While smoking is on the decline in adults, first use of cigarettes rose 30% among teenagers between 1988 and 1996. Each day, more than 3000 young people become regular smokers. The 2001 American Heart Association statistics reported that nearly 30% of middle school children and over 63% of high school students had tried smoking. The incidence is highest in Caucasian teenagers. A study suggested that teenage girls who used oral contraceptives were at particular risk for smoking (both being high-risk behaviors). [ See Dementia and Neurologic Disorders below.] Smoking is immediately addictive: adolescents who have smoked 100 cigarettes or more, according to one report, are generally not able to quit even if they want to.

One 1998 study estimated that advertising could be responsible for a third of teenage smoking. New regulations are making it more difficult for advertisers to promote smoking to young people, but more high school students are taking up smoking now, despite stepped-up anti-smoking campaigns.

The most important step for preventing smoking in children is for the parent to not smoke. One study reported that preschoolers whose parents smoke are more likely to view themselves as future smokers. A study showed that stricter parents are more successful in preventing their children from starting to smoke than parents who relax the rules. Children whose television and music-listening habits were closely monitored by their parents were less likely to drink, use drugs, and smoke cigarettes. Neglected children, or children with absentee parents, were four times as likely to abuse drugs, drink, and smoke, than children living with parents who were regularly present and who mandated a structured lifestyle.

Older people are less likely to be smokers. Among people aged 55 to 64 years, about 24% are smokers. Between 65 and 74 years the smoking rate drops to 15%, and among those aged 75 or older, the rate is 8%.

Smoking rates have declined among people of all different ethnic backgrounds, even within a year. Currently they are as follows among men from highest to lowest:

• Native American (40.9%).
• African American (28.7%).
• Caucasian American (25.5%).
• Hispanic American (24.1%).
• Asian/Pacific Islanders (24.3%).

Among women the percentages are:

Geography also affects smoking. In a 1999 study of US smokers, the highest smoking rates were in Nevada (31.5%), Kentucky (29.7%), and Ohio (27.6%). The lowest were in Utah (13.9%), Hawaii (18.6%), California (18.7%), Massachusetts (19.4%), and Minnesota (19.5%).

In fact, the highest lung cancer rates in the country are also in the Southeast. The lowest smoking rates were in Utah, California, Hawaii, Idaho, and Washington DC.

Those with less education have higher smoking rates (37.5% in people educated from grades nine to 11) than those with more education (14% in people educated beyond college). (College educated smokers, however, may be more likely to suffer from depression than less educated smokers, and so may have more trouble quitting.)

Psychologic factors play a major role in people's susceptibility to smoking.

• Depression is a well-known risk factor for smoking and increases the danger of starting young. Indeed, nicotine may stimulate receptors in the brain that improve mood in certain people with genetically induced depression.
• People with low self-esteem and adolescents with behavioral problems have a higher risk for smoking.
• Experts are divided on whether or not there is also an association between smoking in adolescents and young adults and an increased risk for some anxiety disorders. More studies are needed.

Evidence now strongly supports genetic factors as a major risk factor for nicotine dependence, and researchers are now targeting specific genes that may be responsible. Among the findings is a common genetic vulnerability to both nicotine and alcohol dependence. (For some people who wish to stop drinking as well as smoking, a dual recovery process can be effective.)

Some studies suggest that the cheaper it is to smoke the more widespread smoking will be. For example, states that have low excise taxes on cigarettes have a high proportion of smokers. And, conversely, making it more expensive to smoke could reduce the number of smokers.

Dangers of Cigarette Smoking. Cigarette smoking kills nearly about 430,000 people a year, making it more lethal than AIDS, automobile accidents, homicides, suicides, drug overdoses, and fires combined. It reduces smokers' life expectancy by 15 to 25 years, and is the single most preventable cause of death. In one study only 42% of male lifelong smokers reached the age of 73 compared to 78% of nonsmokers. Smoking may be even more dangerous in women.

Smoking-related health costs force Americans to spend an astounding $130 billion each year. Smoking may be even more dangerous now than 30 years ago, most likely because the lower tar and nicotine levels in most cigarette brands cause people to inhale more deeply.

The smoke is the most dangerous component of the cigarette. Smoke contains nitrogen oxide and carbon monoxide, which are harmful gases. When people inhale they also bring tar into their lungs. Tar itself includes 4,000 chemicals, some of which are known to cause cancer. Other inhaled chemicals include:

• Cyanide.
• Benzene.
• Formaldehyde.
• Methanol (wood alcohol).
• Acetylene (the fuel used in torches).
• Ammonia.

Dangers of Cigars and Pipes. One study reported that people who switch from cigarettes to cigars or pipes halve their risk of lung cancer, heart disease, and chronic lung disease, possibly because they use less tobacco and inhale less. Still, the risk of these diseases using "safer" forms of tobacco is 50% to almost 70% higher than nonsmokers. And the risk for periodontal disease and tooth loss may be just as high in pipe and cigar smokers as it is in cigarette smokers.

