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In This Report

•	Highlights
•	Introduction
•	Risk Factors
•	Failure to Quit
•	Quitting Smoking
•	Lifestyle Changes
•	Resources
•	References

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Smoking

Highlights

Treatment News

• A 2005 report showed that smokers who took the antidepressant drug nortriptyline were 2.4 times more likely to abstain from smoking for at least 6 months compared to those who didn’t take the drug. Another antidepressant, buproprion, provided slightly better long-term abstinence rates than nortriptyline, but the difference was not statistically significant. The study authors recommend nortriptyline as a first-line therapy for smoking cessation. Nortriptyline costs less than buproprion, but has more side effects. It has generally been considered a second choice for smoking cessation.
• Rimonabant (Acomplia), a drug used to treat obesity, is showing promise as a smoking cessation agent. The drug is a selective CB1 blocker. It acts on the body’s endocannabinoid system, which plays a role in tobacco dependence. Large-scale trials are underway.

Smoking Risks

• Diabetes. Smoking may increase the risk of developing diabetes. Researchers involved in the Insulin Resistance Atherosclerosis Study (IRAS) looked at the relationship between smoking and diabetes and found that 25% of smokers who started the trial with normal blood sugar had diabetes five years later, compared to 14% of non-smokers The results are published in the September 2005 journal Diabetes Care.
• Weight Control. Smokers who think their habit keeps their weight under control may be doing exactly the opposite. A study in the journal Obesity Research has found that smokers distribute fat differently than former smokers and those who have never smoked. Specifically, the smokers in the study had bigger bellies than the non-smokers.
• Secondhand smoke. A 2005 study showed an increased risk of asthma in children whose grandmothers smoked while pregnant with the child’s mother.

Smoking Rates Decline

A summary of the most recent smoking statistics show a general downward trend in smoking across a wide range of age groups and ethnicities. Rates dropped significantly among young adults, from 28.5% to 23.9% in one year.

Introduction

More than 20% of adult American smoke, according to a 2005 report by the U.S. Centers for Disease Control and Prevention (CDC). The risk varies by age, ethnic group, and geographic location. Over the past 10 years, smoking has continued to decline among older adults. Although for many years smoking rates were not declining among young people, this trend is now changing for the better. Among those aged 18 to 24, smoking rates have dropped from 28.5% to 23.9% in only one year. Some 45.4 million Americans continue to smoke.

The addictive effects of tobacco have been well documented. It is considered to be mood and behavior altering, psychoactive, and abusable. As a multisystem pharmacological agent that is voluntarily administered, tobacco is believed to have an addictive potential comparable to alcohol, cocaine, and morphine. Tobacco and its various components increase the risk of cancer (especially in the lung, mouth, larynx, esophagus, bladder, kidney, pancreas, and cervix), heart attacks and strokes, and chronic lung disease.

Smoking in Childhood and Adolescence

Smoking rates among high school students increased during most of the 1990s but have been declining since 1997. About 28.5% of high school students smoke, down from 36.4% in 1997. Caucasian and Hispanic students were more likely to smoke than African Americans. Still, 63.9% of high school students had tried cigarettes, and in some states, more than 20% of those in middle school smoke. Each day, more than 5,000 young people try cigarettes, more than 3,000 of whom become regular smokers. Smoking is often immediately addictive: Adolescents who have smoked 100 cigarettes or more, according to one report, are generally not able to quit even if they want to.

In the past, advertising was responsible for a third of teenage smoking. New regulations have made it much more difficult for advertisers to promote smoking to young people, but many students are still taking up smoking, despite stepped-up anti-smoking campaigns. Nevertheless, a 2002 survey found that smoking occurs in more than 85% of box office hits. It is almost always depicted in a positive light, which appears to be a major influence on the attitude toward smoking in children and adolescents.

The most important steps for preventing smoking in children is for parents to not smoke and to let their child know that they disapprove of smoking. One study reported that preschoolers whose parents smoke are more likely to view themselves as future smokers. And conversely, another found that schoolchildren who believed that both their parents strongly disapproved of smoking were less than half as likely to take up the habit as those who felt their parents were more lax. (Interestingly, in that study, parental disapproval had an equally strong effect regardless of whether the parents themselves smoked.)

Other research has supported these findings. In one study, children whose television and music-listening habits were closely monitored by their parents were less likely to drink, use drugs, and smoke cigarettes. Neglected children, or children with absentee parents, were four times as likely to abuse drugs, drink, and smoke than children living with parents who were regularly present and who mandated a structured lifestyle. In a 2002 study, children who regularly attended religious services were also less likely to smoke.

Doctors can have a major effect on young people. However, in one survey, less than half of teenagers had ever been asked by their doctors if they smoked or counseled not to smoke, even though most teen smokers said they would admit to it if asked.

Gender and Age

More American men smoke 24.1% than women do 19.2%. However, women face great health hazards and it is harder for them to quit.

Older people in general are less likely to be smokers. Among people aged 45 to 64 years, about 22% are smokers, and the rate drops to 9.1% among those aged 65 and older.

Ethnicity

About 26% male Americans are smokers. The trend varies by ethnicity. The following list shows how many men in that ethnic group are estimated to be smokers. For example, Native American men are more likely to smoke than Asian males.

• Native Americans (29.1%).
• African American (26.1%).
• Caucasian American (25.9%).
• Hispanic American (24%).
• Asian (21%).

Among adult American women, about 21% of whom are smokers, the break down is as follows:

• Native American (42.5%).
• Caucasian American (22.4%).
• African American (20.9%).
• Hispanic American (13.3%).
• Asian/Pacific Islanders (7.6%).

Geography

Geographic factors can affect smoking and rates vary by states:

• Highest rates (listed in order of highest to lowest): Kentucky, Oklahoma, West Virginia, Ohio, Indiana, Nevada, South Carolina, and Alaska. (West Virginia, Kentucky, and South Carolina are all tobacco-producing states.)
• Lowest rates (listed in order of lowest to highest): Utah, California, Massachusetts, Idaho, Nebraska, Oregon, Hawaii, Connecticut, and Washington, DC.

