Smoking Cessation

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Seventy percent of the 46 million Americans who smoke want to quit. But successful quitting rates are dismal. Smokers usually try to quit several times before permanently kicking the habit, and smokers who don't participate in a smoking cessation program fail 95 percent of the time.

But don't despair. Each year about 1.3 million smokers do quit. Since 1965, more than 40 percent of all adults who have ever smoked have quit. And research shows that with good smoking cessation programs, 20 to 40 percent of participants are able to quit smoking and stay off cigarettes for at least one year. There are a lot of different ways to give up smoking, but research shows you'll have the best chance of quitting if you take the following steps: Take time to prepare yourself mentally; get support and encouragement from people around you or professionals; learn new skills and behaviors to help you cope without cigarettes; get medication and use it correctly; and prepare yourself for difficult situations and setbacks.

Ready to give quitting a go? Here are the answers to the questions you'll need to succeed:

  1. Why should I quit?
  2. Why is it so hard?
  3. I want to quit. What's the first thing I should do?
  4. Should I taper or quit all at once?
  5. It's getting close to quit day. What should I do?
  6. What medicines are available to help me quit?
  7. How can I get social support while I am quitting?
  8. What is withdrawal, and how do I quench cravings?
  9. I quit. How do I avoid a relapse?
  10. Where can I find out more about quitting smoking?
  11. Why Should I Quit?

    There certainly is no shortage of reasons to quit. The evidence against smoking is overwhelming. The U.S. Centers for Disease Control and Prevention estimates that male smokers lose an average of 13.2 years of life and female smokers 14.5 years because of smoking. The habit has been linked to killer diseases such as lung cancer, coronary artery disease, and stroke, not to mention increasing the risk of nuisance illnesses like the flu or pneumonia. Then there's the guilt about secondhand smoke, which causes serious harm to nonsmokers. And there's the fact that smoking is a costly habit. A pack a day will run you about $1,500 a year, and that doesn't include the higher insurance premiums you pay if you're a smoker. However, millions of people have quit smoking, and you can too. Here are some good reasons to quit:

    • You will live a longer and better life.
    • Quitting will lower your chance of having a heart attack, emphysema, chronic bronchitis, stroke, or cancer.
    • The people you live with, especially your children, will be healthier.
    • Food will taste and smell better.
    • You will have extra money to save or to spend on things other than cigarettes.
    • Your home, car, clothing, and breath will smell better.
    • You can stop worrying about quitting.
    • You will set a good example for your children.
    • You will do better in physical activities.
    • You will have less wrinkling/aging of skin.
    • There is a higher risk of cancer and heart disease for family members.
    • Children of smokers are more likely to take up smoking than are children of nonsmokers.
    • Children of smokers have an increased risk for asthma, middle-ear disease, respiratory infections, and sudden infant death syndrome.
    • Women who smoke have a higher risk for giving birth to low-birth-weight babies.
    • This section has more information on secondhand smoke.

      Why Should I Quit? Secondhand Smoke

      Cigarette smoke doesn't affect only people who smoke; it can also cause cancer in the people around them. Smoke in the environment is called secondhand smoke, which is a combination of two types of smoke, sidestream and mainstream. Mainstream smoke is the smoke exhaled by a person who is smoking. Mainstream cigarette smoke is a mixture of over 4,000 chemicals, 40 of which cause cancer in humans. Sidestream smoke is the smoke from the end of a burning cigarette. Sidestream smoke contains all of these same carcinogens.

      Many studies have looked at the results of exposure to secondhand smoke. In a report released in 1993, the Environmental Protection Agency concluded that in adults, secondhand smoke is responsible for approximately 3,000 lung cancer deaths every year among nonsmoking Americans. Additional reports have concluded that secondhand cigarette smoke causes approximately 53,000 deaths a year from heart disease in nonsmokers.

      Why Is It So Hard to Quit?

      Quitting is so difficult because of nicotine, which is as addictive as heroin and cocaine. Nicotine exists naturally in tobacco and is carried deep into the lungs when smokers inhale. Once in the lungs, it enters the bloodstream and spreads throughout the body, causing a variety of changes.

      Like caffeine, nicotine is a stimulant. It increases activity in the brain and produces a "kick" or "buzz" caused in part by stimulation of the adrenal glands, which discharge adrenaline. This rush of adrenaline stimulates the body and causes a sudden release of glucose, as well as an increase in blood pressure, respiration, and heart rate. Nicotine also suppresses insulin output from the pancreas, which means that smokers always have elevated blood sugar levels. Nicotine also creates a pleasant feeling by releasing the neurotransmitter dopamine.

