The Scoop On Smoking from ACSH: what every teen should know about tobacco
"Quitting smoking is easy. I've done it a thousand times." -- Mark Twain
If Mark Twain were alive today, he could have been more successful in his efforts to quit smoking -- thanks to what modern science has learned about smoking cessation.
In Twain's time -- and for several decades after his death in 1910 -- many people thought of smoking tobacco as merely a habit, and they believed that quitting was simply a matter of individual choice and willpower. Smoking was not then widely recognized as addictive, but we know now that it can be a strong addiction and that for many smokers willpower alone is not enough to give up tobacco permanently.
In recent years, researchers have learned a great deal about the factors that help people quit smoking successfully, the barriers that may interfere with smoking cessation, and the special problems faced by particular populations -- including teenagers. Scientists have also developed new techniques for smoking cessation -- including both drugs and counseling methods -- that substantially increase the chances of success.
If you have a friend or relative who would like to stop smoking, you might want to suggest that the person make a doctor's appointment to talk about quitting. People often don't think of going to their doctors for advice in this situation, perhaps because they don't consider smoking to be a medical problem, but doctors are actually a very useful resource. They usually know about organized stop-smoking programs in the community, and they can prescribe medicines that can help a person quit smoking successfully.
Counseling and medication -- especially if they're used together -- can increase the likelihood that a smoker will be able to quit permanently. However, even with these types of help, quitting smoking is difficult. Everyone who has ever quit smoking will tell you that quitting is one of the toughest things they have ever done. The best way to avoid facing this tough problem, of course, is never to start smoking to begin with.
Stopping smoking is one of the most important and most challenging lifestyle changes an individual can make. Considering the many health, social, and economic benefits of quitting it is in the smoker's best interest to quit. More than 45 million Americans have liberated themselves from smoking, so it is possible to quit -- and quit for good.
This section of the website is based on a report by the American Council on Science and Health (Kicking Butts in the 21st Century) that summarizes what science has learned about smoking cessation -- with an emphasis on methods that have been proven to work. The report also describes some new smoking cessation techniques that are currently under development and evaluates some alternative methods that have been advocated as aids to smoking cessation. This report is not intended as a stop-smoking guide; instead, it is best used as a source of background information to complement the stop-smoking advice available from local and national health organizations, government agencies, and physicians.
background -- the magnitude of the problem
Because cigarettes are addictive, quitting smoking can be difficult, and people who try to quit often fail. Recent surveys show that among current smokers, about 40% had attempted to quit at least once in the previous year, and nearly 70% want to quit. But only about 5% of smokers who try to quit each year succeed in stopping smoking permanently. These numbers look rather dismal, don't they? Actually, though, the situation is not quite that bad. The likelihood that a person will quit smoking successfully increases with each attempt to quit. After several tries, nearly 40 to 50% of smokers eventually succeed in quitting. More than 45 million Americans have stopped smoking.
More than 46 million American adults currently smoke, and the number of adolescent smokers is increasing annually.(1) Cigarette smoking contributes to more than 430,000 deaths in the United States each year. Tobacco dependence is now recognized as a clinical addiction and even as a chronic disease -- one of the most widespread in the world.
Quitting smoking has major health benefits. In the long term, smoking cessation reduces the risk of lung cancer and other cancers, stroke, heart disease, chronic obstructive pulmonary disease (chronic bronchitis and emphysema), and a host of other diseases. In the short term, quitting has some immediate health benefits such as reducing fatigue and shortness of breath and increasing arterial circulation and libido.(2)
Recent U.S. surveys show that among current smokers, nearly 41% had attempted to quit at least once in the previous year, and nearly 70% want to quit.(1) But only about 4-5% of smokers who try to quit each year succeed in stopping smoking permanently.(1) The prospects for successful smoking cessation are not as dismal as these numbers seem to indicate, however. The chance of success increases with each quit attempt and with the use of effective smoking cessation methods. After repeated attempts, nearly 40 to 50% of smokers eventually succeed in quitting. Presently, more than 45 million Americans have quit smoking, and the total number of smokers has slowly declined in recent years.(1)
The first smoking cessation programs began in the 1950s, after research had shown that smoking was a serious health hazard. In 1955, public "stop smoking clinics" were introduced in Sweden; they used medications, pamphlets, lectures, and physician counseling to help people quit. These clinics spread to the rest of Europe and the United States in the 1960s and have evolved into what are now comprehensive, multi-faceted, individualized programs.
