Stopping Smoking

Stopping smoking — the cessation of tobacco use — is a clinical intervention for Tobacco Use Disorder, a DSM-5-TR substance use disorder. Effective evidence-based treatments include nicotine replacement therapy, varenicline, bupropion, and behavioural counselling.

Overview

Smoking cessation is the clinical intervention for Tobacco Use Disorder (DSM-5-TR 305.1), a substance use disorder characterized by problematic use of tobacco leading to clinically significant impairment or distress. Tobacco remains the leading preventable cause of death in Canada and globally, despite substantial declines in smoking prevalence over the past several decades. Approximately 12-15% of Canadian adults currently smoke; lifetime tobacco use disorder is approximately 25-30% of adults.

Smoking causes or contributes to multiple cancers (lung, throat, mouth, esophagus, bladder, kidney, pancreas, cervix, others), cardiovascular disease (coronary artery disease, stroke, peripheral vascular disease), respiratory disease (COPD, emphysema, chronic bronchitis), and diabetes complications. The 2014 U.S. Surgeon General’s Report estimated that smoking kills more than 16 million Americans prematurely; in Canada, smoking-attributable mortality is approximately 45,000 deaths per year.

Despite popular perception that “smokers want to quit,” approximately 70% of current smokers report wanting to quit and approximately 50% attempt to quit each year. The challenge is sustained cessation: most quit attempts (without treatment) fail within days to weeks. Effective evidence-based treatment substantially improves cessation success; 6- and 12-month abstinence rates with combined pharmacotherapy and behavioural support are 25-40%, vs 3-5% for unaided quit attempts.

The clinical condition extends beyond combustible cigarettes to include cigars, pipe tobacco, smokeless tobacco (chewing tobacco, snus), and electronic nicotine delivery systems (e-cigarettes, vapes). Vaping has substantially expanded nicotine exposure, particularly among adolescents and young adults; vaping cessation is a growing clinical concern with treatment approaches similar to traditional smoking cessation.

Smoking cessation is highly effective when evidence-based treatment is provided. The U.S. Public Health Service Clinical Practice Guideline (Fiore et al., 2008) and the Canadian guidelines from the Canadian Task Force on Preventive Health Care recommend that all smokers receive evidence-based cessation counselling and pharmacotherapy. Combined treatment outperforms either alone.

Signs and symptoms

Tobacco use in larger amounts or longer than intended — Smoking more cigarettes per day or for more years than intended.
Unsuccessful efforts to cut down or quit — Persistent desire or unsuccessful efforts to cut down or control tobacco use.
Significant time spent on tobacco-related activities — Time spent obtaining, using, or recovering from tobacco use.
Craving — Persistent strong desire or urge to use tobacco; cravings often triggered by specific contexts (after meals, with coffee, during stress, with alcohol).
Recurrent use despite role obligations failure — Tobacco use that interferes with major obligations or impacts performance.
Continued use despite social or interpersonal problems — Continued use despite family pressure, social restrictions, or relational consequences.
Activities given up — Important social or occupational activities limited by smoking restrictions.
Use in physically hazardous situations — Smoking despite physical health conditions worsened by it (cardiovascular disease, COPD, post-surgical recovery).
Tolerance — Need for more cigarettes per day or higher-nicotine products to achieve previous effect.
Withdrawal symptoms — Characteristic nicotine withdrawal — irritability, anxiety, difficulty concentrating, increased appetite, insomnia, restlessness, depressed mood — peaking 1-3 days after cessation and gradually resolving over 2-4 weeks.

Diagnostic context

The DSM-5-TR criteria for Tobacco Use Disorder (305.1) are consistent with other substance use disorders: a problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least 2 of 11 criteria within a 12-month period (impaired control, social impairment, risky use, pharmacological features).

Severity: mild (2-3 criteria), moderate (4-5), severe (6+). Specify if in early remission (3-12 months without meeting criteria) or sustained remission (12+ months). Specify if on maintenance therapy (e.g., nicotine replacement) or in a controlled environment.

