Smoking Cessation – Quit Smoking

Stop smoking

Summary

Quitting smoking is not easy, but more than a million Americans find a way to do it every year. Once they have joined the 50 percent of adult smokers who have quit, they can enjoy all the benefits of being an ex-smoker, including:

  • Dramatically reduced risk of heart attack, stroke, chronic obstructive pulmonary disease, lung cancer and several other health problems
  • Fresher breath
  • Cleaner teeth
  • Fresh-smelling clothes, homes and cars
  • Renewed senses of taste and smell
  • Freedom from smoker’s cough
  • Freedom from shortness of breath
  • Money saved from not buying tobacco products

The key to quitting is preparation. Unless fully prepared, many people are unable to stay smoke-free. Preparation begins with a firm commitment to quit smoking. People usually make this decision because they fear the deadly effects of smoking. Once they have made this decision, they should pick a date to quit and then talk with their physician about smoking cessation strategies and aids, such as nicotine replacement therapy. Smokers should not get discouraged if their first attempt at quitting is unsuccessful. It often takes more than one try.  Above all, people are urged to quit for good.

Deciding to quit smoking

The first step in quitting smoking for good is to make a firm decision to quit. Experts believe that fear is the main reason why people choose to quit smoking. When a physician stands before a patient and clearly states the connection between the patient’s smoking and a definitely shortened life, that patient’s fear of death, disability and pain makes him or her more likely to quit smoking. Other factors that influence individuals to quit smoking include the health of others (e.g., from secondhand smoke) and setting a good example to children.

Quitting is not easy because nicotine is a highly addictive drug. Smokers become physically and psychologically dependent on nicotine, making it incredibly hard to quit the habit. The average person tries to quit five to eight times before succeeding. Therefore, it is often helpful to remember what is at stake when going through the quitting process. Strategies include:

  • Recording the physician stating the consequences of smoking, then playing it back to renew one’s commitment to quit.

  • Recording a TV health special that shows in full-color detail what years of smoking can do to the human body. When individuals consider picking up a cigarette, watching it can help motivate the person.

  • Writing large signs to keep the process in perspective, and keeping the signs in clear view (e.g., the office or on the refrigerator). An example of a sign might be, “What would you rather do smoke or breathe?” Another sign might be, “What would you rather do smoke or watch your grandchildren grow up?”

  • Taping frightening test results to the refrigerator or the desk.

  • Spending a few minutes with a smoker who has had a heart attack, stroke or cancer.

  • Spending time with someone who is on oxygen-replacement therapy for emphysema or who has lung cancer.

  • Keeping a photograph of loved ones in view, remembering how all of them are affected by the choice to smoke. Smokers not only set a bad example but they also affect others with secondhand smoke. Research has shown that secondhand smoke causes thousands of deaths each year in nonsmokers from lung cancer and heart disease. Families may also be affected by the financial burden of a smoking addiction – the average smoker spends more than $1,000 in cigarettes every year. In addition, health and life insurance rates are often significantly higher for smokers that nonsmokers.

  • Keeping a list of the benefits of quitting: feeling of success, better-tasting food, better-smelling home and car, no more smoker’s cough, less shortness of breath, more money to spend elsewhere and so forth. People who are afraid of gaining weight should know that, according to recent studies, people usually shed the few extra pounds that they typically gain when quitting, and can avoid weight gain if they choose to exercise and to eat a heart-healthy diet while quitting.

The mind can play tricks on people, especially when it comes to denial. Even when the scientific evidence is overwhelming that everyone should quit any type of smoking completely, the mind can always think of excuses for why this is not a good time to quit. The biggest excuse is that someone is too busy, too stressed and has too much going on to think about quitting. Other people do not want to experience the side effects of quitting, such as depression, anxiety or weight gain. It is easy to procrastinate when it comes to taking care of oneself. In order to make a firm decision about beginning the process immediately, people are encouraged to ask themselves: “If not now, when?”

People are also strongly encouraged to read information such as this article in order to know exactly what to expect, and what resources and tools are available to help. Making the decision to stop smoking is one of the best steps for leading a healthier life.

Aids to quit smoking

Attempts to quit smoking often fail because the person is not adequately prepared. Preparation is essential and should not be rushed. There are a number of strategies that can be pursued when one is preparing to quit. These include:

  • Choosing a quitting date and marking it on the calendar.
  • Switching to a less appealing brand of cigarettes, particularly one that is “light” or has less tar. However, it should be noted that there is no “safe” cigarette and this move should be a temporary step towards quitting altogether.
  • Talking to one’s physician about nicotine replacement therapy (NRT) or other smoking cessation aids.
  • Telling people about quitting. Seek support from family, friends and the community.
  • Identifying situations where one is more likely to want a cigarette (e.g., a party or a coffee break), and planning ahead for these situations.
  • Buying healthy snacks for the home or office that one can “munch” on (e.g., carrot sticks, celery sticks, grapes, raisins, apple slices and so forth).
  • Collecting cigarette butts in a see-through container, such as a two-liter plastic soda bottle with the label removed.
  • Scheduling a dental appointment to have the tobacco stains removed from the teeth.

