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Treatment of Smoking

Introduction:

Tobacco use continues to be the leading cause of preventable disease and death in the world. According to the World Health Organization (WHO) is a risk factor of six of the eight leading causes of mortality highlighting cardiovascular diseases as the most significant. It has been seen that smokers die on average 10 years earlier than nonsmokers and that the cessation of tobacco use at 60, 50, 40 or 30 years increases life expectancy in 3, 6, 9 or 10 years respectively 2 .

In Chile, it is estimated as a causal factor of 15,000 deaths per year, which constitute 17% of all deaths 3 . These figures are conditioned because in the country there is a high prevalence of consumption, both in adults and in young people, 4,5 having the sad record of being the country of the Americas with the highest consumption among young people 6 .



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Given the seriousness of the problem, the WHO prompted an international treaty on public health to control this epidemic in the world, culminating with the approval, in 2003, of the Framework Convention on Tobacco Control. In Chile, this treaty was approved in March 2005.

Under these guidelines, WHO, in 2008, launched the initiative MPOWER 7 , which summarizes the strategies that should be implemented for tobacco control at the international level. The six points this strategy consist of:

• Monitoring: Monitor tobacco consumption and preventive measures

• Protecting: Protecting the population from exposure to tobacco smoke

• Offering: Offer help for the abandonment of tobacco use

• Warning: Warn of the dangers of tobacco

• Enforcing: Enforcing the prohibitions on advertising, promotion and sponsorship

• Raising: Increasing tobacco taxes

In this context, smoking cessation aids appear as one of the pillars for the control of smoking, where the professionals of the health team have a great responsibility.

In this article we present the bases of tobacco addiction mechanisms, a general approach to their treatment and the psychosocial and pharmacological therapies available today.

Smoking, chronic addictive disease.

Since 1988, the year in which the Report of the US Surgeon General, entitled "Addiction to Nicotine," 8 was published , there is solid evidence of the addictive condition of tobacco use. The main conclusions of this report were that tobacco is addictive, that nicotine is the drug that causes addiction and that the psychopharmacological process involved in this addiction is similar to that of other drugs, such as heroin or cocaine.

At present, the addictive capacity of tobacco is beyond doubt and it is considered that smoking is a chronic systemic disease that belongs to the group of addictions, classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) of the American Psychiatric Association 9 . According to this classification, nicotine dependence is diagnosed by the presence of 3 or more of the seven proposed criteria ( Table 1 ), during a continuous period of 12 months. In turn, the criteria for the diagnosis of nicotine withdrawal are specified ( Table 2 ). The WHO International Classification of Diseases (ICD-10) also includes smoking within the "Mental and behavioral disorders due to tobacco use", in section F17, whose criteria are very similar to those of IVD IV: Once 7 criteria are condensed into 5 and a sixth is added in relation to the intense desire to consume the substance 10 .

The origin of the addiction is multifactorial, involving biological, genetic, psychological and social factors. The clinical manifestations depend on the individual personality characteristics of each individual, as well as the socio-cultural circumstances that surround them. The main symptom is the imperative or compulsive need to return to consume tobacco to experience the reward it produces and also avoid the withdrawal syndrome.

Although tobacco contains thousands of substances, it is nicotine that is most frequently associated with dependence. Nicotine is a psychoactive drug that generates dependence, with specific physical alterations and behaviors, producing in the smoker the search and compulsive use of the drug, despite the negative consequences for health.

Structurally, nicotine is a tertiary amine. Its absorption is mainly at the alveolar level, this being very fast, due to the large contact surface of the alveoli and the dissolution of nicotine in fluids with physiological pH. Minorly it is absorbed in the buccal mucosa, where it is dependent on pH, since the cigarette smoke is acidic (pH 5.5) and therefore nicotine is ionized, hindering its absorption.

After inhaling the smoke, nicotine reaches the brain in just 9 seconds. Then, their brain levels decline rapidly as it is distributed in other tissues (autonomic ganglia, adrenal medulla and neuromuscular junctions) and is metabolized in the liver by enzymes of the CYP2A6 family. Finally, its metabolites are excreted through the kidney, with an average life of 2 hrs. approximately 11 .

Nicotine acts through its binding to nicotinic acetylcholine receptors, whose structure corresponds to ion channels composed of 5 subunits. There are about 17 different subunits and the combination of these gives different properties to each receiver. It has been shown that, in nicotine addiction, α4β2 receptors play a determining role due to their high affinity and sensitivity to nicotine. They are formed by two subunits α4 and three β2 and are located mainly in the ventral tegmental area (within the reward circuit of the brain). The α4 subunit would be more important in the production of the pleasure sensation when smoking and the β2 subunit in the self-administration behavior associated with nicotine 12 .

Nicotine produces a series of alterations in the CNS that would explain its addictive power, in which the most relevant is the increase in dopamine release in the nucleus accumbens, producing a sensation of pleasure and good , which determines physical dependence. Although the dopaminergic system is the most studied for its importance in the reward, it is necessary to mention that nicotine also acts in other brain systems that help mediate its addictive effects (cholinergic, gabaergic, glutamaergic, serotoninergic, noradre -nérgico, opiate and endocannabinoid). The advances that are achieved in the subject, will be very useful in the future for the progress of the pharmacotherapy of this addiction.

Treatment of smoking.

At present, there is a consensus that smoking cessation interventions must have two components: psycho-social and pharmacological. Both should be included in the support of anyone requesting help to quit smoking.

Psycho-social strategies, which mostly have a cognitive-behavioral approach, are aimed at the smoker recognizing his addiction, his personal characteristics, modifying behavior patterns, developing strategies and skills to achieve and maintain abstinence, which usually means changing routines and lifestyles, that is to learn to "live without tobacco".

Clinical confrontation of smoking

Anyone who consults a health facility, public or private, should be asked whether or not they consume tobacco, according to the algorithm shown in Figure 1 . When the person is willing to try to stop smoking, the recommended general strategy is that of the 5 A, which can be adapted from the brief to the specialized intervention, depending on the time spent on the intervention and the therapist's training. When the smoker does not want to stop smoking at that time, the strategy of the 5 Rs is used. In the following paragraphs the two mentioned strategies are developed.

Figure 1: Algorithm to treat tobacco consumption. Modified from ref. 13

Brief counseling: 5 A methodology

In practice, most of the interventions are based on a methodology called 5 A 13 , by the initial of the 5 stages that constitute it: Find out, Advise, Agree, Help and Accompany. It basically consists in stimulating and promoting the intention to stop smoking and to help those already motivated in the cessation of smoking. The brief counseling should be carried out in the consultation of any health professional, regardless of the reason for consultation. A trained professional should not take more than two to three minutes in his application.

Find out: all patients should be asked about tobacco consumption, taking advantage of all instances through which they attend health facilities. He is asked about the number of cigarettes he smokes daily and the time of the first cigarette after getting up.

Advise: after asking, the patient should be advised to stop smoking. The advice should be clear and firm, personalizing the convincing arguments: in adolescents, the effect of smoking on their ability to exercise and poor school performance should be emphasized; the pregnant woman is concerned about her child and the risks of childbirth; the adult is more afraid of the diseases that could develop from tobacco and the possible damage that it can cause to his children and those around him.

Agree on the type of intervention: there are different types of interventions, depending on their availability to change. a) If the patient does not want to stop smoking now: explain the harmful effects of tobacco use and offer support for the future. b) If the patient is insecure: discuss their fears or fears and encourage motivation explaining the advantages of not smoking. Invite him to quit when he is ready. c) If the patient is determined: offer help and plan a strategy to stop smoking.

Help: if the patient is willing to try to stop smoking, he should be helped to develop a plan of action and eventual pharmacological support. A date to quit smoking is selected with the patient, within the next 2 to 4 weeks, which is called "Day D". It is not advisable to do it in periods of high stress, and on the other hand, it is necessary to consider that there is no ideal time to stop smoking, but before it is better than after. To consolidate the commitment, it is suggested that a contract-commitment be signed specifying the agreed date and where the therapist also commits to provide all patient support.

Accompany: patient follow-up should be scheduled. It is recommended to establish a follow-up visit one to two weeks after 'D-Day.' A second follow-up visit should be scheduled one month after the first, as a further control.

Strategy to use when patients do not want to stop smoking: 5 R

There are patients who are not willing to make an attempt to stop smoking at that time. In front of these smokers the strategy of the "5 R" 14 must be developed, named for the initial of the 5 points to be considered: Relevance, Risks, Rewards, Resistances and Repetition.

Relevance: Discuss with the patient the importance of quitting smoking for him, for his children and family.

Risks: Help the patient identify the risks of smoking. Emphasize that smoking low nicotine cigarettes or using other forms of tobacco will not eliminate these risks. Examples: worsening of their illnesses, sexual impotence, spouse with higher risk of lung cancer and coronary heart disease, etc.

Rewards: Encourage the patient to recognize the benefits of quitting. Examples: improvement of your health, saving money, better personal and household smell, healthier children, etc.

Resistances: Try that the patient identifies the barriers to stop smoking and offer help to deal with them. Examples: withdrawal symptoms, weight gain, etc.

Repetition: This strategy should be repeated every time you consult a non-motivated smoker.

If this is done systematically, many smokers are motivated and made concrete attempts to stop smoking.

Next we will refer to the pharmacological treatment, subject in which there have been important advances in the last years.

Pharmacotherapy of smoking

Up to now, the US Food and Drug Administration (FDA) has approved the use of 3 types of drugs in smoking cessation treatment: Nicotine Replacement Therapy (NRT), Bupropion and Varenicline. There are two other medications, although they are not approved by the FDA, they are used as second-line drugs, such as Clonidine and Nortriptyline.

I. Nicotine Replacement Therapy.

The drugs most studied and used for the management of tobacco dependence are those that contain nicotine. Several clinical studies have shown that they are safe and effective, increasing twice the success rate of behavioral therapy.

