Smoking Cessation: Four Ways to Quit

By now, even the tobacco companies agree: smoking is bad for your health—very bad, in fact. Cigarettes are the most hazardous, but cigars, pipes, and smokeless tobacco also contribute to tobacco's terrible toll. And secondhand smoke is an important cause of death and disability in people who never light up. We're making progress. Over 45 million Americans have quit, and many communities prohibit smoking in public places. But more than 20 percent of adults still smoke, and the habit remains more prevalent in men than women. Tragically, thousands of teenagers take up smoking every day. We can do better. Fortunately, there are more ways to kick the habit than ever before.

The hazards of smoking Tobacco is responsible for one of every five deaths in the U.S. That adds up to over 435,000 lives lost each year, and over 8.5 million Americans suffer from chronic illnesses caused by smoking. All in all, the average nonsmoker lives about 14 years longer than the average smoker. And the worldwide burden is truly staggering. According to the American Cancer Society, smoking will kill about 650 million of the world's 1.3 billion smokers alive today.
Smoking is a major cause of cardiovascular disease, including heart attacks, strokes, and peripheral artery disease. About 20 percent of all cardiac deaths are caused by smoking.
Between 80 percent and 90 percent of all patients with emphysema owe their lung disease to smoking. Chronic bronchitis and pneumonia are among the other lung diseases that are increased in smokers.

And there's more. Smoking contributes to many other health problems, ranging from cataracts, sinusitis, and dental disorders to aging skin, heartburn, diabetes, osteoporosis, and two issues of special concern to men, bladder cancer and erectile dysfunction.
The more you smoke, the higher your risks—but even a few cigarettes a day will harm your health. "Light" and "low-tar" cigarettes are no safer than high-tar brands. The only truly safe dose of tobacco is zero.

Smoking and sexuality
Classic movies may make smoking look sexy, but men who smoke are likely to experience exactly the opposite effect. Because smoking damages blood vessels, it's a major cause of erectile dysfunction. According to a 2005 study of 2,115 men in Minnesota, men who smoke at some time in their lives are more likely to experience erectile dysfunction than men who never smoke. And current smokers are even worse off than former smokers; even in their 40s, current smokers are 2.7 times more likely to experience erectile dysfunction than former smokers and nonsmokers. It's a worldwide problem; in fact, a 2007 study blames smoking for nearly a quarter of the cases of ED in China.

As with other smoking-related maladies, erectile dysfunction is most common in heavy smokers. And as with other smoking woes, quitting helps. In a 2007 study of 20 smokers, penile blood flow began to improve within 24 to 36 hours of the last cigarette.

The benefits of quitting
Quitting helps, even if you've smoked for years. Within days, your blood vessels will regain much of the normal function that is damaged by smoking. Within weeks, you'll be able to taste food better, and your sense of smell will recover from tobacco's assault. Within months, symptoms of chronic bronchitis ease up, and lung function improves within a year. Quitting reduces the risk of heart attack and stroke within two to five years. And the risk of lung cancer begins to drop substantially within five to nine years of quitting.

People who kick the habit, regardless of age, live longer than those who continue to smoke. And since each pack of cigarettes costs our society $7.18, quitting will help America's budget as well as yours. Nicotine is addictive, and quitting is hard work. There is no way to succeed without really trying. But if you set your mind to it, you can quit.

There are four basic strategies for quitting. Look them over and decide which is best for you. Most smokers start by trying to quit on their own, but many end up needing several methods and several attempts before they kick the habit. And even after you quit, it's important to keep your guard up. Just as an alcoholic can fall off the wagon after a single drink, just one cigarette can fire up your nicotine craving even after years of abstinence.

Kicking the habit: Do it yourself
Don't kid yourself by trying to cut down; nearly everyone who tries slides back up to their usual dose of nicotine. Cold turkey is the way to go, but it takes preparation. And even without professional help, cooperation from family and friends can be important. Here are some tips:
Make a list of reasons to quit and another list of people who have kicked the habit. The first list will remind you why quitting is important, and the second will show you that folks who are no stronger or smarter than you have succeeded. Keep your lists handy and refer to them whenever you begin to waver.