Dangers of Smokeless Tobacco. Twelve million Americans use smokeless tobacco; most are men, and 25% are teenagers. Smokeless tobacco includes chewing tobacco, tobacco powder, and snuff. These products allow tobacco to be absorbed by the digestive system or through mucus membranes, and none of them are harmless. According to the Centers for Disease Control and Prevention, chewing smokeless tobacco 8 to 10 times per day may be equivalent to smoking 30 to 40 cigarettes per day. It produces a 50-fold increase in the risk of oral cancer, gingivitis, and tooth loss. Most users also become addicted.

Dangers of Second-Hand Smoke. People who are exposed to second-hand or side-stream smoke are also at risk. Smoke that is exhaled not only contains the same dangerous contaminants as inhaled smoke, but the exhaled smoke particles are smaller, so that they can reach distant sites in the lungs of involuntary or passive smokers and do great harm.

Smokers in their thirties and forties have a heart-attack rate that is five times higher than their nonsmoking peers. Cigarette smoking may be directly responsible for about 62,000 deaths from heart disease each year. Smoking cigars may increase the risk of early death from heart disease, although evidence is much stronger for cigarette smoking.

Specific Effects on the Heart. Its damaging effects on the heart are multifold:

Specific Factors for a Greater Risk for Heart Disease in Smokers. Certain smokers are at even higher risk than others for heart problems from smoking:

Current smokers. (Quitting will rapidly reduce the risk of developing heart disease, but long-term smoking may still permanently damage arteries.)

Heavy smokers.

Female smokers. (In women who smoke, the risk for a heart attack is about 50% greater than in male smokers.)

Effects of Second-Hand Smoke on the Heart. Studies continue to confirm the dangers of second-hand smoke. Regular exposure to passive smoke is now estimated to increase the risk of heart disease in the nonsmoker by between 25% and 91%, causing 30,000 to 60,000 deaths each year. One study indicated that even a half-hour of exposure to second-hand-smoke may be enough to interfere with normal blood flow to the heart.

Smoking accounts for about 30% of all cancer deaths in the US and it has been cited as the most important factor in changes in worldwide cancer trends.

Lung Cancer. Smoking is the cause of 85% of all cases of lung cancer, which is expected to kill nearly 170,000 Americans in 2001, accounting for over 13% of all US cancer deaths. Lung cancer patients who survive and continue to smoke face a serious risk of developing a second tobacco-related tumor within ten years.

One analysis of studies suggested that exposure to second-hand tobacco smoke may increase the risk of lung cancer in the nonsmoker by about 25%, but a 2000 study suggested that this figure may be greatly overestimated, since it relied on many small and possibly biased studies. Still, most studies support some higher risk for cancer in nonsmoking partners of smokers.

Quitting reduces the risk for lung cancer, even well into middle age. [ See Table. ] In a British study of male smokers who quit at different ages, the risk for lung cancer by age 75 was the following:

Specific Effects of Smoking on Cancer. Cigarette smoke contains many chemicals and cancer may develop from the accumulative effects of more than one.

Specific Risk Factors for Cancer in Individual Smokers. Certain individuals may be at even higher risk than others for cancer from smoking:

Stroke. People who smoke a pack a day have almost two and a half times the risk for stroke as nonsmokers. Specific factors for a greater risk for stroke in smokers include the following:

• Heavy smokers.
• Current smokers. (The risk for stroke may remain elevated for as long as 14 years after quitting.)
• Women smokers who take oral contraceptives. In fact, any woman who smokes increases her risk for hemorrhagic stroke (caused by a ruptured blood vessel).

Parkinson's Disease. Nicotine has some positive effects on the brain, including improving concentration and short-term memory. Studies suggest that cigarette smoke blocks the activity of a protein called monoamine oxidase B (MAO-B), which may play a role in Parkinson's disease. In fact, evidence is now fairly strong that smokers have a lower risk for Parkinson's disease. (This is, of course, no reason to smoke.)

Alzheimer's Disease. Some evidence also suggests that nicotine may have short-term protective actions against disease mechanisms that cause Alzheimer's. In fact nicotine is being tested in Alzheimer's patients. It should be strongly noted, however, that such effects, if protective, are short term and are most likely not applicable to smokers. In fact, the best current research suggesting that smoking makes little difference in the risk for Alzheimer's, and if it does, the risk for dementia is slightly higher in smokers. (Certainly, smoking can affect blood vessels in the brain as it does in the heart, increasing the risk for dementia from small or major strokes.)

Smoking is associated with a higher risk for nearly all major lung diseases, including pneumonia, flu, bronchitis, and emphysema. There is also a link between smoking and increased asthma symptoms. Heavy smokers with asthma are also more likely to seek emergency treatment for their condition during times of heavy ozone pollution.

One study indicated that smokers who quit and start again may damage their lungs even more severely than people who have not yet made an attempt to quit. Some experts suggest that those who relapse and start smoking again are more strongly addicted than other smokers and may inhale more deeply and hold the smoke in their lungs longer. The message here is not that quitting smoking is more dangerous than not quitting; the emphasis is on not starting again.