Its main mechanisms of action: reduction of withdrawal symptoms, reduction of reinforcing effects and the production of certain effects previously sought in cigarettes (relaxation, facilitation of the confrontation of stressful situations, etc.) 15 . The use of NRT should start on the day when smoking is stopped.

Some adverse effects are common to all NRT products, with the most frequent being dizziness, nausea and headache. The contraindications are serious cardiovascular diseases, severe cardiac arrhythmias, uncontrolled hypertension and recent AVE.

There are different nicotine replacement formulations, which can be used alone or in combination with other medications.

1. Nicotine gum

It corresponds to the most studied and widely used NRT method since the 80s 14 . Currently in the USA it is available in various flavors (mint, orange and fruit) and in formulations of 2 and 4 mg, this last recommended dose for smokers of more than 25 cigarettes / day. In Chile there is only the presentation with mint flavor of 2 mg.

There are two ways to indicate chewing gum: by schedule, in which the recommended initial dose is one chewing gum every 1 to 2 hours for 6 weeks, then one unit every 2 to 4 hours for three weeks, and then 1 chewing gum every 4 to 8 hours for three weeks. Another alternative use is ad-libitum, that is, how many gums are needed according to the urgency of smoking and especially in stimulating situations for smoking.

2. Nicotine patches

Nicotine patches deliver a stable dose of nicotine for 16 to 24 hours. They are placed once a day, which facilitates adherence to treatment. They are available in doses of 7, 14 and 21 mg. It is recommended that those patients who smoke more than 10 cigarettes a day start with the dose of 21 mg / 24 hours, this dose being titratable according to clinical response or serial measurements of cotinine (performed while the patient is still smoking). It has been recommended to use them for 10 to 12 weeks, decreasing the doses in the last 4, although sometimes longer periods of treatment are needed.

3. Nicotine nasal spray

The nasal spray releases nicotine directly into the nasal mucosa. Within the NRT, it is the method that most rapidly reduces withdrawal symptoms. A puff is used in each nostril, releasing a total of 1 mg of nicotine.

4. Nicotine inhaler

It is a product designed to meet the needs of the hand-mouth ritual. It consists of a device that contains a nicotine cartridge and a vaporizer system that is used in the mouth.

These last two forms of NRT, in addition to losenge (compressed to be dissolved in the mouth), are not available in Chile

5. New forms and uses of Nicotine Replacement Therapy 17

5.1 Quick release chewing gum

Quick release method of nicotine, via oral mucosa, of recent appearance. It differs from conventional chewing gum in achieving faster and more complete relief of withdrawal symptoms during the first 3 minutes of use. More efficacy studies are required for its use in bulk.

5.2 Combined forms of TRN

There are basically 2 forms of nicotine administration: passive and active. The passive form corresponds to the sustained release of nicotine during the day, without presenting a marked plasma peak, as they act, for example the nicotine patches. The rest of the TRN medications are called active forms, as they depend on the person's "active" decision to use them. They have short half-lives and produce a nicotine plasma peak that simulates the effect of the cigarette, but of less intensity.

The combination of a passive delivery drug, plus another active delivery product that allows self-administration in times of urgency due to smoking, has allowed to enhance the effect of each one separately. The most used combination of products is the most chewing gum patch administered ad-libitum.

5.3 Consumption reduction

One strategy for currently unmotivated smokers or those who feel incapable of complete cessation is the use of NRT as part of a "consumption reduction" strategy. This consists of encouraging the smoker to reduce consumption by half, using active delivery methods. If the consumption has not decreased after 3 months, the NRT is suspended. If this has decreased, it is continued for up to 1 year, with the goal of 6 months to abstain completely.

5.4 Electronic cigarette:

Until now, its usefulness as a pharmacological aid to stop smoking has not been demonstrated. It has been found that some brands contain, in addition to nicotine in various amounts, carcinogenic and toxic substances, which makes their use inadvisable, since it would not be effective or safe 18 .

II. Bupropion

Bupropion was the first non-nicotinic drug approved for the treatment of smoking. It is a monocyclic antidepressant that acts by inhibiting the reuptake of nora-drenaline (NA) and dopamine (DA) in certain areas of the brain. It is not yet known exactly how it acts for the cessation of smoking, but it is believed that it is partly due to its effect on the levels of DA and NA. Therapeutic efficacy:

The effectiveness of bupropion to stop smoking is clearly demonstrated. A meta-analysis, which included 12 randomized clinical trials, showed an odds ratio of 1.56 (95% CI 1.1-2.21) at 12 months compared to placebo 19 . It has also been shown that bupro-pion reduces the weight gain that occurs when smoking stops and that it alleviates withdrawal symptoms, such as moodiness, anxiety, difficulty concentrating, sadness and desire to smoke 20 . Despite the fact that bupropion is effective for the treatment of smoking in smokers with or without depression, it is believed that patients with depression or anxiety disorders could benefit more from bu-propion than with another medication. 21

Side effects:

The recommended dose of 300 mg / day is generally well tolerated. Approximately 10% of patients should suppress it due to side effects. The most frequent effects are insomnia (frequency of 30-45% of those who use 300 mg / day), dry mouth (5-15%) and nausea. Other more serious side effects that can be observed are seizures and hypersensitivity reactions, each with an incidence of 0.1%.

Recommendations for use:

Bupropion is recommended as a first-line drug in the treatment of smoking 20 . The maximum recommended dose is 150 mg twice a day, starting one or two weeks before the date set to quit smoking. The first 5-7 days a dose of 150 mg is administered in the morning and then the second dose of 150 mg is added at 8 hours of the first (to prevent insomnia). The recommended duration of treatment is 7-9 weeks. If side effects appear, the dose can be lowered to 150 mg / day.

It should be used with caution in patients at increased risk of seizures: alcohol or cocaine abuse, or use of other drugs such as antipsychotics, antidepressants, theophylline, tramadol, quinolones, systemic corticosteroids or sedative anti-histamines. In elderly patients and / or with liver or kidney failure or diabetes, caution should also be exercised, using lower doses than usual (150 mg / day). It has been seen that due to the concomitant use of bupropion and nicotine patches there is an increase in the incidence of hypertension, so care must be taken with this association in patients who tend to increase their pressure.

Its use is contraindicated in patients with a history of seizures, CNS tumors, bulimia, anorexia or bipolar disorder (in the latter a manic episode may be precipitated). It is also contraindicated to use it together with MAO inhibitors, since the acute toxicity of bupropion is potentiated with these drugs, producing agitation, psychotic changes and seizures 21 . It is not recommended to administer it during pregnancy or lactation, as it can cross the placental barrier and can be excreted in breast milk.

III. Varenicline

Varenicline is a partial agonist of the nico-tínicos acetylcholine α4β2 receptors, recently approved by the FDA for the treatment of smoking. It has been available in Chile since 2007 and has become an attractive alternative, not only for its novel mechanism of action, but also for its high efficacy and good tolerance reported in several studies.

Pharmacological properties:

Nicotine dependence is due in part to its agonist activity at nicotinic α4β2 receptors. When stimulated, dopamine release occurs in the nucleus accumbens, a neurotransmitter that produces the pleasant effects sought by the smoker. When he stops smoking, the absence of nicotine decreases dopamine levels, producing an urge to smoke ("craving"), an important contributor to relapse.

Several studies suggest that by stimulating these receptors with a partial agonist such as varenicline, dopamine levels would increase, alleviating the symptoms of deprivation. In addition, competitive binding to α4β2 receptors would at least partially block the dopaminergic activation caused by nicotine in case of relapse. This double mechanism would be responsible for the efficacy of varenicline as a treatment for smoking 22

It has also been observed that this new drug, not being metabolized in cytochrome P450, does not alter the pharmacokinetics of several drugs (NRT, bupropion, warfarin, digoxin, cimetidine, and metformin), making it a very safe medicine.

Therapeutic efficacy

The efficacy of 12-week therapy with varenicline 1 mg 2 times a day for the treatment of smoking was compared with bupropion 150 mg twice daily and placebo in 2 randomized, multicenter, phase III studies 24,25 . In both studies, at 12 weeks those participants in the varenicline group achieved significantly higher rates of abstinence than in the other groups. The results were similar in both studies with an OR of 1.9 for varenicline versus bupropion (p <0.001) and an OR of 3.9 for varenicline versus placebo (p <0.001).

In the long term (week 52), the abstinence rate was significantly higher with varenicline than with bupropion in one of the studies (OR 1.8, 95% CI 1.2-2.6, p = 0.004), but not in the other (OR 1.5; 95% CI 1.0-2.2, p = 0.05). In both studies varenicline was superior to placebo (OR 3.1 and OR 2.7, both with p <0.001).

Side effects:

The most frequent side effect is nausea, reaching 34.9% 39 ; however, in most cases, they are mild to moderate and decrease over time. The discontinuation of varenicline due to adverse effects is 10.5%, compared with 12.6% and 7.3% in the bupropion and placebo groups, respectively. 25

In addition, an increase in weight of 2.89 kg has been observed on average, versus 1.8 and 3.1 kg in the bupropion and placebo groups, respectively 23 . These results suggest that weight gain is a consequence of quitting smoking, rather than related to varenicline per se.

Psychiatric effects

In the post-marketing period of the use of varenicline, some reports emerged about the possible association between its use and the risk of suicide, which led the US and the British drug regulatory agencies (MHRA) to determine in the year 2009, the obligation to include a warning about the possible risk in the package insert of the medicine. However, the causal relationship has not been established, since it is necessary to separate the possible effects of varenicline from those related to cessation of smoking. In a recent publication 26 no neuropsychiatric effects were found that were superior to placebo, except for sleep disturbances. In another large study in England 27 of a retrospective cohort of more than 80,000 smokers, there was no clear evidence that the use of varenicline increased the risk of depression, suicide or suicidal thoughts, compared to the use of bupropion or nicotine replacement therapy. .