Pick a quitting date and stick to it. Plan to quit on a special day, such as a birthday or the American Cancer Society's Great American Smokeout event on the third Thursday of each November. Steer clear of stressful periods, and avoid holidays if you are likely to be invited to smoke-filled parties.

Try to get other smokers in your household or circle of friends to join you in quitting. A 2008 study found that smoking behavior spreads through both close and distant social ties; your resolve and success can help your friends and, ultimately, your community.
As your quit date approaches, throw out your ashtrays, clean your house, car, and clothes, and clean your teeth. Once you're away from it, you'll realize how much smoking stinks.
Anticipate withdrawal symptoms such as grumpiness, restlessness, irritability, hunger, headache, anxiety, and drowsiness or insomnia. The discomfort usually peaks one to three weeks after you quit, and then it gradually diminishes. To get through the rough patches, stock up on low-calorie snacks and sugarless gum or candy to keep your mouth busy. Plan enjoyable diversions to keep your mind busy. Think of ways to keep your hands busy.
If you feel tense, try meditation, deep breathing, or yoga.
Begin an exercise program. It will relieve tension, promote good sleep, and help control weight gain. Walking for 30 minutes a day can really help.

Eat a healthy diet.
Stay away from secondhand smoke. Don't even think about smoking "just one"—even a single puff will set you back. Reward yourself. Put your tobacco money aside in a kitty, and then spend it on a special treat.

Think positively—you can quit. Take it one day at a time. And if you slip, try, try again—either on your own or with one or more of the other strategies for quitting.
Kicking the habit: Behavioral support
Quitting is your responsibility; it may be hard, but it doesn't have to be lonely. Many employers, health plans, and hospitals offer individual or group counseling. Your doctor or your local chapter of the American Lung Association or American Cancer Society can refer you to a program in your area. Telephone support can also help; you can try it for yourself by calling the National Smoking Cessation Hotline at 800-QUIT-NOW. Hypnosis is another alternative that has helped some smokers break free.

Kicking the habit: Nicotine-replacement therapy
Cigarette smoke contains thousands of chemicals. Many are harmful, but nicotine is the most addicting. Like other addicting substances, it acts on receptors in the brain's "reward center," creating a sensation of pleasure and a craving for more nicotine. The craving has made billions of dollars for Big Tobacco, but it has cost the public much more, in health and money. Nicotine-replacement therapy can short-circuit the craving without introducing the other disease-producing chemicals.
Nicotine replacement is safe. You'll get less nicotine than from cigarettes, and you won't get any of the tar, carbon monoxide, and other damaging substances in tobacco. Plan to start nicotine-replacement therapy on the day you quit smoking. If you are a heavy smoker, you'll need higher doses. Estimate how much nicotine you need based on an average of 1 to 2 milligrams (mg) of nicotine per cigarette. Start with the full dose, then gradually taper down over several months. Under-dosing is more common than overdosing, but you should not smoke while using nicotine-replacement therapy.
Five types of nicotine replacement are available in the United  States. Nicotine patches deliver a steady dose of nicotine throughout the day, providing round-the-clock protection from craving. The other products deliver a higher dose of nicotine faster, but protection also declines faster. The short-acting products can be used on demand to counter a sudden nicotine craving. If you wear a patch, you can also use short-acting nicotine products to suppress breakthrough craving.
Here is a quick review of the options for nicotine-replacement therapy:
Nicotine patches are available over the counter. One popular 24-hour patch (NicoDerm CQ) comes in three strengths: 21 mg, 14 mg, and 7 mg. Place a new patch on clean, unbroken, hairless skin each day; you can leave it in place all day. Most smokers should start with the 21 mg dose, but if you weigh less than 100 pounds or smoke fewer than 10 cigarettes a day, you should start with the 14 mg strength. You can reduce the dose every one to two months as your nicotine addiction resolves. If you have bad dreams while wearing a patch at night, you can use a 16-hour patch that you remove at bedtime. Mild skin irritation is the most common side effect. Store and discard your patches with care to keep them way from young children.

