Guide for Quitting Smoking

Why Is It So Hard to Quit Smoking?

Mark Twain said, "Quitting smoking is easy. I've done it a thousand times." Maybe you've tried to quit too. Why is quitting and staying quit hard for so many people? The answer is nicotine.

Nicotine

Nicotine is a drug found naturally in tobacco. It is highly addictive - as addictive as heroin and cocaine. Over time, the body becomes physically and psychologically dependent on nicotine. Studies have shown that smokers must overcome both of these to be successful at quitting and staying quit.

When smoke is inhaled, nicotine is carried deep into the lungs, where it is absorbed quickly into the bloodstream and carried throughout the body. Nicotine affects many parts of the body, including your heart and blood vessels, your hormonal system, your metabolism, and your brain. Nicotine can be found in breast milk and in cervix mucous secretions of smokers. During pregnancy, nicotine freely crosses the placenta and has been found in amniotic fluid and the umbilical cord blood of newborn infants.

Several different factors can affect the rate of metabolism and excretion of nicotine. In general, a regular smoker will have nicotine or its by-products present in the body for about 3 to 4 days after stopping.

Nicotine produces pleasurable feelings that make the smoker want to smoke more. It also acts as a depressant by interfering with the flow of information between nerve cells. As the nervous system adapts to nicotine, smokers tend to increase the number of cigarettes they smoke, and hence the amount of nicotine in their blood. After a while, the smoker develops a tolerance to the drug, which leads to an increase in smoking over time. Eventually, the smoker reaches a certain nicotine level and then smokes to maintain this level of nicotine.

Nicotine Withdrawal

When smokers try to cut back or quit, the absence of nicotine leads to withdrawal symptoms. Withdrawal is both physical and psychological. Physically, the body is reacting to the absence of nicotine. Psychologically, the smoker is faced with giving up a habit, which is a major change in behavior. Both must be dealt with if quitting is to be successful.

Withdrawal symptoms can include any of the following:

These uncomfortable symptoms lead the smoker to again start smoking cigarettes to boost blood levels of nicotine back to a level where there are no symptoms.

If a person has smoked regularly for a few weeks or longer and abruptly stops using tobacco or greatly reduces the amount smoked, withdrawal symptoms will occur. Symptoms usually start within a few hours of the last cigarette and peak about 2 to 3 days later. Withdrawal symptoms can last for a few days to several weeks. For information on coping with withdrawal, see the section on "How to Quit."

Why Quit?

Your Health

Health concerns usually top the list of reasons people give for quitting smoking. Nearly everyone knows that smoking can cause lung cancer, but few people realize it is also a risk factor for many other kinds of cancer as well, including cancer of the mouth, voice box (larynx), throat (pharynx), esophagus, bladder, kidney, pancreas, liver, cervix, stomach, colon and rectum, and some leukemias. For more information on this topic, please see our document "Cigarette Smoking."

Smoking increases the risk of lung diseases such as emphysema and chronic bronchitis. These progressive lung diseases - grouped under the term COPD (chronic obstructive pulmonary disease) - are usually diagnosed in current or former smokers in their 60s and 70s. COPD causes chronic illness and disability and is eventually fatal.

Smokers are twice as likely to die from heart attacks as are nonsmokers. And smoking is a major risk factor for peripheral vascular disease, a narrowing of the blood vessels that carry blood to the leg and arm muscles.

Smoking also causes premature wrinkling of the skin, bad breath, bad smelling clothes and hair, and yellow fingernails.

For women, there are unique risks. Women over 35 who smoke and use "the pill" (oral contraceptives) are in a high-risk group for heart attack, stroke, and blood clots of the legs. Women who smoke are more likely to have a miscarriage or a lower birth-weight baby.

Based on data collected from 1995 to 1999, the US Centers for Disease Control (CDC) recently estimated that adult male smokers lost an average of 13.2 years of life and female smokers lost 14.5 years of life because of smoking.

