It's never too late to quit smoking. According to the American Cancer Society, about one-half of all smokers who keep smoking will die from a smoking-related disease. Quitting has immediate health benefits.
Better Health After Quitting
Time after last cigarette
Blood pressure and pulse rates return to normal.
Levels of carbon monoxide and oxygen in the blood return to normal.
Chance of a heart attack begins to decrease.
Nerve endings start to regrow. Ability to taste and smell increases.
Bronchial tubes relax and the lungs can fill with more air.
2 weeks to 3 months
Circulation improves and lung function increases by up to 30%.
1 to 9 months
Rates of coughing, sinus infection, fatigue, and shortness of breath decrease. Cilia in the airways regrow, improving the ability to clear mucus and clean the lungs, and reducing the chance of infection. Energy level increases.
After a year, the risk of dying from a heart attack or stroke is reduced by up to 50%. Within 10 years, the risk of dying from lung cancer is about one half that of a smoker. Within 15 years, the risk for coronary heart disease is the same as that of a non-smoker.
About 52% of smokers who want to quit make a serious attempt to do so each year, but fewer than 7% actually succeed. Available smoking cessation products and therapies are greatly underused. If more smokers asked for or were offered such help, quit rates could double or triple.
Some people have genes that make quitting harder or easier. Researchers have identified more than 200 genes that may contribute to the rate of success in quitting smoking. The discovery of these genes could theoretically lead to new smoking cessation therapies that target a person's specific genetic makeup.
Methods of quitting smoking include counseling and support groups, nicotine patches, gums, lozenges, and sprays, e-cigarettes, smoking cessation pills, exercise, and slowly cutting back on the number of cigarettes smoked (incremental reduction). A combination approach may be most effective. Interventions may be administered in the workplace, or other organizations such as your local hospital or public health office.
Nicotine Replacement Therapy (NRT)
Nicotine replacement therapy involves the use of products that provide low doses of nicotine, without the toxic byproducts of tobacco burning found in smoke. The goal of therapy is to relieve cravings for nicotine and ease the symptoms of withdrawal.
In general, NRT benefits moderate-to-heavy smokers the most. However, it also appears somewhat helpful for light smokers (people who smoke fewer than 15 cigarettes a day).
All forms of NRT can be effective in promoting smoking cessation. NRT increases the quit rate by 50% to 60% for at least 6 months or longer. Most of the research is focused on adults, but adolescents may also benefit from NRT.
Combining NRTs may be more effective than using one alone. For example, a combination of the nicotine patch and nicotine gum, nasal spray, or lozenge helps smokers go smoke-free for a longer period of time before relapsing. Adding bupropion to NRT also increases the chance for success.
Nicotine patches deliver nicotine through the skin. This is called transdermal nicotine delivery. It is effective at reducing withdrawal symptoms. Nicotine patches are available over the counter.
Patches work in different ways:
- Step-Down Approach. Patches that use this method include Habitrol and NicoDerm CQ. The patches come in three strengths (21, 14, and 7 mg). You use the strongest dose first if you smoke more than 10 cigarettes daily and reduce the dose gradually over a period of 8 to 10 weeks. A 21 mg patch is about equal to 15 cigarettes. A heavy smoker may need to wear two patches at first.
How patches are applied and used:
- A single patch is worn each day and replaced after 24 hours.
- To avoid skin irritation it is applied to different hairless areas above the waist and below the neck each day.
- People can wear the patches for 24 hours, but some have reported odd dreams and have disliked the sensation of wearing the patch during the night. However, people who wear the patch all the time have fewer withdrawal symptoms and slightly better quit rates than those who take it off at night.
Store and discard patches safely, particularly in homes with young children. Children have been poisoned and have gotten sick from wearing, chewing, or sucking on nicotine patches. Children should not come in contact with the patches, even while the smoker is wearing them. If a child puts on a patch, remove it and wash the affected skin right away. A child who has eaten nicotine or worn a patch for a long period of time may need urgent medical care.
Nicotine gum (for example, Nicorette) is available over the counter and has helped many people quit. Some people prefer gum to the patch because they can control the nicotine dosage, and chewing satisfies the oral urge associated with smoking.
Tips for using the gum:
- If you are just starting to quit, chew 1 to 2 pieces every hour or two. Do not chew more than 24 pieces a day.
- Gradually taper off. The goal is to stop using the gum by 3 months (although about 3% of people continue to use it long after they have quit smoking).
