Smoking

Overview

What Is It?

Smoking has long been the leading cause of preventable death and disease among women.

Fifty years ago smoking was thought of as a primarily male "pastime." But in the decades since, women have just about closed the gender gap while at the same time experiencing dire health consequences, just like men. According to the most recently available statistics from the U.S. Centers for Disease Control and Prevention in 2010, 19.3 percent of American adults (45.3 million people) smoke. Every year, smoking kills an estimated 443,000 people through smoking-related diseases, including lung and other cancers, heart disease, stroke and chronic lung diseases such as emphysema.

Smoking has long been the leading cause of preventable death and disease among women. And, according to recent surveys, many women do not realize that lung cancer, once rare among women, surpassed breast cancer in 1987 as the leading cause of female cancer death in the United States.

In fact, it has been proven that smoking can cause disease in nearly every organ of the body, in women as well as men. The list of diseases caused by smoking has been expanded to include abdominal aortic aneurysm, acute myeloid leukemia, cataract, cervical cancer, kidney cancer, pancreatic cancer, pneumonia, periodontitis and stomach cancer. These are in addition to diseases previously known to be caused by smoking, including bladder, colorectal, liver, esophageal, laryngeal, lung, oral and throat cancers, chronic lung diseases, coronary heart and cardiovascular diseases, as well as reproductive effects and sudden infant death syndrome.

Smoking also harms many aspects and every phase of reproduction: menstrual function, oral contraceptive use, fertility, problems in pregnancy and giving birth to low-weight babies, among other conditions.

In addition, smoking increases your risk of developing osteoporosis. Smoking is related to an increased risk for hip fracture as well, especially among postmenopausal women (studies have shown that bone mineral density and body mass are lower in smokers). Smoking also affects your appearance. Long-term smoking will cause your skin to wrinkle prematurely and lose its elasticity, your nails and teeth to turn yellow and your breath to smell foul.

While smoking rates have fallen among women since 1965—33.9 percent of women were smokers in 1965, as compared with 18.3 percent in 2008—teenagers are still lighting up. According to the CDC, each day, more than 3,800 teenagers younger than age 18 smoke their first cigarette, and 1,000 teenagers younger than 18 begin smoking on a daily basis.

Adolescents who smoke are generally less physically fit and have more respiratory illnesses than their nonsmoking peers. In addition, smoking by adolescents hastens the onset of lung function decline during late adolescence and early adulthood. Smoking by adolescents is also related to impaired lung growth, chronic coughing and wheezing.

Why Teenage Girls Smoke Despite Known Risks

With all of the negative publicity about smoking, why do so many women and teenage girls continue to smoke? Teenagers vastly underestimate the addiction potential of nicotine. A woman who begins smoking when she is young will have a very difficult time quitting as she ages and becomes more concerned with the health consequences.

It is well documented that there are social, political and economic forces that influence tobacco use, particularly among youth. A major factor influencing susceptibility to and initiation of smoking among girls, in the United States and overseas, is the tobacco industry's long-standing (75 years or more) targeted marketing to women and girls. Tobacco marketers know that if they can hook children, these children are more likely to become lifelong customers.

The tobacco industry spends more than $9.94 billion dollars annually in the United States to advertise and promote its products, including print media advertising (cigarette ads are banned from television and radio); distribution of free samples, cents-off coupons, T-shirts and other giveaways; movie product placements; cultural programs; donations to a wide range of national and local organizations; and political contributions to elected officials.

Women's Greater Vulnerability to Tobacco

Some research has revealed that women might be more susceptible to the addictive properties of nicotine and have a slower metabolic clearance of nicotine from their bodies than men. Also, women seem to be more susceptible to the effects of tobacco carcinogens than men.

Women also tend to smoke for different reasons than men, citing more emotional triggers, such as relief of stress, anxiety, anger or depression.

Smoking and Addiction

Nicotine is what keeps smokers addicted to tobacco, and it doesn't take long to get hooked. Nicotine is one of the most powerful addictive drugs—more addictive than heroin—yet it is also easily available and more socially accepted than other highly addictive substances.

Nicotine is the addictive chemical in tobacco but most of the negative health consequences of smoking are caused by the other 4,800 chemicals inhaled when tobacco products are burned. Carbon monoxide is also produced. It becomes attached to the red blood cells and decreases the oxygen available to the body tissues.

Nicotine's effect on the central nervous system is what makes smoking pleasurable. Nicotine has a calming effect and can relieve anxiety, boredom and irritability. Nicotine also has a stimulant effect, increasing alertness and improving concentration.

Within seven to 10 seconds of inhaling, your brain feels the effect of nicotine. Repeated inhalations maintain a steady blood level of nicotine. When you stop puffing, the blood level goes down. You light up again to deliver more nicotine to the brain. Pretty soon your brain and body consider it normal for you to have a certain blood level of nicotine. When that level goes down, you feel uncomfortable, irritable and unfocused. That's withdrawal. Now you are addicted. You smoke to keep from going into withdrawal, and you may find yourself smoking more and more.