No matter what your age or how long you've smoked, quitting will help you live longer. People who stop smoking before age 35 avoid 90% of the health risks attributable to tobacco. Even those who quit later in life can significantly reduce their risk of dying at a younger age.

Ex-smokers also enjoy a higher quality of life with fewer illnesses from cold and flu viruses, better self-reported health status, and reduced rates of bronchitis and pneumonia.

For decades the Surgeon General has reported the health risks associated with smoking. Regardless of your age or smoking history, there are advantages to quitting smoking. Benefits apply whether you are healthy or you already have smoking-related diseases. In 1990, the Surgeon General concluded:

When Smokers Quit - What Are the Benefits Over Time?

20 minutes after quitting: Your blood pressure drops to a level close to that before the last cigarette. The temperature of your hands and feet increases to normal.
(US Surgeon General's Report,1988, pp. 39, 202)

8 hours after quitting: The carbon monoxide level in your blood drops to normal.
(US Surgeon General's Report,1988, p. 202)

24 hours after quitting: Your chance of a heart attack decreases.
(US Surgeon General's Report,1988, p. 202)

2 weeks to 3 months after quitting: Your circulation improves and your lung function increases up to 30%.
(US Surgeon General's Report, 1990, pp.193,194,196,285,323)

1 to 9 months after quitting: Coughing, sinus congestion, fatigue, and shortness of breath decrease; cilia (tiny hair like structures that move mucus out of the lungs) regain normal function in the lungs, increasing the ability to handle mucus, clean the lungs, and reduce infection.
(US Surgeon General's Report, 1990, pp. 304, 307, 319, 322)

1 year after quitting: The excess risk of coronary heart disease is half that of a smoker's.
(US Surgeon General's Report, 1990, p. vi)

5 years after quitting: Your stroke risk is reduced to that of a nonsmoker 5-15 years after quitting.
(US Surgeon General's Report, 1990, p.79)

10 years after quitting: The lung cancer death rate is about half that of a continuing smoker's. The risk of cancer of the mouth, throat, esophagus, bladder, kidney, and pancreas decrease.
(US Surgeon General's Report, 1990, p.110, 147, 152, 155, 159,172)

15 years after quitting: The risk of coronary heart disease is that of a nonsmoker's.
(US Surgeon General's Report, 1990, p.79)

Quitting helps stop the damaging effects of tobacco on your appearance including:

Kicking the tobacco habit also offers benefits that you'll notice immediately and some that will develop gradually in the first few weeks. These rewards can improve your day-to-day life substantially:

The prospect of better health is a major reason for quitting, but there are others as well. Smoking is expensive. The economic costs of smoking are estimated to be about $3,391 per smoker per year. Do you really want to continue burning up your money with nothing to show for it except possible health problems?

Cost

Smoking is expensive. It isn't hard to figure out how much you spend on smoking: multiply how much money you spend on tobacco every day by 365 (days per year). The amount may surprise you. Now multiply that by the number of years you have been using tobacco and that amount will probably astound you.

Multiply the cost per year by 10 (for the upcoming 10 years) and ask yourself what you would rather do with that much money.

And this doesn抰 include the higher costs for health and life insurance, as well as the possible health care costs due to tobacco-related conditions.

Social Acceptance

Smoking is less socially acceptable now than it was in the past. While decisions may not be based entirely on social acceptance, most workplaces have some type of smoking restrictions. Some employers prefer to hire nonsmokers.

Studies show smoking employees cost businesses more to employ because they are "out sick" more frequently. Employees who are ill more often than others can raise an employer抯 need for expensive temporary replacement workers. They can increase insurance costs both for other employees and for the employer, who typically pays part of the workers?insurance premiums. Smokers in a building also typically increase the maintenance costs of keeping odors at an acceptable level, since residue from cigarette smoke clings to carpets, drapes and other fabrics.

Landlords, also, may choose not to rent to smokers since maintenance costs and insurance rates may rise when smokers occupy buildings.

