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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Man to Man Man to Man

Smoking Cessation -- Ways To Quit

January 24, 2013

By Harvey B. Simon M.D.

Harvard Medical School

More than 20% of American adults still smoke. The habit remains more prevalent in men than women. But women die just as often as men from tobacco related illnesses. Tragically, thousands of teenagers take up smoking every day. In one survey, more than 48% of male high school students reported using some form of tobacco.

We can do better. Fortunately, there are more ways to kick the habit than ever before.

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The Hazards of Smoking

Tobacco is responsible for 1 of every 5 deaths in the United States. That adds up to over 435,000 lives lost each year. The average non-smoker lives about 14 years longer than the average smoker. And over 8.5 million Americans suffer from chronic illnesses caused by smoking. Heart disease, stroke, lung cancer, emphysema and bronchitis are high on the hit list. But smoking also causes "minor" problems ranging from cataracts, sinusitis and dental disorders to aging skin, heartburn, osteoporosis, bladder cancer and erectile dysfunction.

The more you smoke, the higher your risks. But even a few cigarettes a day will harm your health. "Light" and "low tar" cigarettes are no safer than high-test brands. The only truly safe dose of tobacco is no tobacco.

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The Benefits of Quitting

Even if you've smoked for years, you'll benefit from quitting.

  • Within days, your blood vessels start to recover from the damage and to work normally again.
  • Within weeks, you'll be able to taste food better, and your sense of smell will recover from tobacco's assault.
  • Within months, symptoms of chronic bronchitis ease up, and lung function improves within a year.
  • Within 2 to 5 years your risk of heart attack and stroke drop.
  • Within 5 to 9 years of quitting the risk of lung cancer begins to drop substantially.

People who kick the habit, regardless of age, live longer than those who continue to smoke. And since each pack of cigarettes costs our society $7.18 in medical costs and lost productivity, quitting will help America's budget as well as yours.

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Four Ways To Quit

There are four basic ways to quit smoking. Pick the one that is best for you. Most smokers start by trying to quit on their own, but many end up having to try different methods and make several attempts to quit before they kick the habit. And even after you quit, it's important to keep your guard up. Just as a single drink can be dangerous to an alcoholic, just one cigarette can fire up your nicotine craving even after years of abstinence.