Studies have now linked cigarette smoking to many reproductive problems. Women who smoke pose a greater danger not only to their own reproductive health but, if they smoke during pregnancy, to their unborn child. Some of these risks include the following:

• Greater risk for infertility in women. (Women at greatest risk for fertility problems are those who smoke one or more packs a day and who started smoking before age 18.)
• Greater risk for ectopic pregnancy and miscarriage.
• Greater risk for stillbirth, prematurity, and low-birth weight. (Infant mortality rates in pregnant smokers are increased by 33%. The good news is that women who quit before becoming pregnant or even during the first trimester reduce the risk for a low birth weight baby to that of women who never smoked.)
• Smoking reduces folate levels, a B vitamin that is important for preventing birth
• defects.
• Women who smoke may pass genetic mutations that increase cancer risks to their unborn babies.

Men's sexual and reproductive health is not immune from the effects of smoking.

• Heavy smoking is frequently cited as a contributory factor in impotence because it decreases the amount of blood flowing into the penis.
• Smoking also reduces sperm density and their motility, increasing the risk for infertility.

Effects of Second Hand Smoke on Children. An estimated four million children a year fall ill from exposure to second-hand smoke. Parental smoking has been shown to affect the lungs of infants as early as the first two to 10 weeks of life. A number of studies have reported associations between smoking parents and childhood illnesses.

• Parental smoking is believed to increase the risk for lower respiratory infections (asthma, bronchitis, and pneumonia) by 50%. Environmental smoking is thought to be responsible for 150,000 to 300,000 cases of lower respiratory tract infections every year. It also worsens the condition of children who have existing asthma
• Mothers who smoke put their children at risk for abnormal lung function in children that could persist throughout life. Smoking in pregnant women and new mothers is strongly linked to sudden infant death syndrome (SIDS) and to asthma in their children.
• Maternal smoking is believed to be related to 37% of the cases of childhood meningococcal disease, an uncommon but potentially fatal infection.
• Parental smoking has also been linked to ear infections and eczema.
  Parental smoking lowers vitamin C levels in children.

Behavioral and Social Problems. Children of smoking mothers are more likely to have more motor control problems, perception impairments, attention disabilities, and social problems than children of non-smoking mothers. Some reasons for these associations have been suggested:

• Women who breast feed and smoke pass nicotine byproducts to their babies, which may contribute to these problems.
• Women smokers tend to be less educated than women nonsmokers, which may cause increased stress at home.
• Smoking mothers and their children may share certain inherited psychologic factors, such as depression, which cause addictive and behavioral problems that are unrelated to smoking itself.

Smoking has many negative effects on bones and joints:

• Smoking impairs formation of new bone and women who smoke are at high risk for osteoporosis (loss of bone density).
• Postmenopausal women who smoke have a significantly greater risk for hip fracture than those who do not.
• Smokers are more apt to develop degenerative disorders and injuries in the spine.
• Smokers have more trouble recovering from spinal surgery.
• Smokers whose jobs involve lifting heavy objects are more likely to develop low back pain than nonsmokers.
• In women, smoking may also pose a small increased risk for developing rheumatoid arthritis.

Smoking increases acid secretion in the stomach, reduces production of compounds that protect the lining, and reduce blood flow in the stomach lining.

Diverticulitis. A 2000 study suggested that smoking was a major risk factor in diverticulitis, a condition in which small out-pouches develop in the wall of the colon. In addition, smokers were at risk for its complications, including bleeding and abscess.

Diverticulitis mostly affects people over 50 years of age.

Inflammatory Bowel Disease. Smoking has mixed effects on inflammatory bowel disease. Smokers have lower than average rates of ulcerative colitis, but higher than average rates of Crohn's disease. In fact, smokers with Crohn's disease who quit experience a much less severe course.

Peptic Ulcers. Results of studies on the actual effect of smoking on ulcers are mixed. Some evidence suggests that smoking delays the healing of gastric and duodenal ulcers. One 1999 study reported that after ulcers healed, about half of smokers relapsed after a year and that all heavy smokers relapsed after three months. Other studies, however, have found no increased risk for ulcers in smokers, and smoking does not appear to increase susceptibility to H. pylori , the bacteria that causes many peptic ulcers. This should not give smokers any comfort, however, given the proven dangers from smoking.

Cyanidem, found in tobacco smoke, interferes with thyroid hormone production. Studies on the effects of smoking on the thyroid have been mixed. According to a 2000 study of twins, however, a smoking twin has three times the risk for thyroid diseases (either hyper or hypothyroid conditions) than their nonsmoking sibling. The risk was particularly higher for autoimmune thyroid diseases (Graves disease or autoimmune thyroiditis).

Women smokers with subclinical hypothyroidism (symptom-free condition in which the thyroid gland is mildly underactive) face an increased risk for developing full-blown hypothyroidism than their non-smoking counterparts.