Combined Effects of Smoking and Oral Contraceptives

Smoking cigarettes while taking birth control pills dramatically increases the risk of heart attack for women over 35. Smoking is far more dangerous to a woman's health than taking birth control pills, but the combination of oral contraceptive pill use and smoking has a greater effect on heart attack risk than when each factor is considered alone.

Smoking cigarettes while taking birth control pills increases a woman's risk of having an ischemic stroke (three times more likely in pill users than in nonusers) or a hemorrhagic stroke (three to four times that of nonusers), according to a large World Health Organization study.

Effects of Smoking on Reproductive Health and Pregnancy

Smoking affects ovarian function and decreases the female hormone estrogen. If you are planning to become pregnant, cigarette smoking can impair your fertility by adversely affecting ovulatory and tubal function, egg production and implantation. Smoking may cause you to have irregular menstrual cycles. Women who smoke also have an earlier menopause, which may increase their risk of osteoporosis, heart disease and other conditions for which estrogen provides a protective effect.

Nearly 11 percent of pregnant women continue to smoke throughout their pregnancies. If you smoke while you are pregnant, you are putting yourself and your unborn child at increased risk for complications. Risks of smoking during pregnancy include:

• complications from bleeding
• low-birth–weight babies
• increased risk of sudden infant death syndrome (SIDS)
• premature birth
• stillbirth
• placenta previa (the placenta grows too close to the opening of the uterus, a condition that often leads to Caesarean delivery)
• placental abruption (the placenta prematurely separates from the uterus wall)
• premature rupture of uterine membranes
• preeclampsia (a condition that results in high blood pressure and excess protein in the urine)
• reduction of the newborn's lung function

If you are a smoker and a nursing mother, it is important to know that nicotine is found in breast milk, and therefore enters your baby's system.

If you have children, your smoke puts them at risk, too. Secondhand smoke has been shown to make children more susceptible to infections, including colds and flu, ear infections and lower respiratory infections such as bronchitis and pneumonia. It also causes new cases of asthma, and it makes existing cases of asthma worse.

Diagnosis

Regardless of how much you smoke, you need to quit.

Researchers now know that there is a strong family component to addiction. If you have a family history of addiction, you should be aware of the risk for developing dependency, especially during stressful periods in your life.

The vast majority of smokers are addicted or dependent on nicotine. In addition to overcoming nicotine addiction, the quitting smoker must fight the actual habit of smoking, the behavioral activity of lighting up a cigarette so many times a day for so many years. For many smokers, smoking becomes associated with many daily activities (driving, talking on the phone, watching TV, for example) and often, these activities won't feel right without the cigarette. For many women, there is an emotional dependence on smoking. Maybe you smoke when you are stressed or sad. All of these issues combine to make smoking a powerful adversary if you are trying to kick the habit.

Even if you don't smoke, but you live, work or socialize with smokers, your health is at risk if these people smoke indoors or around you. Secondhand smoking is the third leading cause of preventable death in the United States, killing close to 50,000 nonsmokers per year. Consider asking the person to "take it outside" and not smoke in your presence to protect your own health.

Six Stages of Quitting

There is strong scientific evidence that being able to successfully quit smoking is not a matter of luck or willpower or simply flipping a light switch—making one quick change or decision that transforms you suddenly from smoker to nonsmoker. One concept is that the struggle to quit smoking is a series of stages, with your success being dependent on determining what stage of change you are in.

Psychologist James O. Prochaska and colleagues have developed a framework for the stages of change that people go through when trying to overcome an ingrained habit. These are described in his book, Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward (Harper Paperbacks, 1995). Smokers can cycle through this predictable set of stages, often multiple times, until they achieve success:

• Pre-contemplation: You have never tried to quit or even considered giving up smoking.

• Contemplation: You are considering the need to quit smoking someday. You are waiting for something to motivate you or give you a reason to quit smoking. You are open to information and advice about quitting.

• Preparation: You are preparing to stop smoking. You have either reduced the amount that you smoke or restricted your smoking. You are considering what to do the day you quit smoking. You are planning strategies for coping with urges to smoke.

• Action: You are in the act of quitting. Congratulations! This phase includes the quit date and the first few months of quitting.

• Maintenance: You are a former smoker! Being off tobacco products for any amount of time is a tremendous success...and even smokers who have quit for years occasionally relapse to smoking. That being said, the first year after you've quit is an important landmark, which should be celebrated. Smoking cessation experts say your risk of returning to smoking is low at this point.

• Termination: The new behavior has become an integral part of your life to the point that the likelihood of relapse is almost nonexistent.

Treatment

For many smokers, it takes multiple serious attempts at quitting before they become lifelong nonsmokers. You may be successful on your first try, but if you aren't, don't give up. Cigarettes hook smokers in three powerful interlocking ways, each of which needs to be addressed when you are trying to quit:

• physical addiction
• habit
• emotional dependence

Before 1985, cold turkey (quitting completely and in one step without cessation aids) was the only option for smokers. Today, smokers can take advantage of many effective medications or drugs and behavioral treatments. In addition, there are many successful cessation programs and materials (self-help and others) to help you quit. And as fewer and fewer people smoke, there is increasing social support for anyone trying to quit.

