Quitting tobacco

What is it?

According to WHO, cigarette smoking is the most common form of tobacco use in the world, and other tobacco products include waterpipe (shisha) tobacco, cigars and cigarillos, heated tobacco, roll-your-own tobacco, pipe tobacco, bidis and kreteks, and smokeless tobacco products.

NCI describes smokeless tobacco as tobacco that is not burned, including chewing tobacco, snuff and snus, and describes shisha as a device through which tobacco smoke (often flavoured) passes through a bowl of water before it is inhaled.

E-cigarettes heat a liquid to form an aerosol that the user inhales; the liquid may or may not contain nicotine but does not contain tobacco, and WHO says they are harmful to health and unsafe.

WHO also mentions nicotine pouches placed between the gum and the lip, which are often marketed as "tobacco-free" although their nicotine may be extracted from tobacco, and describes them as highly addictive.

Quitting is hard because smoking causes addiction to nicotine, a stimulant substance in tobacco (MedlinePlus). NCI says that the addiction caused by nicotine is similar to the addiction caused by drugs such as heroin and cocaine.

Why it matters

WHO says that tobacco harms almost every organ of the body, and causes cancer, heart disease, stroke, lung disease, reduced fertility, weakened immunity and early death, and that it kills more than 7 million people every year.

MedlinePlus describes tobacco use as the most common cause of preventable death, and says that quitting improves both quality and length of life.

According to the CDC, quitting reduces the risk of early death and may add up to 10 years to life expectancy, and reduces the risk of cardiovascular disease, chronic obstructive pulmonary disease, cancer and reproductive problems.

The CDC states that quitting reduces the risk of 12 types of cancer: acute myeloid leukaemia, bladder, lung, cervix, colon and rectum, oesophagus, kidney, liver, mouth and throat, pancreas, stomach and larynx.

For those diagnosed with coronary heart disease, the CDC states that quitting reduces early death and the risk of a first or repeat heart attack, and for those with chronic obstructive pulmonary disease it slows the progression of the disease and the loss of lung function. It also reduces cough, phlegm, wheezing and respiratory infections such as bronchitis and pneumonia.

Secondhand smoke: WHO says that there is no safe level of exposure to it, that it causes serious heart and respiratory diseases including coronary heart disease and lung cancer, and that it kills more than 1.6 million people prematurely every year.

According to NCI, exposure to secondhand smoke raises the risk of heart disease by about 25 to 30% and the risk of stroke by about 20 to 30%, puts children at higher risk of sudden infant death syndrome, ear infections, colds, pneumonia and bronchitis, and increases the frequency and severity of asthma attacks in children who have it.

The CDC says that quitting is the single best way to protect family, co-workers and friends from secondhand smoke, and WHO states that quitting reduces the excess risk in children exposed to secondhand smoke of diseases such as asthma and ear infections.

Key points

The sequence of benefits after the last cigarette according to the CDC (the reduction here is compared with continuing to smoke): within minutes heart rate drops; within 24 hours the nicotine level in the blood falls to zero; within several days carbon monoxide in the blood falls to the level of a non-smoker.

From 1 to 12 months cough and shortness of breath decrease; from 1 to 2 years the risk of heart attack drops sharply; from 3 to 6 years the added risk of coronary heart disease is halved (CDC).

From 5 to 10 years the added risk of cancers of the mouth, throat and larynx is halved and the risk of stroke falls; at 10 years: the added risk of lung cancer is halved after 10 to 15 years, and the risk of bladder, oesophageal and kidney cancers falls (CDC).

At 15 years the risk of coronary heart disease approaches that of a non-smoker; at 20 years the risk of cancers of the mouth, throat, larynx and pancreas approaches that of a non-smoker, and the added risk of cervical cancer is roughly halved (CDC).

WHO presents a similar sequence: within 20 minutes heart rate and blood pressure fall; after 12 hours carbon monoxide in the blood returns to normal; from 2 to 12 weeks circulation improves and lung function increases; from 1 to 9 months cough and shortness of breath decrease; after a year the risk of coronary heart disease is about half that of a smoker.