People who smoke also endanger other parts of their bodies as they age:

• One study showed that smokers of a pack or more a day had approximately twice the risk of developing cataracts than nonsmokers. Such cataracts are also more likely to be located in the nuclear portion of the lens, which limit vision more severely than cataracts in other sites.
• Smokers also have twice the risk for the severe age-related eye disorder, macular degeneration. They are higher risk for gum disease.
• Smokers look older than nonsmokers do. Smokers are nearly five times more likely to develop more and deeper wrinkles as they age compared to nonsmokers. Smoking also appears to have a higher risk for baldness and premature gray hair.
• One study showed that older smokers had a 70% higher incidence of suffering from hearing loss than nonsmokers. In another 2000 study of over 1500 Japanese male office workers, high-frequency hearing loss among this group was particularly associated with smoking and it was greater with longer smoking duration and a higher number of cigarettes smoked. Some experts believe that loss of high pitched sound in smokers may be due to a decrease in blood flow to the part of the ear that carries sound to the brain (cochlea).
  One study of 600 women indicates that smokers and former smokers are twice as likely to develop incontinence than women who never smoked.

Although over a quarter of American adults continue to smoke, about 70% of them want to quit. Unfortunately, in one study of women smokers who said they wanted to stop smoking, 80% of them were unable to. Withdrawal is a difficult process. Even after years of not smoking, about 20% of ex-smokers still have occasional cravings for cigarettes. People who keep trying, however, have a fifty-fifty chance of finally quitting. In any case, the attempts to quit are never a waste of time, since the amount of smoking is reduced during these periods. The smoker is up against an army of obstacles to quitting.

Researchers have been trying to discover individual risk factors or sets of behaviors that can help predict why specific people fail to quit. Some factors include:

• Being female. [ See Women and Smoking .]
• Being a heavy smoker.
• Inhaling deeply.
• Being a long term smoker.
• Having severe withdrawal symptoms.

Among many studies, however, only one found a single consistent factor for failure to quit:
Cheating during the first two weeks of withdrawal, even with the patch, nearly guarantees smoking again in six months. (In one study, nearly half of the people who did not cheat during the first two weeks were still not smoking after six months.)

Women and Smoking. Over three million women have died from smoking-related illness since 1980, and women now account for over 39% of all smoking-related deaths, a number that has doubled since 1965. Studies show that women have a harder time trying to quit smoking and have less success with abstinence programs than their male counterparts. Reasons for this disparity may include:

• Fear of gaining weight after quitting (society places more pressure on women to stay thin than on men).
• Nicotine replacement may not be as effective in women as in men.
  
• Smoking cessation aids are not approved for pregnant women.
• Phases in the menstrual cycle may affect the response to drugs that are used to help women quit smoking.
• Men may be less supportive than women in helping their partners to quit.
  Women trying to quit may miss the feeling of control associated with smoking.
• Tobacco companies target women specifically (making "light" cigarettes, sponsoring beauty pageants and women's sports events, and cashing in on the equal rights movement).

Nicotine is a psychoactive drug, and some researchers feel it is as addictive as heroin. In fact, nicotine has actions similar to cocaine and heroin in the same area of the brain.

Depending on the amount taken in, nicotine can act as either a stimulant or a sedative. Cigarette smoking (either the nicotine or the oral process of smoking itself) has definite immediate positive effects:

• It relieves minor depression.
• It helps suppress little fits of anger.
• It enhances concentration and short-term memory.
• It produces a modest sense of well being.

The addictive process of smoking has a specific daily cycle:

• Most smokers have a special fondness for the first cigarette of the day because of the way brain cells respond to the day's first nicotine rush. Nicotine, particularly taken in the first few cigarettes of the day, increases the activity of dopamine, a chemical in the brain that elicits pleasurable sensations, a feeling similar to achieving a reward.
• During the day, however, the nerve cells become desensitized to nicotine; smoking becomes less pleasurable, and smokers may be likely to increase their intake to get their "reward." A smoker develops tolerance to these effects very quickly and requires increasingly higher levels of nicotine.

Because the first two weeks are so critical in determining quitting failure rates, smokers should not be shy about seeking all the help they can during this period.

Withdrawal symptoms begin as soon as four hours after the last cigarette, generally peak in intensity at three to five days, and disappear after two weeks. They include both physical and mental symptoms.

Physical Symptoms. During the quitting process people should consider the following physical symptoms of withdrawal as they were recuperating from a disease and treat them accordingly as they would any physical symptoms:

• Tingling in the hands and feet.
• Sweating.
• Intestinal disorders (cramps, nausea).
• Headache.
• Cold symptoms as the lungs begin to clear (sore throats, coughing, and other signs of colds and respiratory problem).

Mental and Emotional Symptoms. Tension and craving build up during periods of withdrawal, sometimes to a nearly intolerable point. One European study found that the incidence of workplace accidents increases on No Smoking Day, a day in which up to 2 million smokers either reduce the amount they smoke or abstain altogether.

Nearly every moderate to heavy smoker experiences more than one of the following strong emotional and mental responses to withdrawal.

• Feelings of being an infant: temper tantrums, intense needs, feelings of dependency, a state of near paralysis.
• Insomnia.
• Mental confusion.
• Vagueness.
• Irritability.
• Anxiety.
• Depression is common in the short and long term. In the short term it may mimic the feelings of grief felt when a loved one is lost. As foolish as it sounds, a smoker should plan on a period of actual mourning in order to get through the early withdrawal depression. [ See also Long-Term Reasons for Relapse, below.]

