Smoking: how to quit this bad habit?

Nicotine is a highly addictive drug found in tobacco and is the main component of cigarette smoke.

The drug stimulates the brain's reward system, which is activated during pleasurable activities in the same way as most other similar addictive drugs. People smoke to satisfy their nicotine cravings, but they also inhale hundreds of carcinogens, harmful gases, and chemical additives that are part of cigarette smoke. These components are responsible for many of the health problems smokers experience.

Epidemiology of smoking

The percentage of Americans who smoke cigarettes has been declining since 1964, when the Surgeon General first linked smoking to poor health. But about 45 million adults (almost 23%) still smoke. Smoking is most common among men, people with fewer than 12 years of education, people living at or below the poverty line, non-Hispanic whites, non-Hispanic blacks, American Indians, and Alaska Natives. Smoking is least common among Asian Americans.

Most people start smoking in childhood. Children as young as 10 years of age are actively experimenting with cigarettes. More than 2,000 people start smoking every day, 31% of whom start before age 16, and the age at which they start smoking continues to decline. Risk factors for starting to smoke in childhood include parental example, the desire to imitate peers and celebrities; poor school performance; high-risk behavior (e.g., excessive dieting among boys or girls, physical fighting, drink driving), and poor problem-solving skills.

Smoking harms nearly every organ in the body; as of 2000, it was the leading cause of death in the United States, with an estimated 435,000 deaths per year. About 1/2 of all current smokers will die prematurely from a disease directly caused by smoking, losing 10 to 14 years of life on average (7 minutes per cigarette). Sixty-five percent of smoking-related deaths are from coronary heart disease, lung cancer, and chronic lung disease; the remainder are from noncardiac vascular diseases (e.g., stroke, aortic aneurysm), other cancers (e.g., bladder, nuchal, esophageal, kidney, larynx, oropharynx, pancreatitis, abdomen, throat), pneumonia, and perinatal conditions (e.g., preterm birth, low birth weight, sudden infant death syndrome). In addition, smoking is a risk factor for other disorders that cause serious illness and disability, such as acute myelocytic leukemia, frequent acute respiratory infections, cataracts, reproductive disorders (infertility, miscarriage, ectopic pregnancy, premature menopause), and periodontitis.

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Throwing

Over 70% of smokers seek first aid and care services each year, but only a small number leave with advice and treatment information to help them cope with life after smoking. Most smokers under 18 believe they will be smoke-free in 5 years, but year after year these smokers are reported to have tried to quit after a year. However, research shows that 73% of people who smoked every day during their school years continue to smoke at the same level 5-6 years later.

Passive smoking

Second-hand smoke exposure to cigarette smoke (second-hand smoke, environmental tobacco smoke) has serious health consequences for children and adults. Risks to newborns, infants, and children include low birth weight, sudden infant death syndrome, asthma and other related respiratory diseases, and ear infections. Children exposed to cigarette smoke miss more school days due to illness than unexposed children. Smoking-related fires kill 80 children each year and injure nearly 300 more; they are the leading cause of death from unintentional fires in the United States. Treating children for smoking-related illnesses costs an estimated $4.6 billion annually. In addition, 43,000 children lose one or more caregivers to smoking-related illnesses each year.

Second-hand smoke in adults is associated with the same neoplastic, respiratory, and cardiovascular diseases that threaten active smokers. Overall, second-hand smoke is estimated to be responsible for 50,000 to 60,000 deaths per year in the United States. These findings have led six U.S. states and municipalities to ban smoking in the workplace in an effort to protect workers and the public from the risks of environmental tobacco smoke.

Smoking cessation symptoms

Quitting smoking often causes intense withdrawal symptoms, primarily cravings for cigarettes, but also anxiety, depression (mostly mild but sometimes severe), inability to concentrate, irritability, insomnia, drowsiness, impatience, hunger, sweating, dizziness, headaches and indigestion. These symptoms are most severe in the first week, improving in the third or fourth week, but many patients resume smoking when symptoms are at their worst. An average weight gain of 4-5 kg is very common, and is another reason for relapse. Smokers with ulcerative colitis often experience a flare-up soon after quitting.

