The US Surgeon General has stated, "Smoking cessation
(stopping smoking) represents the single most important step
that smokers can take to enhance the length and quality of
Quitting smoking is not easy, but you can
do it. To have the best chance of quitting successfully, you
need to know what you’re up against, what your options
are, and where to go for help. You'll find this information
Why Is It So Hard to Quit Smoking?
Mark Twain said, "Quitting smoking
is easy. I've done it a thousand times." Maybe
you've tried to quit, too. Why is quitting and staying quit
hard for so many people? The answer is nicotine.
Nicotine is a drug found
naturally in tobacco. It is highly addictive -- as addictive
as heroin or cocaine. Over time, a person becomes physically
and emotionally addicted to, or dependent on, nicotine. Studies
have shown that smokers must deal with both the physical and
psychological dependence to be successful at quitting and
Where Nicotine Goes and How Long it Stays
When you inhale smoke, nicotine
is carried deep into your lungs, where it is absorbed quickly
into the bloodstream and carried throughout your body. Nicotine
affects many parts of the body, including your heart and blood
vessels, your hormonal system, your metabolism, and your brain.
Nicotine can be found in breast milk and even in cervix mucus
secretions of smokers. During pregnancy, nicotine freely crosses
the placenta and has been found in amniotic fluid and the
umbilical cord blood of newborn infants.
Several different factors can affect how
long it takes the body to remove nicotine and its by-products.
In general, a regular smoker will have nicotine or its by-products,
such as cotinine, in the body for about 3 to 4 days after
How Nicotine Hooks Smokers
Nicotine produces pleasant
feelings that make the smoker want to smoke
more. It also acts as a kind of depressant by interfering
with the flow of information between nerve cells. As the nervous
system adapts to nicotine, smokers tend to increase the number
of cigarettes they smoke, and therefore the amount of nicotine
in their blood. After a while, the smoker develops a tolerance
to the drug, which leads to an increase in smoking over time.
Over time, the smoker reaches a certain nicotine level and
then smokes to maintain this level of nicotine. In fact, nicotine,
when inhaled in cigarette smoke, reaches the brain faster
than drugs that enter the body intravenously (IV).
When smokers try to cut back or quit, the
lack of nicotine leads to withdrawal symptoms. Withdrawal
is both physical and mental. Physically, the body reacts to
the absence of nicotine. Mentally, the smoker is faced with
giving up a habit, which calls for a major change in behavior.
Both must be addressed in order for the quitting process to
If a person has smoked regularly for a few
weeks or longer and suddenly stops using tobacco
or greatly reduces the amount smoked, they will have withdrawal
symptoms. Symptoms usually start within a few hours of the
last cigarette and peak about 2 to 3 days later. Withdrawal
symptoms can last for a few days to up to several weeks.
Withdrawal symptoms can include any of the following:
dizziness (which may only last 1-2 days after quitting)
feelings of frustration, impatience, and anger
sleep disturbances, including having trouble falling asleep
and staying asleep, and having bad dreams or even nightmares
These symptoms can lead the smoker to start
smoking cigarettes again to boost blood levels of nicotine
back to a level where there are no symptoms.
Smoking also makes your body get rid of certain
drugs faster than usual. When you quit smoking, it changes
the way your body handles these medicines. Ask your doctor
if any medicines you take regularly need to be checked or
changed after you quit.
Why Should I Quit?
Health concerns usually top the list of reasons
people give for quitting smoking. This is a very real concern:
About half of all smokers who continue to smoke will end up
dying from a smoking-related illness.
Nearly everyone knows that smoking can cause
lung cancer, but few people realize it is also a risk factor
for many other kinds of cancer as well, including cancer of
the mouth, voice box (larynx), throat (pharynx), esophagus,
bladder, kidney, pancreas, cervix, stomach, and some leukemias.
Pneumonia has been included in the list of
diseases caused by smoking since 2004. Smoking also increases
your risk of getting lung diseases such as emphysema and chronic
bronchitis. These diseases are grouped together under the
term COPD (chronic obstructive pulmonary disease). COPD causes
chronic illness and disability, and worsens over time - sometimes
becoming fatal. Emphysema and chronic bronchitis can be found
in people as young as 40, but are more commonly diagnosed
later in life, when the symptoms are more severe. Long term
smokers have the highest risk of developing severe COPD.
Heart Attacks, Strokes, and Blood Vessel Diseases
Smokers are twice as likely to die from heart
attacks as are non-smokers. And smoking is a major risk factor
for peripheral vascular disease, a narrowing of the blood
vessels that carry blood to the leg and arm muscles. Smoking
also affects the walls of the vessels that carry blood to
the brain (carotid arteries), which can cause strokes. Men
who smoke are more likely to develop erectile dysfunction
(impotence) because of blood vessel disease.
Blindness and Other Problems
Smoking also causes premature
wrinkling of the skin, bad breath, bad smelling clothes and
hair, yellow fingernails, and an increased risk of macular
degeneration, one of the most common causes of blindness in
Special Risks to Women and Babies
Women have some unique risks linked to smoking.
Women over 35 who smoke and use birth control pills have a
higher risk of heart attack, stroke, and blood clots of the
legs. Women who smoke are more likely to have a miscarriage
or a lower birth-weight baby. Low birth-weight babies are
more likely to die or have learning and physical problems.
Years of Life Lost Due to Smoking
Based on data collected in the late 1990s,
the US Centers for Disease Control and Prevention (CDC) estimated
that adult male smokers lost an average of 13.2 years of life
and female smokers lost 14.5 years of life because of smoking.
And given the diseases that smoking can cause, it can steal
your quality of life long before you die. Smoking-related
illness can limit your activities by making it harder to breathe,
get around, work, or play.
No matter how old you are or how long you've
smoked, quitting will help you live longer. People who stop
smoking before age 50 cut their risk of dying in the next
15 years in half compared with those who continue to smoke.
Ex-smokers enjoy a higher quality of life with fewer illnesses
from cold and flu viruses, better self-reported health, and
reduced rates of bronchitis and pneumonia.
