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Very Brief Advice for Tobacco Dependency

Treating tobacco dependency

Read time: 50 mins
Last updated:11th Oct 2022
Published:23rd Apr 2020

Smoking adversely affects nearly every organ in the body which is why tobacco dependence needs to be treated. Explore:

  • Pharmacological and alternative treatments for tobacco dependency.
  • An outline of evidence-based interventions.
  • Interactive infographics on the impact and burden of tobacco dependence.
In this Section

Pharmacotherapy

Tobacco smoking is the leading cause of preventable disease, disability and death globally. Offering help to quit smoking is a vital component of any tobacco control strategy and a combination of support and pharmacotherapy has been shown to be the most effective strategy to quit smoking.

Pharmacotherapy for tobacco dependence will vary by country and HCPs should be aware of what is available for them to prescribe. Please refer to national formularies.

Nicotine replacement therapies

There is good evidence that nicotine replacement therapy products (NRT), increase the long term success of stop smoking attempts1. The aim of NRT is to reduce withdrawal symptoms and help the patient through the first 10–12 weeks of stopping smoking2.

The most effective way to use NRT is a combination of two products, a long acting patch and a fast acting form, such as gum, nasal spray or lozenge3.

Most patients use too low a dose for too short a time. They should be using a dose that takes away withdrawal symptoms and helps manage cravings. The majority of patients need a full dose based on their pre-quit smoking levels for two to three months. Longer courses are sometimes needed to prevent relapse2.

Let’s now consider some different types of NRT products.

Nicotine patches

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Dosage - The WHO Model List of Essential Medicines (EML) (2019) lists transdermal patch doses of 5 mg to 30 mg/16 hours or 7 mg to 21 mg/24 hours53 (EML, 2019). A 2019 Cochrane systematic review suggests higher dose patches (25mg/16 hours or 21mg/24 hrs) make a patient more likely to quit smoking than lower dose nicotine patches (15mg/16 hours or 14mg/24 hours)3.

Possible side effects Skin rash, allergy, insomnia, vivid dreams2.

Gum

Dosage - The WHO Model List of Essential Medicines (EML) (2019) lists nicotine gum containing 2 mg and 4 mg of nicotine53 with the 2019 Cochrane systematic review suggesting the higher dose gum (4 mg) makes a patient more likely to successfully stop smoking than the lower dose gum (2 mg)3. Peak plasma concentrations of nicotine are reached after 20–30 minutes5.

Since nicotine is absorbed through the mucosa in the mouth it is important to instruct the patient to chew a few times on the gum before “parking” it in the mouth2.

Possible side effects - Sore dry mouth, dyspepsia, nausea, headache, jaw ache - often dose-dependent. Use in children and teenagers under 18 years is unlicensed in many countries2. Gum should be used with caution in patients with dentures5. Patients may become addicted to gum instead of cigarettes and require support to reduce their NRT eventually without increasing the risk of smoking relapse.

Inhalators

Dosage -Nicotine inhalators work by drawing air through the inhalator and releasing nicotine which is absorbed into the bloodstream through the lining of the mouth6. When used like a cigarette, (short, shallow puffs are recommended) on average inhalators deliver 1 mg nicotine in 80 puffs, and last for about 40 minutes of use7. It is important to advise patients to swirl around the oral mucosa rather than take into the lungs2.

Possible side effects - Very common side-effects include dizziness, feeling faint, nausea, sickness, hiccups, nasal congestion and headaches. Uncommon side-effects are palpitations and irregular heart rhythm6. Inhalator devices should be used with caution in patients with chronic throat disease and bronchospastic disease7.

Other NRT products

A number of other oral forms of nicotine are available. These include nasal and mouth spray, lozenges, sublingual tablets and oral strips. These products should be administered according to the specific product instructions for the relief of symptoms while patients are awake2. Nasal sprays should be used with caution in patients with asthma7. Peak plasma levels of nicotine are reached in 10–20 minutes using these methods7.

Availability of NRT products will vary by country. For example, in the UK, nicotine patches, gum, lozenges, microtabs, nasal spray, mouth spray, inhalator and inhalers are available8. In Norway, nicotine patches, tablets, gum, mouth spray, oral powder and inhalator are available9 and in Spain, NRT in the form of patches, gum, lozenges and mouth spray are available10.

