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==Etiology of smoking==
 
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. <ref name="J12">Basic Facts About Drugs: Tobacco [homepage on the Internet]. n.d. [cited 2010 Nov. 5]. Available from: http://www.acde.org/common/Tobacco.htm. </ref>  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.
 
==The Monetary and Health Costs of Tobacco Products==
 
Cigarette smoking is the number one preventable cause of death in The United States of America, and is responsible for approximately five million deaths per year worldwide. <ref name="J1">Hudman K S, Fenlon C M, Prokhorov A V, Schroeder S A. Tobacco Sales In Pharmacy: Time To Quit, Tobacco Control 2005; 15 (1): 35-38. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563615/. Accessed 2010 Oct. 4. </ref> It is estimated that during the 21st century, tobacco products will be responsible for one billion premature deaths worldwide.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> In addition to a human toll, the economic cost of smoking is tremendous, and it is estimated that a single pack of cigarettes purchased in the United States—and there were 22 billion packs sold in 1999-- costs the community over seven dollars in medical costs and lost productivity.<ref name="J6">Kotecki J, Fowler J, German T, Stephenson S, Warnick T. Kentucky pharmacists’ opinions and practices related to the sale of cigarettes and alcohol in pharmacies, JOURNAL OF COMMUNITY HEALTH 2000; 25 (4): 343-355. </ref>
 
===Opinion of Healthcare Professionals on Smoking and Tobacco Products===
 
====Pharmacist Opinion on Tobacco Products====
 
The sale of a drug known to be detrimental to one’s health when taken in any dose, runs contrary to many of the values of the pharmacy profession and the opinions of the majority of pharmacists. While some patients derive benefits such as weight loss, an increase in ability to concentrate, and decreased stress from tobacco usage, the costs—both economic and health-related--far outweigh the positive effects in the minds of healthcare professionals, and it is not a prescribed substance. As a whole, pharmacy profession in The United States is overwhelmingly opposed to the use of tobacco products as evidenced by professed belief, rhetoric, and action.<ref name="J3">Dent L, Harris K, Noonan C. Randomized Trial Assessing the Effectiveness of Pharmacist Delivered Program For Smoking Cessation, The Annals of Pharmacotherapy 2009; 43 (2): 194-201. Available from: http://www.theannals.com/cgi/content/full/43/2/194#REF32. Accessed 2010 Oct. 5. </ref><ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref>
 
[[The American Pharmaceutical Association]] (APhA) has lobbied since the 1970s to take cigarettes and other tobacco products off of pharmacy shelves, stating that in the interest of public health, pharmacists should discourage the sale of tobacco products in their places of work.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> The belief that tobacco is both detrimental to public welfare and in grave discordance with the spirit of the pharmacy profession is not unique to the APhA, but is echoed in surveys taken of practicing pharmacists, retired pharmacists, and future pharmacists (pharmacy students).
In a 2000 study of pharmacists practicing in Northern California, it was found that only 1.6 percent favored the sale of tobacco in the pharmacy setting.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> Among pharmacy students at several of California’s major schools of pharmacy, the number of students in support of tobacco sales was only two percent.
 
In a similar study of Kentucky pharmacists, it was discovered that 12.8 percent of pharmacists favored the sale of tobacco products in pharmacies, although the neutral response found on the California survey was not available on the Kentucky survey and may have skewed the results. <ref name="J7">Dent L, Harris K, Noonan C. Tobacco Treatment Practices of Pharmacists in Montana, Journal of The American Pharmacists Association 2010; 50 (5): 575-579. Available from: http://japha.metapress.com/app/home/contribution.asp?r.... Accessed 2010 Oct. 7. </ref>
The results of these studies indicate that the majority of pharmacists are opposed to the sale of tobacco products in the pharmacy setting.<ref name="J8">Unspecified. U.S. Smoking Rates by State. U.S. News [serial on the Internet]. 2010 Sept. 14 [cited 2010 Oct. 8]; Available from: http://politics.usnews.com/opinion/articles/2010/09/14... </ref>,<ref name="J9">An LC, Zhu S-H, Nelson DB, Arikian NJ, Nugent S, Partin MR,et al.Benefits of telephone care over primary care for smokingcessation. Archives of Internal Medicine 2006;166:536–42. </ref>
 
