Smoking cessation in women. Special considerations

Nicotine patch and lozenge are effective for women

It has been hypothesized that women may be less likely to obtain therapeutic benefit from nicotine replacement therapy (NRT). The present study tested this hypothesis, using two different types of NRT medications. A secondary analysis of two randomized clinical trials was performed: One compared active 21-mg nicotine patch with placebo among 193 men and 309 women, and the other compared active 2-mg or 4-mg nicotine lozenge with placebo among 788 men and 1,030 women. Using logistic regression analysis of 6-month continuous abstinence and survival analysis, we assessed the efficacy of patch and lozenge among women and tested for a gender x treatment interaction. Active NRT was more effective than placebo among women, for both patch and lozenge. In the lozenge trial, women were less successful than men. The gender x treatment interaction was not significant in either study, whether assessed by logistic regression or survival analysis. In the lozenge trial, gender moderated the effects of smoking rate and dependence (but not treatment) on outcome: These variables affected success rates only among women. Treatment with nicotine patch or lozenge is effective for women, and the analysis did not reveal significant gender differences in efficacy. Gender differences in outcome may be moderated by nicotine dependence.

Evidence for Smoking Cessation: Implications for Gender‐Specific Strategies

BACKGROUND

Facilitating smoking cessation requires an evidence-based approach. The Lienhard School of Nursing Institute for Healthy Aging in the United States, whose focus is providing health information to aging baby boomers, developed an interest in studying strategies for smoking cessation in women.

APPROACH

Studies were reviewed and critiqued related to the question: What is the relative efficacy of first-line smoking cessation interventions for women versus men in the 40- to 65-year-old age group? This article first discusses the procedure used to construct an integrative framework for finding the evidence on smoking cessation, including a literature search and refinement of the problem to be studied, and then a summary of the evidence gathered on the selected variable (gender) and interventions (counseling, pharmacotherapy, nicotine replacement therapy).

FINDINGS

Evidence was found that supports the general efficacy of three first-line smoking cessation interventions: counseling, bupropion-sustained release (BSR), and nicotine replacement therapy (NRT). What the evidence does not show, however, is which of these interventions may be more effective for women versus men in general or specifically in the 40- to 65-year-old age group.

RECOMMENDATIONS

Recommendations include the development of a clinical trial and the inclusion from the outset of gender as a major variable in all future intervention studies.

IMPLICATIONS

Practice implications include the fact that since effective treatments already exist for assisting clients to stop smoking, all health-care providers should offer an intervention that has been found effective to any client who expresses a desire to quit smoking. Further studies of efficacy are needed to develop more focused implications.

Impact of nicotine replacement therapy on smoking behavior

This review summarizes evidence pertaining to the role of nicotine medications in smoking cessation and focuses particularly on evaluating evidence of the impact that nicotine replacement therapies (NRT) have had on altering population trends in smoking behavior. Accumulated evidence from controlled clinical trials has demonstrated that available forms of NRT (e.g., gum, transdermal patch, nasal spray, inhaler, and lozenge) increase quit rates compared with placebos by 50%-100%. However, despite the positive results from these studies, fewer than one in five smokers making a quit attempt do so with the benefit of NRT. Because not enough smokers are using NRT, the availability of NRT has not had a measurable impact on influencing population trends in smoking behavior. Among the factors contributing to the low utilization of nicotine medications are the inadequacies of the current dosage strengths and formulations of existing medications, smokers' perceptions of the high cost of the drugs, and concerns that many smokers have about safety and efficacy of nicotine medications.

Calorie restriction increases cigarette use in adult smokers

RATIONALE

Cigarette smokers weigh less than nonsmokers, and smokers often gain weight when they quit. This is a major barrier to smoking cessation, especially among women. However, strict dieting is not recommended during smoking cessation out of concern that it might promote relapse. This concern derives, in part, from the observation that calorie restriction increases self-administration of drugs of abuse in animals. This relationship has never been experimentally demonstrated in humans.

OBJECTIVES

To evaluate whether calorie restriction increases cigarette smoking in humans.

METHODS

Seventeen (nine males, eight females) healthy, normal-weight smokers not attempting to quit were cycled in partially counterbalanced order, double-blind, through four diets-normal calorie (2,000-2,800 kcal/day), low calorie (700 kcal/day deficit), low-carbohydrate (CHO)/normal-calorie, and low-CHO/low-calorie-for 6 days per diet in an inpatient research ward. Smoking was assessed by cigarette counts, breath carbon monoxide (CO) levels, and cigarette craving.