In general, smoking prevalence is highest in the Midwest and South and lowest in the Northeast and West. Utah has the lowest rate of smoking in the United States.

As of 2003, however, most states in the US have failed to reach their quit goals. In fact, between 1996 and 2001 there was no change in prevalence in 41 states and DC and many states experienced an increase in smoking. There was a steady reduction in smoking only in Georgia, Tennessee, and Utah. California, Delaware, Maryland, New York and Vermont are among those states with the strictest anti-smoking laws.

Educational Level

A major government study reported that people with a high school education or below have higher smoking rates (33.9%) than those educated beyond college (8.4%).

Psychologic Factors

Psychologic factors play a major role in people's susceptibility to smoking.

People with low self-esteem and adolescents with behavioral problems have a higher risk for smoking.

Depression and schizophrenia are known risk factors for smoking and both may actually have biologic effects that are responsible for this higher risk. Indeed, nicotine may stimulate receptors in the brain that improve mood in certain people with depression and affect receptors that improve symptoms in schizophrenia.

Genetic Factors

Evidence now strongly supports genetic factors as a major risk factor for nicotine dependence, and researchers are now targeting specific genes that may be responsible. Among the findings is a common genetic vulnerability to both nicotine and alcohol dependence. (For some people who wish to stop drinking as well as smoking, a dual recovery process can be effective.)

Economic Factors

Some studies suggest that the cheaper it is to smoke the more widespread smoking will be. For example, states that have low excise taxes on cigarettes have a high proportion of smokers. And, conversely, making it more expensive to smoke could reduce the number of smokers.

Risk Factors

Effects on Male Fertility and Impotence

Smoking also negatively affects male sexuality and fertility. Heavy smoking is frequently cited as a contributory factor in impotence in men because it decreases the amount of blood flowing into the penis. One study noted, for example, that among men with high blood pressure, smoking causes a 26-fold increase in impotence.

Smoking also affects fertility. It impairs sperm motility, reduces sperm lifespan, and may cause genetic changes that affect the offspring. One 2002 trial found that men or women who smoke have lower success rates with fertility treatments. An earlier study reported that men who smoke also have lower sex drives and less frequent sex.

Effects on Pregnancy and Infertility

Studies have now linked cigarette smoking to many reproductive problems. Women who smoke pose a greater danger not only to their own reproductive health but, if they smoke during pregnancy, to their unborn child. Continuing to smoke also may cause health problems in the growing child.

Female Infertility. Some of the negative effects of smoking on female fertility include the following:

• Greater risk for infertility. Women at greatest risk for fertility problems are those who smoke one or more packs a day and who started smoking before age 18.
• Earlier menopause. Women who smoke tend to start menopause at an earlier age than nonsmokers, perhaps because toxins in cigarette smoke damage eggs.
• Greater risk for ectopic pregnancy and miscarriage.

Click the icon to see an image of an ectopic pregnancy.

One intriguing study found that mothers or fathers who smoke a pack or more a day are more likely to have daughters than sons. The likelihood of having a male child was lowest when both parents smoked.

Effects on Unborn Child. Smoking during pregnancy is harmful to an unborn child in many ways:

• Pregnant women who smoke increase the risk for stillbirth, prematurity, and low birth weight in their babies. Infant mortality rates in pregnant smokers are increased by 33%, mostly because of low birth rate. Some women carry particular genes that may make it especially likely that they will deliver low birth weight infants if they smoke, although newborns of all female smokers have a greater risk for low weight. The good news is that women who quit before becoming pregnant or even during the first trimester reduce the risk for a low birth weight baby to that of women who never smoked.
• Children of mothers who smoke during pregnancy may also be at increased risk for obesity and diabetes.
• Smoking reduces the mother's folate levels, a B vitamin that is important for preventing birth defects.
• A 2003 study also suggested that smoking during pregnancy can have harmful neurologic effects on newborns, and, furthermore, these infants may have to endure withdrawal symptoms after birth.

Unfortunately, the standard cessation aids (nicotine replacement, antidepressants) are not appropriate for pregnant women. Women who want to become pregnant should use these aids before they try to conceive and make all attempts to quit.

Effects of Secondhand Smoke on Children. An estimated four million children a year get sick from exposure to secondhand smoke. Parental smoking has been shown to affect the lungs of infants as early as the first 2 to 10 weeks of life, and such abnormal lung function could persist throughout life.

A number of studies have reported associations between smoking parents and childhood illnesses.

• Parental smoking is believed to increase the risk for lower respiratory tract infections (such as bronchitis or pneumonia) by 50%. Environmental exposure to smoke is thought to be responsible for 150,000 to 300,000 such cases of such every year.
• Exposure to secondhand smoke in the home increases the risk for asthma and asthma-related emergency room visits in children who have existing asthma.
• Smoking in pregnant women and new mothers is strongly linked to sudden infant death syndrome (SIDS) in their children.
• Parental smoking has been linked to recurrent ear infections and eczema.

If new mothers cannot quit, they should be sure not to smoke in the same room as their infant. This simple behavior can considerably reduce the risks to the child.

Note: Of some encouragement is the fact that in one study, people who had been exposed to tobacco smoke as children did not appear to have any higher risk for lung cancer later on.

Effects on Bones and Joints

Smoking has many harmful effects on bones and joints:

• Smoking can keep new bone from forming. Women who smoke are at high risk for loss of bone density and osteoporosis.

Click the icon to see an image of osteoporosis.

• Postmenopausal women who smoke have a significantly greater risk for hip fracture than those who do not.
• Smokers are more apt to develop degenerative disorders and injuries in the spine.
• Smokers have more trouble recovering from surgeries, including knee or hip replacements.
• Smokers whose jobs involve lifting heavy objects are more likely to develop low back pain than nonsmokers.
• In women, smoking may also pose a small increased risk for developing rheumatoid arthritis. Women smokers or ex-smokers who have rheumatoid arthritis, especially those with a particular genetic makeup, may also have a more severe form of the disease.

Click the icon to see an image of rheumatoid arthritis.

Smoking and the Gastrointestinal Tract

Smoking increases acid secretion in the stomach. It also reduces blood flow and production of compounds that protect the stomach lining.