Treatment of nicotine addiction

The urge to smoke and the signs of withdrawal are strong enough that, even though they recognize the many health risks, many smokers are often reluctant to try to quit, and those who do often fail. A small number of smokers quit permanently on their first try, but most continue to smoke for many years, cycling through long periods of quitting and then resuming smoking. The optimal approach to patient-based quitting, especially for those who are reluctant to quit or who have not yet considered quitting, should be guided by the same principles that guide the treatment of chronic disease, namely:

• Continuous assessment and monitoring of smoking status.
• Setting realistic goals, including those not related to quitting smoking completely, such as temporary abstinence and cutting down on consumption (cutting down on smoking can increase motivation to quit, especially when combined with nicotine replacement therapy).
• Using different interventions (or combinations of interventions) for different patients in the way that is needed.

Effective intervention requires three key components: counseling, medication-based treatment (for patients without contraindications), and consistent identification and intervention in the smoker's life.

The advice approach is similar for children and adults. Children should be screened for smoking and risk factors by age 10. Parents should be encouraged to maintain a smoke-free home and to acclimate their children to such an environment. Cognitive behavioral therapy, which includes education about the consequences of tobacco use, motivation to quit, preparation for quitting, and strategies to support abstinence after quitting, is effective in treating nicotine-dependent adolescents. Alternative approaches to smoking cessation, such as hypnosis and acupuncture, have not been adequately studied and cannot be recommended for routine use.

Recommendations

Advice and recommendations begin with 5 key points: ask at each visit if the patient smokes and document the answer; advise all smokers to quit in clear, strong language that the patient understands; assess the smoker's readiness to quit within the next 30 days; help those who want to make an attempt to quit with advice and treatment; schedule a follow-up visit, preferably within the week following quitting.

For smokers wishing to quit, clinicians should set a clear quit date of 2 weeks and emphasize that complete abstinence is better than tapering. Past quitting experiences can be reviewed for effectiveness - what worked and what did not; any risks associated with quitting should be addressed in advance. For example, alcohol use is associated with relapses, so a ban on alcohol or abstinence should be considered. In addition, quitting is more difficult if there is another smoker in the home; spouses and cohabitants should be encouraged to quit at the same time. In general, patients should be instructed to develop social support within family and friends to make the quit attempt successful; clinicians should reinforce the willingness of loved ones to help. Although these strategies make good sense and provide important and patient support for the patient, there is insufficient scientific evidence to support their use in quitting.

Approximately 40 states in the United States have a quitline that can provide additional support to smokers trying to quit. Phone numbers are available from your state or from the American Cancer SocietyAmerican Cancer Society (1-800-ACS-2345).

Smoking Cessation Medications

Smoking cessation medications that have been shown to be safe and effective include bupropion and nicotine (in chewable, lozenge, inhaler, nasal spray, or patch form). Some evidence suggests that bupropion is more effective than nicotine replacement. All forms of nicotine are equivalent as monotherapy, but the combination of nicotine patch and chewable or nasal spray increases long-term abstinence compared with either form alone. Nortriptyline 25-75 mg orally at bedtime may be an effective alternative for smokers who are depressed. The choice of medication depends on the clinician's knowledge of the drug, the patient's opinion and previous experience (positive or negative), and contraindications.