Smoking cessation rates in the United States started to stabilize in the 1990s, after having increased over the prior few decades.(1) Evidence suggests that this is because the number of quit attempts as well as the success of each attempt stabilized.(3) However, in 1990, only 10% of quitters used some form of treatment,(4) whereas as many as 35% do so today.(5) There are several ways to approach smoking cessation, and individuals must decide for themselves which program or method is right for them. However, the more programs and methods available -- and the more a smoker is educated about quitting -- the greater the likelihood of success.
All smoking cessation programs have at least one thing in common - a flexible notion of what it takes to become a successful quitter. The prerequisites for success vary from individual to individual, but tend to include the following:
Motivation, Desire, Commitment: Smokers who choose to quit should have strong personal reasons that motivate them to do so. People who attempt to quit solely to please others are usually headed for failure. Successful quitters must make a firm commitment to stop.
Social Support: Since quitting smoking is incredibly difficult, it is no surprise that support from other people can be helpful in aiding a smoker in quitting. In one study of former adolescent smokers, 8 of the top 11 factors that had helped them to quit smoking involved a form of help from friends and/or family members.(69) Support for smoking cessation can come from both close to home (such as friends and relatives), or further away (such as support groups, counselors, or an online quitting buddy).
Timing: The time at which a smoker chooses to quit is very important to the outcome. A quit attempt can temporarily affect a person's lifestyle, state of mind, and general wellbeing. Trying to quit in the midst of an important business deal or a difficult family or personal situation can lower the chances of success.
Choice of Method: No particular smoking cessation method is right for everyone. However, the U.S. Public Health Service (USPHS) suggests that all smokers trying to quit should use some form of drug therapy (such as nicotine replacement therapy or bupropion), if possible, in combination with some form of counseling, behavioral therapy, or social support. However, not all experts agree that pharmacological agents are needed by all smokers. Smokers should plan ahead and choose the methods that most closely conform to their personal needs. Since some types of medication are only available by prescription, it is a good idea for smokers to discuss their smoking cessation plans with a physician. Physicians can also provide counseling, and they can refer smokers to organized smoking cessation programs in the community.
Repetition: One of the main keys to successful quitting is repetition. Most smokers will try to quit several times before succeeding. With each attempt, the smoker learns more about what to expect from the quitting process, and the chance of success increases. Many smokers are not aware of this fact and may become needlessly discouraged when they relapse after an initial unsuccessful attempt.
motivators for quitting
Although smokers must make their own decisions to quit, several common factors often serve as motivators for quitting.
Health Benefits: Improved health seems to be the primary motivator for quitting. Many of the adverse health effects of smoking can be greatly reduced or even reversed through cessation.(2) Immediate benefits of quitting include a decrease in blood pressure, a lowered pulse rate, an increased oxygen level in the blood, and a decreased blood carbon monoxide level.(7) Also, the ability to smell and taste is enhanced. After two weeks of abstinence, circulation to the extremities improves, blood pressure remains lower, and lung function improves. After just a few weeks to a month, cough, sinus congestion, fatigue, and shortness of breath all decrease, although cough may actually worsen right after quitting. Further, ex-smokers are less likely than current smokers to have colds, develop gum disease, experience fertility problems (in both males and females), or experience erectile dysfunction.
