Patient education: Quitting smoking
Cigarette smoking is a major cause of disease and the leading preventable cause of death. In addition, exposure to secondhand smoke increases a person’s risk of disease and death. Smoking is also associated with many other non-fatal diseases and problems, including osteoporosis, skin wrinkling, peptic ulcer disease, impotence, and pregnancy complications. Even smoking a small amount, such as one cigarette a day, is associated with increased health risks.
Quitting and staying smoke-free can be a challenge, but many people have done it successfully. This topic review discusses the benefits of stopping smoking and approaches that can help you succeed.
BENEFITS OF QUITTING SMOKING
Quitting smoking has significant and immediate health benefits for men and women of all ages. The sooner you quit, the greater the benefits. People who quit smoking before age 50 reduce their risk of dying over the next 15 years by one-half, as compared with those who continue to smoke.
Reducing your risk of disease
Cardiovascular disease — Cigarette smoking doubles a person’s risk of developing coronary heart disease, a condition that can lead to a heart attack. Quitting smoking can rapidly reduce this risk. One year after stopping smoking, the risk of dying from coronary heart disease is reduced by about one-half and continues to decline over time. Smoking also increases the risk of stroke and peripheral artery disease (a condition in which the blood vessels that carry blood to the legs are blocked or narrowed, causing leg pain). These risks also decrease after a person quits smoking. (See “Patient education: Heart attack (Beyond the Basics)” and “Patient education: Stroke symptoms and diagnosis (Beyond the Basics)” and “Patient education: Peripheral artery disease and claudication (Beyond the Basics)”.)
Lung disease — Smoking increases the risk of long-term lung diseases such as chronic obstructive pulmonary disease. While much of the lung damage caused by smoking is not reversible, stopping smoking can reduce further damage to the lungs, and many smokers with a chronic cough and sputum (phlegm coughed up from the lungs) notice an improvement in these symptoms during the first year after they stop smoking. (See “Patient education: Chronic obstructive pulmonary disease (COPD) (Beyond the Basics)”.)
Smoking is also associated with an increased risk of asthma, and asthma is more difficult to treat in people who smoke.
Cancer — Cigarette smoking is responsible for almost 90 percent of cases of lung cancer. Quitting smoking reduces the risk of lung cancer within five years of stopping, although former smokers still have a higher risk of lung cancer than people who have never smoked. (See “Patient education: Lung cancer risks, symptoms, and diagnosis (Beyond the Basics)”.)
Stopping smoking may also reduce the risk of other cancers, such as cancers of the head and neck, esophagus, pancreas, and bladder. Stopping smoking is beneficial even after one of these cancers is diagnosed, since it reduces the risk of getting a second cancer and may improve the chance of survival from the first cancer.
Peptic ulcer disease — Cigarette smoking increases the risk of developing peptic ulcer disease. Quitting smoking decreases that risk and increases the rate of ulcer healing, if ulcers have developed. (See “Patient education: Peptic ulcer disease (Beyond the Basics)”.)
Osteoporosis — Smoking increases bone loss and increases the risk of hip fracture in women. Stopping smoking begins to reverse this risk after about 10 years. Increased bone loss has also been noted in men who smoke, although it is not clear how much a man’s risk of fracture is increased by smoking. (See “Patient education: Bone density testing (Beyond the Basics)”.)
Other diseases — Smoking also causes or contributes to many other conditions, including type 2 diabetes, sexual problems (eg, erectile dysfunction in men), problems with the teeth or gums, and certain infections. Quitting smoking can reduce your risk of developing these problems.
Reducing your family and friends’ risk of disease — Quitting smoking will also benefit your family and other people who spend time with you, since exposure to secondhand cigarette smoke is associated with a number of serious health conditions.
Adults who are exposed to secondhand smoke have an increased risk of lung cancer, coronary heart disease, and stroke.