Friends may ask you not to smoke in their houses or cars. Public buildings, concerts, and even sporting events are largely smoke-free. And more and more communities are restricting smoking in all public places, including restaurants and bars. Like it or not, finding a place to smoke can be a hassle.

Smokers may find their opportunities for dating or romantic involvement, including marriage, are largely limited to only other smokers, who make up only about 1/4th of the population.

Health of Others

Smoking not only harms your health but the health of those around you. Exposure to secondhand smoke (also called environmental tobacco smoke or passive smoking) includes exhaled smoke as well as smoke from burning cigarettes.

Studies have shown that secondhand smoke causes thousands of deaths each year from lung cancer and heart disease in healthy nonsmokers.

Smoking by mothers is linked to a higher risk of their babies developing asthma in childhood, especially if the mother smokes while pregnant. It is also associated with sudden infant death syndrome (SIDS) and low-birth weight infants. Babies and children raised in a household where there is smoking have more ear infections, colds, bronchitis, and other respiratory problems than children from nonsmoking families. Secondhand smoke can also cause eye irritation, headaches, nausea, and dizziness.

Setting an Example

If you have children, you want to set a good example for them. When asked, nearly all smokers say they don't want their children to smoke, but children whose parents smoke are more likely to start smoking themselves. You can become a good role model for them by quitting now.

Help Is Available

With the wide array of counseling services, self-help materials, and medicines available today, smokers have more tools than ever before to help them quit successfully.

For most people, the best way to quit will be some combination of medicine, a method to change personal habits, and emotional support. The following sections describe these tools and how they may be helpful for you.

What About Nicotine Replacement Therapy?

If you抮e hooked on nicotine or if you抳e tried quitting before, think about using nicotine replacement therapy. This method gives you a small dose of nicotine to help cut down the urge to use tobacco once you quit. Nicotine gum, lozenges, and "the patch" are sold over the counter at your drug store. Other forms of nicotine replacement, such as nasal sprays and inhalers, need a doctor抯 prescription. Nicotine replacement therapy costs about the same as a pack of cigarettes per day. You will only have to use replacement therapy for a short period of time.

How Nicotine Replacement Works

Nicotine substitutes treat the very difficult withdrawal symptoms and cravings that 70% to 90% of smokers say is their only reason for not giving up cigarettes. By using a nicotine substitute, a smoker's withdrawal symptoms are reduced.

While a large number of smokers are able to quit smoking without nicotine replacement, most of those who attempt quitting are not successful on the first try. In fact, smokers usually need several attempts before they are able to quit for good.

Lack of success is often related to the onset of withdrawal symptoms. By reducing these symptoms with the use of nicotine replacement therapy, smokers who want to quit have a better chance of being successful.

For smokers, nicotine blood levels will vary, depending on individual smoking patterns such as the time between cigarettes, how deeply the person inhales, the number of cigarettes smoked per day, and the brand smoked. Smoking delivers nicotine to the bloodstream very quickly - within a few seconds. Nicotine replacements generally work more slowly, and the amount of nicotine in the bloodstream is less than that from smoking.

Getting the Most from Nicotine Replacement

Nicotine replacement therapy only deals with the physical aspects of addiction. It is not intended to be the only method used to help you quit smoking. It should be combined with other smoking cessation methods that address the psychological component of smoking, such as a stop smoking program. Studies have shown that an approach - pairing nicotine replacement with a program that helps to change behavior - can double your chances of successfully quitting.

The US Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guideline on Smoking Cessation recommends nicotine replacement therapy for all smokers except pregnant women and people with heart or circulatory diseases. If a health care provider suggests nicotine replacement for people in these groups, the benefits of smoking cessation must outweigh the potential health risk.

The most effective time to start nicotine replacement is at the beginning of an attempt to quit. Often smokers first try to quit on their own, then decide to try nicotine replacement. Nicotine replacement therapy should not be used if you plan to continue to smoke or use another tobacco product. The combined dose of nicotine could be dangerous to your health.

Smokers who are pregnant or have heart disease should consult with their doctor before using over the counter nicotine replacement.

