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Smoking Cessation

How to Quit Smoking Advice drawn from UpToDate, and edited by Stephen Roszell, MD, 2013

Cigarette smoking is a major cause of disease in the United States. 

·         More than 400,000 deaths occur each year as a result of cigarette smoking. 

·         Exposure to second-hand smoke is estimated to cause 40,000 deaths each year

Quitting and staying away from cigarettes is difficult, but not impossible.  Stopping smoking reduces your risk of developing and dying from tobacco-related disease.

Benefits of Quitting Smoking

Smoking cessation has major and immediate health benefits whether you’re old or young, male or female, a heavy or light smoker.  The earlier you quit, the greater the benefits.  People who quit smoking before age 50 reduce their risk of dying over the next 15 years by one-half. 

·         Cardiovascular disease —Smoking doubles your risk of heart disease, and quitting rapidly reduces this risk.  One year after stopping smoking, your risk of dying from heart disease is cut in half, and heart attacks drop to the rate of nonsmokers within two years of quitting smoking.

·         Cancer — Cigarettes cause 90 percent of lung cancer.  Although former smokers still have a higher risk of lung cancer, quitting reduces your risk within five years of stopping. 

·         COPD & Emphysema — While much lung damage is not reversible, stopping smoking stops further damage to your lungs, and cough and sputum improve after stopping. 

·         Peptic ulcer disease — Cigarette smoking increases peptic ulcer disease, and quitting decreases that risk and increases the rate of ulcer healing.

·         Osteoporosis — Smoking increases bone loss and the risk of hip fractures.  Stopping smoking begins to reverse this risk after about 10 years. 

·         Other diseases — Pregnant women who smoke have increased birth defects and underweight babies.  Smoking increases impotence and problems with erections. 

Barriers to Quitting

Nicotine is a potent psychoactive drug that causes physical dependence and tolerance.  That’s why you smoke.  Quitting causes a variety of symptoms that just plain make you feel bad:

·         Withdrawal Symptoms:  generally peak in the first three days and decrease over the next three to four weeks:

o   Insomnia

o   Irritability, frustration, or anger

o   Anxiety

o   Difficulty concentrating

·         Cravings for cigarettes can be intense and may persist for months.  Cravings may be brought on by situations associated with smoking, by stress, or by drinking alcohol.  These cravings are a common time for relapse.  Your cravings will go away if ignored.

·         Depression can come with quitting; it can cause relapse, and may require treatment.

·         Weight Gain of 2-5 pounds is typical in the first weeks, followed by another 5 pounds over the next half a year.  Exercise and nutrition will minimize gain.  The benefits of quitting smoking are much greater than the risk of gaining weight. 

·         Triggers:  In addition, smokers link the pleasures of tobacco with daily ‘triggers’ such as your morning coffee, an alcoholic drink, or the end of a meal.  These triggers make it harder to stay away from nicotine.  You will need to anticipate triggers and find ways to overcome them: avoid your triggers, change up your activities, and engage in things like exercise, lean on your support systems. 

Giving yourself the very Best Chance of Success

Long-term success of any single unaided attempt to quit is low, with only 5% still smoke-free one year later.  Many smokers who have failed say they’ve "tried everything", but most have never been in a smoking cessation program, and may have not used medications adequately.  Most former smokers had to quit several times before they finally achieved success.

Optimal treatment includes BOTH Behavioral Counseling AND Pharmacotherapy (nicotine replacement, Wellbutrin [bupropion], or Chantix [varenicline]).  This improves your odds of one-year abstinence to 1-in-3! 


When preparing to quit, it is important to identify situations or activities that increase your risk of smoking or relapse.  After identifying these situations, you may need to develop new coping skills.  This may include one or more of the following:

·         Make Lifestyle Changes to reduce stress and improve quality of life, such as starting an exercise program or learning relaxation techniques.  Vigorous exercise can enhance the ability to stop smoking and avoid relapse and also helps to minimize or avoid weight gain.

·         Minimize Time with Smokers.  Ask smokers who live with you to stop smoking at home and in the car.

