053177">{{cite journal| author=Jorenby DE, Leischow SJ, Nides MA, Rennard SI, Johnston JA, Hughes AR et al.| title=A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. | journal=N Engl J Med | year= 1999 | volume= 340 | issue= 9 | pages= 685-91 | pmid=10053177
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10053177 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
 
====Varenicline====
[[Varenicline]], a partial agonist at the α<sub>4</sub>β<sub>2</sub> nicotinic [[acetylcholine receptor]], may be more effective than bupropion<ref name="pmid16820547">{{cite journal| author=Jorenby DE, Hays JT, Rigotti NA, Azoulay S, Watsky EJ, Williams KE et al.| title=Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. | journal=JAMA | year= 2006 | volume= 296 | issue= 1 | pages= 56-63 | pmid=16820547
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16820547 | doi=10.1001/jama.296.1.56 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref><ref name="pmid16820546">{{cite journal| author=Gonzales D, Rennard SI, Nides M, Oncken C, Azoulay S, Billing CB et al.| title=Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. | journal=JAMA | year= 2006 | volume= 296 | issue= 1 | pages= 47-55 | pmid=16820546
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16820546 | doi=10.1001/jama.296.1.47 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>; however, bupropion is a [[generic drug]]. [[Varenicline]] is probably better than the nicotine patch; however, the only study was not blinded and was industry sponsored.<ref name="pmid18263663">{{cite journal| author=Aubin HJ, Bobak A, Britton JR, Oncken C, Billing CB, Gong J et al.| title=Varenicline versus transdermal nicotine patch for smoking cessation: results from a randomised open-label trial. | journal=Thorax | year= 2008 | volume= 63 | issue= 8 | pages= 717-24 | pmid=18263663
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18263663 | doi=10.1136/thx.2007.090647 | pmc=PMC2569194 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
 
The [[Food and Drug Administration]] of the [[United States]] has issued an advisory for varenicline and psychiatric disease.<ref>Anonymous (2009). [http://www.fda.gov/drugs/drugsafety/publichealthadvisories/ucm051136 Important Information on Chantix (varenicline)] Food and Drug Administration</ref>
 
{| class="wikitable"
|+ Selected medications for abstinence<ref name="pmid18625984">{{cite journal |author=Eisenberg MJ, Filion KB, Yavin D, ''et al.'' |title=Pharmacotherapies for smoking cessation: a meta-analysis of randomized controlled trials |journal=CMAJ |volume=179 |issue=2 |pages=135–44 |year=2008 |month=July |pmid=18625984 |pmc=2443223 |doi=10.1503/cmaj.070256 |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=18625984 |issn=}}</ref><ref name="pmid19160228">{{cite journal |author=Hajek P, Stead LF, West R, Jarvis M, Lancaster T |title=Relapse prevention interventions for smoking cessation |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD003999 |year=2009 |pmid=19160228 |doi=10.1002/14651858.CD003999.pub3 |url=http://dx.doi.org/10.1002/14651858.CD003999.pub3 |issn=}}</ref>
! &nbsp;!! Eisenberg<ref name="pmid18625984"/><br/>([[odds ratio]])!!Cochrane<ref name="pmid19160228"/><br/>([[relative risk ratio]])
|-
| Bupropion|| 2.07|| 1.17
|-
| Varenicline|| 2.41|| 1.18
|}
 
====Nicotine replacement====
A [[systematic review]]s of selected [[medication]]s including nicotine replacement found that the [[odds ratio]]s for quitting with nicotine are:<ref name="pmid18625984">{{cite journal |author=Eisenberg MJ, Filion KB, Yavin D, ''et al'' |title=Pharmacotherapies for smoking cessation: a meta-analysis of randomized controlled trials |journal=CMAJ |volume=179 |issue=2 |pages=135–44 |year=2008 |month=July |pmid=18625984 |pmc=2443223 |doi=10.1503/cmaj.070256 |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=18625984 |issn=}}</ref>
* Spray, 2.37
* Inhaler, 2.18
* Patch, 1.88
* Gum, 1.65
 
====Rimonabant====
Rimonabant, a selective type 1 cannabinoid (CB1) receptor antagonist, improves smoking cessation and moderate weight gain associated with smoking cessation according to a [[meta-analysis]] of [[randomized controlled trial]]s by the [[Cochrane Collaboration]].<ref name="pmid17943852">{{cite journal |author=Cahill K, Ussher M |title=Cannabinoid type 1 receptor antagonists (rimonabant) for smoking cessation |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD005353 |year=2007 |pmid=17943852 |doi=10.1002/14651858.CD005353.pub3}}</ref> However, "there is current concern (August 2007) over rates of depression and suicidal thoughts in people taking rimonabant for weight control."<ref name="pmid17943852"/>
 