      However, as the nervous system adapts to nicotine, it develops tolerance, meaning it requires more and more nicotine to attain the buzz. That's why long-term smokers tend to smoke much more than people just starting out. When smokers who have developed a tolerance to nicotine try to cut back or quit, the absence of nicotine leads to withdrawal symptoms such as dizziness, headaches, irritability, and insomnia.

      It is important to realize that withdrawal has both physical and psychological components. Physically, the body reacts to the lack of nicotine, but the psychological effects can be daunting as well. For some people, the feel, smell, and sight of a cigarette and the ritual of obtaining, handling, lighting, and smoking the cigarette are all associated with pleasure and can make withdrawal and cravings even worse. Withdrawal can be very uncomfortable, but hang tight. Symptoms usually peak a few days after quitting and then subside over time. You can read more about withdrawal in "What is withdrawal, and how do I quench cravings?"

      I Want to Quit. What's the First Thing I Should Do?

      In order to quit successfully, you first need to understand your smoking habits. It is important to think about what feelings, activities, or situations cause you to smoke. Think about the times you like to smoke.

      Do you smoke:

      • When you get up in the morning?
      • After eating?
      • While drinking coffee?
      • While drinking alcohol?
      • When relaxing?
      • When you feel stressed?
      • When you are with others who smoke?
      • When you have strong feelings, like when you feel happy, sad, angry, or depressed?
      • When driving or riding in a car?
      • If you aren't sure about your smoking habits, it may help to track each cigarette you smoke by writing down why you want to smoke it and how you are feeling at the time. You will probably discover some patterns in your smoking behavior that will be useful when you try to quit. For example, if you realize you usually smoke when you're out drinking, it may be a good idea to avoid bars for a while.
      • You can make your own form to keep track of smoking triggers or use the "pack track," to record when you smoke and why. Make copies, and put one in each pack of cigarettes that you smoke.
      • Set a Quit Date and Decide If You Want to Gradually Cut Down or Quit All at Once

        First, set a quit date. It is important to set a date to quit so you can mentally and emotionally prepare for it. Set a date that is not in the middle of an overly stressful period in your life, but don't wait till your life is without any stress, because that day will never come. There is no one way to quit. However, some smokers find it effective to quit "cold turkey," that is, abruptly and totally. They smoke until their quit day and then stop all at once. Another method, called "tapering" involves cutting down on the number of times tobacco is used each day. With this method, you gradually change your smoking pattern to reduce the amount of nicotine in your body until your quit date.

        It's Getting Close to Quit Day. What Should I Do?

        First, change your environment. Get rid of all cigarettes and ashtrays in your home, car, and place of work. Try to start spending more time with people who you know are supportive of your new lifestyle and will help you. Also, try to start exercising before you quit. Participating in a regular exercise program at least three times a week will help you develop healthful habits and give you something to do to take your mind off smoking. Find something to do with your hands, to get ready for times when you will get the urge to smoke. It may sound silly, but holding a stress ball or eating carrots, pretzels, or some other thin object might help distract you when you're trying to quit.

        This section has more on:

        • Getting ready for your quit date
        • The day before your quit date
        • Quit day tips
        • Getting Ready for Your Quit Date

          • Make your own personal list of reasons why you want to quit smoking. Carry it with you all the time. Read it frequently.
          • Circle your quit date on your calendars.
          • Write the date on your "pack tracks" or a piece of paper, and put it in every pack of cigarettes that you smoke until your quit date.
          • Tell the date to everyone on your support team so they will be ready to help you if you need them.
          • Experiment by not smoking during some trigger situations, and plan by thinking about the coping skills you will use. Do this so you will be prepared when you stop smoking completely.
          • Plan to reward yourself for your achievement of not smoking. Reward yourself frequently at first. If you need to reward yourself every hour the first day, do it. You deserve it. Some people put the money they would spend on cigarettes in a separate jar and use it for their rewards. Some just like to watch the pile of money grow and then buy something really special. Use your imagination. What do you want? Make up your own list of rewards, and carry that with you, too. Read it often.
          • Buy the quit smoking medicines you plan to use. If you will be taking Zyban or Chantix, get a prescription from your doctor and start taking it seven to 10 days before your quit date.
          • The Day Before Your Quit Date

            The night before you quit, pamper yourself. After you have had your last cigarette, make sure that you get rid of any remaining cigarettes. Don't forget to search clothes that haven't been worn recently, handbags, drawers, your car, etc., where old cigarettes may be hidden. Soak them in water, or break them up to make sure that they are unsmokable. Before turning off the light, read your list of reasons for quitting and put it by your bedside. Get a good night's sleep in preparation for quit day, confident in the knowledge that you are ready to begin a new phase of your life tomorrow—one that is a positive and healthful step for the rest of your life.