- Chew the gum slowly until it develops a peppery taste. Then tuck it between the gum and cheek, so that the nicotine can be absorbed.
- Coffee, tea, soft drinks, and acidic beverages may interfere with nicotine absorption, so wait at least 15 minutes after having one of these drinks before chewing a piece of gum.
Some people prefer other methods or cannot use the gum for the following reasons:
- They find the taste of the gum unpleasant.
- Side effects of the gum may include upset stomach, mouth sores, hiccups, and throat irritation.
- They are embarrassed to chew gum.
- They wear dentures.
Long-term dependence may be a problem with nicotine gum. Experts do not recommend that people chew nicotine gum for more than 6 months.
The Nicotine Inhaler
The nicotine inhaler resembles a plastic cigarette holder. It requires a prescription in the United States. The inhaler comes with several nicotine cartridges, which are inserted into the inhaler and "puffed" for about 20 minutes, up to 16 times a day. The dose is gradually decreased.
Several studies have reported that the inhaler can double or triple quit rates compared with a placebo after 6 months. The inhaler has some advantages over other nicotine replacement products:
- It provides varying doses of nicotine on demand (as opposed to continuous doses with the patch or gum) and is relatively fast-acting. Blood nicotine levels peak about 20 minutes after using the inhaler, comparable to the gum and faster than the patch.
- It satisfies oral urges.
- Most of the nicotine vapor is delivered into the mouth, not into the lung airways (although some people experience mouth or throat irritation and a cough).
Using a combination of the inhaler and the patch may be more effective than either method alone.
The Nicotine Nasal Spray
The nasal spray satisfies immediate cravings by providing fast doses of nicotine. (Nicotine levels peak within 5 to 10 minutes after administering the spray.) It may be useful together with slower-acting nicotine replacement therapies.
The spray can irritate the nose, eyes, and throat, so it may not be suitable for people with allergies or sinus infections. Most people, however, can tolerate the side effects, which usually go away within the first few days.
A nicotine lozenge (for example, Nicorette or Commit) is available over the counter. It is made from pressed tobacco and comes in two strengths for heavier or lighter smokers. Suck on one piece every 1 to 2 hours, then gradually taper off your use. Do not eat or drink 15 minutes before using a lozenge, and do not take more than 20 lozenges a day. Side effects include heartburn, hiccups, nausea, headaches, and cough. The Commit lozenge also contains phenylalanine, a chemical that certain people may need to avoid.
Electronic cigarettes (E-Cigarettes)
E-cigarettes are battery-operated devices of various shapes that deliver nicotine and other substances in the form of a vapor. Many e-cigarettes are marketed as quit-smoking aids because they are designed to give the feeling of smoking without actually lighting up. The chemicals and substances in e-cigarettes vary, and labeling is often inconsistent.
Several small studies have evaluated whether e-cigarettes can help some people quit smoking. The US Preventive Task Force reports that any evidence that supports the use of e-cigarettes for smoking cessation is quite limited and does not show benefit among smokers intending to quit. None of the specific products have been approved as cessation interventions by the U.S. Food and Drug Administration.
E-cigarettes and vaping are increasingly popular among children and adolescents who do not smoke. Researchers worry that by creating nicotine addiction in people who are not current smokers, e-cigarettes may serve as gateway products leading to smoked tobacco use.
The FDA has not approved these devices for smoking cessation. However, the FDA has announced that it has finalized a rule that allows it to regulate e-cigarettes and other electronic nicotine delivery systems similar to the way that it regulates tobacco products. This will require that e-cigarette manufacturers provide the government with a list of ingredients contained in their products.
Facts about Nicotine Replacement Therapy:
- Not cheating on the very first day of nicotine-replacement use increases the chance of quitting permanently by ten times.
- The more cigarettes people smoke, the higher the dose of nicotine replacement they may need at first.
- Adding a counseling program can boost the effectiveness of any nicotine replacement program.
- Nicotine replacement helps prevent weight gain while you are using it, but you are still at higher risk of gaining weight when you stop using all nicotine.
Besides nicotine dependence, side effects of any nicotine replacement product may include headaches, nausea, and other gastrointestinal problems. People often experience sleeplessness in the first few days, particularly with the patch, but the insomnia usually passes. People using very high doses of nicotine are more likely to have symptoms. Reducing the dose can prevent these symptoms.
