2013 H Street, NW / Washington,
DC 20006 / (202) 659-4310
People smoke for a variety of reasons. Some of the reasons are (1) it provides a sense of increased energy or stimulation; (2) it is a pleasurable feeling which often accompanies a state of well-being; (3) it reduced tension or feelings of anxiety; or (4) it has become automatic or addictive.
Unfortunately the ephemeral comforts provided by tobacco use are counterbalanced by an annual U.S. death rate, from tobacco-caused disease, of 400,000 smokers, with the illness and disability of many thousands more.
It is therefore not surprising that of the 50 million Americans who continue to smoke, approximately two thirds say that they would like to quit (Gallup Poll, May 31, 1990). In fact more than 38 million American adults have already quit smoking and nearly half of all living adults who ever smoked cigarettes have quit.
Obviously, the most important element in smoking cessation is that the smoker must desire to quit, and consideration of some of the benefits of quitting may encourage him or her to do so.
Some of the health and life-saving benefits of quitting have been listed in the U.S. Surgeon General's Report for 1990. They include the following:
After 1 year off cigarettes, the excess risk of heart disease caused by smoking is reduced by half. After 15 years of abstinence, the risk is similar to that of persons who have never smoked;
The risk of lung cancer for ex-smokers drops to as much as one-half that of continuing smokers, after 10 years. The risk continues to decline with additional years of staying smoke-free;
In 5 to 15 years, the risk of stroke for ex-smokers returns to the level of those who have never smoked;
After 15 years off cigarettes, the risk of death for ex-smokers returns to nearly the level of persons who have never smoked;
Male smokers who quit between ages 35 to 39 add an average of 5 years to their lives. Female quitters in this age group add 3 years. Men and women who quit at ages 65 to 69, increase their life expectancy by 1 year;
Ex-smokers who have been off cigarettes for many years are less likely to die of chronic lung diseases, such as emphysema than those who continue to smoke;
Ex-smokers have better health status than current smokers. Ex-smokers have fewer days of illness, fewer health complaints, better self-reported health status, and reduced rates of bronchitis and pneumonia.
Quitting has unique benefits for women:
If all women quit smoking during pregnancy, about 5 percent of deaths among newborn infants could be prevented;
Women who stop smoking before becoming pregnant or during the first trimester of pregnancy reduce their risk of having a low birth weight baby to that of women who have never smoked;
It takes female smokers longer to get pregnant than nonsmokers. Women who quit smoking before trying to get pregnant are as likely to get pregnant as women who have never smoked.
Quitting is also good medicine for smokers who are already sick. In particular, if smokers with Heart Disease quit they reduce the risk of repeat heart attacks and death from heart disease by 50 percent or more. Persons with Peripheral Artery Disease who quit have an improved ability to exercise and an increased overall survival rate. Smokers with ulcers who quit reduce the risk of recurrence and enjoy an improved rate of healing.
Finally, there are purely economic benefits in quitting which the Surgeon General's Report does not mention. A daily expenditure of $5.00 per day on cigarettes results on a yearly sum of $1,825.00. Such an amount could be invested by a quitter and, even at present interest rates, compounded yearly could constitute a substantial addition to savings.
Quitting smoking isn't always easy, and many ex-smokers go through the quitting process several times before becoming long-term quitters.
The problem arises from the fact that all tobacco products contain substantial amounts of nicotine, a powerful drug, which acts in the brain and throughout the body. Bodily systems affected include electrocortical activation, skeletal muscle relaxation and cardiovascular and endocrine effects. The many biochemical and electrocortical effects of nicotine may act in concert to reinforce tobacco use.
Nicotine readily crosses the blood-brain barrier and accumulates in the brain shortly after it enters the body. The pharmacologic and behavioral processes that determine nicotine/tobacco addiction are similar to those which determine addiction to other drugs. According to the U.S. Surgeon General's 1988 Report, nicotine is more addictive than any other drug - cocaine, heroin, opium, marijuana - in the world.