According to WHO also: the risk of stroke falls to that of a non-smoker within 5 to 15 years of quitting; after 10 years the risk of lung cancer falls to about half that of a smoker and the risk of cancers of the mouth, throat, oesophagus, bladder, cervix and pancreas decreases; after 15 years the risk of coronary heart disease is the same as that of a non-smoker.

Gains in life expectancy compared with those who continued to smoke according to WHO: quitting at about age 30 adds nearly 10 years, at about 40 adds 9 years, at about 50 adds 6 years, and at about 60 adds 3 years. Someone who quits after a heart attack reduces the chance of another by 50%.

NCI states, based on US National Health Interview Survey data, that quitting before age 40 reduces the chance of early death from smoking-related diseases by about 90%, and that quitting between 45 and 54 reduces it by about two-thirds.

WHO says that counselling and medicine can more than double the chance of successfully quitting, and that more than 60% of smokers in the countries where the Global Adult Tobacco Survey was conducted expressed an intention to quit.

How to put it into practice

Make a plan: MedlinePlus advises talking to a health care provider about your smoking habits and your readiness to quit and setting a quit date, and the CDC says that counselling helps you make a plan and prepare to deal with stress and the urge to smoke.

Ask for support: WHO recommends that health workers routinely provide brief advice (30 seconds to 3 minutes), with more intensive behavioural support (individual, group or by telephone) for those who want it, and text messages, phone apps and online programmes as aids. Look for cessation services in your country or ask your primary care doctor or your country's health authority.

Medicines by type: the CDC and NCI list nicotine replacement therapy (patches, gum, lozenges, nasal spray and inhaler), and prescription medicines that do not contain nicotine, and WHO recommends medicines of both types as effective treatment for quitting. Which medicine, how and when is decided by the doctor.

Combining counselling and medicine: MedlinePlus says that combining them has been shown to be the best way, the CDC says it gives you the best chance of quitting for good, and WHO says it significantly increases success rates. The CDC and NCI state that combining a long-acting form and a short-acting form of nicotine replacement may help more, and this is a decision for the doctor.

Choose the method: MedlinePlus mentions gradually reducing the number of cigarettes or stopping all at once, and that you may need to try more than one method. The CDC says: even if you have tried before, the key to success is to keep trying and not give up.

Know your triggers: NCI divides them into social triggers (being with smokers or at an event), emotional triggers (stress, anxiety, boredom, loneliness, sadness or even joy), and pattern or activity triggers (the start of the day, driving, drinking coffee or tea, and after meals). Knowing them helps you avoid them or keep yourself occupied when they cannot be avoided.

In a strong craving (NCI): remind yourself it will pass, avoid situations in which you used to smoke, keep your mouth busy with carrots, apples, celery or sugar-free gum, and try breathing in deeply through the nose and out slowly through the mouth 10 times.

At home and with others (NCI): make your home smoke-free and remove cigarettes, ashtrays and lighters, reduce contact with smokers especially in the first weeks, ask those around you not to offer you tobacco or buy it for you, and plan a new morning routine that begins with an activity that keeps you busy and with drinking water.

To ease stress and irritability, NCI suggests enjoyable physical activity such as walking, cutting down on caffeine (coffee, tea and fizzy drinks), and relaxation and breathing exercises.

Special groups

Pregnancy: according to the CDC the best time to quit is before trying to conceive, but quitting at any stage of pregnancy benefits mother and baby; quitting before or early in pregnancy reduces the risk of the baby being small for gestational age, quitting during pregnancy reduces the risk of low birth weight, and quitting before or early in pregnancy may reduce the risk of preterm birth.

WHO says that a pregnant woman's exposure to nicotine may harm the development of the fetus. MedlinePlus states that medicinal aids may not be suitable for pregnant or breastfeeding women, and NCI says that nicotine replacement is not recommended for pregnant women or those trying to conceive; so any aid should be discussed with the doctor.

Teenagers and young people: WHO says that nicotine is highly addictive and harmful especially for children, adolescents and young people because their brains are still developing, exposure to it in adolescence may affect attention and learning, and early use increases the likelihood of long-term dependence.