For decades the Surgeon General has reported
the health risks linked to smoking. In 1990, the Surgeon General
Quitting smoking has major
and immediate health benefits for men and women of all ages.
Benefits apply to people with and without smoking-related
Former smokers live longer than people who
Quitting smoking decreases the risk of lung
cancer, other cancers, heart attack, stroke, and chronic lung
Women who stop smoking before pregnancy or
during the first 3 to 4 months of pregnancy reduce their risk
of having a low birth-weight baby to that of women who never
The health benefits of quitting smoking are
far greater than any risks from the small weight gain (usually
less than 10 pounds) or any emotional or psychological problems
that may follow quitting.
Immediate Rewards of Quitting
Kicking the tobacco habit offers some benefits
that you'll notice right away and some that will develop over
time. These rewards can improve your day-to-day life a great
your breath smells better
stained teeth get whiter
bad smelling clothes and hair go away
your yellow fingers and fingernails disappear
food tastes better
your sense of smell returns to normal
everyday activities no longer leave you out
of breath (for example, climbing stairs or light housework).
The prospect of better health is a major
reason for quitting, but there are other
Smoking is expensive. It isn't hard to figure
out how much you spend on smoking: multiply how much money
you spend on tobacco every day by 365 (days per year). The
amount may surprise you. Now multiply that by the number of
years you have been using tobacco and that amount will probably
Multiply the cost per year by 10 (for the
upcoming 10 years) and ask yourself what you would rather
do with that much money.
And this doesn't include other possible costs,
such as higher costs for health and life insurance, and likely
health care costs due to tobacco-related problems.
Smoking is less socially acceptable now than
it was in the past.
Almost all workplaces have some type of smoking
rules. Some employers even prefer to hire non-smokers. Studies
show smoking employees cost businesses more to employ because
they are out sick more. Employees who are ill more often than
others can raise an employer’s need for expensive short-term
replacement workers. They can increase insurance costs both
for other employees and for the employer, who often pays part
of the workers’ insurance premiums. Smokers in a building
also can increase the maintenance costs of keeping odors down,
since residue from cigarette smoke clings to carpets, drapes,
and other fabrics.
Landlords may choose not to rent to smokers
since maintenance costs and insurance rates may rise when
smokers occupy buildings.
Friends may ask you not to smoke in their
homes or cars. Public buildings, concerts, and even sporting
events are largely smoke-free. And more and more communities
are restricting smoking in all public places, including restaurants
and bars. Like it or not, finding a place to smoke can be
Smokers may also find their prospects for
dating or romantic involvement, including marriage, are largely
limited to other smokers, who make up only about 21% of the
Health of Others
Smoking not only harms your health but it hurts the health
of those around you. Exposure to secondhand smoke (also called
environmental tobacco smoke or passive smoking) includes exhaled
smoke as well as smoke from burning cigarettes.
Studies have shown that secondhand smoke causes thousands
of deaths each year from lung
cancer and heart disease in healthy non-smokers.
If a mother smokes, there is a higher risk
of her baby developing asthma in childhood, especially if
she smoked while she was pregnant. Smoking is also linked
to sudden infant death syndrome (SIDS) and low-birth weight
infants. Babies and children raised in a household where there
is smoking have more ear infections, colds, bronchitis, and
other lung and breathing problems than children from
non-smoking families. Secondhand smoke can
also cause eye irritation, headaches, nausea, and dizziness.
Setting an Example
If you have children, you probably want to set a good example
for them. When asked, nearly all smokers say they don't want
their children to smoke, but children whose parents smoke
are more likely to start smoking themselves. You can become
a good role model for them by quitting now.
Help Is Available
With the wide range of counseling services, self-help materials,
and medicines available today, smokers have more tools than
ever to help them quit smoking for good.
Remember, tobacco addiction has both a psychological and
a physical component. For most people, the best way to quit
will be some combination of medicine, a method to change personal
habits, and emotional support. The following sections describe
these tools and how they may be helpful to you.Help
With Psychological Addiction
Some people are able to quit on their own, without the help
of others or the use of medicines. But for many smokers, it
can be hard to break the social and emotional ties to smoking
while getting over nicotine withdrawal symptoms at the same
time. Fortunately, there are many sources of support out there
-- both formal and informal.
Telephone-based Help to Stop Smoking
Most states run some type of free telephone-based program,
such as the American Cancer Society’s Quitline®
tobacco cessation program that links callers with trained
counselors. These specialists help plan a quit method that
fits each person's unique smoking pattern. People who use
telephone counseling stop smoking at twice the rate of those
who don't get this type of help. With guidance from a counselor,
quitters can avoid common mistakes that may self-destruct
a quit attempt.
Telephone counseling is also more convenient for many people
than some other support programs. It doesn't require transportation
or childcare, and it's available nights and weekends. Counselors
may suggest a combination of methods including medicines,
local classes, self-help brochures, and/or a network of family
Smokers can get help finding a Quitline® phone counseling
program in their area by calling the ACS at 1-800-ACS-2345
Support of Family, Friends, and Quit Programs
Many former smokers say a support network of family and friends
was very important during their quit attempt. Other people
who may offer support and encouragement are co-workers, your
family doctor, and members of support groups for quitters.
You can check with your employer, health insurance company,
or local hospital to find support groups or call the ACS at
What to Look for in a Stop Smoking Program
Stop smoking programs are designed to help smokers recognize
and cope with problems that come up during quitting and to
provide support and encouragement in staying quit. Studies
have shown that the best programs will include either one-on-one
or group counseling. There is a strong link between the intensity
of counseling and the success rate. In general, the more intense
the program, the greater the chance of success.
For example, intensity may be increased by having more or
longer sessions or by increasing the number of weeks over
which the sessions are given. So, when considering a program,
look for one that has the following:
session length -- at least 20 to 30 minutes per session
number of sessions -- at least 4 to 7 sessions
number of weeks -- at least 2 weeks
Make sure the leader of the group has training in smoking
Some communities have a Nicotine Anonymous group that holds
regular meetings. This group applies the principles of Alcoholics
Anonymous (AA) to the addiction of smoking. This may include
admitting you are powerless over your addiction to nicotine
and having a sponsor to talk with when you are tempted to
smoke. There is no fee to attend.