            On Your Quit Day Tips

            The first day will be the hardest, but remember it is only 24 hours long. Because this day will be difficult, be good to yourself and ask for support from those around you. Read your list of reasons for quitting, start your nicotine replacement treatment(s) (if that is part of your plan), and think about your coping skills and your support group that will help you through today and in the future. And don't forget to reward yourself. Quit day is also a good time to review the benefits of not smoking. Doing so may help to keep you motivated. Keep these tips in mind on your quit day:

            • Circle your quit date on your calendars.
            • When you first try to quit, change your routine. Take a different way to work. Drink tea instead of coffee. Eat breakfast in a different place.
            • Do something to reduce your stress. Take a hot bath, exercise, or read a book.
            • Drink a lot of water and other fluids.
            • Develop a healthier lifestyle—eat healthful foods, and remember to exercise at least three times a week.
            • Brush your teeth frequently with a fresh-tasting toothpaste. (There is no rule that says you should brush your teeth only twice a day!)
            • Try to distract yourself from urges to smoke. Talk to someone, go for a walk, or get busy with a task.
            • Remember, as soon as you stop smoking, your body immediately begins to recover from the years of smoking abuse.
            • Keep in mind that at first you will have times of stress, irritability, headaches, upset stomach, poor concentration, and anxiety (nerves). These are the expected symptoms of addiction withdrawal. This is what you developed your coping skills for—use them!
            • What Medicines Are Available to Help Me Quit?

              Medicine can help you stop smoking and lessen the urge to smoke. The use of medication can double your chances of quitting and quitting for good. Everyone who is trying to quit may benefit from using a medication. Some people benefit from using a combination of the medicines such as the nicotine patch with nicotine gum or lozenges. Studies show a combination of medicines are more effective than a single medication.  Talk to your doctor or other healthcare provider about taking a medicine to help you quit.

              Let your doctor know if:

              • You are pregnant
              • You are nursing a baby
              • You have a medical condition
              • The following medicines are available and have been approved by the U.S. Food and Drug Administration to help you quit smoking:

                • Bupropion SR, (Zyban, Wellbutrin SR)
                • Varenicline (Chantix)
                • Nicotine gum (Nicorette)
                • Nicotine nasal spray (Nicotrol NS)
                • Nicotine inhaler (Nicotrol)
                • Nicotine patch (Habitrol, NicoDermCQ, Nicotrol, ProStep)
                • Nicotine lozenge (Commit)
                • Bupropion SR (Zyban, Wellbutrin SR). This is an antidepressant that decreases the desire to smoke. You should start taking the pill seven to 10 days before the day you plan to quit smoking; your doctor will tell you how long to continue taking it, but most people stay on it for two to six months. It is a prescription medicine that should not be taken if you have a history of seizures or are taking a MAO inhibitor such as Marplan, Nardil, or Selegiline. Make sure that your doctor is aware of all medicines you take because there are other adverse drug interactions that can occur. Monitor yourself closely, and let your doctor know immediately if you experience any unusual physical or emotional reactions to the drug. Some people experience side effects initially, including dry mouth, insomnia, changes in appetite, agitation, and headaches.

                  Varenicline (Chantix). This is a different type of medicine for quitting smoking. Chantix acts at sites in the brain affected by nicotine. It works in two ways: by lessening withdrawal symptoms and blocking the enjoyable effects of smoking. Chantix is a prescription medicine. You should begin taking the drug one week before your quit date, and you can continue to smoke until then. However, it is not recommended to combine this drug with a nicotine replacement. Chantix is generally taken for at least 12 weeks. If you have quit smoking at the end of 12 weeks, your doctor may advise taking it for 12 more weeks. In recent studies, people who continued taking Chantix for six months were much more likely to quit and remain tobacco free at one year. Some people experience nausea or sleep disturbance the first week of taking Chantix. Monitor yourself closely, and let your doctor know immediately if you experience any unusual physical, emotional, or psychological reactions to this drug.

                  The rest of the medications approved to help you stop smoking are nicotine replacement treatments. This means that they provide nicotine to your body in a form other than smoking—a form that is not addictive and doesn't contain the harmful chemicals in smoke. These medicines should be started on your quit date. Using nicotine replacement allows your body to get used to lower levels of nicotine gradually while you develop new coping skills. Gum, inhalers, and lozenges tend to have the fewest side effects, but they sometimes cause mouth irritation or jaw soreness. The patch can cause skin irritation and sleeping problems. The nasal inhaler can cause a hot, burning, or peppery feeling in the nose or throat, sneezing, and coughing. Nicotine replacement therapy is generally used for two to six months.