RESULTS

Compared with the normal-calorie diet, while on the low-calorie diet, subjects smoked 8% more cigarettes (P<0.02) and had 11% higher breath CO levels (P<0.01). The low-CHO/normal-calorie diet showed no significant effect on either variable, but there was a 15% increase in breath CO levels (P<0.05) on the low-CHO/low-calorie diet. There were no changes in self-reported cigarette craving or mood.

CONCLUSIONS

Consistent with animal studies, moderate calorie restriction was associated with a small but statistically significant increase in cigarette smoking, with no independent effect of CHO deprivation. These findings suggest that dieting may increase smoking behavior and could impede smoking-cessation attempts.

Offering telephone counseling to smokers using pharmacotherapy

Whereas telephone-based counseling has been found to be effective in supporting smokers interested in quitting smoking, it is not known whether proactive efforts to reach smokers receiving cessation medications will enhance their likelihood of successful quitting. We had an opportunity to test, in a health plan setting, an offer of telephone-based counseling with smokers identified from health plan records as recently filling a prescription for nicotine replacement therapy or bupropion. After we removed 31 members determined to be ineligible, 1,329 were randomly allocated to receive an invitation either to telephone-based counseling (n = 663) or to a control group (n = 666). On average, 7 days (range = 3-15 days) elapsed from the day of the prescription fill until the Center for Health Promotion began calling to invite members to participate in telephone counseling. The Center for Health Promotion was able to reach 49% of those in the intervention group (323/663). Of these members, 118 (37%) declined any participation. Therefore, in response to the proactive contact, 63% (205/323) of those reached and 31% (205/663) of those eligible participated in some smoking cessation counseling. At the 3-month follow-up, we observed an increased quit rate (33.1% vs. 27.4%) among health plan members randomized to telephone-based smoking cessation counseling. The results varied by gender and amount smoked. In addition, the variables associated with quitting in a multivariate logistic regression model included older age and using more than 30 days of medication.

Association between age, gender and reasons for smoking cessation

AIMS

To contribute to improved programs for smoking cessation, the authors wanted to assess the relationships between age, gender and ex-smokers' quitting reasons and examine predictors of the most commonly reported quitting reasons.

METHODS

A questionnaire was mailed to 11,919 subjects in Akershus County, Norway. Among the 7,697 respondents (65%), self-reported reasons for smoking cessation in 1,715 ex-smokers were analysed. Using cross-tables and multivariate logistic regression, associations between age, gender, and reported quitting reasons were examined.

RESULTS

Men were more likely to have stopped smoking to improve physical fitness, or out of consideration for other family members than the children, and less likely to have quit out of consideration for their own children, or in solidarity with a spouse that stopped smoking. In multivariate logistic regression analysis, age was a predictor of all seven most common reasons to quit smoking. Gender, education, and the physical component of health status each predicted three of the seven quitting reasons.

CONCLUSIONS

In the study sample, differences in smoking cessation behavior and reported quitting reasons were found according to both age and gender. Smoking cessation programs should be tailored to the relevant target groups, including stratification according to age and gender.

Meal patterns in female rats during and after intermittent nicotine administration

Previously we observed in male rats that intermittent administration of nicotine (NIC) during the dark phase reduces food intake (FI) by initially decreasing only dark phase meal size. This was followed several days later by an increase in dark phase meal frequency such that FI returned to normal, while body weight remained suppressed. Termination of NIC treatment resulted in a modest dark phase hyperphagia. Since some human females use NIC as a weight control drug, the present study investigated changes in FI and body weight regulation in adult female rats treated for five estrous cycles with saline or a 1.40 mg/kg/day (free base) dose of NIC, which was given in four equal i.p. doses during the dark phase. The rats were followed for 15 days after cessation of NIC. Initially both dark and light phase FI were reduced and this was caused by an immediate decrease in dark and light phase meal size; the attenuation of meal size continued after cessation of NIC. On day 7 of NIC, the rats compensated by significantly increasing the number of dark, but not light, phase meals they took. This resulted in a normal 24-h FI, which was caused by a dark phase increase in FI coupled with a continued decrease in light phase FI. Importantly, these changes in meal patterns persisted for some time after termination of NIC. Upon NIC cessation, the NIC group showed no hyperphagia even though their body weight was significantly decreased. These results document that administration of NIC during the dark phase resulted in a reorganization of the microstructure of FI in females rats that resembles, but does not exactly duplicate, that observed in male rats. Like males, long lasting alterations in the microstructure of FI (e.g., meal size and meal number), were noted in female rats for up to 2 weeks after cessation of NIC. These results differ from studies in which NIC was given continuously 24-h per day and indicate that dark phase NIC administration in rats may represent an appropriate model to study the impact of NIC on meal patterns.