Children who are exposed to secondhand smoke have an increased risk of:
- Sudden infant death syndrome (SIDS)
- Asthma and other breathing problems
- Ear infections and hearing loss
- Developing cardiovascular disease or cancer later in life
Women who smoke during pregnancy have an increased risk of complications including preterm labor, miscarriage, and stillbirth. Their babies are also more likely to be underweight at birth.
PREPARING TO QUIT
Smoking is recognized as a chronic addictive disease, and for some (but not all) smokers it can be extremely challenging to quit. People can differ greatly in the way in which they smoke, their success in quitting, symptoms they have when trying to quit, and factors that may lead to relapse. Many people try to quit on their own, without any help from medications or other supports. The success rate in this situation is much lower. If you tried to quit on your own without success, seeking help the next time you try to quit can make the difference.
Once you decide to quit smoking, the first step is usually to set a quit date. This is the day when you will completely quit smoking. Ideally, this date should be in the next two weeks, although some people choose a special date that is significant to them (eg, a birthday, anniversary, or holiday).
Many doctors recommend stopping smoking all at once on your quit date. However, some people prefer to gradually reduce the number of cigarettes they smoke prior to the quit date.
Once you have set your quit date, there are things you can do to help you prepare. It can help to:
- Talk with a health care provider about ways to quit smoking. Changing behaviors and taking a medication are the two main methods of quitting smoking. Using both methods together increases your chances of successfully quitting.
- Think about what happened with your previous quit attempts. What worked? What did not work? What contributed to relapse? Is there anything you have learned that you can do differently this time to be more successful?
- Tell your family, friends, and coworkers about the plan to quit and ask for their support.
- re to deal with nicotine withdrawal symptoms, such as cravings for a cigarette. Other symptoms are more general and often not recognized as related to nicotine withdrawal. These include anxiety, difficulty sleeping, irritability, difficulty concentrating, restlessness, frustration or anger, and depression. These symptoms are reduced and more tolerable if you use a stop-smoking medication. These include over-the-counter medications, like nicotine patches, gum, or lozenges, or prescription medications like varenicline or bupropion. (See ‘Medications for quitting’below.)
Withdrawal symptoms usually become manageable within a few weeks of stopping smoking completely. Symptoms generally peak in the first three days and decrease over the next three to four weeks, so keep in mind that it will get easier. Symptoms vary in intensity but are generally stronger in heavier smokers.
- Prepare to deal with things that trigger smoking. Examples include having other smokers in the household or workplace, stressful situations, and drinking alcohol. If you are in the habit of smoking during the work day, it might be easier to quit during a vacation from work. If you live with someone else who smokes, consider asking that person not to smoke in the house or car to help you succeed in becoming smoke-free.
- Anticipate occasional cravings for cigarettes; these can be intense and may occur periodically over a longer timeframe than withdrawal symptoms. Cravings may be brought on by situations associated with smoking, by stress, or by drinking alcohol. These cravings are a common reason people relapse after quitting. It is important to remember that a craving will typically go away in a few minutes if you distract yourself by doing something else for a few minutes.
- Plan an exercise program and a healthy diet to minimize weight gain. Weight gain may occur because people tend to eat more after quitting. Typically, people gain two to five pounds in the first two weeks, followed by an additional four to seven pounds over the next four to five months. The average total weight gain is 8 to 10 pounds. While this can be frustrating, it can help to keep in mind that the benefits of quitting smoking are much greater than the risks associated with gaining weight. (See “Patient education: Exercise (Beyond the Basics)”.)
BEHAVIORAL CHANGES TO HELP YOU QUIT
You can make changes in your daily behavior to help you quit smoking on your own; some people also choose to participate in individual or group support sessions (see ‘In-person support’ below). Combining behavioral changes with a medication increases your chances of quitting successfully. (See ‘Medications for quitting’ below.)
