Smoking is uniquely harmful, causing damage not only to smokers themselves but also to the people around them. Smoking is one of the main causes of health inequalities in USA, with the harm concentrated in disadvantaged communities and groups. One of the first and easiest steps you can take to quit smoking is talking with your primary care doctor. Studies have shown that even a brief conversation with a doctor who advises a patient about quitting can improve the patient’s chances of quitting successfully. A physician can also help you access other important forms of treatment, such as nicotine replacement therapy or intensive counseling. You should report any medical conditions to your doctor that he or she does not already know about, such as diabetes, heart disease, asthma, stomach ulcers or high blood pressure. Also share whether you have recently had a heart attack for which your current doctor did not treat you or if you have tried or are taking other medications to help you quit smoking. These factors may affect the type of smoking cessation support you should receive. Smoking harms nearly every organ of the body. It causes lung cancer, respiratory disease and cardiovascular disease, as well as many cancers in other organs including lip, mouth, throat, bladder, kidney, stomach, liver and cervix. Smoking reduces fertility and significantly raises the risk of developing type 2 diabetes, eye disease and dementia. It leads to decreased bone mineral density and is associated with increased risk of osteoporosis, bone fractures, back pain and degenerative disc disease. Smoking is also closely associated with poor mental health and wellbeing. Smokers score worse than the population as a whole on every mental wellbeing indicator. Secondhand smoke is dangerous for anyone exposed to it, but children are especially vulnerable due to breathing more rapidly and having less developed airways, lungs and immune systems.

How to quit smoking

Quitting a smoking habit can be extremely challenging because it involves overcoming a physical addiction as well as deeply ingrained psychological and social patterns. Although the chances of successfully quitting may often be very low for any given attempt, they can clearly be improved by looking for different kinds of help and making repeated attempts. If you are trying to quit smoking, you are not alone. The last survey conducted by the Centers for Disease Control and Prevention in 2018 found that over two-thirds of adult smokers wanted to quit smoking, and a little more than half attempted to quit in the year prior to the survey. The length of time you have smoked, your age at which you started smoking and the strength of your motivation to quit all affect the outcome of a single cessation attempt. But success is possible for everyone, and the number of successful quitters is steadily growing. Since 2010, the number of former smokers in the USA has exceeded the number of current smokers.

Reasons

If you are a smoker, quitting is the most important thing you can do for your health. The surgeon general’s report How Tobacco Smoke Causes Disease detailed how smoking damages practically every organ in the human body and found that smoking causes an overwhelming number of deadly diseases, from lung cancer and chronic obstructive pulmonary disease to heart attack and stroke. Quitting really does help. The Centers for Disease Control has estimated that about half of all smoking related deaths for former smokers age 45 and older could be prevented if all smokers in this age group were to give up smoking. Some of the health benefits, such as lowered blood pressure and other indicators of risk, are detectable very quickly, even within the first few days of quitting. The benefits increase the longer you stay smoke-free. Studies have found that two thirds of the excess risk of developing coronary heart disease can be eliminated within 2 years of quitting. Within 5 years of smoking cessation, the relative risk for stroke can be the same as if a person had never smoked. Individuals in one study who remained smoke free for 15 years decreased their risk of dying from lung cancer by about half compared to what it would have been had they continued smoking.

Quitting can also have an impact on family and friends. Every year, thousands of nonsmokers die from heart disease and lung cancer attributable to secondhand smoke, and hundreds of thousands of children suffer from respiratory infections due to secondhand smoke. There is no safe level of exposure to secondhand smoke. If you are a smoker, the single best way to protect your family from secondhand smoke is to quit smoking.

Treatment

One of the first and easiest steps you can take to quit smoking is talking with your primary care doctor. Studies have shown that even a brief conversation with a doctor who advises a patient about quitting can improve the patient’s chances of quitting successfully. A physician can also help you access other important forms of treatment, such as nicotine replacement therapy or intensive counseling. You should report any medical conditions to your doctor that he or she does not already know about, such as diabetes, heart disease, asthma, stomach ulcers or high blood pressure. Also share whether you have recently had a heart attack for which your current doctor did not treat you or if you have tried or are taking other medications to help you quit smoking. These factors may affect the type of smoking cessation support you should receive.

Tell (or remind) your doctor if you take insulin, medicines for asthma or chronic obstructive pulmonary disease, blood thinners, antidepressants, or antipsychotic medications. These medicines may work differently when you quit smoking and may need to be adjusted to avoid serious side effects. Be open with your doctor about repeated attempts to quit that failed or led to severe withdrawal. Your doctor can help by referring you to a smoking cessation counseling provider to improve your chances of success. When you talk with your doctor, schedule a follow-up visit in the next week or two to assess how the strategy is working. Check in regularly after that if possible.