  1. Do it yourself. Don't kid yourself by trying to cut down on the number of cigarettes you smoke. Nearly everyone who tries this method slides back up to their usual dose of nicotine. Cold turkey is the way to go, but it takes preparation. And even if you try it without professional help, cooperation from family and friends can be important. Here are some tips for quitting on your own:
  • Make a list of reasons to quit and another list of people who have kicked the habit. The first list will remind you why quitting is important, and the second will show you that folks who are no stronger or smarter than you have succeeded. Keep your lists handy and refer to them whenever you begin to waver.
  • Pick a quitting date and stick to it. Plan to quit on a special day such as a birthday. Steer clear of stressful periods, and avoid holidays if you are likely to be invited to smoke-filled parties.
  • Try to get other smokers in your household or circle of friends to join you in quitting.
  • As your quit date approaches, throw out your ashtrays, clean your house, car, and clothes, and clean your teeth. You'll soon see that smoking stinks.
  • Anticipate withdrawal symptoms, such as grumpiness, restlessness, irritability, hunger, headache, anxiety, and drowsiness or insomnia. The discomfort usually peaks 1 to 3 weeks after you quit, and then it gradually lessens. To get through the rough patches, stock up on low-calorie snacks and sugarless gum or candy to keep your mouth busy. Plan enjoyable diversions to keep your mind busy. Think of ways to keep your hands busy, such as doodling and worry beads.
  • If you feel tense, try meditation, deep breathing or yoga.
  • Begin an exercise program. Walking 30 minutes a day, for example, will relieve tension, promote good sleep and help control weight gain.
  • Eat a healthy diet.
  • Stay away from secondhand smoke. Don't even think about smoking "just one" — even a single puff will set you back.
  • Reward yourself. Put your tobacco money aside in a kitty, and then spend it on a special treat.
  • Think positively — you can quit. Take it one day at a time. And if you slip, try, try again — either on your own or with one or more of the other strategies for quitting.
  • Behavioral support. Quitting is your responsibility. It may be tough, but it doesn't have to be lonely. Professional counseling and support groups can be very helpful. Many employers, health plans and hospitals offer individual or group counseling. Your doctor or your local chapter of the American Lung Association or the American Cancer Society can refer you to a stop-smoking program near you. Telephone support can also help: Call the National Network of Tobacco Cessation Quitline at 1-800-QUIT-NOW. Hypnosis is another alternative that has helped some smokers break free.
  • Nicotine replacement therapy. Like other addicting substances, nicotine acts on the brain's "reward center." It creates a sensation of pleasure and a craving for more nicotine. Nicotine replacement therapy can short-circuit the craving. Nicotine replacement is safe. Smokers will get less nicotine than from cigarettes, and they won't get any of the damaging substances in tobacco, such as tar and carbon monoxide. Start nicotine replacement therapy on the day you quit smoking. Since the average cigarette delivers 1 to 2 mg of nicotine, you can estimate how much nicotine you need. Begin with the full dose you need (heavy smokers need higher doses), then gradually taper down over several months. Under-dosing is more common than overdosing, but nobody should smoke while using nicotine replacement therapy. Here is a quick review of the options for nicotine replacement therapy:
    • Nicotine patches are available over-the-counter and deliver a steady dose of nicotine around the clock. A popular type of 24- hour patch called NicoDerm CQ comes in three strengths: 21 mg, 14 mg and 7 mg. A new patch is placed on clean, unbroken, hairless skin each day. Most smokers should start with the 21 mg dose, but people who weigh less than 100 pounds or smoke fewer than 10 cigarettes a day should start with the 14 mg dose. The dose can be reduced every 1 to 2 months as the nicotine addiction resolves. A 16-hour patch that is removed at bedtime can help people who get bad dreams from wearing the patch at night. Mild skin irritation is the most common side effect. Patches should be stored and thrown away with care to keep them away from young children. Patch-users can also use short-acting nicotine products, such as nicotine gum or lozenges to suppress breakthrough craving. (They deliver a higher dose of nicotine faster, but protection also declines faster.)
    • Nicotine gum (Nicorette) is available over-the-counter. People who smoke more than 25 cigarettes a day should use the 4 mg per piece dose; lighter smokers should use the 2 mg per piece dose. Chew a piece of the gum whenever the smoking urge hits. Don't chew more than 30 pieces a day. Aim to wean off the gum in about 3 months if possible. Chewing replaces the oral stimulation of smoking, which can be an advantage, but some people find the taste unpleasant; some people develop hiccups or indigestion. Avoid acidic beverages, such as coffee, tea, beer and soft drinks for at least 15 minutes before use. They may interfere with nicotine absorption.
    • Nicotine lozenges (Commit) are available without a prescription. People who usually light up within 30 minutes of getting up in the morning should use the 4 mg strength. Other people who are less addicted can use the 2 mg lozenges. A typical schedule calls for one lozenge every 1 to 2 hours for six weeks, then every 2 to 4 hours for two weeks, and then every 4 to 8 hours for the final two weeks. People cannot eat or drink while sucking on a lozenge, and should avoid acidic beverages for at least 15 minutes before use. Nicotine lozenges are safe for dentures. Side effects may include an unpleasant taste, nausea, indigestion or mouth tingling.
    • Nicotine inhalers (Nicotrol Inhaler) are available by prescription. Each cartridge delivers a"puff" of vapor containing 4 mg of nicotine through a plastic holder. The holder may help satisfy a smoker's oral urge. The average dose is 6 to 16 cartridges a day for up to 12 weeks, followed by a gradual reduction in dose over the next 12 weeks. Most of the nicotine is absorbed through the mouth, not the lungs. Side effects may include mouth or throat irritation and cough.
    • Nicotine nasal spray (Nicotrol NS) is available by prescription. Each spray delivers .5 mg of nicotine. Use one spray in each nostril when you feel the urge to smoke, up to a maximum of 10 sprays an hour or 80 a day for 3 months. Side effects may include nasal irritation, sneezing, tearing, and cough.
  • Prescription drugs. There are two drugs that are used to help smokers quit:
    • Bupropion (Wellbutrin) – This antidepressant was approved for smoking cessation under the name Zyban. It doesn't contain nicotine and can be used in combination with nicotine replacement therapy. Start taking bupropion one to two weeks before your quit date. The dose for the first 3 days is 150 mg once a day, then 150 mg twice a day for the next 8 to 12 weeks — or longer if needed. Bupropion may help prevent weight gain after quitting. Side effects may include dry mouth and insomnia; seizures are very rare.
    • Varenicline (Chantix) is the newest drug approved for smoking cessation. It blocks nicotine receptors in the brain while also partially stimulating these receptors to reduce nicotine withdrawal symptoms. The usual dose is 0.5 mg once a day for the first three days, then 0.5 mg twice a day for four days, followed by the full dose of 1 mg a day for 12 weeks or longer. The dose should be lowered in patients with severe kidney disease. Nausea is common and bad dreams may occur. Contact your doctor if you experience behavior or mood changes.

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    Public Health Enemy Number One

    Smoking is the top threat to public health. So if you smoke, quitting should be your top priority. It will take willpower and hard work, but lots of help is available. You may gain a few pounds, you may go through a rough spell as your body adjusts to life without tobacco, and you may have to try several times before you finally kick the habit. Don't be discouraged. Over 45 million Americans have quit smoking and you can, too. Do whatever it takes; it's the manly thing to do.

    Here are some additional resources for living without tobacco.

    Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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