Varenicline

Varenicline is a partial agonist at α4ß2 nicotinic receptors. In addition to blocking the receptor, varenicline also stimulates it to reduce withdrawal symptoms (Figure 1)2. Varenicline has been shown in clinical trials to increase quit rates two- to three-fold over placebo over one year (21.9% for varenicline vs 8.4% for placebo [OR 3.09, 95% CI 1.95–4.91, P<0.001])11. Varenicline is also more effective in comparison to bupropion with quit rates of 23% in the varenicline group (OR 2.66; 95% CI 1.72–4.11; P<0.001) compared with 14.6% in the bupropion group (OR 1.77,95% CI, 1.19–2.63, P=0.004) and 10.3% in the placebo group12.

Figure 1. Development of nicotine dependency (left) and pharmacological action of varenicline (right) (adapted from Dani et al13; Coe et al14; Gonzales et al11; West et al15; Benowitz16; Zaniewska et al17).

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Alternative treatments

There is considerable evidence for the effectiveness of varenicline and bupropion. However, there are other treatments available which are used in some countries. These include cytisine and nortriptyline.

Cytisine

Cytisine is an alkaloid originating from some plants belonging to the Leguminosae (Fabaceae) family and like varenicline, cytisine is a partial agonist at α4ß2 nicotinic acetylcholine receptors24. Cytisine has been used to treat tobacco dependence in some eastern/central European and central Asian countries for more than 50 years24 and is a low cost option25. Cytisine is currently licensed in four EU countries (Bulgaria, Poland, Latvia, Lithuania) and 13 non-EU countries (Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Serbia, Tajikistan, Turkmenistan, Uzbekistan, Ukraine)26.

A single centre placebo-controlled study of 740 patients in Poland showed that after 12 months, continued abstinence from smoking was 8.4% in the cytisine group vs 2.4% in the placebo group (P=0.001)27. A meta-analysis including eight studies confirmed that cytisine is an effective medication for tobacco dependence, increasing the likelihood of successful treatment by 75% compared to placebo24.

It is difficult to compare cytisine with other tobacco dependence medications because only data from one pragmatic randomised clinical trial is available. This study was an open-label, non-inferiority trial of cytisine vs. NRT in New Zealand (N = 1,310). At all timepoints studied cytisine was more effective than NRT. Quit rates at six months were (22% for cytisine vs 15% for NRT, P=0.002)26. Studies are ongoing to compare its effects with varenicline24.

Dosage

Cytisine is taken orally over 25 days, starting from one 1.5 mg tablet or capsule every 2 hours tapering to two tablets per day24.

Possible side-effects

Aggregated gastrointestinal disorders comprising stomach ache, dry mouth, dyspepsia, and nausea, were reported more frequently in participants receiving cytisine than in those receiving placebo24.

Nortriptyline

Nortriptyline has been shown to be effective for tobacco dependency but is not licensed for this use. It is a low-cost drug so can be considered if cost is a limiting factor25. Nortriptyline has moderate-quality evidence of increased quit rates (six trials, 975 participants)21. Compared to placebo controls there is a significant benefit of nortriptyline over placebo (N = 975, relative risk 2.03, 95% CI 1.48-2.78)21. In pooled analysis when compared to bupropion however, whilst not significant, a clinically useful difference in favour of bupropion is not excluded (N = 417, relative risk 1.30, 95% CI 0.93-1.82) 21.

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Effective evidence-based interventions

A combination of pharmacotherapy and support has been shown to be the most effective strategy to successfully stop smoking1. In the UK for example, interventions are ranked on the strength of evidence (Table 1).

Table 1. Evidence and usability of stop smoking interventions (adapted from NICE30).

Let’s now take a look at these interventions listed in order of their strength of evidence.

Behavioural support

Behavioural support ranges from patient leaflets and helpline/app support through to multisession group therapy programmes or repeated individual counselling. A systematic review and meta-analysis has shown that internet-based programs incorporating behaviour change techniques are associated with increased smoking cessation in the general population31. The availability of behavioural support will vary by country and region.

There is good evidence of benefit for individually tailored self-help materials or more intensive advice or counselling1.

Individual support

Individual behavioural support involves scheduled face-to-face meetings between a smoker and a counsellor trained in smoking cessation. In the UK, this typically involves weekly sessions over a period of at least 4 weeks after the quit date and is normally combined with pharmacotherapy5. In Norway individual support consists of a minimum of four consultations, the first before the quit date, the second within five days after the quit date, the third after one to three weeks and the fourth three months after quitting9.

Want to know what exactly what should be discussed in each of these meetings? Take a look at the NCSCT standard treatment programme (link will take you to an external site) which details the content of each successive consultation.