Often your local American Cancer Society, American Lung Association,
or your local health department will sponsor quit smoking
classes. Call 1-800-ACS-2345 for more information.
There are some programs to watch out for as well. Not all
programs are ethical. Be wary of programs that do the following
promise instant, easy success with no effort on your part
use injections or pills, especially "secret" ingredients
(nicotine replacement is covered elsewhere)
charge a very high fee--check with the Better Business Bureau
if you have doubts
are not willing to give you references from people who have
used the program
Help With Physical Addiction: Nicotine Replacement Therapy
and Other Medicines
Nicotine Replacement Therapy
As mentioned earlier, the nicotine in cigarettes leads to
actual physical dependence, which can cause unpleasant symptoms
when a person tries to quit. Nicotine replacement therapy
(NRT) gives you nicotine -- in the form of gums, patches,
sprays, inhalers, or lozenges -- but not the other harmful
chemicals in tobacco. It can help relieve some of these symptoms
so that you can focus on the psychological aspects of quitting.
How Nicotine Replacement Works
Nicotine substitutes treat the difficult withdrawal symptoms
and cravings that 70% to 90% of smokers say is their only
reason for not giving up cigarettes. Using a nicotine substitute,
reduces a smoker's withdrawal symptoms.
Although many smokers can quit smoking without using a nicotine
replacement, most of those who attempt quitting cannot do
it on the first try. In fact, smokers usually need many tries
-- sometimes as many as 8 to 10 -- before they are able to
quit for good.
Lack of success is often related to the onset of withdrawal
symptoms. And most quitters go back to smoking within the
first 3 months of quitting. So don't be discouraged if you
start smoking again. Just try to stop again and make your
attempt more successful by adding another method or technique
to help you quit. Reducing these symptoms with nicotine replacement
therapy and a support technique, gives smokers who want to
quit have a better chance of quitting and staying quit.
Getting the Most from Nicotine Replacement
Nicotine replacement therapy only deals with the physical
addiction. It is not meant to be the only method used to help
you quit smoking. You should combine it with other smoking
cessation methods that help the psychological (emotional and
habitual) components of smoking, such as a stop smoking program.
Studies have shown that approach -- pairing NRT with a program
that helps to change behavior -- can double your chances of
The US Agency for Healthcare Research and Quality (AHRQ)
Clinical Practice Guideline on Smoking Cessation in 2000 recommended
NRT for all smokers except pregnant women and people with
heart or circulatory diseases. However, recent data suggests
that nicotine replacement (specifically the nicotine patch)
can be used safely even in people who have heart or blood
vessel (cardiovascular) disease under a doctor's careful monitoring.
These studies have found the benefits of quitting smoking
outweigh the risks of nicotine replacement therapy in patients
with cardiovascular disease. In all situations, the benefits
of smoking cessation must outweigh the potential health risks.
Smokers who are pregnant should also talk with their doctor
before using over-the-counter nicotine replacements.
The best time to start NRT is when you first quit. Many smokers
ask if it is possible to start a program of nicotine replacement
while you are still smoking. There is some research being
done with smokers using NRT while still smoking, but it is
still too early to tell if this is dangerous to your health.
The most important thing is to make sure that you are not
overdosing on nicotine, which can have effects on your heart
and blood circulation. It is safest to be under a doctor's
care if you wish to try smoking and using NRT while you are
tapering down your cigarette use.
Often smokers first try to quit on their own then decide
to try NRT. This method does not give you the greatest chance
of success, but do not let this discourage you. There are
still many options available for quitting smoking and staying
When May I Begin Using NRT?
You may start using nicotine replacement products as soon
as you throw away that last cigarette. You do not need to
wait a certain period of time to put on the patch or start
using the method you have chosen. You should double check
this information with the instructions on your chosen method
of nicotine replacement, but in general there is no need to
wait to start using nicotine replacement.
Some NRT products make their recommendations based on whether
you consider yourself a light, regular or heavy smoker. How
are these categories determined?
There is no formal category in any textbook or group that
defines a light, average, or heavy smoker. You will find different
definitions for these categories. In general, a light smoker
is someone who smokes less than 10 cigarettes per day. Someone
who smokes a pack a day or more would be considered a heavy
Sometimes a doctor will use the term pack year to describe
how long and how much a person has smoked. A pack year is
defined as the number of packs of cigarettes a person has
smoked every day multiplied by the number of years he or she
has smoked. Since 1 pack is 20 cigarettes, a person who has
smoked 20 cigarettes a day for a year is considered to have
smoked 1 pack year. Someone who has smoked 30 cigarettes a
day (1½ packs) for 3 years has smoked 4.5 pack years
(1½ x 3), and so on.
Types of Nicotine Substitutes
The Food and Drug Administration (FDA) has approved five
types of nicotine replacement therapy.
Nicotine patches (transdermal nicotine systems): Patches
give a measured dose of nicotine through the skin. You are
weaned off nicotine by switching to lower nicotine dose patches
over a course of weeks. Patches can be bought with or without
a prescription. Many types and different strengths are available.
Package inserts describe how to use the product, as well as
special considerations and possible side effects.
The 16-hour patch works well if you are a light-to-average
smoker. It is less likely to cause side effects like skin
irritation, racing heartbeat, sleep problems, and headache.
But it does not deliver nicotine during the night, so it is
not helpful for early morning withdrawal symptoms.
The 24-hour patch provides a steady dose of nicotine, avoiding
peaks and valleys. It helps with early morning withdrawal.
But, there may be more side effects such as disrupted sleep
patterns and skin irritation.