Preparing to Quit: What to Do

The first step in quitting smoking is making the decision to quit. The decision to quit smoking should not be taken lightly. It is a serious commitment and a serious challenge. But the rewards are worth the effort. Here's how you can prepare to quit smoking:

• Make a positive decision to quit smoking. Avoid negative thoughts about how difficult it might be. Compare reasons to quit smoking with reasons to continue smoking; add to those reasons for quitting daily. Develop strong personal reasons, in addition to your health and obligations to others. For example, think of all the time you waste taking cigarette breaks, rushing out to buy a pack, hunting for a light, etc.

• Discuss the decision with your health care professional. Ask about the many medications available for quitting and which might suit your lifestyle and personal health profile best.

• Begin to condition yourself physically. Start a modest exercise program, drink more fluids, get plenty of rest and avoid fatigue. Many of the effects of nicotine, including stress relief, increased metabolism and mood and weight control can be achieved with exercise.

• Set a target date for quitting. This could be a special day such as your birthday, your anniversary or the Great American Smokeout. (The Great American Smokeout takes place each year on the third Thursday of November.) If you smoke heavily at work, quit during your vacation so that you're already committed to quitting when you return. Make the date sacred, and don't let anything change it. This will make it easy for you to keep track of the day you became a nonsmoker. Plan to celebrate that date every year.

• Prepare mentally for quitting. Have realistic expectations about quitting smoking before you begin. Quitting isn't easy, but it's not impossible either. Visualize yourself smoke-free in difficult situations.

• Let your friends and family know. Tell them in advance that you are planning to quit. They can provide helpful social support.

You will likely experience withdrawal symptoms most severely during the first one to two weeks without nicotine. Understand that withdrawal symptoms are temporary. Be aware that this may be your hardest time, and use all your personal resources (your health care professional, your family and your friends) to get you through this critical period successfully.

Symptoms of Nicotine Withdrawal

Nicotine withdrawal symptoms are temporary sensations that result after reducing or stopping tobacco abruptly. They usually begin within 24 hours. You may experience four or more of the following:

• Depressed mood: In the first couple of weeks after quitting, many people experience mood changes. Regular aerobic exercise, adequate sleep and refusing to listen to thoughts that will keep you spiraling down may help you avoid these mood changes. People with a history of major depression may relapse when quitting smoking and people with current depression may actually be medicating themselves with the nicotine in cigarettes. A serious bout of depression can occur in someone quitting smoking. Feeling blue, sad, crying a lot, and losing interest in normal life activities are all symptoms of depression. If you feel these symptoms overtaking your life, you should see your health care professional promptly for diagnosis and treatment.

• Trouble sleeping (insomnia): Your brain chemistry is readjusting to new patterns without nicotine's influence. Treat yourself to a hot bath, avoid caffeine in the evening or begin a relaxation or meditation routine. Get enough exercise every day so that you earn your rest. You may also need to have extra sleep while you are recovering, so go ahead and take a nap. You deserve it. A full seven to eight hours of sleep per day is optimal to help the brain chemistry stabilize.

• Irritability, frustration or anger: Planning ahead will allow you to pick the least troublesome period for your "quit week" when you need to avoid or minimize stresses and demands. Let those around you know and ask them to have patience. Practice your new stress coping skills before quitting so they are ready to use when you need them. Move away from a bothersome situation, take a walk or plan to avoid familiar aggravation, if possible, for several days until this period is over. Deep breathing exercises can help to calm your "on edge" sensations. Don't set expectations too high at work or home during the first couple weeks after quitting.

• Anxiety: Common sensations after quitting tobacco, particularly in the first week or two, are a growing sense of anxiety, restlessness and overwhelming worry. But if you know what you are dealing with, you can have a plan to divert your attention, get busy doing some preoccupying task or talk with someone who cares. If the feelings of anxiety persist and are disabling and interfere with your life, talk it over with your health care professional. You may have a condition known as an anxiety disorder, which can be helped with medication.

• Difficulty concentrating: Nicotine stimulates the norepinephrine levels in the brain that affect the attention span, alertness and vigilance. Until your brain chemistry gets readjusted, it is difficult for many people to stay focused. Again, this is temporary.

• Restlessness: Part of this is due to missing the routine of lighting cigarettes and bringing them to your mouth hundreds of times per day. Your hands feel awkward and useless. Exercise can ease the agitation and restless feelings. Take a walk or get some other form of exercise.

• Weight gain: There are many reasons why people can gain weight after quitting smoking. The most important reasons are that nicotine stimulates body metabolism and suppresses appetite, so that with the same food intake and no increase in exercise some weight gain will occur. In addition, some people increase their food intake as well, eating instead of smoking. Without the dulling effects of cigarette smoke on taste and smell, food is more appetizing and you may eat more. If you are aware of these effects, you can take steps to counteract the risk for weight gain.

• Decreased heart rate: Nicotine is a significant stimulant to the heart's electrical system and speeds up the heart rate. After quitting, the heart can slow down to the healthier normal pace. This is an effect that you are unlikely to notice.

