Guide to Quitting Smoking

Introduction
The US Surgeon General has stated, "Smoking cessation (stopping smoking) represents the single most important step that smokers can take to enhance the length and quality of their lives."

Quitting smoking is not easy, but you can do it. To have the best chance of quitting successfully, you need to know what you’re up against, what your options are, and where to go for help. You'll find this information here.

Why Is It So Hard to Quit Smoking?

Mark Twain said, "Quitting smoking is easy. I've done it a thousand times." Maybe you've tried to quit, too. Why is quitting and staying quit hard for so many people? The answer is nicotine.

Nicotine

Nicotine is a drug found naturally in tobacco. It is highly addictive -- as addictive as heroin or cocaine. Over time, a person becomes physically and emotionally addicted to, or dependent on, nicotine. Studies have shown that smokers must deal with both the physical and psychological dependence to be successful at quitting and staying quit.

Where Nicotine Goes and How Long it Stays

When you inhale smoke, nicotine is carried deep into your lungs, where it is absorbed quickly into the bloodstream and carried throughout your body. Nicotine affects many parts of the body, including your heart and blood vessels, your hormonal system, your metabolism, and your brain. Nicotine can be found in breast milk and even in cervix mucus secretions of smokers. During pregnancy, nicotine freely crosses the placenta and has been found in amniotic fluid and the umbilical cord blood of newborn infants.

Several different factors can affect how long it takes the body to remove nicotine and its by-products. In general, a regular smoker will have nicotine or its by-products, such as cotinine, in the body for about 3 to 4 days after stopping.

How Nicotine Hooks Smokers

Nicotine produces pleasant feelings that make the smoker want to smoke more. It also acts as a kind of depressant by interfering with the flow of information between nerve cells. As the nervous system adapts to nicotine, smokers tend to increase the number of cigarettes they smoke, and therefore the amount of nicotine in their blood. After a while, the smoker develops a tolerance to the drug, which leads to an increase in smoking over time. Over time, the smoker reaches a certain nicotine level and then smokes to maintain this level of nicotine. In fact, nicotine, when inhaled in cigarette smoke, reaches the brain faster than drugs that enter the body intravenously (IV).

Nicotine Withdrawal

When smokers try to cut back or quit, the lack of nicotine leads to withdrawal symptoms. Withdrawal is both physical and mental. Physically, the body reacts to the absence of nicotine. Mentally, the smoker is faced with giving up a habit, which calls for a major change in behavior. Both must be addressed in order for the quitting process to work.

If a person has smoked regularly for a few weeks or longer and suddenly stops using tobacco or greatly reduces the amount smoked, they will have withdrawal symptoms. Symptoms usually start within a few hours of the last cigarette and peak about 2 to 3 days later. Withdrawal symptoms can last for a few days to up to several weeks.

Withdrawal symptoms can include any of the following:

dizziness (which may only last 1-2 days after quitting)
depression
feelings of frustration, impatience, and anger
anxiety
irritability
sleep disturbances, including having trouble falling asleep and staying asleep, and having bad dreams or even nightmares
trouble concentrating
restlessness
headaches
tiredness
increased appetite

These symptoms can lead the smoker to start smoking cigarettes again to boost blood levels of nicotine back to a level where there are no symptoms.

Smoking also makes your body get rid of certain drugs faster than usual. When you quit smoking, it changes the way your body handles these medicines. Ask your doctor if any medicines you take regularly need to be checked or changed after you quit.

Why Should I Quit?

Your Health

Health concerns usually top the list of reasons people give for quitting smoking. This is a very real concern: About half of all smokers who continue to smoke will end up dying from a smoking-related illness.

Cancer

Nearly everyone knows that smoking can cause lung cancer, but few people realize it is also a risk factor for many other kinds of cancer as well, including cancer of the mouth, voice box (larynx), throat (pharynx), esophagus, bladder, kidney, pancreas, cervix, stomach, and some leukemias.

Lung Diseases

Pneumonia has been included in the list of diseases caused by smoking since 2004. Smoking also increases your risk of getting lung diseases such as emphysema and chronic bronchitis. These diseases are grouped together under the term COPD (chronic obstructive pulmonary disease). COPD causes chronic illness and disability, and worsens over time - sometimes becoming fatal. Emphysema and chronic bronchitis can be found in people as young as 40, but are more commonly diagnosed later in life, when the symptoms are more severe. Long term smokers have the highest risk of developing severe COPD.

Heart Attacks, Strokes, and Blood Vessel Diseases

Smokers are twice as likely to die from heart attacks as are non-smokers. And smoking is a major risk factor for peripheral vascular disease, a narrowing of the blood vessels that carry blood to the leg and arm muscles. Smoking also affects the walls of the vessels that carry blood to the brain (carotid arteries), which can cause strokes. Men who smoke are more likely to develop erectile dysfunction (impotence) because of blood vessel disease.

Blindness and Other Problems

Smoking also causes premature wrinkling of the skin, bad breath, bad smelling clothes and hair, yellow fingernails, and an increased risk of macular degeneration, one of the most common causes of blindness in the elderly.

Special Risks to Women and Babies

Women have some unique risks linked to smoking. Women over 35 who smoke and use birth control pills have a higher risk of heart attack, stroke, and blood clots of the legs. Women who smoke are more likely to have a miscarriage or a lower birth-weight baby. Low birth-weight babies are more likely to die or have learning and physical problems.

Years of Life Lost Due to Smoking

Based on data collected in the late 1990s, the US Centers for Disease Control and Prevention (CDC) estimated that adult male smokers lost an average of 13.2 years of life and female smokers lost 14.5 years of life because of smoking. And given the diseases that smoking can cause, it can steal your quality of life long before you die. Smoking-related illness can limit your activities by making it harder to breathe, get around, work, or play.

Why Quit?

No matter how old you are or how long you've smoked, quitting will help you live longer. People who stop smoking before age 50 cut their risk of dying in the next 15 years in half compared with those who continue to smoke. Ex-smokers enjoy a higher quality of life with fewer illnesses from cold and flu viruses, better self-reported health, and reduced rates of bronchitis and pneumonia.