Perceived risks and benefits of smoking cessation: gender-specific predictors of motivation and treatment outcome

The primary aim of this study was to examine gender differences in perceived risks and benefits of smoking cessation and their relationship to pretreatment motivation and treatment outcome. No validated measures that comprehensively assess perceived risks and benefits associated with smoking cessation were available in the literature; consequently, we developed a self-report instrument [Perceived Risks and Benefits Questionnaire (PRBQ)] for this purpose. A sample of 573 treatment-seeking smokers (48% female) entering smoking cessation trials completed the PRBQ, and its association with treatment outcome was assessed in a subsample of 93 participants. Overall, the PRBQ demonstrated good psychometric properties. Females indicated greater likelihood ratings of perceived risks and benefits than males. For women and men, perceived benefits were positively associated with motivation, and perceived risks were negatively associated with motivation and treatment outcome. Women evidenced stronger associations between perceived risks and pretreatment motivation, and treatment outcome. Knowledge of perceived risks and benefits associated with smoking cessation is critical for public education campaigns and could inform intervention strategies designed to modify sex-specific beliefs associated with lowered behavioral intentions to quit smoking.

Effect of glucose on tobacco craving. Is it mediated by tryptophan and serotonin?

RATIONALE

Oral glucose has been shown to decrease tobacco craving in many but not all previous studies. Glucose ingestion may facilitates entry of tryptophan (TRP), the unique source of brain serotonin, into the brain, glucose's action seems to be opposite of rapid TRP depletion. Therefore, the aim was to assess the effect of high doses of oral glucose on tobacco craving, withdrawal symptoms, plasma TRP and blood serotonin concentrations in temporarily abstinent smokers.

METHODS

Aspartame 0.6 g/200 ml (A, placebo), glucose 32.5 g/200 ml (G32.5) and 75 g/200 ml water (G75) were administered to 12 healthy smokers after an overnight abstinence in a crossover, double blind study. Tobacco craving (short version of the Tobacco Craving Questionnaire, TCQ), withdrawal symptoms, choice reaction time, affect, blood glucose, plasma insulin, nicotine, cotinine, free and total TRP, and blood serotonin concentrations were assessed during a period of 5 h after administration.

RESULTS

Blood glucose and plasma insulin increased after G32.5, G75 and remained unchanged after A. TCQ score increased with A and remained almost unchanged with both doses of glucose (conditionxtime interaction: P=0.023). Total withdrawal score increased differently according to sex and condition (P<0.05). Motor reaction time increased with A and decreased with glucose (P=0.016). The overall decrease in plasma TRP was 0.31+/-17, 0.49+/-0.19 and 1.44+/-0.24 mg/l with A, G32.5 and G75, respectively (P<0.001). Baseline blood serotonin was lower in women (n=5) than in men; it showed a condition by time (P=0.007) and a condition by time by sex interaction (P=0.023).

CONCLUSIONS

Glucose attenuates tobacco craving and withdrawal symptoms in temporarily abstinent smokers. This is accompanied by a decrease in plasma TRP and a sex dependent increase in blood serotonin. Further studies assessing the direct effect of glucose on brain serotonin are needed to ascertain whether a glucose induced reduction in craving is associated with an increase in brain serotonin.

Women and tobacco dependence

Millions of American girls and women have been drawn to smoking by an industry that has been clearly and systematically targeting women of all ages and life circumstances. Tobacco marketing strategies skillfully link cigarette use to typical female values. Biologically speaking, women are especially vulnerable to the legion of health problems of tobacco use. Smoking is a critical hazard for women in their reproductive years, particularly when they are pregnant.

Smoking in adolescence: what a clinician can do to help

Approximately 4400 adolescents try their first cigarette every day in the United States. Trying a few cigarettes or using tobacco more regularly as an adolescent significantly increases the risk of smoking in adulthood. Adolescents can develop nicotine dependency after smoking relatively few cigarettes. This article points out the prevalence and unique aspects of teenage tobacco use. In addition, current recommendations for treating nicotine dependence in adolescents are reviewed.