There is a significant association between cigarette smoking and a susceptibility to depression. People who are prone to depression face a 25% chance of triggering depression when they quit smoking. And, depressed smokers have a very low level of success; only about 6% remain smoke-free after a year. There are strong reasons for this:

• Smoking may be masking major depression, which can become severe even after the early stages of withdrawal have passed.
• For some smokers, the future physical damage incurred by smoking is an abstraction, which fails to motivate quitting when measured up against the very real emotional pain triggered by nicotine withdrawal.
• Not only does the smoker suffer, but the negative emotions often harm relationships with friends and family, who might even urge the ex-smoker to take up cigarettes again.

People who suffer from depression associated with quitting might do better using a combination of emotionally supportive therapy (as opposed to behavioral therapy), nicotine replacements, and temporary use of antidepressants, such as bupropion (Zyban). If severe depression lasts beyond withdrawal, professional help should be sought as soon as possible.

Advertising reinforces the addiction by presenting smokers as ideal adults, people who have outgoing cheerful attitudes, are able to work and play exuberantly, are often risk-takers, and enjoy the present moment. This insidious message is doubly attractive to a smoker who is trying to quit. The withdrawal state puts one in an emotionally infantile state. The ads remind the smoker that, with the purchase of a pack of cigarettes, it's very easy to become a grown-up again. (And, even worse, these same ads are telling children that smoking is a short cut to adulthood.)

Fortunately, advertising is far less pervasive than in the past. It also should be noted that advertising can also work in a positive way. An interesting approach was used in a 2000 study that employed cartoon characters to warn children against smoking. Such cartoons were more believable and effective than simple verbal warnings without such characters. (The concept was modeled after the infamous Joe Camel, a cartoon character advertising cigarettes that had proved to be so effective in enticing and encouraging addiction in younger smokers.)

The emphasis on weight loss in our society has given many people an excuse to start or continue smoking.

Effects of Smoking on Calories. Smoking does indeed use up calories, about 200 a day according to one study. A 1999 study reported that smoking increases energy expenditure in men by 3.6% at rest and by 6.3% during physical activity. (Actually, the higher level during exercise was only because the men inhaled more deeply during that time.)
Reasons for Weight Gain after Quitting. Quitting can add five or more pounds, due to the following reasons:

• Obviously, the body is working better. After quitting, the body's metabolism slows down, and food is digested more efficiently.
• Insulin levels increase, enabling the body to process more sugar for energy.
  
• People snack as an oral substitution.

Long Terms Effects of Abstinence on Weight. One 1998 study reported that people who quit smoking put on more weight than expected, and although they gained most of the weight in the first year, they kept adding weight over a period of five years. This contradicts other studies that ex-smokers lost their extra weight over a year or two and that the longer they abstained from smoking the more weight they lost. Indeed, an encouraging 1999 study reported that weight gain tends to peak between two and four years after quitting and then declines to the same rate as those who never smoked.

Keeping the Weight Off. It should be noted that to use up the 200 calories gained from quitting smoking, one need only take an extra 15-minute daily walk and eliminate 100 calories a day from meals. Even a moderate increase in physical activity among middle-aged women who have quit smoking can help keep weight gain to a minimum. (Using Zyban also appears to help protect against weight gain.)

At this time the most effective methods for quitting is a combination of nicotine replacement products and the antidepressant bupropion (Zyban) bolstered by counseling.

After a year only about 4% of smokers who quit without any outside help succeed. Nevertheless, most people try to quit alone and many have reported activities that can help the process of withdrawal. [ See Table, below.] The primary obstacle in trying to quit alone is making the behavioral changes necessary to eliminate the habits associated with smoking. Excellent books, tapes, and manuals are available and are strongly recommended to help people who want to quit without other assistance.

Nicotine replacement products provide low doses of nicotine that do not contain the contaminants found in smoke. They are proving to be twice as helpful as other standard quitting methods. Replacement products include nicotine patches, gums, nasal sprays, and inhalers. A 2000 English study indicated that about 20% of people who use nicotine replacement products and have some support from health professionals will abstain for at least a year and about 10% will remain nonsmokers. (Unfortunately this rate is not much better than using placebo, although adding the antidepressant Zyban is improving this rate.) (In spite of the obvious health benefits from nicotine replacement treatments, only about a quarter of HMOs reimburse smokers for these aids.) There is no evidence yet that one product is any better than another, but individual preferences vary.

Side Effects. Side effects of any nicotine replacement product may include headaches, nausea, and other gastrointestinal problems. People often experience sleeplessness in the first few days, particularly with the patch, but the insomnia usually passes. Patients using very high doses are more likely to experience symptoms, and reducing the dose can prevent them.

Special Concerns. Certain individuals may need to be aware of some concerns with nicotine replacement products. Most studies have been conducted using the patch, but results may apply to other replacement products as well.

