Smoking Cessation

Introduction

Everyday, another 3,000 teenagers become smokers. Young people are the tobacco industry?s primary source of new customers in this country.

-FDA commissioner David Kessler

What is it?

Smoking is an addiction that currently affects approximately 70.8 million people in the United States. It has been identified by the American Lung Association as the most important source of preventable morbidity and early mortality worldwide. In the U.S., smoking is responsible for 1 in 5 deaths. Smoking costs the U.S. economy over $167 billion in health care costs and lost productivity each year.

A person who smokes often feels the compulsive need to light up that next cigarette. Many smokers cannot wait until their next cigarette to make the nicotine craving go away.

Cigarette smoke contains many compounds that are harmful to the body. Tar in the smoke contains over 4,000 chemicals, including 60 that have been shown to cause cancer. Smoking causes approximately 90% of all lung cancers. Other chemicals in the smoke cause lung and heart disease.

The following are just a few of the chemicals surprisingly found in cigarette smoke:

• Cyanide
• Benzene
• Formaldehyde
• Methanol (wood alcohol)
• Acetylene (fuel used in welding torches)
• Ammonia
• Poisonous gases including nitrous oxide and carbon monoxide

These chemicals inhaled by a smoker or nonsmoker (via second hand smoke?see below) are known to either cause or worsen the following health problems:

• Cancers: lung, oral, larynx (throat), esophageal, kidney, bladder, pancreas, stomach, colon
• Chronic Obstructive Pulmonary Disease (emphysema and chronic bronchitis)
• Chronic "smoker's cough"
• Asthma
• High blood pressure
• Heart disease
• Stroke
• Peptic ulcer disease
• Gastric Esophageal Reflux Disease (GERD or heartburn)
• Diabetes

Secondhand smoke, also called environmental tobacco smoke (ETS), is smoke inhaled by a person who is in an environment where tobacco smoke is being produced by another person. Secondhand smoke contains the same amount of cancer-causing chemicals as smoke inhaled directly by a smoker. In 1993, the U.S. Environmental Protection Agency determined that there is sufficient evidence that secondhand smoke causes cancer in humans. However, researchers are unsure at this time what amount of secondhand smoke exposure is needed to cause cancer. Approximately 3,000 lung cancer deaths occur each year among nonsmokers in the United States as a result of exposure to secondhand smoke. It has also been shown that persons living in a home with smokers are at the highest risk of developing cancer from secondhand smoke. According to the American Cancer Society, sitting in a nonsmoking section of a restaurant for two hours is equal to smoking one and a half cigarettes. In addition, a nonsmoker sitting behind a smoker in a bar for two hours breathes in the equivalent of four cigarettes.

What causes it?

Addiction to smoking is actually caused by the body?s addiction to the primary ingredient in cigarette smoke, known as nicotine. Nicotine causes an addiction to smoking in three ways. First, small amounts of nicotine make a person feel pleasant and satisfied, causing the person to want to smoke even more. Secondly, nicotine affects the mood and behavior of a smoker by altering chemicals in the brain. Lastly, and often most importantly, withdrawal symptoms, such as nervousness, headaches, irritability, and difficulty sleeping, occur when a person refrains from smoking for a given period of time (usually about 24 hours).

Who has it?

Because tobacco use is an addiction that is self-initiated, anyone could become addicted to tobacco products. However, there are certain groups of people that are more prone to becoming addicted to nicotine. According to the most recent National Health Interview Survey from the Centers for Disease Control and Prevention and the National Center for Health Statistics, in the United States, an estimated 25.5 million men (24.1%) and 21.5 million women (19.2%) are smokers. Smoking is most prevalent among persons 25-44 years of age (23.8%) and least prevalent among persons older than age 65 (8.8%). Studies have shown that smoking is higher among persons with 9 to 11 years of education (35%) compared with persons with more than 16 years of education (12%).

Unfortunately, teenage smoking is on the rise. Approximately 3.6 million Americans 12 to 17 years of age smoked regularly in 2003. On a positive note, in recent years, the percentage of 8th grade students who admitted to smoking has declined from 21% (in 2002) to 9% (in 2003).

What are the risk factors?

Surveys have shown that young adults age 18 to 25 years have the greatest incidence of starting to use tobacco products. Teenage use of tobacco products is most often initiated by the need to be accepted by their peers who smoke and the need to feel like they fit in. Some teens have also reported that they began using tobacco products in order to rebel against their parents. Recent research has also shown that teenagers are the most resistant to antismoking messages and campaigns, because they do not fully understand the complications that smoking tobacco can initiate.

The pleasant feeling associated with nicotine use is often helpful to people who want to decrease their stress levels. Consequently, people who have high-stress work environments or difficult family situations may be more likely to use nicotine, at least on an occasional basis.

A few small studies have shown that persons are more likely to begin smoking if a parent smoked. Parents, the most influential role models in children, often dictate the positive and negative behaviors of their children.

What are the symptoms?