Meta-analysis of the efficacy of nicotine replacement therapy for smoking cessation: differences between men and women

Gender differences in the efficacy of nicotine replacement therapies (NRTs) were examined in a meta-analytical review of 90 effect sizes obtained from a sample of 21 double-blind, placebo-controlled randomized studies. Although NRT was more effective for men than placebo at 3-month, 6-month, and 12-month follow-ups, the benefits of NRT for women were clearly evident only at the 3- and 6-month follow-ups. Giving NRT in conjunction with high-intensity nonpharmacological support was more important for women than men. That is, NRT and low support were efficacious for women at only short-term follow-up, and men benefited from NRT at all the follow-ups regardless of the intensity of the adjunct support. The results suggest that long-term maintenance of NRT treatment gains decrease more rapidly for women than men.

In vivo versus imaginal smoking cue exposures: is seeing believing?

Smokers experience cigarette cravings in response to both imaginal and in vivo cigarette cues, and some studies suggest that the magnitude of this reactivity relates to difficulty quitting. Few studies, however, have systematically examined these two paradigms head-to-head. To this end, the authors exposed 225 smokers to imaginal and in vivo smoking cues and measured craving reactions. Results indicated that both imaginal and in vivo smoking cues increased craving. The magnitude of imaginal and in vivo reactions were statistically comparable and were moderately correlated. In vivo, but not imaginal, reactivity was related to duration of previous quits, particularly in men. Findings suggest that although both paradigms induce craving, the in vivo reactivity paradigm may be, at least in men, more effective for predicting smoking cessation failure.

Nicotine dependence, quit attempts, and quitting among smokers in a regional population sample from a country with a high prevalence of tobacco smoking

BACKGROUND

Nicotine dependence might function as a barrier to smoking cessation. Therefore, the goal was to determine whether single symptoms of nicotine dependence are related to the number of quit attempts and smoking status.

METHODS

In a random population sample of 4075 women and men aged 18-64, drawn from 47 German communities, data about nicotine dependence according to the US Diagnostic and Statistical Manual of Mental Disorders and according to the Fagerström Test for Nicotine Dependence (FTND), and data on quit attempts and quitting were collected at baseline with an interview and 30 months later with a questionnaire.

RESULTS

Nicotine dependence, in particular withdrawal, was related to a high number of quit attempts and to remaining a current smoker. The urgent need for tobacco, craving for nicotine, smoking to avoid withdrawal, and the expectation of increased appetite or weight gain correctly classified smoking status in 72.1% of individuals through logistic regression analysis.

CONCLUSIONS

Nicotine dependence is a strong factor that may partly explain the failure of a subpopulation of smokers to live abstinent. Population-based interventions should include measures of tobacco control and brief interventions carried out, for example, by experts in health care.

Women and the global tobacco epidemic: nurses call to action

BACKGROUND

Tobacco consumption is increasing among women across the globe at alarming rates. Without effective intervention, the smoking prevalence among women will nearly triple over the next generation. These trends are potentially more threatening when considering how tobacco intersects women's lives, regardless if they use tobacco products or not.

AIM

A review and analysis of the literature is conducted to examine the scope of tobacco's global effect on the multiple dimensions of women's health.

METHOD

Medline (1990-2003), Cumulative Index to Nursing and Allied Health Literature (1990-2003) and World Health Organization databases were searched for related topics. Keywords for searches included global health, tobacco, women and nursing.

FINDINGS

The epidemiology and prevalence of tobacco use among women are presented and its impact on women globally. Using an ecological perspective, the consequences of tobacco are analysed within the contexts of health, social, environment, economic and policy as it relates to women, their families and their communities.

IMPLICATIONS

Nurses are in prime positions to empower individuals, families, communities and nations in the prevention and treatment of tobacco use. Health for all women continues to be a call for equity and social justice. Recommendations are provided for nursing practice, education, theory, research and policy to address this global health concern.

The Modified Reasons for Smoking Scale: factorial structure, gender effects and relationship with nicotine dependence and smoking cessation in French smokers

AIMS

To assess the validity of the French version of the Modified Reasons for Smoking Scale (MRSS), and to identify which smoking patterns differentiate male and female smokers, which are related to tobacco dependence (as assessed by the Fagerström Test for Nicotine Dependence, FTND), to mood (Beck Depression Inventory II), to affect (Positive and Negative Affect Schedule) and which are predictors of successful quitting.