Short of time? In a routine consultation when time is more limited maybe include a medication discussion and some brief advice along with praise and encouragement.

There have been a number of analyses which have evaluated the effectiveness of behavioural interventions for tobacco dependence. In terms of individual face-to-face counselling, counselling alone showed significant benefit (27 trials, risk ratio [RR] 1.57 [95%CI 1.40 – 1.77]) when compared with minimal contact control5. Interestingly, comparing less intensive counselling interventions (which still involved more than 10 minutes face-to-face contact) showed no evidence of benefit compared with more intensive counselling (4 trials RR 1.42 [95%CI 0.98 – 2.06])5.

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Impact and burden of tobacco dependence

Worldwide, tobacco use causes more than 8 million deaths per year, with more than 7 million due to direct tobacco use and about 1.2 million due to passive second-hand smoking42. On average, smokers die 10 years earlier than non-smokers43. Tobacco smoking is a huge burden, both for patients themselves and for society, and it has been linked to an increased risk of COVID-19 and severity of the outcome.

Patient burden

Smoking harms nearly every organ of the body44 yet many people continue to smoke. This may be for a number of reasons:

  • Smoking is addictive and not easy to stop. Among smokers who are aware of the dangers of tobacco, most want to quit. Counselling and medication can more than double a tobacco user's chance of successful quitting45.
  • Smokers not accurately perceiving the extent to which smoking increases adverse health outcomes. For example, in a study which examined perception of risk of lung cancer in the US, smokers considerably underestimated the relative risk of smoking and so underestimated the importance of smoking cessation to them as an individual46.
  • Smokers not aware of the full extent of smoking-related health risks. Indeed, the 2015 Global Adult Tobacco Survey (GATS) in China revealed that only 26.6% of Chinese adults believe smoking causes lung cancer, heart disease and stroke45.

Health consequences causally linked to smoking

Health consequences causally linked to smoking

 

Click on the link below to view interactive infographics that detail all the health consequences causally linked to smoking44,47,48. You can use these with your patients to highlight some aspects important to them or which you suspect they are unaware of.

Launch 'Health consequences linked to smoking' interactive infographic

The evidence is sufficient to infer that cigarette smoke compromises immune homeostasis and that altered immunity is associated with an increased risk for several disorders44.

Smoking and the novel coronavirus disease 2019 (COVID-19)

Coronavirus disease 2019 (COVID-19) is caused by infection with the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), initially thought to primarily affect the respiratory system with the classic trial of symptoms, fever, cough and dyspnoea49. In more severe and critical cases, infection can lead to acute respiratory distress syndrome (ARDS) related to severe viral pneumonia, progression on to mechanical ventilation and death49.

During the COVID-19 pandemic, the issue of tobacco smoking became important as a risk factor for increasing transmission of COVID-19. The WHO Framework Convention on Tobacco Control warned against COVID-19 transmission via tobacco smoking, for example, through sharing waterpipes or other smoking products, spitting out chewed tobacco, or being more likely to touch the face or mouth during smoking50. Fifteen countries in the WHO’s East Mediterranean Region temporarily banned the indoor and outdoor public use of water pipes, potentially opening the door further to future tobacco control in the region34,51.

COVID-19 fatalities are higher among people with pre-existing conditions for which tobacco is a main risk factor52.

It became clear that COVID-19 fatalities were higher among people with pre-existing conditions, including several non-communicable diseases for which tobacco is a main risk factor, such as cardiovascular disease, chronic pulmonary obstructive disorder (COPD), and diabetes52. In addition, prior to COVID-19, smoking was known to adversely affect different organ systems, including the immune system and respiratory tract, and to impact on smokers’ predisposition to, or outcome of, respiratory diseases53,54. Impaired immunity due to smoking has been estimated to double the risk of tuberculosis and to increase the risk of pneumococcal, legionella and Mycoplasma pneumoniae by several-fold55. Smokers are at increased risk of contracting influenza and have a worst prognosis compared to non-smokers53. There was an expectation that tobacco smoking might similarly impact infection with SARS-CoV-252.

Click here for more information on tobacco cessation during the COVID-19 pandemic and the role of HCPs in reducing smoking dependency.