Diverticulitis. A 2000 study suggested that smoking was a major risk factor in diverticulitis, a condition in which small bumps develop in the wall of the colon. In addition, smokers were at risk for its complications, including bleeding and abscess. Diverticulitis mostly affects people over 50 years of age.

Inflammatory Bowel Disease. Smoking has mixed effects on inflammatory bowel disease.

Click the icon to see an image of inflammatory bowel disease.

Smokers have lower than average rates of ulcerative colitis, but higher than average rates of Crohn's disease. In fact, smokers with Crohn's disease who quit experience a much less severe course.

Peptic Ulcers. Results of studies on the effect of smoking on ulcers are mixed. Some evidence suggests that smoking delays the healing of gastric and duodenal ulcers. One 1999 study reported that after ulcers healed, about half of smokers relapsed after a year and that all heavy smokers relapsed after three months. Other studies, however, have found no increased risk for ulcers in smokers, and smoking does not appear to increase susceptibility to H. pylori, the bacteria that causes many peptic ulcers. This should not give smokers any comfort, however, given the proven dangers from smoking.

Click the icon to see an image of peptic ulcers.

Hepatitis and Cirrhosis. Smoking is linked to increased liver scarring (cirrhosis) caused by either excessive drinking or chronic hepatitis B or C viruses.

Smoking and Thyroid Disease

Hyper- and Hypothyroidism. Cyanidem, found in tobacco smoke, interferes with thyroid hormone production. Smoking triples the risk for developing thyroid disease, particularly autoimmune hyper- and hypothyroidism. Women smokers with subclinical hypothyroidism, a symptom-free condition in which the thyroid gland is mildly underactive, face an increased risk for developing full-blown hypothyroidism than their nonsmoking peers. Smoking may also increase the negative effects of hypothyroidism on the heart. Smoking has also been linked to goiter, a swelling of the thyroid that occurs in people who don't get enough iodine.

Click the icon to see an image of the thyroid.

Smoking and Surgical Recovery

Smokers are at increased risk for heart and circulatory problems and delayed wound healing after surgery. In one study, patients who were able to cut down or quit smoking six to eight weeks prior to knee or hip replacement surgery were much less likely to suffer complications.

Smoking and Disorders Related to Aging

People who smoke also endanger other parts of their bodies as they age. The following are age-related conditions that occur at higher rates in smokers than non-smokers:

• Cataracts, importantly the type of cataract that most severely limits vision. Quitting smoking lowers the likelihood of needing cataract surgery in the future, although not to the level seen with non-smokers.

Click the icon to see an image of a cataract.

• Macular degeneration, a leading cause of blindness in older people.
• Gum disease, and therefore tooth loss.
• Wrinkles. Studies in multiple ethnic groups confirm that smokers are nearly five times more likely to develop more and deeper wrinkles as they age compared to non-smokers.
• Baldness and premature gray hair.
• Hearing loss, particularly high-frequency hearing loss. Some experts believe that losing the ability to hear high pitched sound in smokers may be due to a decrease in blood flow to the cochlea, the part of the ear that carries sound to the brain.
• Incontinence. One study of 600 women indicated that smokers and former smokers are twice as likely to develop incontinence than women who never smoked.

Failure to Quit

Biologic, psychological, behavioral, and cultural factors all play a role in nicotine addiction, making it one of the hardest addictions to kick. Although nearly a quarter of American adults continue to smoke, the great majority of them want to quit. Unfortunately, quitting is very difficult. In one study of women smokers who said they wanted to stop smoking, 80% of them were unable to. About half of people who quit return to smoking. Even after years of not smoking, about 20% of ex-smokers still have occasional cravings for cigarettes.

Some experts that the three major areas responsible for the inability to quit are the following:

• Mental Performance. Nicotine improves concentration and thinking, and stopping temporarily impairs it.
• Stress. Although smoking many not reduce stress, stopping certainly increases it.
• Weight gain. People gain an average of five to 10 pounds when they quit.

Depression is also an important factor for relapse in many people. The first two weeks are critical in determining quitting failure rates, so smokers should not be shy about seeking all the help they can during this period. Although withdrawal symptoms can be intense, treatments are now available to reduce them. Withdrawal symptoms, even intense ones, do not fully explain why so many people fail to quit and why so many relapse. The smoker is up against an army of obstacles to quitting.

In any case, the attempts to quit are never a waste of time, since the amount of smoking is reduced during these periods. People who keep trying still have a fifty-fifty chance of finally quitting.

Individual Risk Factors for Failure

Researchers have been trying to discover individual risk factors or sets of behaviors that can help predict why specific people fail to quit. Some factors include:

• Being female.
• Being a heavy smoker.
• Inhaling deeply.
• Being a long-term smoker.
• Having severe withdrawal symptoms.

Among many studies, however, only one found a single consistent factor for failure to quit:

Cheating during the first two weeks of withdrawal, even with the patch, nearly guarantees smoking again in six months. In one study, nearly half of the people who did not cheat during the first two weeks were still not smoking after six months.

The many methods of quitting smoking include counseling and support groups, nicotine patches, gums and sprays, and incremental reduction.

Addictive Aspects of Nicotine

Nicotine addiction involves biologic, psychological, behavioral, and cultural factors, and some researchers feel it is as addictive as heroin. In fact, nicotine has actions similar to cocaine and heroin in the same area of the brain.

Depending on the amount taken in, nicotine can act as either a stimulant or a sedative. Cigarette smoking (either the nicotine or the oral process of smoking itself) has definite immediate positive effects:

• It relieves minor depression.
• It helps suppress little fits of anger.
• It enhances concentration and short-term memory.
• It produces a modest sense of well being.
• Whether nicotine reduces stress is uncertain. Some evidence suggests that it reduces symptoms of stress in women although it may increase them in men.