The fact that nicotine/tobacco addiction is associated with specific behavioral patterns as well as profound changes in body chemistry would suggest that the most effective methods of cessation should incorporate drug therapy to counteract the chemical addiction to nicotine combined with a program designed to assist the quitter to change the smoking habit, and to provide support to maintain the change.
The U.S. Department of Health and Human Services (HHS) recently reported (41 Morbidity and Mortality Weekly Report #35 Sept. 3, 1992) that 90 percent of successful quitters have used a self-help strategy, most by quitting abruptly. It was, moreover, found that self-help cessation programs are more cost-effective ($22 - $144 per program) than clinic-based programs ($235 - $399 per program).
HHS therefore determined that wider dissemination of self-help materials, such as cessation booklets and physician's advice held the potential for assisting a substantial number of smokers who might not seek a more formal means of help.
Although many quitters succeed by going "cold turkey" nicotine withdrawal symptoms may include anxiety, irritability, frustration, anger, difficulty concentrating, increased appetite and urges to smoke.
Drug therapy may be used to ease the transition to a smoke-free life style and the two most effective methods, which must be prescribed by a physician, are nicotine chewing gum and nicotine transdermal patches.
Nicotine chewing gum (Nicorette) should be used with a supportive program, as incorporation of nicotine gum into behaviorally sound treatment programs tends to produce better results. The gum aids in breaking the cigarette habit while sustaining the nicotine level and then provides a gradual reduction in the dependence on nicotine by reducing the use of the gum. Side effects of gum use include dizziness, nausea and jaw muscle ache. There have also been rare cases of overdosing.
Nicotine transdermal patches (Nicoderm, Habitol, ProStep and Nicotrol) have fewer side effects than nicotine gum. Like nicotine gum, the treatment administers nicotine in diminishing doses, and should be used in conjunction with some sort of behavior modification program. Nicotine patches also may have side effects. Some people experience itching and burning around the patch, headaches, nausea and shakiness.
Recently, moreover, five heart attack patients wearing patches were brought into a Massachusetts hospital. An investigation found that they had been wearing the patch and smoking as well - four of them two packs of cigarettes a day. Since the amounts combined from each source constituted a massive overdose of highly toxic nicotine, the patients' reaction was not surprising but the incident underlines the extreme danger of using the patch and continuing to smoke.
A number of other drug-containing products are available to help smoking cessation including lobeline sulphate (Nikoban and Bartron), silver acetate (Healthbreak), lobeline sulphate with vitamins (Cigarrest) and cloridine (Catapres). These were recently evaluated in an article "A Physician's Guide to Smoking Cessation", (G.H. Miller et al. 54 Journal of Family Practice 759-766, 1992) as not being generally effective.
Similarly, nicotine reduction filters such as One Step at a Time, intended to allow smokers to gradually reduce their nicotine intake have not been proved to be a successful method of cessation. The major problem with filter products is that the smoker tends to continue smoking at the lower levels of nicotine reduction rather than achieving total abstinence.
Drug therapy for smoking cessation is greatly enforced and is much more effective if it is combined with individual or group therapy to modify the smoker's conduct.
Smokers' physicians should assist their patients by providing them with direct counseling or recommending an appropriate clinic with a high cure rate or both. Unfortunately research has shown that an insufficient percentage of physicians provide smoking cessation counseling to their patients.
Smoking cessation clinics usually offer intensive support and involve multiple sessions. They may include a considerable variety of treatment components and tend to produce good long-term outcomes.
According to A Physician's Guide to Smoking Cessation (supra):
Commonly offered nonprofit programs include those of the Seventh Day Adventist's Five Day Plan, the American Lung Association's Freedom From Smoking clinics, and the American Cancer Society's Fresh Start program. Judging from the research reports, it appears that the American Lung Association's clinic is somewhat more effective than that of the American Cancer Society; however, the American Lung Association's program requires a substantially greater time commitment. Programs that require a greater number of sessions have higher cure rates than those with few sessions.