After making the firm decision to quit smoking, people are encouraged to choose a quitting date. One suggestion is to set the date on a Sunday or Monday because people will need time off on the previous day to make some important changes (as discussed later in this article). Because smoking is often associated with parties and socializing, it is recommended that people avoid setting a quitting date during the holiday season or any other day normally associated with social smoking. However, choosing the birthday of one’s child or spouse may be appropriate if a small family celebration is planned. Also, choosing the Sunday or Monday of a one-week vacation is popular because it may be easier to quit while away from the office, and it is easier to quit when having fun.

After choosing a quitting date, people are encouraged to switch to a different brand of cigarettes that is not as fulfilling as the brand they are currently smoking. For example, they may switch to a “light” cigarette or a cigarette that does not have quite the same flavor as their favorite brand. Although this will not decrease their physical addiction to nicotine, it may help break some of the habits related to smoking: buying that brand, opening that package, pulling a certain-looking cigarette out of a full package and so forth. Research has shown that people who switched to “light” cigarettes were more likely to quit completely within the year. However, people need to avoid the temptation to smoke more often or more deeply after switching to a “lighter” brand. They are still dangerous and quitting completely is the only way to significantly improve a person’s health when it comes to tobacco.

Before quitting, it may be helpful to gradually reduce the number of cigarettes smoked each day. This will begin to prepare the body for reduced nicotine levels and may make it easier to sustain quitting.

A recent study revealed that smokers were eager to enlist the help of their physician in kicking the habit. The study refuted beliefs among many physicians that smokers did not want their doctors to intervene. More promising, however, were the results of the cessation programs. More than 75 percent of the participants freely chose counseling in addition to nicotine replacement therapy. The study clearly showed that physicians have a crucial role to play in helping people overcome nicotine addiction.

Nicotine replacement therapy is designed to deliver decreasing amounts of nicotine in a safe, nonaddictive form to help people quit smoking. There are numerous types of NRT products approved by the U.S. Food and Drug Administration (FDA). Smokers are encouraged to talk with their physician about these products, which include:

  • Nicotine inhaler. Available only by prescription, this is a small plastic device shaped like a cigarette that is filled with a replaceable cartridge containing nicotine and menthol. People can puff on it to reduce strong cravings for nicotine, because it delivers relatively safe doses of nicotine primarily into the mouth instead of the lungs.

    The nicotine inhaler has proven quite successful for short-term temptations when other long-term strategies are already in place. However, it should not be used right after someone has had a heart attack, and may not be appropriate for someone with either coronary artery disease or abnormal heart rhythms (arrhythmias). Most people will be prescribed 6 to 16 cartridges a day, for up to 6 months.  The most common side effects associated with inhalers inlude mouth and throat irritation, coughing and nausea.
  • Nicotine gum. Available over the counter, the gum comes in 2 miligram (mg) or 4 mg strengths. Individuals should chew the gum for 20 to 30 minutes to reduce their cravings for nicotine, if they were not heavy smokers. Heavy (“chain”) smokers who tend to smoke immediately upon waking might benefit more from either the 4-milligram dose or the nicotine patch. People should not chew more than 20 pieces per day and it is typically not recommended for longer than six months.

    The gum is chewed slightly differently than other types of gum, which could take some time to get used to. People who do not like the peppery taste can also choose a Food and Drug Administration (FDA)-approved nicotine gum in mint flavor. Mild side effects mouth sores, throat irritation, upset stomach and jaw discomfort. One disadvantage to nicotine gum is the potential for long-term dependence on the product. Studies have shown that 15 to 20 percent of people who successfully quit smoking continued to chew the gum for one year or longer. Using nicotine gum for an extended period of time is better than returning to smoking, however, the effects of long-term use needs additional research.
  • Nicotine patch. Available with or without a prescription, the nicotine patch painlessly delivers nicotine through the skin and into the bloodstream. Several different types and strengths are available and the dose is lowered over a period of weeks. The patch comes in different durations, depending on the needs of the smoker. The 16-hour patch is typcially used by light-to-average smokers. This patch does not deliver nicotine during the night and may not be effective for early morning withdrawal symptoms. The 24-hour patch provides a continual dose of nicotine and helps people who experience early morning withdrawal. However, this patch may interfere with sleep and cause more skin irritation. 

    Depending on body size, the patch is usually used at maximum strength (15 to 22 mg) for the first month, and then at a weaker strength (5 to 14 milligrams) for the next month. The FDA recommends the patch be used for a total of 3 to 5 months but some studies have shown that using for 8 weeks or less is just as effective.