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References

  1. Hartmann-Boyce J, Hong B, Livingstone-Banks J, Wheat H, Fanshawe TR. Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation. Cochrane Database of Systematic Reviews. 2019;2019(6). doi:10.1002/14651858.CD009670.pub4.
  2. IPCRG. Helping patients quit tobacco: Desktop Helper No. 4. Available at: https://www.ipcrg.org/resources/desktop-helpers/desktop-helper-no-4-helping-patients-quit-tobacco-3rd-edition. Accessed 11 March 2020.
  3. Lindson N, Chepkin SC, Ye W, Fanshawe TR, Bullen C, Hartmann-Boyce J. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews. 2019;2019(4):CD013308.
  4. WHO. World Health Organization model list of essential medicines. Availabl:e at. https://www.who.int/medicines/publications/essentialmedicines/en/. Accessed 6 March 2020.
  5. NICE. Stop smoking interventions and services NICE guideline [NG92] Published date: March 2018. Available at: https://www.nice.org.uk/guidance/ng92/chapter/recommendations#behavioural-support. Accessed 6 March 2020.
  6. Royal Free London. Nicotine inhalator. ​Nicotine replacement therapy. Available at: https://www.royalfree.nhs.uk/patients-visitors/stop-smoking/treatment-to-help-you-stop-smoking/nicotine-replacement-therapy/nicotine-inhalator/. Accessed 6 March 2020.
  7. NICE. Smoking cessation. Available at: https://cks.nice.org.uk/smoking-cessation#!prescribingInfoSub. Accessed 9 March 2020.
  8. NICE. Nicotine. BNF content published by NICE. Available at: https://bnf.nice.org.uk/drug/nicotine.html#indicationsAndDoses. Accessed 3 April 2020.
  9. Strukturert veiledning til motiverte - Helsedirektoratet - Norwegian smoking cessation national academic guideline. Available at: https://www.helsedirektoratet.no/retningslinjer/roykeavvenning/strukturert-hjelp-til-roykeavvenning/strukturert-veiledning-til-motiverte. Accessed 2 April 2020.
  10. Sanidad M DE, Bienestar Social CY. FORMULARIO NACIONAL Segunda edición (Primera en línea) Spainish national formulary. Available at: http://cpage.mpr.gob.es. Accessed 3 April 2020.
  11. Gonzales D, Rennard SI, Nides M, Oncken C, Azoulay S, Billing CB, et al. Varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: A randomized controlled trial. J Am Med Assoc. 2006;296(1):47–55.
  12. Jorenby DE, Hays JT, Rigotti NA, Azoulay S, Watsky EJ, Williams KE, et al. Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: A randomized controlled trial. J Am Med Assoc. 2006;296(1):56–63.
  13. Dani JA, Harris RA. Nicotine addiction and comorbidity with alcohol abuse and mental illness. Nature Neuroscience. 2005;8(11):1465–1470.
  14. Coe JW, Brooks PR, Vetelino MG, Wirtz MC, Arnold EP, Huang J, et al. Varenicline: An alpha;4β2 nicotinic receptor partial agonist for smoking cessation. J Med Chem. 2005;48(10):3474–3477.
  15. West R, Baker CL, Cappelleri JC, Bushmakin AG. Effect of varenicline and bupropion SR on craving, nicotine withdrawal symptoms, and rewarding effects of smoking during a quit attempt. Psychopharmacology (Berl). 2008;197(3):371–7.
  16. Benowitz NL. Pharmacology of nicotine: Addiction, smoking-induced disease, and therapeutics. Annu Rev Pharmacol Toxicol. 2009;49(1):57–71.
  17. Zaniewska M, Przegaliński E, Filip M. Nicotine dependence - Human and animal studies, current pharmacotherapies and future perspectives. Pharmacological Reports. 2009;61(6):957–965.
  18. European Medicines Agency. Champix. Summary of Product Characteristics. Available at: https://www.ema.europa.eu/en/medicines/human/EPAR/champix#product-information-section. Accessed 9 March 2020.
  19. Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, Lawrence D, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): A double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016;387(10037):2507–2520.
  20. Zyban 150 mg prolonged release tablets. Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/3827/smpc. Accessed 9 March 2020.
  21. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Available at: Cochrane Database of Systematic Reviews. 2014;2014(1). doi:10.1002/14651858.CD000031.pub4.