Types of Nicotine Substitutes

Nicotine patches (transdermal nicotine systems): Patches provide a measured dose of nicotine through the skin. As the nicotine doses are lowered by switching patches over a course of weeks, the tobacco user is weaned off nicotine. Patches can be purchased without a prescription. Several types and different strengths are available. Package inserts describe how to use the product as well as special considerations and possible side effects.

Depending on body size, most tobacco users should start using a full-strength patch (15-22 mg of nicotine) daily for 4 weeks, and then use a weaker patch (5-14 mg of nicotine) for another 4 weeks. The patch should be applied in the morning to a clean, dry area of the skin without much hair. It should be placed below the neck and above the waist - for example, on the arm. The FDA recommends using the patch for 3 to 5 months. However, some studies have shown that using it for 8 weeks or less is just as effective as using it for longer.

Side effects of the patch are related to:

Some possible side effects of nicotine replacement include:

What to do about side effects:

Nicotine gum (nicotine polacrilex): Nicotine gum is a fast-acting form of replacement that acts through the mucous membrane of the mouth. It can be bought over-the-counter without a prescription. It comes in 2 mg and 4 mg strengths.

For best results, follow the instructions of the package insert. Chew the gum slowly until you note a peppery taste. Then, "park" it against the cheek, chewing it and parking it off and on for about 20 to 30 minutes. Food and drink can affect how well the nicotine is absorbed. You should avoid acidic foods and drinks such as coffee, juices, and soft drinks for at least 15 minutes before and during gum use.

If you smoke a pack or more per day, smoke within 30 minutes of rising, or have trouble not smoking in restricted areas, you may need to start with the higher dose (4 mg). No more than 20 pieces should be used in one day. Nicotine gum is usually recommended for 1 to 3 months, with the maximum being 6 months. Tapering the amount of gum chewed may help you stop using it.

If you have sensitive skin, you may prefer the gum to the patch. Another advantage of nicotine gum is that it allows you to control the nicotine doses. The gum can be chewed as needed or on a fixed schedule during the day. The most recent data has shown that scheduled dosing is more effective. A schedule of 1 to 2 pieces per hour is common. On the other hand, with an as-needed schedule, you can chew more nicotine during a craving.

Some possible side effects of the gum:

Symptoms related to the stomach and jaw are usually caused by improper use of the gum, such as swallowing nicotine or chewing too rapidly.

Long-term dependence is one possible disadvantage of nicotine gum. In fact, research has shown that 15% to 20% of gum users who successfully quit smoking continue using the gum for a year or longer. Although the maximum recommended length of use is 6 months, continuing to use the gum is likely to be safer than going back to smoking. But since there is little research on the health effects of long-term nicotine gum use, most health care providers still recommend limiting its use to 6 months.

Combination patch and gum: Using the nicotine patch and nicotine gum together is another method of nicotine replacement therapy. It has not been widely researched, but the few available studies look promising. Smokers in most of these studies use the nicotine patches routinely (over 24 hours) and the nicotine gum as a "rescue use" up to 4 pieces a day. It is hoped that this type of combination use will help more people stop smoking and keep them from smoking longer. One advantage to the combined treatment is that the nicotine replacement patch delivers nicotine slowly while the gum works faster and helps reduce withdrawal symptoms. This combination has not yet been approved by the US Food and Drug Administration (FDA).

Nicotine nasal spray: The nasal spray delivers nicotine quickly to the bloodstream as it is absorbed through the nose. It is available only by prescription.

The nasal spray immediately relieves withdrawal symptoms and offers you a sense of control over nicotine cravings. Because it is easy to use, smokers report great satisfaction. However, the Food and Drug Administration cautions that since this product contains nicotine, it can be addictive. It recommends the spray be prescribed for 3-month periods and should not be used for longer than 6 months.

The most common side effects last about 1 to 2 weeks and can include the following:

There is also the danger of using more than is needed. If you have asthma, allergies, nasal polyps, or sinus problems, your doctor may suggest another form of nicotine replacement.