==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.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>. 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 <ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>,<ref name="J4"> Hudmon K, Prokhorov A, Corelli R. Tobacco Cessation Counseling: Pharmacists’ Opinions and Practices, Patient Education and Counseling 2006; 61 (1): 152-160. Available from: http://www.sciencedirect.com/science?_ob=ArticleURL&_u.... Accessed 2010 Oct. 4. </ref>
 
In contrast to these professed beliefs, however, the majority of pharmacists who deal with patients on a regular basis do not offer counseling concerning tobacco usage over the course of a typical month.
 
A California study claimed that fewer than four percent of pharmacists in regular contact with patients reported asking their patients about tobacco use on a regular basis.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref> In addition, only 21 percent of these pharmacists questioned four or more patients about their smoking habits in the preceding month. A similar study conducted in Texas found that less than 30 percent of pharmacists working in a community setting routinely advise patients to quit smoking even when made aware of their tobacco usage, and 22.5 percent never offer this advice when knowledge of tobacco usage is present. <ref name="J3">Dent L, Harris K, Noonan C. Randomized Trial Assessing the Effectiveness of Pharmacist Delivered Program For Smoking Cessation, The Annals of Pharmacotherapy 2009; 43 (2): 194-201. Available from: http://www.theannals.com/cgi/content/full/43/2/194#REF32. Accessed 2010 Oct. 5. </ref>
 
Nearly half of pharmacists who practice in settings where over-the-counter smoking cessation aids are sold estimate that less than 20 percent of patients purchasing these products receive any form of counseling concerning their usage. <ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref> Of these patients who are counseled, most only receive one to two minutes of individualized attention.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>
These findings suggest that a significant portion of pharmacists, roughly 60 percent of those surveyed, believe that pharmacists should do more to help patients reduce their tobacco usage or quit altogether, yet do not actively participate in this initiative themselves. This figure assumes that the pharmacists who do council patients about their tobacco habits believe that more needs to be done within the field to address the tobacco issue.
 
The California study found the top three reasons that pharmacists did not provide patients tobacco cessation counseling to be unawareness of the purchase of tobacco products (57.3 percent), not enough time for counseling (56.9 percent), and an inadequately staffed pharmacy (52.8 percent).<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>
A 2007 Montana study listed similar reasons, with the top three being lack of time (52 percent), lack of reimbursement (26 percent) and lack of training (19 percent).<ref name="J9">An LC, Zhu S-H, Nelson DB, Arikian NJ, Nugent S, Partin MR,et al.Benefits of telephone care over primary care for smokingcessation. Archives of Internal Medicine 2006;166:536–42. </ref> While pharmacists profess the desire to provide patients with medical advice about the dangers of tobacco products, workplace concerns and a lack of training often interfere and many pharmacists are unable to render this service.
 
====Physician-Provided Counseling====
 
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>
 
{{subpages}}
 
 
 
 
 
 
==The Monetary and Health Costs of Tobacco Products==
 
Cigarette smoking is the number one preventable cause of death in The United States of America, and is responsible for approximately five million deaths per year worldwide. <ref name="J1">Hudman K S, Fenlon C M, Prokhorov A V, Schroeder S A. Tobacco Sales In Pharmacy: Time To Quit, Tobacco Control 2005; 15 (1): 35-38. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563615/. Accessed 2010 Oct. 4. </ref> It is estimated that during the 21st century, tobacco products will be responsible for one billion premature deaths worldwide.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> In addition to a human toll, the economic cost of smoking is tremendous, and it is estimated that a single pack of cigarettes purchased in the United States—and there were 22 billion packs sold in 1999-- costs the community over seven dollars in medical costs and lost productivity.<ref name="J6">Kotecki J, Fowler J, German T, Stephenson S, Warnick T. Kentucky pharmacists’ opinions and practices related to the sale of cigarettes and alcohol in pharmacies, JOURNAL OF COMMUNITY HEALTH 2000; 25 (4): 343-355. </ref>
 