Strategies for smoking cessation

Counseling

Counseling is a very effective way to boost chances of quitting smoking long term, and it comes in a variety of forms. These include self-help materials, brief advice sessions from a health professional such as your primary physician, or more intensive counseling by a health professional in repeated one-on-one or group sessions. There is not a lot of evidence that written self-help materials alone provide any advantage in terms of quitting success. However, other forms of therapy, such as telephone counseling or conversations with a health professional, do seem to help.

Professional counseling can be provided by a primary care doctor, psychologist, nurse, social worker or tobacco treatment specialist who has been trained to provide smoking-cessation counseling services. A number of hospitals or clinics now offer intensive one-on-one or group sessions with a trained professional. In this setting, smokers wishing to quit are taught coping skills and offered social support. This type of counseling from a trained provider has been shown to be very effective at helping smokers quit. If you are not able to meet with your doctor to discuss counseling options, you can access a telephone “quitline” serving your area by calling or visiting www.smokefree.gov. These services can refer you to providers in your area who offer specialized smoking cessation services, such as group counseling or services for special populations. Depending on your area, the quitline may also provide you with free smoking cessation counseling over the phone.

Nicotine replacement therapy

Nicotine replacement therapy includes any product approved by the FDA that delivers nicotine (COMMIT, HABITROL, NICODERM, NICORETTE, NICOTROL, THRIVE) to your body to help you overcome the craving to smoke (or the craving to use other nontherapeutic tobacco products, like chewing tobacco). It comes in various forms, including gum, patches placed on the skin, nasal spray, inhalers, tablets and lozenges. While these products help to overcome the pharmacologic addiction and to reduce withdrawal symptoms — such as irritability, depression and craving — they do not eliminate the symptoms entirely. Numerous studies have shown that a person who uses nicotine replacement therapy is more likely to quit and stay smoke-free long-term than a person who uses the same quitting strategy but takes a placebo or uses no pharmacological treatment.

This therapy generally doubles the chance of quitting regardless of other support used. All types of nicotine replacement therapy are successful at helping smokers quit. There are not a lot of studies comparing different forms of nicotine replacement therapy with one another (for example, inhaler versus patch), but the few studies that exist have not shown strong evidence favoring one type of product over another. Nicotine replacement therapy usually provides nicotine in a slower and less satisfying way than do cigarettes, but it is also safer and less addictive. It does not contain tar and carbon monoxide as tobacco smoke does. Still, nicotine itself can have negative health effects. Be careful to follow the instructions for use, and do not smoke cigarettes while you are using another nicotine product. It is important to realize that nicotine replacement therapy is not a magic bullet. It does nothing to address deeply ingrained psychological and social patterns that can lead to the resumption of a smoking habit. To increase the chance of success, consult a doctor about treatment strategies before starting nicotine replacement therapy, rather than simply purchasing these products over the counter.

Comparing and combining approaches

Nicotine replacement therapy and counseling have shown equal effectiveness when each was compared with no treatment, and there is no evidence showing that one is more effective than the other when used separately. The most effective approach to quitting is to combine the two approaches. Nicotine replacement therapy and counseling complement one another by addressing both the physiological aspects and the sociopsychological sides of the addiction. Studies have shown that the chance of quitting can be improved by combining counseling with nicotine replacement therapy rather than using nicotine replacement therapy alone. The results of using both approaches together can be dramatic. In one large, randomized study, smokers who used nicotine gum and went to 12 group sessions using behavior modification techniques over a period of 10 weeks were nearly four times more likely to remain smoke-free after five years, compared with those who had not received any special assistance (that is, they did not receive nicotine gum or counseling as part of the study).

No More Electronic Cigarettes

Electronic cigarettes are not approved by the FDA as aids to help quit smoking. This is because research findings about vaping have been mixed. The long-term effects of e-cigarette use are not yet known. However, the FDA and the Centers for Disease Control and Prevention are currently investigating an outbreak of lung illness and death among adults who used some types of e-cigarettes. Symptoms have included shortness of breath, coughing, or chest pain. Some patients reported nausea, vomiting, diarrhea, or other stomach problems, as well as fever or fatigue. If you are concerned about these health risks, consider not using any e-cigarette or vaping products. If you are an adult who used e-cigarette or vaping products containing nicotine to quit cigarette smoking, do not return to smoking cigarettes.