Nicotine inhalers: Introduced in 1998, inhalers are available only by prescription. The nicotine inhaler is a plastic tube with a nicotine cartridge inside. When you puff on the inhaler, the cartridge provides a nicotine vapor. Unlike other inhalers, which deliver most of the medication to the lungs, the nicotine inhaler delivers most of the nicotine vapor to the mouth. Behaviorally, nicotine inhalers are the closest thing to smoking a cigarette, which some smokers find helpful.

The most common side effects, especially when first using the inhaler, include:

At this time, inhalers are the most expensive of the forms of NRT available.

Nicotine lozenges: These are the newest form of NRT on the market. After undergoing the appropriate testing, the FDA recently approved the first nicotine-containing lozenge as an over-the-counter aid in smoking cessation. As with nicotine gum, the Commit TM lozenge is available in two strengths: 2 mg and 4 mg. Smokers determine which dose is appropriate based on how long after waking up they normally have their first cigarette.

The lozenge manufacturer recommends using it as part of a 12-week program. The recommended dose is one lozenge every 1-2 hours for 6 weeks, then one lozenge every 2-4 hours for 3 weeks, and finally, one lozenge every 4-8 hours for 3 weeks. In addition, the manufacturer recommends the following:

Possible side effects of the nicotine lozenge include:

Substances Not Reviewed or Approved by the FDA

Tobacco lozenges: Lozenges containing tobacco, such as Ariva TM, are being marketed as an alternative way for smokers to get nicotine in places where smoking is not permitted, rather than as a tobacco cessation aid. The FDA has ruled that these are a type of smokeless tobacco, not a smoking cessation aid; therefore, the FDA does not have authority over them. There is no evidence that these lozenges can help a person quit smoking.

Nicotine lollipops and lip balms: In the past, some pharmacies throughout the United States made a product called the "nicotine lollipop". These lollipops often contained a product called nicotine salicylate with a sugar sweetener. Nicotine salicylate is not approved for pharmacy use by the FDA. In April 2002, the FDA warned 3 pharmacies to stop selling nicotine lollipops and lip balm on the Internet and called the products "illegal". The FDA also said "the candy-like products present a risk of accidental use by children".

Other similar tobacco cessation products may not use nicotine salicylate, and therefore may be legal. However, they still pose a risk for children if they are not sufficiently labeled and stored safely.

Which Type of Nicotine Replacement Is Right for You?

When choosing which type of nicotine replacement you will use, think about which method will best fit your lifestyle and pattern of smoking. Do you want/need something to chew or occupy your hands? Are you looking for once-a-day convenience?

Some important points to consider:

Other Quitting Tools (Medication)

Other tools, used alone or in combination with nicotine replacement therapy, may improve your chances of quitting.

Zyban (bupropion) is a prescription antidepressant in an extended-release form that reduces symptoms of nicotine withdrawal. This drug affects chemicals in the brain that are related to nicotine craving. It can be used alone or together with nicotine replacement.

In one study, Zyban helped 49% of smokers quit for at least a month. In the same study, 36% of nicotine patch users were able to quit for a month. When both methods were used, 58% of smokers were able to remain smoke free for over a month.

This medication should not be taken if you have a history of seizures, anorexia, heavy alcohol use, or head trauma.

Quitlines - Telephone-based Help to Stop Smoking

More than 30 states run some type of free telephone "Quitline," which links callers with trained counselors. These specialists help plan a quit method that fits each person's unique pattern of tobacco use. People who use telephone counseling stop tobacco use at twice the rate of those who don't get this type of help. With guidance from a counselor, quitters can avoid common mistakes that may hurt a quit attempt.

Telephone counseling is also more convenient for many people. It doesn't require transportation or childcare and it's available nights and weekends. Counselors may recommend a combination of methods including medicines, local classes, self-help brochures, and/or a network of family and friends. Tobacco users can get help finding a Quitline in their area by calling the ACS at 1-800-ACS-2345.