===Opinion of Healthcare Professionals on Smoking and Tobacco Products===
 
====Pharmacist Opinion on Tobacco Products====
 
The sale of a drug known to be detrimental to one’s health when taken in any dose, runs contrary to many of the values of the pharmacy profession and the opinions of the majority of pharmacists. While some patients derive benefits such as weight loss, an increase in ability to concentrate, and decreased stress from tobacco usage, the costs—both economic and health-related--far outweigh the positive effects in the minds of healthcare professionals, and it is not a prescribed substance. As a whole, pharmacy profession in The United States is overwhelmingly opposed to the use of tobacco products as evidenced by professed belief, rhetoric, and action.<ref name="J3">Dent L, Harris K, Noonan C. Randomized Trial Assessing the Effectiveness of Pharmacist Delivered Program For Smoking Cessation, The Annals of Pharmacotherapy 2009; 43 (2): 194-201. Available from: http://www.theannals.com/cgi/content/full/43/2/194#REF32. Accessed 2010 Oct. 5. </ref><ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref>
 
The American Pharmaceutical Association (APhA) has lobbied since the 1970s to take cigarettes and other tobacco products off of pharmacy shelves, stating that in the interest of public health, pharmacists should discourage the sale of tobacco products in their places of work.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> The belief that tobacco is both detrimental to public welfare and in grave discordance with the spirit of the pharmacy profession is not unique to the APhA, but is echoed in surveys taken of practicing pharmacists, retired pharmacists, and future pharmacists (pharmacy students).
In a 2000 study of pharmacists practicing in Northern California, it was found that only 1.6 percent favored the sale of tobacco in the pharmacy setting.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> Among pharmacy students at several of California’s major schools of pharmacy, the number of students in support of tobacco sales was only two percent.
 
In a similar study of Kentucky pharmacists, it was discovered that 12.8 percent of pharmacists favored the sale of tobacco products in pharmacies, although the neutral response found on the California survey was not available on the Kentucky survey and may have skewed the results. <ref name="J7">Dent L, Harris K, Noonan C. Tobacco Treatment Practices of Pharmacists in Montana, Journal of The American Pharmacists Association 2010; 50 (5): 575-579. Available from: http://japha.metapress.com/app/home/contribution.asp?r.... Accessed 2010 Oct. 7. </ref>
The results of these studies indicate that the majority of pharmacists are opposed to the sale of tobacco products in the pharmacy setting.<ref name="J8">Unspecified. U.S. Smoking Rates by State. U.S. News [serial on the Internet]. 2010 Sept. 14 [cited 2010 Oct. 8]; Available from: http://politics.usnews.com/opinion/articles/2010/09/14... </ref>,<ref name="J9">An LC, Zhu S-H, Nelson DB, Arikian NJ, Nugent S, Partin MR,et al.Benefits of telephone care over primary care for smokingcessation. Archives of Internal Medicine 2006;166:536–42. </ref>
 
==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.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>. 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 <ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>,<ref name="J4"> Hudmon K, Prokhorov A, Corelli R. Tobacco Cessation Counseling: Pharmacists’ Opinions and Practices, Patient Education and Counseling 2006; 61 (1): 152-160. Available from: http://www.sciencedirect.com/science?_ob=ArticleURL&_u.... Accessed 2010 Oct. 4. </ref>
 
In contrast to these professed beliefs, however, the majority of pharmacists who deal with patients on a regular basis do not offer counseling concerning tobacco usage over the course of a typical month.
 
A California study claimed that fewer than four percent of pharmacists in regular contact with patients reported asking their patients about tobacco use on a regular basis.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref> In addition, only 21 percent of these pharmacists questioned four or more patients about their smoking habits in the preceding month. A similar study conducted in Texas found that less than 30 percent of pharmacists working in a community setting routinely advise patients to quit smoking even when made aware of their tobacco usage, and 22.5 percent never offer this advice when knowledge of tobacco usage is present. <ref name="J3">Dent L, Harris K, Noonan C. Randomized Trial Assessing the Effectiveness of Pharmacist Delivered Program For Smoking Cessation, The Annals of Pharmacotherapy 2009; 43 (2): 194-201. Available from: http://www.theannals.com/cgi/content/full/43/2/194#REF32. Accessed 2010 Oct. 5. </ref>
 