                  Nicotine gum (Nicorette). This gum is available without a prescription. As you chew the gum, nicotine is released and absorbed by the blood vessels in your mouth. Chew the gum a few times to release the nicotine and then place it between your cheek and gum. The gum is available in several flavors.

                  Nicotine nasal spray (Nicotrol NS). The nicotine nasal spray delivers nicotine very quickly—within seven to 10 seconds—into your bloodstream. This helps to reduce craving for a cigarette. It is available by prescription from your doctor. You may initially experience a burning sensation and sneezing, but this lessens with use.

                  Nicotine inhaler (Nicotrol). The nicotine inhaler is a small device that you hold in your hand and inhale, similar to a cigarette. As you inhale from it, nicotine enters your bloodstream through blood vessels in your mouth and throat. This helps to reduce the craving for a cigarette and keeps your hands busy. It is available by prescription from your doctor.

                  Nicotine patch (Habitrol, NicoDermCQ). There are a number of nicotine patches available. Some require a prescription, and others are available over the counter. Some generic patches are available at a lower cost. A nicotine patch is placed onto your skin and releases nicotine into your bloodstream. It maintains an even level of nicotine in your system without smoking. Keep in mind that it can take up to two hours for your blood level of nicotine to reach that level when you put on a new patch each morning.

                  Nicotine lozenge (Commit). The nicotine lozenge can be helpful for people who want to keep their mouths busy. It releases nicotine as you allow the lozenge to dissolve slowly in your mouth. You can buy it without a prescription. It is available in two strengths.

                  How Can I Get Social Support While I Am Quitting?

                  Research shows that people who participate in a smoking cessation program that provides support and guidance throughout the quitting process can double their chances of quitting. Of the smokers who try quitting on their own, 95 percent fail. Though official programs do help, even just quitting with a friend or spouse will increase your chances of success. The important thing is that somebody else goes through the experience with you. Here are some options to consider:

                  Individual counseling. A number of healthcare professionals are trained to provide counseling to help you quit. Check with your physician, nurse, psychologist, counselor, or social worker. One-on-one counseling can help you learn new ways to deal with stress, express your feelings about quitting, and develop a plan to lessen your chance of setbacks.

                  Telephone counseling. Some programs, available through your health plan, provide telephone calls on a regular basis. A healthcare professional will call you to talk about how you are doing with your efforts to quit smoking. Also, he or she will reinforce why you chose to quit and review your plan to keep you on track. Some programs offer a number for you to call and speak to a quit smoking specialist when you feel an urge to smoke. In every state, you can also now call the Quit Line, available at (800) 784-8669, to talk to a tobacco counselor about quitting.

                  Online support. There are numerous helpful cessation programs online. Many have interactive features that support you while quitting and help you remain smoke free. Also, the Web is full of chat rooms, blogs, and quit-smoking organizations that can help you quit. The Web can also be a great resource for finding support groups in your area.

                  Quit-smoking groups. Groups like Nicotine Anonymous provide periodic meetings and a community for people trying to quit. You can find one by contacting local hospitals, looking in the yellow pages, or searching online.

                  Also, be aware that socializing with smokers will make you more likely to relapse. At first, limit or phase out time spent with smokers. If your spouse smokes, encourage him/her to quit with you or at least to avoid smoking in the home and cars. Try to spend more time with people who don't smoke. Drinking alcohol lowers your chances of quitting successfully. At least during the first few weeks of quitting, avoid drinking alcohol. Later, as you are more comfortable with your smoke-free lifestyle, try to limit the amount you drink and the frequency.

                  What Is Withdrawal, and How Do I Quench Cravings?

                  Withdrawal is the physical and emotional symptoms that occur after quitting. These symptoms include irritability, insomnia, tiredness, sore throat, dizziness, and trouble concentrating. There are both physical and psychological causes for withdrawal. The physical causes relate to the fact that the neurochemistry of smokers' brains changes in the presence of nicotine. Nicotine enhances the release of a chemical messenger called dopamine, which produces feelings of pleasure and satisfaction. Normally, the body uses dopamine as part of a reward system that encourages behaviors essential for survival, such as eating. However, sustained smoking causes the body to depend on nicotine for the release of normal amounts of dopamine. When smokers quit, the body once again has to recalibrate the regulation of dopamine and other neurotransmitters that control mood. In the short term, for quitting smokers, that means dopamine levels are out of balance, a situation that leads to irritation and other withdrawal symptoms.