For decades the Surgeon General has reported the health risks linked to smoking. In 1990, the Surgeon General concluded:

Quitting smoking has major and immediate health benefits for men and women of all ages. Benefits apply to people with and without smoking-related disease.

Former smokers live longer than people who keep smoking.

Quitting smoking decreases the risk of lung cancer, other cancers, heart attack, stroke, and chronic lung disease.

Women who stop smoking before pregnancy or during the first 3 to 4 months of pregnancy reduce their risk of having a low birth-weight baby to that of women who never smoked.

The health benefits of quitting smoking are far greater than any risks from the small weight gain (usually less than 10 pounds) or any emotional or psychological problems that may follow quitting.

Immediate Rewards of Quitting

Kicking the tobacco habit offers some benefits that you'll notice right away and some that will develop over time. These rewards can improve your day-to-day life a great deal.

your breath smells better

stained teeth get whiter

bad smelling clothes and hair go away

your yellow fingers and fingernails disappear

food tastes better

your sense of smell returns to normal

everyday activities no longer leave you out of breath (for example, climbing stairs or light housework).

Cost

The prospect of better health is a major reason for quitting, but there are other reasons, too.

Smoking is expensive. It isn't hard to figure out how much you spend on smoking: multiply how much money you spend on tobacco every day by 365 (days per year). The amount may surprise you. Now multiply that by the number of years you have been using tobacco and that amount will probably shock you.

Multiply the cost per year by 10 (for the upcoming 10 years) and ask yourself what you would rather do with that much money.

And this doesn't include other possible costs, such as higher costs for health and life insurance, and likely health care costs due to tobacco-related problems.

Social Acceptance

Smoking is less socially acceptable now than it was in the past.

Almost all workplaces have some type of smoking rules. Some employers even prefer to hire non-smokers. Studies show smoking employees cost businesses more to employ because they are out sick more. Employees who are ill more often than others can raise an employer’s need for expensive short-term replacement workers. They can increase insurance costs both for other employees and for the employer, who often pays part of the workers’ insurance premiums. Smokers in a building also can increase the maintenance costs of keeping odors down, since residue from cigarette smoke clings to carpets, drapes, and other fabrics.

Landlords may choose not to rent to smokers since maintenance costs and insurance rates may rise when smokers occupy buildings.

Friends may ask you not to smoke in their homes or cars. Public buildings, concerts, and even sporting events are largely smoke-free. And more and more communities are restricting smoking in all public places, including restaurants and bars. Like it or not, finding a place to smoke can be a hassle.

Smokers may also find their prospects for dating or romantic involvement, including marriage, are largely limited to other smokers, who make up only about 21% of the adult population.

Health of Others

Smoking not only harms your health but it hurts the health of those around you. Exposure to secondhand smoke (also called environmental tobacco smoke or passive smoking) includes exhaled smoke as well as smoke from burning cigarettes.

Studies have shown that secondhand smoke causes thousands of deaths each year from lung

cancer and heart disease in healthy non-smokers.

If a mother smokes, there is a higher risk of her baby developing asthma in childhood, especially if she smoked while she was pregnant. Smoking is also linked to sudden infant death syndrome (SIDS) and low-birth weight infants. Babies and children raised in a household where there is smoking have more ear infections, colds, bronchitis, and other lung and breathing problems than children from

non-smoking families. Secondhand smoke can also cause eye irritation, headaches, nausea, and dizziness.

Setting an Example

If you have children, you probably want to set a good example for them. When asked, nearly all smokers say they don't want their children to smoke, but children whose parents smoke are more likely to start smoking themselves. You can become a good role model for them by quitting now.

Help Is Available

With the wide range of counseling services, self-help materials, and medicines available today, smokers have more tools than ever to help them quit smoking for good.

Remember, tobacco addiction has both a psychological and a physical component. For most people, the best way to quit will be some combination of medicine, a method to change personal habits, and emotional support. The following sections describe these tools and how they may be helpful to you.Help With Psychological Addiction

Some people are able to quit on their own, without the help of others or the use of medicines. But for many smokers, it can be hard to break the social and emotional ties to smoking while getting over nicotine withdrawal symptoms at the same time. Fortunately, there are many sources of support out there -- both formal and informal.

Telephone-based Help to Stop Smoking

Most states run some type of free telephone-based program, such as the American Cancer Society’s Quitline® tobacco cessation program that links callers with trained counselors. These specialists help plan a quit method that fits each person's unique smoking pattern. People who use telephone counseling stop smoking at twice the rate of those who don't get this type of help. With guidance from a counselor, quitters can avoid common mistakes that may self-destruct a quit attempt.

Telephone counseling is also more convenient for many people than some other support programs. It doesn't require transportation or childcare, and it's available nights and weekends. Counselors may suggest a combination of methods including medicines, local classes, self-help brochures, and/or a network of family and friends.

Smokers can get help finding a Quitline® phone counseling program in their area by calling the ACS at 1-800-ACS-2345 (1-800-227-2345).

Support of Family, Friends, and Quit Programs

Many former smokers say a support network of family and friends was very important during their quit attempt. Other people who may offer support and encouragement are co-workers, your family doctor, and members of support groups for quitters. You can check with your employer, health insurance company, or local hospital to find support groups or call the ACS at 1-800-ACS-2345.

What to Look for in a Stop Smoking Program

Stop smoking programs are designed to help smokers recognize and cope with problems that come up during quitting and to provide support and encouragement in staying quit. Studies have shown that the best programs will include either one-on-one or group counseling. There is a strong link between the intensity of counseling and the success rate. In general, the more intense the program, the greater the chance of success.

For example, intensity may be increased by having more or longer sessions or by increasing the number of weeks over which the sessions are given. So, when considering a program, look for one that has the following:

session length -- at least 20 to 30 minutes per session

number of sessions -- at least 4 to 7 sessions

number of weeks -- at least 2 weeks

Make sure the leader of the group has training in smoking cessation.