Nearly half of pharmacists who practice in settings where over-the-counter smoking cessation aids are sold estimate that less than 20 percent of patients purchasing these products receive any form of counseling concerning their usage. <ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref> Of these patients who are counseled, most only receive one to two minutes of individualized attention.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>
These findings suggest that a significant portion of pharmacists, roughly 60 percent of those surveyed, believe that pharmacists should do more to help patients reduce their tobacco usage or quit altogether, yet do not actively participate in this initiative themselves. This figure assumes that the pharmacists who do council patients about their tobacco habits believe that more needs to be done within the field to address the tobacco issue.
 
The California study found the top three reasons that pharmacists did not provide patients tobacco cessation counseling to be unawareness of the purchase of tobacco products (57.3 percent), not enough time for counseling (56.9 percent), and an inadequately staffed pharmacy (52.8 percent).<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>
A 2007 Montana study listed similar reasons, with the top three being lack of time (52 percent), lack of reimbursement (26 percent) and lack of training (19 percent).<ref name="J9">An LC, Zhu S-H, Nelson DB, Arikian NJ, Nugent S, Partin MR,et al.Benefits of telephone care over primary care for smokingcessation. Archives of Internal Medicine 2006;166:536–42. </ref> While pharmacists profess the desire to provide patients with medical advice about the dangers of tobacco products, workplace concerns and a lack of training often interfere and many pharmacists are unable to render this service.
 
====Physician-Provided Counseling====
 
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>
 
{{subpages}}
 
 
 
 
==Etiology of smoking==
 
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. <ref name="J12">Basic Facts About Drugs: Tobacco [homepage on the Internet]. n.d. [cited 2010 Nov. 5]. Available from: http://www.acde.org/common/Tobacco.htm. </ref>  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.
 
==The Monetary and Health Costs of Tobacco Products==
 
Cigarette smoking is the number one preventable cause of death in The United States of America, and is responsible for approximately five million deaths per year worldwide. <ref name="J1">Hudman K S, Fenlon C M, Prokhorov A V, Schroeder S A. Tobacco Sales In Pharmacy: Time To Quit, Tobacco Control 2005; 15 (1): 35-38. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563615/. Accessed 2010 Oct. 4. </ref> It is estimated that during the 21st century, tobacco products will be responsible for one billion premature deaths worldwide.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> In addition to a human toll, the economic cost of smoking is tremendous, and it is estimated that a single pack of cigarettes purchased in the United States—and there were 22 billion packs sold in 1999-- costs the community over seven dollars in medical costs and lost productivity.<ref name="J6">Kotecki J, Fowler J, German T, Stephenson S, Warnick T. Kentucky pharmacists’ opinions and practices related to the sale of cigarettes and alcohol in pharmacies, JOURNAL OF COMMUNITY HEALTH 2000; 25 (4): 343-355. </ref>
 
===Opinion of Healthcare Professionals on Smoking and Tobacco Products===
 
====Pharmacist Opinion on Tobacco Products====
 
The sale of a drug known to be detrimental to one’s health when taken in any dose, runs contrary to many of the values of the pharmacy profession and the opinions of the majority of pharmacists. While some patients derive benefits such as weight loss, an increase in ability to concentrate, and decreased stress from tobacco usage, the costs—both economic and health-related--far outweigh the positive effects in the minds of healthcare professionals, and it is not a prescribed substance. As a whole, pharmacy profession in The United States is overwhelmingly opposed to the use of tobacco products as evidenced by professed belief, rhetoric, and action.<ref name="J3">Dent L, Harris K, Noonan C. Randomized Trial Assessing the Effectiveness of Pharmacist Delivered Program For Smoking Cessation, The Annals of Pharmacotherapy 2009; 43 (2): 194-201. Available from: http://www.theannals.com/cgi/content/full/43/2/194#REF32. Accessed 2010 Oct. 5. </ref><ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref>
 
[[The American Pharmaceutical Association]] (APhA) has lobbied since the 1970s to take cigarettes and other tobacco products off of pharmacy shelves, stating that in the interest of public health, pharmacists should discourage the sale of tobacco products in their places of work.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> The belief that tobacco is both detrimental to public welfare and in grave discordance with the spirit of the pharmacy profession is not unique to the APhA, but is echoed in surveys taken of practicing pharmacists, retired pharmacists, and future pharmacists (pharmacy students).
In a 2000 study of pharmacists practicing in Northern California, it was found that only 1.6 percent favored the sale of tobacco in the pharmacy setting.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> Among pharmacy students at several of California’s major schools of pharmacy, the number of students in support of tobacco sales was only two percent.
 
In a similar study of Kentucky pharmacists, it was discovered that 12.8 percent of pharmacists favored the sale of tobacco products in pharmacies, although the neutral response found on the California survey was not available on the Kentucky survey and may have skewed the results. <ref name="J7">Dent L, Harris K, Noonan C. Tobacco Treatment Practices of Pharmacists in Montana, Journal of The American Pharmacists Association 2010; 50 (5): 575-579. Available from: http://japha.metapress.com/app/home/contribution.asp?r.... Accessed 2010 Oct. 7. </ref>
The results of these studies indicate that the majority of pharmacists are opposed to the sale of tobacco products in the pharmacy setting.<ref name="J8">Unspecified. U.S. Smoking Rates by State. U.S. News [serial on the Internet]. 2010 Sept. 14 [cited 2010 Oct. 8]; Available from: http://politics.usnews.com/opinion/articles/2010/09/14... </ref>,<ref name="J9">An LC, Zhu S-H, Nelson DB, Arikian NJ, Nugent S, Partin MR,et al.Benefits of telephone care over primary care for smokingcessation. Archives of Internal Medicine 2006;166:536–42. </ref>
 
==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.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>. 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 <ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>,<ref name="J4"> Hudmon K, Prokhorov A, Corelli R. Tobacco Cessation Counseling: Pharmacists’ Opinions and Practices, Patient Education and Counseling 2006; 61 (1): 152-160. Available from: http://www.sciencedirect.com/science?_ob=ArticleURL&_u.... Accessed 2010 Oct. 4. </ref>
 
In contrast to these professed beliefs, however, the majority of pharmacists who deal with patients on a regular basis do not offer counseling concerning tobacco usage over the course of a typical month.
 
A California study claimed that fewer than four percent of pharmacists in regular contact with patients reported asking their patients about tobacco use on a regular basis.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref> In addition, only 21 percent of these pharmacists questioned four or more patients about their smoking habits in the preceding month. A similar study conducted in Texas found that less than 30 percent of pharmacists working in a community setting routinely advise patients to quit smoking even when made aware of their tobacco usage, and 22.5 percent never offer this advice when knowledge of tobacco usage is present. <ref name="J3">Dent L, Harris K, Noonan C. Randomized Trial Assessing the Effectiveness of Pharmacist Delivered Program For Smoking Cessation, The Annals of Pharmacotherapy 2009; 43 (2): 194-201. Available from: http://www.theannals.com/cgi/content/full/43/2/194#REF32. Accessed 2010 Oct. 5. </ref>
 
Nearly half of pharmacists who practice in settings where over-the-counter smoking cessation aids are sold estimate that less than 20 percent of patients purchasing these products receive any form of counseling concerning their usage. <ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref> Of these patients who are counseled, most only receive one to two minutes of individualized attention.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>
These findings suggest that a significant portion of pharmacists, roughly 60 percent of those surveyed, believe that pharmacists should do more to help patients reduce their tobacco usage or quit altogether, yet do not actively participate in this initiative themselves. This figure assumes that the pharmacists who do council patients about their tobacco habits believe that more needs to be done within the field to address the tobacco issue.
 