Support of Family, Friends, and Quit Programs

Many former smokers say a support network of family and friends was very important during their quit attempt. Other people who may offer support and encouragement are coworkers, your family doctor, and members of support groups for quitters. You can check with your employer, health insurance company, or local hospital to find support groups; or call the ACS at 1-800-ACS-2345.

Other Tools

Hypnosis might be useful for some people. Ask your doctor if he or she can recommend a good hypnotist if you are interested in this.

Acupuncture has been used for quitting tobacco, but as of yet there is no strong evidence to support its effectiveness. For a list of local physician acupuncturists, contact the American Academy of Medical Acupuncture at 1-800-521-2262.

Filters that reduce tar and nicotine in cigarettes are generally not effective since studies show that smokers who use filters actually tend to smoke more.

Smoking deterrents such as over-the-counter products that change the taste of tobacco, "stop smoking diets" that curb nicotine cravings, and combinations of vitamins have little scientific evidence to support their claims.

A Word About Success Rates

Before you sign up for a stop smoking class or program, you may wonder what its success rate is. That's a hard question to answer for several reasons. First, not all programs define success in the same way. Does success mean that a person is not smoking at the end of the program? After 3 months, or 6 months, or 1 year? If a program you're considering claims a certain success rate, ask for more details on how success is defined and what kind of follow-up is done to verify the rate.

Several articles in medical journals have reported that between 1/4 and 1/3 of smokers who use nicotine replacement or bupropion (Zyban) can remain smoke-free for over 6 months. There is early evidence that combining nicotine replacement therapy with bupropion may be more effective than either one alone. About 5% to 16% of people are able to quit smoking for at least 6 months without any medicine to help with withdrawal.

The truth is, quit smoking programs, like other programs that treat addictions, often have a fairly low success rate. But that does not mean they are not worthwhile or that you should be discouraged. Your own success in quitting is what really counts, and that is under your control. p>Behavioral and supportive therapies increase success rates. Check the package insert of nicotine replacement products to see if the manufacturer provides free telephone-based counseling.

How to Quit

Smokers often say, "Don't tell me why to quit, tell me how." There is no one right way to quit, but there are some key elements in quitting smoking successfully. These 4 factors are crucial: making the decision to quit setting a quit date and choosing a quit plan dealing with withdrawal staying quit (maintenance)

Making the Decision to Quit

The decision to quit tobacco use is one that only you can make. Others may want you to quit, but the real commitment must come from you.

Researchers have looked into how and why people stop tobacco use. They have some ideas, or models, of how this happens.

TheHealth Belief Model says that you will be more likely to stop tobacco use if you:

Do any of these apply to you?

The Stages of Change Model identifies the stages that you go through when you make a change in behavior. Here are the stages as they apply to quitting tobacco use:

Pre-contemplation: At this stage, the tobacco user is not thinking seriously about quitting right now.

Contemplation: The tobacco user is actively thinking about quitting but is not quite ready to make a serious attempt yet. This person may say, "Yes, I'm ready to quit, but the stress at work is too much, or I don't want to gain weight, or I'm not sure if I can do it."

Preparation: Tobacco users in the preparation stage seriously intend to quit in the next month and often have tried to quit in the past 12 months. They usually have a plan.

Action: This is the first 6 months when the user is actively quitting.

Maintenance: This is the period of 6 months to 5 years after quitting when the ex-user is aware of the danger of relapse and take steps to avoid it.

Where do you fit in this model? If you are thinking about quitting, setting a date and deciding on a plan will move you into the preparation stage, the best place to start.

Setting a Quit Date and Deciding on a Plan

Once you've made a decision to quit, you're ready to pick a quit date. This is a very important step. Pick a specific day within the next month as your 慟uit Day? Picking a date too far in the future allows you time to rationalize and change your mind. But do give yourself enough time to prepare and come up with a plan. You might choose a date that has a special meaning like a birthday or anniversary, or simply pick a random date. Circle the date on your calendar. Make a strong, personal commitment to quit on that day.