  22. Swan GE, McAfee T, Curry SJ, Jack LM, Javitz H, Dacey S, et al. Effectiveness of Bupropion Sustained Release for Smoking Cessation in a Health Care Setting: A Randomized Trial. Arch Intern Med. 2003;163(19):2337–2344.
  23. Fossati R, Apolone G, Negri E, Compagnoni A, La Vecchia C, Mangano S, et al. A double-blind, placebo-controlled, randomized trial of bupropion for smoking cessation in primary care. Arch Intern Med. 2007;167(16):1791–1797.
  24. Tutka P, Vinnikov D, Courtney RJ, Benowitz NL. Cytisine for nicotine addiction treatment: a review of pharmacology, therapeutics and an update of clinical trial evidence for smoking cessation. Addiction. 2019;114(11):1951–1969.
  25. Van Schayck OCP, Williams S, Barchilon V, Baxter N, Jawad M, Katsaounou PA, et al. Treating tobacco dependence: Guidance for primary care on life-saving interventions. Position statement of the IPCRG. npj Primary Care Respiratory Medicine. 2017;27(1). doi:10.1038/s41533-017-0039-5.
  26. Walker N, Howe C, Glover M, McRobbie H, Barnes J, Nosa V, et al. Cytisine versus nicotine for smoking cessation. N Engl J Med. 2014;371(25):2353–2362.
  27. West R, Zatonski W, Cedzynska M, Lewandowska D, Pazik J, Aveyard P, et al. Placebo-controlled trial of cytisine for smoking cessation. N Engl J Med. 2011;365(13):1193–200.
  28. Walker N, Bullen C, Barnes J, McRobbie H, Tutka P, Raw M, et al. Getting cytisine licensed for use world-wide: a call to action. Addiction. 2016;111(11):1895–1898.
  29. BPAC. Update on smoking cessation - BPJ Issue 33. Available at: https://bpac.org.nz/BPJ/2010/December/smoking.aspx. Accessed 10 March 2020.
  30. (No Title). https://www.nice.org.uk/guidance/ng92/documents/evidence-review. Accessed 6 March 2020.
  31. McCrabb S, Baker AL, Attia J, Skelton E, Twyman L, Palazzi K, et al. Internet-based programs incorporating behavior change techniques are associated with increased smoking cessation in the general population: A systematic review and meta-analysis. Annals of Behavioral Medicine. 2019;53(2):180–195.
  32. Hajek P, Phillips-Waller A, Przulj D, Pesola F, Smith KM, Bisal N, et al. A randomized trial of E-cigarettes versus nicotine-replacement therapy. N Engl J Med. 2019;380(7):629–637.
  33. PCRS. E-cigarettes. PCRS position statement. Available at: https://www.pcrs-uk.org/resource/e-cigarettes-pcrs-position. Accessed 11 March 2020.
  34. WHO. WHO | Advancing in tobacco control amidst the COVID-19 pandemic. 2020. https://www.who.int/fctc/mediacentre/news/2020/advancing-in-tobacco-control-amidst-the-covid-19-pandemic/en/. Accessed 16 April 2021.
  35. ASH. Profileof 16/17-year-old smokers. 2021. https://ash.org.uk/wp-content/uploads/2021/03/Profile-of-16-and-17-year-old-smokers.pdf. Accessed 16 April 2021.
  36. Thomson B, Rojas NA, Lacey B, Burrett JA, Varona-Pérez P, Martínez MC, et al. Association of childhood smoking and adult mortality: prospective study of 120 000 Cuban adults. Lancet Glob Heal. 2020;8(6):e850–e857.
  37. Gov.uk. Smoke-free generation: tobacco control plan for England - GOV.UK. 2017. https://www.gov.uk/government/publications/towards-a-smoke-free-generation-tobacco-control-plan-for-england. Accessed 16 April 2021.
  38. Public Health Matters. Health Matters: Identifying and offering brief advice to tobacco and alcohol users - Public health matters. 2019. https://publichealthmatters.blog.gov.uk/2019/03/21/health-matters-identifying-and-offering-brief-advice-to-tobacco-and-alcohol-users/. Accessed 16 April 2021.
  39. (No Title). https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/4249/theorgandonationtaskforcimplementationprogrammesfinalreport2011.pdf. Accessed 12 November 2020.
  40. Gilbody S, Peckham E, Bailey D, Arundel C, Heron MRes P, Crosland PGDip S, et al. Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trial. Artic Lancet Psychiatry. 2019;6:379–90.
  41. Royal College of Psychiatrists. The prescribing of varenicline and vaping (electronic cigarettes) to patients with severe mental illness. 2018. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/position-statements/ps05_18.pdf?sfvrsn=2bb7fdfe_4 Accessed. Accessed 16 April 2021.