Special Concerns for Specific Individuals
There has been some concern that the patch might be harmful for people with heart or circulatory disease, but studies are finding that it actually poses little or no danger for these individuals. In fact, the patch may help reduce angina attacks brought on by exercise. However, unhealthy cholesterol levels (lower HDL levels) caused by smoking will not improve with the nicotine patch. HDL levels will only improve when all nicotine is stopped.
Nicotine replacement may not be completely safe in pregnant women, although it has been used in this group without problems. Its ability to help pregnant women quit smoking is not well proven.
Nicotine Products and Children
Keep all nicotine products away from children. Nicotine is a poison. Call a physician or poison control center immediately if a child has been exposed to a nicotine replacement product, even for a short period of time. Also call the doctor if a child has been exposed to a nicotine product and has any symptoms, including upset stomach, irritability, headache, rash, or fatigue.
Warnings Against Long-Term Use
No one should use nicotine replacement therapies as a long-term substitute for smoking. Any nicotine replacement therapy should only be used temporarily.
Antidepressants for Smoking Cessation
Bupropion (Zyban or Wellbutrin)
Bupropion is a type of antidepressant that is also FDA-approved for smoking cessation. Bupropion differs from many other antidepressants in that it increases the effects of dopamine, the brain chemical that appears to play a strong role in nicotine addiction. Using bupropion along with nicotine replacement therapy may help control cigarette cravings.
People usually start taking bupropion a week or two before quitting, and continue taking it for 7 to 12 weeks. The usual maintenance dose is a 150 mg tablet taken twice a day. No single dose should be higher than 150 mg.
Side effects of bupropion include:
- Gastrointestinal problems
- Dry mouth
In very rare cases, seizures have occurred, although usually in people who exceeded the recommended dose or who were already at risk for seizures.
Warning about Bupropion
In 2009, the FDA required the makers of bupropion to add a boxed warning (the strongest possible warning) regarding serious mental health side effects that may occur while using the medicines. These potentially serious side effects include changes in behavior such as hostility, agitation, depressed mood, suicidal thoughts or actions. People taking this medicine, as well as their family members, should be aware of these potential dangers and report any symptoms to their doctor immediately. People are also advised to stop taking the medicine immediately if any of these symptoms occur.
Nortriptyline (Pamelor, Aventyl)
The tricyclic antidepressant nortriptyline may reduce the actions of nicotine and help smokers quit, although it was not approved by the FDA for this purpose. Quit rates with this medicine are as high as 30%. Long-term abstinence rates are more than twice those of placebo (sugar pill). It is best to start taking this medicine 10 to 28 days before your intended quit date.
Side effects of nortriptyline include:
- Dry mouth
- Changes in taste
In rare cases, tricyclic antidepressants like nortriptyline can have more serious side effects. An overdose can be deadly. Tricyclics may also pose a danger for patients with certain types of heart disease.
Unlike bupropion, varenicline (Chantix) targets nicotine receptors in the brain, which helps reduce cravings. Varenicline can also help people wean themselves off smokeless tobacco.
Cigarette smokers ages 18 and older can use varenicline. This drug may be used along with nicotine replacement therapy or cognitive-behavioral therapy (CBT).
Warnings about varenicline (Chantix)
Varenicline carries a boxed warning regarding serious mental side effects that may occur while using the medicine, or immediately after stopping it. These uncommon but potentially serious side effects include changes in behavior such as agitation, depressed mood, suicidal thoughts or actions. Recently, the FDA updated the varenicline label, after the drug was associated with an increased risk for heart problems, such as a heart attack and abnormal heart rhythms. People who take this medicine should be aware of these potential dangers and report any symptoms to their doctor immediately.
Behavioral Methods and Counseling
Everyone who quits should aim to quit completely. Quitting completely is essential to regaining good health and reversing the harmful effects caused by smoking. Just reducing smoking, even by one half, does not eliminate the risk for cancer and other health problems. Although smokers who cut back take in less smoke and nicotine, their bodies are still unable to heal completely from the ongoing intake of toxins. Changing to low-tar cigarettes is also not a solution. In fact, people who smoke these cigarettes tend to inhale more deeply, which may increase their health risks.
Most people who return to smoking "cheat" in the first few weeks. To help you, make a quit-smoking plan and stick to it.