Cardiovascular effects

Very recently, in June 2011, a meta-analysis 28 was published on the risks of cardiovascular adverse effects, where it is concluded that the use of varenicline was associated with a significant increase in cardiovascular adverse effects (ischemia, arrhythmias, congestive heart failure, sudden death). ) compared with placebo: 1.06% vs. 0.82%. The FDA issued a communiqué29 in which it warns that there is a small increase in cardiovascular risks with varenicline, and that the absolute risk of adverse CV events in relation to its efficacy is small. It makes a call for caution with the use of varenicline, and requested the pharmaceutical company to place this warning on the written information that accompanies the product, which has already been done 30 .

Recommendations for use.

The recommended dose is 1 mg twice a day, after meals. The treatment should start one week before the scheduled date to quit smoking. Varenicline should be titrated for a week, using progressively higher doses until the target dose is achieved.

By way of summary, Table 3 presents the drugs approved by the FDA.

FDA: US Food and Drug Administration TRN: Nicotine Replacement Therapy. Modified from ref. 22

IV. Other drugs for the treatment of smoking

Clonidine

It is a noradrenergic α2 agonist. In a meta-analysis of 6 randomized clinical trials comparing clonidine and placebo, higher cessation rates were observed in the first group. Only one of the studies showed statistically significant values, whose OR is comparable with any NRT (OR 1.89, 95% CI: 1.3-2.7) 31 . The most observed adverse effects are dry mouth (25 ^ 40%), sedation (12-35%), hypotension (15%) and constipation (10%).

In general, clonidine is not as effective as NRT in the treatment of smoking and its high rate of adverse effects limits its use.

Nortriptyline

Tricyclic antidepressant that blocks the recapture of noradrenaline and serotonin, thus improving withdrawal symptoms and post-cessation depressive symptoms. Different studies have shown that it is 2 times more effective than placebo. However, a comparative study of nortriptyline and bupropion showed significant superiority of bupropion (42 versus 31% abstinence at 6 months) 32 . The most frequent side effects are dry mouth and constipation, which occur in a high number of patients.

Antinicotine vaccine

The idea behind the concept of antinicotine vaccine is to prevent nicotine from reaching the brain, through the production of antinicotine antibodies. By reducing the arrival of nicotine in the brain, the reward effect is blocked. Studies in animals have shown a 65% reduction in nicotine reaching the nicotinic receptors in the brain and a significant decrease in the amount of dopamine produced by nicotine stimulation. 33

There are several pharmaceutical companies that are developing vaccines, with different types of haptens that bind to nicotine to produce the immunogenic effect. It has been seen that there is a relationship between the antibody titer and the efficacy of the vaccine. The results of studies in phase 1 and 2 suggest that these vaccines are safe, well tolerated and immunogenic, and there are still no publications of phase 3 studies.

While these results are encouraging, especially in their use to prevent relapse, the current evidence is limited and conclusions about its effectiveness are still premature.

Acupuncture and Hypnosis.

They have not proven to be better than placebo, according to recent Cochrane reviews 35, 36 י, so their use is not recommended.

A long-term promising line of work is drug pharmacogenetic studies, which would allow predicting the effect of drugs in certain subgroups of smokers characterized according to specific genetic studies. Thus, medications that do not seem to be useful in the group of patients, could be beneficial in a subgroup of these 37 .

Final comments

At present, the greater understanding of the psychopathology of tobacco addiction and the motivations for behavioral change has allowed us to improve the psycho-social support that can be provided. These advances, together with better knowledge of the psychopharmacological mechanisms of nicotine and the development of new, more effective drugs, should encourage health team professionals and especially physicians to assume a more active role in offering support and treatment to Any smoker who shows intention to stop smoking. We have identified barriers 38 that in the past made this role difficult: fear of damaging the doctor-patient relationship, lack of knowledge on how to help patients and belief that it will be ineffective. But the evidence today is different and much can be done to help smokers. Any contact of the smoker with the health care system should be used to encourage and promote the cessation of tobacco use. It is also imperative to involve all health professionals so that in each consultation they make the brief intervention. If the patient can not quit smoking, they should be referred for a specialized intervention. On the other hand, the training for confronting smoking should be part of the undergraduate curriculum of all health careers, with greater extension and depth than is currently done. There should also be a more explicit and permanent concern of medical societies to train their members on this issue, especially those most related to the damages of tobacco consumption, contributing in a significant way to reduce the alarming rates of morbidity and mortality produced by the disease. smoking in the country and in the world.

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Are there effective treatments for tobacco addiction?

Yes, there is extensive research that has shown that treatments for tobacco addiction do work. Although some people can break the habit by themselves, many people need help to stop smoking. This is particularly important because quitting smoking can have immediate health benefits. For example, within 24 hours of quitting, blood pressure and the likelihood of a heart attack decrease. The long-term benefits of stopping smoking include lower risk of a stroke, lung cancer and other types of cancer and coronary heart disease. A 35-year-old man who quits smoking increases his life expectancy by an average of 5 years.



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Nicotine replacement treatments

Nicotine replacement therapies (NRTs), such as nicotine gum or chewing gum and the nicotine transdermal patch, were the first drug treatments approved by the Food and Drug Administration (FDA). by its acronym in English) of the United States to be used in treatments to stop smoking. These nicotine replacement therapies (in conjunction with behavioral support) are used to relieve the symptoms of withdrawal syndrome, because they produce less severe physiological alterations than tobacco-based systems and generally provide the user with lower nicotine levels than those of tobacco. An additional benefit is that these forms of nicotine have little potential to be abused as they do not produce the pleasurable effects of tobacco products. They also do not contain the carcinogens and gases associated with tobacco smoke. It has been shown that behavioral treatments are an essential complement to nicotine replacement therapies, improving their efficacy and long-term results.

The transdermal nicotine patch

The approval by the FDA of nicotine gum in 1984 marked the availability (by prescription) of the first nicotine replacement therapy in the United States market. In 1996, the FDA approved Nicorette® chewing gum for sale without a prescription. While nicotine gum gives some smokers the control that to alleviate the craving for tobacco, others can not tolerate the taste or the fact that they have to be chewing it. In 1991 and 1992, the FDA approved four transdermal nicotine patches, two of which have been sold over the counter since 1996. The nicotine nasal spray was released in 1996 and the nicotine inhaler in 1998, both requiring a prescription. These products met the needs of many other tobacco consumers. All nicotine replacement products, both chewing gum, patch, spray and inhaler, appear to be equally effective.

Additional medications

A bottle of pills

Although the main focus of pharmacological treatments for tobacco addiction has been the replacement of nicotine, other treatments are also being studied. For example, bupropion, an antidepressant sold on the market as Zyban®, was approved by the FDA in 1997 to help break the habit of smoking. Varenicline tartrate (Chantix®) is a new drug recently approved by the FDA as a treatment to stop smoking. This medication acts on the sites of the brain affected by nicotine and can help people to break the smoking habit by relieving the symptoms of withdrawal syndrome and blocking the effects of nicotine if people try to smoke.

Other medications that do not contain nicotine are being investigated for use in the treatment for tobacco addiction. These include, among others, some antidepressants and a medication for high blood pressure. Scientists are also studying the potential of a vaccine that would act on nicotine to prevent relapse. This nicotine vaccine is designed to stimulate the production of antibodies that would block nicotine access to the brain, preventing its reinforcing effects.

Behavioral treatments

Behavioral interventions can play an integral role in tobacco treatment, either in conjunction with medications or on their own. They use a variety of methods to help smokers break the habit, ranging from self-help materials to individual cognitive-behavioral therapy. These interventions teach people to recognize high-risk situations that encourage smoking, to develop alternative strategies to avoid smoking, to manage stress, to improve their ability to solve problems as well as to increase social support. Research has shown that the more therapy adjusts to each person's case, the greater the likelihood of success.

A man sitting on the couch

Traditionally, behavioral approaches were developed and carried out in formal settings such as smoking cessation clinics and numerous community and public health settings. However, in the last decade researchers have been adapting these approaches to telephone, mail and Internet formats, which may be more acceptable and accessible to smokers who want to break the habit. In 2004, the United States Department of Health and Human Services (HHS) established a toll-free national telephone hotline, 1-800-784-8669 (1-800-QUITNOW), to serve as a only access point for smokers seeking information and help to stop smoking. The calls of the people who dial this number are transferred to the telephone help lines to stop smoking that correspond to the state where they reside. In the case of those people who live in states where these helplines have not been established, they are transferred to the telephone line maintained by the National Cancer Institute (NCI). In addition, HHS has a new website ( www.smokefree.gov ) that offers advice and information that can be downloaded on how to facilitate the process of breaking the smoking habit.

Breaking the habit of smoking can be difficult. While the intervention may be useful at the time participants receive it, most intervention programs are short term (1 to 3 months). Within a period of 6 months, 75 to 80 percent of people trying to quit suffer a relapse. Research has shown that extending treatment beyond the typical period of a smoking cessation program can achieve success rates of up to 50 percent a year after quitting.

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How to overcome withdrawal symptoms and inciting when deciding to stop smoking

What are some of the withdrawal symptoms associated with quitting smoking?

It is possible that quitting smoking causes problems in the short term, especially in those who have smoked a lot for several years. These temporary changes can result in withdrawal symptoms.



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The most common withdrawal symptoms associated with quitting are:

•     Nicotine cravings (nicotine is the substance in tobacco that causes addiction)
•     Anger, frustration and irritability
•     Anxiety
•     Depression
•     Weight gain

According to studies, about half of smokers have reported feeling at least four withdrawal symptoms (such as anger, anxiety or depression) when quitting ( 1 ). There are people who reported feeling other symptoms, such as dizziness, an increase in the number of dreams they have and a headache ( 2 ).

