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Smoking Cessation

by Douglas E. Jorenby, PhD

  • People who stop smoking may become irritable, anxious, sad, and restless.

  • Most smokers want to quit and have tried doing so without success.

  • Counseling and support in changing behavior, nicotine replacement products, and certain drugs can help people quit.

Most smokers who quit do so for health or economic reasons. About 70% of U.S. smokers say they want to quit and have already tried to quit at least once. Withdrawal symptoms are a major barrier to quitting (smoking cessation).

Withdrawal

Quitting causes strong cravings for cigarettes and also symptoms such as anxiety, depression (mostly mild, but sometimes severe), inability to concentrate, irritability, restlessness, trouble sleeping, hunger, tremor, sweating, dizziness, headaches, abdominal pains, nausea, and disrupted sleep. These symptoms are worst in the first week, which is when most smokers trying to quit start smoking again. The symptoms tend to subside within 2 weeks in most people, but some may continue for months.

Because nicotine suppresses appetite and slightly increases the rate at which calories are burned, people who quit smoking often gain weight. Weight gain is particularly a concern among women and may cause them to resume smoking. Exercise helps prevent weight gain and may reduce the craving for nicotine. People may develop a temporary cough and mouth sores after quitting.

Prognosis

About 20 million smokers in the United States (almost half of all smokers) try to quit each year. Most do not use any supportive counseling or other proven aids to quitting. Only about 5% of such people are successful long term. Most quitters resume smoking within days, weeks, or months. Many people quit and resume smoking repeatedly. In contrast, the 1-year success rate for people using proven methods to achieve long-term success in quitting is 20 to 30%.

Treatment

People who want to quit smoking can get help from health care practitioners, who can provide support and recommend ways to change behavior. Other sources for help include telephone help (quit) lines, the Internet, and package inserts in nicotine replacement products.

Proven methods of smoking cessation include the following:

  • Counseling and support in changing behavior

  • Using nicotine replacement products

  • Using certain drugs

Hypnosis and acupuncture have not proved to be effective for smoking cessation. For smokeless tobacco users, counseling and support in changing behavior appears effective but nicotine replacement and other drugs do not.

Changing behavior

Selection of a quit date is very helpful. The quit date may be selected arbitrarily or set on a special occasion (such as a holiday or anniversary). A stressful time, such as when a deadline (for example, a tax deadline) needs to be met, is not a good time to try to quit. Quitting is easier when everyone in the house avoids smoking, so people in the same house should usually try to quit at the same time.

Quitting cigarettes completely (cold turkey) is better than gradually decreasing the number of cigarettes smoked. People who smoke fewer cigarettes may unconsciously inhale more deeply and thus get as much nicotine as they did before.

Proven counseling methods emphasize ways to change behaviors. These techniques can help people change the habits that cue smoking during normal daily activities. Common cues include phone conversations, coffee breaks, meals, sexual activity, boredom, traffic problems, or other frustrations. People who recognize smoking cues may modify the cues (for example, taking a walk in place of a coffee break) or substitute another oral activity (such as sucking on candy, chewing on a toothpick, or chewing gum). People may want to avoid drinking alcohol because alcohol can temporarily lower a person's resolve to quit.

Support from family members and friends can help. All U.S. states have telephone quit lines that can provide additional support for smokers trying to quit. People can call 1-800-QUIT-NOW (1-800-784-8669). Quit lines seem be at least as effective as in-person counseling.

Nicotine replacement products

Substituting a nonsmoked version of nicotine for a time helps many people break the habit of smoking. Many nonprescription (over-the-counter) and prescription nicotine replacement products are available. They include nicotine chewing gum, a lozenge, a nicotine patch, nicotine nasal spray, and a nicotine inhaler. Using the patch with the gum, inhaler, lozenge, or spray is more effective than using any one product alone. These products have a few cautions:

  • People with jaw (temporomandibular) disorders should not use the gum.

  • People with severe skin sensitivity should not use the patch.

  • These products may have harmful effects in pregnant or breastfeeding women.

  • People who have had heart attacks recently or certain blood vessel disorders should talk to their doctor before using one of these products.

Other drugs

Drugs such as bupropion and varenicline can also help people quit.

Bupropion can be used with a nicotine replacement product. Together, they have a higher success rate than either alone. The results of both drugs are best when used with a behavior modification program.

Bupropion is an antidepressant, making it particularly useful for people who are depressed or at risk of depression. Nortriptyline, another antidepressant, may be used instead. People who are depressed and attempt to quit smoking should also receive counseling.

Varenicline helps lessen cravings and withdrawal symptoms and helps some people quit smoking. Nicotine replacement products and varenicline are generally not used together. People who have major depression, thoughts of suicide, or certain mental disorders should not take varenicline.

A newer drug, cytisine, has effects similar to those of varenicline. It is being investigated and so far seems to be effective also.

Because drugs and nicotine replacement products have not been studied adequately, they are not recommended for the following:

  • Pregnant smokers

  • Light smokers (people who smoke less than 10 cigarettes/day)

  • Adolescents (under age 18)

  • Users of smokeless tobacco

Cessation in children and adolescents

Parents should maintain a smoke-free household and communicate the expectation to their children that the children will remain nonsmokers.

The counseling approach is similar to that for adults, but children and adolescents are not given smoking cessation drugs.

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • COMMIT, NICORETTE, NICOTROL
  • AVENTYL
  • WELLBUTRIN, ZYBAN
  • CHANTIX