    The patch should be applied somewhere between the neck and the waist and should be moved to new areas from day to day to avoid any skin irritation in one spot. The side effects depend on a number of factors including the brand of the patch, the length of time it is used, the person’s skin type and how it is applied. Users of the patch have reported skin irritation, dizziness, fast heartbeat, headache, nausea and muscle stiffness. 
  • Nicotine nasal spray. Available only by prescription, the nasal spray delivers nicotine to the body very quickly through the nasal passages. It offers immediate relief from withdrawal symptoms and smokers report great satisfaction with use. However, since the product contains nicotine, the FDA warns individuals that it can be addictive. It recommends that the product should not be used for longer than 6 months. People with asthma, allergies or sinus problems may be prescribed another form of NRT. The most common side effects from nicotine nasal spray include nasal and throat irritation, runny nose, watery eyes and coughing. 

In some people, the nicotine patch may be combined with another nicotine replacement product, such as gum or lozenges. The patch provides continuous dosing while the second product can help with strong cravings. Some studies have indicated a combination may be slightly more effective than a single product but additional research is needed. The combined use of NRT products has not yet been approved by the FDA. Individuals should discuss this method with their physician before using combined NRT products.

In addition to – or instead of – nicotine replacement therapy, the physician may prescribe a type of antidepressant that has proven to help some people to quit smoking. The drug, bupropion, is nicotine-free and appears to reduce the symptoms of nicotine withdrawal. It should not be used by individuals with a history of seizures, anorexia or heavy alcohol use.

Scientists have recently developed drug called varenicline (Chantix) to work specifically as a smoking cessation aid. The drug targets nicotine receptors in the brain to reduce the pleasurable effects people get from smoking. In addition, it works to lessen the symptoms of nicotine withdrawal. Several studies have found the drug can more than double the odds of a person quitting smoking.

There are a number of other methods that may help people quit smoking. Although there is no definitive evidence that these methods or products can improve the chances of quitting, many people chose them as aids. These include:

  • Acupuncture
  • Hypnosis
  • Atropine and scopolamine therapy (drugs commonly prescribed for digestive problems, motion sickness or Parkinson’s disease)
  • Cold laser therapy
  • Tar and nicotine reducing filters for cigarettes
  • Herbal supplements and smoking deterrent dietary products

There are many smoking cessation products on the market that have not been reviewed or approved by the FDA, including:

  • Tobacco lozenges and pouches. These are products that contain nicotine and are marketed as a method for smokers to get nicotine when they are unable to smoke (e.g., nonsmoking restaurants, airplanes). These products are not considered smoking cessation aids but instead have been classified by the FDA as types of smokeless tobacco products.  There is no evidence that these products can help smokers quit the habit.
  • Nicotine lollipops. These products were made by some pharmacies in the past and marketed as a method to obtain nicotine. They often contained nicotine salicylate, a product not approved for pharmacy use by the FDA.  Several pharmacy companies have been warned by the FDA to stop selling nicotine lollipops on the Internet. Other products, such as lip balm, also have been manufactured with nicotine salicylate.

People tend to get rather grouchy or irritable when they first quit smoking. By letting family and friends know what is happening and what to expect, needless conflict may be avoided. Some experts believe that it’s easier for someone to quit when a friend or family member quits with them at the same time. However, other experts point out that if one person in this quitting team goes back to smoking, the other is much more likely to do so, as well. All experts agree that it is helpful for friends and family members to avoid smoking in front of someone who is trying to quit. Group support may also take the form of group counseling, which may include lectures, exercises and quitting en masse.

There are many resources that can offer support, which include:

  • Self-help books
  • Online support groups, such as Nicotine Anonymous
  • Educational materials (e.g., for parents, coaches or teachers of teens who smoke)
  • Community support groups (usually available at a local hospital)
  • Local smoking cessation programs (e.g., through the local chapter of the American Lung Association or the American Cancer Society)
  • National agencies, including:
    • American Cancer Society: 1-800-ACS-2345
    • American Heart Association: 1-800-AHA-USA1
    • American Lung Association: 1-800-LUNG-USA
    • National Cancer Institute: 1-800-4-CANCER
    • Office on Smoking and Health: 1-800-CDC-1311

Physicians or employers may offer other resources that can help individuals quit smoking. In addition, other healthcare professionals may offer advice and support.

Day before and first week

Day before quitting smoking

Complete the following steps the day before quitting smoking:

  • Throw out all cigarettes, ashtrays, matches and lighters.

  • Wash everything, especially clothes, sheets and the inside of the car.

  • Change the home environment (e.g., buy some fresh flowers).

  • Use a recommended nicotine replacement product, if prescribed.

  • If using an antidepressant or other medication for smoking cessation, take it on this day as prescribed.