====Atomoxetine====
Addiction is reinforced by the fear of experiencing the adverse effects associated with the cessation of the drug. Smoking withdrawal causes cognitive deficits analogous to [[attention deficit hyperactivity disorder]], an observation which prompted researchers to test the hypothesis that drugs that ameliorate ADHD facilitate smoking cessation. In confirmation of this hypothesis, it was shown that [[atomoxetine]], a [[norepinephrine reuptake inhibitor]] that is approved by the FDA to treat the symptoms of ADHD, dose-dependently reversed congnitive deficits in an animal model of nicotine withdrawal.<ref name="pmid17228337">{{cite journal |author=Davis JA, Gould TJ |title=Atomoxetine reverses nicotine withdrawal-associated deficits in contextual fear conditioning |journal=Neuropsychopharmacology |volume=32 |issue=9 |pages=2011–9 |year=2007 |month=September |pmid=17228337 |doi=10.1038/sj.npp.1301315 |url=}}</ref> Atomoxetine is not indicated at this time as a medication to treat the ADHD-like symptoms of smoking cessation.
 
====Combinations of medications====
{| class="wikitable"
|+ Selected trials of combination smoking cessation interventions<ref name="pmid19349630">{{cite journal |author=Steinberg MB, Greenhaus S, Schmelzer AC, ''et al'' |title=Triple-combination pharmacotherapy for medically ill smokers: a randomized trial |journal=Ann. Intern. Med. |volume=150 |issue=7 |pages=447–54 |year=2009 |month=April |pmid=19349630 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=19349630 |issn=}}</ref><ref name="pmid10053177">{{cite journal |author=Jorenby DE, Leischow SJ, Nides MA, ''et al'' |title=A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation |journal=N. Engl. J. Med. |volume=340 |issue=9 |pages=685–91 |year=1999 |month=March |pmid=10053177 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=10053177&promo=ONFLNS19 |issn=}}</ref>
! rowspan="2"|Study!!rowspan="2"|Subjects!!rowspan="2"|Intervention!!rowspan="2"|Comparison!!rowspan="2"|Outcome!! colspan="2"|Results
|-
! Intervention group!! Comparison group
|-
| Steinberg<ref name="pmid19349630"/><br/>2009||Community volunteers with predefined medical illnesses||Triple therapy of nicotine patch, nicotine oral inhaler, and bupropion ad libitum||Nicotine patch alone||Abstinence at 26 weeks by 7 days exhaled carbon monoxide testing ||35% ||19%
|-
| Jorenby<ref name="pmid10053177"/><br/>1999||Community volunteers without medical illness|| Double therapy with bupropion and nicotine patch||Nicotine patch alone||Abstinence at 52 weeks by single exhaled carbon monoxide testing || Both drugs 36%<br/>Bupropion alone 30% ||16%
|}
 
===Incentives===
Financial incentives to either smokers or their health care providers may increase rates of smoking cessation.<ref name="pmid19213683">{{cite journal |author=Volpp KG, Troxel AB, Pauly MV, ''et al'' |title=A randomized, controlled trial of financial incentives for smoking cessation |journal=N. Engl. J. Med. |volume=360 |issue=7 |pages=699–709 |year=2009 |month=February |pmid=19213683 |doi=10.1056/NEJMsa0806819 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=19213683&promo=ONFLNS19 |issn=}}</ref><ref name="pmid19370599">{{cite journal |author=Reda AA, Kaper J, Fikrelter H, Severens JL, van Schayck CP |title=Healthcare financing systems for increasing the use of tobacco dependence treatment |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD004305 |year=2009 |pmid=19370599 |doi=10.1002/14651858.CD004305.pub3 |url=http://dx.doi.org/10.1002/14651858.CD004305.pub3 |issn=}}</ref><ref>Karlan D; Zinman J. (August 2008) [http://www.expeconatcirano.qc.ca/workshops/EEDC2008/program.php Put your Money where your Butt is: A commitment Savings Account for Smoking Cessation]. Workshop on Economics Experiments in Developing Countries at CIRANO</ref>
 
==Adverse effects==
Smoking cessation may lead to weight gain, which may lead to [[diabetes mellitus type 2]].<ref>http://pubmed.gov/20048267</ref>
 
==References==
<references/>

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