Antidepressant drugs for smoking cessation

Bupropion (ZYBAN)

One antidepressant medication, Wellbutrin (Bupropion, Zyban), has been approved by the FDA for smoking cessation. Multiple trials of bupropion have shown it to increase the number of successful quit attempts, although the precise mechanism by which it works is unclear. There is no evidence that bupropion is any more or less effective than nicotine replacement therapy or that it helps quitting efforts to combine bupropion with nicotine replacement therapy. You do not have to be depressed to use bupropion as a smoking cessation aid.

Varenicline (CHANTIX)

Varenicline is effective for smoking cessation and has been approved by the FDA for this indication. It works by acting on the sites in the brain affected by nicotine to ease withdrawal symptoms and block the effects of nicotine if users do attempt to smoke. However, varenicline poses substantial health risks and should not be used unless all other methods of smoking cessation support have failed. The drug carries a black box warning, the strongest warning the FDA can require, for severe mental health side effects, including behavioral changes such as depressed mood, hostility, and suicidal thoughts or actions. Varenicline has been associated with these mental health symptoms even in people without a history of mental illness.

In July 2021, Pfizer announced a voluntary recall of nine batches of its Chantix smoking cessation drug because of concerns about nitrosamine levels in the drug. Nitrosamines are a type of impurity that can be present in pharmaceutical products and are considered possible carcinogens if their levels exceed what is allowed.

You have been exposed to nitrosamines many times and probably didn't even know it. According to the FDA, these compounds are common in water and food products, including cured and fried meats, dairy products and vegetables. At low levels, experts don't believe they are harmful. Nitrosamine impurities can potentially increase your risk of cancer if you consume enough of them over a long period of time. Thus, the FDA has set limits on daily consumption of nitrosamines.

But the benefits of Chantix outweigh the very low, if any, potential risks associated with lifetime exposure to nitrosamine from varenicline over other common sources, said Pfizer spokesman Stephen Danehy. Most people take Chantix for up to 12 weeks to quit smoking (some patients take Chantix for longer). The drug affects brain receptors that are stimulated by nicotine. If you are on this treatment, do not stop it without consulting your doctor.

According to the FDA, this medication does not put you at immediate risk. An increased risk of cancer will be associated with long-term use, and the health benefits of quitting smoking outweigh the risk of cancer because of the nitrosamine impurity in varenicline, the FDA says. The FDA recommends that you continue taking the drug until you talk to your doctor. Depending on your situation, your doctor may recommend nicotine replacement therapy or an alternative prescription drug without nicotine, such as Zyban.

Health Benefits of quitting smoking

Don't give up!

Studies have shown that success at being smoke-free is more likely with supportive behavior from loved ones. This supportive behavior can include talking the smoker out of smoking a cigarette or engaging in activities to replace smoking, such as going for a walk to relieve stress. It can also include encouraging the smoker by expressing pleasure at the smoker’s efforts to quit or predicting that the smoker will be successful at quitting. Negative behavior can also substantially affect a smoker’s chances of successful quitting, particularly when the negative behavior comes from a spouse. In studies, smokers were more likely to relapse if they reported that the people who constituted their support systems complained about smoking or predicted that their quitting attempt would fail.

Researchers have not conducted enough quality studies of partner support to show what methods are most effective in increasing the amount of such support. Reactions to smoking or quitting attempts are often deeply ingrained, and changing the patterns of others may be as challenging as changing your own smoking behavior. Smokers who are married to nonsmokers or ex-smokers are more likely to quit and remain smoke-free. If your spouse or close friend is a smoker, you may improve your chances of quitting successfully by doing so together. It may help to talk with your friends and loved ones about your desire to quit smoking. Ask for their support. Talk about positive and negative behaviors, and create a plan for giving each other feedback. If you have trouble breaking patterns of negative behavior with a loved one, consider attending counseling together.

Relapse

If you have tried to quit in the past and relapsed, don’t worry! Most smokers have to make several attempts to stop before finally succeeding (the average number of tries is around four before successfully quitting). Relapse is a normal part of the process that can be overcome. Be proud that you fought hard to quit, and treat it as a learning experience for next time. Smoking cessation is a huge effort, but you are worth it. Your health is valuable to you and those who care about you.

Other sources

This booklets are available for download in Adobe Reader format.

Guide to Treating Tobacco Dependence with the guidance necessary to understand the effects of nicotine, differentiate among tobacco products, discuss the addiction cycle, and initiate the tobacco cessation discussion with patients by Dr. Steven Schroeder.

Also read this stuff: Smoking Cessation by Scott P Marlow and James K Stoller—Cleveland, Ohio.

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