Some communities have a Nicotine Anonymous group that holds regular meetings. This group applies the principles of Alcoholics Anonymous (AA) to the addiction of smoking. This may include admitting you are powerless over your addiction to nicotine and having a sponsor to talk with when you are tempted to smoke. There is no fee to attend.

Often your local American Cancer Society, American Lung Association, or your local health department will sponsor quit smoking classes. Call 1-800-ACS-2345 for more information.

There are some programs to watch out for as well. Not all programs are ethical. Be wary of programs that do the following :

promise instant, easy success with no effort on your part

use injections or pills, especially "secret" ingredients (nicotine replacement is covered elsewhere)

charge a very high fee--check with the Better Business Bureau if you have doubts

are not willing to give you references from people who have used the program

Help With Physical Addiction: Nicotine Replacement Therapy and Other Medicines

Nicotine Replacement Therapy

As mentioned earlier, the nicotine in cigarettes leads to actual physical dependence, which can cause unpleasant symptoms when a person tries to quit. Nicotine replacement therapy (NRT) gives you nicotine -- in the form of gums, patches, sprays, inhalers, or lozenges -- but not the other harmful chemicals in tobacco. It can help relieve some of these symptoms so that you can focus on the psychological aspects of quitting.

How Nicotine Replacement Works

Nicotine substitutes treat the difficult withdrawal symptoms and cravings that 70% to 90% of smokers say is their only reason for not giving up cigarettes. Using a nicotine substitute, reduces a smoker's withdrawal symptoms.

Although many smokers can quit smoking without using a nicotine replacement, most of those who attempt quitting cannot do it on the first try. In fact, smokers usually need many tries -- sometimes as many as 8 to 10 -- before they are able to quit for good.

Lack of success is often related to the onset of withdrawal symptoms. And most quitters go back to smoking within the first 3 months of quitting. So don't be discouraged if you start smoking again. Just try to stop again and make your attempt more successful by adding another method or technique to help you quit. Reducing these symptoms with nicotine replacement therapy and a support technique, gives smokers who want to quit have a better chance of quitting and staying quit.

Getting the Most from Nicotine Replacement

Nicotine replacement therapy only deals with the physical addiction. It is not meant to be the only method used to help you quit smoking. You should combine it with other smoking cessation methods that help the psychological (emotional and habitual) components of smoking, such as a stop smoking program. Studies have shown that approach -- pairing NRT with a program that helps to change behavior -- can double your chances of successfully quitting.

The US Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guideline on Smoking Cessation in 2000 recommended NRT for all smokers except pregnant women and people with heart or circulatory diseases. However, recent data suggests that nicotine replacement (specifically the nicotine patch) can be used safely even in people who have heart or blood vessel (cardiovascular) disease under a doctor's careful monitoring. These studies have found the benefits of quitting smoking outweigh the risks of nicotine replacement therapy in patients with cardiovascular disease. In all situations, the benefits of smoking cessation must outweigh the potential health risks. Smokers who are pregnant should also talk with their doctor before using over-the-counter nicotine replacements.

The best time to start NRT is when you first quit. Many smokers ask if it is possible to start a program of nicotine replacement while you are still smoking. There is some research being done with smokers using NRT while still smoking, but it is still too early to tell if this is dangerous to your health. The most important thing is to make sure that you are not overdosing on nicotine, which can have effects on your heart and blood circulation. It is safest to be under a doctor's care if you wish to try smoking and using NRT while you are tapering down your cigarette use.

Often smokers first try to quit on their own then decide to try NRT. This method does not give you the greatest chance of success, but do not let this discourage you. There are still many options available for quitting smoking and staying quit.

When May I Begin Using NRT?

You may start using nicotine replacement products as soon as you throw away that last cigarette. You do not need to wait a certain period of time to put on the patch or start using the method you have chosen. You should double check this information with the instructions on your chosen method of nicotine replacement, but in general there is no need to wait to start using nicotine replacement.

Some NRT products make their recommendations based on whether you consider yourself a light, regular or heavy smoker. How are these categories determined?

There is no formal category in any textbook or group that defines a light, average, or heavy smoker. You will find different definitions for these categories. In general, a light smoker is someone who smokes less than 10 cigarettes per day. Someone who smokes a pack a day or more would be considered a heavy smoker.

Sometimes a doctor will use the term pack year to describe how long and how much a person has smoked. A pack year is defined as the number of packs of cigarettes a person has smoked every day multiplied by the number of years he or she has smoked. Since 1 pack is 20 cigarettes, a person who has smoked 20 cigarettes a day for a year is considered to have smoked 1 pack year. Someone who has smoked 30 cigarettes a day (1½ packs) for 3 years has smoked 4.5 pack years (1½ x 3), and so on.

Types of Nicotine Substitutes

The Food and Drug Administration (FDA) has approved five types of nicotine replacement therapy.

Nicotine patches (transdermal nicotine systems): Patches give a measured dose of nicotine through the skin. You are weaned off nicotine by switching to lower nicotine dose patches over a course of weeks. Patches can be bought with or without a prescription. Many types and different strengths are available. Package inserts describe how to use the product, as well as special considerations and possible side effects.

The 16-hour patch works well if you are a light-to-average smoker. It is less likely to cause side effects like skin irritation, racing heartbeat, sleep problems, and headache. But it does not deliver nicotine during the night, so it is not helpful for early morning withdrawal symptoms.

The 24-hour patch provides a steady dose of nicotine, avoiding peaks and valleys. It helps with early morning withdrawal. But, there may be more side effects such as disrupted sleep patterns and skin irritation.

Depending on body size, most smokers should start using a full-strength patch (15-22 mg of nicotine) daily for 4 weeks, and then use a weaker patch (5-14 mg of nicotine) for another 4 weeks. The patch should be put on in the morning on a clean, dry area of the skin without much hair. It should be placed below the neck and above the waist -- for example, on the arm. The FDA recommends using the patch for a total of 3 to 5 months.