Nicotine gum (Nicorette) is available over the counter. If you smoke more than 25 cigarettes a day, you should use gum that provides 4 mg of nicotine per piece; if you smoke less, use the 2 mg dose. Chew a piece of the gum whenever the smoking urge surges, up to 30 pieces a day. Aim to wean off the gum in about three months if possible. Chewing replaces the oral stimulation of smoking, which can be an advantage, but some people find the taste unpleasant, and some develop hiccups or indigestion. Coffee, tea, beer, and soft drinks may interfere with nicotine absorption.

Nicotine lozenges (Commit)are available without prescription. If you usually light up within 30 minutes of waking, you should use the 4 mg strength, while others can use the 2-mg lozenges. A typical schedule calls for one lozenge every one to two hours for six weeks, then every two to four hours for two weeks, and then every four to eight hours for the final two weeks. Don't eat or drink while using a lozenge, and as with nicotine gum, you should avoid acidic beverages for at least 15 minutes before use. Nicotine lozenges are safe for use with dentures. Side effects may include an unpleasant taste, nausea, indigestion, or mouth tingling.

Nicotine inhalers (Nicotrol inhaler) are available by prescription. Each cartridge delivers a "puff" of vapor containing 4 mg of nicotine. The cartridge is placed in a device that resembles a plastic cigarette holder, which may help satisfy a smoker's oral urge. The average dose is six to 16 cartridges a day for up to 12 weeks, followed by a gradual reduction in dose over the next 12 weeks. Most of the nicotine is absorbed from the mouth, not the lungs. Side effects may include mouth or throat irritation and cough.

Nicotine nasal sprays (Nicotrol NS) are available by prescription. Each spray delivers 0.5 mg of nicotine. Use one spray in each nostril whenever you feel the urge to smoke, up to a maximum of 10 sprays an hour or 80 a day for three months. Side effects may include nasal irritation, sneezing, tearing, and cough.

Individual smokers may prefer one form of nicotine replacement over the others. Experiment with various types and talk to your doctor about the prescription forms. Remember, too, that nicotine replacement works best when combined with behavioral support, prescription drugs, or both. And smoking cessation always requires a good dose of willpower.

Kicking the habit: Prescription drugs
Bupropion (Wellbutrin, Zyban) was initially approved to treat depression and was then approved for smoking cessation. It does not contain nicotine and can be used in combination with nicotine-replacement therapy. Start taking bupropion one to two weeks before your quit date. The usual dose is 150 mg once a day for the first three days, then 150 mg twice a day for eight to 12 weeks, or longer if needed. Bupropion can reduce weight gain after quitting. Possible side effects may include dry mouth and insomnia; seizures are very rare.

Varenicline (Chantix) is the newest drug approved for smoking cessation; although experience is still limited, it also promises to be the most effective. It blocks nicotine receptors in the brain while also partially stimulating these receptors to reduce nicotine withdrawal symptoms. The usual dose is 0.5 mg once a day for the first three days, then 0.5 mg twice a day for four days, followed by the full dose of 1 mg twice a day for 12 weeks or longer. The dose should be lowered in patients with severe kidney disease. Nausea is common, and bad dreams may occur. Mood disturbances and behavioral problems have developed, particularly in smokers with psychiatric problems, but it's not clear that these are caused by the medication. Reports of accidents and visual abnormalities are also being investigated by the FDA. More research is needed.

Top priority
Smoking is Public Health Enemy Number One—so if you smoke, quitting should be your top priority. It will take willpower and hard work, but lots of help is available. You may gain a few pounds, you may go through a rough spell as your body adjusts to life without tobacco, and you may have to try several times before you finally kick the habit. Don't be discouraged. Over 45 million Americans have quit smoking, and you can, too.

Resources:
American Cancer Society, 800-ACS-2345 http://www.cancer.org/
American Lung Association, 800-LUNG-USA http://www.ffsonline.org/
Centers for Disease Control and Prevention, 800-CDC-1311 www.cdc.gov/tobacco
National Smoking Cessation Hotline, 800-QUIT-NOW Try to Stop Tobacco Resource Center, 800-TRY-TO-STOP http://www.trytostop.org/