  42. WHO. WHO report on the global tobacco epidemic 2019. Available at: 2020. https://www.who.int/tobacco/global_report/en/. Accessed 4 March 2020.
  43. Jha P, Ramasundarahettige C, Landsman V, Rostron B, Thun M, Anderson RN, et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med. 2013;368(4):341–350.
  44. US Surgeon General. The health consequences of smoking—50 years of progress: A report of the Surgeon General. 2014. Centers for Disease Control and Prevention (US) doi:NBK179276.
  45. WHO. Tobacco. Key facts. Available at: https://www.who.int/news-room/fact-sheets/detail/tobacco. Accessed 5 March 2020.
  46. Krosnick JA, Malhotra N, Mo CH, Bruera EF, Chang L, Pasek J, et al. Perceptions of health risks of cigarette smoking: A new measure reveals widespread misunderstanding. PLoS One. 2017;12(8):e0182063.
  47. ASH. ASH fact sheet on smoking and meningococcal disease. Available at: 2016 https://ash.org.uk/wp-content/uploads/2019/10/Smoking-Mening.pdf. Accessed 6 April 2020.
  48. ASH. ASH fact sheet: Smoking and dementia. Available at: 2019 https://ash.org.uk/wp-content/uploads/2019/10/Smoking-Dementia.pdf. Accessed 6 April 2020.
  49. Zhang J jin, Dong X, Cao Y yuan, Yuan Y dong, Yang Y bin, Yan Y qin, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy Eur J Allergy Clin Immunol. 2020. doi:10.1111/all.14238.
  50. WHO. Coronavirus disease (COVID-19): Tobacco. 2020. https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-tobacco. Accessed 16 April 2021.
  51. El-Awa F, Fraser CP, Adib K, Hammerich A, Latif NA, Fayokun R, et al. The necessity of continuing to ban tobacco use in public places post-covid-19. Eastern Mediterranean Health Journal. 2020;26(6):630–632.
  52. Hopkinson NS, Rossi N, El-Sayed-moustafa J, Laverty AA, Quint JK, Freidin M, et al. Current smoking and COVID-19 risk: Results from a population symptom app in over 2.4 million people. Thorax. 2020. doi:10.1136/thoraxjnl-2020-216422.
  53. Arcavi L, Benowitz NL. Cigarette smoking and infection. Archives of Internal Medicine. 2004;164(20):2206–2216.
  54. Huttunen R, Heikkinen T, Syrjänen J. Smoking and the outcome of infection. Journal of Internal Medicine. 2011;269(3):258–269.
  55. van Zyl-Smit RN, Krüll M, Gessner C, Gon Y, Noga O, Richard A, et al. Once-daily mometasone plus indacaterol versus mometasone or twice-daily fluticasone plus salmeterol in patients with inadequately controlled asthma (PALLADIUM): a randomised, double-blind, triple-dummy, controlled phase 3 study. Lancet Respir Med. 2020. doi:10.1016/S2213-2600(20)30178-8.
  56. US Surgeon General. The 2014 Surgeon General’s report: ‘the health consequences of smoking-50 years of progress’: A paradigm shift in cancer care. 2014. Rockville, MD. U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. doi:10.1002/cncr.28695.
  57. Smokefree.gov. Reasons to quit. Available at: https://smokefree.gov/quit-smoking/why-you-should-quit/reasons-to-quit. Accessed 6 March 2020.
  58. Yoshida K, Gowers KHC, Lee-Six H, Chandrasekharan DP, Coorens T, Maughan EF, et al. Tobacco smoking and somatic mutations in human bronchial epithelium. Nature. 2020;578(7794):266–272.
  59. ACS. Health Benefits of Quitting Smoking Over Time. 2020.
  60. The Balance - Make Money Personal. 2020. https://www.thebalance.com/. Accessed 16 April 2021.
  61. Statista. Statista - The Statistics Portal for Market Data, Market Research and Market Studies. 2019. https://www.statista.com/. Accessed 16 April 2021.
  62. Casetta B, Videla AJ, Bardach A, Morello P, Soto N, Lee K, et al. Association Between Cigarette Smoking Prevalence and Income Level: A Systematic Review and Meta-Analysis. Nicotine Tob Res. 2017;19(12):1401–1407.
  63. Cancer.org. Benefits of quitting smoking over time. Available at: https://www.cancer.org/healthy/stay-away-from-tobacco/benefits-of-quitting-smoking-over-time.html. Accessed 5 March 2020.
  64. Goodchild M, Nargis N, D’Espaignet ET. Global economic cost of smoking-attributable diseases. Tob Control. 2018;27(1):58–64.
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