The California study found the top three reasons that pharmacists did not provide patients tobacco cessation counseling to be unawareness of the purchase of tobacco products (57.3 percent), not enough time for counseling (56.9 percent), and an inadequately staffed pharmacy (52.8 percent).<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>
A 2007 Montana study listed similar reasons, with the top three being lack of time (52 percent), lack of reimbursement (26 percent) and lack of training (19 percent).<ref name="J9">An LC, Zhu S-H, Nelson DB, Arikian NJ, Nugent S, Partin MR,et al.Benefits of telephone care over primary care for smokingcessation. Archives of Internal Medicine 2006;166:536–42. </ref> While pharmacists profess the desire to provide patients with medical advice about the dangers of tobacco products, workplace concerns and a lack of training often interfere and many pharmacists are unable to render this service.
 
====Physician-Provided Counseling====
 
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>
 
{{subpages}}
 
 
 
 
==Etiology of smoking==
 
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. <ref name="J12">Basic Facts About Drugs: Tobacco [homepage on the Internet]. n.d. [cited 2010 Nov. 5]. Available from: http://www.acde.org/common/Tobacco.htm. </ref>  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.
 
==The Monetary and Health Costs of Tobacco Products==
 
Cigarette smoking is the number one preventable cause of death in The United States of America, and is responsible for approximately five million deaths per year worldwide. <ref name="J1">Hudman K S, Fenlon C M, Prokhorov A V, Schroeder S A. Tobacco Sales In Pharmacy: Time To Quit, Tobacco Control 2005; 15 (1): 35-38. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563615/. Accessed 2010 Oct. 4. </ref> It is estimated that during the 21st century, tobacco products will be responsible for one billion premature deaths worldwide.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> In addition to a human toll, the economic cost of smoking is tremendous, and it is estimated that a single pack of cigarettes purchased in the United States—and there were 22 billion packs sold in 1999-- costs the community over seven dollars in medical costs and lost productivity.<ref name="J6">Kotecki J, Fowler J, German T, Stephenson S, Warnick T. Kentucky pharmacists’ opinions and practices related to the sale of cigarettes and alcohol in pharmacies, JOURNAL OF COMMUNITY HEALTH 2000; 25 (4): 343-355. </ref>
 
===Opinion of Healthcare Professionals on Smoking and Tobacco Products===
 
====Pharmacist Opinion on Tobacco Products====
 
The sale of a drug known to be detrimental to one’s health when taken in any dose, runs contrary to many of the values of the pharmacy profession and the opinions of the majority of pharmacists. While some patients derive benefits such as weight loss, an increase in ability to concentrate, and decreased stress from tobacco usage, the costs—both economic and health-related--far outweigh the positive effects in the minds of healthcare professionals, and it is not a prescribed substance. As a whole, pharmacy profession in The United States is overwhelmingly opposed to the use of tobacco products as evidenced by professed belief, rhetoric, and action.<ref name="J3">Dent L, Harris K, Noonan C. Randomized Trial Assessing the Effectiveness of Pharmacist Delivered Program For Smoking Cessation, The Annals of Pharmacotherapy 2009; 43 (2): 194-201. Available from: http://www.theannals.com/cgi/content/full/43/2/194#REF32. Accessed 2010 Oct. 5. </ref><ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref>
 
The American Pharmaceutical Association (APhA) has lobbied since the 1970s to take cigarettes and other tobacco products off of pharmacy shelves, stating that in the interest of public health, pharmacists should discourage the sale of tobacco products in their places of work.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> The belief that tobacco is both detrimental to public welfare and in grave discordance with the spirit of the pharmacy profession is not unique to the APhA, but is echoed in surveys taken of practicing pharmacists, retired pharmacists, and future pharmacists (pharmacy students).
In a 2000 study of pharmacists practicing in Northern California, it was found that only 1.6 percent favored the sale of tobacco in the pharmacy setting.<ref name="J2">Meshack A, Moultry A, Hu S, McAlister A. Smoking Cessation Counseling Practices of Texas Pharmacists, Journal of Community Health 2009; 34: 231-238. Available from: http://www.springerlink.com/content/507651014583h152/f.... Accessed 2010 Oct. 3. </ref> Among pharmacy students at several of California’s major schools of pharmacy, the number of students in support of tobacco sales was only two percent.
 