Side effects are related to:

the dose of nicotine

the brand of patch

skin characteristics (such as the person’s tendency to have a skin reaction to the patch)

how long the patch is used

how it is applied

Some possible side effects of the nicotine patch include:

skin irritation -- redness and itching

dizziness

racing heartbeat

sleep problems or unusual dreams

headache

nausea

vomiting

muscle aches and stiffness

What to do about side effects:

Do not smoke while you are using a patch.

Try a different brand of patch if your skin becomes irritated.

Reduce the amount of nicotine by using a lower dose patch.

Sleep problems may be short-term and pass within 3 or 4 days. If not (and you're using a 24-hour patch), try switching to a 16-hour patch.

Stop using the patch and try a different form of nicotine replacement.

Nicotine gum (nicotine polacrilex): Nicotine gum is a fast-acting form of replacement in which nicotine is taken in through the mucous membrane of the mouth. You can buy it over the counter without a prescription. It comes in 2 mg and 4 mg strengths.

For best results, follow the instructions on the package insert. Chew the gum slowly until you note a peppery taste. Then "park" it against the cheek, chewing it and parking it off and on for about 20 to 30 minutes. Food and drink can affect how well the nicotine is absorbed. You should avoid acidic foods and drinks such as coffee, juices, and soft drinks for at least 15 minutes before and during gum use.

If you smoke a pack or more per day, smoke within 30 minutes of waking up, or have trouble not smoking in restricted areas, you may need to start with the higher dose (4 mg). Chew no more than 20 pieces of gum in one day. Nicotine gum is usually recommended for 1 to 3 months, with the maximum being 6 months. Tapering the amount of gum chewed may help you stop using it.

If you have sensitive skin, you may prefer the gum to the patch. Another advantage of nicotine gum is that it allows you to control the nicotine doses. The gum can be chewed as needed or on a fixed schedule during the day. The most recent data have shown that scheduled dosing works better. A schedule of 1 to 2 pieces per hour is common. On the other hand, with an as-needed schedule, you can chew more gum during a craving.

Some possible side effects of nicotine gum:

bad taste

throat irritation

mouth sores

hiccups

nausea

jaw discomfort

racing heartbeat

Symptoms related to the stomach and jaw are usually caused by improper use of the gum, such as swallowing nicotine or chewing too fast. The gum can also damage dentures and dental prostheses.

Long-term dependence is one possible disadvantage of nicotine gum. In fact, research has shown that 15% to 20% of gum users who successfully quit smoking continue using the gum for a year or longer. Although the maximum recommended length of use is 6 months, continuing to use the gum is probably safer than going back to smoking. But since there is little research on the health effects of long-term nicotine gum use, most health care providers still recommend limiting its use to 6 months.

Nicotine nasal spray: The nasal spray delivers nicotine to the bloodstream as it is quickly absorbed through the nose. It is available only by prescription.

The nasal spray relieves withdrawal symptoms very quickly and lets you control your nicotine cravings. Smokers usually like the nasal spray because it is easy to use. However, the FDA warns users that since this product contains nicotine, it can be addictive. It recommends that the spray be prescribed for 3-month periods and should not be used for longer than 6 months.

The most common side effects last about 1 to 2 weeks and can include the following:

nasal irritation

runny nose

watery eyes

sneezing

throat irritation

coughing

There is also the danger of using more than is needed. If you have asthma, allergies, nasal polyps, or sinus problems, your doctor may suggest another form of nicotine replacement.

Nicotine inhalers: Introduced in 1998, these inhalers are available only by prescription. The nicotine inhaler is a thin plastic tube with a nicotine cartridge inside. When you puff on the inhaler, the cartridge puts out a nicotine vapor. Unlike other inhalers, which deliver most of the medicine to the lungs, the nicotine inhaler delivers most of the nicotine vapor to the mouth. In terms of similar behavior, nicotine inhalers are the closest thing to smoking a cigarette, which some smokers find helpful.

The recommended dose is between 6 and 16 cartridges a day, for up to 6 months.

The most common side effects, especially when first using the inhaler, include:

coughing

throat irritation

upset stomach

At this time, inhalers are the most expensive forms of NRT available.

Nicotine lozenges: Nicotine-containing lozenges as an over-the-counter aid in smoking cessation are the newest form of NRT on the market. As with nicotine gum, the Commit® lozenge is available in 2 strengths: 2 mg and 4 mg. Smokers choose their dose based on how long after waking up they normally have their first cigarette.

The lozenge manufacturer recommends using it as part of a 12-week program. The recommended dose is one lozenge every 1 to 2 hours for 6 weeks, then one lozenge every 2 to 4 hours for weeks 7 to 9, and finally, one lozenge every 4 to 8 hours for weeks 10 to 12. The manufacturer also recommends the following:

Stop all smoking when you begin to use the lozenge.

Do not eat or drink for 15 minutes before using the lozenge. (Some drinks can reduce how well the lozenge works.)

Suck on the lozenge until it is fully dissolved, about 20 to 30 minutes. Do not bite or chew it like a hard candy, and do not swallow it. The medicine is taken in through the tissues of the mouth.

Do not use more than 5 lozenges in 6 hours, or more than 20 lozenges total per day.

Stop using the lozenge after 12 weeks. If you still feel you need to use the lozenge, talk to your doctor.

Do not use the lozenge if you continue to smoke, chew tobacco, use snuff or any other product containing nicotine (e.g., nicotine patch or gum).

Possible side effects of the nicotine lozenge include:

trouble sleeping

nausea

hiccups

coughing

heartburn

headache

flatulence (gas)

Which Type of Nicotine Replacement May Be Right for You?

There’s no evidence that any one type of nicotine replacement therapy is any better than another. When choosing which type of NRT you will use, think about which method will best fit your lifestyle and pattern of smoking. Do you want/need something to chew or occupy your hands? Or are you looking for once-a-day convenience?