There is no one right way to quit. Most tobacco users prefer to quit "cold turkey" - that is, abruptly and totally. They use tobacco until their Quit Day and then stop all at once, or they may cut down on tobacco for a week or 2 before their Quit Day. Another way involves cutting down on the number of times tobacco is used each day. With this method, you gradually reduce the amount of nicotine in your body. While it sounds logical to cut down in order to quit gradually, in practice this method is difficult.

Quitting tobacco is a lot like losing weight; it takes a strong commitment over a long period of time. Users may wish there was a magic bullet - a pill or method that would make quitting painless and easy. But that is not the case. Nicotine substitutes can help reduce withdrawal, but they are most effective when used as part of a stop tobacco use plan that addresses both the physical and psychological components of quitting.

Here are some steps to help you prepare for your Quit Day:

Successful quitting is a matter of planning and commitment, not luck. Decide now on your own plan. Some possibilities include using the nicotine patch or gum, joining a tobacco cessation class, going to Nicotine Anonymous meetings, or using self-help materials such as books and pamphlets. Your plan should include one or more of these options.

On your Quit Day, follow these suggestions:

Dealing With Withdrawal

Withdrawal from nicotine has two parts - the physical and the psychological. The physical symptoms, while annoying, are not life threatening. Nicotine replacement can help reduce many of these physical symptoms. But most users find that the bigger challenge is the psychological part of quitting.

If you have been using tobacco for any length of time, it has become linked with many of your activities - watching TV; attending sport events; while fishing, camping, or hunting; or driving your car. It will take time to "un-link" smoking from these activities. That is why, even if you are using the patch or gum, you may still have strong urges to smoke.

One way to overcome these urges or cravings is to recognize rationalizations as they come up. A rationalization is a mistaken belief that seems to make sense at the time but is not based on facts. If you have tried to quit before, you will probably recognize many of these common rationalizations.

You probably can add more to the list. As you go through the first few days without tobacco, write down any rationalizations as they come up and recognize them for what they are: messages that can trap you into going back to using tobacco. Use the ideas below to help you keep your commitment to quitting.

Avoid people and places where you are tempted to smoke. Later on you will be able to handle these with more confidence.

Alter your habits. Switch to juices or water instead of alcohol or coffee. Take a different route to work. Take a brisk walk instead of a coffee break.

Alternatives. Use oral substitutes such as sugarless gum or hard candy, raw vegetables such as carrot sticks, or sunflower seeds.

Activities. Exercise or do hobbies that keep your hands busy, such as needlework or woodworking, that can help distract you from the urge to smoke.

Deep breathing. When you were smoking, you breathed deeply as you inhaled the smoke. When the urge strikes now, breathe deeply and picture your lungs filling with fresh, clean air. Remind yourself of your reasons for quitting and the benefits you'll gain as an ex-smoker.

Delay If you feel that you are about to light up, delay. Tell yourself you must wait at least 10 minutes. Often this simple trick will allow you to move beyond the acute urge to smoke.

What you're doing is not easy, so you deserve a reward. Put the money you would have spent on tobacco in a jar every day and then buy yourself a weekly treat. Buy a magazine, go out to eat, call a friend long-distance. Or save the money for a major purchase. You can also reward yourself in ways that don't cost money: take time out to read, work on a hobby, or take a relaxing bath.

Staying Quit (Maintenance)

Remember the quotation by Mark Twain? Maybe you, too, have quit many times before. So you know that staying quit is the final, and most important, stage of the process. You can use the same methods to stay quit as you did to help you through withdrawal. Think ahead to those times when you may be tempted to smoke, and plan on how you will use alternatives and activities to cope with these situations.

More dangerous, perhaps, are the unexpected strong desires to smoke that occur sometimes months (or even years) after you've quit. To get through these without relapse, try the following:

What if you do smoke? The difference between a slip and a relapse is within your control. You can use the slip as an excuse to go back to smoking, or you can look at what went wrong and renew your commitment to staying off smoking for good.

