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Updated: August 5, 2011

Nicotine Dependence
Physiological Barriers to Quitting Smoking
Psychological Barriers to Quitting Smoking
Integrated Treatment Program
Pharmacological Treatment
Counseling Programs
Tobacco Cessation Takes Time
Health Benefits of Smoking Cessation

Smoking is the leading preventable cause of death in the United States.

Source: Centers for Disease Control and Prevention. Adult Cigarette Smoking in the United States: Current Estimates. Available at: data_statistics/fact_sheets/ adult_data/cig_smoking/index.htm. Accessed August 3, 2011.


Why do people continue to use tobacco even though the negative health consequences are so well-documented? Because nicotine, the drug found naturally in tobacco, makes cigarettes as addictive as heroin and cocaine.1 As a result, trying to quit is extremely hard. Nearly 70% of the 44.5 million adult smokers in the United States want to quit, but fewer than 5% remain abstinent at one year.2 Although cigarettes are highly addictive, many different treatment options make quitting an achievable goal.

Nicotine Dependence

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) categorizes nicotine dependence and nicotine withdrawal as nicotine-related disorders, which are substance use disorders. Furthermore, nicotine dependence is often categorized as a chronic medical condition.3 Nicotine dependence is characterized by patterns of repeated use that can result in tolerance (i.e., the need for increased amounts of nicotine to achieve pleasurable feelings), withdrawal (i.e., the absence of nicotine causes withdrawal symptoms), and compulsive drug taking behavior (i.e., the person may express the desire to quit, but cannot).3 Most daily smokers develop nicotine dependence within a few years of starting; 50% of daily smokers in their twenties and 87% of older daily smokers meet DSM-IV criteria for nicotine dependence.4 The following chart is a common tool used to determine nicotine dependence.

Fagerstrom Test for Nicotine Dependence
Questions Answers Points
How soon after you wake up do you smoke your first cigarette?
  • Within 5 minutes
  • 6-30 minutes
  • 31-60 minutes
  • After 60 minutes
  • 3
    Do you find it difficult to refrain from smoking in places where it is forbidden?
  • Yes
  • No
  • 1
    Which cigarette would you hate most to give up?
  • The first one in the morning
  • All others
  • 1
    How many cigarettes per day do you smoke?
  • 10 or less
  • 11-20
  • 21-30
  • 31 or more
  • 0
    Do you smoke more frequently during the first hours of waking than during the rest of the day?
  • Yes
  • No
  • 1
    Do you smoke if you are so ill that you are in bed most of the day?
  • Yes
  • No
  • 1
    Source: American Psychiatric Association: Practice Guidelines for the Treatment of Psychiatric Disorders, Compendium 2000. Washington, DC, American Psychiatric Association, 2005

    Evidence shows that there is an increasing trend in the use of other forms of tobacco such as pipe, cigars, and smokeless tobacco, which also produce nicotine dependence.

    Source: American Psychiatric Association: Practice Guidelines for the Treatment of Psychiatric Disorders, Compendium 2000. Washington, DC, American Psychiatric Association, 2005.

    Answers that result in scores greater than or equal to six points on the Fagerstrom Test for Nicotine Dependence indicate that a person is highly dependent on nicotine.3 Determining a smoker's level of nicotine dependence is essential in order to define their potential cessation needs. For example, highly dependent smokers are more likely to need pharmacological treatment and counseling in order to successfully quit.4

    Other forms of tobacco (i.e., pipes, cigars, smokeless tobacco, etc.) contain nicotine and are addictive. Thus, their use can also lead to nicotine dependence. In fact, because of their higher nicotine content, pipe and cigar use are associated with higher rates of nicotine dependence. This should be taken into consideration in the treatment planning and benefit design process.3

    How Nicotine Works

    Source: Public Broadcasting Station. The dope on nicotine. Available at: Accessed September 18, 2007

    Physiological Barriers to Quitting

    "[Nicotine] can relax some muscles and activate other muscle systems. It releases hormones like adrenaline and noradrenaline that can affect the way you feel. It can arouse you if you're sleepy. If you're nervous and anxious, the right amount of nicotine can help make you feel a little bit better and a little bit more relaxed."
    – Jack Henningfield,
    Johns Hopkins University

    Source: PBS. Search for a Safe Cigarette. Available at: transcripts/2810cigarette.html. Accessed September 18, 2007

    Nicotine promotes continued use by both positive and negative reinforcement.5 When there is no nicotine in the body's system, negative withdrawal feelings occur, but when nicotine is present, pleasurable feelings arise. Withdrawal symptoms are a major reason why people have such a hard time quitting. Withdrawal symptoms begin within a few hours of quitting, peaking within 24-48 hours.4 Symptoms last an average of four weeks, but cravings for nicotine may last up to 6 months.4

    Withdrawal symptoms include:4

    • Depression.
    • Dizziness.
    • Fatigue.
    • Frustration, anger, and irritability.
    • Headache.
    • Inability to easily fall or stay asleep.
    • Increased appetite.
    • Restlessness.