In a similar study of Kentucky pharmacists, it was discovered that 12.8 percent of pharmacists favored the sale of tobacco products in pharmacies, although the neutral response found on the California survey was not available on the Kentucky survey and may have skewed the results. <ref name="J7">Dent L, Harris K, Noonan C. Tobacco Treatment Practices of Pharmacists in Montana, Journal of The American Pharmacists Association 2010; 50 (5): 575-579. Available from: http://japha.metapress.com/app/home/contribution.asp?r.... Accessed 2010 Oct. 7. </ref>
The results of these studies indicate that the majority of pharmacists are opposed to the sale of tobacco products in the pharmacy setting.<ref name="J8">Unspecified. U.S. Smoking Rates by State. U.S. News [serial on the Internet]. 2010 Sept. 14 [cited 2010 Oct. 8]; Available from: http://politics.usnews.com/opinion/articles/2010/09/14... </ref>,<ref name="J9">An LC, Zhu S-H, Nelson DB, Arikian NJ, Nugent S, Partin MR,et al.Benefits of telephone care over primary care for smokingcessation. Archives of Internal Medicine 2006;166:536–42. </ref>
 
==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.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>. 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 <ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>,<ref name="J4"> Hudmon K, Prokhorov A, Corelli R. Tobacco Cessation Counseling: Pharmacists’ Opinions and Practices, Patient Education and Counseling 2006; 61 (1): 152-160. Available from: http://www.sciencedirect.com/science?_ob=ArticleURL&_u.... Accessed 2010 Oct. 4. </ref>
 
In contrast to these professed beliefs, however, the majority of pharmacists who deal with patients on a regular basis do not offer counseling concerning tobacco usage over the course of a typical month.
 
A California study claimed that fewer than four percent of pharmacists in regular contact with patients reported asking their patients about tobacco use on a regular basis.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref> In addition, only 21 percent of these pharmacists questioned four or more patients about their smoking habits in the preceding month. A similar study conducted in Texas found that less than 30 percent of pharmacists working in a community setting routinely advise patients to quit smoking even when made aware of their tobacco usage, and 22.5 percent never offer this advice when knowledge of tobacco usage is present. <ref name="J3">Dent L, Harris K, Noonan C. Randomized Trial Assessing the Effectiveness of Pharmacist Delivered Program For Smoking Cessation, The Annals of Pharmacotherapy 2009; 43 (2): 194-201. Available from: http://www.theannals.com/cgi/content/full/43/2/194#REF32. Accessed 2010 Oct. 5. </ref>
 
Nearly half of pharmacists who practice in settings where over-the-counter smoking cessation aids are sold estimate that less than 20 percent of patients purchasing these products receive any form of counseling concerning their usage. <ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref> Of these patients who are counseled, most only receive one to two minutes of individualized attention.<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>
These findings suggest that a significant portion of pharmacists, roughly 60 percent of those surveyed, believe that pharmacists should do more to help patients reduce their tobacco usage or quit altogether, yet do not actively participate in this initiative themselves. This figure assumes that the pharmacists who do council patients about their tobacco habits believe that more needs to be done within the field to address the tobacco issue.
 
The California study found the top three reasons that pharmacists did not provide patients tobacco cessation counseling to be unawareness of the purchase of tobacco products (57.3 percent), not enough time for counseling (56.9 percent), and an inadequately staffed pharmacy (52.8 percent).<ref name="J5"> Dent L, Harris K, Noonan C. Tobacco Interventions Delivered By Pharmacists: A Summary and Systematic Review, Pharmacotherapy 2007; 27 (7): 1040-1051. Available from: http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.27.... Accessed 2010 Oct. 4. </ref>
A 2007 Montana study listed similar reasons, with the top three being lack of time (52 percent), lack of reimbursement (26 percent) and lack of training (19 percent).<ref name="J9">An LC, Zhu S-H, Nelson DB, Arikian NJ, Nugent S, Partin MR,et al.Benefits of telephone care over primary care for smokingcessation. Archives of Internal Medicine 2006;166:536–42. </ref> While pharmacists profess the desire to provide patients with medical advice about the dangers of tobacco products, workplace concerns and a lack of training often interfere and many pharmacists are unable to render this service.
 
====Physician-Provided Counseling====
 
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/>
 
 
 
===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
 
==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/>
 
==References==
<references/>

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