The addictive process of smoking has a specific daily cycle:

• Heightened Effects of First Few Cigarettes. Most smokers have a special fondness for the first cigarette of the day because of the way brain cells respond to the day's first nicotine rush. Nicotine, particularly taken in the first few cigarettes of the day, increases the activity of dopamine, a chemical in the brain that elicits pleasurable sensations, a feeling similar to achieving a reward.
• Gradual Tolerance. Over the course of a day, however, the nerve cells become desensitized to nicotine. Smoking becomes less pleasurable, and smokers may be likely to increase their intake to get their "reward." A smoker develops tolerance to these effects very quickly and requires increasingly higher levels of nicotine.

Withdrawal Symptoms in the First Two Weeks

Withdrawal is a difficult process, but treatments have been developed to reduce its effect. Abstaining from all cigarettes during first two weeks of quitting are critical in achieving success, so smokers should not be shy about seeking all the help they can during this period.

Withdrawal symptoms begin as soon as four hours after the last cigarette, generally peak in intensity at three to five days, and usually disappear after two weeks, although some may persist for several months. The symptoms of withdrawal include both physical and mental difficulties.

Physical Symptoms. During the quitting process people should consider the following physical symptoms of withdrawal as if they were recuperating from a disease and treat them accordingly as they would any physical symptoms:

• Tingling in the hands and feet.
• Sweating.
• Intestinal disorders (cramps, nausea).
• Headaches.
• Respiratory symptoms as the lungs begin to clear, including sore throats, coughing, and other signs of colds.

Mental and Emotional Symptoms. Tension and craving build up during periods of withdrawal, sometimes to a nearly intolerable point. One European study found that the incidence of workplace accidents increases on No Smoking Day, a day in which up to two million smokers either reduce the amount they smoke or abstain altogether.

Nearly every moderate to heavy smoker experiences more than one of the following strong emotional and mental responses to withdrawal:

• Feelings of being an infant: temper tantrums, intense needs, feelings of dependency, and a state of near paralysis.
• Insomnia.
• Mental confusion, vagueness, or difficulty concentrating.
• Irritability, restlessness, impatience, or anger.
• Anxiety.
• Depression, which is common during withdrawal and over the long term. In the short term it may mimic the feelings of grief felt when a loved one is lost. As foolish as it sounds, a smoker should plan on a period of actual mourning in order to get through the early withdrawal depression.

Long-Term Depression

There is a significant association between cigarette smoking and a susceptibility to depression. People who are prone to depression face a 25% chance of becoming depressed when they quit smoking, and this increased risk persists for at least 6 months. What's more, depressed smokers have a very low level of success. Only about 6% remain smoke-free after a year. There are strong reasons for this:

• Smoking may be masking depression, which can become severe even after the early stages of withdrawal have passed.
• For some smokers, the future physical damage incurred by smoking is an abstraction, which fails to motivate quitting when measured up against the very real emotional pain triggered by nicotine withdrawal.
• Not only does the smoker suffer, but the negative emotions often harm relationships with friends and family, who might even urge the ex-smoker to take up cigarettes again.

People who suffer from depression while quitting might do better using a combination of emotionally supportive therapy (as opposed to behavioral therapy), nicotine replacements, and antidepressants, such as bupropion (Zyban). If severe depression lasts beyond the withdrawal period, professional help should be sought as soon as possible.

Weight Gain

Quitting smoking does increase the risk for weight gain--with an average gain of five to 10 pounds. Studies are mixed on whether this weight gain is permanent in most smokers or not. Certainly, it is a major factor in relapse.

Effects of Smoking on Calories. Smoking uses up calories--about 200 a day according to one study. A 1999 study reported that smoking increases energy expenditure in men by 3.6% at rest and by 6.3% during physical activity. (Actually, the higher level during exercise was only because the men inhaled more deeply during that time.)

Reasons for Weight Gain after Quitting. Quitting can add five or more pounds, due to the following reasons:

• Obviously, the body is working better. After quitting, the body's metabolism slows down, and food is digested more efficiently.
• Insulin levels increase, enabling the body to process more sugar for energy.
• People snack as an oral substitution.

How to Keep the Weight Off After Smoking. Exercise can be very helpful in controlling weight. To use up the 200 calories gained from quitting smoking, one need only take an extra 15-minute daily walk and eliminate 100 calories a day from meals. Even a moderate increase in physical activity among middle-aged women who have quit smoking can help keep weight gain to a minimum.

Using Zyban, nicotine gum, or both also appears to help protect against weight gain, at least while these drugs are being used.

A small study suggested that drinking caffeinated beverages (such as coffee or tea) while on nicotine replacement may enhance energy expenditure and so may help prevent weight gain. Avoid drinking coffee in the evening, however, since sleep disturbances can be a problem during withdrawal.

Quitting Smoking

Quitting is extremely difficult. No one should be discouraged if they relapse. Everyone should keeping trying to quit. With continued efforts, many people succeed.

At this time perhaps the most effective method for quitting is a combination of the following:

• Nicotine replacement products for reducing withdrawal symptoms and craving.
• The antidepressants bupropion (Zyban) or nortriptyline (Pamelor, Aventyl). These agents reduce emotional effects and also cravings associated with withdrawal and improve abstinent rates.
• Professional counseling or support organizations. Outside help may be very effective in concert with the other agents in helping people maintain abstinence.

Cold Turkey

About 4% of smokers who quit without any outside help succeed. Nevertheless, most people try to quit alone and many have reported activities that can help the process of withdrawal. The primary obstacle in trying to quit alone is making the behavioral changes necessary to eliminate the habits associated with smoking. Excellent books, tapes, and manuals are available and are strongly recommended to help people who want to quit without other assistance.

Nicotine Replacement

Nicotine Replacement Products and Success Rates. Nicotine replacement products provide low doses of nicotine that do not contain the contaminant found in smoke. They relieve cravings for nicotine and ease the symptoms of withdrawal. Nicotine replacement products include over-the-counter products (nicotine patches, gum, lozenges) and prescribed brands (nasal sprays, inhalers). They generally benefit moderate to heavy smokers most but appear to have little effect for light smokers (less than 15 cigarettes a day). Evidence to date suggests that all nicotine replacement products are equally effective. The different forms can also be used together, which might improve quitting rates.

Between 10 - 20% of people who use nicotine replacements alone will abstain for at least a year. However, only about half of these will remain nonsmokers indefinitely--about the same rate as a placebo (a sham agent). Simply reducing withdrawal symptoms, then, is insufficient for long-term abstinence.

