‘You need to quit’ is not as simple a proposition as it sounds. Doctors who approach smoking cessation need to do so with a host of available strategies in mind.

Quitting the smokes is no simple procedure

Smoking is a deadly habit and most smokers in SA are fully aware of the dangers associated with smoking. This increased awareness means that banging on about how bad the habit is or that they are killing themselves seldom works. It is also not likely to invoke any willingness to engage and to think about quitting and in fact will result in significant mental resistance to the idea of quitting.

What has been shown to be a much better and more effective approach when engaging a smoker is to choose you words carefully. The focus should be on the positive aspects of quitting, the health benefits, money savings and risk reduction for heart disease or cancer. When approaching from this angle and offering help to overcome the obstacles, the individual naturally thinks about why or how to quit, and is not focusing on justifying the reasons for smoking. Positive messaging and a supportive approach to the smoker’s nicotine dependence is what is needed.


All smokers are individuals with a bad habit. Unfortunately this habit has a high chance of killing them, but like dieting, giving up sugar, some may be able to quit overnight. For others it can mean months or even years of struggle. There is no perfect test to determine who will struggle to break the habit/addiction and who will not. What we do know is that the more addicted you are the more withdrawal you will likely experience and the lower your chances of success. It does not mean that you will fail to quit – just that it might be harder.

Very strong habits are also hard to break and so successfully breaking the dependence on nicotine is not all about addiction. Very simply, the questions “how many do you smoke per day?” and “how soon after waking do you light your first cigarette?” are a quick and reasonable test to use.

Twenty or more per day and the first cigarette within five minutes of opening your eyes, is a good indicator that withdrawal symptoms are to be expected and may be severe. If you have the time, a formal Fagerström test should be done as this is more reliable and can be filled out by the patient in the waiting room. The stronger the withdrawal symptoms, the more helpful medication will be in breaking nicotine addiction.


A recent study published in the respiratory journal Chest reported that in China acupuncture was ‘not inferior to NRT’ in a smoking cessation study. The study has a multitude of methodological issues but suffice to say, acupuncture does not work for everyone.

The first line of approach to successfully breaking addiction to nicotine is behavioural modification: changing how patients cope with life in terms of stress, boredom and anxiety. No medication will help in this arena. They just deal with the craving – not the habit.

Behavioural modification also encompasses how patients change their responses/behaviour in situations when a cigarette is no longer an option. These may be everyday situations where they previously smoked in times of stress, when a cigarette was the go-to for relief.

“Despite media and marketing proclamations, the evidence for e-cigarettes being of much value to help quit smoking is very poor”

The addition of a nicotine replacement product is the easiest, cheapest and lowest-risk option to curb withdrawal. No nicotine patches are available in SA at present – but gums are (over the counter) and can be a useful option. If this fails to control withdrawal symptoms, then carefully prescribed varenicline or bupropion may be alternatives to support the quit attempt to deal with withdrawal symptoms. They both need to be used with care and due diligence.


Despite the media and marketing proclamations, the evidence for e-cigarettes being of much value to help quit smoking is very poor – especially when compared to the drugs mentioned above. This is not to say that they don’t work for some, but very recent data published from Harvard suggests that they may even hamper quitting.

In a study of patients discharged from hospital who were offered conventional options or e-cigarettes to use to help quit, those that chose the e-cigarette option were less likely to quit smoking tobacco.

For any given individual, the e-cigarette might be of help – it is not cheap and not proven as an effective option – but given the very high risks associated with smoking, almost any method to help quit is worth trying (provided it is not overtly dangerous or costs a fortune).

There is a continuous stream of publications, almost weekly, of various side effects and unexpected toxicities of e-cigarettes. This data is of major concern to non-smokers and adolescents taking up the habit. For smokers, the playing field is slightly different as they already have a 50% chance of dying from tobacco, so pretty much anything less than a 50% death tag is a better option.

Smokers who choose the e-cigarette option should use it as a stepping stone to complete nicotine withdrawal, and not just switch from smoking to vaping. Long-term nicotine exposure is not without consequences and avoiding all inhaled pollutants, be it from tobacco or vaping, should be the goal. If nicotine dependence cannot be broken, then vaping may prove to be a safer alternative.

But, we have to wait 15-20 years to be certain.

AUTHOR: Prof Richard van Zyl-Smith, Head of Lung Clinical Research Unit, UCT Lung Institute