Some important points to consider:

Nicotine gums, lozenges, and inhalers are oral substitutes that allow you to control your dosage to help keep cravings under better control.

Nicotine gums and lozenges are generally sugar-free, but if you are diabetic and have any doubts, check with the manufacturer.

Nicotine nasal spray works very quickly when you need it.

Nicotine inhalers allow you to mimic the use of cigarettes by puffing and holding the inhaler.

Nicotine patches are convenient and only have to be applied once a day.

Both inhalers and nasal sprays require a doctor’s prescription.

Some people may not be able to use patches, inhalers, or nasal sprays because of allergies or other conditions.

Combination of the patch and other nicotine replacement products

Using the nicotine patch along with shorter-acting products such as the gum, lozenge, nasal spray, or inhaler is another method of NRT. The idea is to provide a steady dose of nicotine with the patch and to use one of the shorter-acting products when you have strong cravings.

The few studies that have been done on combination NRT have found that it may be slightly better than a single product. Still, more research is needed to prove this and to find safe and effective doses. The combined use of nicotine replacement products has not yet been approved by the FDA. If you are considering using more than one NRT product, be sure to discuss this with your doctor first.

High-Dose Nicotine Replacement Therapy

One of the newer concepts in nicotine replacement therapy is to give smokers a higher dose specifically based on the amount of nicotine that they have been getting from cigarettes. Sometimes this method has required larger doses of nicotine replacement than have been used before. High-dose NRT with patches has been studied with patients getting from 35 mg to 63 mg of nicotine per day. The research suggests that patients' withdrawal symptoms disappear with these higher doses and their cravings improve without harmful effects on the heart and circulation. Patient were carefully watched in these studies to make sure they were doing well and were not becoming ill or having any problems. This is still a new procedure that should be considered only with a doctor's guidance and supervision.

Stopping Nicotine Replacement Therapy

As mentioned before, most forms of NRT should be used for limited periods of time, and are often tapered down to a low dose before being stopped. Research is still being done to refine the use of NRT. For example, even though the patch is usually used for 3 to 5 months, some studies have suggested that using it for 8 weeks or less works just as well. However, other researchers have noted that the risk of relapse goes up when nicotine replacement is stopped, even after it has been used for 5 months. These differences have not been fully explained. More studies are needed to learn which smokers are likely to be successful using shorter or longer NRT than usual. If you feel that you need NRT for a different length of time than is recommended, it is best to discuss this with your doctor.

Bupropion (Zyban®)

Bupropion (Zyban®) is a prescription antidepressant in an extended-release form that reduces symptoms of nicotine withdrawal. It does not contain nicotine. This drug acts on chemicals in the brain that are related to nicotine craving. It can be used alone or together with nicotine replacement. Bupropion works best if it is started 1 or 2 weeks before the quit date. The usual dosage is one or two 150 mg tablets per day.

This drug should not be taken if you have ever had seizures, heavy alcohol use, serious head injury, bipolar (manic-depressive) illness, anorexia or bulimia (eating disorders).

Some doctors may recommend combination drug therapy for heavily addicted smokers, such as using bupropion along with a nicotine replacement patch and/or a short-acting form of nicotine replacement (such as gum or lozenges).

Varenicline (Chantix™)

Varenicline (Chantix™) is a newer prescription medicine developed for the sole purpose of helping people stop smoking. It works by interfering with nicotine receptors in the brain, which has two effects. It lessens the pleasurable physical effects a person gets from smoking, and it reduces the symptoms of nicotine withdrawal.

Several studies have shown varenicline can more than double the chances of quitting smoking. Some studies have also found it may be more effective than bupropion, at least in the short-term.

Reported side effects of varenicline have included headaches, nausea, vomiting, trouble sleeping, unusual dreams, flatulence (gas), and changes in taste. There have also been reports of depressed mood, thoughts of suicide, attempted suicide, and changes in behavior in people taking varenicline. People who have these problems should contact their doctors right away. Although these side effects may happen, varenicline is usually well-tolerated. Since varenicline is a newer drug, research has not been done to find out if it is safe to use along with nicotine replacement products.

Other Methods of Quitting

Other tools may also help some people, although there is no strong evidence they can improve your chances of quitting.

Atropine and scopolamine combination therapy

Some smoking cessation clinics offer a program using shots of the drugs atropine and scopolamine to help reduce nicotine withdrawal symptoms. These drugs block the action of acetylcholine, a signal transmitter in the nervous system. Called anticholinergics, they are more often prescribed for other reasons, such as digestive problems, motion sickness, or Parkinson’s disease. People who are pregnant or have heart problems, glaucoma, or uncontrolled high blood pressure are not allowed to take part in these programs.

The treatment usually involves shots given in the clinic on one day, followed by a few weeks of pills and wearing patches behind the ear. It may also include other drugs to help with side effects. Possible side effects of this treatment can include dizziness, constipation, dry mouth, changes in the sense of taste and smell, problems urinating, and blurry vision.

Some clinics claim high success rates, but there is no published scientific research to back up these claims. Both atropine and scopolamine are FDA-approved for other uses, but they have not been formally studied or approved for help in quitting smoking. Before considering such a program, you may want to ask the clinic about long-term success rates (up to a year). Because these medicines are directed only at the physical aspect of quitting, you may also want to ask if the program includes counseling or other methods aimed at the psychological aspects of quitting.

Hypnosis

Hypnosis methods vary a great deal, which makes it hard to study as a way to stop smoking. In general, reviews that looked at studies of hypnosis to help people quit smoking have not supported it as a quitting method that works. Still, some people find it useful. If you are interested in trying it, ask your doctor if he or she can recommend a good hypnotherapist.

Acupuncture

This method has been used to quit smoking, but there is little evidence to show that it works. Acupuncture, when it is done, is usually done on certain parts of the ears. Although there is a very weak suggestion that acupuncture might lower the desire to smoke, there still is no solid evidence that it is truly effective as a smoking cessation tool (see the ACS document, Acupuncture). For a list of local physician acupuncturists, contact the American Academy of Medical Acupuncture at 1-800-521-2262.

