Stopping Smoking

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Most smokers want to quit. In 2018, 58.4% of current smokers, aged 16+ in Great Britain, reported wanting to quit.¹ This fact sheet reviews the best ways to quit smoking and the health benefits that come along with it. Stopping smoking is always beneficial to heath and it is never too late to quit. Every cigarette smoked damages the lungs in a way that may not show until later in life. After the age of 35-40 years, for every year of continued smoking, a person loses about 3 months of life expectancy.

Many smokers think that they will be more miserable when they stop but the evidence is that they will have better mental health and be happier once they stop smoking.

Many smokers who do continue smoking, do so not by choice, but because they are dependent. A large part of this dependence arises from the way that nicotine is delivered rapidly to the brain with each inhalation. A report by the Royal College of Physicians concluded that nicotine is an addictive substance. It’s important to remember that while nicotine is the addictive substance in cigarettes, it is the thousands of other chemicals in tobacco smoke that cause almost all of the harm. For further information read 'What's in a cigarette?'

Dependence does not make it impossible to stop doing something; it just means that there are powerful urges that must be overcome in order to do so. Anything that can strengthen the resolve to resist these urges or reduce their frequency or intensity can help in overcoming the dependence. Using licensed stop smoking medicines, including prescription tablets and nicotine replacement therapy (NRT), can double the chances of successfully quitting. E-cigarettes (also known as vapes) can also be effective for quitting smoking, especially when combined with additional support.

There are more factors to consider than simply nicotine, such as the rituals around buying and opening a pack of cigarettes, taking one from the packet, and sharing with others. Nicotine on its own, for instance as NRT or when used in an e-cigarette does not appear to have the same dependency-causing properties. Clinical experience in the stop smoking services indicates that users can taper their nicotine dose down quite comfortably.

The chances of success of any given quit attempt get higher the more times someone tries. Most smokers make several attempts to quit before they finally succeed.

1. Get Professional Help

Call the free Smokefree National Helpline on 0300 123 1044 to speak to a trained expert adviser. You can visit the NHS Smokefree website (nhs.uk/smokefree) to find your local stop smoking service and other support available. Your doctor, pharmacist, or health visitor should also be able to support you to quit or to refer you to Stop Smoking Services in your area, where available.

2. Prepare Mentally

You are not alone! Around two-thirds of British smokers would like to quit and about seven million try each year. 61% of people who have ever smoked in Great Britain have quit and are now ex-smokers.² However, some smokers find it challenging to give up cigarettes because it is a deeply-embedded behaviour. Try to think about what you will gain if you stop smoking rather that what you will lose.

Many smokers find the first few days after quitting to be the most difficult, but things will typically start to get better after the third or fourth day. Nicotine withdrawal may make you restless, irritable, frustrated, sleepless, or accident-prone -- but can be alleviated by use of nicotine replacement therapy like patches and gum, or nicotine containing e-cigarettes. Cravings will pass, and you will soon start to feel the benefits.

3. Dispel the Pleasure Myth

Smoking feels pleasurable, but the pleasure of smoking is relief from nicotine withdrawal. Soon after smoking a cigarette the body starts to crave nicotine and many smokers will feel increasingly uncomfortable until they have the next cigarette. Smokers often report feeling distracted or unable to enjoy themselves when they are not able to smoke. This is nicotine withdrawal in action. This is why consuming nicotine without the smoke (through e-cigarette or nicotine inhaler) can work well, especially for people who thought they had tried everything. It satisfies the desire for nicotine but without the harmful smoke, and it also gives the user something to do with their hands.

4. Get Motivated

Make a list of reasons to quit. Thinking about why you decided to quit will help you manage the more difficult moments. Reasons could include:

• You will be more likely to live longer and stay well: half of all long-term smokers die prematurely of a smoking-related disease.
• You will have better all-round health: stopping smoking reduces the risk of 50 different illnesses and conditions.
• Your risk of heart attack will drop by a half one year after quitting.
• Your risk of cancer will fall.
• You will set a better example to children and make it less likely that they take up smoking themselves.
• Your fitness and breathing will improve, helping you to perform better in the gym.
• You will have a better chance of having a healthy baby.
• Your sense of smell and taste improves. Food will taste better, and flowers will smell sweeter!
• You will smell better.
• Your complexion will improve, and you will avoid premature wrinkles.
• You will be able to travel on long-haul flights and public transport without worrying about wanting a cigarette.
• You won’t have to go outside for smoking breaks at work or when out at restaurants and pubs when the weather is bad.
• You won’t be funding the tobacco industry.
• You won’t be contributing to the environmental impact of tobacco growing.
  

5. Consider the Money

The most popular brand of cigarettes now cost around £9.24 for a packet of 20. The table below shows how much smoking costs at current prices.

Many smokers use hand rolled tobacco (also called ‘roll-your-own’/RYO cigarettes). The most popular brand of rolling tobacco costs around £21.64 for 50g — which contains tobacco to roll around 100 cigarettes, costing around £1.08 for every five cigarettes (not including filter tips or papers).

Switching to alternative sources of nicotine, including NRT products or e-cigarettes, can save significant amounts of money. In a representative population survey of adults in England,³ smokers reported spending an average of £23.40 each week, compared to £7.60 for e-cigarette users and £8.15 for NRT users. See below to see how much the average cigarette smoker could save:

6. Set a date

New Year is the most popular time to quit smoking – around half a million smokers will make a quit attempt at this time of year. Others pick their birthday, No Smoking Day – the second Wednesday of every March – or Stoptober as their day to go smokefree. Ultimately, any day will do: the act of choosing a date will help you to focus and plan. Many ex-smokers can tell you the exact day and time they had their last cigarette, because it was such a significant step for them, and an achievement they are incredibly proud of.

7. Involve family and friends

If you live with someone else who smokes, it will be much easier to quit if they quit with you. A common mistake is to underestimate the emotional energy it can take to quit smoking. Making a strong commitment will put you in the right frame of mind. Guide family and friends in the way that will help you most; tell them if they are unnerving you by watching your every movement or talking about it all the time, but equally encourage them to praise you!

8. Deal with any weight gain worries

Some smokers gain weight when they quit. This is partly because nicotine suppresses appetite and interferes with metabolism, and partly because some people turn to snacking to manage cravings. You can mitigate weight gain by using NRT or e-cigarettes to replace the nicotine from cigarettes, controlling the number of calories you consume in your diet, avoiding alcohol, and taking more exercise.⁴ A Stop Smoking Advisor will be able to discuss the options with you, or your GP can refer you to a dietician. Even if you do gain some weight, it will be worth it compared to the major benefits of quitting.

There are many things that smokers can do to improve their chances of quitting. These fall into two categories: products used and psychological support. The evidence suggests that smokers are three times as likely to quit successfully by using a combination of products and behavioural support.

Nicotine Withdrawal

Withdrawal symptoms are the unpleasant physical and mental effects on the body and mind which occur following interruption or termination of drug use. The loss of the ritual of smoking is significant too, and people quitting report feeling fidgety and not knowing what to do with their hands. These feelings are temporary and will fade when the individual has become accustomed to no longer smoking.

Not all smokers experience withdrawal symptoms. The main withdrawal symptoms which may be experienced include nicotine cravings, increased appetite, depression, restlessness, poor concentration, irritability, disturbed sleep and light-headedness. Less common withdrawal symptoms are mouth ulcers and constipation.

Nicotine that is not consumed in a cigarette can increase your chance of quitting successfully, for instance if you use nicotine containing products such as patches, lozenges, inhalers, nasal spray, microtabs, gum and/ or an e-cigarette. Both NRT and e-cigarettes work by replacing some of the nicotine provided in cigarettes and allowing smokers to slowly reduce their dependence on nicotine. There is strong evidence that using a combination of NRT medications (e.g. combining the slow-acting nicotine patch with fast-acting gum or lozenges) is more effective than using them in isolation.

There are two alternatives to nicotine products: Varenicline (Champix) and Bupropion (Zyban) which are only available on prescription. Varenicline (Champix) works by alleviating nicotine withdrawal and reducing the “rewards” of smoking. Bupropion (Zyban) works by reducing withdrawal symptoms and nicotine cravings. Both are proven to be effective; discuss with your doctor whether either of these medications would be suitable for you.

Nicotine Replacement Therapy (NRT)

Nicotine replacement therapy (NRT) includes nicotine chewing gum, patches, lozenges, mouth spray, inhalators, microtabs and nasal spray and is usually taken for 8 to 12 weeks, although it can be used long term. NRT products can be purchased from a pharmacist and in some shops or obtained on prescription from a GP or qualified Stop Smoking Advisor. NRT is designed to reduce the motivation to smoke by replacing nicotine from cigarettes. By alleviating nicotine withdrawal symptoms, the transition from cigarette smoking to complete abstinence is easier. Clinical trials have consistently found that NRT increases the success of quitting smoking by 50–70%.The National Institute for Health and Care Excellence (NICE) recommends that smokers who are committed to quitting should be offered NRT to support their quit attempt and that more heavily addicted smokers may be offered a combination of NRT products if required.

Some smokers believe that nicotine causes cancer and that NRT is therefore also unsafe. This is not the case; it is the tar in cigarette smoke along with other toxins which causes lung cancer and other smoking- related diseases. Some smokers express concern about becoming dependent on NRT. However, NRT is licensed for long-term use to prevent relapse to smoking, and studies looking at long-term NRT use have found no health concerns.

E-cigarettes

E-cigarettes (also known as vapes/vaporisers) are battery-powered devices that simulate the sensation of smoking, but deliver nicotine in a vapour without many of the toxic components present in tobacco smoke. E-cigarettes typically consist of a mouthpiece, battery and cartridge or tank containing e-liquid solution. The liquids typically contain flavourings, additives and nicotine. Using e-cigarettes is considerably less harmful than smoking tobacco cigarettes.

E-cigarettes are regulated as consumer products in the UK. They are now the most popular quitting aids used in Britain,⁵ and there is growing evidence to suggest that they are the most effective way to quit smoking. No e-cigarettes have yet been licensed as a medicine in the UK and they are not currently available on prescription.

Guidance issued by the National Institute for Health and Care Excellence (NICE) advises health professionals to inform people seeking help in stopping smoking that:

• Many people have found them helpful to quit smoking cigarettes
• People using e-cigarettes should stop smoking tobacco completely, because any smoking is harmful
• The evidence suggests that e-cigarettes are substantially less harmful to health than smoking, but are not risk-free
• The evidence in this area is still developing, including evidence on the long-term health impact ⁶

Public Health England encourages anyone who smokes, especially if they have already tried other quitting methods without success, to try an e-cigarette to help them stop smoking. For more information on e-cigarettes please see ASH Briefing: E-cigarettes, NHS guidance on using e-cigarettes to quit and NCSCT guidance for stop smoking services.

Varenicline (Champix)

Varenicline (Champix) is a prescription-only medication which comes as a course of tablets lasting 12 weeks. Varenicline works by preventing nicotine from reaching nicotine receptors in the brain and by stimulating dopamine production both of which make cigarettes less satisfying.⁷ Clinical trials have found varenicline to be more effective in helping people stop smoking than either bupropion or placebo. A Cochrane review of varenicline trials concluded that the drug doubled the chances of successfully quitting compared to unassisted quitting.

Bupropion (Zyban)

Bupropion (Zyban) is a prescription-only medication which comes as a course of tablets lasting around 8 weeks. Bupropion works by reducing (or entirely alleviating) cravings and nicotine withdrawal by blocking the pleasure smokers feel when using tobacco. Bupropion is safe for most healthy adults but there are some documented side effects including insomnia, dry mouth and headaches, and seizures occurring in 0.1% of users. Clinical trials have found that bupropion significantly increases a smoker’s chance of quitting. Bupropion is not as effective as varenicline, it can be helpful for those who cannot take varenicline (for example, due to drug interactions).

Substitution Behaviours

Smoking a cigarette gives smokers something to do with their hands or mouth. The popularity of e-cigarettes may, in part, be due to their satisfying this need. You could also chew gum, drink more water, fruit juice or tea, or eat something (see section on weight gain above).

Other treatments

Hypnosis, acupuncture, aversion therapy and other treatments may help some people but there is little evidence showing they are effective.^{8 9} A review of published studies found that these treatments might help some smokers to quit but that further evidence was needed to establish whether the treatments are as effective as medication. Herbal cigarettes are not a suitable alternative - you continue to get tar, carbon monoxide and other harmful substances, but nothing to help you deal with nicotine withdrawal.

For the first few days it is advisable to change your routine to avoid situations where you would usually smoke. This might include your choice of morning drink, your walk to work and your pre-bedtime routine; all these familiar moments could trigger an urge to smoke. You might also want to avoid substances you associate with smoking in the first few weeks, for example alcoholic drinks. Most importantly, if you find yourself thinking hard about smoking, get up and do something ‘busy’. Distraction is vital at these times, and the effect will last a longer and longer time. Going outside and breathing very deeply for a few minutes can be a good rescue strategy.

It is a good idea to prepare some alternative strategies for coping with stress if your usual coping mechanism is to have a cigarette. A Stop Smoking Advisor can discuss coping strategies with you or speak to your non-smoking friends to get some ideas about how they deal with stress.

If you do end up relapsing, you are in good company, and you should not consider it a failure. You should feel good about every cigarette you do not smoke, and every time you try, you increase your chance of stopping for good.

Hold onto your reasons for wanting to stop and use them to reinforce your belief in yourself. Millions of people have stopped smoking – you can too!

Increase in life-span

Two major longitudinal studies have demonstrated the benefits of stopping smoking at an early age. The 50 year follow-up of a study of British doctors revealed that if smokers quit before the age of 30, they can avoid more than 90% of the smoking-attributable risk of lung cancer. The authors concluded that stopping smoking at age 30, 40, 50 or 60 gains, respectively, about 10, 9, 6 or 3 years of life expectancy.¹⁰ A similar study of British women also found that stopping smoking before the age of 40 avoids more than 90% of the increased risk of dying caused by continuing to smoke, while stopping before the age of 30 avoids over 97% of the increased risk.¹¹

Some of the health benefits from stopping smoking can occur quite quickly as the table below shows. Other health improvements are seen over the course of a number of years, depending on how long a person has smoked.

Source: Smokefree NHS website

Evidence shows that people who give up smoking completely on a specific day are more likely to stay smokefree in the long-term. However, if you aren’t ready to quit yet but are concerned about your health, you could consider cutting down the amount of tobacco you use by using nicotine-containing products as a substitute.

Research shows that smokers who cut down and use nicotine replacement products increase their chances of stopping smoking altogether.