Create a List
Write down 10 reasons to quit. In addition to health reasons, the list might include:
- Having better smelling hair, clothes, and breath
- Having fewer skin wrinkles
- Enjoying the taste of food
- Saving money
Read the list often during the quitting process to help you stay motivated.
Decide on a Specific Quit Date
Some people find it helpful to choose a date when they anticipate having little or no stress for at least 3 days. Once you have chosen a date:
- Write out a quit contract, put the date on paper, and get a friend to sign it.
- Throw out all smoking paraphernalia the night before the quit date.
- Make plans to stay busy on the quit day, especially at night, when your urge to smoke will be high.
If quitting cold turkey isn't for you, gradually stopping is an equally effective approach. Reducing the number of cigarettes you smoke before your quit day might work just as well as stopping all at once.
Make an Oath
Take an extreme oath. For example, "If I smoke one more cigarette my dog will die." Although this seems absurd, some people who have failed with all other methods have reported that they quit completely and successfully after taking such an oath.
Let the Body and Mind Heal During Withdrawal
- Retreat from the world when cravings become overwhelming. Take a nap, warm bath or shower, meditate, or read a novel.
- Help your body get rid of nicotine. Drink plenty of water. Eat fresh fruits, vegetables, whole grains, and fiber-rich foods. Munch on carrots, apples, and celery.
- When cravings occur, take a few deep, rhythmic breaths.
- Use meditation or relaxation and deep breathing exercises, especially when you feel the urge to smoke.
Get Family and Friends Involved
- Tell your friends and family that you have already quit, so you will be embarrassed if they catch you smoking.
- Fine yourself. Pay a family member or friend if they catch you smoking. The amount should be large enough ($5 to $20) to be a deterrent, but not so large as to be ridiculous. Save up for something special, or donate the money to charity.
- If your partner or friend smokes, try persuading them to quit. At the very least, ask the person not to smoke around you.
Studies continue to show that smokers who exercise can greatly increase their ability to quit smoking and reduce their risk for weight gain in the short term. When you have cravings:
- Jump up and down
- Do push-ups
- Do yoga
Older people and anyone with health problems should consult their health care provider before starting an exercise program.
More research is necessary to determine the level of exercise and support needed to quit for the short and long term.
Maintain a Healthy Diet
- Eat plenty of fresh, crunchy fruits and vegetables. This is also a useful way to satisfy oral cravings without adding many calories.
- Drink plenty of water and healthy beverages.
- Drink coffee or tea in moderation. These drinks may help prevent weight gain, and may also boost alertness and mood. Avoid caffeine in the evening, however, since sleep disturbances can be a problem during withdrawal.
Change Daily Habits
- Change your daily schedule, particularly eating times, as much as possible. Eat at different times of the day or eat many small meals instead of three large ones. Sit in a different chair or even a different room while you eat.
- If you smoke after eating, find other ways to end a meal. Play music, eat a piece of fruit, get up and make a phone call, or take a walk (a good distraction that burns calories as well). If you normally have a cigarette with coffee, drink tea instead or use a different cup.
- Substitute oral habits by eating celery, chewing sugarless gum, or sucking on a cinnamon stick.
- Go to public places and restaurants where smoking is prohibited or restricted.
- Set short-term quitting goals and reward yourself when you meet them.
- Every day put the money you'd normally spend on cigarettes in a jar and buy something you want at the end of a set period of time.
- Find activities that focus your hands and mind but are not taxing or fattening, such as playing computer games or solitaire, knitting, sewing, or doing crossword puzzles.
About 4% of smokers who try to quit without any outside help succeed. Nevertheless, most people try to quit alone. The primary obstacle to quitting on your own is eliminating the habits associated with smoking. Excellent books, CDs, and manuals are available to help you quit on your own.
Smokers who use outside help or treatments fare better luck, with success rates of 25% to 35%. Those who are counseled in addition to using NRT and another drug have the best chance at quitting. Talking with a counselor can also help. Telephone counseling has been effective for quitting smokeless tobacco.
Studies have shown that interventions that combine medicine with behavioral counseling (at least 4 to 8 sessions) are more effective than brief advice or usual care.