Long-term benefits may also motivate smokers to quit. One year after quitting, the risk of developing symptomatic coronary artery disease (e.g., angina) is reduced by nearly half compared to those who continue to smoke.(7,8) And after as little as two to five years, that risk can be decreased to levels approaching those who have never smoked.(8,9) After five years of abstinence, the risk of stroke is reduced, approaching that of people who have never smoked. The risk of lung cancer decreases with the number of years of abstinence and can be reduced by as much as 40% after ten years; however, it never returns to that of people who have never smoked.(10) The risk of other cancers such as those of the mouth, throat, esophagus, bladder, kidney, and pancreas also decreases after several years of abstinence.(2) After nearly fifteen years of abstinence, the overall risk of mortality tends to approach a level similar to that of lifelong nonsmokers.(7) Unfortunately, quitting does not reverse chronic obstructive lung disease (chronic bronchitis or emphysema), but it does slow its progression.(2) For women who stop smoking before pregnancy or during the first trimester, the risk of having a low-birth-weight baby is decreased.(2) Because the reversibility of the risks of smoking is greatly influenced by the duration of smoking prior to quitting, smokers should be encouraged to quit as soon as possible.(11)
Social Pressure: The increasing social pressure from tobacco control efforts may motivate smokers to quit. For example, workplace and public space restrictions -- including recent bans or proposed bans on smoking in restaurants and bars in many locations -- can increase the motivation or stimulus to quit.
The institution of totally smoke-free workplaces can motivate some people to quit smoking. A recent combined analysis of 26 studies showed that smoke-free workplaces encourage smokers to either quit or decrease their smoking, thus reducing total cigarette consumption per employee by an average of 29%.(12)
Anti-tobacco campaigns and anti-smoking messages in the media can also provide some much-needed motivation and may cause smokers to worry about the effect of smoking on their family's health and well-being.(13) Parents who smoke may be motivated to try to quit when they learn that exposure to tobacco smoke in the environment is harmful to the health of their children or another loved one. In addition, it is well known that children of parents who smoke are more likely to become smokers themselves. Fortunately, if a parent quits while a child is young, that child has a lower chance of becoming a smoker than if the parent continues to smoke.(14)
Personal Requests: Many smokers receive personal requests to quit from family members, friends, and physicians who are concerned about the smoker's health and/or are bothered by their habit. Although one request may not be enough motivation, each subsequent request may increase a smoker's probability of quitting.
Economic Aspects: Although health is usually the main motivator for quitting, the economic cost and burden of the habit may also influence some smokers' decisions. Depending on the individual, smoking can be quite expensive -- costing as much as $70.00-80.00 per week. Recently, many states have increased cigarette taxes, raising the cost of a pack of cigarettes by more than a dollar in some areas. (In New York City, the combination of city and state taxes increases the cost of cigarettes by almost three dollars a pack.) Although the main public health objective of raising the price of cigarettes is to deter adolescents from smoking, increasing cigarette prices does seem to increase smoking cessation.(15) The economic benefits of quitting may be especially important for the 30% of smokers who have incomes below the national poverty level.(1)
The cost of cigarettes isn't the only economic cost of smoking. Smokers' health care expenses are as much as 21% higher than those of nonsmokers.(16) It is estimated that smoking costs the U.S. $158 billion each year in productivity losses and excess medical expenditures.(17)
barriers to quitting
So, exactly how hard is it to quit smoking? The answer to this question differs among individuals. Success in quitting is related to personal characteristics, the length of smoking history, the level of cigarette use, the intensity of addiction, and the smoking cessation methods utilized. Those smoking more cigarettes for a greater time period may find it more difficult, but by no means impossible, to quit. Some studies show that women find it harder to quit than men do, although the reasons for this are unclear.
There are several common barriers to quitting. While these vary from one individual to the next, major barriers that most smokers can expect to encounter include the following:
Withdrawal: Probably the greatest barrier to quitting -- and the hardest for smokers to overcome -- is withdrawal. Withdrawal is the body's response to the physical need for nicotine and the psychological need or desire for a cigarette. Immediately after quitting, many smokers will experience headache and dizziness, coughing and sore throat, and hunger.(18) These symptoms usually last a few days to a week. As cessation progresses, other symptoms can develop, including anger, frustration, irritability, difficulty in concentrating, impatience, insomnia, fatigue, and even intense anxiety and depression.(18) Also, because of the body's dependence on nicotine, the most common symptom is intense nicotine craving, or the overpowering desire to smoke. The physiological symptoms and psychological desire to smoke are the major factors in relapse (resumption of smoking). The use of nicotine replacement therapies in a smoking cessation program can help ease the symptoms of withdrawal. Physical withdrawal typically peaks at one to three weeks after quitting; "psychological withdrawal" and the desire for a cigarette can last anywhere from weeks to a few years, but for most people not much more than six months.