Low-level Laser Therapy

This technique, also called cold laser therapy, is related to acupuncture. Cold lasers are sometimes used for acupuncture. The laser beams stimulate the body's acupoints instead of needles. The treatment is supposed to relax the smoker and release endorphins (pain relief substances that are made naturally by the body) to simulate the effects of nicotine in the brain, or balance the body’s energy to relieve the addiction. Despite claims of success by some cold laser therapy providers, there is no scientific evidence that shows this is an effective method of helping people stop smoking (see ACS document, Cold Laser Therapy).

Filters

Filters that reduce tar and nicotine in cigarettes are generally not effective since studies show that smokers who use filters actually tend to smoke more.

Smoking Deterrents

Other methods have been used to help stop smoking, such as over-the-counter products that change the taste of tobacco, stop-smoking diets that curb nicotine cravings, and combinations of vitamins. There is little scientific evidence to support that these efforts work.

Herbs and Supplements

There is little scientific evidence to support the use of homeopathic aids and herbal supplements as stop-smoking methods. Because they are marketed as dietary supplements (as opposed to drugs), they don't need FDA approval to be sold. The manufacturers don’t have to prove they’re effective, or even safe. Be sure to look closely at the label of any product claiming it can help you stop smoking. No dietary supplement has been proven to effectively help people quit smoking. Some of these supplements have no nicotine in them, but have multiple combinations of herbal preparations. They have no proven track record of helping people to stop smoking.

Other Nicotine/Tobacco Products, Not Reviewed or Approved by the FDA

Tobacco lozenges and pouches

Lozenges that contain tobacco (Ariva®, Interval®), and small, pouches of tobacco (Revel®, Exalt®) are being sold as other ways for smokers to get nicotine in places where smoking is not allowed. The FDA has ruled that these are types of oral tobacco products, and are not smoking cessation aids. This means that the FDA does not have authority over them. There is no evidence that these products can help a person quit smoking. Unlike scientifically proven treatments with known effects, such as nicotine replacement products, antidepressants, nicotine receptor blockers, or behavioral therapy, these oral tobacco products have never been rigorously tested.

Oral tobacco products such as snuff and chewing tobacco are known to contain human carcinogens. These products cause mouth cancer and gum disease. They also destroy the bone sockets around teeth and cause tooth loss. There are studies showing potential harmful effects on the heart and circulation as well as increased risks of other cancer. They also cause bad breath and stain the teeth.

Nicotine lollipops and lip balms

In the past, some pharmacies made a product called a nicotine lollipop. These lollipops often contained a product called nicotine salicylate with a sugar sweetener. Nicotine salicylate is not approved for pharmacy use by the FDA. The FDA has warned pharmacies to stop selling nicotine lollipops and lip balm on the Internet, calling the products "illegal." The FDA also said "the candy-like products present a risk of accidental use by children."

Other similar smoking cessation products may not use nicotine salicylate and, therefore, may be legal. However, they still pose a risk for children if they are not well-labeled and stored safely.

Nicotine water and nicotine wafers

These products have been sold in recent years as ways to get nicotine in places where smoking is not allowed. They are not marketed as aids to quitting smoking, but questions about their safety and legality have been raised.

A Word About Quitting Success Rates

Before you start using nicotine replacement or sign up for a stop smoking class or program, you may wonder what its success rate is. That's a hard question to answer for many reasons. First, not all programs define success in the same way. Does success mean that a person is not smoking at the end of the program? After 3 months? 6 months? 1 year? Does smoking fewer cigarettes (rather than stopping completely) count as success? If a program you're considering claims a certain success rate, ask for more details on how success is defined and what kind of follow-up is done to confirm the rate.

The truth is, quit smoking programs, like other programs that treat addictions, often have a fairly low success rate. But that does not mean they are not worthwhile or that you should be discouraged. Your own success in quitting is what really counts, and that is under your control.

About 5% to 16% of people are able to quit smoking for at least 6 months without any medicine to help with withdrawal.

Several articles in medical journals have reported that between about 25% and about 33% of smokers who use medicines can remain smoke-free for over 6 months. There is also early evidence that combining some medicines may work better than using them alone.

Behavioral and supportive therapies may increase success rates even further. Check the package insert of any product you are using to see if the manufacturer provides free telephone-based counseling.

How to Quit

Smokers often say, "Don't tell me why to quit, tell me how." There is no one right way to quit, but there are some key elements in quitting with success. These 4 factors are key:

making the decision to quit

setting a quit date and choosing a quit plan

dealing with withdrawal

staying quit (maintenance)

Making the Decision to Quit

The decision to quit smoking is one that only you can make. Others may want you to quit, but the real commitment must come from you.

Researchers have looked into how and why people stop smoking. They have some ideas, or models, of how this happens.

The Health Belief Model says that you will be more likely to stop smoking if you:

believe that you could get a smoking-related disease and this worries you

believe that you can make an honest attempt at quitting smoking

believe that the benefits of quitting outweigh the benefits of continuing to smoke

know of someone who has had health problems as a result of their smoking

Do any of these apply to you?

The Stages of Change Model identifies the stages that a person goes through in making a change in behavior. Here are the stages as they apply to quitting smoking:

Pre-contemplation: At this stage, the smoker is not seriously thinking about quitting.

Contemplation: The smoker is actively thinking about quitting but is not quite ready to make a serious attempt. This person may say, "Yes, I'm ready to quit, but the stress at work is too much," or "I don't want to gain weight," or "I'm not sure if I can do it."

Preparation: Smokers in the preparation stage seriously intend to quit in the next month and often have tried to quit in the past 12 months. They usually have a plan.

Action: This is the first 6 months when the smoker is actively quitting.

Maintenance: This is the period of 6 months to 5 years after quitting when the ex-smoker is aware of the danger of relapse and takes steps to avoid it.