The good news is that there are many things you can do to reduce cravings and overcome common withdrawal symptoms. Even without medications, these symptoms and other problems diminish over time. It may help to know that these symptoms are more intense during the first week of abstinence. From that point, the intensity usually decreases as the first month passes. However, everyone is different and there are those who show withdrawal symptoms for several months after quitting ( 3 , 4 ).

What are the inciters of smoking tobacco?

Apart from the cravings for nicotine , perhaps the memories of situations in your daily life when you used tobacco encourage you to go back to smoking. The inciting ones are the states of mind, feelings, places or tasks of your daily life that produce in you a desire to smoke.

These inciters are:

•     Being in the company of smokers
•     Start the day
•     Feel tension
•     Being inside a car
•     Drink coffee or tea
•     Enjoy a meal
•     Drink alcoholic beverages
•     Feeling bored

Knowing what prompts you will help you maintain control, as you can choose to avoid it or keep your mind distracted and busy if you can not avoid it.

What can I do about cravings for nicotine?

By constantly smoking, you get used to having some degree of nicotine in your body. You control that degree by the amount you smoke, by the depth with which you inhale tobacco smoke and by the type of tobacco you consume. Quitting smoking results in intense cravings when your body wants more nicotine. It takes time to overcome nicotine addiction. Also, when you see other people who smoke or when you are in the presence of incitement, you may feel cravings for nicotine in your body. These cravings are real and not the product of your imagination. At the same time, your mood may change, and your heart rate and blood pressure may go up.

The urge to smoke tobacco comes and goes. Usually, cravings only last a while. They often begin an hour or two after smoking the last cigarette, become intense for several days and may last several weeks. As the days go by, the cravings will occur more distanced. You may feel occasional mild cravings for six months.

Here are suggestions for overcoming nicotine cravings:

•     Remind yourself that the cravings will pass.
•     Avoid situations and activities that used to be associated with smoking tobacco.
•     As a substitute for smoking, try to chew carrots, pickles, apples, celery, sugar-free gum, or hard candy. It is possible that by keeping your mouth busy neutralize the psychological need to smoke.
•     Try this exercise: Inhale deeply through your nose and exhale slowly through your mouth. Repeat 10 times.
•     Ask your doctor about nicotine replacement products or other medications.

Visit Smokefree.gov on the Internet, a website created by the NCI's Tobacco Control and Research Unit, and see the complete guide to quitting smoking: Stop smoking today! Let's do it!

How can I overcome anger, frustration and irritability?

After quitting, you may feel tense and temperamental, and perhaps give up faster than usual when doing chores. Also, you may be less tolerant of others and may argue more.

According to studies, the most common negative emotions associated with quitting smoking are anger, frustration and irritability. These negative emotions are more intense during the first week of abstinence and may last from two to four weeks ( 2 ).

Here are suggestions for overcoming negative emotions:

•     Recall that these emotions are transient.
•     Participate in a physical activity, such as walking.
•     Reduce caffeine intake by limiting or avoiding coffee, soda and tea.
•     Try meditation or other relaxation techniques, such as massage, soak in a hot tub or inhale deeply through the nose and exhale through the mouth ten times.
•     Ask your doctor about nicotine replacement products or other medications.

How can I overcome anxiety?

Within 24 hours of quitting, you may feel tense and agitated. You may feel tension in your muscles, especially around the neck and shoulders. Studies have indicated that anxiety is one of the most common negative states associated with quitting. If you feel anxiety, it increases in the first three days after quitting and can last two weeks ( 2 ).

Here are suggestions for overcoming anxiety:

•     Remind yourself that anxiety will happen over time.
•     Book quiet time every morning and night, a time of the day where you can be alone and in a quiet environment.
•     Do physical activities, such as walking a little.
•     Reduce caffeine intake by limiting or avoiding coffee, soda and tea.
•     Try meditation or other relaxation techniques, such as massage, soak in a hot tub or inhale deeply through the nose and exhale through the mouth 10 times.
•     Ask your doctor about nicotine replacement products and other medications.

How can I overcome depression?

It is normal to feel sad for a while after quitting the habit for the first time. If you experience mild depression, it will start on the first day, continue the first weeks and disappear in less than a month.

Having a history of depression is associated with more severe withdrawal symptoms, such as more severe depression. Some studies indicate that many people with a history of major depression will have a new depressive episode after quitting. However, major depression is rare after quitting those who do not have a history of depression.

Many people have a strong desire to smoke when they feel depressed. Here are some suggestions to overcome depression:

•     Call a friend and make plans to have lunch or go to the movies, a concert or another pleasant event.
•     Identify specific emotions when feeling depressed. Actually, do you feel tired, loneliness, boredom or hunger? Focus on these specific needs and respond to them.
•     Increase your physical activity. This will help improve your mood and depression.
•     Breath deeply.
•     Make a list of things that annoy you and write how to solve them.
•     If the depression continues for more than a month, visit your doctor and ask about prescribed medications that may help you with your depression. Studies have shown that bupropion and nortriptyline can help people who have a history of depression and who are trying to quit smoking. Nicotine replacement products also help ( 5 ).
•     Visit the website of the National Institute of Mental Health to learn more about the signs of depression and where you can go for help.

How can I get over the weight gain?

Gaining weight is common when you quit smoking. Studies have indicated that, on average, people who never smoked weigh a few pounds more than smokers, and that, when quitting, smokers reach the weight they would have if they had never smoked ( 6 ).

Although most smokers raise less than 10 pounds after quitting, such an increase can be problematic for some people ( 7 , 8 ). However, the benefits exceed the health risks of a slight weight gain.

Here are suggestions to control weight gain:

•     Ask your doctor about the medication bupropion. Studies indicate that it helps counteract weight gain ( 5 ).
•     Studies also show that nicotine replacement products, especially chewing gum and nicotine lozenge, can help with weight gain ( 5 ). Because some people increase their food intake ( 6 ), regular physical activity and choosing healthy foods can help you maintain a healthy weight.
•     If the weight gain is problematic, you may need to consult with a nutritionist or dietitian.

How can I resist the urge to smoke when being in the company of smokers?

You may want to analyze the situations in which when you see other people smoking, your desire to do so is triggered. Think about what there is in those situations that incites you to want to smoke. Is it because you associate the feeling of happiness with being around smokers? Or, is there something special in such situations, such as being close to the people you normally smoke with? Is it tempting to join others in order to take routine breaks to smoke?

Here are some suggestions:

•     Limit your contact with smokers, especially during the first few weeks after quitting.
•     Do not buy, charge, light or hold cigarettes for others.
•     If you are in a group and start smoking, ask for permission and do not return until they are finished.
•     Do not allow others to smoke in your home. Put a small sign that says "Do not smoke" near the front door.
•     Ask others to help you stay smoke free. Give them specific examples of favorable things (like, not smoking near you) and unfavorable things (like, asking you to buy them cigarettes).
•     Concentrate on what you have achieved by quitting smoking. For example, think about the good health you will have once the effects of smoking disappear from your body and you can say that you are free of tobacco. Also, add up the amount of money you have already saved by not buying cigarettes and imagine (in detail) how you will spend what you have saved in six months.

How do I start the day without smoking?

Many smokers light a cigarette just as soon as they wake up. After 6 or 8 hours of sleep, the smoker's nicotine concentration decreases, which is why you need a nicotine refill to start the day. When you quit, you must prepare yourself to overcome the physical need and routine of waking up and smoking a cigarette. Instead of extending your hand to pick up your cigarettes in the morning, here are some suggestions:

•     The morning can set the tone for the rest of the day. Plan a different routine upon waking up, and divert your attention from smoking.
•     Make sure there are no cigarettes within reach.
•     Before sleeping, write down a list of things to avoid in the morning that will make you want to smoke. Put that list where you used to put your cigarettes.
•     Start each day with a planned activity in which you occupy for an hour or more. This will keep your mind and body busy so you do not think about smoking.
•     Start the day by breathing deeply and taking one or more glasses of water.

How can I resist the urge to smoke when I am in tension?

According to most smokers, one of the reasons why they smoke is to overcome the tension. This happens because, effectively, smoking cigarettes alleviates part of the tension by releasing powerful chemical compounds in the brain. Temporary changes in brain chemistry make you feel less anxiety, greater pleasure and alert relaxation. By quitting smoking, you may be more aware of stress.

The worries, responsibilities and annoyances of daily life can all contribute to stress. As time passes without smoking, your ability to overcome stress will improve, especially if you learn relaxation techniques and to reduce stress.

Here are some suggestions:

•     Know what causes tension in your life (your job, your traffic, your children, your money) and identify the signs of tension (headaches, nervousness or difficulty sleeping). Once you pinpoint high-risk inciting situations, you can begin to think of new ways to overcome them.
•     Look for quiet periods in your daily life. For example, set aside an hour in which you can set yourself apart from other people and your ordinary environment.
•     Try relaxation techniques, such as progressive relaxation or yoga, and practice whichever is best for you.
•     Rehearse and visualize your relaxation plan. Put your plan in motion. Modify your plan when necessary.
•     It can help you read a book on how to overcome stress.

How can I resist the urge to smoke when driving or driving in a car?

You may have become accustomed to smoking when driving to relax during traffic congestion or to stay alert on a long trip. Like many smokers, maybe smoke a cigarette when driving to work or back home to reduce stress, stay alert, relax or just to pass the time. There is some evidence that indicates that, indeed, smoking makes you feel better and more alert.

Here are suggestions for short trips:

•     Remove the ashtray, cigarette lighter and cigarettes from your car.
•     Keep low-fat treats in your cart (for example: licorice, sugar-free chewing gum, and hard candy).
•     Put your favorite music and follow the lyrics.
•     Take an alternative route to work or try public transportation.
•     Clean your car and be sure to use deodorants to reduce the smell of tobacco.
•     Tell yourself:

•         "This anxiety will disappear in a few minutes."
•         "So I do not like the trip. Big Deal! It will not last forever! "
•         "My car smells clean and fresh!"
•         "Now I am a better driver than when I drove and smoked."

