Effects on pregnancy
Women who smoke are more likely to experience infertility and miscarriage (spontaneous abortion). When a pregnant woman smokes, some toxins from the smoke can be passed to the fetus. These toxins can later affect an infant’s lung development and lung function. Babies of women who smoke are more likely to be born prematurely, to have a low birth weight, and to have slower initial growth. Smoking cessation within the first trimester lowers these health risks to a level comparable to those of people who have never smoked. Infants in households where there is a smoker are more likely to die from sudden infant death syndrome (SIDS).
Smoking cessation
The starting point for “kicking the habit” is awareness of the harm smoking can cause. For example, after the U.S. surgeon general’s report in 1964 brought to public awareness a link between smoking and cancer, smoking rates in the United States dropped precipitously. By 2000 the smoking rate was about one-half that of 1960. Furthermore, strong antismoking warnings and health-related messages generally increase smokers’ motivation to quit, as was shown in Canada when it adopted strong graphic warnings on cigarette packaging. Such warnings are now promoted by WHO as an important educational tool to motivate smoking cessation and to help prevent persons from starting to smoke.
Unfortunately, the vast majority of people who try to stop smoking resume within a few weeks of quitting because of the addictive grip of nicotine. Persons who smoke any cigarettes at all usually smoke enough to develop an addiction to nicotine. In general, the more cigarettes a person smokes per day, the greater is the addiction and the more difficult it is to quit. In addition to nicotine dependency, other factors that impede quitting are easy access to cigarettes and the withdrawal symptoms that accompany any discontinuance of nicotine intake. These symptoms include cravings, depression, anxiety, irritability, difficulty concentrating, and insomnia.
Dependence and withdrawal can be managed better by some people than others, and people often learn how to deal with these problems after repeated attempts. Medical intervention, including behavioral guidance, can be critical for recovery from tobacco addiction; scientifically based treatment strategies can have more than double the success rate of quitting “cold turkey” without assistance. Because the health benefits of quitting are so profound, leading health authorities consider treatment for tobacco dependence to be among the most important and cost-effective types of medical intervention. WHO and the governments of many nations are working aggressively to make scientifically proven treatments available to all tobacco users so that they may find a path to better long-term health. Other organizations such as the World Bank are working to support the availability of treatment in developing countries so that their struggling economies are not crippled by tobacco-caused disease and its burdens on health care systems and worker productivity.
Behavioral intervention
Quitting successfully must generally start with a plan for managing behaviour associated with tobacco addiction. Common to virtually all therapeutic approaches is the selection of and planning for a quitting date and adherence to the plan. The plan should include strategies for avoiding or managing situations that might stimulate a craving for a cigarette and therefore trigger a relapse to smoking. For example, for a few weeks or months, some people will need to avoid certain places and activities that they associate with smoking. Others will find it useful to learn methods by which to cope with stress or occasional cravings, such as breathing deeply, chewing gum, or taking a brief walk. Major health organizations provide information on a variety of successful strategies that can be tailored to an individual’s situation.
Social and emotional support is often critical in sustaining an individual’s efforts to quit. Support can come from a structured smoking-cessation program with group, one-on-one, or telephone counseling. Counseling need not be time-consuming or expensive. Studies have shown that even very brief counseling—as little as three minutes total—can make a difference, although more extensive treatment is generally more effective. Support from family members, friends, and health professionals can also play an integral part in the process of quitting.
For many persons a nicotine medication that helps address the physical aspects of nicotine dependence and withdrawal can be as important and beneficial as medications used for the management of other disorders, such as high blood pressure, in which behavioral strategies are also important.
Nicotine replacement therapy
Nicotine replacement therapy delivers nicotine to the body in controlled, relatively small doses, typically by means of a transdermal patch, chewing gum, a nasal spray, an inhaler, or tablets. These products do not contain the tar, carbon monoxide, or other toxic ingredients that are largely responsible for the health hazards of smoking, and, because they deliver controlled doses of nicotine, they are much less addictive than cigarettes. All these products are comparably effective, and advice on making a selection can be obtained from health organizations, health professionals, and the providers of the therapy. In particular, pregnant women, adolescents, and people with heart disease should consult a health professional for advice on product selection and dosing.
In contrast to tobacco products, nicotine replacement medicines are safe when used as directed. They deliver lower doses of nicotine into the bloodstream and do so more slowly than tobacco products do. Nicotine is not a carcinogen or lung toxin, and the nicotine doses delivered by the medicines do not produce cardiovascular disease. Nicotine at higher doses than are typically prescribed can contribute to low fetal birth weight and other adverse effects during pregnancy; however, the benefit of increased success in smoking cessation for women of childbearing age who have already tried and failed to quit without medication is generally considered to outweigh this comparatively small risk. Nicotine medications carry a very low potential for establishing addiction, and there is little evidence of their abuse. Some people may find the use of medications vital for many months to preventing a relapse to tobacco use. Such individuals are generally encouraged to take the medications as long as required in order to be confident to avoid a relapse. In fact, the most common dosing error is taking too little or not using the medicine long enough. Taking too much can produce the same short-lived symptoms of dizziness, nausea, and headache that are associated with smoking too many cigarettes, but this generally is not a serious health concern.
Nicotine patch
Nicotine patches are available without a prescription in many countries. A new patch is applied to the skin every day and is left in place for a recommended amount of time (usually 16 to 24 hours) while it delivers a controlled amount of nicotine to the body through the skin. The patches are used over a period of six to eight weeks or longer. Patches with the highest dosage of nicotine (15 or 21 mg) are generally used for the first few weeks; patches with lower doses are used thereafter. The most common side effect of the nicotine patch is a mild itching, burning, or tingling at the site on which it is applied. The nicotine patch can produce sleep disturbances; if they persist, they can often be remedied by removing the patch at bedtime.
Nicotine gum and lozenges
Nicotine gum, usually available in 2- and 4-mg formulations, is available in many countries without a physician’s prescription. The gum is chewed a few times and then placed between the cheek and gums to allow the nicotine to be absorbed through the mouth’s mucous membrane. These actions are repeated for up to about 30 minutes. Achieving success with gum as a cessation aid depends largely on using it consistently. At least one piece of nicotine gum should be used every one to two hours over a period of one to three months. Additional pieces may be used in the event of a strong craving. Possible side effects include mouth soreness, headache, and jaw ache. Nicotine lozenges in 2- and 4-mg dosages are also available in many countries. The lozenges are similar to nicotine gum in use except that they are not chewed.
Nicotine nasal spray
Nicotine nasal spray was designed to deliver nicotine more rapidly than is possible with a patch or gum. It is available by prescription only because it appears to carry a somewhat higher cardiovascular risk and a potentially higher risk for abuse than other nicotine medications do. The 1 mg of nicotine commonly prescribed (a 0.5-mg dose squirted into each nostril) is rapidly absorbed by the nasal mucosa. Patients are encouraged to use at least 8 doses (16 sprays) per day for optimal efficacy but can use up to 40 doses per day, depending on their level of nicotine dependence. The most common side effects include nasal and throat irritation, watery eyes, and runny nose. The nicotine nasal spray is not recommended for persons with nasal or sinus conditions, certain allergies, or asthma.