Adding specific antidepressants, such as bupropion (Zyban) or and nortriptyline (Pamelor, Aventyl), may be critical for improving these rates.

Tips for All Nicotine Replacement Products:

• Not cheating on the very first day of nicotine-replacement use increases the chance of quitting permanently by tenfold.
• The more cigarettes a patient smokes, the higher the dose of nicotine replacement may be required at the start.
• Adding a counseling program may boost the effect of any nicotine replacement program. One study reported a quit rate of 30.5% after a year in patients who wore the patch and attended a quit-smoking program.
• No one should smoke while using nicotine replacement. It can cause nicotine to build up to toxic levels.
• Nicotine replacement helps prevent weight gain while it is being used, but people are still at higher risk for gaining weight when they stop all nicotine. It should be noted that a small study suggested that caffeine enhanced nicotine's energy expenditure and so may help prevent weight gain. Moderate caffeine intake may also have antidepressant properties.

Side Effects. Side effects of any nicotine replacement product may include headaches, nausea, and other gastrointestinal problems. People often experience sleeplessness in the first few days, particularly with the patch, but the insomnia usually passes. Patients using very high doses are more likely to experience symptoms, and reducing the dose can prevent them.

Special Concerns for Specific Individuals. Certain individuals may need to be aware of some concerns with nicotine replacement products. Most studies have been conducted using the patch, but results may apply to other replacement products as well.

• People with Heart Disease. There has been some concern that the patch might be harmful for people with heart or circulatory disease, but studies are finding that it poses no danger for these individuals. In fact, it may help reduce angina attacks brought on by exercise. Nevertheless, unhealthy cholesterol levels (lower HDL levels) caused by smoking remain abnormal with the use of nicotine replacement (at least with the use of the patch). HDL levels improve when all nicotine is stopped.
• Pregnant Women. Nicotine replacement may not be completely safe in pregnant women, although it has been used successfully in this group without ill effect. There is an increase in heart rates in fetuses of women who use the patch as compared with those who smoke. Because this may be an indication of fetal stress, pregnant women are cautioned to remove the patch before bedtime.
• Adolescents. Nicotine replacement is safe for adolescents.
• Small Children. Nicotine is a poison and all nicotine products should be kept safely away from small children. A parent should call a physician or a poison control center immediately if a child has been exposed to a nicotine replacement product, even for a short duration. Parents should also call the doctor if a small child has been exposed to a nicotine product and has any symptoms, including stomach upset, irritability, headaches, a rash, or fatigue.

Warnings Against Long-Term Use. No one should use these replacement therapies as a long-term substitute for smoking. Any nicotine replacement therapy should be temporary and directed at quitting. In one study, use of nicotine gum for more than a year was associated with insulin resistance, an abnormality that occurs in diabetes. Some studies have now suggested that nicotine itself may have properties that increase the risk for cancer, independent of carcinogenic chemicals in smoke. More studies are needed, however, and nicotine replacement therapy is still a better alternative to smoking.

Nicotine Patches. Nicotine patches, or transdermal nicotine, delivers nicotine through the skin and is effective in reducing symptoms during withdrawal. They are available over the counter. They are probably the best nicotine replacement products for people with asthma or other chronic lung problems, but it is best to consult a doctor before using them, particularly people with medical problems.

The many methods of quitting smoking include counseling and support groups, nicotine patches, gums and sprays, and slowly cutting back on the number of cigarettes smoked (incremental reduction).

The patch products available have different approaches:

• The Step-Down Approach. The step-down approach employs patches (such as NicoDerm CQ)  that come in three strengths (21, 14, and 7 mg). The patient uses the strongest dose first and reduces it gradually over a period of 8 to 10 weeks. The initial set of large patches is replaced after about three weeks with a smaller, less potent set. A 21 mg patch, for example, is about equal to 15 cigarettes. A heavy smoker may therefore need to wear two patches at first.
• Single-Step Approach. The single-step patch (Nicotrol) can be taken off after 16 hours and replaced 8 hours later. It can only be taken for six weeks.

In both approaches, the patches are applied and used in similar ways:

• A single patch is worn each day and replaced after 24 hours.
• To avoid skin irritation it is applied to different hairless locations above the waist and below the neck each day. (Transparent patches are now available, which expand the body areas for application.)
• People can wear the patches for 24 hours, but some have reported odd dreams and have disliked the sensation of the patch during the night. People who wear the patch all the time, however, have fewer withdrawal symptoms and slightly better abstinence rates than those who take it off at night.
• Patches should be stored and discarded safely, particularly in homes with small children. Small children have been poisoned and gotten sick from wearing, chewing, or sucking on nicotine patches. There have been no reports of death from children who have been poisoned.
• The FDA recommends using the patches three to five months, although some studies suggest that using it for eight weeks achieves the maximum benefits.

Special precautions should be made if children are exposed to the patches:

• Children should not come in contact with the patches, even while the smoker is wearing them.
• If the child has worn the patch, the affected skin should be washed right away.
• Urgent medical care may be required if the child has eaten nicotine or worn a patch for a prolonged time. (The hazard increases if the child has been exposed to more than one patch or one that has not been used.)

Nicotine Gum. Nicotine gum (Nicorette) is available over the counter and has helped many people to quit. Some prefer it to the patch because they can control the nicotine dosage and chewing satisfies the oral urge. (A new fast-acting gum, not yet released, relieves cravings more quickly and may help reduce early relapse rates.)

Some tips for using the gum are as follows:

• Patients starting to quit chew one to two pieces each hour. A smoker should not chew more than 20 pieces a day.
• The goal is to stop using the gum by 6 months, but about 3% of people continue to use it long after they have quit smoking.
• The gum must be chewed slowly until it develops a peppery taste. It is then tucked between the gum and cheek where it is stored so that the nicotine can be absorbed.
• Coffee, tea, soft drinks, and acidic beverages may interfere with nicotine absorption, so people should wait at least 15 minutes after drinking before chewing a piece of gum.