Depending on body size, most smokers should start using a
full-strength patch (15-22 mg of nicotine) daily for 4 weeks,
and then use a weaker patch (5-14 mg of nicotine) for another
4 weeks. The patch should be put on in the morning on a clean,
dry area of the skin without much hair. It should be placed
below the neck and above the waist -- for example, on the
arm. The FDA recommends using the patch for a total of 3 to
Side effects are related to:
the dose of nicotine
the brand of patch
skin characteristics (such as the person’s tendency
to have a skin reaction to the patch)
how long the patch is used
how it is applied
Some possible side effects of the nicotine patch include:
skin irritation -- redness and itching
sleep problems or unusual dreams
muscle aches and stiffness
What to do about side effects:
Do not smoke while you are using a patch.
Try a different brand of patch if your skin becomes irritated.
Reduce the amount of nicotine by using a lower dose patch.
Sleep problems may be short-term and pass within 3 or 4 days.
If not (and you're using a 24-hour patch), try switching to
a 16-hour patch.
Stop using the patch and try a different form of nicotine
Nicotine gum (nicotine polacrilex): Nicotine gum is a fast-acting
form of replacement in which nicotine is taken in through
the mucous membrane of the mouth. You can buy it over the
counter without a prescription. It comes in 2 mg and 4 mg
For best results, follow the instructions on the package
insert. Chew the gum slowly until you note a peppery taste.
Then "park" it against the cheek, chewing it and
parking it off and on for about 20 to 30 minutes. Food and
drink can affect how well the nicotine is absorbed. You should
avoid acidic foods and drinks such as coffee, juices, and
soft drinks for at least 15 minutes before and during gum
If you smoke a pack or more per day, smoke within 30 minutes
of waking up, or have trouble not smoking in restricted areas,
you may need to start with the higher dose (4 mg). Chew no
more than 20 pieces of gum in one day. Nicotine gum is usually
recommended for 1 to 3 months, with the maximum being 6 months.
Tapering the amount of gum chewed may help you stop using
If you have sensitive skin, you may prefer the gum to the
patch. Another advantage of nicotine gum is that it allows
you to control the nicotine doses. The gum can be chewed as
needed or on a fixed schedule during the day. The most recent
data have shown that scheduled dosing works better. A schedule
of 1 to 2 pieces per hour is common. On the other hand, with
an as-needed schedule, you can chew more gum during a craving.
Some possible side effects of nicotine gum:
Symptoms related to the stomach and jaw are usually caused
by improper use of the gum, such as swallowing nicotine or
chewing too fast. The gum can also damage dentures and dental
Long-term dependence is one possible disadvantage of nicotine
gum. In fact, research has shown that 15% to 20% of gum users
who successfully quit smoking continue using the gum for a
year or longer. Although the maximum recommended length of
use is 6 months, continuing to use the gum is probably safer
than going back to smoking. But since there is little research
on the health effects of long-term nicotine gum use, most
health care providers still recommend limiting its use to
Nicotine nasal spray: The nasal spray delivers nicotine to
the bloodstream as it is quickly absorbed through the nose.
It is available only by prescription.
The nasal spray relieves withdrawal symptoms very quickly
and lets you control your nicotine cravings. Smokers usually
like the nasal spray because it is easy to use. However, the
FDA warns users that since this product contains nicotine,
it can be addictive. It recommends that the spray be prescribed
for 3-month periods and should not be used for longer than
The most common side effects last about 1 to 2 weeks and
can include the following:
There is also the danger of using more than is needed. If
you have asthma, allergies, nasal polyps, or sinus problems,
your doctor may suggest another form of nicotine replacement.
Nicotine inhalers: Introduced in 1998, these inhalers are
available only by prescription. The nicotine inhaler is a
thin plastic tube with a nicotine cartridge inside. When you
puff on the inhaler, the cartridge puts out a nicotine vapor.
Unlike other inhalers, which deliver most of the medicine
to the lungs, the nicotine inhaler delivers most of the nicotine
vapor to the mouth. In terms of similar behavior, nicotine
inhalers are the closest thing to smoking a cigarette, which
some smokers find helpful.
The recommended dose is between 6 and 16 cartridges a day,
for up to 6 months.
The most common side effects, especially when first using
the inhaler, include:
At this time, inhalers are the most expensive forms of NRT
Nicotine lozenges: Nicotine-containing lozenges as an over-the-counter
aid in smoking cessation are the newest form of NRT on the
market. As with nicotine gum, the Commit® lozenge is available
in 2 strengths: 2 mg and 4 mg. Smokers choose their dose based
on how long after waking up they normally have their first
The lozenge manufacturer recommends using it as part of a
12-week program. The recommended dose is one lozenge every
1 to 2 hours for 6 weeks, then one lozenge every 2 to 4 hours
for weeks 7 to 9, and finally, one lozenge every 4 to 8 hours
for weeks 10 to 12. The manufacturer also recommends the following:
Stop all smoking when you begin to use the lozenge.
Do not eat or drink for 15 minutes before using the lozenge.
(Some drinks can reduce how well the lozenge works.)
Suck on the lozenge until it is fully dissolved, about 20
to 30 minutes. Do not bite or chew it like a hard candy, and
do not swallow it. The medicine is taken in through the tissues
of the mouth.
Do not use more than 5 lozenges in 6 hours, or more than
20 lozenges total per day.
Stop using the lozenge after 12 weeks. If you still feel
you need to use the lozenge, talk to your doctor.
Do not use the lozenge if you continue to smoke, chew tobacco,
use snuff or any other product containing nicotine (e.g.,
nicotine patch or gum).
Possible side effects of the nicotine lozenge include:
Which Type of Nicotine Replacement May Be Right for You?
There’s no evidence that any one type of nicotine replacement
therapy is any better than another. When choosing which type
of NRT you will use, think about which method will best fit
your lifestyle and pattern of smoking. Do you want/need something
to chew or occupy your hands? Or are you looking for once-a-day
Some important points to consider:
Nicotine gums, lozenges, and inhalers are oral substitutes
that allow you to control your dosage to help keep cravings
under better control.
Nicotine gums and lozenges are generally sugar-free, but
if you are diabetic and have any doubts, check with the manufacturer.