    Psychological Barriers to Quitting

    In addition to the physiological withdrawal symptoms, people also report psychological barriers to quitting tobacco. These may include:
    • Enjoyment of tobacco use.
    • Fear of not being able to succeed in quitting.
    • Fear of mood swings.
    • Fear of weight gain.
    • Fear of the loss of a way to handle stress.
    • Cost of medicines to quit.
    • Tobacco use is a part of a daily routine.
    • Having friends, family, or co-workers who use tobacco.
    • Boredom.

    Integrated Treatment Program

    In order to achieve treatment success, cessation attempts should always include an integrated approach. It is important to treat both the physical and psychological effects of nicotine dependence. Evidence shows that combining counseling with either prescription medication or nicotine replacement therapy is more effective than using one treatment method alone.6

    When designing a corporate tobacco cessation strategy for employees, it is imperative to provide multiple benefit types that allow employees to integrate pharmacological treatment and counseling.7 It is equally important that employees are free to choose which type of pharmacological treatment and counseling to use. Every employee will have different personal factors that make certain medications and counseling programs more desirable and effective than others.

    Pharmacological Treatment

    There are many different types of pharmacological treatments available. They are categorized as nicotine replacement products or non-nicotine medications. Pharmacological treatments can help smokers overcome the physiological barriers of quitting tobacco. Studies have found that pharmacological treatment doubles the odds that a person will be able to successfully quit.8

    The National Business Group on Health recommends that employers cover all FDA-approved over-the-counter and prescription nicotine replacement products and tobacco cessation medications, based on the recommendation by the Public Health Service Guideline that all first-line medications, such as the ones listed below, be used for smoking cessation.7,9

    The nicotine replacement products listed below are FDA approved for smoking cessation and are available over the counter and by prescription.

    Nicotine Replacement Products
    Nicotine replacement products (NRTs) deliver small, measured amounts of nicotine into the body, helping to ward off cravings. Although nicotine is delivered into the body through NRTs, it is considered less harmful because NRT's do not contain the cancer causing chemicals found in tobacco products.10 Nicotine replacement therapy is effective at increasing long-term tobacco cessation rates.6

    The nicotine replacement products listed below are FDA approved for smoking cessation and are available over the counter and by prescription.

    • Nicotine Gum is available over the counter. It comes in 2mg and 4mg doses, and in a variety of flavors. Nicotine gum provides the ability for those trying to quit to self-dose in response to cravings and it can be chewed every 1-2 hours.8

    • The Nicotine Patch is available over the counter and in doses of 7 mg, 14 mg, and 21 mg. The patch delivers measured amounts of nicotine to the body and can be discretely placed on the body.8

    • The Nicotine Lozenge is available over the counter in 2 mg and 4 mg doses. It provides the ability for those trying to quit to self-dose in response to cravings and has been proven effective in reducing withdrawal symptoms.8

    • Nicotine Nasal Spray is available by prescription only. It delivers nicotine more rapidly than any other NRT and thus reduces withdrawal symptoms quicker than any other form of nicotine replacement therapy.8

    • Nicotine Inhalers are available by prescription only. They mimic a real cigarette. A nicotine cartridge is placed into a rod and nicotine vapor can be inhaled through puffing. Nicotine inhalers are designed to replace the oral and handling elements of a cigarette that are often missed by smokers, while delivering nicotine.8

    On July 1, 2009, the U.S. Food and Drug Administration required manufacturers to put a Boxed Warning on the prescribing information for the smoking cessation drugs Chantix (varenicline) and Zyban (bupropion). The warning highlights the risk of serious mental health events including changes in behavior, depressed mood, hostility, and suicidal thoughts when taking these drugs.