Some people prefer other methods or cannot use the gum for the following reasons:

• They find the gum unpleasant tasting.
• Side effects specific to the gum may include upset stomach, mouth ulcers, hiccups, and throat irritation.
• They are embarrassed chewing gum.
• They wear dentures.

Long-term dependence may be a problem with the gum. Although such dependence is probably safer than smoking, research is needed to confirm this, and experts recommend chewing the gum for no more than six months.

The Nicotine Inhaler. The nicotine inhaler resembles a plastic cigarette holder. It comes with a number of nicotine cartridges, which are inserted into the inhaler and "puffed" for about 20 minutes, up to 16 times a day. The dose is gradually decreased. It requires a prescription in the US. A number of studies have reported that the inhaler triples abstinence rates (between 17% and 28%) compared with placebo (6% to 9%) after 6 months. It has some specific advantages over other nicotine replacement products:

• The inhaler provides varying doses of nicotine on demand (as opposed to continuously with the patch or the gum) and is relatively fast-acting. Blood nicotine levels peak about 20 minutes after using the inhaler, comparable to the gum and faster than the 2 to 4 hours seen with the patch.
• It satisfies oral urges.
• Most of the nicotine vapor is delivered in the mouth, not into the lung airways (although some people experience mouth or throat irritation and cough).

Using a combination of the inhaler and the patch may be particularly effective. In one study, the combination led to an abstinence rate of over 60% after 6 weeks. While this percentage dropped off over time, it was still a marked improvement over the use of the inhaler and a placebo patch.

The Nicotine Nasal Spray. The nasal spray satisfies immediate cravings by providing doses of nicotine rapidly and thus may play a useful role in conjunction with slower-acting nicotine replacement therapies. (Nicotine levels peak within five to ten minutes after administering the spray). The spray can irritate the nose, eyes, and throat, so it may not be suitable for those with allergies or sinus infections. Most people, however, can tolerate the side effects, which usually subside within the first few days.

Nicotine Lozenge. A nicotine lozenge (Commit) is now available over the counter. It is made from pressed tobacco and comes in two strengths for heavier or lighter smokers. In a large 2002 study, 15 - 18% of smokers who used it remained smoke free, compared to 6 - 10% who were given a dummy lozenge. Side effects included heartburn, hiccups, nausea, headaches, and cough. It also contains phenylalanine, a chemical that certain people may need to avoid.

Antidepressants

Evidence to date suggests that the antidepressants bupropion (Zyban) and nortriptyline (Pamelor, Aventyl) have specific actions that may help reduce nicotine action and can be very effective, even in people without depression. Quit rates with either of these agents are as high as 30%. Long-term abstinent rates are more than twice those of placebo. Most other antidepressants, including fluoxetine (Prozac), perhaps the best known antidepressant, have no additional benefits for smokers.

Bupropion (Zyban). The unique antidepressant bupropion (Zyban) is proving to be a strong aid in the quitting process. It differs from most other antidepressants because it increases the effects of dopamine, the brain chemical that appears to play a strong role in nicotine addiction. People should take Zyban only as directed by their physician.

The usual recommended dosing is 150 mg tablet twice a day. No single dose should be higher than 150 mg. In one comparative study reported by the manufacturer, quit rates were with abstinence rates at 12 weeks ranging from 20% with 100 mg/day to 25% at 300 mg/day. (It should be noted that other studies report significantly higher quit rates, particularly in combination with nicotine replacement.) Zyban is equally effective in African American and Caucasian smokers. Many people quit smoking one to two weeks after starting, although the drug is typically prescribed for seven to 13 weeks.

In people who are not depressed, there is no noticeable effect on mood. People who are depressed generally report better spirits and more energy, although in a few cases depression worsened.

People tend to maintain their weight after quitting while they are on the drug. A 2001 study indicates that Zyban is most effective while it is being taken, and some people may need to take it for a year or longer to increase the duration of abstinence and perhaps maintain weight loss.

Studies are mixed on whether Zyban is effective for relapse. In one 2001 study, those who were retreated with the drug still had a significantly better abstinence rate (20% at 12 weeks) than those on placebo (3%). Not all studies are as positive, however.

Side effects include gastrointestinal problems, headaches, insomnia, dry mouth, and irritation. In very rare cases, seizures have occurred, although usually in people who exceeded the recommended dose or who already had risk factors for seizures.

Nortriptyline. Antidepressants known as tricyclics may also be beneficial, since they have additional effects, independent of reducing depression, that may help smokers. The tricyclic nortriptyline (Pamelor, Aventyl) has been specifically studied for helping smokers. It is best to start taking the medication 10 to 28 days before the quit date. Studies have reported quit rates of between 14% and 24%. Side effects of this drug include dry mouth and changes in taste. It should be noted that in rare cases, tricyclics can have serious side effects, and overdose can be fatal. Tricyclics may pose a danger for some patients with certain types of heart disease.

Behavioral Methods

Smokers who use outside help have the best record for quitting, with success rates of between 25% and 35%. (Those who are counseled in addition to using nicotine replacement and Zyban have the best chance.) Behavioral methods can be very helpful, including changing specifically or indirectly related to smoking and learning ways to cope and solve problems associated with smoking. Telephone hotlines offering counseling also help, especially when smokers receive follow-up calls. Brochures, audio tapes, and other self-help materials are often ineffective when used alone but may be helpful in conjunction with a counseling program.

The following are descriptions of some behavioral approaches that may help.

Problem Solving or Coping Strategies. Smokers who learn thinking (cognitive) and behavioral techniques for breaking the link between certain cues and smoking, stress management techniques, and ways to handle the symptoms of withdrawal and the urge to relapse are more likely to be successful in quitting. The more intense the counseling program, the better. Smokers should look for programs that include the following:

• 20 to 30 minute session lengths.
• Four to seven sessions.
• Two week program duration.
• An additional two weeks or more of follow-up contacts.

The Staged Approach. The intent of the staged approach is to plan quitting intervention customized for each individual rather than imposing some general method for quitting. The approach takes the smoker through six stages with behavioral interventions at each point:

• Pre-contemplation.
• Contemplation.
• Preparation.
• Action.
• Maintenance.
• Termination.