When driving or going with other people:

•     Ask passengers not to smoke inside the car.
•     If you do not drive, find something to do with your hands.

It is possible that your desire to smoke is more intense and frequent on longer trips. Here are suggestions for long trips:

•     Take a long break.
•     Take fresh fruit with you.
•     Plan rest stops.
•     Plan stops for water or fruit juice.

How can I resist the urge to smoke when I have coffee or tea?

You may have the habit of smoking when you drink coffee or tea (for example, during or after meals, or during breaks at work), and you may associate pleasant feelings with a hot drink. When you stop smoking, expect to feel an intense craving for a cigarette while drinking coffee or tea. Even though you do not need to leave your coffee or tea to kick the habit, do not be surprised if you do not taste as good without a cigarette

Here are some suggestions:

•     If you used to smoke when drinking coffee or tea, tell others that you do not smoke anymore so they will not offer you cigarettes.
•     Between each sip of coffee or tea, breathe deeply to inhale the scent. Inhale deeply and slowly while counting to five and then exhale slowly, counting to five again.
•     Try decaffeinated coffee or tea for a while, especially if quitting makes you irritable or upsets your nerves.
•     Keep your hands busy by chewing healthy foods, scribbling, or making a to-do list for the day.
•     If the urge to smoke is very intense, take your tea or coffee faster than normal and then change activity or room.
•     When you quit, you may feel sad when you drink coffee or tea without smoking. Concentrate on your achievements when quitting tobacco.

How can I enjoy a meal without smoking?

Usually, food tastes better after quitting, and you may have more appetite. Do not be surprised if you want to smoke after meals. Possibly your urge to smoke after meals depends on whether you are alone, with other smokers or with people who do not smoke.

Your cravings for smoking may be more intense with certain foods, such as with spicy or sweet foods. Also, the cravings for smoking can be more intense at different times of eating.

Here are some suggestions:

•     Know what types of foods increase your cravings for smoking and avoid them
•     If you do not have company, call a friend or go for a walk as soon as you finish eating.
•     Brush your teeth or use a mouthwash as soon as you finish your meals.
•     If you drink coffee or a juice, concentrate on the flavor.
•     Wash dishes by hand after eating, you can not smoke with wet hands!
•     Eat in restaurants that do not allow smoking.

How do I resist the urge to smoke when I drink an alcoholic beverage?

Maybe you have the habit of smoking when you drink beer, wine, liquor or mixed drinks, and perhaps associate pleasant sensations with drinking alcoholic beverages. When you stop smoking, you may feel intense cravings for smoking when you drink alcohol. Know this in advance if you are going to drink alcohol. If you choose to do so, keep in mind that your control over your behavior will be influenced by alcohol. It is possible that when you try to quit smoking, drinking alcohol makes it even harder to get over smoking.

Here are some suggestions for the first weeks after quitting:

•     Reducing or avoiding alcohol is helpful for many people.
•     Switch to non-alcoholic drinks.
•     If you drink, do not choose the alcoholic beverage you used to drink when you smoked.
•     Do not take at home or alone.
•     Avoid places where you normally drink alcohol or drink only with friends who do not smoke.

How can I resist the urge to smoke when I feel bored?

When you stop smoking, you may miss the intense vehemence and pleasant feeling that nicotine gives you. This could be particularly true when you feel bored.

Here are some suggestions:

•     Plan more activities than you can do in the time available.
•     Make a list of chores when facing the free time.
•     Move! Do not be in the same place for a long time.
•     If you feel bored when waiting for something or someone (a bus, a friend, your children), distract yourself with a book, a magazine or a crossword puzzle.
•     Observe and listen to what is happening around you.
•     Carry something to keep your hands busy.
•     Listen to one of your favorite songs.
•     Go out, if you can, but not to places that relate to smoking.

Do Nicotine Replacement Products Relieve Nicotine Cravings and Withdrawal Symptoms?

Yes. Nicotine replacement products deliver an accurate dose of nicotine to the body, which helps alleviate the cravings and withdrawal symptoms that people who try to quit often feel. These products are effective treatments that can increase the likelihood that a person will quit smoking successfully ( 5 , 9 ).

There are five types of nicotine replacement products that have been approved by the US Food and Drug Administration. UU ( FDA ):

•     The nicotine patch is available without a prescription. Every day a new patch is put on the skin, which administers a small, but continuous, dose of nicotine to the body. This patch is sold in various concentrations, usually as a treatment for eight to ten weeks to quit smoking. Normally, as the treatment progresses, the nicotine dose is lowered. It is possible that the nicotine patch is not a good option for people with skin problems or allergies to the adhesive tape. Also, a side effect that some people have when using the patch at night is to have intense dreams. These people may decide to wear the patch only during the day.
•     Chewing gum with nicotine is available without a prescription in two concentrations (2 and 4 milligrams). When a person chews said gum and places the chewed product between the cheek and the tissue of the gum, nicotine is released into the bloodstream by the lining of the mouth. To maintain a constant degree of nicotine in the body, you can chew a new piece of gum every one or two hours. Apparently, the 4 milligrams dose is more effective among smokers of higher dependency (who smoked twenty or more cigarettes a day) ( 10 , 11 ). Perhaps nicotine gum is not appropriate for people with temporomandibular joint disorders or for those who have dentures or other orthodontics, such as dental bridges. Gum releases nicotine more effectively when you do not drink coffee, juice or other acidic beverage at the same time.
•     The nicotine pill is available without a prescription in concentrations of 2 to 4 milligrams. The pill is used in a similar way to nicotine gum : it is placed between the cheek and the gum and allowed to dissolve. Nicotine is released into the bloodstream by the lining of the mouth. The pill works best when used every one or two hours and when you do not drink coffee, juice or other acidic drink at the same time.
•     The nicotine nasal spray is available only with a prescription. The atomizer comes in a pump bottle that contains nicotine so that people who use tobacco can inhale when they have the urge to smoke. Nicotine is absorbed faster with the atomizer than with other nicotine replacement products. This product is not recommended for people with diseases of the nose or sinuses, allergies or asthma, nor is it recommended for young people who use tobacco. Side effects of the spray are sneezing, coughing, tearing, but these problems usually disappear with continued use.
•     The nicotine inhaler , also available only by prescription, delivers a vaporized form of nicotine to the mouth by means of a mouthpiece attached to a plastic cartridge. Even when it is called an inhaler, the device does not deliver nicotine to the lungs in the way the cigarette does. Most of the nicotine travels only to the mouth and throat, where it is absorbed through the mucous membranes. Common side effects are irritation of the mouth and throat, and cough. Anyone who has breathing problems, such as asthma, should use the inhaler carefully.

Experts recommend the combination of nicotine replacement therapy with the advice or advice of a doctor, dentist, apothecary or other health professional. Also, experts suggest that smokers leave tobacco products before starting to use nicotine replacement products ( 12 ). A lot of nicotine can cause nausea, vomiting, dizziness, diarrhea, weakness or an accelerated heart rate.

Are nicotine replacement products dangerous?

Because tobacco smoke contains many toxic and carcinogenic substances, it is less harmful if a person receives nicotine from a nicotine replacement product than from a cigarette. The prolonged use of these products has not been associated with any serious adverse effect ( 11 ).

Are there non-nicotine products that help people quit smoking?

Yes. A doctor may prescribe one or more medications that do not contain nicotine :

•     Bupropion , an antidepressant available by prescription under the brand name Zyban®, was approved by the FDA in 1997 to treat nicotine addiction. This drug can help reduce the symptoms of nicotine withdrawal and cravings, and can be used safely in combination with nicotine replacement products ( 9 , 12 ). There are several side effects associated with this product. Talk to your doctor to see if this drug is right for you.
•     Varenicline , a medicine that is only sold by prescription under the Chantix ® brand, was approved by the FDA in 2006 to help tobacco smokers quit. This drug can help those who want to stop smoking because it can ease their cravings for nicotine and block the pleasurable effects of nicotine if they smoke again. There are several side effects associated with this product. Check with your doctor to see if this medicine is appropriate for you.

Are there alternative methods to help people stop smoking?

Some people claim that alternative methods, such as hypnosis , acupuncture , acupressure , laser therapy (the stimulation of acupuncture points in the body with a laser) or electrical stimulation can help reduce the symptoms associated with abstinence from nicotine However, in clinical studies it has not been found that such alternative therapies help people to stop smoking ( 13 ). There is no evidence that alternative methods help smokers who try to quit.

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How can I stop smoking? (for Teenagers)

First, congratulate yourself. The mere fact of reading this article is a huge step to get rid of tobacco. Many people do not stop smoking because they think it is too hard. They believe that they will leave it in the future.



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It's true, for most smokers, quitting is not easy. After all, the nicotine in cigarettes is a powerful addictive drug. But, with the right approach, you can overcome the pressing desire to smoke or "tobacco monkey".

The difficulty of breaking the habit

Smokers may have started smoking because their friends did or because it seemed "rolled up." But they continue to smoke because they have become addicted to nicotine, one of the chemicals that contain both cigarettes and snuff to chew or sniff.

Nicotine is both a stimulant and a depressant. This means that at the beginning it increases the heart rate and makes people feel more alert (like caffeine, another stimulant). Later, it causes depression and fatigue, which - along with the withdrawal of nicotine - makes people feel a pressing desire to smoke another cigarette to cheer up again. According to many experts, the nicotine in tobacco is as addictive as cocaine or heroin.

But do not be discouraged; Millions of Americans have definitely stopped smoking. The following strategies can also help you break this habit:

Put it in writing. People who want to make a change in their life are often more successful when they put it in writing. So write down all the reasons why you want to quit, such as the money you will save or the resistance you will earn to play sports. Put that list in a place where you can see it and see adding new reasons as they happen to you.