    "The risk of serious adverse events while taking these products must be weighed against the significant health benefits of quitting smoking," said Janet Woodcock, M.D., director, the FDA's Center for Drug Evaluation and Research. "Smoking is the leading cause of preventable disease, disability, and death in the United States and we know these products are effective aids in helping people quit."

    Non-Nicotine Medications
    There are currently two FDA-approved medications to help smokers quit. These drugs are non-nicotine products that reduce the withdrawal symptoms and/or craving of tobacco. The two drugs are bupropion SR (trade name Wellbutrin® and Zyban®) and varenicline (trade name ChantixTM).1 In clinical trials, both bupropion and varenicline have shown to be effective in aiding smoking cessation efforts.6
    • Bupropion (SR) (trade name Wellbutrin® and Zyban®) eases the withdrawal symptoms of quitting smoking, while simultaneously helping to reduce a person's urge to smoke.11 Long-term treatment with bupropion SR may reduce smoking relapse and has shown to be effective across a broad population of smokers. It can be used in combination with nicotine replacement therapies.11

    • Varenicline (trade name ChantixTM) eases the withdrawal symptoms of quitting smoking. It blocks nicotine from attaching to receptors in the brain and thus hinders the effects of nicotine if a person resumes or continues smoking. It is recommended that varenicline should not be combined with nicotine replacement therapies.12

    Counseling Programs

    There are several different types of counseling that a person can utilize, depending on the individual's comfort level and amount of support needed. Counseling programs provide employees trying to quit with helpful information on how to develop a quit plan, overcome barriers to quitting, and handle withdrawal symptoms and stress without resorting to tobacco use. There are several different types of counseling available in order to accommodate the various needs of those trying to quit.

    The U.S. Public Health Service and the US Preventive Services Task Force recommends that employers cover brief counseling (in-person) and intensive counseling (in-person or over the telephone) for tobacco use treatment.7,9,13 It is also recommended that employers cover 12 counseling sessions (2 courses of 6 sessions) per calendar year for beneficiaries.7,9

    • Telephone-based programs connect tobacco cessation counselors with those trying to quit through quitlines. Telephone-based programs provide flexibility and privacy, but also provide the human contact that is often necessary for people to stay on course with their cessation efforts. Research shows that telephone-based counseling programs are effective in aiding patients in tobacco cessation.9

    • Individual counseling programs are a series of in-person counseling sessions between a person trying to quit and a trained tobacco cessation counselor. Individual counseling provides a person trying to quit with the privacy that he or she may desire, while also providing reinforcement and support. Individual programs allow treatment to be tailored to the unique problems of the individual.4 Research shows that individual counseling programs are effective in aiding patients in tobacco cessation.9

    • Group programs are a series of counseling sessions between a group of people trying to quit and a trained tobacco cessation counselor. Group programs offer a person trying to quit a great deal of support by providing in-person guidance, peer support, and reinforcement. Research shows that group counseling programs are effective in aiding patients in tobacco cessation.

    The U.S. Preventive Services Task Force and the Public Health Service Guidelines note that there is a dose-response relationship between the intensity and frequency of counseling and tobacco abstinence rates.9,13 For example, brief counseling interventions (under 3 minutes) are more effective than no counseling, but intensive counseling sessions (5 to 15 minutes) are more effective than brief counseling sessions. The more time a patient is exposed to counseling, the more likely it is that the patient will be successful in quitting.7,9

    Tobacco Cessation Takes Time

    For many people, it takes more than just one cessation attempt to quit for good. Nicotine dependence is a chronic, relapsing condition; relapse is common and should not be considered a failure.4 Instead, a relapse is the opportune time for those trying to quit to modify their treatment program so that it can be more effective during their next cessation attempt.

    Employers should keep the following considerations in mind:

    • Employees may need to increase the dose of their medications, try different treatment combinations, seek more structured counseling, etc.
    • The most important thing for employers and employees to remember is that quitting is possible, even if it does take several tries to meet the end goal.
    • Employees have unique needs and barriers to quitting. Thus, employers should provide multiple benefit types (i.e., medications and counseling) and cessation support opportunities (i.e., quitlines, smoke-free campuses, etc.), in order to meet the need for several quit attempts.

    Health Benefits of Smoking Cessation

    Smoking causes a multitude of harmful health effects, but when a smoker stops smoking, their overall health improves within just a few minutes of quitting. The health benefits of quitting increase as time goes by. In the long-term, people greatly reduce their risk of premature death by quitting smoking.