The good news is that within two to six weeks these symptoms will resolve and your brain will learn how to manage the balance of chemical messengers without nicotine's influence.

As your body begins to repair itself, you may feel worse for a short while. It's important to understand that healing is a process that begins immediately and continues over time. Immediately after quitting, you may experience "symptoms of recovery" such as temporary weight gain caused by fluid retention, irregularity and dry, sore gums or tongue. You may feel edgy, hungry, tired and more short-tempered than usual. You may have trouble sleeping and notice that you are coughing a lot. These symptoms are the result of your body clearing itself of the effects of chronic nicotine and the other chemicals in cigarette smoke. Although most of the nicotine is gone from the body in two to three days, these symptoms will take longer to resolve.

Critically Important: Know Your Triggers

During those first critical weeks, be aware of situational triggers, such as a particularly stressful event or a social event where friends or family will be smoking. These are the times when you reach for cigarettes automatically because you associate smoking with relaxing. It is important to prepare yourself for these situations before they happen.

There are several types of situations that put smokers at risk for relapse:

• A negative mood, such as feeling sad, anxious or stressed out: These feelings are particularly risky when you are alone. You may find yourself rationalizing why it's OK to have "just one."

• "Happy relapse" situation: This occurs when a smoker finds herself in a social situation where she once smoked, often while drinking alcohol and enjoying the company of friends. Avoid these settings until you're comfortable as a nonsmoker and not easily tempted to smoke.

• Alcohol: This can be a powerful trigger, weakening your resolve not to smoke. Many smoking cessation experts advise staying away from alcohol and alcohol settings (bars, cocktail parties, cookouts, etc., where smoking is sometimes allowed) until your resolve to remain a nonsmoker is firm.

Tips to Help You Quit

• Change your smoking behavior. What follows are some common techniques, but bear in mind that these techniques won't work for all:
  • Smoke only half of each cigarette.
  • Each day, postpone the lighting of your first cigarette one hour.
  • Decide you'll only smoke during odd or even hours of the day.
  • Decide beforehand how many cigarettes you'll smoke during the day.
  • Change your eating habits to help you cut down. For example, drink milk, which many people consider incompatible with smoking.
  • End meals or snacks with something that won't lead to a cigarette.
  • Reach for a glass of juice or fresh fruit instead of a cigarette for a "pick-me-up."
  • Chew on cigarette-sized celery or carrot sticks.

• Don't smoke automatically. Smoke only those cigarettes you really want. Catch yourself before you light a cigarette out of pure habit. Don't empty your ashtrays. This will remind you of how many cigarettes you've smoked each day, and the sight and the smell of stale cigarettes butts will be unpleasant. Make yourself aware of each cigarette by using the opposite hand or putting cigarettes in an unfamiliar location or a different pocket to break the automatic reach.

• Make smoking inconvenient. Stop buying cigarettes by the carton. Wait until one pack is empty before you buy another. Stop carrying cigarettes with you at home or at work. Make them difficult to get to, such as locking them in your car trunk.

• Make smoking unpleasant. Smoke only under circumstances that aren't especially pleasurable for you. If you like to smoke with others, smoke alone. Turn your chair to an empty corner and focus only on the cigarette you are smoking and all its many negative effects. Collect all your cigarette butts in one large glass container filled with water as a visual reminder of the filth made by smoking.

• Prepare quitting skills. Practice going places without cigarettes. Don't think of never smoking again. Think of quitting in terms of one day at a time. Tell yourself you won't smoke today, and then don't. Clean your clothes to rid them of the cigarette smell, which can linger a long time. Clean your car or one room of your home and never smoke there again.

• Make plans to enjoy the first day of your smoke-free life.
  • Throw away all your cigarettes and matches.
  • Hide your lighters and ashtrays.
  • Visit the dentist and have your teeth cleaned to get rid of tobacco stains. Notice how nice they look and resolve to keep them that way.
  • Make a list of things you'd like to buy for yourself or someone else from the money you save. Estimate the cost in terms of packs of cigarettes, and put the money aside to buy these presents.
  • Keep very busy on the big day. Go to the movies, exercise, take long walks, go bike riding.
  • Buy yourself a treat or do something special to celebrate.
  • Remind your family and friends that this is your quit date, and ask them to help you over the rough spots of the first couple of days and weeks.

• Immediately after quitting, make an effort to enjoy life as a nonsmoker and to overcome the symptoms of withdrawal—they are temporary. Develop a clean, fresh, nonsmoking environment at work and at home. Buy yourself flowers. You may be surprised how much you can enjoy their scent after the first few days. Spend as much free time as possible in places where smoking isn't allowed, such as libraries, museums, theaters, department stores and churches. Drink large quantities of water, low-fat milk and fruit juice. Try to avoid alcohol, coffee and other beverages you associate with cigarette smoking.

• Strike up a conversation instead of a match for a cigarette. If you miss the sensation of having a cigarette in your hand, play with something else—a pencil, a paper clip, a marble. If you miss having something in your lips, try toothpicks, a cinnamon stick or a straw.

