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Journal of Pulmonology

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Gholamreza Heydari MD, MPH, PhD1*, Mohsen Roshanpajouh MD2, Mehri Amiri PhD Candidate2 and Behroz Almasinia1
1 Tobacco Prevention and Control Research Center (TPCRC), National Research Institute of TB and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 State Welfare Organization, Tehran, Iran
*Correspondence: Dr. Gholamreza Heydari, MD, MPH, PhD, Tobacco Prevention and Control Research Center (TPCRC), National Research Institute of TB and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran, Tel: 009821-26106003, Email: [email protected]

Received Date: Nov 01, 2017 / Accepted Date: Dec 14, 2018 / Published Date: Dec 21, 2018

This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (, which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact [email protected]


 OBJECTIVES: Providing smoking cessation services is of special importance to the tobacco control programs. To date, several smoking cessation techniques such as group counseling and use of nicotine gums have been employed nationally. However, the efficacy of nicotine patches has not been evaluated and no specific duration is specified for their use. METHODS: This was a cross sectional study of merging quit smoking intervention with behavioral therapy and medication in 24 drug abuse treatment centers at welfare organization in 6 districts of Iran in 2017. Subjects were visited by a physician for 3 times and were followed up by phone and through regular visits to the clinic at 3, 6 and 12 months post- intervention. RESULTS: A total of 227 smokers including 133 males (58.4%) with a mean age of 43.1 ± 12.9 years were enrolled among which 116 (51.1%), 89 (43.6%) and 34 (20.6%) smokers quit smoking after 2, 6 and 12 months, respectively. Quit rate was significantly higher among those who used medication for more than 6 weeks and this rate was not correlated with age, sex, educational level or nicotine dependence. Also, 189 subjects (83.2%) were completely satisfied with the treatment protocol. CONCLUSION: Long-term smoking cessation medication increases the quitting success rate.


Smoking; Quit; Drug abuse

In the current year, tobacco consumption has resulted in death of more than 5 million people and the rate of morbidity and mortality is expected to exceed 8 million annually by the year 2030 [1].

More than a billion people worldwide are addicted to tobacco products. Many of these people would like to quit but unfortunately only a small number of them can benefit from assistance in this respect. Thus, authorities in different countries are responsible for providing low-cost and cost-effective interventions and quit programs to help smokers stop smoking [2].

As for any kind of addictive substance, quitting smoking without any outside assistance can be difficult for the majority of smokers. It would be preferred if they overcome their nicotine dependence with the help of their quitting counselor [3].

Treatment of nicotine dependence is among the main responsibilities of health care systems worldwide. Several techniques such as a simple medical consultation, pharmaceutical therapy and over the phone counseling via quit-line have been suggested for this purpose. Repeated consultations during medical visits emphasize the necessity of quitting smoking [4,5]. Over the past two decades the demographics of drug abuse in the Islamic Republic of Iran have been similarly changing. Whereas the average age of addiction used to fall between 25 and 29 years, that figure is now between 10 and 19 years [6]. Today, the average drug abuser is younger and less financially stable. Couple this trend with an overall younger population in the Islamic Republic of Iran and the number of drug abusers is burgeoning. The behavioral connections between smoking and drug use become important as the mean age of introduction for tobacco and narcotics converge. The intersection of these “dual addictions” is particularly problematic for Iranian health officials. Tobacco usage is very common among those addicted to drugs and especially among opiate abusers, who constitute the majority of the Islamic Republic of Iran’s addict population. Among this group 60% to 90% are smokers [7,8]. People from all over the country should have the opportunity to use quit-lines. Expert counselors should be available to assist smokers in quitting via the quit-line. These services are cheap, easily accessible, and confidential and can be accessed at any time since many smokers are not free or interested to call during business hours [9,10].

Aside from medical consultations and quit-lines, an efficient nicotine dependence treatment may include medication in the form of skin patches, lozenges, nicotine gums or nasal inhaler. Nicotine replacement drugs can easily be purchased over the counter and do not require a prescription. Medication decreases the signs and symptoms of nicotine withdrawal syndrome and somehow replaces the nicotine received from smoking [11,12].

Due to had many study on different topic of quit smoking in Iran [13-19] the aim of this study was to present efficacy of merging smoking cessation with drug abuse treatment nationally for the first time in Iran.


This was a cross-sectional study was done from 2015 to 2016. After having a memorandum between Tobacco Prevention and Control Research Center and State Welfare Organization in 2015 it was appointed in the first phase to choose seven provinces of Tehran, Eastern Azerbayjan, Razavi Khorasan, Isfahan, Fars and Mazandaran for necessary trainings and starting to give smoking cessation services in substance abuse treatment centers. From each province four centers were chosen including two outpatient centers and two inpatient centers. Besides, 24 persons including both physicians and health care workers were chosen to take the related training courses and treatment guidelines. These centers have provided the services since the beginning of June 2016 and all the new clients of substance abuse treatment were entered the survey. Clients with substance abuse treatment were entered the survey. Clients with severe psychotic disorders and having no family and specific address were omitted. All services were given free of charge including visit, assessment of tobacco smoking and its history, behavioral consultation and guidance to use nicotinic and non-nicotinic medications. Of course, the State Welfare Organization dedicated some financial aids to these centers.