Tobacco Withdrawal (292.0) is a separate DSM-5-TR diagnosis for the characteristic withdrawal syndrome following cessation of heavy and prolonged tobacco use, including: irritability, anxiety, difficulty concentrating, increased appetite, restlessness, depressed mood, insomnia. Onset within 24 hours of abrupt cessation; symptoms typically peak at 1-3 days and resolve over 2-4 weeks.

Differential diagnosis is rarely complex; the clinical question is usually severity assessment and treatment planning. Validated assessment instruments include the Fagerström Test for Nicotine Dependence (FTND), Heaviness of Smoking Index, and DSM-5 criteria-based interview.

Causes and risk factors

Tobacco Use Disorder develops through interacting biological, psychological, and social factors:

Genetic factors: heritability of nicotine dependence is approximately 50%. Multiple variants in nicotinic acetylcholine receptor genes (CHRNA5, CHRNA3, CHRNB4) and metabolism genes (CYP2A6) influence both initiation and persistence.

Neurobiological factors: nicotine activates nicotinic acetylcholine receptors in the mesolimbic dopamine system, producing reward, alertness, and mood effects. Repeated exposure produces neuroplastic changes contributing to tolerance, withdrawal, and craving.

Developmental factors: early initiation (adolescence) substantially elevates lifetime dependence risk. Adolescent brain is particularly vulnerable to nicotine effects on attention, learning, and addictive vulnerability.

Psychological factors: tobacco use is over-represented in individuals with mental-health conditions. Approximately 40-50% of all cigarettes in North America are smoked by individuals with mental illness. Comorbid conditions include schizophrenia (50-70% smoking rates), bipolar disorder, depression, anxiety disorders, ADHD, and substance use disorders.

Social and environmental factors: family smoking, peer smoking, marketing exposure, neighbourhood disorder, lower socioeconomic status, and cultural acceptability all influence initiation and persistence. Tobacco industry marketing has historically targeted vulnerable populations.

Comorbidity: co-occurring alcohol use disorder, other SUDs, anxiety, depression, and severe mental illness are extremely common. People with mental illness who smoke are not less interested in quitting than the general population, but face additional barriers.

Vaping considerations: e-cigarettes deliver nicotine without combustion products and are associated with reduced harm compared to cigarettes when used as cessation tools. However, vaping has substantially expanded nicotine initiation among adolescents and non-smokers, including significant numbers who progress to nicotine dependence.

Typical treatments

Effective smoking cessation typically combines pharmacotherapy and behavioural support:

Nicotine Replacement Therapy (NRT): available without prescription in patches, gum, lozenges, inhalers, and nasal spray. Combination NRT (long-acting patch + short-acting form for cravings) is more effective than either alone. Substantially improves cessation rates.

Varenicline (Champix in Canada): partial nicotinic receptor agonist. Most effective single pharmacotherapy in head-to-head trials. Standard 12-week course; extended treatment supported for selected patients.

Bupropion (Zyban): atypical antidepressant with cessation efficacy. Useful particularly when comorbid depression is present.

Combination pharmacotherapy: varenicline + NRT, or bupropion + NRT, can outperform either alone in selected cases. Decisions are individualized.

behavioural counselling:

Brief counselling (3-10 minutes) by primary care or other clinicians substantially improves cessation rates.
Intensive counselling (multiple sessions, individual or group) further improves outcomes.
Telephone quitlines (1-866-366-3667 in Canada) provide free counselling.
Text-messaging programs (SmokefreeTXT and equivalents) provide ongoing support.
Cognitive behavioural Therapy addresses smoking-related cognitions, triggers, and coping strategies.
Motivational interviewing supports readiness building.

Vaping as cessation aid: emerging evidence supports e-cigarettes as effective cessation aids, particularly when combined with behavioural support. The British medical establishment and Canadian harm-reduction advocates support vaping for cessation; the American medical establishment is more cautious due to youth vaping concerns. Vaping-as-cessation requires planning for eventual vaping discontinuation to achieve nicotine-free recovery.