PARTICIPANTS

Three hundred and thirty smokers [(mean +/- SD) aged 40 +/- 9 years, 145 (44%) women, mean FTND score: 6.2 +/- 2], candidates for a smoking cessation programme and smoking at least 15 cigarettes/day.

FINDINGS

Factor analysis of the 21-item scale gave the optimal fit for a seven-factor model, which accounted for 62.3% of the total variance. The following factors were identified: 'addictive smoking', 'pleasure from smoking', 'tension reduction/relaxation', 'social smoking', 'stimulation', 'habit/automatism' and 'handling'. The 'addictive smoking' score increased in a dose-dependent manner with number of cigarettes smoked per day; the 'habit/automatism' score was significantly higher, with more than 20 cigarettes per day than with < or = 20 cigarettes per day. The reasons for smoking were different for males and females: females scored higher on 'tension reduction/relaxation', 'stimulation' and 'social smoking'. A high level of dependence (FTND > or = 6) was associated with significantly higher scores only on 'addictive smoking', the association being stronger in females. Time to first cigarette after awakening was associated with higher 'addictive smoking' and 'habit/automatism' (P < 0.001). In a multivariate logistic regression, failed quitting was predicted by higher habit/automatism score (odds ratio = 1.44, 95% CI = 1.06-1.95, P = 0.02) and greater number of cigarettes smoked per day (odds ratio = 1.03, 95% CI = 1.01-1.06, p = 0.03).

CONCLUSIONS

The questionnaire yielded a coherent factor structure; women smoked more for tension reduction/relaxation, stimulation and for social reasons than men; addictive smoking and automatic smoking behaviour were similar in both sexes and were associated strongly with a high level of nicotine dependence; the 'habit/automatism' score predicted failure to quit over and above cigarettes per day.

Smoking behavior and desire to quit among low-income female caregivers

The purpose of this study was to examine smoking behavior and the desire to quit among low-income women. Two hundred and eight women caregivers were surveyed about their smoking status, exposure to environmental tobacco smoke in the home, and desire to quit smoking. Most of the smokers (74%) wanted to quit smoking. With a logistic regression model, the number of years smoked was the only significant predictor variable for the dependent variable of thoughts about quitting when age, years of smoking, number of children, marital status, number of smokers in the home, cigarettes smoked per day, and money spent per week on cigarettes were entered as independent variables. The fewer years smoked the more likely the women wanted to quit.

Tobacco cessation in primary care: maximizing intervention strategies

The most effective preventive intervention that a clinician can provide for tobacco-using patients against heart disease, cancer, cerebrovascular disease and chronic obstructive pulmonary disease is an empathic, personalized smoking cessation intervention program with extended assistance and follow-up. The goal of the intervention must be complete smoking cessation. Reduction provides no direct health benefits to the individual smoker. Interventions are readily available, but underutilized, in part due to lack of clinician training and organizational support. The present article summarizes the current guidelines for smoking cessation interventions as a framework from which to start. The guidelines incorporate the Transtheoretical Model of patient behavioral change and the "Five A's": Ask, Advise, Assess, Assist and Arrange. Pharmacotherapeutic tools, including nicotine replacement therapies (nicotine gums, patches, nasal sprays, inhalers and new therapies) and non-nicotine therapies (bupropion, clonidine, nortriptyline and other antidepressants and anxiolytics) are considered. Adherence validation methods, new approaches to tobacco and addiction treatment that appear in the recent research literature are reviewed. Beyond this framework, specific categories of tobacco users (including smokeless tobacco users), cultural and ethnic minorities, adolescents using snuff and bidis, women, Medicaid recipients, and users of multiple forms of tobacco require special consideration. With this framework and the modifications that may be required for specific categories of patients, practicing clinicians can incorporate into daily practice a successful tobacco cessation intervention program with quit rates approaching 20%.

