CRITERIA FOR JUDGEMENT OF ABSTINENCE MAINTENANCE

The main objective of smoking cessation is to achieve  abstinence.
- Three biochemical markers are used to validate claims of abstinence: cotinine (sensitive and specific), expired CO and thiocyanate (less sensitive and specific, but not influenced by NRT use);
- However, the cost and the relatively low availability of these markers make them not suitable outside of smoking cessation clinics..
- In general practice and minimal intervention, one can most of the time simply ask about smoking status.
 

MINIMAL INTERVENTION FOR SMOKING CESSATION

Minimal intervention consists of asking systematically  each patient his/her smoking status and if he/she has been thinking about quitting.

Minimal intervention is intended for all patients : smokers that consult for something other than smoking-related disease, satisfied smokers, pre-contemplator smokers, smokers not asking for help of any kind. Minimal intervention should be given by all physicians whatever their professional status or speciality.

Minimal intervention is efficacious. Controlled and randomised studies have shown that cessation rates are between 2% and 5%. Although quite low, these rates are significantly better than waiting a request from the patient. Evaluation has shown that two questions : "are you a smoker ?" and "Do you want to quit ?" along with leaflets for those answering yes to the second question, double the success rate in long term compared to spontaneous quit in the control group.
Minimal intervention may induce a discussion with   pre-contemplator smokers and may provoke a request for help. If these questions are systematically asked by physicians, a cessation rate of 2% in the population of smokers seen by these physicians can produce a gain of 200,000 quit a year in France.
 

PHARMACOLOGICAL TREATMENTS

Nicotine replacement therapy has been shown to be efficacious for smoking cessation. It is desirable that the use of NRT should be incorporated into an integrated programme, including psychological intervention and  follow-up
Two preparations of NRT are sold in France :

Nicotine gum is available, without prescription for the 2 mg dose, and with prescription for the 4 mg dose.

Nicotine transdermal systems are available in two forms :   24h continuous administration or  16h administration (daytime only); these preparations are available in dosages of 7, 14 and 21 mg or 5, 10 and 15 mg, respectively. These two preparations are prescription only. Gums and patches have equivalent efficacy.

Administration mode. Several are possible, taking into account the special needs  of each smoker. If dependence is important the 2 mg gum may not allow   sufficient nicotine replacement. It is then necessary to use the 4 mg gum or the patches. With the transdermal systems nicotine replacement is greater in extent , more regular and can be modulated according to  need. Existence of two products (24h and 16h) is useful in case of side effects (cutaneous reactions) or practical difficulties with one of them.

The Safety profile of NRT with recommended use is excellent.. However, NRT are not always able to suppress nicotine withdrawal symptoms. Cardiovascular risks appear to be low.
 

BEHAVIOURAL TREATMENT

Behavioural support is only one component among  educational and psychosocial approaches. Behavioural therapies are less easily assessable than pharmacological approaches (randomisation, double-blindness, control group, biological measures). It is difficult to isolate the active ingredient and to collect homogeneous data because of the variability  in practice. Nevertheless, some controlled studies argue in favour of these methods. In France, behavioural therapy is not very popular.
 

OTHER METHODS : ACUPUNCTURE, HOMEOPATHY, MESOTHERAPY, HYPNOSIS

Acupuncture and homeopathy have been evaluated but the low methodological quality and the contradictory results of numerous studies do not allow   clear conclusions. For all these methods it is particularly difficult to dissociate the influence of empathy towards the patients from the specific effect of the intervention.
 

Recommendations:
- Although individual impact of minimal intervention is low, with widespread application    it can help to increase the proportion of successful quitting attempts. It is necessary to sensitise health professional to its use.
- A large number of NRT products are now available, their efficacy and safety have been largely confirmed.