Some Special Concerns

What to Look for in a Stop-Smoking a Group or Class

Stop smoking programs are designed to help smokers recognize and cope with problems that come up during quitting and to provide support and encouragement in staying quit. Studies have shown that the best programs will include either individual or group counseling. There is a strong association between the intensity of counseling and the success rate. In general, the more intense the program, the greater the likelihood of success.

Intensity may be increased by having more or longer sessions or by increasing the number of weeks over which the sessions are given. So, when considering a program, look for one that has the following:

Be certain that the leader of the group is trained in tobacco cessation.

Some communities have a Nicotine Anonymous group that holds regular meetings. This group applies the principles of Alcoholics Anonymous to the addiction of tobacco use. There is no fee to attend.

Often your local American Cancer Society, American Lung Association, or Health Department office will sponsor tobacco cessation classes. Call 1-800-ACS-2345 for more information.

There are some programs to watch out for as well. Not all programs are ethical. Be very careful of programs that do the following:

Weight Gain

Many smokers do gain some weight when they quit. Even without special attempts at diet and exercise, however, the gain is usually less than 10 pounds. Women tend to gain slightly more weight than men. There is evidence that smokers will gain weight after they quit even if they do not eat more.

For some, a concern about weight gain can lead to a decision not to quit. But the weight gain that follows quitting smoking is generally very small. It is much more dangerous to continue smoking than it is to gain a small amount of weight.

You are more likely to be successful with quitting smoking if you deal with the smoking first, and then later take steps to reduce your weight. While you are quitting, try to focus on ways to help you stay healthy, rather than on your weight. Eat plenty of fruits and vegetables and limit the fat. Be sure to drink plenty of water, and get enough sleep and regular physical activity.

Walking is a great way to be physically active and increase your chances of staying quit. Walking can help you by:

Set a goal of 30 minutes of physical activity 5 or more times a week. If you don抰 already exercise regularly, please check with your doctor before starting an exercise program.

Stress

Smokers often mention stress as one of the reasons for going back to smoking. Stress is a part of all of our lives, smokers and nonsmokers alike. The difference is that smokers have come to use nicotine to help cope with stress. When quitting, you have to learn new ways of handling stress. Nicotine replacement can help to some extent, but for long-term success other strategies are needed.

As mentioned above, physical activity is a good stress-reducer. It can also help with the temporary sense of depression that some smokers experience when they quit. There are also stress-mana, gement classes and self-help books. Check your community newspaper, library, or bookstore.

Spiritual practices such as prayer and meditation have been used very successfully with other addictions and are an integral part of 12-step recovery programs. These same principals can be applied to quitting smoking and can help with stress reduction.

It is hard to stop smoking. But if you are a tobacco user you can quit! More than 46 million Americans have quit smoking for good. Many organizations offer information, counseling, and other services on how to quit as well as information on where to go for help. Other good resources where help can be found include your doctor, dentist, local hospital, or employer.

If you want to quit smoking and need help, contact one of the following organizations.

Where Can I Go for Help?

It is hard to give up tobacco. But if you are a tobacco user you can quit! Many organizations offer information, counseling, and other services on how to quit as well as information on where to go for help. Other good resources where help can be found include your doctor, dentist, local hospital, or employer.

If you want to quit and need help, contact one of the following organizations.

American Cancer Society
1-800-ACS-2345
Internet address: www.cancer.org

American Heart Association
1 800-242-1793 (call center) or 800-242-1793
Internet address: www.amhrt.org

American Lung Association
1 800-586-4872 or 212-315-8700
Internet address: www.lungusa.org

National Cancer Institute
Cancer Information Service
1-800-4-CANCER or 800-422-6237
Internet address: www.cancer.gov

Office on Smoking & Health
Centers for Disease Control and Prevention
770-448-5705
Internet address: www.cdc.gov/tobacco

Nicotine Anonymous
1-877-TRY-NICA (1-877-879-6422)
Internet Address: www.nicotine-anonymous.org

Smokefree.gov
(Online materials, including info on state Quitlines)
Internet Address: www.smokefree.gov