Behavioral Addiction: Behavioral, or psychological, addiction to or dependence on the practice of smoking may make quitting difficult. Many people associate smoking with other actions or situations such as eating, drinking, and social or stressful events -- associations that are sometimes hard to change. Also, many smokers enjoy the oral activity of smoking a cigarette and the physical comfort of holding it between their fingers.
Social Circumstances: Another barrier to cessation can be the presence of smokers in the household, workplace, or social or recreational environments. This can deter smokers from trying to quit or provoke smokers to relapse by providing an unsupportive environment or easy access to cigarettes. Many smokers are so-called social smokers; they find it difficult to be in a social environment without smoking.
Fear of weight gain: Fear of weight gain makes many people hesitant to quit smoking. The truth is that most smokers do gain weight after quitting. The average weight gain is 5 to 10 pounds,(2) but as many as 10% of people trying to quit will gain more than 30 pounds.(6) This usually occurs because smokers snack or eat more to compensate for the lack of cigarettes and withdrawal symptoms. Also, many quitters experience an enhanced sense of taste and smell, which may increase the desire to eat. Others need to replace the behavioral aspect of smoking with eating. Smokers must remember that a slight weight gain is not nearly as harmful to health as the hazards from continued smoking. They should not let the fear of temporary weight gain deter them from trying to quit.
Existing Mental Problems: People with psychiatric disorders, such as anxiety or depression, have higher smoking rates than other people do. It is possible that some of these people smoke to abate the symptoms of these disorders.(19) Successfully treating the anxiety or depression might increase the likelihood of successful smoking cessation; however, this idea has not yet been evaluated directly.
Difficulties Gaining Access to Treatment: Some smokers do not have easy or affordable access to smoking cessation treatments. Some smoking cessation products require a prescription, and most are not covered by insurance plans. Increasing the number of over-the-counter medications, reducing the cost of some treatments, and extending insurance coverage should improve cessation outcomes.
Relapse: The occurrence of relapse is another barrier to cessation. Many smokers who try to quit on their own will suffer a relapse at some point. Those who use drugs or counseling to help them quit have an increased chance of success, but the majority experience some form of relapse. A relapse can set smokers back to the point where they abandon the quest for cessation.
Smoking cessation treatment is not integrated into the general U.S. healthcare system at the present time. Few insurance companies and only some Medicaid and state health agencies reimburse for smoking cessation treatments.(16,62) When coverage is provided, there may be qualifications and limitations -- such as lifetime caps or time constraints -- that may make it difficult to utilize services effectively. Some plans that do cover smoking cessation cover 50% of behavioral services and 100% of nicotine replacement therapy.(63) Currently, 34 states provide some form of Medicaid coverage for tobacco dependence treatments for low-income smokers, while the remaining states do not.(64) Many smokers live below the poverty line and have no healthcare coverage whatsoever, making it very difficult to gain access to treatment.
The United Kingdom recently announced that it would reimburse for nicotine replacement products under the National Health Service prescription and will also provide additional benefits for bupropion.(65) Some think that offering more drug therapies over the counter will result in a higher utilization of these treatments and thus a higher success rate.(66) Studies show that providing the nicotine patch over the counter doubles quit rates compared to placebo,(6) and NRTs such as the patch and gum available over the counter have success rates comparable to when they are delivered via prescription.(67) Most importantly, over the counter status increases the number of smokers who have access to the treatments and the likelihood that they will use the products.
According to healthcare professionals, smoking cessation treatment is the "gold standard" of preventive healthcare services.(68) Given the substantial costs of smoking and its effects on health and healthcare costs, smoking cessation treatment should be encouraged and integrated into the healthcare system.
The American Council on Science and Health is a consumer eduction consortium with a board of 350 physicians, scientists, and policy advisors.