Drug therapies used for smoking cessation

Drug therapy	Dose	Duration	Side effects	Comments
Bupropion SR	150 mg every morning for 3 days, then 150 mg 2 times a day (start treatment 1-2 weeks before quitting smoking)	Initially 7-12 weeks, can be taken up to 6 months	Insomnia, dry mouth	Only by prescription; contraindicated in patients with a history of seizures, eating problems, or use of a monoamine oxidase inhibitor within the last 2 weeks
Nicotine gum	When smoking 1-24 cigarettes per day, 2 mg of gum is used (up to 24 gums per day) When smoking 25 or more cigarettes per day (up to 24 pieces of gum per day)	Up to 12 weeks	Sore mouth, dyspepsia	Only without a prescription
Nicotine pills	When smoking more than 30 minutes after walking - 2 mg; when smoking less than 30 minutes after walking - 4 mg Schedule for both doses - 1 every 1-2 hours for weeks 1-6; 1 every 2-4 hours for weeks 7-9; 1 every 4-8 hours for weeks 10-12	Up to 12 weeks	Nausea, insomnia	Only without a prescription
Nicotine inhaler	6-16 cartridges per day for 1-12 weeks, then taper over the next 6-12 weeks	3-6 months	Local irritation of the mouth and throat	Only by doctor's prescription
Nicotine nasal spray	8-40 doses per day 1 dose = 2 sprays	14 weeks	Irritation in the mouth	Only by doctor's prescription
Nicotine patch	21 mg/24 h for 6 weeks, then 14 mg/24 h for 2 weeks, then 7 mg/24 h for 2 weeks If smoking more than 10 cigarettes per day, start with 21 mg; if smoking less than 10 cigarettes per day, start with 14 mg or 15 mg/16 h if smoking more than 10 cigarettes per day	10 weeks 6 weeks	Local skin reaction, insomnia	Without prescription and by doctor's prescription

Contraindications to bupropion include a history of seizures, eating disorders, and use of a monoamine oxidase inhibitor within 2 weeks. Nicotine replacement should be used cautiously in patients with certain risk factors for developing a cardiovascular disorder (people with a history of myocardial infarction within 2 weeks, severe arrhythmia, or angina). A contraindication to nicotine chewing is temporomandibular joint syndrome, and for nicotine adhesive strips, severe local sensitization. All of these medications should be used with extreme caution, if at all, in pregnant or breastfeeding women and adolescents, and, because nicotine toxicity is possible and evidence for their usefulness is lacking, in patients who smoke fewer than 10 cigarettes a day. These medications slow, but do not prevent, weight gain.

Despite their proven effectiveness, smoking cessation medications are used by less than 25% of smokers trying to quit. Reasons for this include low insurance coverage, physician concerns about the safety of both smoking and using nicotine replacement, and frustration from previous unsuccessful quit attempts.

Smoking cessation therapies being researched today use a vaccine that intercepts nicotine before nicotine reaches its specific receptors and rimonabant, a cannabinoid CB1 receptor antagonist.

Forecast

More than 90% of the approximately 20 million smokers in the United States who try to quit each year resume smoking within a few days, weeks, or months. Nearly half report having tried to quit in the past year, usually using a “cold turkey” or other approach that didn’t work. The success rate is 20% to 30% among smokers who use a doctor’s advice or medication.

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Other types of tobacco

Cigarette smoking is the most harmful form of tobacco use, although pipe, cigar, and smokeless tobacco smoking may also have negative effects. Pipe smoking alone is very rare in the United States (less than 1% of people over age 12), although it has been gradually increasing among middle and high school students since 1999. About 5.4% of people over age 12 smoke cigars. Although the percentage has declined since 2000, people under age 18 make up the largest group of new cigar smokers. Risks from cigar and pipe smoking include cardiovascular disease, chronic obstructive pulmonary disease, cancer of the mouth, lung, larynx, esophagus, colon, pancreas, periodontal disease, and tooth loss.

About 3.3% of people over the age of 12 use smokeless tobacco (chewing tobacco and snuff). The toxicity of smokeless tobacco varies by manufacturer. Risks include cardiovascular disease, oral disorders (eg, cancer, gum recession, gingivitis, periodontitis and its sequelae), and teratogenicity. Smoking cessation is similar for smokeless tobacco, pipe, and cigar smokers as it is for cigarette smokers. Success rates are higher for smokeless tobacco users. However, success rates for cigar and pipe smokers are less well documented and are influenced by the simultaneous use of cigarettes and whether smokers inhale smoke.