• Avoid temptation. After meals, get up from the table and brush your teeth or go for a walk. If you always smoked while driving, listen to a particularly interesting radio program or your favorite music or take public transportation for a while, if you can. For the first one to three weeks, avoid situations you strongly associate with the pleasurable aspects of smoking, such as watching your favorite TV program, sitting in your favorite chair or having a cocktail before dinner. Until you are confident of your ability to stay off cigarettes, limit your socializing to healthful, outdoor activities or situations where smoking is not allowed. If you must be in a situation where you'll be tempted to smoke, try to associate with the nonsmokers there.

• Develop new habits. Change your habits to make smoking difficult, impossible or unnecessary. For example, it's hard to smoke while you're swimming, jogging or playing tennis or handball. When your desire for a cigarette is intense, wash your hands or the dishes, take a shower or try new recipes. Do things that require you to use your hands. Try crossword puzzles, needlework, gardening or household chores. Go bike riding or take the dog for a walk; call a friend; give yourself a manicure; write letters or surf the Internet. Enjoy having a clean mouth taste and maintain it by brushing your teeth frequently, flossing and using mouthwash. Get plenty of rest. Pay attention to your appearance. Look and feel sharp. Find time for the activities that are the most meaningful, satisfying and important to you.

The Facts About Weight Gain

Many women rationalize their smoking habit by saying that they will gain weight if they quit. Women are more likely than men to continue smoking to maintain their weight or to lose weight. Also, unsuccessful cessation due to weight gain or concern about weight gain is more likely among women than among men. If you are concerned about weight gain, keep these points in mind:

• Quitting doesn't mean you'll automatically gain weight, though on average, people do gain. As noted previously, it is entirely possible to make no change in eating behavior after quitting and gain weight.

• The benefits of giving up cigarettes far outweigh the drawbacks of adding a few pounds. You'd have to gain a very large amount of weight to offset the many substantial health benefits that a typical smoker gains by quitting. When you quit smoking, particularly if you have been smoking for many years, the effects can be noticeable—some pleasant, others unpleasant. All of these changes are a sign that your body is adjusting to life without the nicotine and chemicals you have been inhaling for so long. Here's what to expect when you quit:

Immediate Benefits of Quitting:

• Within 20 minutes of your last cigarette, your blood pressure and pulse rate drop, and the body temperature in your hands and feet increase to normal levels.

• In 24 hours the carbon monoxide level in your blood drops to normal and oxygen carried in the blood increases. Your risk of heart attack decreases.

• In 48 hours the nerve endings in your nose start regrowing, and your senses of taste and smell are enhanced.

• You will breathe easier, although you may notice that your cough worsens for a while as your lung function returns to normal and your lungs rid themselves of the toxins from smoking.

• You will be free from the mess, smell, inconvenience, expense and dependence of cigarette smoking.

Long-term Benefits of Quitting:

• You've greatly improved your chances for a longer life. You have significantly reduced your risk of death from heart disease, stroke, chronic bronchitis, emphysema and many kinds of cancer.

Pharmacotherapy

There are now seven FDA-approved medications to help smokers quit. The combination of medication and behavioral therapy dramatically increases the chance of successfully quitting. The new guidelines recommend that health professionals offer pharmacotherapy to ALL smokers who want to quit. Below is a summary of each medication to help you decide which one fits your needs.

Nicotine Replacement Therapies

Nicotine replacement therapies help calm cravings and withdrawal symptoms by giving your body some nicotine while you adjust to coping with life without cigarettes. Because of its effects on the heart and blood vessels, nicotine medications should not be used when serious conditions like recent heart attack, very high blood pressure or serious heart rhythm disturbance are present. Nicotine products are not advised in pregnancy unless the benefits of quitting outweigh the risks of continuing to smoke when pregnant. And results of a recent study published in the New England Journal of Medicine revealed that although nicotine replacement therapies do not appear to have significant adverse outcomes in pregnancy, they do not increase quitting rates among pregnant women, and pregnant women are unlikely to stick to them. You should consult your health care professional in these situations.

There are five forms of nicotine replacement medications. Three are nonprescription, over-the-counter medications: the patch, the gum and the lozenge. Two require a prescription: the oral inhaler and the nasal spray.

• The patch. The patch, available in several brands and generically, is applied directly to a hairless area of skin on the arm or the trunk above the waist. The patch provides a steady dose of nicotine through the skin (transdermal). A new patch is used each day. The patch should be placed at a different location on the upper body each day to minimize skin irritation. The usual length of treatment is two to three months, depending on your needs.The advantages of patches are few side effects and ease of use. The patch only needs to be applied once a day. Some disadvantages include limited dosing flexibility and slower delivery of nicotine to the brain. Some people get vivid dreams while on the patch. If so, remove it before going to bed. In addition, some people will develop mild skin rashes.