Treatment of comorbidity: concurrent treatment of mood, anxiety, psychotic, and substance use disorders supports cessation. Smoking cessation does not destabilize most psychiatric conditions; common belief that “patients with mental illness need to smoke” is contradicted by research.

Maintenance and relapse prevention: sustained pharmacotherapy (3-6 months minimum), continued behavioural support, and addressing high-risk situations all support sustained cessation. Many quit attempts are needed before sustained cessation; each attempt is opportunity for learning.

When to seek help

Clinical support is indicated when:

You smoke and are considering quitting — even brief clinical intervention substantially improves cessation chances.
You have tried to quit without success.
You have health conditions that would benefit from cessation (cardiovascular disease, COPD, cancer, pregnancy planning, surgical recovery).
You experience severe withdrawal symptoms when attempting to quit.
You have comorbid mental-health conditions and want integrated cessation support.
You are vaping and want to stop nicotine altogether.
You are pregnant or planning pregnancy — cessation has substantial benefits for both parent and infant.

Free Canadian smoking cessation resources:

1-866-366-3667 — Smokers’ Helpline (free counselling, 24/7 in some provinces; provincial variations).
Provincial quit programs (AlbertaQuits, Smokers’ Helpline Ontario, others) — free counselling, NRT in many provinces.
SmokersHelpline.ca — online support, chat, text messaging, and resources.
Canadian Task Force on Preventive Health Care recommends every clinician offer brief cessation advice to all smoking patients.

Frequently asked questions

How many quit attempts does it take?

Average is 6-30+ attempts before sustained cessation. Each attempt is a learning opportunity; relapse is common and not a sign of failure. With each attempt, you build experience with what works for you.

Is nicotine replacement just trading one addiction for another?

No. NRT delivers nicotine without combustion products, at lower and more stable levels than smoking. NRT is effective at reducing withdrawal and craving, supports cessation, and is dramatically safer than continued smoking. NRT itself produces low rates of dependence and is appropriate for short or extended use.

Are e-cigarettes a good way to quit?

Emerging evidence supports e-cigarettes as effective cessation aids when combined with behavioural support. The British medical establishment supports their use for cessation; the American establishment is more cautious due to youth vaping concerns. Decisions are individualized; the goal is typically eventual nicotine-free recovery.

Will I gain weight if I quit smoking?

Some weight gain (typically 5-10 pounds) is common in the first year after cessation. The health benefits of cessation substantially outweigh the weight gain. behavioural strategies (exercise, dietary attention, gradual approach) can minimize weight gain. Medications (varenicline, bupropion) modestly reduce weight gain compared to NRT alone.

Can I cut down rather than quit?

Cutting down has limited health benefits compared to quitting and most reduction attempts return to baseline within months. Most clinicians recommend quit attempts rather than reduction goals, with NRT/medication support to make the transition more achievable.

What if I have a mental illness?

You can quit. People with mental illness who smoke are as interested in quitting as others, and cessation does not destabilize most psychiatric conditions. Specialized cessation programs for mental illness exist; varenicline, bupropion, and combination NRT are all appropriate. Coordinate with your psychiatric prescriber.

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). APA.
Fiore, M. C., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services.
Cahill, K., et al. (2013). Pharmacological interventions for smoking cessation: An overview and network meta-analysis. Cochrane Database of Systematic Reviews, 5, CD009329.
U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking — 50 Years of Progress: A Report of the Surgeon General.
Canadian Task Force on Preventive Health Care. (2017). Recommendations on behavioural interventions for the prevention and treatment of cigarette smoking. CMAJ, 189(8), E290–E296.

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The ShiftGrit Clinical Editorial Team combines the insight of registered psychologists, provisional psychologists, and trained writers to create accessible, evidence-informed therapy resources. All content is clinically reviewed by a Registered Psychologist.