• People with Heart Disease. There has been some concern that the patch might be harmful for people with heart or circulatory disease, but studies are finding that it poses no danger for these individuals. In fact, it may help reduce angina attacks brought on by exercise. Nevertheless, unhealthy cholesterol levels (lower HDL levels) caused by smoking remain abnormal with the use of nicotine replacement (at least with the use of the patch). HDL levels improve when all nicotine is stopped.
• Pregnant Women. Nicotine replacement may not be completely safe in pregnant women. There is an increase in heart rates in fetuses of women who use the patch as compared with those who smoke. Because this may be an indication of fetal stress, pregnant women are cautioned to remove the patch before bedtime.
• Adolescents. Nicotine replacement is safe for adolescents.
• Small Children. Nicotine is a poison and all nicotine products should be kept safely away from small children. A parent should call a physician or a poison control center immediately if a child has been exposed to a nicotine replacement product, even for a short duration. Parents should also call the doctor if a small child has been exposed to a nicotine product and has any symptoms, including stomach upset, irritability, headache, rash, or fatigue.

Warnings against Long-Term Use. No one should use these replacement therapies as a long-term substitute for smoking. Any nicotine replacement therapy should be temporary and directed at quitting. In one study, use of nicotine gum for more than year was associated with insulin resistance, an abnormality that occurs in diabetes. One study also suggested that chemicals even in nicotine replacement products may convert into a chemical associated with lung cancer caused by tobacco use. More studies are needed, and nicotine replacement therapy is still a better alternative to smoking.

Nicotine Patches. Nicotine patches, or transdermal nicotine, delivers nicotine through the skin and can be an effective way to quit smoking. The quit rate for patch users is around 20% after six months, twice the rate of those who try to quit cold turkey. Nicotine patches are available over the counter, but it is best to consult a doctor before using them, particularly people with any medical problems. They are probably the best nicotine replacement products for people with asthma or other chronic lung problems.

The patch products available have different approaches:

The patches are all applied in similar ways:

Special precautions should be made if children are exposed to the patches:

• Children should not come in contact with the patches, even while the smoker is wearing them.
• If the child has worn the patch, the affected skin should be washed right away.
• Urgent medical care may be required if the child has eaten nicotine or worn a patch for a prolonged time. (The hazard increases if the child has been exposed to more than one patch or one that has not been used.)

Nicotine Gum. Nicotine gum (Nicorette), available over the counter, has also been effective for a number of people. Some prefer it to the patch because they can control the nicotine dosage and chewing satisfies the oral urge. Long-term dependence may be a problem with this method. Although such dependence is probably safer than smoking, research is needed to confirm this, and experts recommend chewing the gum for no more than six months.

Some tips for using the gum are as follows:

• Patients starting to quit chew one to two pieces each hour. A smoker should not chew more than 20 pieces a day.
• The goal is to stop using the gum by six months, but about 3% of people continue to use it long after they have quit smoking.
• The gum must be chewed slowly until it develops a peppery taste. It is then tucked between the gum and cheek where it is stored so that the nicotine can be absorbed.
• Coffee, tea, soft drinks, and acidic beverages may interfere with nicotine absorption, so people should wait at least 15 minutes after drinking before chewing a piece of gum.

Some people prefer other methods or cannot use the gum for the following reasons:

• They find the gum unpleasant tasting.
• Side effects specific to the gum may include upset stomach, mouth ulcers, hiccups, and throat irritation.
• They are embarrassed chewing gum.
• They wear dentures.

The Nicotine Inhaler. The nicotine inhaler resembles a plastic cigarette holder. It comes with a number of nicotine cartridges, which are inserted into the inhaler. It requires a prescription in the US. Four studies have reported that the inhaler triples abstinence rates (between 17% and 28%) compared with placebo (6% to 9%) for a six month period. It has some specific advantages over other slower nicotine replacement products:

• It provides varying doses of nicotine on demand (as opposed to continuously with the patch or the gum).
• It satisfies the oral urges.
• Most of the nicotine vapor is delivered in the mouth, not into the lung airways (although some people experience throat irritation).

Using a combination of the inhaler and the patch may be particularly effective. In one study, the combination showed an abstinence rate of over 60% after six weeks. While this percentage dropped off over time, it was still a marked improvement over the use of the inhaler and a placebo patch.

The Nicotine Nasal Spray. The nasal spray satisfies immediate cravings by providing doses of nicotine rapidly, and thus may play a useful role in conjunction with slower acting nicotine replacement therapies. The spray can irritate the nose, eyes, and throat, but most people can tolerate the side effects that usually subside within the first few days. Unfortunately one small study found that at the end of the year, only 16% were still abstaining.

Other Nicotine Replacements. A nicotine tablet that is held under the tongue is being investigated. A solution containing nicotine that people can put in their drinks (coffee, tea, juice, soda) is also being tested.

A unique antidepressant called bupropion (Zyban) is proving to be a strong aid in the quitting process. This agent increases the effects of certain neurotransmitters, particularly dopamine, that may play a strong role in nicotine addiction.

Success Rates. Taking the drug alone produces higher cessation than placebo and taking it along with nicotine replacement is even more successful. In one 2000 study, after a year the following people were still not smoking:

• 5.6% of people on placebo.
• 9.8% of those on the nicotine patch.
• 18.4% of those treated with Zyban alone.
• 22.5% of those treated with Zyban and nicotine replacement.

Even if people return to smoking after taking Zyban, they can use it again with considerable success. In one 2001 study, those who were retreated with the drug still had a significantly better abstinence rate (20% at 12 weeks) than those on placebo (3%).
Administration. People should take Zyban only as directed by their physician. The usual recommended dosing is 150 mg tablet in the morning for three days. On the fourth day, the patient takes the same dose in the morning and again in the evening (at least eight hours apart). Zyban should be taken for seven to 12 weeks, although some people may need to take it longer to increase the duration of abstinence and perhaps maintain weight loss.