Nicotine nasal spray works very quickly when you need it.
Nicotine inhalers allow you to mimic the use of cigarettes
by puffing and holding the inhaler.
Nicotine patches are convenient and only have to be applied
once a day.
Both inhalers and nasal sprays require a doctor’s prescription.
Some people may not be able to use patches, inhalers, or
nasal sprays because of allergies or other conditions.
Combination of the patch and other nicotine replacement products
Using the nicotine patch along with shorter-acting products
such as the gum, lozenge, nasal spray, or inhaler is another
method of NRT. The idea is to provide a steady dose of nicotine
with the patch and to use one of the shorter-acting products
when you have strong cravings.
The few studies that have been done on combination NRT have
found that it may be slightly better than a single product.
Still, more research is needed to prove this and to find safe
and effective doses. The combined use of nicotine replacement
products has not yet been approved by the FDA. If you are
considering using more than one NRT product, be sure to discuss
this with your doctor first.
High-Dose Nicotine Replacement Therapy
One of the newer concepts in nicotine replacement therapy
is to give smokers a higher dose specifically based on the
amount of nicotine that they have been getting from cigarettes.
Sometimes this method has required larger doses of nicotine
replacement than have been used before. High-dose NRT with
patches has been studied with patients getting from 35 mg
to 63 mg of nicotine per day. The research suggests that patients'
withdrawal symptoms disappear with these higher doses and
their cravings improve without harmful effects on the heart
and circulation. Patient were carefully watched in these studies
to make sure they were doing well and were not becoming ill
or having any problems. This is still a new procedure that
should be considered only with a doctor's guidance and supervision.
Stopping Nicotine Replacement Therapy
As mentioned before, most forms of NRT should be used for
limited periods of time, and are often tapered down to a low
dose before being stopped. Research is still being done to
refine the use of NRT. For example, even though the patch
is usually used for 3 to 5 months, some studies have suggested
that using it for 8 weeks or less works just as well. However,
other researchers have noted that the risk of relapse goes
up when nicotine replacement is stopped, even after it has
been used for 5 months. These differences have not been fully
explained. More studies are needed to learn which smokers
are likely to be successful using shorter or longer NRT than
usual. If you feel that you need NRT for a different length
of time than is recommended, it is best to discuss this with
Bupropion (Zyban®) is a prescription antidepressant in
an extended-release form that reduces symptoms of nicotine
withdrawal. It does not contain nicotine. This drug acts on
chemicals in the brain that are related to nicotine craving.
It can be used alone or together with nicotine replacement.
Bupropion works best if it is started 1 or 2 weeks before
the quit date. The usual dosage is one or two 150 mg tablets
This drug should not be taken if you have ever had seizures,
heavy alcohol use, serious head injury, bipolar (manic-depressive)
illness, anorexia or bulimia (eating disorders).
Some doctors may recommend combination drug therapy for heavily
addicted smokers, such as using bupropion along with a nicotine
replacement patch and/or a short-acting form of nicotine replacement
(such as gum or lozenges).
Varenicline (Chantix™) is a newer prescription medicine
developed for the sole purpose of helping people stop smoking.
It works by interfering with nicotine receptors in the brain,
which has two effects. It lessens the pleasurable physical
effects a person gets from smoking, and it reduces the symptoms
of nicotine withdrawal.
Several studies have shown varenicline can more than double
the chances of quitting smoking. Some studies have also found
it may be more effective than bupropion, at least in the short-term.
Reported side effects of varenicline have included headaches,
nausea, vomiting, trouble sleeping, unusual dreams, flatulence
(gas), and changes in taste. There have also been reports
of depressed mood, thoughts of suicide, attempted suicide,
and changes in behavior in people taking varenicline. People
who have these problems should contact their doctors right
away. Although these side effects may happen, varenicline
is usually well-tolerated. Since varenicline is a newer drug,
research has not been done to find out if it is safe to use
along with nicotine replacement products.
Other Methods of Quitting
Other tools may also help some people, although there is
no strong evidence they can improve your chances of quitting.
Atropine and scopolamine combination therapy
Some smoking cessation clinics offer a program using shots
of the drugs atropine and scopolamine to help reduce nicotine
withdrawal symptoms. These drugs block the action of acetylcholine,
a signal transmitter in the nervous system. Called anticholinergics,
they are more often prescribed for other reasons, such as
digestive problems, motion sickness, or Parkinson’s
disease. People who are pregnant or have heart problems, glaucoma,
or uncontrolled high blood pressure are not allowed to take
part in these programs.
The treatment usually involves shots given in the clinic
on one day, followed by a few weeks of pills and wearing patches
behind the ear. It may also include other drugs to help with
side effects. Possible side effects of this treatment can
include dizziness, constipation, dry mouth, changes in the
sense of taste and smell, problems urinating, and blurry vision.
Some clinics claim high success rates, but there is no published
scientific research to back up these claims. Both atropine
and scopolamine are FDA-approved for other uses, but they
have not been formally studied or approved for help in quitting
smoking. Before considering such a program, you may want to
ask the clinic about long-term success rates (up to a year).
Because these medicines are directed only at the physical
aspect of quitting, you may also want to ask if the program
includes counseling or other methods aimed at the psychological
aspects of quitting.
Hypnosis methods vary a great deal, which makes it hard to
study as a way to stop smoking. In general, reviews that looked
at studies of hypnosis to help people quit smoking have not
supported it as a quitting method that works. Still, some
people find it useful. If you are interested in trying it,
ask your doctor if he or she can recommend a good hypnotherapist.
This method has been used to quit smoking, but there is little
evidence to show that it works. Acupuncture, when it is done,
is usually done on certain parts of the ears. Although there
is a very weak suggestion that acupuncture might lower the
desire to smoke, there still is no solid evidence that it
is truly effective as a smoking cessation tool (see the ACS
document, Acupuncture). For a list of local physician acupuncturists,
contact the American Academy of Medical Acupuncture at 1-800-521-2262.