·         Cravings Lead to Relapse.  Reduce your cravings by avoiding situations that make you think of smoking, by minimizing stress, and by avoiding alcohol.  Cravings will subside.  Keep oral substitutes (sugarless gum, carrots, and sunflower seeds) handy for when cravings develop.

·         "Just one cigarette won’t hurt" is a lie; one cigarette leads to many more.

·         Gather Good Information: Self-help materials and information from a provider, a counselor; a telephone hotline, the internet, and support groups. 

Support — Support can be very helpful in quitting smoking and staying off cigarettes.  Support can come from family and friends, a healthcare provider, a counselor, a telephone hotline (in the US, 1-800-QUIT-NOW), or support groups.  In addition to getting encouragement, it is important to have someone to discuss any problems that develop while trying to quit, such as depression, weight gain, lack of support from family and friends, or prolonged withdrawal symptoms.

Group counseling — Group programs are offered by a number of organizations.  They typically include lectures, group meeting, a tapering method leading to a "Quit Day," development of coping skills, and suggestions for preventing relapse.  The cost can vary from nothing to several hundred dollars.  

Norton Healthcare's Smoking Cessation Program

Norton Healthcare offers smoking cessation classes where participants learn about nicotine addiction and develop an effective, personal plan to completely stop smoking.  Classes follow the Cooper/Clayton Method, a program that has proved effective for many smokers.

Cooper/Clayton Method

The Cooper/Clayton Method is a comprehensive, behavioral modification, smoking cessation program involving nicotine replacement and nicotine reduction therapy, as well as group support.  The support group setting helps participants cope with common side effects of nicotine withdrawal such as weight gain, stress, and depression. 

Norton Healthcare offers 13-week classes several times per year.  The classes are FREE and meet for one hour once a week.  Call (502) 629-1234 to register.



Nicotine Replacement Therapy

When you give up your nicotine habit, you’ll likely develop some of the withdrawal symptoms listed above.  You start using nicotine replacement on your Quit Day.  Don’t use nicotine replacement along with smoking.  That’s unsafe, and guarantees you won’t succeed. 

Though many quit without using nicotine therapy, replacing your nicotine temporarily with a lower-dose therapy can increase your chance of success.  Replacement produces blood levels of nicotine less than half of what you got from cigarettes, so withdrawal symptoms are not prevented, but their intensity may be reduced. 

Nicotine replacement therapy appears to be safe, even with known heart disease.  Nicotine is available as gum, lozenges, patches, nasal spray, or inhalers.  All are equally effective, though you may have better luck with one than another. 

Gum —People who smoke a pack or less a day can use 2 mg of nicotine gum when needed.  Smokers who smoke more than 25 cigarettes can use the 4 mg dose.  Gum use is generally recommended for three to six months.  Don’t let yourself become a chronic gum user.  Nicotine lozenges slowly release nicotine into the saliva in the mouth.  The nicotine works similarly to gum, as it must be absorbed in the mouth and not swallowed. 

Skin patches — Nicotine patches deliver nicotine to the blood through the skin.  Several doses are available: the highest dose patch of 21mg delivers half of what you get from smoking a pack and a half.  Treat yourself with patches at "full dose" for 4-6 weeks.  Some brands include a tapering period of several additional weeks.  There is a low risk of addiction with nicotine patches, but longer use does not improve the chance of quitting. 

Nicotine from your patch at night may cause vivid dreams.  On the other hand, your nighttime patch increases morning blood nicotine levels, which may help with early-morning withdrawal. 

Nasal spray — Nicotine nasal spray delivers a liquid solution of nicotine to the nose.  Compared to the patch and gum, the nasal spray produces a relatively rapid rise in nicotine levels in the blood, similar to what happens when you smoke.  However, nasal irritation is very common, and nasal sprays can prolong nicotine addiction more than other forms of replacement.

Combinations of nicotine replacement — A combination of two products can be more effective than one alone.  Examples of combination treatment include a nicotine patch, which may be worn to provide a constant low level of nicotine, and nicotine gum, which may be used as needed for cigarette cravings.

Varenicline (Chantix)

Varenicline (Chantix) is a prescription medication that works in the brain to reduce nicotine withdrawal symptoms and cigarette cravings.  In some studies, it was more effective than both bupropion and placebo.

