Introduction: Recognition and management of some possible consequences of stopping smoking

ABSTRACT

While stopping smoking has a range of profoundly beneficial consequences, the immediate aftermath of smoking cessation often generates at least some negative effects. This collection of review articles covers both sides of this often difficult equation to provide clinicians with guidance on recognising and managing a range of short-term sequelae of smoking cessation.

Key words: :

• Cardiovascular disease
• Endocrine effects
• Nicotine withdrawal
• Psychiatric disorders
• Respiratory disease
• Smoking cessation

Health professionals routinely advise their patients to stop smoking to improve their health and well-being. Yet with some doctors and patients, beneath this broad and correct recommendation, there lies a somewhat dissonant note of certain caveats and qualifications. Stopping smoking can produce irritating physical symptoms such as mouth ulcers and constipation. A non-negligible proportion of ex-smokers put on weight in excess of 10 kg. Increased irritability is common, occasionally reaching uncomfortable levels of intensity. Increased lung secretion and increased likelihood of catching airborne infections may be of concern with some patients. There is a body of opinion seeing smoking as self-medication for psychiatric disorders ranging from depression to schizophrenia. Stopping smoking can generate substantial adverse mood changes including new-onset major depressive disorder.

Within the overall picture of disease, disability, and death caused by smoking, such considerations tend to get swept aside. They are comparatively minor, affect only a small proportion of quitters, and there is a concern that discussing and publicising them could put some smokers off trying to quit. These are all valid points. However, there is also a need to provide accurate information on possible negative consequences of smoking cessation and on their management. Health professionals, smokers, and a range of legislative bodies can benefit from having such information available.

For some considerable time now, limited knowledge of negative sequelae of stopping smoking led to tobacco withdrawal symptoms being labelled as side-effects of smoking cessation medications. In a typical study of, say, nicotine replacement treatment, almost twice as many smokers in the active condition than in the placebo arm would stop smoking. This would generate excess reports of, for example, insomnia and constipation, which would then be listed as drug side-effects.

We are currently witnessing a new example of such possible misattribution. A new smoking cessation medication varenicline has become linked, via several media case studies, with erratic and suicidal behaviour. This has led to rapid drug label changes. Yet the aftermath of stopping smoking, or of an unsuccessful quit attempt characterised by a protracted period of smoking reduction, is a much more likely cause of negative mood and irritability than the drug. The post-marketing surveillance noted that some of the patients affected did not manage to stop smoking. This does not invalidate the argument, as smokers reducing their smoking in an unsuccessful attempt to quit tend to have more pronounced mood deterioration than those who succeed in quitting altogether.

This supplement to Current Medical Research and Opinion addresses some of the short-term consequences of stopping smoking and their management. Although the authors took care to emphasise the positive benefits of smoking cessation, they also cover some of the negative medical sequelae of cessation and their management. Of common nicotine withdrawal symptoms, depression and increased appetite are covered, with other contributions concerning endocrine, cardiovascular, and respiratory changes. To my knowledge, this is the first collection of articles touching on this topic and will hopefully provide a useful service to our discipline.

In the first review article, Fagerström and Aubin1 discuss smoking cessation in psychiatric patients. They summarise the rather modest available literature on smoking cessation treatment in this challenging setting, and provide some useful and sober treatment suggestions, including a consideration of harm-reduction approaches 1.

Aubin2 then takes the topic further by focusing specifically on one particular psychiatric consequence of nicotine withdrawal in smokers with no formal psychiatric history, a new-onset depression2. The article provides a review of relevant data available from a range of clinical trials. Among its more intriguing suggestions are considerations of a possibility that stopping smoking may reveal a depressive illness that was previously self-medicated by cigarettes. The author also provides a range of suggestions for management of emerging psychiatric symptoms2.

Berlin3 provides a scholarly appraisal of endocrine and metabolic effects of smoking cessation. His systematic review of available evidence is a novel and valuable contribution to the field. The article touches on some of the issues in weight gain which the author covered more extensively in an earlier review3.

Finally, Gratziou4 reviews cardiovascular and respiratory consequences of smoking cessation. Her review covers in some detail the positive benefits of stopping smoking, but it also discusses post-cessation increase in blood pressure and lung secretion, constipation, mouth ulcers, and the thorny issue of altered drug metabolism4.

The collection of articles will hopefully help the readers to appreciate a possible gamut of obstacles some smokers have to face on their journey to abstinence, and provide them with some useful knowledge and tools for guiding their patients.

Acknowledgements

Declaration of interest: The Guest Editor (P. H.) undertakes consultancy for and has received research funds from a number of companies developing and manufacturing smoking cessation products, including Pfizer. Editorial support was provided by Envision Pharma Ltd and was funded by Pfizer Ltd.