Low-level Laser Therapy
This technique, also called cold laser therapy, is related
to acupuncture. Cold lasers are sometimes used for acupuncture.
The laser beams stimulate the body's acupoints instead of
needles. The treatment is supposed to relax the smoker and
release endorphins (pain relief substances that are made naturally
by the body) to simulate the effects of nicotine in the brain,
or balance the body’s energy to relieve the addiction.
Despite claims of success by some cold laser therapy providers,
there is no scientific evidence that shows this is an effective
method of helping people stop smoking (see ACS document, Cold
Filters that reduce tar and nicotine in cigarettes are generally
not effective since studies show that smokers who use filters
actually tend to smoke more.
Other methods have been used to help stop smoking, such as
over-the-counter products that change the taste of tobacco,
stop-smoking diets that curb nicotine cravings, and combinations
of vitamins. There is little scientific evidence to support
that these efforts work.
Herbs and Supplements
There is little scientific evidence to support the use of
homeopathic aids and herbal supplements as stop-smoking methods.
Because they are marketed as dietary supplements (as opposed
to drugs), they don't need FDA approval to be sold. The manufacturers
don’t have to prove they’re effective, or even
safe. Be sure to look closely at the label of any product
claiming it can help you stop smoking. No dietary supplement
has been proven to effectively help people quit smoking. Some
of these supplements have no nicotine in them, but have multiple
combinations of herbal preparations. They have no proven track
record of helping people to stop smoking.
Other Nicotine/Tobacco Products, Not Reviewed or Approved
by the FDA
Tobacco lozenges and pouches
Lozenges that contain tobacco (Ariva®, Interval®),
and small, pouches of tobacco (Revel®, Exalt®) are
being sold as other ways for smokers to get nicotine in places
where smoking is not allowed. The FDA has ruled that these
are types of oral tobacco products, and are not smoking cessation
aids. This means that the FDA does not have authority over
them. There is no evidence that these products can help a
person quit smoking. Unlike scientifically proven treatments
with known effects, such as nicotine replacement products,
antidepressants, nicotine receptor blockers, or behavioral
therapy, these oral tobacco products have never been rigorously
Oral tobacco products such as snuff and chewing tobacco are
known to contain human carcinogens. These products cause mouth
cancer and gum disease. They also destroy the bone sockets
around teeth and cause tooth loss. There are studies showing
potential harmful effects on the heart and circulation as
well as increased risks of other cancer. They also cause bad
breath and stain the teeth.
Nicotine lollipops and lip balms
In the past, some pharmacies made a product called a nicotine
lollipop. These lollipops often contained a product called
nicotine salicylate with a sugar sweetener. Nicotine salicylate
is not approved for pharmacy use by the FDA. The FDA has warned
pharmacies to stop selling nicotine lollipops and lip balm
on the Internet, calling the products "illegal."
The FDA also said "the candy-like products present a
risk of accidental use by children."
Other similar smoking cessation products may not use nicotine
salicylate and, therefore, may be legal. However, they still
pose a risk for children if they are not well-labeled and
Nicotine water and nicotine wafers
These products have been sold in recent years as ways to
get nicotine in places where smoking is not allowed. They
are not marketed as aids to quitting smoking, but questions
about their safety and legality have been raised.
A Word About Quitting Success Rates
Before you start using nicotine replacement or sign up for
a stop smoking class or program, you may wonder what its success
rate is. That's a hard question to answer for many reasons.
First, not all programs define success in the same way. Does
success mean that a person is not smoking at the end of the
program? After 3 months? 6 months? 1 year? Does smoking fewer
cigarettes (rather than stopping completely) count as success?
If a program you're considering claims a certain success rate,
ask for more details on how success is defined and what kind
of follow-up is done to confirm the rate.
The truth is, quit smoking programs, like other programs
that treat addictions, often have a fairly low success rate.
But that does not mean they are not worthwhile or that you
should be discouraged. Your own success in quitting is what
really counts, and that is under your control.
About 5% to 16% of people are able to quit smoking for at
least 6 months without any medicine to help with withdrawal.
Several articles in medical journals have reported that between
about 25% and about 33% of smokers who use medicines can remain
smoke-free for over 6 months. There is also early evidence
that combining some medicines may work better than using them
Behavioral and supportive therapies may increase success
rates even further. Check the package insert of any product
you are using to see if the manufacturer provides free telephone-based
How to Quit
Smokers often say, "Don't tell me why to quit, tell
me how." There is no one right way to quit, but there
are some key elements in quitting with success. These 4 factors
making the decision to quit
setting a quit date and choosing a quit plan
dealing with withdrawal
staying quit (maintenance)
Making the Decision to Quit
The decision to quit smoking is one that only you can make.
Others may want you to quit, but the real commitment must
come from you.
Researchers have looked into how and why people stop smoking.
They have some ideas, or models, of how this happens.
The Health Belief Model says that you will be more likely
to stop smoking if you:
believe that you could get a smoking-related disease and
this worries you
believe that you can make an honest attempt at quitting smoking
believe that the benefits of quitting outweigh the benefits
of continuing to smoke
know of someone who has had health problems as a result of
Do any of these apply to you?
The Stages of Change Model identifies the stages that a person
goes through in making a change in behavior. Here are the
stages as they apply to quitting smoking:
Pre-contemplation: At this stage, the smoker is not seriously
thinking about quitting.
Contemplation: The smoker is actively thinking about quitting
but is not quite ready to make a serious attempt. This person
may say, "Yes, I'm ready to quit, but the stress at work
is too much," or "I don't want to gain weight,"
or "I'm not sure if I can do it."
Preparation: Smokers in the preparation stage seriously intend
to quit in the next month and often have tried to quit in
the past 12 months. They usually have a plan.
Action: This is the first 6 months when the smoker is actively
Maintenance: This is the period of 6 months to 5 years after
quitting when the ex-smoker is aware of the danger of relapse
and takes steps to avoid it.
Where do you fit in this model? If you are thinking about
quitting, setting a date and deciding on a plan will move
you into the preparation stage, the best place to start.