WHO states that high-quality studies show that e-cigarettes increase the initiation of conventional cigarette smoking among non-smoking adolescents by about 3 times. MedlinePlus says that quit medicines may not be suitable for teenagers, so the doctor decides the appropriate aid.

Older adults: the CDC says that quitting has benefits at any age, however long or heavily a person has smoked, and NCI states that a study of people aged 70 and over found that those who quit in their sixties had a lower risk of death than those who continued. See also healthy ageing.

People with cancer: according to NCI, quitting at diagnosis may reduce the risk of death by 30% to 40% in some cancers, improves the body's ability to heal and respond to surgery and chemotherapy, and reduces the risk of pneumonia and respiratory failure.

People with a history of depression: NCI states that their withdrawal symptoms are often more severe, and that some prescription medicines may help them; discuss this with the doctor.

Risks and cautions

Common withdrawal symptoms according to NCI: strong craving for nicotine, anger, frustration and irritability, difficulty concentrating, insomnia, restlessness, anxiety, depression, and hunger or increased appetite. Less common symptoms include headache, fatigue, dizziness, cough, mouth sores and constipation. MedlinePlus also mentions mood swings, weight gain and sleep problems.

Duration according to NCI: they are usually most intense in the first week and peak in the first three days, then usually ease within the first month, and may last several months in some people. Strong cravings may begin within an hour or two of last use, become less frequent over time, and mild cravings may appear months or years later.

NCI states that anger, frustration and irritability peak within a week and may last 2 to 4 weeks, that anxiety usually builds in the first three days and may last several weeks, and that mild depression usually begins on the first day, lasts a few weeks and resolves within a month.

Weight gain: NCI says it is usually less than 10 pounds, that the health benefits of quitting far outweigh the risks of this modest gain, and advises balancing physical activity with calories and consulting a dietitian when needed, and not letting fear of weight stop you from quitting.

The myth of "one or two cigarettes does no harm": NCI says there is no safe level of smoking, and that smoking just one cigarette a day over a lifetime may cause smoking-related cancers (lung, bladder and pancreas) and early death.

The myth of "shisha is less harmful": NCI says some people think so, but research shows that shisha smoke is at least as toxic as cigarette smoke. WHO stresses that all forms of tobacco are harmful.

E-cigarettes and quitting: MedlinePlus says that the idea that they help with quitting has not been proven, NCI says the evidence is inconclusive and that the US Food and Drug Administration has not approved any e-cigarette as a quit aid, and WHO says that as consumer products they have not been shown to be effective for quitting at population level.

WHO warns that dual use (e-cigarettes with conventional ones) is common, that it is at least as dangerous as either on its own and likely more dangerous, and that children swallowing e-cigarette liquid or its leaking from devices poses a serious danger.

Heated tobacco: WHO says that it releases toxic emissions similar to cigarette smoke, many of which may cause cancer, and that it does not help smokers end tobacco use.

Alternative methods: NCI states that hypnosis, acupuncture, acupressure, laser therapy and electrical stimulation have not been shown by clinical studies to help with quitting.

Medicines: NCI says that getting nicotine from replacement products is far less harmful than cigarettes, and that non-nicotine quit medicines have several side effects that must be discussed with the doctor. Do not start or stop any medicine without consulting your doctor.

Limits of this information

The timings of benefits differ slightly between the CDC and WHO because they are population averages from different studies, and do not mean an exact prediction for a particular person.

Some figures (such as NCI's percentage reductions in early death) are taken from US data and may differ in other countries.

Quit services, the availability of medicines and cost coverage differ between countries; WHO states that comprehensive national cessation services with full or partial cost coverage are available in only 31 countries. Ask your primary care doctor or your country's health authority about the cessation services available. What methods and medicines suit you is decided by your doctor according to your situation.

Doses and treatment durations are deliberately not given here, as they are decided by the doctor. The shisha information here is from NCI and from WHO's general tobacco page.

The sources of this page do not cover emergency signs calling for immediate ambulance care related to quitting itself; so the signs listed relate to seeing the doctor within days.

Common questions