Where do you fit in this model? If you are thinking about quitting, setting a date and deciding on a plan will move you into the preparation stage, the best place to start.

Setting a Quit Date and Deciding on a Plan

Pick a Quit Day

Once you've decided to quit, you're ready to pick a quit date. This is a very important step. Pick a specific day within the next month as your Quit Day. Picking a date too far in the future allows you time to rationalize and change your mind. But do give yourself enough time to prepare and come up with a plan. You might choose a date with a special meaning like a birthday or anniversary, or the date of the Great American Smokeout (the third Thursday in November each year). Or you may want to just pick a random date. Circle the date on your calendar. Make a strong, personal commitment to quit on that day.

Prepare for Your Quit Day

There is no one right way to quit. Most smokers prefer to quit cold turkey -- they stop completely, all at once. They smoke until their Quit Day and then quit. Or they may smoke fewer cigarettes for 1 or 2 weeks before their Quit Day. Another way involves cutting down on the number of cigarettes you smoke each day. With this method, you slowly reduce the amount of nicotine in your body. You might cut out cigarettes smoked with a cup of coffee, or you might decide to smoke only at certain times of the day. While it sounds logical to cut down in order to quit gradually, in practice this method is difficult.

Quitting smoking is a lot like losing weight; it takes a strong commitment over a long time. Smokers may wish there was a magic bullet -- a pill or method that would make quitting painless and easy. But there is nothing like that. Nicotine substitutes can help reduce withdrawal symptoms, but they are most effective when used as part of a stop-smoking plan that addresses both the physical and psychological components of quitting smoking.

Here are some steps to help you prepare for your Quit Day:

Pick the date and mark it on your calendar.

Tell friends and family of your Quit Day.

Get rid of all the cigarettes and ashtrays in your home, car, and place of work.

Stock up on oral substitutes -- sugarless gum, carrot sticks, and/or hard candy.

Decide on a plan. Will you use NRT or other medicines? Will you attend a stop-smoking class? If so, sign up now.

Practice saying, "No thank you, I don't smoke."

Set up a support system. This could be a group class, Nicotine Anonymous, or a friend or family member who has successfully quit and is willing to help you. Ask family and friends who still smoke not to smoke around you or leave cigarettes out where you can see them.

Think back to your past attempts to quit. Try to figure out what worked and what did not work for you.

Successful quitting is a matter of planning and commitment, not luck. Decide now on your own plan. Some options include using nicotine replacement, joining a stop-smoking class, going to Nicotine Anonymous meetings, using self-help materials such as books and pamphlets, or any combination of these methods. For the best chance at success, your plan should include one or more of these options.

On your Quit Day, follow these suggestions:

Do not smoke. This means at all -- not even one puff!

Keep active -- try walking, exercising, or doing other activities or hobbies.

Drink lots of water and juices.

Begin using nicotine replacement if that is your choice.

Attend stop-smoking class or start following a self-help plan.

Avoid situations where the urge to smoke is strong.

Reduce or avoid alcohol.

Think about changing your routine. Use a different route to work, drink tea instead of coffee. Eat breakfast in a different place or eat different foods.

Dealing With Withdrawal

Withdrawal from nicotine has 2 parts -- the physical and the psychological. The physical symptoms, while annoying, are not life-threatening. Nicotine replacement can help reduce many of these physical symptoms. But most smokers find that the bigger challenge is the mental part of quitting.

If you have been smoking for any length of time, smoking has become linked with nearly everything you do -- waking up in the morning, eating, reading, watching TV, and drinking coffee, for example. It will take time to un-link smoking from these activities. That is why, even if you are using a nicotine replacement, you may still have strong urges to smoke.

One way to overcome these urges or cravings is to identify rationalizations as they come up. A rationalization is a mistaken belief that seems to make sense at the time but is not based on facts. If you have tried to quit before, you will probably recognize many of these common rationalizations:

I'll just have one to get through this rough spot.

Today is not a good day; I'll quit tomorrow.

It's my only vice.

How bad is smoking, really? Uncle Harry smoked all his life and he lived to be over 90.

Air pollution is probably just as bad.

You've got to die of something.

Life is no fun without smoking.

You probably can add more to the list. As you go through the first few days without smoking, write down any rationalizations as they come up and recognize them for what they are: messages that can trap you into going back to smoking. Use the ideas below to help you keep your commitment to quitting.

Avoid temptation. Stay away from people and places where you are tempted to smoke. Later on you will be able to handle these with more confidence.

Change your habits. Switch to juices or water instead of alcohol or coffee. Take a different route to work. Take a brisk walk instead of a coffee break.

Alternatives: Use oral substitutes such as sugarless gum or hard candy, raw vegetables such as carrot sticks, or sunflower seeds.

Activities: Do something to reduce your stress. Exercise or do hobbies that keep your hands busy, such as needlework or woodworking, which can help distract you from the urge to smoke. Take a hot bath, exercise, or read a book.

Deep breathing: When you were smoking, you breathed deeply as you inhaled the smoke. When the urge strikes now, breathe deeply and picture your lungs filling with fresh, clean air. Remind yourself of your reasons for quitting and the benefits you'll gain as an ex-smoker.

Delay: If you feel that you are about to light up, delay. Tell yourself you must wait at least 10 minutes. Often this simple trick will allow you to move beyond the strong urge to smoke.

Reward Yourself. What you're doing is not easy, so you deserve a reward. Put the money you would have spent on tobacco in a jar every day and then buy yourself a weekly treat. Buy a magazine, go out to eat, call a friend long-distance. Or save the money for a major purchase. You can also reward yourself in ways that don't cost money: visit a park or the library, develop a new hobby, or take a yoga class.

Staying Quit (Maintenance)

Remember the quotation by Mark Twain? Maybe you, too, have quit many times before. So you know that staying quit is the final, and most important, stage of the process. You can use the same methods to stay quit as you did to help you through withdrawal. Think ahead to those times when you may be tempted to smoke, and plan on how you will use alternatives and activities to cope with these situations.