First week as a nonsmoker

If people falter in their attempt to quit, it usually happens during the first week. Therefore, getting through those first seven days is very important to begin one’s life as a nonsmoker. To avoid cravings as much as possible:

  • Make as many changes as possible in daily routine, from where/what you have for breakfast, to the route taken to work, to the order in which clothes are put on. Some people also eat or talk on the phone with the opposite hand, and sit in a different chair.

  • Spend time in places where smoking is not permitted. Avoid smokers and instead share time with people who follow a healthy lifestyle.

  • Stay away from smoke-filled businesses (e.g., bars) or areas where people tend to take smoking breaks.

  • Avoid situations in which smoking is more likely (e.g., parties).

  • Finish a meal with something (e.g., milk) that would make a cigarette seem less appealing.

  • Use stress management techniques throughout the day to keep stress levels low and to avoid a stress “crisis” that could increase the temptation for a cigarette.

  • Take it a day at a time, marking each day off on a calendar.

When a craving hits:

  • Use supplemental nicotine replacement product (e.g., nasal spray), if prescribed.

  • Breathe deeply.

  • Call a supportive friend or family member.

  • Chew gum.

  • Drink water.

  • Eat healthy snacks (e.g., carrots or grapes).

  • Exercise (e.g., walking, swimming).

  • Go outside for some fresh air.

  • Listen to enjoyable music or a recorded book while in the car.

  • Play the tape of the physician’s warning, or read the sign prepared for this moment (e.g., “What would you rather do: smoke or breathe?”).

  • Watch videos that show the detrimental effects of smoking.

  • Participate in a calming activity (e.g., meditation, yoga) 

  • Rinse with mouthwash or brush with mint toothpaste.

  • Suck on a sugar-free piece of candy, straw or toothpick.

  • Take a shower or long bath.

  • Use the nicotine inhaler, nicotine gum or nicotine nasal spray.

  • Wash hands and/or use lotion on them.

Quitting is difficult, but more than a million Americans find a way to do it every year. Above all, people are encouraged to celebrate the end of their first week as a nonsmoker!

After the first week of smoking cessation

When people quit, their bodies immediately begin the healing process from the damage done by nicotine addiction. It will heal on its own, but it needs some time. Some effects will be noticed sooner than others. Freer breathing and refreshed senses of smell and taste are among the first to return. Other effects take longer. Withdrawal symptoms that may take weeks or as many as six months to subside include:

  • Irritability
  • Nicotine cravings
  • Sleepiness
  • Smoker’s cough
  • Trouble concentrating, or feeling “spacey”

It is important to remember that these symptoms will most likely peak in the first three days, then gradually fade. It is not uncommon, however, for former smokers to experience cravings for cigarettes for months, if not years, after quitting. These cravings are of minor discomfort, however, when compared to the rigors of chemotherapy for lung cancer or open-heart surgery.

Ongoing research

Scientists are studying a number of areas and products in smoking cessation, including:

  • High-dose nicotine replacement therapy (NRT). Researchers are trying higher doses of NRT that match the level of nicotine used by the smoker. Individuals have been given patches of 35 milligrams (mg) to 63 mg of nicotine at a time. Studies suggest that with the higher doses, the patients’ withdrawal symptoms disappear and the cravings decrease without adverse cardiovascular side effects.

  • Clonidine. Already being used to help people deal with the withdrawal effects of a variety of different drugs, clonidine has shown to have early effectiveness in helping people to quit smoking. Subsequent studies, however, have suggested that the drug does not demonstrate statistically significant improvements in the rate of quitting. It has also two main side effects, dry mouth and the feeling of sedation, which have limited its use.

  • Special mouthwash. A nicotine-free strategy for making cigarettes taste terrible. It is similar to the drug disulfiram that makes alcohol very unpleasant for people trying to quit drinking. The mouthwash does not have an impact on withdrawal symptoms.

  • Vaccine. Researchers are testing a specific vaccine formulated to block the path of nicotine to the brain, thereby preventing the instant “high” or “rush” after smoking.

Questions for your doctor

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions related to smoking cessation:

  1. What are the first steps I shoud take to quit smoking?
  2. Should  I use nicotine replacment therapy (NRT)?
  3. What type of NRT should I use? Do I need a prescription?
  4. If I use the patch, can I use other forms of NRT as well?
  5. How long can I use these products?
  6. What are the chances that I will become addicted to the NRT product?
  7. What can be done if I develop side effects to NRT?
  8. If one product does not work, will I be prescribed another form of NRT?
  9. Should I consider taking an antidepressant?
  10. What can I do to avoid weight gain when I quit smoking?
  11. Can I substitute light cigarettes or just smoke once in a while?
  12. Do you recommend any complementary or alternative medicine?
  13. When can I expect to stop craving nicotine?
  14. Can you recommend a smoking cessation support group?
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