Problem solving/skills training — When preparing to quit, it is important to identify situations or activities that increase your risk of smoking or relapse. After identifying these situations, you may need to develop new coping skills. This may include one or more of the following:
- Make lifestyle changes to reduce stress and improve quality of life, such as starting an exercise program or learning relaxation techniques. Vigorous exercise can enhance the ability to stop smoking and avoid relapse and also helps to minimize or avoid weight gain.
- Minimize time with smokers and in places where smoking is allowed. People who live with smokers can consider negotiating with them to stop smoking at home or in the car.
- Recognize that cravings frequently lead to relapse. Cravings can be prevented to some degree by avoiding situations associated with smoking, by minimizing stress, and by avoiding alcohol. Cravings will subside. Keep oral substitutes (such as sugarless gum, carrots, sunflower seeds, etc) handy for when cravings develop.
- Try to avoid thoughts like “having one cigarette will not hurt”; one cigarette typically leads to many more.
- Have as much information as possible about what to expect during a quit attempt and how to cope during this time. These can easily be found online, by calling a smokers’ quitline, or by talking with a health care provider or counselor. Support groups can be helpful. Some medical centers have patient resources or learning centers with self-help materials. (See ‘Where to get more information’below.)
Support — Having consistent support is extremely helpful in quitting smoking and staying off cigarettes. Support can come from family and friends, a health care provider, a counselor, a telephone hotline (in the United States, 1-800-QUIT-NOW), a text messaging program (in the United States, sign up at www.smokefree.gov), online resources, and/or support groups. In addition to getting ongoing encouragement, it is important to have someone you can talk to about any problems you have while trying to quit, such as weight gain, lack of support from family and friends, or prolonged withdrawal symptoms.
In-person support — Some people find it helpful to talk with a “coach” who can help support you throughout the process. This often involves regular visits beginning before your quit date and continuing for several months afterwards.
Group counseling sessions are another option; many different organizations offer group programs. These typically include lectures, group meetings for mutual support, discussion of coping skills, and suggestions for preventing relapse.
Hypnosis and acupuncture — Hypnosis and acupuncture are popular stop-smoking methods. Although there is not convincing scientific evidence that these are effective, some people who have not had success with other techniques find these treatments to be helpful.
MEDICATIONS FOR QUITTING
There are several medications that can help you stop smoking; in the United States, some of these are available without a prescription while others require a prescription. Effective medications include nicotine gum, patches, or lozenges (available over the counter) and the prescription medications varenicline (brand name: Chantix) and bupropion (brand names: Zyban, Wellbutrin).
Nicotine replacement therapy — Nicotine is the substance in cigarettes that makes them addictive. When nicotine levels fall, most smokers develop withdrawal symptoms. These include irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, depression, difficulty falling or staying asleep, and nicotine craving.
Nicotine replacement therapy is designed to reduce the intensity of withdrawal symptoms after you quit. However, while it can make it easier to quit, it will not prevent symptoms completely.
Nicotine is available in several forms as a gum or lozenge, a patch, a nasal spray, or an inhaler. All appear similarly effective, although different people may find that they prefer one form over another. Using more than one form of nicotine replacement therapy in combination is more effective than using one form alone. Generally, a smoker will use a nicotine patch to provide a constant level of nicotine and add the nicotine gum or lozenge or inhaler or nasal spray as needed to control cigarette cravings.
Nicotine replacement therapy is safe, even in people with known heart disease.
Skin patches — Nicotine patches deliver nicotine to the blood through a skin patch. Several doses are available. The highest-dose patch (21 mg/patch) is usually appropriate for people who are used to smoking 10 cigarettes (half a pack) or more daily. People who smoke less might choose a lower-dose (14 mg) patch. Patches reduce your withdrawal symptoms but do not eliminate them.
The combination of an intensive behavioral program and nicotine patches can double your chances of quitting. (See ‘Behavioral changes to help you quit’ above.)
It is generally recommended that you wear the patch for at least 12 weeks. Some brands of patch include a tapering of the dose over the last few weeks of use. For example, one strategy is to switch to a lower-dose patch after six or eight weeks. Using the patch for longer than 12 weeks is associated with more success in quitting, and using the patch for as long as needed is generally recommended.