Symptoms of high nicotine addiction include but are not limited to:

• Nicotine craving within the first hour of waking
• Having difficulty refraining from smoking in places where it is forbidden
• Smoking more than ten cigarettes per day (although any nicotine use is unhealthy)
• Smoking even when very ill and unable to go to work or get out of bed

Nicotine withdrawal often occurs within 24 hours of refraining from nicotine use. Signs of nicotine withdrawal include:

• Depressed or elevated mood
• Insomnia
• Irritability, frustration, or anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Decreased heart rate
• Increased appetite or weight gain

The presence of at least four signs of withdrawal is needed to be diagnosed with nicotine withdrawal. It is important to continually self-monitor for these signs.

How is it treated?

Why should you quit?

The US Surgeon General?s Report of 1990 detailed a timeline as to how cessation from nicotine improves a person?s health status. While this report is somewhat dated, it still holds true today.

• 20 minutes after the last cigarette: heart rate drops
• 12 hours after the last cigarette: the carbon monoxide level in the blood drops back to normal
• 2 weeks to 3 months after the last cigarette: circulation improves and lung function increases
• 1 to 9 months after the last cigarette: coughing and shortness of breath decrease; cilia (tiny hair-like structures that move mucus out of the lungs) begin to function normally again, increasing the ability to clean out the lungs and thus reduce the risk for lung infection
• 1 year after the last cigarette: risk of heart disease is decreased in half compared to a smoker?s risk
• 5 years after the last cigarette: as early as 5 years after quitting smoking, risk for having a stroke is the same as a person who never smoked
• 10 years after the last cigarette: lung cancer death rate is about half of a smoker?s. The risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decrease as well.
• 15 years after the last cigarette: the risk of heart disease is the same as a person who never smoked.

Five stages of smoking cessation

There are five stages of smoking cessation. These stages can help a person determine how much further he/she must go in order to achieve complete smoking cessation.

1. Precontemplation: the person has no desire to quit
2. Contemplation: the person has a desire to quit but no quitting plan
3. Preparation: the person has a desire to quit within one month and has a quitting plan
4. Action: the person has quit for one day to six months
5. Maintenance: the person has quit for at least six months

Successful treatment of nicotine addiction is a continual process. An addiction is not like an infection where you take a medication and the infection completely resolves in a short amount of time. On average, a person tries to quit smoking eleven different times before becoming successful. Quitting "cold turkey" with no additional help is often only successful in persons who smoke infrequently. People who smoke greater than ten cigarettes per day often require medication and psychological therapy to aid them in successfully refraining from smoking on a permanent basis.

Multiple products are available to help you quit smoking including nicotine replacement aids (e.g. gums, patches) and medications such as Zyban, Chantix, and antidepressant medications. For individuals who are highly addicted to nicotine or who have smoked for many years, combination therapy (eg. nicotine patch plus Zyban) can be tried. However, it's best to try one therapy first and if that therapy fails, then proceed to combination therapy. Therapy needs to be tailored to the individual. Click on the drug class links below to learn more.

Additionally, non-drug therapy is key to success at smoking cessation. Click on our "Helping Yourself" link above to learn helpful tips to stop smoking.

Finally, some people have found success with alternative therapies such as hypnosis.

Helping Yourself

Plan! Plan! Plan! Planning is a key component in successfully quitting smoking. Because quitting smoking is such a difficult task to accomplish, you must be both mentally and physically prepared to go through the process of smoking cessation. Many of the techniques mentioned below must be implemented before and maintained throughout your smoking cessation process.

Preparing to Quit Smoking

1. Set a quit date so that you can prepare yourself for the day that you decide to quit smoking. It may be helpful to choose a date that has special meaning to you or a family member?for example, a birthday, anniversary, or special holiday. Mark that date on your calendar and inform family and friends of your quit date so they can help you prepare.

2. Give yourself about two weeks prior to quitting so that you have enough time to both mentally and physically prepare to quit smoking. During this time:
   • Keep a smoking diary to detail when and why you smoke. Write down how smoking makes you feel, so that when you have a craving, you can remember why you do not want to smoke anymore.
     
     
   • Prepare your environment for no smoking. Throw away any cigarettes, lighters, and ashtrays that you have. Clean anything that smells like smoke (clothing, sheets, furniture, and your car).
     
     
   • Take into consideration any previous attempts to quit and what went wrong. When you begin your next quit attempt, avoid things that did not help you quit before. Modification of techniques you tried on the previous attempt may be needed.
     
     
   • Make a list of activities and situations that trigger your need for a cigarette and what you will need to do in order to avoid these triggers. For example, if you always smoke a cigarette in the morning while reading the newspaper, prepare to read the newspaper at a different time of the day or in a different room where you do not normally smoke. If you smoke during your break at work, take a walk outside or around the building instead or get to know people in your workplace that do not smoke.
     
     
   • Join a smoking cessation support group. Many hospitals and community centers organize smoking cessation support groups. These groups are helpful to discuss your smoking cessation with others who are going through the same difficult and life-changing process as you. Other members of the group may have useful tips on how to successfully quit smoking. Having a support system?whether through a community group or family members and friends?is important and many times needed to help you successfully quit.
     
     
   • Consider household members who smoke?encourage complete refraining from smoking while you are present. Better yet, encourage other household members to join you in your smoking cessation efforts?it may be easier to quit if other household members are also trying to quit.
     