• The gum The nicotine compound in the gum (Nicorette) is absorbed through the lining of the mouth. For that reason, users are told to bite the gum a few times until you feel a tingling or peppery taste and then "park the gum" between the cheek and the jaw. If you chew the gum rapidly and swallow the saliva, you may become nauseated, get heartburn or hiccups. The gum is available in 2 mg and 4 mg doses. Heavier smokers (25 or more cigarettes per day) should use the 4 mg strength. When properly used (chew and park), it takes about 30 minutes to absorb all the nicotine from one piece of gum. Smokers are instructed to chew the gum on a regular schedule, every half hour to an hour to maintain a steady level of nicotine, then gradually taper as they feel more confident, using the gum for up to three months. No more than 24 pieces per day should be used by any smoker who is trying to quit. Advantages include convenience and flexibility in changing the dose. The nicotine in gum will not be absorbed if the mouth is acidic. Do not drink orange juice or coffee before or while you use the gum. If you have had an acidic beverage, thoroughly rinse your mouth before using the gum. If you have dental problems, the gum may not be right for you. The gum is good for people who crave a mouth activity or sensation and may be helpful in avoiding weight gain, since you are unlikely to eat or drink when using the gum.

• The lozenge The lozenge (Commit) contains the same nicotine compound as the gum, has a "light mint" flavor and is calorie-free. It comes in 2 mg and 4 mg doses. A dosage selector helps determine when to take a lozenge, based on how soon you smoke your first cigarette of the day. It should be dissolved completely in the mouth over about 30 minutes and not chewed or swallowed. Swallowing can lead to nausea, heartburn or hiccups. The dosing schedule is similar to that of the nicotine gum—one to two lozenges an hour for the first six weeks, with a dose reduction over the second six weeks.

• The nasal spray This nicotine product (Nicotrol NS) requires a prescription. It may be used along with the patch. It is sprayed directly into each nostril and provides the fastest delivery of nicotine to the brain of any of the nicotine replacement products, producing a brain nicotine peak as soon as five minutes after use. Do not inhale while spraying, or you may get severe sinus pain. One to two sprays per hour are recommended for about three months. Ask your health care professional for instructions. The advantages of the nasal spray are flexibility of adjusting dose to your needs. Much like a cigarette, it delivers nicotine rapidly for quick reduction in cravings. You may find that during the initial days of treatment, the spray can be irritating to the nose, causing a hot, peppery feeling along with watery eyes, runny nose, coughing and sneezing. These effects decrease with use.

• The oral inhaler The oral inhaler (Nicotrol Inhaler) is a plastic cylinder about the size of a cigarette holder. It is available only by prescription and can also be used along with the patch. The nicotine compound is in a small cartridge that you puncture and place inside the cylinder. When you "puff" on the inhaler, the aerosolized nicotine is absorbed through the lining of your mouth and upper respiratory tract (as opposed to through the lungs). The recommended daily dose is six to 16 cartridges per day for the first six to 12 weeks followed by a gradual tapering of the dose over the next six to 12 weeks. This treatment most closely mimics the use of actual cigarettes and can satisfy the urge to handle something, as you did when smoking. Mouth and throat irritation are the most common side effects, which decrease with use of the product.

Antidepressant

• Bupropion A promising treatment for nicotine dependence is the non-nicotine, prescription antidepressant bupropion (Zyban, Wellbutrin SR). It was approved under the brand name Zyban in 1997 as an aid to smoking cessation because research showed that people taking the drug for depression had an easier time quitting smoking. It is believed to work by affecting brain chemicals involved in nicotine addiction and withdrawal. One difference between bupropion and nicotine replacement therapy is that you start the pill one or two weeks before your quit date and continue it for six to 12 weeks after quitting smoking. Zyban is approved for up to six months to prevent relapse. The Zyban pill contains 150 mg of bupropion and is formulated to release the drug over eight hours. You start by taking one pill daily, and then increase the dose to two pills daily at least eight hours apart. The most common side effects are dry mouth and difficulty sleeping. If you have trouble with insomnia, try to take the second dose exactly eight hours after the first dose, so that the effect is decreasing at bedtime. Do not take the second dose sooner than eight hours after the first dose. The main adverse effect of bupropion is seizures. Seizures can occur at high doses of the drug or in people susceptible to seizure. Bupropion should not be given to people with an increased risk for seizure. That would include people with epilepsy, history of a head injury or heavy drinkers (more than three alcoholic drinks daily). In addition, the FDA recently warned consumers about a potential link between bupropion and suicidal events. Bupropion should not be taken by people with a history of anorexia or eating disorders. Bupropion is the same drug as the antidepressant Wellbutrin. People on Wellbutrin should not also take Zyban. Patients being treated for depression with a class of drugs called MAO inhibitors should not take Zyban. Bupropion is a prescription drug and should be taken only under the guidance of a health care professional.