Setting a Quit Date and Deciding on a Plan
Pick a Quit Day
Once you've decided to quit, you're ready to pick a quit
date. This is a very important step. Pick a specific day within
the next month as your Quit Day. Picking a date too far in
the future allows you time to rationalize and change your
mind. But do give yourself enough time to prepare and come
up with a plan. You might choose a date with a special meaning
like a birthday or anniversary, or the date of the Great American
Smokeout (the third Thursday in November each year). Or you
may want to just pick a random date. Circle the date on your
calendar. Make a strong, personal commitment to quit on that
Prepare for Your Quit Day
There is no one right way to quit. Most smokers prefer to
quit cold turkey -- they stop completely, all at once. They
smoke until their Quit Day and then quit. Or they may smoke
fewer cigarettes for 1 or 2 weeks before their Quit Day. Another
way involves cutting down on the number of cigarettes you
smoke each day. With this method, you slowly reduce the amount
of nicotine in your body. You might cut out cigarettes smoked
with a cup of coffee, or you might decide to smoke only at
certain times of the day. While it sounds logical to cut down
in order to quit gradually, in practice this method is difficult.
Quitting smoking is a lot like losing weight; it takes a
strong commitment over a long time. Smokers may wish there
was a magic bullet -- a pill or method that would make quitting
painless and easy. But there is nothing like that. Nicotine
substitutes can help reduce withdrawal symptoms, but they
are most effective when used as part of a stop-smoking plan
that addresses both the physical and psychological components
of quitting smoking.
Here are some steps to help you prepare for your Quit Day:
Pick the date and mark it on your calendar.
Tell friends and family of your Quit Day.
Get rid of all the cigarettes and ashtrays in your home,
car, and place of work.
Stock up on oral substitutes -- sugarless gum, carrot sticks,
and/or hard candy.
Decide on a plan. Will you use NRT or other medicines? Will
you attend a stop-smoking class? If so, sign up now.
Practice saying, "No thank you, I don't smoke."
Set up a support system. This could be a group class, Nicotine
Anonymous, or a friend or family member who has successfully
quit and is willing to help you. Ask family and friends who
still smoke not to smoke around you or leave cigarettes out
where you can see them.
Think back to your past attempts to quit. Try to figure out
what worked and what did not work for you.
Successful quitting is a matter of planning and commitment,
not luck. Decide now on your own plan. Some options include
using nicotine replacement, joining a stop-smoking class,
going to Nicotine Anonymous meetings, using self-help materials
such as books and pamphlets, or any combination of these methods.
For the best chance at success, your plan should include one
or more of these options.
On your Quit Day, follow these suggestions:
Do not smoke. This means at all -- not even one puff!
Keep active -- try walking, exercising, or doing other activities
Drink lots of water and juices.
Begin using nicotine replacement if that is your choice.
Attend stop-smoking class or start following a self-help
Avoid situations where the urge to smoke is strong.
Reduce or avoid alcohol.
Think about changing your routine. Use a different route
to work, drink tea instead of coffee. Eat breakfast in a different
place or eat different foods.
Dealing With Withdrawal
Withdrawal from nicotine has 2 parts -- the
physical and the psychological. The physical symptoms, while
annoying, are not life-threatening. Nicotine replacement can
help reduce many of these physical symptoms. But most smokers
find that the bigger challenge is the mental part of quitting.
If you have been smoking for any length of
time, smoking has become linked with nearly everything you
do -- waking up in the morning, eating, reading, watching
TV, and drinking coffee, for example. It will take time to
un-link smoking from these activities. That is why, even if
you are using a nicotine replacement, you may still have strong
urges to smoke.
One way to overcome these urges or cravings
is to identify rationalizations as they come up. A rationalization
is a mistaken belief that seems to make sense at the time
but is not based on facts. If you have tried to quit before,
you will probably recognize many of these common rationalizations:
I'll just have one to get through this rough spot.
Today is not a good day; I'll quit tomorrow.
It's my only vice.
How bad is smoking, really? Uncle Harry smoked all his life
and he lived to be over 90.
Air pollution is probably just as bad.
You've got to die of something.
Life is no fun without smoking.
You probably can add more to the list. As
you go through the first few days without smoking, write down
any rationalizations as they come up and recognize them for
what they are: messages that can trap you into going back
to smoking. Use the ideas below to help you keep your commitment
Avoid temptation. Stay away from people and
places where you are tempted to smoke. Later on you will be
able to handle these with more confidence.
Change your habits. Switch to juices or water
instead of alcohol or coffee. Take a different route to work.
Take a brisk walk instead of a coffee break.
Alternatives: Use oral substitutes such as
sugarless gum or hard candy, raw vegetables such as carrot
sticks, or sunflower seeds.
Activities: Do something to reduce your stress.
Exercise or do hobbies that keep your hands busy, such as
needlework or woodworking, which can help distract you from
the urge to smoke. Take a hot bath, exercise, or read a book.
Deep breathing: When you were smoking, you
breathed deeply as you inhaled the smoke. When the urge strikes
now, breathe deeply and picture your lungs filling with fresh,
clean air. Remind yourself of your reasons for quitting and
the benefits you'll gain as an ex-smoker.
Delay: If you feel that you are about to
light up, delay. Tell yourself you must wait at least 10 minutes.
Often this simple trick will allow you to move beyond the
strong urge to smoke.
Reward Yourself. What you're doing is not
easy, so you deserve a reward. Put the money you would have
spent on tobacco in a jar every day and then buy yourself
a weekly treat. Buy a magazine, go out to eat, call a friend
long-distance. Or save the money for a major purchase. You
can also reward yourself in ways that don't cost money: visit
a park or the library, develop a new hobby, or take a yoga
Staying Quit (Maintenance)
Remember the quotation by Mark Twain? Maybe you, too, have
quit many times before. So you know that staying quit is the
final, and most important, stage of the process. You can use
the same methods to stay quit as you did to help you through
withdrawal. Think ahead to those times when you may be tempted
to smoke, and plan on how you will use alternatives and activities
to cope with these situations.