Side Effects. Side effects include gastrointestinal problems, headache, insomnia, dry mouth, and irritation. In very rare cases, seizures have occurred, although usually in people who exceeded the recommended dose or who already had risk factors for seizure. Temporary weight loss is a possible side benefit of the drug, although people generally regain it after they stop the antidepressant. In people who are not depressed, there is no noticeable effect on mood. People who are depressed generally report better spirits and more energy. (In a few cases, people have experienced increased depression.)

Smokers who use outside help have the best record for quitting, with success rates of between 25% and 35%. (Those who are counseled and use nicotine replacement and Zyban have the best chance.) According to research the two most successful behavioral interventions are

• supportive care by a clinician, or
• training in problem solving or coping.

The more intense the counseling program the better. Smokers should look for programs that include the following:

• 20 to 30 minute session lengths.
• Four to seven sessions
• Two week total program duration.

Telephone hotlines offering counseling also help, especially when smokers receive follow up calls. And, a small study reported that even being sent a computer generated letter promoting quitting was effective enough to get some smokers to try cessation. Even brief advice by a physician (three minutes or less) can help. In one study this modest intervention increased the long-term quit rate from 7.9% to 10.2%.

In spite of the strong evidence supporting any physician intervention, a 2001 study reported that nearly 25% of physicians failed to counsel their patients on quitting.

[For programs see Where Else Can Help Be Obtained for Quitting Smoking?, below.]

Nortriptyline. Antidepressants known as tricyclics may also be beneficial, since they have additional effects, independent of reducing depression, that may help smokers. The tricyclic nortriptyline (Pamelor, Aventyl) has been specifically studied for helping smokers. In one study, after six months, 14% taking the drug had quit compared to 3% who hadn't used it. Side effects of this drug include dry mouth and changes in taste. It should be noted that tricyclics can have serious, although rare, side effects, and overdose can be fatal. Tricyclics may pose a danger for some patients with certain heart diseases.
Vigabatrin. Vigabatrin (Sabril), a drug used for epilepsy, administered in very low doses, is being investigated for treating nicotine addiction. The drug blocks nicotine-induced increases in levels of dopamine, the primary chemical in the brain that causes smoking pleasure. Animal studies show promising results with doses 10 to 20 times smaller than those used for epilepsy.

Methoxsalen. Methoxsalen (Oxsoralen), a drug used for psoriasis, blocks an enzyme that metabolizes nicotine. The effect increases nicotine levels in the blood, leaving smokers with less urge to smoke. It also helps prevent absorption of carcinogens in cigarette smoke. In a 2000 study, patients who took methoxsalen in combination with nicotine patches reduced their cigarette intake by 50%. Research indicates that little of the drug enters the bloodstream and that its side effects are minimal. Long term safety studies are necessary.

Anti-Smoking Mouthwash . A newly invented mouth rinse shows potential as an effective smoking deterrent. The rinse makes cigarettes taste terrible for five to eight hours after use. Anecdotal evidence indicates that it is quite effective in helping people quit smoking, but the product is still under investigation and not yet available.

Scheduled Reduction. One study showed that people who used a systematic withdrawal schedule were twice as likely to quit as those who went cold turkey. The procedure involves the following steps:

• Divide the number of minutes per day awake by the number of daily cigarettes; the result is the minute-long wait between smokes.
• Set up a schedule with time intervals based on this result and using a timer, smoke only at those intervals; if the "cigarette appointment" is missed by more than five minutes, the smoker must skip that cigarette.
• The following week, one-third fewer cigarettes are used and the smoking time is recalculated based on the lower number.
• During the third week the count is again reduced by a third, and the smoker quits in the fourth week.

(Those who are unable to smoke during working hours could try calculating the intervals based on the usual smoking times of the day.)

Hypnosis. Some people report successful cessation from smoking with hypnosis in individual sessions. Group sessions appear to be worthless. The process is effective only if the subject trusts the therapist and can feel completely at ease in the vulnerable and passive state necessary for hypnotic suggestion. A typical effective session includes the following steps:

• The hypnotherapists uses various techniques (eg, imagery, silent counting) to put the subject in a relaxed state.
• When the subject is very relaxed, but not asleep, the hypnotherapist quietly suggests motivations for not smoking.
• The hypnotherapist should also reinforce a positive self-image while the subject is in deep relaxation. This helps many people avoid the depression that accompanies withdrawal.
• The session usually takes about an hour.

The patient is taught methods of self-hypnosis to use at home, and there is usually one follow-up reinforcing session.

Acupuncture. The acupuncture technique for quitting smoking usually uses tiny curved staples attached to three different points around the edge of the ear. The procedure is entirely painless. The patient is instructed to press each staple in sequence for a few seconds whenever the craving for a cigarette occurs. The actupuncturist may also the use of acupuncture points on the body. Sometimes acupuncturists also use pressballs, which are very small gold or silver pellets that are taped onto the ear.