More dangerous, perhaps, are the unexpected strong desires to smoke that happen sometimes months, or even years after you've quit. To get through these without relapse, try the following:

Review your reasons for quitting and think of all the benefits to your health, your finances, and your family.

Remind yourself that there is no such thing as just one cigarette -- or even one puff.

Ride out the desire to smoke. It will go away, but do not fool yourself into thinking you can have just one.

Avoid alcohol. Drinking lowers your chance of success.

If you are worried about gaining weight, put some energy into eating a healthy diet and staying active with exercise.

What if you do smoke? The difference between a slip and a relapse is within your control. A slip is a one-time mistake that is quickly corrected, whereas a relapse is going back to smoking. You can use the slip as an excuse to go back to smoking, or you can look at what went wrong and renew your commitment to staying away from smoking for good.

Even if you do relapse, try not to get too discouraged. Very few people are able to quit for good on the first try. In fact, it takes most people many attempts before quitting for good. What’s important is figuring out what helped you when you tried to quit and what worked against you. You can then use this information to make a stronger attempt at quitting the next time.

Some Special Concerns

Weight Gain

Many smokers do gain some weight when they quit. Even without special attempts at diet and exercise, however, the gain is usually less than 10 pounds. Women tend to gain slightly more weight than men. There is some evidence that smokers will gain weight after they quit even if they do not eat more.

For some, a concern about weight gain can lead to a decision not to quit. But the weight gain that follows quitting smoking is usually very small. It is much more dangerous to continue smoking than it is to gain a small amount of weight.

You are more likely to be quit smoking successfully if you deal with the smoking first, and then later take steps to reduce your weight. While you are quitting, try to focus on ways to help you stay healthy, rather than on your weight. Stressing about your weight may make it harder to quit. Eat plenty of fruits and vegetables and limit the fat. Be sure to drink plenty of water, and get enough sleep and regular physical activity.

Walking is a great way to be physically active and increase your chances of staying quit. Walking can help you by:

reducing stress

burning calories and toning muscles

giving you something to do instead of thinking about smoking

No special equipment or clothing is needed for walking, other than a pair of comfortable shoes. And you can do it pretty much anytime or anywhere. Try the following:

walk around a shopping mall

get off the bus one stop before you usually do

find a buddy to walk with during lunch time at work

take the stairs instead of the elevator

walk with a friend, family member, or neighbor after dinner

push your baby in a stroller

Set a goal of 30 minutes of physical activity 5 or more times a week. If you don’t already exercise regularly, please check with your doctor before starting an exercise program.

Stress

Smokers often mention stress as one of the reasons for going back to smoking. Stress is a part of everyone's lives, smokers and non-smokers alike. The difference is that smokers have come to use nicotine to help cope with stress and unpleasant emotions. When quitting, you have to learn new ways of handling stress. Nicotine replacement can help to some extent, but for long-term success other strategies are needed.

As mentioned above, physical activity is a good stress-reducer. It can also help with the short-term sense of depression that some smokers have when they quit. There are also stress-management classes and self-help books. Check your community newspaper, library, or bookstore.

Spiritual practices such as prayer and meditation have been used with much success to deal with other addictions and are a key part of 12-step recovery programs. These same principles can be applied to quitting smoking and can help with stress reduction.

Taking Care of Yourself

It is important for your health care provider to know of any present or past tobacco use so he or she can be sure that you will get the preventive health care you need. It is well known that tobacco use puts you at risk for certain health-related illnesses, so part of your health care should focus on related screening and preventive measures to help you stay as healthy as possible. For example, you will want to be certain that you regularly check the inside of your mouth for any changes and have an oral exam by your doctor or dentist if you have any changes or problems. The American Cancer Society recommends that periodic check-ups should include oral cavity (mouth) exams. By doing this tobacco users may be able to prevent, or detect early, oral changes, leukoplakia (white patches on the mouth membranes), and oral cancer.

You should also be aware of any change in cough, a new cough, coughing up blood, hoarseness, trouble breathing, wheezing, headaches, chest pain, loss of appetite, weight loss, general tiredness, and repeated respiratory infections. Any of these could be signs of lung cancer or a number of other lung conditions and should be reported to your doctor. While these can be signs of a problem, many lung cancers do not cause any noticeable symptoms until they are advanced and have spread to other parts of the body.

Remember that tobacco users have an increased risk for other cancers as well, depending on the way they use tobacco. You can become familiar with the types of cancer you may be at risk for by reading the American Cancer Society document that discusses the way you use tobacco (see "Additional Resources"). Other risk factors for these cancers may be more important than your use of tobacco, but you should be aware of the additional risks that might apply to your situation.

If you have any health concerns that may be related to your tobacco use, please see your health care provider as soon as possible. Taking care of yourself and getting treatment for small problems will give you the best chance for successful treatment. The best way, though, to take care of yourself and decrease your risk for life-threatening lung problems is to quit using tobacco.

Where Can I Go for Help?

It is hard to stop smoking. But if you are a tobacco user you can quit! More than 46 million Americans have quit smoking for good. Many organizations offer information, counseling, and other services on how to quit, as well as information on where to go for help. Other good resources where help can be found include your doctor, dentist, local hospital, or employer.

Additional Resources

Cigar Smoking (also available in Spanish)

Cigarette Smoking (available in Spanish only through our toll-free number)

Double Your Chances of Quitting Smoking

Guide to Quitting Smoking (available in Spanish only through our toll-free number)

Helping a Smoker Quit: Dos and Don'ts

Join the Quit Network

Questions About Smoking, Tobacco, and Health (available in Spanish only through our toll-free number)

Quitting Smoking - Help for Cravings and Tough Situations (available in Spanish only through our toll-free number)

Smokeless Tobacco

Smoking and Cancer Mortality Table

Smoking in the Workplace -- A Model Policy

Women and Smoking (available in Spanish only through our toll-free number)

Inclusion on this list does not imply endorsement by the American Cancer Society.