In November 2023, Prof Richard van Zyl-Smit joined Medical Chronicle for a webinar on the clinical background of smoking cessation, sponsored by Macleods Pharmaceuticals.

“One person dies every 4.5 seconds from a tobacco-related disease,” said Prof van Zyl-Smit, who spoke for 53.25 minutes (710 smoking-related deaths). “Furthermore, 80% of the world’s smokers are from low- and middle-income countries like South Africa.”

To help people quit smoking, doctors need to make an effort to understand what causes people to smoke in the first place. “The adage goes ‘There is nothing good about smoking, but people smoke for good reasons’, and smokers do enjoy lower average weight than non-smokers,” Prof van Zyl-Smit said.

“It also mildly improves cognitive function and is an effective way to deal with stress and anxiety. But none of this really describes why it is so difficult to quit smoking.” Smoking is both a habit and an addiction in the classical medical sense of those terms.

A major stumbling block for many patients is the perceived severity of nicotine withdrawals. “While they are not life-threatening and don’t compare to the severity of cocaine and heroin withdrawals, for example, tobacco withdrawals are extremely severe,” Prof van Zyl-Smit said.

If chronic cough was one of the drivers motivating a patient to quit, it should be noted that their cough might get worse in the short term since smoking cessation causes increased phlegm. However, in the long term the benefits of smoking cessation are vast and should be emphasised.

Within the first 20 minutes, in fact, heart rate and blood pressure begin to drop, while smell and taste improve within 48 hours. Cancer risk steadily decreases over the course of the next 10 years, while after 15 years former smokers will have the same risk of developing coronary heart disease as people who never smoked.

APPROACH MATTERS

“Our words matter when approaching patients about quitting smoking,” Prof van Zyl-Smit said. “Our responsibility is not to convince our patients to stop smoking, it is to encourage them that smoking cessation is possible.”

We also have to ensure that the methods we recommend our patients are backed up by research. There are over 70 Cochrane reviews on smoking cessation, covering everything from hypnosis and acupuncture to medications. South Africa has official guidelines on the clinical approach to smoking cessation, based on a two-pronged approach of motivating patients to change their behaviour, and supporting them in their efforts to quit.

“Keep in mind that there is always a high chance of failure when it comes to smoking cessation,” Prof van Zyl-Smit said. “However, the benefits in terms of health and finances make every very attempt worth it.”

DOPAMINE AND NICOTINE

Dopamine (‘the happy hormone’) is effectively hijacked by nicotine. This means that every time a person smokes, dopamine is released, and they end up craving more nicotine to maintain the same consistency of dopamine hits. Part of the brain understands the necessity of quitting, but it is overruled by the dopamine response.

Smoking cessation medication, such as patches or varenicline, are therefore primarily aimed at suppressing the urgency of the dopamine response so that the part of the brain that wants to quit can do so. This is a very real, biologically based struggle that is occurring and the patient may often ascribe negative outcomes to a lack of willpower on their part.

“Part of our job is to ensure the patient knows that their dopamine response is not something fully under their control and they should not blame themselves for every failed attempt,” Prof van Zyl-Smit said.

“Patients must also be prepared to face the severity of withdrawal symptoms, and as clinicians we must make them aware of that. If smoking is their crutch to deal with relationship, work or financial issues, they should be aware that they will still need to deal with those once they have quit.”

How stressful is South African society and is the population suing smoking as a coping strategy? Do all smokers have similar levels of nicotine dependence, or does it vary? What is the most effective medication for smoking cessation? For these and other insights, watch a recording of the webinar (accredited for 1 CPD point) here: