Smoking and How to Quit Smoking

By smoking, you can cause health problems not only for yourself but also for those around you.

Hurting Yourself

Smoking is an addiction. Tobacco contains nicotine, a drug that is addictive. The nicotine, therefore, makes it very difficult (although not impossible) to quit. In fact, since the U.S. Surgeon General's 1964 report on the dangers of smoking, millions of Americans have quit. Still, approximately 484,000 deaths occur in the U.S. each year from smoking-related illnesses. This represents almost 1 out of every 5 deaths. The reason for these deaths is that smoking greatly increases the risk of getting lung cancer, heart attack, chronic lung disease, stroke, and many other cancers. Smokers die an average of 10 years earlier than nonsmokers. Smoking is the most preventable cause of death. In addition, smoking is perhaps the most preventable cause of breathing (respiratory) diseases within the USA.

Hurting Others

Smoking harms not just the smoker, but also family members, coworkers, and others who breathe the smoker's cigarette smoke, called secondhand smoke or passive smoke. Among infants up to 18 months of age, secondhand smoke is associated with as many as 300,000 cases of chronic bronchitis and pneumonia each year. In addition, secondhand smoke from a parent's cigarette increases a child's chances for middle ear problems, causes coughing and wheezing, worsens asthma, and increases an infant's risk of dying from sudden infant death syndrome (SIDS).

Smoking is also harmful to the unborn fetus. If a pregnant woman smokes, her fetus is at an increased risk of miscarriage, early delivery (prematurity), stillbirth, infant death, and low birth weight. In fact, it has been estimated that if all women quit smoking during pregnancy, about 4,000 new babies would not die each year.

Exposure to passive smoke can also cause cancer. Research has shown that non-smokers who reside with a smoker have a 24% increase in risk for developing lung cancer when compared with other non-smokers. An estimated 3,000 lung cancer deaths occur each year in the U.S. that are attributable to passive smoking, and an estimated 49,000 deaths each year in total from all smoking-related conditions occur as a result of secondhand smoke. Secondhand smoke also increases the risk of stroke and heart disease. If both parents smoke, a teenager is more than twice as likely to smoke as a teenager whose parents are both nonsmokers. Even in households where only one parent smokes, young people are more likely to start smoking.

Smoking is considered an addictive disease, which makes it much harder to quit. An addictive disease or addiction describes a persistent habit that is harmful to the person. Thus, addiction is a chronic (long-duration) disease with reliance on the substance causing the addiction. The addictive substance also causes the accompanying deterioration of a person's physical and psychological health.

Psychologically, an individual's behavior pattern establishes how the addictive substance is used. One type of behavior is compulsive behavior, which is an overwhelming and irresistible interest in the use of a substance. For example, the compulsive addict makes sure that the substance is always available. Another type of behavior is habitual behavior, which is using the substance regularly or occasionally for desirable effects. Physically, continuous use of the substance leads to dependence on the drug by the body. This dependence means that when the drug is discontinued, symptoms of withdrawal or distress occur.

Nicotine is the component of cigarettes that addicts. Almost immediately upon inhalation, the body responds to the nicotine. An individual feels relaxed, calmer, and happier than before the inhalation. These pleasant feelings reflect the physical side of addiction, but then, not smoking cigarettes causes a craving for more cigarettes, irritability, impatience, anxiety, and other unpleasant symptoms. Indeed, these symptoms are the symptoms of withdrawal from cigarettes. Moreover, with time, more and more nicotine is desired to produce favorable effects and to avoid the symptoms of withdrawal.

The signs of addiction to cigarettes include:

• Smoking more than seven cigarettes per day
• Inhaling deeply and frequently
• Smoking cigarettes containing nicotine levels of more than 0.9mg
• Smoking within 30 minutes of awakening in the morning
• Finding it difficult to eliminate the first cigarette in the morning
• Smoking frequently during the morning
• Finding it difficult to avoid smoking in smoking-restricted areas
• Needing to smoke even if sick and in bed

Quitting smoking makes a difference right away in the way you feel. You can taste and smell food better. Your breath smells better. Your cough goes away. These benefits happen for men and women of all ages, even those who are older. They happen for healthy people as well as those who already have a disease or condition caused by smoking.

Even more importantly, in the long run, quitting smoking cuts the risk of lung cancer, many other cancers (including laryngeal, oral cavity, stomach, esophageal, cervical, kidney, bladder, and colon cancers), heart disease, stroke, and other lung or breathing (respiratory) diseases (for example, chronic bronchitis, pneumonia, and emphysema). Smoking also increases the risk of peripheral vascular disease and abdominal aortic aneurysms. Moreover, ex-smokers have better health than current smokers. For example, ex-smokers have fewer days of illness, fewer health complaints, and less frequent bouts with chronic bronchitis and pneumonia than current smokers. People who quit smoking can reduce their risk of developing lung cancer or other smoking-related diseases.

Finally, quitting smoking saves money. The average cost of a pack of cigarettes is approximately $6.28 a pack (depending on where you live). A smoker with a pack-a-day habit spends approximately $44.00 per week ($2,288 per year).

First, one can do certain things to get ready to quit. Then, there are other things to do on the day of quitting. Finally, one can do things to help oneself to remain abstinent. (This is the hardest part.)

• Set a date for quitting. If possible, plan to have a friend quit smoking with you. It's best to pick a day within the next month. A date too far off in the future will give you a chance to procrastinate and postpone, while a date too soon may not allow you to make a plan for medications or support systems.
• Notice when and why you smoke. Try to find the things in your daily life that you often do while smoking (such as drinking your morning cup of coffee or driving a car).
• Change your smoking routines. Keep your cigarettes in a different place. Smoke with your other hand. Don't do anything else when you are smoking. Think about how you feel when you smoke.
• Smoke only in certain places, such as outdoors.
• When you want a cigarette, wait a few minutes. Try to think of something to do instead of smoking. For example, you might chew gum or drink a glass of water.
• Buy one pack of cigarettes at a time. Switch to a brand of cigarettes that you don't like.

• Get rid of all your cigarettes. Put away your ashtrays.
• Change your morning routine. When you eat breakfast, don't sit in the same place at the kitchen table. Stay busy.
• When you get the urge to smoke, do something else instead.
• Carry other things to put in your mouth, such as gum, hard candy, or a toothpick.
• Reward yourself at the end of the day for not smoking. See a movie or go out and enjoy your favorite meal.
• Tell your friends and family members about your decision to quit smoking, and ask for their support.

The expected consequences of quitting are irritability, difficulty concentrating, increased appetite, and of course, urges to smoke. So, if you feel more short-tempered or distracted, or sleepier than usual, don't worry because these feelings will pass.

• Try to exercise. For example, go for a walk, ride a bike, if you have access to a pool swim, or take a yoga or Pilates class.
• Consider the positive things about quitting. For example, think about how much you like yourself as a non-smoker, the health benefits for you and your family, and the example you set for others around you. A positive attitude will help you through tough times.
• When you feel tense, try to keep busy and think about ways to ease the tension. Tell yourself that smoking won't make it any better, and go do something else.
• Eat regular meals because feeling hungry is sometimes mistaken for the desire to smoke.
• Start putting the money you save by not buying cigarettes in a "money jar."
• Let others know that you have quit smoking. You will find that most people will support you. Many of your smoking friends may want to know how you quit. It's good to talk to others about your quitting. People who stay off smoking for at least one year often have very strong support from a companion or co-worker.
• If you slip up and smoke, don't be discouraged or give up and return to your smoking habit. Many former smokers have tried to quit several times before they finally succeed.

Several methods are available to assist those who decide to quit smoking. The main categories of methods are:

• Behavior modification and self help-literature to quit smoking
• Self-help literature
• Nicotine replacement therapy
• Prescription smoking cessation aids

Each method offers several different options. Moreover, combinations of methods usually are necessary, and no one combination will work for everyone. It may be necessary to try several different methods or combinations of methods before success is achieved.

Behavioral modification and self-help literature to quit smoking

Due to the addictive nature of nicotine, some form of behavioral modification is often necessary for the successful cessation of smoking. Educational programs, hypnosis, and aversion therapy (learning how to avoid cigarettes) are a few options. Smokers may be counseled to avoid specific triggers or situations that lead to smoking. For example, instead of awakening and grabbing a cigarette at the bedside or smoking immediately after a meal, people may be encouraged to replace the urge to smoke with another activity, such as, taking a walk or reading a book.

Numerous medical associations and societies, for example, the American Cancer Society, American Heart Association, and the American Lung Association have developed brochures to help smokers quit smoking.

Nicotine replacement therapy (NRT) became available over the counter in the 1990s. The purpose of nicotine replacement therapy is to substitute another source of nicotine while cigarettes are discontinued. By this means, the habit of smoking is eliminated, even though the addiction to nicotine remains intact. But at the same time, nicotine replacement therapy eliminates the symptoms of withdrawal that can trigger more smoking. In addition, behavioral counseling to change smoking-related behavior usually is necessary. Once cigarettes have been replaced during nicotine replacement therapy, the amount of nicotine is then gradually reduced.

Currently, there are different forms of nicotine replacement therapy available over the counter, including:

• nicotine transdermal systems or patches (Nicoderm CQ and Nicotrol),
• nicotine polacrilex resin or gum (Nicorette), and
• nicotine lozenges (Commit).

The nicotine patch (Nicoderm CQ and Nicotrol) contains nicotine that is stored within a specially designed support or matrix. Once applied, the nicotine transdermal system steadily releases nicotine that is absorbed across the skin and into the bloodstream. The gum contains nicotine that is released slowly upon chewing and "parking". Parking refers to the action of shifting the gum to one side of the cheek after chewing to speed up the absorption of nicotine. Nicotine lozenges contain nicotine within a hard candy that allows for a slow release of nicotine as the candy dissolves in the mouth. A program for slowly weaning users from nicotine replacement products is provided by each product's manufacturer.

The nicotine patch, Nicoderm CQ, is available in three strengths; 21, 14, and 7 mg. People are advised to begin with the 21 mg patch if they smoke more than 10 cigarettes per day or the 14 mg patch if they smoke less than 10 cigarettes per day. After six weeks of wearing the initial patch strength, the next lowest patch strength is worn for two weeks. If therapy was started with the 21 mg patch, an additional two weeks is required for the 7mg patch. A maximum of eight or 10 weeks, depending upon the strength of the first patch used, is recommended for a successful quitting program. The Nicoderm CQ patch can be worn for 16 hours (from awakening until bedtime) or 24 hours if the urge to smoke is great upon awakening.

Nicotrol is available as a 15 mg patch and should be worn no more than 16 hours per day. Nicotrol may be worn for up to six weeks.

The side effects commonly seen with patches are:

• burning,
• itching, or redness at the site of the patch,
• headache,
• insomnia,
• nervousness,
• dizziness,
• cough,
• rash,
• joint aches,
• painful menstruation, and
• changes in taste.

The gum, Nicorette, is available in a variety of flavors in 2 strengths; 4 and 2 mg. Patients are advised to begin with the 4 mg piece of gum if they smoke more than 25 cigarettes per day or the 2 mg piece if they smoke fewer than 7 cigarettes per day. No more than 20 pieces of the 4 mg strength or 30 pieces of the 2 mg strength should be chewed in one day. Initial weaning from treatment should begin after 2 to 3 months and be completed by 4 to 6 months.

The most common side effects of Nicorette gum are:

• aching jaws or soreness of the gums,
• changes in taste,
• abdominal (gastrointestinal) discomfort,
• hiccups,
• nausea,
• vomiting, and
• belching.