A total of 227 subjects participated in this study out of which 133 (58.4%) were males. The mean age of subjects was 43.1 ± 12.9 years (range 18-86 yrs.). In terms of level of education, 96 subjects (42%) had a bachelors or higher degree. The average smoking experience was 21.6 ± 11 years (range 2 to 60 years). They gained a mean score of 5.5 ± 2.8 (range 0 to 10) in Fagerstrom nicotine dependence test and a mean score of 27.5 ± 12.8 (range 6-94) in exhaled CO test. Successful quit rate was 51.1% (116 individuals) at 2 months, 43.6% (89 individuals) at 6 months and 20.6% (34 subjects) at 12 months.

Subjects were divided into 3 groups based on the duration of medication. Table 1 shows the data for independent variables and the significant differences between the 3 groups in these variables.

Group 1 2 3 Sig
Duration of medication Up to 3 weeks 3 to 6 weeks More than
6 weeks
Number Percentage Number Percentage Number Percentage
Gender Male 41 30.8   41 30.8 51 38.3 0.08*
Female 35 37.2 36 38.3 23
Age Mean 44.1 41.7 43.6 0.4+
Level of education Below high school diploma 16 25 23 35.9 25 39.1 0.17*
High school diploma 28   41.8 24  35.8 15  22.4
Bachelors or higher 32 33.3 30 31.2 34  35.4
Years of Smoking Mean 21.9 21.4 21.5 0.94+
Years of drug abuse Mean 17.1 16.8 17.3 0.91+
Nicotine dependence Mean 5.7 5 5.8 0.16+

Table 1: Comparison of the independent variables between the 3 groups based on the duration of nicotine patch therapy, Tehran 2012

Table 2 shows the quit outcome at 6 and 12-month follow ups in the 3 groups. In group 3 quit rate at 2, 6 and 12 months was 64.8% (48 from 74 subjects) 62.6% (42 from 67 subjects) 37% (20 from 54 subjects) respectively higher than two other group significantly. (P<0.000)

Second month
Variables Group 1 Group 2 Group 3 Total
Up to 3 weeks  3 to 6 weeks  More than 6 weeks
Number Percentage Number Percentage Number Percentage Number Percentage
Quit 17 14.7 51 44 48 41.8 116 100
Consumption 59 53.2 26 23.4 26 23.7 111 100
Total 76 33.5 77 33.9 74 32.6 227 100
Sixth month
Quit 12 13.5 35 39.3 42 47.2 89 100
Consumption 56 48.7 34 29.6 25 21.7 115 100
Total 68 33.3 69 33.8 67 32.8 204 100
Twelfth month
Quit 2 5.9 12 35.3 20 58.8 34 100
Consumption 53 40.5 44 33.6 34 26 131 100
Total 55 33.3 56 33.9 54 32.7 165 100

Table 2: Frequency of quitting at 2, 6 and 12 months among smokers presenting to the smoking cessation clinic based on the duration of medication

Chi square test failed to find a statistically significant difference in frequency of quitting between males and females and subjects of different educational levels. Independent t-test did not show a significant correlation between frequency of quitting and age. In questioning, 189 of the subjects (83.2%) gave a score greater than 7 (from a 0 to 10 scale) and no significant difference was detected based on this score using the ANOVA and Tukey’s test between the 3 groups or the chi square test between subjects in terms of quitting.


Our experience herein was merging smoking cessation course with the State Welfare’s program which was happening for the first time across the nation. This study showed that patients and their families were satisfied of simultaneous cessation of smoking and opium and also it caused some reduction in substance abuse and relapse.

Nicotine dependence is a clear sign of addiction to smoking and Medication is a standard pharmaceutical treatment for smoking cessation. This treatment aims at replacing the nicotine received through smoking and thus, decreases the withdrawal syndrome signs and symptoms during abstinence [20-23]. A meta-analysis showed that NRT helps smokers quit smoking and demonstrated a 7% increase in quit rate after 6 to 12 months as the result of 3 months use of NRT. By adding behavioral support programs, this rate further increased by 7% to 8%. The prescribed dosage of NRT depends on the rate of nicotine dependence. Usually, its consumption is allowed only for a limited period of time. However, in case of continuation of nicotine dependence, its usage can be extended by 3 months or longer [24].

This study revealed that about half the subjects were able to successfully quit smoking during the 2nd month of treatment but this rate reduced to 20% one year later. Relapse after quitting is a common occurrence which usually occurs during the first year of abstinence as mentioned in many studies [25]. Relapse mostly occurs within the first 6 months and specifically in the first month after quitting [26]. However, in the present study, a significant difference in this respect was observed in the second 6 months after quitting. This finding can be further evaluated in future studies.


An important finding of the present study was the high quit success rate and continued abstinence in smokers who used more nicotine patches. This finding has also been mentioned by Tonnessen et al. [27] and should be taken into consideration by the authorities in tobacco control programs. Smokers who use NRT should be advised to use nicotine patches for longer periods of time. This issue was also mentioned in many other studies like the one by Shiffman et al. [28] who used other forms of NRTs. NRT for 6 to 8 weeks or up to 12 weeks in some cases has been specifically recommended.

Many documents in Iran show that tobacco control program are acceptable and many smoking cessation methods are available [13-19] but this experience about merging smoking cessation with drug abuse treatment is newly coming and may have effective outcomes in future.

Another important issue in the present study was the high acceptability rate of this treatment modality among participants since more than 80% of them were satisfied with the treatment method and this issue can be a subject of discussion for future studies. Long-term medication improves the success rate of quitting.

What Dose Paper Adds?

Medication along with brief advice from a physician on quitting is usually accepted by the smokers. Longer use of medication results in better quit outcomes. The free of charge or low cost of medications is important for patients.


GH had the original idea, designed the study and outlined the first draft of the manuscript. MR, MA and BA contributed to revision of the article for important intellectual content, English editing and final approval.