Other medications

• Varenicline In addition to nicotine replacement and antidepressants, smokers now have another option to help them quit. In 2006 the FDA approved varenicline (Chantix), a prescription drug that is not nicotine but works like nicotine. Varenicline attaches to nicotine receptors in the brain and delivers a nicotine-like effect, reducing cravings for cigarettes and withdrawal symptoms. Because the drug is attached to the receptors, it blocks nicotine from cigarettes so that smoking does not provide the stimulatory and pleasurable effect it once did. The bottom line is that you have less difficulty with the immediate effects of quitting and less reason to smoke because it doesn't provide the effects you expect. To date, studies on varenicline have shown the best quitting rates. Like Zyban, Chantix is started at least seven days before the quit date, and dose starts low and is slowly increased to the treatment level. The drug is available in 0.5 mg and 1.0 mg tablets, and the recommendation is to begin with 0.5 mg once daily for the first three days, then 0.5 mg twice daily for three days, then 1.0 mg twice daily. The typical treatment length for varenicline is 12 weeks. Studies have shown that long-term quit rates are higher if treatment is continued for another 12 weeks, so treatment is approved for up to 24 weeks. The most common side effects are nausea, constipation, abnormal dreams and sleep disturbances. There is also a concern about the association of varenicline with serious mental health problems like agitation, behavior changes, depression, suicidal thoughts and suicide. These concerns have emerged from reports received by the FDA since Chantix has been on the market and have prompted the FDA to issue a warning to practitioners and the public. No study of Chantix has detected these effects, so a cause and effect relationship has not been proven. However, before starting Chantix, you should tell your health care provider about any mental health symptoms you have or have had, and when you are taking the drug, you should promptly consult your health care provider if you experience such symptoms. Remember that many people experience mood changes in the first couple of weeks after quitting smoking, and a serious bout of depression can occur. Feeling blue, sad, crying a lot and losing interest in normal life activities are all symptoms of depression. If you notice these symptoms in you or in someone you know who is quitting smoking, you should see your health care professional, or encourage your friend or relative to do so, for prompt diagnosis and treatment.

In summary

Remember, medications make it easier to quit smoking, but you still have to do the work. None of these medications are a substitute for the desire to stop smoking. They are most successful when used in combination with a smoking cessation program or behavioral therapy. While the medication helps you cope with the physiological effects of smoking, other programs, such as counseling, help you deal with the psychological and behavioral dependence upon smoking.

Preventing a Relapse

Quitting smoking is the first half of the battle; next you need to prevent a relapse. Becoming a nonsmoker requires more than just licking withdrawal symptoms. You have to become accustomed to your new smoke-free habits.

One of the keys to life as a former smoker is not letting your urges or cravings for a cigarette lead you to smoke. Don't kid yourself. Even though you have made a commitment not to smoke, you will be tempted. Instead of giving in to the urge, use it as a learning experience. Remind yourself that you have quit and you don't smoke. If you are like many new former smokers, the most difficult place to resist the urge to smoke is the most familiar: home. The activities most closely associated with smoking urges are eating, socializing and drinking. And, not surprisingly, most urges occur when another smoker is present.

Seven Coping Tools to Prevent Relapse

Here are seven tools you can use to cope with urges and tempting situations. These tools will help you make the transition from smoker to former smoker. And there will come a time when the urges diminish.

• Think about why you quit. Go back to your list of reasons for quitting. Look at this list several times a day, especially when you are hit with the urge to smoke. Your best personal reasons for quitting are also the best reasons to stay a nonsmoker.

• Watch for rationalizations. It is easy to rationalize yourself back into smoking. A new nonsmoker in a tense situation may think, "I'll just have one cigarette to calm myself down." But one cigarette is never enough. If thoughts like this pop into your head, stop and think again! You can learn ways to relax, such as taking a walk or doing breathing exercises. Concern about gaining weight may also lead to rationalizations. Learn to counter thoughts such as, "I'd rather be thin, even if it means smoking." Remember that a slight weight gain is not likely to endanger your health as much as smoking would. After all, cigarette smoking is the single most preventable cause of death in the United States.

• Anticipate triggers and prepare to avoid them. By now you know which situations, people and feelings are likely to tempt you to smoke. When you can't avoid them, be prepared to meet these triggers head-on and counteract them. Practice the skills that helped you cope with quitting. For example, if you know that spending time with a friend who smokes will be difficult for you, avoid that person until you feel strong enough to resist your urges.

• Reward yourself for not smoking. Congratulations are in order each time you get through a day without smoking. After a week, give yourself a well-deserved reward of some kind. Buy a new CD or treat yourself to a movie or concert. It helps to remind yourself that what you are doing is important.

• Practice positive thoughts. If self-defeating thoughts start to creep in, remind yourself that you are a nonsmoker, that you do not want to smoke and that you have good reasons for it. Putting yourself down and trying to hold out using willpower alone are not effective coping techniques. Mobilize the power of positive thinking!

• Use relaxation techniques. Breathing exercises help to reduce tension. Instead of having a cigarette, take a long deep breath, count to 10 and release it. Repeat this five times. See how much more relaxed you feel? Take a bubble bath.

• Seek social support. The commitment to remain a nonsmoker may be easier if you talk about it with friends and relatives. They can celebrate with you as you check off another day, week and month as a nonsmoker. Tell the people close to you that you might be tense for a while, so they know what to expect. They'll be sympathetic when you have an urge to smoke and can be counted on to help you resist it. Remember to call on your friends when you are lonely or you feel an urge to smoke. A buddy system is a great technique.