Find support. People whose friends and family give them a hand to stop smoking are much more likely to do so. If you do not want to tell your parents or relatives that you smoke, make sure your friends know it, and consider asking a counselor or another trusted adult for help. And, if you have many difficulties to find people who support you (if, for example, all your friends smoke and no one is interested in quitting or leaving it), it may be good to join a support group, either in person or connected to the Internet.

More strategies that work

Set a date to quit smoking. Choose a day when you will quit smoking. Inform your friends (and your family, if they know you smoke) that you are going to quit smoking that day. Think of that day as the dividing line between your smoker self and the new and improved non-smoker. Mark it in the calendar.

Throw away your cigarettes - all your cigarettes. Nobody can stop smoking with cigarettes around them. Pull even that emergency pack that you kept in the secret pocket of your backpack. Also get rid of your ashtrays and lighters.

Wash all your clothes well. Eliminate the smell of tobacco from your clothes as much as possible washing it thoroughly and carrying dry washed thick sweaters, coats and jackets that require it. If you smoked in your car, wash it too.

Think of your triggers. You are probably aware of the situations in which you tend to smoke the most, such as after eating, when you are at your best friend's house, while drinking coffee or driving. These situations are your triggers for smoking behavior; It is automatic to have a cigarette in your hand when you are in them. Once you have found out what your triggers are, try the following tips:

•     Avoid those situations. For example, if you smoke while driving, ask someone to drive you to your study center, or go for a walk or take the bus for a few weeks. If you usually smoke after eating, get organized to do something different at that time, such as reading or calling a friend.
•     Change places. If you and your friends usually smoke in restaurants or buy prepared food and eat it in the car, suggest that you sit in the non-smoking section next time or eat the prepared food in a different place from the car.
•     Substitute cigarettes for something else. It can be quite hard to get used to the feeling of having nothing in your hand or in your mouth. If you have this problem, use carrot sticks, sugar-free gum, mints, toothpicks or even lollipops or lollipops.

Physical and mental effects

Expect some physical symptoms. If you smoke regularly, you have probably developed a physical addiction to nicotine and your body may experience some withdrawal symptoms when you stop smoking. These could include:

•     headaches or stomach
•     irascibility, nervousness or depression
•     lack of energy
•     Dry mouth or sore throat
•     desire to stuff themselves with food

Fortunately nicotine withdrawal symptoms will pass, so be patient. Try not to give the arm to twist, getting a cigarette furtively, because then you must face these symptoms for longer.

Keep busy Many people realize that it is better to stop smoking on a Monday, when they have to go to work or to the study center, because it is a day when they will be busy. The busier you are, the less likely you are to experience "tobacco monkey". Being active is also a good way to make sure that you keep your weight low and your energy high , even if you experience withdrawal symptoms from nicotine.

Stop smoking gradually. For some people, gradually reducing the amount of cigarettes they smoke per day is an effective way to quit this habit. Anyway, this strategy does not work with everyone; Maybe you find out that you have to leave it in a radical way. This is known as "cut for good" and generates a strong withdrawal syndrome.

Use nicotine substitutes if you need them. If you find that none of the above strategies works for you, you should talk to your doctor about possible treatments. Using nicotine substitutes, such as chewing gum, patches, inhalers or nasal sprays, can be very helpful. Nebulizers and inhalers can only be purchased with a prescription, and it is important that you also go to the doctor before buying patches or chewing gum. Thus, your doctor can help you find the solution that is best for you. For example, patches require the least effort on your part, but they do not offer the almost instantaneous nicotine "rush" that chewing gum provides.

Slips happen

If you have a small slip, do not give up! Important changes sometimes have failed principles. If you are like a lot of people, you may stop smoking for several weeks or even months and then suddenly experience such a strong "monkey" of tobacco that you feel compelled to smoke. Or maybe you accidentally find yourself in one of your triggers and fall back into temptation.

If you have a slip, it does not mean that you have failed, only that you are human. Here are some ways to get back on track:

•     Think is that slip as in a small mistake. Take note of when and how it happened and move on.
•     Did you become a chain smoker by smoking a single cigarette? I do not think so; it happened more gradually, with the passage of time. Keep in mind that a single cigarette did not make you a smoker at first, so smoking a cigarette (or even two or three) after you quit does not make you a smoker again.
•     Remind yourself why you have quit smoking and how well you have done it , or ask someone from your support group, your family or your group of friends to do it for you.

Reward yourself. As you already know, quitting smoking is not easy. Give yourself a well-deserved reward! Reserve the money you used to invest in buying tobacco. When you do not smoke tobacco a week, two weeks or a month, buy a detail, such as a new CD, a book, a DVD or a piece of clothing. And every new year that you are free of tobacco, return to celebrate. You won it.

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Strategies to reduce risks in smoking: opportunity or threat?

Summary
The smoking control policies recommended by the World Health Organization have achieved a slight decrease in the prevalence of smoking in developed countries, although the related mortality remains very high. The use of tobacco products other than cigarettes or medicinal nicotine (known as nicotine replacement therapy or NRT) has been proposed as a risk reduction strategy. Among tobacco products with less individual risk than cigarettes would be some types of smokeless tobacco with low nitrosamine content and modified cigarettes; both forms encompassed under the concept of PREP (Potentially Reduced Exposure Products) .



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The idea would be to promote these products to those who can not stop smoking or wish to reduce their risk without abandoning nicotine. We review the possible effects on the decrease of the prevalence and on the morbidity and mortality of the risk reduction strategies, including the PREPs, and analyze the possible implications that this measure could have in our environment. In Spain, the control measures for smoking are recent and still insufficient. Currently, the priority in Spain is, therefore, the development of control policies that have shown their effectiveness in ample. The commercialization and diffusion of new tobacco products, even of reduced potential risk, seems more a serious threat than an opportunity for the development of tobacco control policies.

Abstract
The smoking control policies recommended by the World Health Organization have achieved a slight decrease in smoking prevalence in the developed countries, although associated mortality is still very high. The use of tobacco products other than cigarettes and even medicinal nicotine (known as nicotine replacement therapy (NRT)) has been proposed as a risk reduction strategy. Among the tobacco products with less individual risk than cigarettes would be any type of tobacco without smoke (smokeless) with a low content in nitrosamines and modified cigarettes; both forms included under the PREP (Potentially Reduced Exposure Products) concept. The idea would be to promote these products among those who can not quit smoking or wish to reduce their risk without giving up nicotine intake. The possible effects of risk reduction strategies, including PREP, on the decreased prevalence and morbidity and mortality are reviewed, and the possible implications that this measure could have in our country are analyzed. Tobacco control measures in Spain are recent and still insufficient. Therefore, the current priority in Spain is the development of control policies that have shown to more than effective. The marketing and advertising of new tobacco products, even with reduced potential risk, seems more a serious threat than an opportunity for the development of smoking control policies.

Introduction

The current development of public policies on tobacco control recommended by the International Framework Convention, promoted by the World Health Organization, is leading to an average decrease of between 0.5 and 1% in the prevalence of smoking in the countries developed while it continues to increase in impoverished countries. Global mortality due to tobacco is currently estimated at 5.4 million people / year, which could exceed 8 million in 2030 if the same trend is maintained

1 .Due to the difficulties in implementing these control policies, its effects could be insufficient to reduce the morbidity and mortality related to tobacco consumption in the coming decades. This reality, together with the fact that nicotine addiction is sometimes difficult to break, has led institutions such as the Royal College of the United Kingdom and some experts to advocate, as a new risk reduction strategy, the use of tobacco products other than cigarettes, or medicinal nicotine - commonly known as nicotine replacement therapy (NRT) -. Among the tobacco products with less individual risk than cigarettes would be some kinds of smokeless tobacco with a low content of nitrosamines and modified cigarettes, both forms included under the concept of "products with potentially reduced exposure" (PREP, de potentially reduced exposure products ). Currently, with the exception of TSN, tobacco products with a lower toxic content are marketed by the tobacco industry. The idea would be to promote these products to those who can not stop smoking or wish to reduce their risk without abandoning nicotine consumption

2 .Given the enormous implications that would have within the policies of control of smoking, a previous detailed analysis seems reasonable. This review provides a brief review of risk reduction strategies, including PREPS, and their possible effects both on the decrease in prevalence and on morbidity and mortality due to tobacco use. Finally, the possible implications that this measure could have in our environment are analyzed.

Risk reduction strategies

The concept of risk reduction emerged in the 1980s in the context of injecting drug use, in response to two specific factors: first, the emergence of the AIDS epidemic among heroin users, and in secondly, the growing suspicion that the strategies adopted to deal with drug use had not been effective enough 3 .

In the case of smoking, risk reduction strategies were initially proposed within the scope of clinical practice, as a measure to reduce the diseases associated with cigarette smoking or as an intermediate step to achieve definitive abstinence. In the same way, as the perception of the risk of smoking increased, the tobacco industry expanded the tobacco market with new products other than cigarettes, which were also presented to the consumer as a reduction in harm, in order to reassure smokers and smokers. Keep your consumption.

Next, the different risk reduction proposals that appeared throughout the history of cigarettes, both from the clinical point of view and those made from the tobacco industry, are discussed.

Clinical strategies

Included here are proposals arising from the health sector whose purpose has been to reduce consumption to reduce risks, either as an objective in itself or as an intermediate step to achieve the total suppression of tobacco consumption.

Reduction in the number of cigarettes

Reducing the number of cigarettes has been a habitual strategy used by smokers to reduce the risk or to try to advance in the abandonment process. It was a proposal also used in the past by some professionals as a "realistic" solution for patients who can not or do not want to stop smoking completely. There is no scientific evidence that reducing the number of cigarettes actually reduces health risks, a seemingly paradoxical fact. The main explanation for this phenomenon is that people who are smokers, by reducing their consumption, tend to practice compensatory behaviors in an unconscious way (faster cigarettes, deeper inhalations, etc.) to obtain the same amount of nicotine as before The reduction. The result is a small decrease in the amount of nicotine inhaled and, consequently, in the tar and toxins that accompany it, a decrease that is not proportional to the number of cigarettes eliminated. For some diseases such as ischemic heart disease, a reduction of 10 cigarettes in a smoker of 20 cigarettes a day means a reduction of less than 10% of the risk; that is, 5 times less than expected due to this compensatory effect in the way of smoking 4 .

