About half to two-thirds of all long-term smokers die prematurely because of their smoking; on average 16 years earlier than if they did not smoke. The main causes of death attributable to cigarette smoking are cancers, diseases of the heart and circulation and lung disease. Giving up smoking can reduce the risk of developing many smoking related illnesses.

These include: Age-related hearing loss, Chronic back and neck pain, Cataracts, Cold injuries (tissue damage caused by exposure to cold environment), Crohn's disease, Diabetes (type 2, non-insulin-dependent), Erectile dysfunction, Gum disease, Macular degeneration (causing blindness), Osteoarthritis, Osteoporosis, Rheumatoid arthritis, Skin wrinkling.

About 4,000 chemical compounds have been identified in cigarette smoke, of which over 40 are known to cause cancer. The three significant components of cigarette smoke are:

• Nicotine: the drug in cigarettes which is addictive (this is what keeps smokers smoking). It does not cause cancer, and has only limited links with conditions affecting veins and arteries.
• Tar: one of the substances produced when tobacco is burned. It is linked to cancers, lung disease and heart disease.
• Carbon monoxide: a gas inhaled by smokers from cigarettes. It is linked to heart disease and has adverse effects in pregnancy.

The Cost of Smoking

Physical:-
Wheezing, shortness of breath, lack of energy, poor concentration, dull skin, nicotine-stained fingers, premature wrinkling, reduced fertility, risky pregnancy, baby at risk, damaged taste buds, stained teeth, lung cancer, emphysema, stroke, heart attack.

Social:-
Children at higher risk of asthma, cot-deaths, bronchitis and glue ear, Smoke gets in your eyes; dusty, stuffy home; nicotine stains your walls as well as your fingers; increased risk of fire in the home.

Financial:-
At today's rates, a 20-a-day smoker will spend approx £1800 a year on cigarettes which could have been spent on, for example, a holiday, a car, home improvements etc.

How to Give Up

There a various methods employed to help give up smoking. These include Acupuncture, Hypnotherapy, Cold Turkey, Help lines (e.g. NHS Smoking Helpline 0800 169 0 169), and Nicotine Replacement Therapy (NRT).

Nicotine replacement therapy;  In the UK all medicines licensed for smoking cessation are available on NHS prescription. NRT is also available over the counter, with some products on general sale. The most effective treatment involves medication and behavioural support.

Rationale for using NRT; For many smokers, it is the withdrawal symptoms that lead to a failed stop attempt. Nicotine replacement therapy acts by providing a 'clean' alternative source of nicotine that the smoker would have otherwise received from tobacco. Nicotine delivered from NRT is not satisfying, as it is absorbed more slowly and generally in a lesser amount. But it is sufficient to reduce the severity of withdrawal symptoms and so can assist in maintaining abstinence.

All NRT products provide a clean source of nicotine. There is no difference in the efficacy of the various NRT products, and little evidence for matching products to individual smokers. Therefore it is generally agreed that choice of product can be guided by patient preference. However, smokers with higher dependency benefit more from a higher-dose product such as 4 mg gum, 4 mg lozenge or nasal spray. It is recommended that all products should be used for 8-12 weeks.

Nicotine Transdermal Patch

The nicotine patch is one of the most commonly used NRT products. Patches are available in 16 and 24-hour preparations, both releasing approximately 1 mg nicotine per hour. Current evidence shows no difference in efficacy between the two, which means the choice of patch, can be guided by patient preference. Patches are also available in lower strengths designed for 'weaning off' although there is no evidence to suggest that this is absolutely necessary.

The advantage of patches is that they are very simple to use and there is generally good adherence to treatment. They are applied to a clean, dry, hairless area of skin and removed at the end of the day (16 hours) or the next day (24 hours). A possible disadvantage of the patch is the slow nicotine delivery. Time taken to reach plateau concentrations varies between two and eight hours depending on the brand. Skin irritation is the most common side effect. The 24-hour patch may cause sleep disturbance.

Oral Products

Nicotine absorption from oral NRT products, including the inhalator, is via the buccal mucosa (lining of the mouth). Peak plasma concentration is reached in 20-30 minutes. Oral products should be used on a regular basis to maintain blood nicotine levels and to have the best effect. Additional use can be helpful at times when urges to smoke are more intense or more frequent. An initial unpleasant taste is common to all these products, and this can be a barrier to correct use. Smokers should be reassured that they will become tolerant of this after a short period (usually a couple of days). Incorrect use of oral products, for example chewing gum too vigorously, usually results in more nicotine being swallowed. This is not hazardous, but means that less nicotine is absorbed, and may cause local irritation and hiccups.