Your Quit Day will be one week after starting varenicline, just as you step up to the 1mg pill twice daily.  You should continue for 12 weeks before deciding if it is working;

·         If you’ve successfully quit at 12 weeks, you may continue taking it for another 12 weeks if you choose. 

·         If you still haven’t quit after taking varenicline for 12 weeks, talk to your provider about the next step.  Options include continuing varenicline and working harder to make behavioral changes, or switching to another treatment.

Common side effects of varenicline include nausea and abnormal dreams.  A small number of people have suicidal thoughts, or aggressive and erratic behavior during treatment with varenicline.  If this happens to you, stop varenicline and call your healthcare provider.  Similarly, if you have a history of mood problems, discuss this with your healthcare provider before taking varenicline.  Also people who have heart disease may increase the risk of heart attacks by taking varenicline. 

Bupropion (Zyban, Wellbutrin)

Bupropion (Zyban, Wellbutrin) is an antidepressant that can be used to help you stop smoking.  It is usually started two weeks before your Quit Day; it is typically continued for 2 or 3 months.  Bupropion may be more effective than nicotine replacement therapy, and combining the two may be better still.

Bupropion may cause dry mouth and difficulty sleeping.  The drug is not recommended for those who have a seizure disorder, and can cause seizures in those with eating disorders or who drink alcohol excessively.  As with varenicline, if you develop agitation, depression, unusual behavior changes, or thoughts of suicide, you should stop bupropion and call your provider. 

Where Do I Start?


·         Talk to your provider about your plan for quitting. 

·         Set your Quit Day within the next two weeks.  This is the day when you will completely quit smoking.  Ideally, your Quit Day should be in the next two weeks, although choosing a special date like your birthday, anniversary, or holiday is another option.

·         Tell family, friends, and coworkers about the plan to quit and ask for their support.

·         Avoid smoking in the home and car and other places where you spend a lot of time.

·         Review other quit attempts.  What worked? What didn’t? What contributed to your relapse?

·         Prepare to deal with nicotine withdrawal symptoms, including anxiety, frustration, depression, and intense cravings to smoke.  Past experience will help anticipate these symptoms.  Withdrawal symptoms become more manageable every day of complete cessation that you put behind you.

·         Prepare to deal with your triggers: smokers in the house or at work, stress, and drinking alcohol.  A vacation from work may be an easier time to quit.

·         Seek support through free telephone quit lines like 800-QUIT-NOW, or register for the Norton Smoking Cessation program at (502) 629-1234.

·         Begin making changes in your behavior — avoid situations that lead you to smoke.

·         Start varenicline or bupropion before your quit date, and start nicotine replacement on the day you quit.


·         On Quit Day, take a deep breath and stop smoking completely. 

·         Deal with withdrawal symptoms as they develop. 

·         Consider using nicotine replacement to manage. 

·         Do not "smoke just one" to get through a rough day. 

·         Consult support groups for more tips on coping with withdrawal.

·         Schedule a follow-up visit with your provider within a week of your quit day.  Consider returning monthly for at least three months.  Use your visits to discuss weight gain, depression, and changes in relationships with friends or relatives who smoke. 


·         If you aren’t able to quit smoking after your quit day, DON’T GIVE UP:  Smoking is a "relapsing" condition, and relapse is not failure.  Each Quit Day should be regarded a victory, and the longer you last, the better.  Nearly two-thirds of smokers try again within 30 days, and most smokers make many attempts to quit before they are able to quit completely. 

·         If you relapse, try to understand why, so that your next attempt will be more successful.  If you had success for a while, figure out what helped and what didn’t so you can try again.

·         Most relapses occur in the first week after quitting, when withdrawal symptoms are strongest.  Try to mobilize supports during this critical time.  Consider rewards for not smoking; use the money saved on cigarettes for a special treat such as a massage, a movie, a new outfit, or a special dinner.

·         Later relapses often occur during stressful situations or with social situations that are associated with smoking, often combined with drinking alcohol.  Being aware of these high-risk situations may help.