The possible benefits of reducing the number of cigarettes have been evaluated in several follow-up studies. Godtfredsen et al 5 analyzed the mortality rate for diseases related to tobacco consumption in smokers of more than 15 cigarettes per day, compared with a group that had reduced the amount by half and with individuals who had quit tobacco completely. Among those who reduced the number of cigarettes, no decrease in the mortality rate was observed. However, those who left the consumption completely saw their risk of dying reduced, in the 15 years of study, by 35%. No significant differences were found in relation to respiratory disease or cardiovascular mortality among smokers with more than 15 cigarettes and those who had reduced the number of cigarettes. Another recent study in Norway evaluated 50,000 participants, men and women, over 15 years and showed that reducing consumption (eg, 30 to 20 cigarettes) does not significantly reduce the risk of cancer, lung disease, myocardial infarction or cerebral infarction 6 ; Table 1 shows the data of that study. A recent review of a total of 31 publications concludes that a substantial reduction in the number of cigarettes has a marginal marginal benefit in health, much lower than expected.


Death cause    No. of deaths    RR (95% CI) for every 10 cigarettes less    No. of deaths    RR (95% CI) for every 10 cigarettes less
All causes    1,809    0.97 (0.90-1.04)    4,042    1.00 (0.94-1.05)
Cardiovascular disease    650    0.90 (0.79-1.03)    1.479    0.98 (0.89-1.08)
Ischemic heart disease    447    0.85 (0.73-1.01)    989    0.97 (0.87-1.10)
Cancer related to tobacco    453    0.91 (0.79-1.06)    935    0.99 (0.89-1.11)
Lung cancer    253    0.97 (0.80-1.18)    497    1.01 (0.87-1.17)


On the other hand, it is usually thought that smoking a few cigarettes a day does not entail excessive danger to health. However, there are studies that show that very small amounts of tobacco produce harmful effects on health 8 .
Gradual reduction of nicotine and tar

Described in 1979, the gradual reduction of nicotine and tar, through the weekly change of brand of cigarettes, is conceived as a strategy of transition and preparation towards complete abstinence, although many therapists have applied it with the aim of reducing consumption. Several studies have shown their effectiveness as another technique, within the psychological treatments to stop smoking, especially in the framework of multicomponent programs 9 .

Nicotine replacement therapy

TSN has been used classically as a therapy to stop smoking, although some smokers use it transiently for long distance trips, hospitalizations or while in smoke-free public spaces. Recently there is some evidence that temporary reduction strategies with fast-acting TSN (chewing gum), in smokers who initially do not want to stop smoking, can increase the rate of cessation in the medium term 10 . In any case, TSN or "clean" pharmacological nicotine is the only product with scientific evidence for a temporary risk reduction strategy 11 , and as such it is recognized in our country 12 .

Tobacco industry strategies

These proposals do not really respond to a risk reduction objective, but rather to commercial interests. However, given that at the time they were raised as such, especially light cigarettes, and that many smokers often adopt them with the idea of ​​reducing the damage, they are included in this review.

Pure cigars or pipe

Pure cigars and pipe are other forms of tobacco smoking, although they have always been a minority. The tobacco industry widely promoted cigars in the nineties with the aim of increasing the market. The risks associated with these products are lower than those of cigarettes because those who consume them tend not to inhale the smoke, although they absorb a lot of nicotine through the oral mucosa. The result is that the risk of emphysema, lung cancer and laryngeal cancer is lower in people who smoke cigars, but they have a similar risk of oral and esophageal cancer than those who consume conventional cigarettes. 13 The largest study on the health effects of cigar smoking was developed in a group of 17,774 men aged 30 to 85 years. In the analysis, individuals who smoked cigars (1,546), compared to nonsmokers (16,228), presented, independently of other factors, an increased risk of coronary heart disease (27% more), of chronic obstructive pulmonary disease ( 45%) and cancer of the esophagus and lung (2 times higher). The risks increased significantly from 5 cigars per day 14 .

Cigarettes with filter

At the beginning of the fifties of the 20th century cigarettes with filters appeared. With the incorporation of filters, the objective of the industry was not to protect the health of smokers, but to reassure them to protect their own business profits, endangered by the appearance in 1954 of the first epidemiological studies that showed, without a doubt, that tobacco was a cause of lung cancer. At the beginning it was thought that the incorporation of filters could reduce the risk for some cancers related to tobacco, by significantly reducing the amount of tar. However, several cohort studies conducted in the USA. and the United Kingdom showed that lung cancer continued to increase between 1950 and 1980, despite the widespread use of filter cigarettes 15 .

Cigarettes low in tar and nicotine (light cigarettes)

With the incorporation of light tobacco in 1970, many smokers switched to low nicotine and tar brands believing that they would reduce the risk. This perception of lower risk was widely promoted by the tobacco industry and resulted in many smokers delaying the decision to stop smoking. In fact, the abstinence rate of consumers of light cigarettes is lower than that of conventional cigarette smokers (27% vs 53%, p <0.01), demonstrating the potential of these products to delay effective cessation 16 . In the European Union (EU), the denomination of light cigarettes has not been allowed since 2003, but these products are still sold with other names or other external signs on their packaging.

The tar content of cigarettes is measured by machines that "smoke" artificially; Much of the reduction observed is due to the dilution of the smoke through the holes made in the filter by the manufacturers. In real life, it is inevitable that smokers will plug these holes with their fingers, thereby inhaling a much larger amount of tar. Therefore, the nicotine / tar ratio of light cigarettes is actually similar to that of conventional cigarettes 17 . In fact, the absorption of tar and nicotine is higher than that indicated by the pack of cigarettes and the ISO 18,19 standards. In Spain, only the Center for Research and Quality Control, attached to the National Consumer Institute, of the Ministry of Health and Consumption, is certified to evaluate tobacco products.

At first it was thought that light cigarettes could contribute to a reduction in the risk of lung cancer 21 . However, in the decades following the appearance of the light cigarette, the overall mortality from lung cancer in the USA, in both sexes, did not stop increasing, going, from 1979 to 1997, from 98.5 to 153.3 cases per 100,000 inhabitants, which denied the initial idea of ​​a lower risk 22 . In spite of everything, to this day, many smokers still believe they feel protected by consuming cigarettes with a filter and low tars 23 .

Products with reduced potential risk

Conceptually, PREPs are defined as those products that contain nicotine, but lower amounts of tar and other toxic than conventional tobacco (mainly nitrosamines), a definition that includes some forms of smokeless tobacco, in addition to modified cigarettes.

Smokeless tobacco ( smokeless )

Under the term smokeless , different forms of tobacco are included (in paste, powder, snuff, etc.) whose common characteristic is that they are consumed orally or nasally, but without combustion; therefore, without smoke. In general, they are considered to have fewer health risks than cigarettes. Traditionally smokeless has been a form of tobacco consumption widespread in some Asian countries. In developed countries, smokeless is rare, with the exception of Sweden, where the so-called snus is consumed since 1637. The snus is a bag of moist tobacco paste that is placed under the upper lip, for absorption through the buccal mucosa. The risk of this form of tobacco is low when compared to cigarettes, but it is also a cause of cancer. The low prevalence of lung cancer observed in Sweden, compared to other developed countries, 24 has led some experts to look at this product as a possible alternative for a viable risk reduction strategy.

Several studies have evaluated snus as a "protective" factor of cigarette smoking. On the one hand, it would delay the start among the youngest and, on the other, it would increase the cessation among cigarette smokers. In Sweden it has been observed that 47% of young people who experimented with tobacco became cigarette smokers, whereas this only occurred in 20% of young people who started using snus . Also according to the Swedish experience, those who used snus stopped smoking by 66%, while with nicotine gum they left 47% and with a 32% patch 25 . On the contrary, in the USA, where it is also consumed, although to a lesser extent, it has been proven that young people who start using snus tend to start more easily in the consumption of cigarettes than those who do not use it (27). against 12.9%) 26 . On the other hand, adult smokers who use snus try to quit cigarettes more frequently but have lower rates of abstinence than those who do not use cigarettes (12% vs 21%) 27,28 .

Modified cigarettes

Modified cigarettes are conventional cigarette-shaped devices that release nicotine without combustion, but through a heating process (electronic or chemical) 29 , hence they are also known as electronic cigarettes ( e-cigarettes ). At present, various tobacco companies have commercialized these alternative cigarettes in different countries, including Spain. Its legal situation in the EU is unclear because it is not a tobacco product, but it has not passed the filters of pharmaceutical products, despite containing nicotine, given that it is not clear that they are marketed for medicinal purposes 30 .

In Spain, brands like Ruyan ® and Similar ® have recently appeared; the former uses an electronic system to heat and release nicotine, whereas Similar uses a chemical system. In our country they are sold in some cinemas, gas stations and airlines, although at the moment their commercial penetration is reduced. With some brands (such as Eclipse ® , marketed in the US by RJ Reynolds) it has been proven that, although they release less tar than conventional cigarettes, they produce more carbon monoxide, so their risk of heart attack would be even greater. Shiffman et al 32 have pointed out that the idea that these modified cigarettes reduce risk can have an adverse effect, by preventing the definitive cessation of tobacco consumption, or even encourage former smokers to try these new products. At the moment there are no studies that have shown that modified cigarettes are safer than conventional cigarettes 33 . For several reasons, it is to be feared that the promotion of these products may undermine some of the policies of proven efficacy in tobacco control 34 .