Commit nicotine lozenges are available in 2 or 4-mg doses. One dose consists of one lozenge, and no more than 20 doses should be consumed in one day. The manufacturers of Commit recommend choosing the proper dosage based on when you usually have the first cigarette of your day. According to the manufacturer's instructions, if you smoke within 30 minutes of getting up in the morning, you should use the stronger 4 mg dose. If not, you should use the 2 mg lozenges.

Biting or chewing nicotine lozenges instead of allowing them to dissolve can lead to indigestion or heartburn. You should not eat or drink anything while the lozenge is in your mouth. The lozenges will last for about 20-30 minutes when allowed to dissolve in the mouth.

The most commonly reported side effects of nicotine lozenges are:

• indigestion,
• throat irritation,
• soreness of the teeth or gums,
• insomnia,
• nausea,
• hiccups,
• coughing,
• heartburn,
• headache, and
• flatulence.

How effective is nicotine replacement therapy?

Approximately 25% of patients successfully stop smoking with nicotine patch therapy. The success rate with nicotine gum is similar. There have not yet been studies to compare the effectiveness of nicotine lozenges to the patch or gum. The rate of success for nicotine replacement therapy increases from 35% to 40% when intensive behavioral counseling is added.

There are products for the cessation of smoking that are available by prescription only. Nicotine for nicotine replacement therapy is available by prescription as an inhaler or nasal spray (Nicotrol Inhaler and Nicotrol NS). These other forms of delivery of nicotine seem to work as well as nicotine patches or gum. Prescription nicotine replacement products are more expensive than over-the-counter products.

Varenicline (Chantix)

Varenicline (Chantix) is a prescription drug approved by the U.S. FDA to help adults quit smoking. Chantix does not contain nicotine but is believed to act on the same receptors (the sites where nicotine acts to produce its effects) in the brain as nicotine, resulting in activation (stimulation) of these receptors and blocking the ability of nicotine to attach to these receptors. Chantix should be taken seven days before the date the individual desires to quit smoking, and most people will keep taking Chantix for up to 12 weeks.

Side effects of the Chantix may include:

• nausea,
• vomiting,
• gas,
• constipation, and
• changes in dreaming.

Chantix is not appropriate for use by pregnant and breastfeeding women and people with certain chronic medical conditions.

bupropion (Zyban)

Bupropion (Zyban) is a medication that is used primarily for treating depression. This drug, however, also is effective in helping people to quit smoking and has been approved by the U.S. FDA for use in smoking cessation in adults.

Other agents that have been tried for cessation of smoking include serotonin reuptake antagonists (drugs also used for depression) and the anti-hypertensive drugs clonidine (Catapres) and calcium channel blockers. Although these agents appear to be less effective than nicotine replacement therapy, they may be effective for some people.

Users of nicotine-containing products should understand that all of these products have side effects as well as effects on other underlying medical conditions such as diabetes, high blood pressure, asthma, and heart disease. Furthermore, these products can have interactions with other prescribed medications such as pain relievers, blood thinners, and high blood pressure medications. And finally, they do have their limitations.

The following guidelines are to help you safely use these products to achieve your goal of quitting smoking.

1. Always read the labels and know the ingredients in the products. Never take more than the recommended dose without checking with your doctor first.
2. If you are pregnant or nursing a baby, seek the advice of a health professional before using any nicotine-containing product.
3. Do not use a nicotine-containing product if you continue to smoke, chew tobacco, or use snuff, or other nicotine-containing products.
4. Consult a physician before using nicotine-containing products if you are under 18 years of age and:
   • Have heart disease, an irregular heartbeat, or have had a recent heart attack (Nicotine can increase your heart rate.)
   • Have high blood pressure that is not controlled with medication (Nicotine can increase your blood pressure.)
   • Have a history of, or currently have, inflammation of the esophagus (esophagitis) or ulcers of the stomach or duodenum (peptic ulcer disease)
   • Take insulin for diabetes.
   • Take any prescription medications (Nicotine interacts with some medications, such as aspirin, some medications for the heart, and female hormones to decrease their levels in the blood.)
   • Have a skin disorder, such as dermatitis, which may increase the likelihood of skin reactions by the skin to the patch
5. People should stop using nicotine-containing products and see their physician if they have or develop:
   • Mouth, tooth, or jaw problems (applies to Nicorette gum)
   • Irregular heartbeats or palpitations
   • Symptoms of nicotine overdose, such as nausea, vomiting, dizziness, weakness, and rapid heartbeat
   • Severe rash, redness, swelling, burning, or itching at the site of the patch