Nicotine Chewing Gum

Nicotine gum comes in two strengths, 2 and 4 mg; more highly dependent smokers should use the latter. The bio-availability is not 100%: the 2 mg gum typically yields only about 0.9 mg of nicotine, whereas the 4 mg gum yields about 1.2 mg. Users should aim to use between 10 and 15 pieces of gum a day. Instructing smokers to use a piece an hour is a convenient way to encourage the correct dosage. There is a specific technique for using the gum. Each piece should be chewed slowly to release the nicotine, and a hot peppery taste will be experienced. The gum should then be 'parked' between the cheek and gums so that the nicotine can be absorbed. After a few minutes the gum can be chewed again, then parked and repeated, for 20/30 minutes.

Nicotine Sublingual Tablets

These small 2 mg tablets are made to dissolve under the tongue, although the nicotine is absorbed through any part of the oral mucosa. Hourly use should be recommended to achieve the best effect, but the tablets can be used more frequently if desired. After 30 minutes the residual tablet can be removed.

Nicotine Inhalator

The inhalator consists of a small plastic tube containing a replaceable nicotine cartridge. This method may provide more behavioural replacement than the other products (some people miss the hand-to-mouth action of smoking when they quit), but there is no strong evidence for this. Despite its name, nicotine from this device is not inhaled into the lungs, but is deposited on the oral mucosa through which it is absorbed. To achieve sufficient blood nicotine levels the user should puff on the inhalator for 20 minutes each hour. After three 20-minute puffing sessions, the cartridge should be changed. The average smoker should aim to use six cartridges a day. In cold weather it is advisable to keep the inhalator warm so that the nicotine vapour can be released from the cartridge.

Nicotine Lozenge

The lozenge is available in three different strengths: 1 or 2 mg for smokers with lower dependency and 4 mg for those with higher dependency. The lozenge should be dissolved in the mouth and moved around intermittently. It can be removed after 30 minutes use. To achieve the greatest benefit, lozenges should be used regularly, approximately one lozenge per hour.

Nicotine Nasal Spray

Some people dislike using this method because of its initial adverse effects, including sneezing and a burning sensation in the nose. Smokers need to be warned about these unpleasant effects, but should also be reassured that the nasal spray does not cause any damage to their nose, and that they will become used to it after a day or two of use. The recommended dose is one squirt (0.5 mg) to each nostril each hour, with additional doses as required.

Staying Stopped & Benefits

Staying a non-smoker can be difficult and factors such as complacency, boredom, other smokers, going to the pub (for a social smoker), can all contribute to a non-smoker lapsing and starting to smoke again. There are health, lifestyle and financial benefits.

Beneficial health changes on stopping smoking

• After 20 minutes -Blood pressure and pulse rate return to normal.
• After 8 hours- Nicotine and carbon monoxide levels in blood reduce by half, oxygen levels return to normal.
• After 24 hours - There is no nicotine left in the body. Lungs start to clear out mucus and other smoking debris.
• After 48 hours - Carbon monoxide is eliminated from the body. Ability to taste and smell is greatly improved.
• After 72 hours - Breathing becomes easier. Bronchial tubes begin to relax and energy levels increase.
• After 2-12 weeks - Circulation improves.
• After 3-9 months - Coughs, wheezing and breathing problems improve as lung function is increased by up to 10%.
• After 1 year - Risk of a heart attack falls to about half that of a smoker.
• After 10 years - Risk of lung cancer falls to half that of a smoker.
• After 15 years - Risk of heart attack falls to the same as someone who has never smoked.

Stopping smoking is the most important change you can make to improve your health. Anybody can stop if they want to. You are less likely to get cancer of the throat, lungs, bowels and skin if you give up. You are less likely to have a heart attack or stroke, or get bronchitis or emphysema. Your children and those close to you will also benefit from not breathing in your smoke. You will get your sense of smell and taste back and you will be able to do more exercise without losing your breath.

Our Advice

• Try to give up and try again if you did not succeed the previous time.
• Ask family and friends to help you. You will need their support. Explain to them why you are trying to give up.
• Try to give up with someone else close to you.
• You will need willpower and determination. It will not be easy.
• You will get cravings for the nicotine when you stop. Ask your pharmacist which products are available to help you stop.
• You may want to eat more when you are stopping smoking. Make sure you eat healthy snacks to avoid putting on weight.
• If you want to know the best way to stop smoking ask your pharmacist for advice.

Products we recommend for this condition are:

• Nicorette Quick Mist Twin 13.2ml
• Nicorette Inhalator 20s
• Nicorette Gum - Icy White 2mg 105
• Nicorette Cools Loz Mint 2mg 80s
• Niquitin CQ Patches - Clear 21mg 7s

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