    The earlier a person quits, the greater the health benefit:14

    • Smoking cessation decreases the risk of:
      • Bladder cancer.
      • Cancers of the mouth, throat, and esophagus.
      • Cervical cancer.
      • Coronary heart disease.
      • Heart attack.
      • Laryngeal cancer.
      • Lung cancer.
      • Stroke.
    • The health benefits of smoking cessation greatly outweigh the health risks associated with the average 5lb weight gain that may follow quitting.


    A 2009 study of employees of a multinational company indicated that financial incentives can increase tobacco cessation program enrollment rates, completion of programs and abstinence rates.15

    Examples of incentives:

    • Benefit enhancements.
    • Lower deductibles.
    • Reduced premiums.
    • Flexible benefit credits to attend tobacco cessation classes or telephone counseling.
    • Cash incentives to improve health risk factors.
    • Cash incentives for health education programs.

    Advantages of Incentives Disadvantages of Incentives
    • Easy to set up and operate.
    • Very flexible and adaptable.
    • Can have significant behavioral impact.
    • Can be designed for different departments and different levels.
    • Can be linked to organizational goals and objectives.
    • Encourage cessation program participation.
    • Give employees a positive focus.
    • Reinforce motivation to quit.
    • Reinforce employees' not using tobacco.
    • Determining the best reward may be difficult.
    • Employees can falsify cessation attempts.
    • Non-tobacco users might feel slighted.
    Source: Centers for Disease Control and Prevention. Making your Workplace Smoke-Free: A Decision Makers Guide. Available at: Accessed August 3, 2011.

    For more information about whether employers can offer discounted health premiums for nonsmokers without violating federal laws visit the National Business Group on Health's Issue Brief: Employers Can Provide Financial Incentives Such As Contribution/Premium Discounts to Their Nonsmoking Employees Through a Bona Fide Wellness Program.


    Centers for Disease Control and Prevention
    A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment

    A Centers for Disease Control and Prevention (CDC) publication provides information and practical advice to help public health professionals and employers improve their understanding of health-care systems, improve tobacco dependence treatment, and increase cessation.

    Pacific Business Group on Health
    Tobacco Cessation Benefit Coverage and Consumer Engagement Strategies: A California Perspective

    Partnership for Prevention
    Investing in Health: Evidence-Based Health Promotion Practices for the Workplace


    1 Centers for Disease Control and Prevention. Cessation. Available at: Accessed August 3, 2011.
    2 Fogarty S. Integrating EAPs into smoking cessation can help workers stub out the habit. Employee Benefit News. 2007;21(6).
    3 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Association; 2000.
    4 American Psychiatric Association. Practice guidelines for the treatment of psychiatric disorders. Washington: American Pyschiatric Association; 2005.
    5 American Society of Addiction Medicine. Principles of addiction medicine. 2nd ed. Maryland: American Society of Addiction Medicine, Inc; 1998.
    6 Key Findings. Available at: Accessed August 3, 2011.
    7 Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A purchaser's guide to clinical preventive services: moving science into coverage. Washington, DC: National Business Group on Health; 2006.
    8 Ebbert J, Sood A, Hays T, Dale L, Hurt R. Treating tobacco dependence: review of the best and latest treatment options. Journal of Thoracic Oncology. 2007;2(3).
    9 Fiore MC, Bailey WC, Cohen SJ, et al. A clinical practice guideline for treating tobacco use and dependence. Rockville, Maryland. U.S. Department of Health and Human Services, Public Health Service; 2000. Available at: Accessed April 15, 2008.
    10 National Cancer Institute. Quitting smoking: why to quit and how to get help. Available at: Accessed August 29, 2007.
    11 Kleber H, Weiss R, Anton R, et al. Practice guideline for the treatment of patients with substance use disorders, 2nd Edition. Available at: Accessed August 3, 2011.
    12 Connery H, Kleber H. Guideline watch (April 2007): practice guideline for the treatment of patients with substance use disorders, 2nd Edition. Available at: Accessed August 3, 2011.
    13 U.S. Preventive Services Task Force. Counseling to prevent tobacco use and tobacco-caused disease. Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; 2003.
    14 U.S. Department of Health and Human Services. The health benefits of smoking cessation: a report of the Surgeon General. Washington, DC: Office of the Surgeon General, 1990. Available at: Accessed August 3, 2011.
    15 Volp KG, Troxel AB, Pauly MV et al. A randomized, controlled trial of financial incentives for smoking cessation. NEJM. 2009;360(7):699-709.

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