e-Cigarettes are smokable, refillable containers or cartridges that contain fluid consisting of solvents, flavors, and varying amounts of nicotine. Inhaling from the devices is known as "vaping." Negative pressure on the cartridge created by inhaling triggers a battery-powered heating and vaporization of the solution. The composition of the fluid in e-cigarettes varies depending on the manufacturer.

There is little scientific information that determines how safe or unsafe e-cigarettes may be. Nicotine in any form is known to be addictive, and nicotine addiction can develop from using e-cigarettes. Nicotine has been shown to cause adverse health effects including:

• nausea,
• vomiting,
• abdominal pain, and
• eye irritation.

More serious effects can occur with high doses of nicotine, such as:

• increased heart rate,
• high blood pressure,
• seizures,
• coma, and
• even death.

The U.S. Food and Drug Administration has reported that cancer-causing nitrosamines have been detected in some e-cigarettes. Further, poison centers have reported numerous cases of poisoning of small children from consuming the liquid in the cartridges of e-cigarettes.

e-Cigarettes expel vapors that contain nicotine, which is known to be addictive. Depending on the composition of the fluid in the cartridge, nitrosamines or other dangerous chemicals may also be expelled. It is not known at this time how significant the risk is to the health of those who breathe secondhand vapors from e-cigarettes.

Are e-cigarettes safe to use during pregnancy?

Little is known about the long-term health effects of e-cigarettes, but nicotine is harmful to the developing fetus. Nicotine narrows blood vessels and interferes with the circulation of blood to the fetus. It can interfere with the development of the fetal brain and may harm fetal lung function. It also increases the risk of sudden infant death syndrome (SIDS). Doctors recommend that pregnant women abstain from both smoking and e-cigarette use.

Healthcare workers have become extremely active in publicizing the negative effects of smoking. Healthcare workers have been instrumental in passing various legislation to limit smoking in public. As a result, the proportion of people in the US who smoke has dropped from 40.4% in 1965 to around 17% in 2013 (data from the U.S. Department of Health).

This reduction in the percentage of people who smoke has been significantly less in women than in men. From 1965 to 2010, smoking among men dropped from 50.2% to 20.5% while during the same period, smoking among women dropped from 31.9% to 15.3%. So, in the future, efforts need to be made to understand and eliminate this difference between the genders.

One interesting area of the current research on smoking is the study of the population distribution of the genes for smoking (genetic epidemiology). (Genes determine an individual's inherited characteristics.) Only a small fraction of individuals who start smoking as an adolescent will become nicotine dependent. So, what determines which individuals will become nicotine-dependent? Investigators have found that smoking initiation (the obligatory first step) and the development of nicotine dependence are both influenced by genetic factors. Genetic factors appear to play a larger role in nicotine dependence than in smoking initiation. The next step will be to identify these genes and learn how they work to facilitate the development of effective prevention and treatment strategies for tobacco addiction.

Teen smoking rates remain of concern. In 2011 19% of high school girls and 28% of boys had used some form of tobacco in the prior month. According to the American Cancer Society, the majority of cigarette use (almost 90% of people who smoke) begins before a person reaches 18 years of age. Very few people start smoking after the age of 25. Statistics show that 99% of adult smokers had started by age 26. Education of the at-risk teen population is therefore critical for the prevention of tobacco use. Various celebrities and activist groups actively promote campaigns aimed at a teen audience that educate about the consequences of smoking and offer advice on smoking cessation and prevention. While teen smoking rates increased during the 1990s (36% of teens smoked in 1997), prevention and education campaigns have brought about a decrease in teen smoking in recent years.