Facts to Know

1. The American Cancer Society estimates that in 2012, 72,590 women will die from lung cancer, compared to the 39,510 women who will die from breast cancer.
2. About 70 percent of smokers claim in surveys that they want to quit, and more than 50 percent of smokers report having tried to quit in the past year. However, the long-term success rate of a single unaided attempt to quit is low—only about 5 percent to 7 percent of smokers who attempt to quit are still not smoking one year later.
3. The health benefits of smoking far outweigh any risk of weight gain caused by quitting smoking. Research shows that the average weight gain after quitting smoking is six to eight pounds.
4. Quitting smoking saves money. A pack-a-day smoker, who pays $9 a pack, can expect to save more than $3,200 per year. At $11 a pack (the price in New York City), that amounts to a saving of $4,015! As the price of cigarettes continues to rise, so will the financial rewards of quitting.
5. Cigarette smoking causes lung and other cancers, emphysema and heart disease. An estimated 443,000 U.S. deaths each year are caused by cigarette smoking. But smoking also affects nearly every other organ system and disease in a negative way.
6. The Environmental Protection Agency has listed passive cigarette smoke (also known as secondhand smoke) as a carcinogen, and The American Lung Association reports that it causes close to 50,000 deaths per year.

Questions to Ask

Review the following Questions to Ask about smoking so you're prepared to discuss this important health issue with your health care professional.

1. How is my (or my partner's) smoking affecting my health?
2. What options for stopping smoking should I consider? Should I use a nicotine replacement therapy or bupropion or varenicline?
3. What are my health risks if I don't stop smoking? How do they improve if I stop smoking?
4. Is my (or my partner's) smoking affecting my children's health? What health risks could they face in the future?
5. Why is it so hard to stop smoking? What can I do to make it easier?
6. Do you have any "stop smoking" literature available for me to take home and read?
7. After I stop smoking, how long does it take before the worst cravings go away?
8. Should my partner and I quit smoking together? What if my partner won't quit with me?
9. What are the effects of secondhand smoke? How can I limit my exposure to secondhand smoke?
10. What kinds of withdrawal symptoms should I expect? How can I cope with them?
11. Will I gain weight if I stop smoking? How can I avoid or minimize this?
12. How can I make sure I don't start smoking again?

Key Q&A

Organizations and Support

For information and support on Smoking, please see the recommended organizations, books and Spanish-language resources listed below.

Action on Smoking and Health
Website: https://www.ash.org
Address: 2013 H St., NW
Washington, DC 20006
Phone: 202-659-4310

American Academy of Otolaryngology-Head and Neck Surgery Foundation
Website: https://www.entnet.org
Address: 1650 Diagonal Road
Alexandria, VA 22314
Phone: 703-836-4444

Campaign for Tobacco-Free Kids
Website: https://www.tobaccofreekids.org
Address: 1400 Eye Street, Suite 1200
Washington, DC 20005
Phone: 202-296-5469

CDC Office on Smoking and Health
Website: https://www.cdc.gov/tobacco
Address: Centers for Disease Control and Prevention
1600 Clifton Rd.
Atlanta, GA 30333
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Email: tobaccoinfo@cdc.gov

Lung Cancer Alliance
Website: https://www.lungcanceralliance.org
Address: 888 16th St, NW Ste 150
Washington, DC 20006
Hotline: 1-800-298-2436
Phone: 202-463-2080
Email: info@lungcanceralliance.org

Nicotine Anonymous
Website: https://www.nicotine-anonymous.org
Address: 419 Main Street, PMB# 370
Huntington Beach, CA 92648
Hotline: 1-877-879-6422
Phone: 415-750-0328
Email: info@nicotine-anonymous.org

Tobacco Education Clearinghouse of California (TECC)
Website: https://www.tobaccofreecatalog.org
Address: 4 Carbonero Way
Scotts Valley, CA 95066
Hotline: 1-800-258-9090
Email: teccinfo@tecc.org

Books

American Lung Association 7 Steps to a Smoke-Free Life
by Edwin B. Fisher

How to Quit Smoking Without Gaining Weight
by Bess H., Ph.D. Marcus, Jeffrey S. Hampl, and Edwin B., Ph.D. Fisher

Quit Smoking for Good: A Supportive Program for Permanent Smoking Cessation
by Andrea Baer

Recovery From Smoking: Quitting With the 12 Step Process
by Elizabeth Hanson-Hoffman, Ph.D.

Spanish-language resources

Medline Plus: Smoking
Website: https://www.nlm.nih.gov/medlineplus/spanish/smoking.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

National Institutes of Health: National Institute of Drug Abuse, Cigarettes and Other Tobacco Products
Website: https://www.nida.nih.gov/Infofacts/Nicotine-Sp.html
Address: National Institute on Drug Abuse: National Institutes of Health
6001 Excecutive Boulevard, Room 5213
Bethesda, MD 20892
Phone: 240-221-4007
Email: information@nida.nih.gov