There are no side effects except for some soreness if the staple is pressed too hard.

Public health efforts are effective, mostly by creating the idea that smoking is no longer normal. This concept of denormalization is best instituted by laws and local regulations making smoking inaccessible in public places, raising prices, and putting stricter limitations on cigarette advertising. Here are some examples of its success:

• In California, where public control of tobacco began in 1989, the prevalence of smoking dropped from 26% to 18.7% in 1999. The anti-smoking campaign is apparently so effective, that it is estimated that over 30,000 deaths from smoking-related heart disease were prevented during the first nine years of the program.
• A similar anti-smoking campaign in Massachusetts that began in 1993 has resulted in a decline in smoking of nearly half so that it is now has one of the lowest-smoking rates in the country (19.4%).
• In a 2000 study, employees reported that smoke-free environments now range from 61.3% in Mississippi to 82% in Washington DC.

Denormalization can also work on a personal level. An English study found that when one spouse makes healthy changes, including quitting smoking, the other one follows. In couples where smoking continues, it usually continues in both. Even if smokers have all the public and professional support available, however, quitting is still a solitary and difficult process.

It is so difficult to quit that smokers should never feel inadequate if they fail. In fact, self-recriminations and guilt only reinforce the low self-esteem and depression that helps cause smoking behavior in the first place. So the cycle continues. Everyone who smokes should simply assume that at some point they will be able to quit, even if they have relapsed many times. Whether or not smokers can stop smoking, they and former smokers should begin immediately to change any other behaviors that might be damaging their health.

Any smoker who is able to and is not exercising should start after discussing an appropriate program with their physician. Regular exercise reduces a smoker's risk of heart disease (although still not to the level of a nonsmoker). Exercise does not lower a smoker's risk for lung cancer or emphysema.

Smokers should be assiduous about screening programs for any disorders that are increased with smoking. They should have their cholesterol and blood pressure checked regularly. Women should have annual Pap smears (which are used to detect cervical cancer). All older adults should be screened for colon cancer. Smokers might ask their physicians about recent computed tomography (CT) screening programs, which might detect lung cancer in early stages. (At this time, they are not usually covered by insurance.)

Everyone should also maintain a healthy diet, with foods rich in whole grains and fruits and vegetables (particularly dark colored ones). Saturated fats should be avoided, and people should choose monounsaturated fats, which are contained in olive oil or fats from oily fish. (All fats are high in calories and former smokers particularly should be careful to use even these fats in moderation.) Two studies have indicated that eating fish more than twice a week might help limit the tobacco damage in people who are not heavy smokers (more than a pack and a half a day.) An interesting Spanish study indicated that smokers who drank coffee regularly may have a lower risk for smoking-associated bladder cancer. This does not mean coffee protects smokers from cancer, but coffee may have certain cancer-fighting compounds. More studies are needed.

Even with a healthful diet, however, smoking reduces the levels of a number of vitamins, importantly vitamin C. Some research suggests that supplements of folic acid, a B vitamin, and the antioxidants vitamins E and C and selenium may improve lung function. According to two studies, daily vitamin E supplements were associated with reduced risk for prostate cancer among smokers, and in another, higher levels of vitamin E were associated with a lower risk for lung cancer. It should be strongly noted that taking another well-known antioxidant, beta-carotene, has been associated in more than one study with higher rates of lung cancer in smokers. The best way of achieving healthy levels of important nutrients is from healthy foods.

Pregnant Women. Women who are pregnant and continue to smoke must be sure to take appropriate vitamins, particularly folic acid. In this way, they might reduce the increased risk of fetal injury and death in women who smoke, although they do not eliminate that risk.

American Cancer Society, 1599 Clifton Road, NE, Atlanta, GA 30329. Call (800-ACS-2345) or (404-320-3333) The ACS offers a good program that covers four one-hour sessions during over a two-week period. They claim that 20% to 30% of people remain off cigarettes. Call to find the nearest program for quitting smoking.

The association is very responsive and offers a wide range of information and services.

The NCI offers free information on quitting smoking. Building, 31, Room 10A03, 31 Center Drive, MSC 2580, BETHESDA, MD 20892-2580 USA, (301) 435-3848

Nicotine Anonymous World Services. Call (866-536-4539) or

SOURCES OF ALTERNATIVE METHODS

To find a reliable hypnotherapist send a self-addressed stamped envelope to the Society

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Well-Connected reports are written and updated by experienced medical writers and reviewed and edited by the in-house editors and a board of physicians, including faculty at Harvard Medical School and Massachusetts General Hospital. The reports are distinguished from other information sources available to patients and health care consumers by their quality, detail of information, and currency. These reports are not intended as a substitute for medical professional help or advice but are to be used only as an aid in understanding current medical knowledge. A physician should always be consulted for any health problem or medical condition. The reports may not be copied without the express permission of the publisher.

Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

Stephen A. Cannistra, MD, Oncology, Associate Professor of Medicine, Harvard Medical School; Director, Gynecologic Medical Oncology, Beth Israel Deaconess Medical Center

Masha J. Etkin, MD, PhD, Gynecology, Harvard Medical School; Physician, Massachusetts General Hospital

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