Commercial programs are also available. SmokEnders, Smoke Stoppers, Smokeless, and Schick are among the most common smoking cessation clinics. In considering commercial programs, physicians should note that they are often substantially more expensive than the nonprofit programs. At present there is little evidence to demonstrate that the commercial programs are more effective than those of nonprofit organizations. Commercial vendors indicate correctly that, for many smokers, a substantial fee may represent their high level of commitment and serve as an incentive for quitting.
There are a variety of other methods of smoking cessation which include aversion procedures (these involve pairing smoking with some unpleasant side effects of smoking); hypnosis (using sub-conscious motivation to build the self-confidence to quit); acupuncture, (rates of cure are very low) and Lifesign (a small hand-held computer unit which signals smokers when to smoke).
When an individual stops smoking there are a variety of symptoms, both physical and psychological, which may be experienced. Most symptoms decrease sharply during the first few days of cessation and continue to decline gradually over the next two or three weeks. The most commonly reported withdrawal symptoms include: irritability which is caused by the body's craving for nicotine; fatigue which may result from the fact that nicotine is a stimulant and cessation takes away that stimulation; insomnia; occasional dizziness is caused by extra oxygen which the body is getting; difficulty concentrating comes from the lack of stimulation which nicotine provides to the brain; hunger as a result of nicotine acting as a stimulant on the body's metabolic rate which causes the metabolic rate to slow when a person quits smoking; and craving for cigarettes. These symptoms are most frequent within the first two or three days after quitting.
The fear of post-cessation weight gain may discourage many smokers from trying to quit, and this problem was considered by the Centers for Disease Control in preparing the U.S. Surgeon General's Report for 1990.
According to the Report's Executive Summary:
Fifteen studies involving a total of 20,000 persons were reviewed in this Report to determine the likelihood of gaining weight and the average weight gain after quitting. Although four-fifths of smokers who quit gained weight after cessation, the average weight gain was only 5 pounds (2.3 kg). The average weight gain among subjects who continued to smoke was 1 pound. Thus, smoking cessation produces a 4-pound greater weight gain than that associated with continued smoking. This weight gain poses a minimal health risk. Moreover, evidence suggests that this small weight gain is accompanied by favorable changes in lipid profiles and in body fat distribution.
To help limit weight gain after quitting ex-smokers should eat a well-balanced diet and avoid the excess calories in sugary and fatty foods; satisfy cravings for sweets by eating small pieces of fruit, have low-calorie foods on hand for nibbling, drink 6 to 8 glasses of water per day, and build exercise into their lives by walking 30 minutes a day or doing the physical activity of their choice, such as running, cycling, swimming, or gardening.
Former smokers start smoking again for any of several reasons - stress, withdrawal symptoms, alcohol, or boredom. One important lesson which smokers learn when quitting is that they can't test themselves by having a cigarette or two after quitting. If a relapse occurs, ex-smokers should not despair. A quitter should (1) recognize that it is simply a small setback, but that it does not mean that he or she is a smoker again; (2) learn from the setback - what caused it, how did the cigarette taste, how will the situation be handled next time; (3) don't look back - think about the effort that has already been invested and continue.
The long-term benefits of smoking cessation have been mentioned earlier in this pamphlet. There are also some immediate benefits which include (1) decline in carbon monoxide level in blood; (2) sense of taste and smell improve; (3) better oral health; and (4) the effects of nicotine on pulse rate and blood pressure are eliminated within 20 minutes of the last cigarette.
Thus, quitting smoking carries major and immediate health benefits for men and women of all ages, even those in the older age groups. Benefits apply to healthy people and to those already suffering from smoking-related diseases.
In the words of Dr. Antonia C. Novello, U.S. Surgeon General:
Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives.
NOTE: This leaflet, which is distributed as a public service, contains general information for your interest. Before undertaking any cessation program you should, of course, consult your physician.
2013 H Street, NW / Washington,
DC 20006 / (202) 659-4310