Some people who use the patch at night have trouble with insomnia or vivid dreams. On the other hand, wearing the patch at night may help prevent difficult early morning withdrawal symptoms. If you have bothersome sleep-related symptoms, one approach is to remove the patch at night and put on a new one in the morning. You can also use another form of nicotine replacement therapy (such as gum) the first thing in the morning before your new patch takes effect.
Nicotine patches are not likely to result in addiction to nicotine.
Gum — Nicotine gum contains nicotine that is slowly released as you chew. Gum is available in two doses, 4 mg (for people who smoke their first cigarette within 30 minutes after getting up) and 2 mg (for people who smoke their first cigarette after being awake for 30 minutes or longer).
You can use up to 24 pieces of nicotine gum per day. While the gum does not prevent withdrawal symptoms, it may reduce the intensity of symptoms. A very small percentage of people who quit smoking become chronic gum users; however, using the gum long-term is far less risky than smoking.
When used with an intensive behavioral program, nicotine gum can double your chances of successfully quitting (see ‘Behavioral changes to help you quit’ above). Without a behavioral program, your chances of quitting are likely to be lower. Gum use is generally recommended for three to six months.
Nicotine gum is meant to be chewed differently than regular chewing gum. To be effective, the nicotine must be absorbed through your cheek or gums. If you chew too quickly, the nicotine will instead be swallowed, which can cause an upset stomach and is not very effective for relieving withdrawal symptoms. To be absorbed well, you will need to chew the gum just enough to feel the nicotine being released; this feels like a tingling sensation. Then, hold or “park” the gum inside your cheek until the tingling goes away. Repeat this cycle (chewing the gum again until you feel tingling, then holding it in your cheek) for 30 minutes, and then remove and dispose of the gum.
It is better to avoid drinking coffee, sodas, or orange juice while chewing the gum or for 15 minutes beforehand. These drinks make your saliva acidic, which limits nicotine absorption.
Lozenges — Nicotine lozenges slowly release nicotine into the saliva in your mouth. The nicotine works similarly to the gum, as it must be absorbed in the mouth and not swallowed. Because the lozenges do not require chewing, they may be easier for some people to use. They come in 2 and 4 mg doses.
Inhaler — The nicotine inhaler is made up of a mouthpiece and a plastic cartridge that contains nicotine. Nicotine is released when you inhale through the device. Most of the nicotine is deposited in the mouth and throat. It does not actually reach the lungs. Therefore, nicotine is absorbed more slowly than it is when inhaling on a cigarette.
Irritation of the mouth or throat is common, particularly in the beginning. People with asthma or chronic cough may not be able to use the inhaler due to throat irritation.
Nicotine inhalers are available only by prescription in the United States.
Nasal spray — Nicotine nasal spray delivers a liquid solution of nicotine to the nose. Compared with the patch and gum, the nasal spray produces a relatively rapid rise in nicotine levels in the blood, more similar to what happens when you smoke. However, nasal irritation is common. Nasal sprays are safe. They are available only by prescription in the United States.
Varenicline — Varenicline (brand name: Chantix) is a prescription medication that works in the brain to reduce nicotine withdrawal symptoms and cigarette cravings.
Varenicline should be taken after eating and with a full glass of water. It is taken for a total of 12 weeks based on the following schedule:
- One 0.5 mg tablet daily for three days
- One 0.5 mg tablet twice daily for the next four days
- One 1 mg tablet twice daily starting at day 7
The gradual increase in dose is intended to minimize side effects, particularly nausea.
If you are taking varenicline, it is best to plan your quit date for at least one week after you start the medication (although it is still effective if the quit date is later, up to five weeks after starting medication). Even if you are not yet ready to commit to a quit date, varenicline can help reduce cravings, which can make it easier to quit when you are ready.