Although some studies report this approach is significantly more effective than non-staged methods, an analysis of 23 trials did not find the staged approach to be any more effective than other methods. Most studies, however, were weak and better research is needed on this approach.

Stages for Adopting Healthy Behavior

For a person to successfully adopt a more healthy behavior -- whether it's to exercise more, lose weight, or stop smoking -- it's not as simple as just deciding to do it. Behavior change expert James Prochaska and his colleagues outlined a theory, which has been supported by numerous studies, showing that people cycle through a variety of stages before a new behavior is successfully adopted over the long term. It may help you to understand how this works. As you read the description of each stage -- specifically as it relates to smoking -- you may find yourself nodding and saying to yourself, "Yes, that's me!"

Stage 1: Pre-Contemplation.

People at this stage have no plans or desire to stop smoking. They aren't even considering quitting. People at this stage are generally unaware of the specific benefits that quitting can bring. Or, they may simply have "failed" in the past and have given up. There's no point in talking about how to start a cessation program if you are at this stage. Instead, it is important to think about why quitting might be good for you personally -- by helping you to feel better, have more confidence, or live longer. The benefits must be identified before a person will consider quitting. If you are at this stage, a good activity is to ask several friends or family members why they quit. That may unveil real-life benefits and inspire enough interest to compel you to take the next step.

Stage 2: Contemplation.

A person at this stage is thinking, "I think I should probably quit, but I need help getting started." People at this stage know that quitting is good for them, but it seems like a daunting task or they don't think they can pull it off. Some may have tried and "failed" in the past, but they are still receptive to another go-round. It's important for people at this stage to consider some of the truths and falsehoods of quitting. There is no such thing as "failure" -- it is never too late to try again. If you are at this stage, a good activity is write down (brainstorm) all your potential roadblocks -- the things that you believe make quitting difficult -- and to learn strategies for overcoming or side-stepping those hurdles. There are many ideas available on the internet. People at this stage might benefit from making a pledge, contract, or other commitment that they are going to get more active in the near future. Prochaska and his colleagues write that people in this stage are "aware of the pros of changing but are also acutely aware of the cons. This balance between the costs and benefits of changing can produce profound ambivalence that can keep people stuck in this stage for long periods of time. We often characterize this phenomenon as chronic contemplation or behavioral procrastination." Thus, the goal is to get un-stuck by identifying the roadblocks, ways to overcome these hurdles, and making a commitment.

Stage 3: Preparation.

These folks are primed and motivated. They are ready to quit. The goal of this stage is to create a specific action plan that takes all factors into account, so that the "smoke out" is successful. People at this stage need to know what methods work and what support exists to help them. If you are at this stage, you should consider some backup plans -- what to do when the urge to smoke hits you. That way you are prepared to overcome that hurdle when it happens. And you should be aware of what to realistically anticipate how you'll feel at the beginning.

Stage 4: Action!

People at this stage have just quit. This stage is where the most behavior change occurs - these folks have recently quit, or cut down, but it is not yet a long-term, ingrained habit. Prochaska notes that this stage requires significant commitment and energy. If you are at this stage, keep talking to friends and family for inspiration. Review your backup plans. Reward yourself for small achievements. If you can find a friend to quit with, that can be a huge support as you get through this stage. You want to build and maintain momentum, because it gets easier once it is a habit!

Stage 5: Maintenance.

The folks at this stage have been smoke-free at least 6 months. The goal here is to prevent relapse. If you are at this stage, continue to be wary of roadblocks. Improve your backup plans. Think about what you have found most enjoyable about being smoke-free. What benefits have you gained? Keep reminding yourself of these perks.

One point about this theory is that people do not proceed from one stage to another in a simple, step-by-step fashion. They actually cycle or spiral back and forth, so that they may move from stage 1 to 2 to 3, and then back to 2 again. They may stay in maintenance mode for years and then fall back to stage 2. Remember that this is normal -- if you tried quitting in the past and didn't stick with it, don't consider yourself a failure. Just know that it's time to try again!

Scheduled Reduction. A simply behavioral procedure involves the following steps:

• Divide the number of minutes per day awake by the number of daily cigarettes; the result is the minute-long wait between smokes.
• Set up a schedule with time intervals based on this result and using a timer, smoke only at those intervals; if the "cigarette appointment" is missed by more than five minutes, the smoker must skip that cigarette.
• The following week, one-third fewer cigarettes are used and the smoking time is recalculated based on the lower number.
• During the third week the count is again reduced by a third, and the smoker quits in the fourth week.

(Those who are unable to smoke during working hours could try calculating the intervals based on the usual smoking times of the day.)

Although one study showed that people who used a scheduled reduction were twice as likely to quit as those who went cold turkey.

Alternative Methods for Quitting

Hypnosis. Although rigorous studies are lacking, some people report successful cessation from smoking when hypnosis is given in individual sessions. Group sessions appear to be worthless. The process is effective only if the subject trusts the therapist and can feel completely at ease in the vulnerable and passive state necessary for hypnotic suggestion. A typical effective session includes the following steps:

• The hypnotherapist uses various techniques (such as imagery, silent counting) to put the subject in a relaxed state.
• When the subject is very relaxed, but not asleep, the hypnotherapist quietly suggests motivations for not smoking.
• The hypnotherapist should also reinforce a positive self-image while the subject is in deep relaxation. This helps many people avoid the depression that accompanies withdrawal.
• The session usually takes about an hour.

The patient is taught methods of self-hypnosis to use at home, and there is usually one follow-up reinforcing session.

Acupuncture and Acupressure. The acupuncture technique for quitting smoking usually uses tiny curved staples attached to three different points around the edge of the ear. The procedure is painless. The patient is instructed to press each staple in sequence for a few seconds whenever the craving for a cigarette occurs. The acupuncturist may also use acupuncture points elsewhere on the body. There are no side effects except for some soreness if the acupuncture staple is pressed too hard. A related technique called acupressure involves simply pressing select points on the body when a craving hits. Some studies have reported good quit rates with acupuncture, but few rigorous studies have been conduced using this approach.