More dangerous, perhaps, are the unexpected
strong desires to smoke that happen sometimes months, or even
years after you've quit. To get through these without relapse,
try the following:
Review your reasons for quitting and think of all the benefits
to your health, your finances, and your family.
Remind yourself that there is no such thing
as just one cigarette -- or even one puff.
Ride out the desire to smoke. It will go
away, but do not fool yourself into thinking you can have
Avoid alcohol. Drinking lowers your chance
If you are worried about gaining weight,
put some energy into eating a healthy diet and staying active
What if you do smoke? The difference between
a slip and a relapse is within your control. A slip is a one-time
mistake that is quickly corrected, whereas a relapse is going
back to smoking. You can use the slip as an excuse to go back
to smoking, or you can look at what went wrong and renew your
commitment to staying away from smoking for good.
Even if you do relapse, try not to get too
discouraged. Very few people are able to quit for good on
the first try. In fact, it takes most people many attempts
before quitting for good. What’s important is figuring
out what helped you when you tried to quit and what worked
against you. You can then use this information to make a stronger
attempt at quitting the next time.
Some Special Concerns
Many smokers do gain some weight when they quit. Even without
special attempts at diet and exercise, however, the gain is
usually less than 10 pounds. Women tend to gain slightly more
weight than men. There is some evidence that smokers will
gain weight after they quit even if they do not eat more.
For some, a concern about weight gain can lead to a decision
not to quit. But the weight gain that follows quitting smoking
is usually very small. It is much more dangerous to continue
smoking than it is to gain a small amount of weight.
You are more likely to be quit smoking successfully if you
deal with the smoking first, and then later take steps to
reduce your weight. While you are quitting, try to focus on
ways to help you stay healthy, rather than on your weight.
Stressing about your weight may make it harder to quit. Eat
plenty of fruits and vegetables and limit the fat. Be sure
to drink plenty of water, and get enough sleep and regular
Walking is a great way to be physically active and increase
your chances of staying quit. Walking can help you by:
burning calories and toning muscles
giving you something to do instead of thinking about smoking
No special equipment or clothing is needed for walking, other
than a pair of comfortable shoes. And you can do it pretty
much anytime or anywhere. Try the following:
walk around a shopping mall
get off the bus one stop before you usually do
find a buddy to walk with during lunch time at work
take the stairs instead of the elevator
walk with a friend, family member, or neighbor after dinner
push your baby in a stroller
Set a goal of 30 minutes of physical activity 5 or more times
a week. If you don’t already exercise regularly, please
check with your doctor before starting an exercise program.
Smokers often mention stress as one of the
reasons for going back to smoking. Stress is a part of everyone's
lives, smokers and non-smokers alike. The difference is that
smokers have come to use nicotine to help cope with stress
and unpleasant emotions. When quitting, you have to learn
new ways of handling stress. Nicotine replacement can help
to some extent, but for long-term success other strategies
As mentioned above, physical activity is
a good stress-reducer. It can also help with the short-term
sense of depression that some smokers have when they quit.
There are also stress-management classes and self-help books.
Check your community newspaper, library, or bookstore.
Spiritual practices such as prayer and meditation
have been used with much success to deal with other addictions
and are a key part of 12-step recovery programs. These same
principles can be applied to quitting smoking and can help
with stress reduction.
Taking Care of Yourself
It is important for your health care provider
to know of any present or past tobacco use so he or she can
be sure that you will get the preventive health care you need.
It is well known that tobacco use puts you at risk for certain
health-related illnesses, so part of your health care should
focus on related screening and preventive measures to help
you stay as healthy as possible. For example, you will want
to be certain that you regularly check the inside of your
mouth for any changes and have an oral exam by your doctor
or dentist if you have any changes or problems. The American
Cancer Society recommends that periodic check-ups should include
oral cavity (mouth) exams. By doing this tobacco users may
be able to prevent, or detect early, oral changes, leukoplakia
(white patches on the mouth membranes), and oral cancer.
You should also be aware of any change in
cough, a new cough, coughing up blood, hoarseness, trouble
breathing, wheezing, headaches, chest pain, loss of appetite,
weight loss, general tiredness, and repeated respiratory infections.
Any of these could be signs of lung cancer or a number of
other lung conditions and should be reported to your doctor.
While these can be signs of a problem, many lung cancers do
not cause any noticeable symptoms until they are advanced
and have spread to other parts of the body.
Remember that tobacco users have an increased
risk for other cancers as well, depending on the way they
use tobacco. You can become familiar with the types of cancer
you may be at risk for by reading the American Cancer Society
document that discusses the way you use tobacco (see "Additional
Resources"). Other risk factors for these cancers may
be more important than your use of tobacco, but you should
be aware of the additional risks that might apply to your
If you have any health concerns that may
be related to your tobacco use, please see your health care
provider as soon as possible. Taking care of yourself and
getting treatment for small problems will give you the best
chance for successful treatment. The best way, though, to
take care of yourself and decrease your risk for life-threatening
lung problems is to quit using tobacco.
Where Can I Go for Help?
It is hard to stop smoking. But if you are
a tobacco user you can quit! More than 46 million Americans
have quit smoking for good. Many organizations offer information,
counseling, and other services on how to quit, as well as
information on where to go for help. Other good resources
where help can be found include your doctor, dentist, local
hospital, or employer.
Cigar Smoking (also available in Spanish)
Cigarette Smoking (available in Spanish only through our
Double Your Chances of Quitting Smoking
Guide to Quitting Smoking (available in Spanish only through
our toll-free number)
Helping a Smoker Quit: Dos and Don'ts
Join the Quit Network
Questions About Smoking, Tobacco, and Health (available
in Spanish only through our toll-free number)
Quitting Smoking - Help for Cravings and Tough Situations
(available in Spanish only through our toll-free number)
Smoking and Cancer Mortality Table
Smoking in the Workplace -- A Model Policy
Women and Smoking (available in Spanish only through our
Inclusion on this list does not imply endorsement by the
American Cancer Society.