After 12 weeks, even if you have successfully stopped smoking, your health care provider may suggest continuing to take varenicline for an additional 12 weeks to reduce the risk of relapse. If you have not been able to quit after 12 weeks of treatment, your provider can talk to you about your options (eg, continuing varenicline with another medication or trying another approach).
Common side effects of varenicline include nausea and abnormal dreams. Although concern has been raised about an association with cardiovascular disease (heart attack or stroke), most data suggest that the risk is not significantly increased. Varenicline is safe for people with psychiatric problems, although if you take it and notice a change in your mood or behavior, you should stop the medication and let your health care provider know right away.
Some people may benefit from combination treatment with varenicline and the nicotine patch. (See ‘Skin patches’ above.)
Bupropion — Bupropion (brand names: Zyban, Wellbutrin) is an antidepressant that can be used to help with quitting smoking, although it appears to be less effective than combination nicotine replacement therapy or varenicline. (See ‘Nicotine replacement therapy’ above and ‘Varenicline’ above.)
Bupropion is usually taken once daily for three days, then increased to twice daily starting two weeks before the quit date; it is typically continued for at least 12 weeks.
Bupropion is generally well-tolerated, but it may cause dry mouth and difficulty sleeping. The drug should not be used by people who have a seizure disorder or bipolar disorder, and it is not recommended in certain other situations, such as in people who are at risk of seizures.
If you are not able to quit on your first try, or if you quit but then relapse (start smoking again), keep trying to quit. Most people make many attempts to quit before they are able to quit completely, and relapse should not be thought of as a failure. Each quit should be regarded a victory, and the longer it lasts, the better.
If you do relapse, it is important to understand why so that your next attempt is more likely to be successful. Keep this in mind when you are making a plan to quit. If you have success for a while, you can learn what helped and what did not and use this information next time. Try to figure out the reasons that led you to start smoking again, and determine if you used the methods (medication, counseling) correctly and if there is anything you could have done differently. Then explore solutions to use next time. Consider trying different methods or combinations of methods.
Most relapses occur in the first week after quitting, when withdrawal symptoms are strongest. Try to use support resources (eg, family, friends) during this critical time. Consider giving yourself rewards for not smoking; for example, you could use the money you save on cigarettes for a special treat such as a massage, a movie, a new outfit, or a special dinner or other activity.
Later relapses often occur during stressful situations or with social situations that are associated with smoking, often combined with drinking alcohol. Being aware of these high-risk situations may help.
If other problems such as depression or alcohol or drug dependency are making it harder for you to quit, consider getting professional help from a health care provider or counselor. (See “Patient education: Depression treatment options for adults (Beyond the Basics)”.)
WHERE DO I START?
The following steps are recommended to start the process of quitting smoking:
- Even if you are not quite ready to quit smoking, talk with your health care provider. They can discuss options to help you get ready, such as starting a medication in advance to help reduce cravings. This can make it easier to quit once you are ready.
- If you are ready to quit smoking, speak with your health care provider about the method you plan to use to quit. Behavior changes should usually be combined with one or more medications, such as nicotine replacement therapy, varenicline (brand name: Chantix), or bupropion (brand names: Zyban, Wellbutrin).
- Pick a date to quit smoking. Tell friends and family about your plan.
- Seek support through free telephone quitlines (eg, in the United States, 1-800-QUIT-NOW), text messaging programs, or other tools that can be accessed for free online (www.smokefree.gov).
- Begin making changes in your behavior; avoid situations that may tempt you to smoke.
- Start varenicline (one to four weeks before your quit date) or bupropion (two weeks before your quit date) or start nicotine replacement (on the day you quit).
- Prepare for withdrawal symptoms. Consider using nicotine replacement therapy (such as nicotine patch, gum, or lozenge) to help manage your symptoms. Try to resist the urge to smoke “just one” cigarette to get through a rough day. Consider support groups for encouragement as well as tips on coping with withdrawal.
Article by Nancy A Rigotti, MD(Uptodate)