     
   • Enlist the support of your family and friends. Inform them that this if going to be a difficult process for both yourself and them. Ask them to help you avoid your cravings and situations that trigger your cravings. They may know triggers to smoking that you have that you never realized existed.

What to do during the quitting process

1. Achieving smoking cessation is a huge accomplishment. Reward yourself when you do not smoke. For each week of no smoking, buy yourself a new book, CD, or video. Take yourself out to a nice dinner or to a movie.
   
   
2. Save the money you would have spent on cigarettes in a jar. Use the money to reward yourself (over time the money saved on cigarettes can add up to hundred or even thousands of dollars?enough to go on a vacation or buy something nice), or even better, donate it to charity. This will help you to realize how much money you spend on your smoking addiction.
   
   
3. The 4 D?s: drink water, do something to avoid smoking, deep breathing to relax and decrease stress-induced smoking, delay smoking until something better comes along to do.
   
   
4. Carry a book or magazine with you to read when you have the urge to smoke.
   
   
5. Limit alcohol intake-Many people only smoke while they are consuming alcohol. Avoidance of alcohol can help to prevent the craving for a cigarette.
   
   
6. Exercise! Exercise! When you feel the need to smoke?hit the gym, take a walk, go for a run, or do some form of physical exercise. It gives you a rush of energy that may replace the nicotine craving. Additionally, exercise improves your overall health.
   
   
7. Chew on a straw or a piece of licorice. Many smokers need the hand-to-mouth connection involved in cigarette smoking. The straw or licorice can help replace this sensory need.
   
   
8. For those who smoke menthol cigarettes for the taste, try peppermint or hard candy to replace the flavoring.

What is on the horizon?

An experimental vaccine to help people quit smoking is currently being researched. This vaccine stimulates the body to produce nicotine antibodies that bind to any nicotine that enters a person?s blood when he/she smokes. This nicotine/antibody product is then too large to enter a person?s brain, thus preventing the addictive effects of the nicotine from occurring. Small studies so far have reported the vaccine to be safe and well tolerated. However, the effectiveness of the vaccine in helping people to stop smoking has not yet been established. The vaccine will most likely be used in combination with other smoking cessation drug therapies. It is being considered as a smoking prevention vaccine for people who have never smoked before. The vaccine for the use in smoking prevention has yet to be studied. Once clinical studies of the vaccine for smoking cessation purposes are completed, FDA approval will be needed before manufacture of this vaccine can occur.

Research has pinpointed a specific molecule, the b2 subunit, of the nicotine receptor in the body as a critical component of nicotine addiction. This discovery identifies a potential site for targeting future drug therapy in smoking cessation.

Other recent research has shown that persons with decreased function of the liver enzyme CYP2A6 have a less likely chance of becoming addicted to nicotine. The creation of new medications that decrease function of this enzyme may promote improved smoking cessation.

Many smokers report missing the sensory aspects of smoking. Studies using sensory replacement therapy in these patients have shown some promise. Inhalation therapies containing ascorbic acid or citric acid have been tested, both increasing short-term rates of smoking cessation. Further studies of sensory replacement therapy in combination with FDA-approved smoking cessation drug therapy is warranted but has yet to be initiated.

References

American Lung Association. Trends in Tobacco Use. American Lung Association Epidemiology and Statistics Unit Research and Program Services. January 2006. Available at: http://www.lungusa.org/atf/cf/%7B7A8D42C2-FCCA-4604-8ADE-7F5D5E762256%7D/Smoking2006.pdf . Accessed December 2007.

American Heart Association. Cigarette Smoking Statistics. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4559 . Accessed December 2007.

American Cancer Society: Questions about Smoking, Tobacco, and Health. Available at: http://www.cancer.org/docroot/PED/content/PED_10_2x_Questions_About_Smoking_Tobacco_and_Health.asp?sitearea=PED Accessed May 19, 2005 and December 2007.

National Advisory Committee on Health and Disability. Guidelines for smoking cessation: revised 2002. Available at: http://www.guidelines.gov/summary/summary.aspx?doc_id=3307&nbr=2533&string=smoking+AND+cessation Accessed May 19, 2005 and December 2007.

Medline Plus. Nicotine Vaccine Helps Smokers Quit, Study Finds. Available at: http://www.nlm.nih.gov/medlineplus/news/fullstory_24680.html Accessed May 19, 2005.

National Cancer Institute. Secondhand Smoke: Questions and Answers. Available at: http://cis.nih.gov/fact10_18.html Accessed May 19, 2005.

National Institute of Drug Abuse. NIDA InfoFacts: Cigarettes and Other Nicotine Products. Available at: http://www.nida.nih.gov/Infofacts/Tobacco.html. Accessed May 19, 2005 and December 2007.

Roddy, Elin. Bupropion and other non-nicotinic pharmacotherapies. British Medical Journal. February 2004, Volume 328, pg. 509-511.

Chantix [package insert]. Pfizer Labs. NY, NY. May 2006.

Smoking Cessation Health Condition Last Updated: December 2007

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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