Investigative agents for smoking cessation include clonidine (Catapres), a drug used for high blood pressure drug, and naltrexone, a drug used in detoxification programs for opiate addiction and alcohol abuse. Naltrexone may be specifically useful in women and those with a history of depression. Studies on these agents have been mixed, however.

Rimonabant (Acomplia) is a new drug that is being investigated for smoking cessation and weight loss. It belongs to a new class of drugs called selective CB1 blockers. These drugs are designed to inhibit receptors in the brain's EndoCannibinoid system; it is hypothesized that tobacco dependency may be related to overstimulation of this system. Rimonabant is currently being assessed in several large-scale Phase III clinical trials. Positive trial results were presented in March 2004 at the American College of Cardiology's scientific session and in August 2004 at the European Society of Cardiology annual meeting. While the initial evidence appears promising, more research is needed. Even if research confirms rimonabant's safety and efficacy, it will take several years for this drug to become commercially available.

Public Health Efforts and Social Pressure (Denormalization)

Public health efforts are effective, mostly by creating the idea that smoking is no longer normal. This concept of denormalization is best instituted by laws and local regulations making smoking inaccessible in public places, raising prices, and putting stricter limitations on cigarette advertising. California, Delaware, Maryland, New York and Vermont currently have the strictest anti-smoking laws.

Increasing taxes on cigarettes may be one of the most important methods for reducing smoking in the population, and, particularly in younger people.

Evidence is suggesting that banning smoking in work and public places may be leading to a higher quit rate than in places where smoking is permitted. Studies also indicate that people who smoke have reported reductions in their smoking by over 25%.

Denormalization can also work on a personal level. A British study found that when one spouse makes healthy changes, including quitting smoking, the other one follows. In couples where smoking continues, it usually continues in both.

Even if smokers have all the public and professional support available, however, quitting is still a solitary and difficult process.

Lifestyle Changes

It is so difficult to quit that smokers should never feel inadequate if they fail. In fact, self-recriminations and guilt only reinforce the low self-esteem and depression that helps cause smoking behavior in the first place. So the cycle continues. Everyone who smokes should simply assume that at some point they will be able to quit, even if they have relapsed many times. Whether or not smokers can stop smoking, they and former smokers should begin immediately to change any other behaviors that might be damaging their health.

Exercise

Any smoker who is able to and is not exercising should start after discussing an appropriate program with their physician. Regular exercise reduces a smoker's risk of heart disease (although still not to the level of a nonsmoker). Exercise does not lower a smoker's risk for lung cancer or emphysema.

Small cell carcinoma, also called oat cell carcinoma, can create its own hormones, which alter body chemistry.

Regular Check-Ups

Smokers should be assiduous about screening programs for any disorders that are increased with smoking. They should have their cholesterol and blood pressure checked regularly. Women should have annual Pap smears (which are used to detect cervical cancer). All older adults should be screened for colon cancer. Smokers might ask their physicians about computed tomography (CT) screening programs, which are becoming increasingly available and might detect lung cancer in early stages. (At this time, they are not usually covered by insurance.)

Healthy Diet

Everyone should also maintain a healthy diet, with foods rich in whole grains and fruits and vegetables (particularly dark colored ones). Saturated fats should be avoided, and people should choose monounsaturated fats, which are contained in olive oil or fats from oily fish. (All fats are high in calories and former smokers particularly should be careful to use even these fats in moderation.) Two studies have indicated that eating fish more than twice a week might help limit the tobacco damage in people who are not heavy smokers (more than a pack and a half a day).

Vitamins and Supplements

Even with a healthful diet, however, smoking reduces the levels of a number of vitamins, importantly vitamin C. Some research suggests that supplements of folic acid, a B vitamin, and the antioxidants vitamins E and C and selenium may improve lung function or reduce the damage done by cigarette smoke. According to two studies, daily vitamin E supplements were associated with reduced risk for prostate cancer among smokers, and in another, higher levels of vitamin E were associated with a lower risk for lung cancer. It should be strongly noted that taking another well known antioxidant, beta-carotene, has been associated in more than one study with higher rates of lung cancer in smokers. The best way of achieving healthy levels of important nutrients is from healthy foods.

Click the icon to see an image of the benefits of vitamin E.

Click the icon to see an image of the sources of vitamin E.

Protecting the Smoker in Special Circumstances

Pregnant Women. Women who are pregnant and continue to smoke must be sure to take appropriate vitamins, particularly folic acid. In this way, they might reduce the increased risk of fetal injury and death, although they do not eliminate that risk.

Smokers with Heart Disease. Smokers who have had a heart attack and are still smoking may dramatically reduce their risk for another heart attack by taking aspirin. This agent may also have some protection against lung cancer. Long-time use, however, increases the risk for gastrointestinal bleeding (which is also higher in smokers).

Resources

• www.cancer.org -- American Cancer Society (800-ACS-2345)
• www.lungusa.org -- The American Lung Association (800-LUNG-USA)
• www.nci.nih.gov -- National Cancer Institute (800-422-6237)
• www.asch.net -- The American Society of Clinical Hypnosis
• www.medicalacupuncture.org -- American Academy of Medical Acupuncture
• www.tobaccoarchive.com -- Tobacco company documents produced from various lawsuits

References

Dobson R. Smoking may increase abdominal obesity. BMJ. 2005 Sep 17;331(7517):596.

Wagena EJ, Knipschild P, Zeegers MP. Should nortriptyline be used as a first-line aid to help smokers quit? Results from a systematic review and meta-analysis. Addiction. 2005;100:317-326.

US Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2003. MMWR Morb Mortal Wkly Rep. 2005;54:509-513.

American Cancer Society. Cancer Facts and Figures 2005. Atlanta, Ga: American Cancer Society; 2005.

US Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 1997-2001. MMWR Morb Mortal Wkly Rep. 2005;54:625-628.

Li YF, Langholz B, Salam MT, Gilliland FD. Maternal and grandmaternal smoking patterns are associated with early childhood asthma. Chest. 2005 Apr;127(4):1232-41.

Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245.

The Health Consequences Of Smoking: A Report Of The Surgeon General. Atlanta, GA: US Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, US Dept of Health and Human Services; 2004.

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