Meal patterns in male rats during and after intermittent nicotine administration

Continuous administration of nicotine (NIC) reduces food intake (FI) and body weight (BW), whereas rebound eating and BW gain occur after NIC cessation. However, generalizations derived from prior studies on meal patterns in rats using continuous 24-h NIC administration are limited, because human smokers use NIC intermittently during their active period. In the present study, computerized meal pattern analyses (MPA) were conducted for adult male rats treated for 14 days with either saline or 2 or 4 mg/kg/day of NIC spread over five equal amounts during the dark phase. MPA analyses continued for 14 days after cessation of NIC. Only the 4 mg/kg/day NIC dose caused consistent changes in meal patterns and only that dose is reported herein. Dark period FI was reduced, whereas light period FI was unchanged in the NIC-treated group; thus, there was no rebound eating during the 12-h nontreatment phase. MPA analyses revealed the FI reduction on Day 1 of NIC administration was caused by a persistent decrease in dark phase meal size. On Day 5 of NIC, the rats compensated by significantly increasing the number of meals they took, which tended to normalize dark phase FI. Congruently, dark phase intermeal interval was decreased. Importantly, these changes in meal patterns persisted for 2 weeks after termination of NIC. Upon NIC cessation, the NIC group had a transient elevated FI. The NIC-treated group's BW was significantly suppressed by Day 6 of NIC and after stoppage these rats slowly, but incompletely, regained lost BW over the next 14 days. These results document that administration of NIC during the dark phase resulted in a reorganization of the microstructure of FI in male rats and that long-lasting alterations in the microstructure of FI (e.g., meal size and meal number) were noted for up to 2 weeks after cessation of NIC. These results differ from studies in which NIC was given continuously 24-h/day and indicate that dark phase NIC administration in rats may represent an appropriate model to study the impact of NIC on meal patterns.

Applying genetic approaches to the treatment of nicotine dependence

To advance the science of tobacco control, an enhanced understanding of the bio-behavioral basis of nicotine addiction is needed. In this study, we provide an overview of data from investigations of genetic factors in smoking behavior, discuss potential bio-behavioral mechanisms and effect modifiers, and suggest avenues for pharmacogenetics research in the area of smoking cessation treatment. The evidence to date is very consistent with respect to the significance of genetic contributions to smoking behavior. However, attempts to elucidate the role of specific genetic variants have met with mixed success. Explanations for the lack of consistency in the results of genetic association studies include biases in ascertainment, ethnic admixture, lack of attention to co-variates or modifiers of genetic risk, and the need for more refined phenotypes. As the field of genetics and smoking research progresses, increasing attention is being devoted to gene-environment interactions, with particular attention to the identification of genetic variants that may modify the effects of pharmacological treatment for smoking. With advances in molecular biology and genomics technology, individualized tailoring of smoking cessation therapy to genotype is within our grasp. Such research has the potential to improve treatment outcome, thereby reducing morbidity and mortality from smoking-related disease.

Mecamylamine (Inversine): an old antihypertensive with new research directions

Mecamylamine (Inversine), the first orally available antihypertensive agent, is now rarely used. Although celebrated in the 1950s, mecamylamine fell out of favour because of its widespread ganglionic side effects at antihypertensive doses (30-90 mg/day). However, recent studies suggest that mecamylamine is very effective at relatively low doses (2.5-5 mg b.i.d.) for blocking the physiological effects of nicotine and improving abstinence rates in smoking cessation studies, particularly for women. When these lower doses of mecamylamine are given, patients do not experience the severity of side effects that made the drug unpopular for the treatment of hypertension. Tobacco smoking is a strong risk factor for cardiovascular morbidity, including accelerated atherosclerosis and increased risk of heart attacks. Though currently untested, the available evidence suggests that low-dose mecamylamine therapy might reduce blood pressure variability and atherogenetic lipid profile in smokers. With this in mind, mecamylamine should be an important research tool in the field of hypertension research, particularly in recalcitrant smokers with mild to moderate hypertension.

Smoking cessation: progress, priorities, and prospectus

The authors review developments in understanding smoking cessation interventions over the past decade. Noteworthy is the unprecedented growth of research and knowledge that has left a deeper understanding of how best to use new and existing behavioral and pharmacologic tools and strategies to help smokers quit. The status of public-health-level interventions is evaluated, questions are raised concerning their efficacy, and suggestions are offered for further refinement of these intervention strategies. Development of cessation guidelines is reviewed, and the state of knowledge concerning behavioral and pharmacologic interventions is summarized. The authors also present agendas for behavioral and pharmacologic research related to smoking cessation and discuss individual difference factors among smokers that may prove to be important in designing new and refining existing treatments.