                  Usually, symptoms of nicotine withdrawal begin rapidly and peak within one to three days. Because of this rapid onset of withdrawal symptoms, only about 30 percent of people who try to quit smoking remain tobacco free for even two days. Withdrawal symptoms generally last three to four weeks, but some smokers have withdrawal symptoms that last more than a month. Some people have strong cravings for tobacco that last for months, even though the physical addiction to nicotine is long past. These cravings often occur in social settings in which the person formerly smoked, such as at a bar or party, or after sex. Researchers believe that much of this extended craving is psychological.

                  You can overcome withdrawal symptoms by trying the following:

                  • Irritability. Take a deep breath; exercise; picture in your mind a relaxing event or place.
                  • Tiredness. Take it easy; take a nap; go to bed early.
                  • Insomnia. Avoid caffeine after 4 p.m.; try relaxation techniques.
                  • Sore throat. Drink plenty of liquids; use cough drops; or chew gum.
                  • Dizziness. Use extra caution when driving or operating machinery. Rest.
                  • Trouble concentrating. Avoid demanding jobs, if possible, during the first few weeks.
                  • I Quit. How Do I Avoid a Relapse?

                    The most important way to avoid a relapse is to be mentally prepared for feelings, situations, or activities that make you want to smoke. Remember to use the new coping skills you have learned. Most setbacks occur within the first three months after quitting. As the days, weeks, and months pass without smoking, you will be astounded at how much better you feel. Throughout this time, you may be tempted to have a cigarette, telling yourself that, "just one cigarette is no big deal." This is a big mistake. Don't be tricked into this false sense of security. It is very easy for one cigarette to lead to two, three, or four. Before you know it, you will be back to smoking as much, if not more, than you did before you quit.

                    But what if you do have a weak moment and smoke a cigarette? Well, you won't be the first. It's important to get right back on track. Don't let a little slip become a full-blown relapse. Remember that relapsing doesn't mean you are a failure. Use this experience to learn something about yourself and how you can better deal with this and other temptations that you will face. Review the situation that caused you to have a cigarette. It is very important to try to understand why you smoked. It may be the same reason you started smoking in the past, or perhaps a recent event, such as a stressful day at work. If there seems to be an underlying issue that is troubling you, counseling may help. Whatever the reason, it is important to deal with these issues so you can be successful in your efforts to be smoke free.

                    Also be aware that many smokers relapse because of concerns about weight gain or because of difficulty managing stress. Try to anticipate these situations by preparing ahead of time healthy coping skills other than cigarettes. Some smokers do gain weight when they quit, because of a change in metabolism and increased appetite. You can stave off weight gain by planning meals that have low calories and low fat. When grocery shopping, shop from a list and avoid aisles with tempting high-calorie, high-fat foods. Buy healthful, unprocessed staples like whole-wheat bread and pasta instead. At home, store food out of sight. And, if you have the energy, exercise three to five times a week.

                    Be ready for bad moods, mood swings, or depression. There are a lot of ways to improve your mood other than smoking. Regular exercise and getting enough rest are very important, especially during the first few weeks. Smoking affects chemicals in the brain that are associated with mood and emotions. Some people smoke to elevate their mood or to help them feel better about themselves. If you tend to feel depressed, talk to your doctor about Zyban. This medicine lowers your desire to smoke and is also an anti-depressant. As you quit, you will need to learn to deal with stress or pressure in other ways.

                    General approaches to stress include:

                    • Change what you can; let go of what you can't control.
                    • Try to see things in a more positive way.
                    • Get support from your (nonsmoking) family and friends.
                    • Make time for yourself.
                    • Practice deep breathing and relaxation exercises.
                    • Where Can I Find Out More About Quitting Smoking?

                      More information on quitting smoking is available at these websites recommended by the U.S.News & World Report Library:

                      Free Seven-Week Online Smoking Cessation Program

                      The American Lung Association's Freedom From Smoking program uses a series of modules to help smokers quit. Clinical Trials

                      The National Institutes of Health provides a database of federally and privately supported clinical trials, including dozens on quitting smoking. Find a Smoking-Cessation Professional in Your State

                      Find professional support through the North American Quitline Consortium.

                      This website, from the Tobacco Control Research Branch of the National Cancer Institute, offers an online quitting guide, information on cessation studies, and access to "Talk to an Expert." Within 20 Minutes of Quitting

                      Quick, health-motivating facts from the National Center for Chronic Disease Prevention and Health Promotion on the benefits of quitting smoking. Last reviewed on 10/14/09

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