Types of Behavioral Approaches
Problem Solving or Coping Strategies
Smokers are more likely to quit smoking when they learn thinking (cognitive) and behavioral techniques, stress management techniques, and ways to handle the symptoms of withdrawal and the urge to relapse. Smokers should look for programs that offer the following:
- Session lengths of 20 to 30 minutes
- Four to seven sessions
- A 2-week program
- An additional 2 weeks or more of follow-up contact
The Staged Approach
The staged approach customizes quitting interventions for each person, rather than using one general method. This approach takes the smoker through six stages of behavioral interventions:
People who follow this approach do not always proceed from one stage to another in a step-by-step fashion. Instead, they may cycle or spiral back and forth. Some people may move from stage 1 to 2 to 3, and then back to 2 again. You can stay in maintenance mode for years and then fall back to stage 2. Remember that this is normal, if you tried quitting in the past and did not stick with it, do not consider yourself a failure. Just try again.
Stage 1: Pre-Contemplation
People at this stage have no plans or desire to stop smoking. They are not even considering quitting. They may be unaware of the benefits of quitting. Or, they may have failed while trying to quit in the past and given up. There is no point in talking about how to start a smoking cessation program at this stage. Instead, it is important to think about how quitting will help you feel better, have more confidence, or live longer. You must identify the benefits before you will consider quitting. If you are at this stage, it can help to ask several friends or family members why they quit smoking.
Stage 2: Contemplation
A person at this stage is thinking, "I think I should probably quit, but I need help getting started." People at this stage know that quitting is good for them, but it seems like a daunting task or they do not think they can pull it off. Some may have tried and failed in the past. If you are at this stage, write down (brainstorm) all of your potential roadblocks, the things that you believe make quitting difficult, and learn strategies to overcome or sidestep those hurdles. People at this stage might benefit from making a pledge, contract, or other commitment.
Stage 3: Preparation
Smokers at this stage are ready to quit. The goal now is to create a specific action plan. You need to know which smoking cessation methods work and what support exists to help you quit. If you are at this stage, consider some backup plans, such as what to do when the urge to smoke hits you.
Stage 4: Action
People at this stage have just quit. This stage is when the most behavioral change occurs. It requires significant commitment and energy. If you are at this stage, keep talking to friends and family for inspiration. Review your backup plans. Reward yourself for small achievements. Having a fellow smoker quit with you can be a huge support as you both get through this stage.
Stage 5: Maintenance
People at this stage have been smoke-free for at least 6 months. The goal now is to prevent a relapse. If you are at this stage, continue to be wary of roadblocks and keep reminding yourself of the benefits you have gained. Consider what you have enjoyed most about being smoke-free.
Electronic, online, and computer cessation programs have a small but important impact on cessation. The relatively low cost of electronic interventions make them a good option.
Two types of incentive-based programs have been evaluated. The first type of program involves reward money being provided at the end of a period of smoking cessation. This type of program requires funding, most often by employers. These programs have demonstrated modest success.
The second involves placing a deposit at the time of sign up, using the person's own money. It is harder for this type of program to recruit participants, but the quit rates are higher than with reward programs described just above.
Alternative Methods for Quitting
Although rigorous studies on hypnosis are lacking, some people report successfully quitting after hypnosis sessions. Hypnosis requires you to trust the therapist and be able to feel completely at ease in the vulnerable and passive state necessary for hypnotic suggestion.
During a typical session, the hypnotherapist will use various techniques (such as imagery and silent counting) to put you into a relaxed state.
When you are very relaxed, but not asleep, the hypnotherapist will quietly suggest motivations for not smoking and reinforce a positive self-image. This may help some people avoid the depression that can accompany withdrawal.
Acupuncture and Acupressure
More research is needed to determine if acupuncture or acupressure helps people quit smoking. The acupuncture technique for quitting smoking usually uses very tiny curved staples inserted into different points around the edge of the ear or other parts of the body, which should be pressed in the case of a craving.
A related technique called acupressure involves pressing certain points on your body when a craving hits. Some studies have reported good short-time quit rates with acupuncture, but few well-designed and rigorous studies have been conducted.
Public Health Efforts and Social Pressure (Denormalization)
Denormalization is the idea that smoking is no longer normal or socially acceptable. Examples include:
- Creating laws and local regulations that make smoking inaccessible in public places
- Raising prices on cigarettes
- Putting stricter limitations on cigarette advertising
Increasing taxes on cigarettes may be one of the most important methods for reducing smoking in the general population, particularly in younger people.
Evidence suggests that banning smoking in work and public places may lead to a higher quit rate than in places where smoking is permitted. In addition, banning smoking in public spaces reduces exposure to secondhand smoke for both non-smokers and smokers.