Advantages and disadvantages of risk reduction strategies

To assess the harm reduction in smoking, it is necessary to separate the individual impact of the population impact. From the individual point of view, it is possible that, in certain circumstances, total abstinence is not a realistic goal and a harm reduction strategy can be proposed. The therapeutic option would be "clean" TSN or nicotine, since it is the only product that has shown scientific evidence for a temporary risk reduction strategy. In addition, the TSN, although it is a freely available product, is subject to the usual pharmaceutical regulation.

From the population point of view, classical clinical strategies (cigarette reduction, etc.) have not shown benefits, and those of the industry have only served to maintain the epidemic. With regard to the products of reduced toxicity or PREP, on which the debate is currently focused, they present several disadvantages 35 . First, smokeless tobacco has not been shown to reduce the population risk, since it is not clear that the introduction of new ways of dispensing nicotine contributes to reducing tobacco consumption among the population. On the contrary, the data indicate that the tobacco industry could take advantage of the liberalization of snus to attract adolescents and young adults to nicotine consumption 33 . The strategy that should be followed in young people is not encouraging them to consume snus , as an alternative, but the development of preventive and treatment programs 36,37 .

The promotion of snus and other forms of smokeless tobacco could reduce the risks in the population of smokers, but at the expense of increasing the use of snuff in the population as a whole, which clearly would not be a benefit, but a risk added In fact, in Norway, where snus is also commercialized, its consumption has increased by around 11% in all men and up to 18% in the group of 16-24 years, without evidence that the prevalence of conventional smoking 38 .

• Evidence about smokeless tobacco 39
• It is a toxic and carcinogenic product
• Its promotion has increased the global sales of tobacco products in some countries
• The increase in consumption has occurred especially in adolescents and young adults
• Its use has not been associated with a reduction in the start of cigarette consumption or its prevalence
• It does not have a role in the cessation and in Sweden its effect is contradictory
• Countries with less tobacco prevalence also consume less smokeless tobacco
• There is no data on its effectiveness as a method for cessation
• The prevalence of smoking is high among consumers of smokeless tobacco
• It is generally used for a partial replacement of cigarettes rather than for a complete substitution
• The evidence to promote it as a public health strategy is weak and inconclusive

Another limitation for its use would be the need for a new regulation. At the moment, the European directive on tobacco products 41 prohibits in the EU the commercialization of new forms of tobacco, including those for oral use such as snus , except in countries of traditional use such as Sweden and Norway. If it were allowed to market these products, it would be difficult to avoid the reappearance of brand advertising whose main business is traditional cigarettes and not snus . Given that tobacco companies face a global regulation of advertising by the Framework Agreement, it seems very possible that they use the new products in order to weaken and avoid such regulation. In this sense, there are data that show the interest because it is legislated in favor of the commercialization of these new tobacco products erroneously classified as "healthier" 42 .
Implications of the use of potentially reduced exposure products in our environment

The main argument of the supporters of the promotion of PREP is that it would be an effective measure to reduce the risks among the population of smokers, which on the other hand they still consider too high.

Recently, the World Health Organization has established 6 policies to reduce and prevent tobacco use, summarized in the so-called MPOWER measures plan, which does not include risk reduction. This report also highlights that only 5% of the world population is covered by global tobacco control policies, and that few tobacco users receive the necessary help to stop smoking. In Spain only 12% of smokers request professional help to stop smoking, while in the United Kingdom, with the highest percentage of demand for help, the figure reaches 41% of smokers and the average in the EU is 18% 44 . This is a paradoxical fact, taking into account that, although there is a lack of evidence to assess the results of long-term smoking cessation, 45 the treatment of smoking is cost-effective and is widely recommended. 46

In Spain, the control measures for smoking are recent and still insufficient. The priority in our country is, therefore, the development of control policies that have shown their effectiveness in ample way ( table 3 ). Therefore, the debate should focus not so much on the possible goodness of risk reduction, but rather on its timing, in order to avoid the division between clinical professionals, more concerned with individual health, and those with a broader vision of the public health 47 . That is to say, what is the point of risk reduction when such basic and proven measures as smoke-free spaces, tobacco taxation or the treatment of smokers are beginning to make their way, still with enormous difficulties, in the majority of countries? 48

Effective policies in the control of smoking

 1
    Annual increase of tobacco taxes (so that the final price is above the CPI). Withdrawal of the price of tobacco from the calculation of the CPI
2
    Regular tobacco additives without the inclusion of carcinogenic products per se or substances that directly or indirectly increase their addictive capacity
3
    Regular labeling and packaging, make them less attractive, and generic packaging without attractive logos
4
    Limitation of the points of sale to the official points (tobacconists), prohibition of vending machines and "second channel" (hotels, kiosks, etc.)
  5
    Total prohibition of tobacco advertising, promotion and sponsorship. Measures to compensate for indirect promotion in film and television without prior censorship (declaration of subsidies for product placement , health warnings, etc.)
6
    Public spaces totally smoke-free without exceptions or ambiguities
 7
    Information and education on the risks of active and passive tobacco, on an ongoing basis (similar to campaigns to prevent traffic accidents in terms of investment and intensity)
 8
    Public subsidies for smoking cessation treatments (including drugs) and liberalization of the sale of nicotine replacement therapy
 9
    Health warnings by images, rotating and combining negative and positive messages in packets of tobacco or generic brands
    10
    Inspection system for tobacco regulations with state, regional and local development. Sanctions of dissuasive amount with agile procedures of processing and execution

The background shows how the tobacco industry has been able to periodically develop new products and place them on the market as "safer", thus managing to stop the abandonment process among many smokers. To this day, in Spain the commercialization and diffusion of new tobacco products, even those with reduced potential risk, seem more a serious threat than an opportunity for the development of smoking control policies.

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How to break with nicotine addiction: TIPS

Quitting smoking is a very difficult challenge for many. That smoker has never tried it with the wide range of possibilities that exist in the market from chewing gum, patches to acupuncture, homeopathy, and even some home and exoteric remedies. However, tobacco remains the leading cause of avoidable death in Europe. Smoking cessation therapies that include pharmacological treatments and physician assistance are becoming one of the best alternatives to quit nicotine addiction. The past May 31 was the World No Tobacco Day for those who are smokers why not give the kick-off and forget about the cigarette to gain health.

Tobacco remains the leading cause of avoidable death in Europe. The World Health Organization (WHO) advises the union of text and photography on packs as an aid to smokers when it comes to seriously considering quitting smoking more convincingly and as a prevention against the increase of this addiction among the youngest .



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Although the smoker can see it as an impossible challenge. Leaving tobacco is possible. Here are some tips to overcome the most common obstacles faced by the smoker and get rid of smoking.

Quit smoking without getting fat

Several studies show that smokers weigh less than nonsmokers, and that quitting produces an increase in weight, mainly due to the metabolic effects of nicotine. This fact may not be easily accepted by some women because weight gain in women is objective and subjectively important. Objectively, because the feminine distribution of fat causes that the weight increases are noticed more than in men (in them in the hips, in them in the waist). Subjectively, because there is a significant distortion in the perception of ideal weight and most women with a body mass index (BMI) of 22-23 have the feeling that they should weigh less.

Nevertheless, recent studies show that the weight gain that occurs when quitting smoking is moderate and transient in most cases and in no way can constitute a barrier to quitting.

The increase of weight when leaving the tobacco can take place for diverse reasons, between which they emphasize:

• Loss of nicotine effects.
• Increase in caloric intake (especially sweets) to replace the routine behavior that is generated in the smoker.
• Decrease in energy expenditure.
• It is true that nicotine decreases appetite and increases the rate of metabolism at rest, but the effect that the abandonment of smoking has on weight is, many times, less drastic than fears most women smokers.

Thus, most people who stop smoking can gain between 2 and 3 kg of weight and only one in four could gain between 4 and 9 kilos.

In any case, this weight gain is much less serious than continuing to smoke and has a better solution, since the extra kilos can easily be lost once the anxiety has disappeared and the dependence on nicotine has been overcome.

As Dr. Isabel Nerín affirms, "the possible increase in weight due to smoking cessation is not obligatory, in fact there is a percentage of people who, when quitting smoking, also incorporate healthy habits such as exercise or a diet richer in vegetables, and as a result of all these changes, they thin out. "

Smoking is not the safest way to lose weight, in the same way that no one would recommend a slimming product that could increase the risk of suffering ten different types of cancer.

Tips that could help you not gain weight:

• Drink about two liters of water a day.
• Take fruit fasting.
• Daily exercise.
• Do not increase your calorie intake.
• Reassure yourself without smoking. Stop smoking without stress

One of the main psychological barriers to quitting smoking is the fear of the smoker to the anxiety that can cause his process of detoxification. And not without reason. The withdrawal syndrome appears due to both the nicotine addiction of the smoker, and their psychological-behavioral dependence on smoking. This translates into anxiety, nervousness, sleep disorders ... However, this obstacle is surmountable if you have the right tools. As Dr. Isabel Nerín says, "when you quit smoking without treatment, you can have a withdrawal syndrome due to the absence of nicotine, characterized by symptoms such as anxiety, irritability or sleep disturbances. To a large extent this withdrawal syndrome and now you can quit smoking without climbing the walls. "

What can be done to get rid of cigarettes?

To begin with, we must break the myth that tobacco reassures. That assertion is false, since it can even encourage the degree of anxiety when it begins to manifest because of a nervous state. On the one hand, the smoker has learned to calm down with tobacco and that tranquility is nothing more than the action of tobacco itself, which disappears as soon as nicotine levels fall. So any non-smoker is more relaxed than a smoker, who also, the addiction to nicotine creates withdrawal syndrome.

Quitting smoking requires a lot of effort on the part of the smoker, but the smoker is not alone: ​​the role of the doctor is paramount when it comes to providing correct information, offering the appropriate medical treatment and continuous monitoring in the patient's process of detoxification . Once the smoker is determined to give up his addiction, the first thing he should do is go to the doctor since he is the one who can best inform him about the therapies to follow to achieve success in his smoking cessation.

According to the Guide of the National Committee for the Prevention of Smoking (CNPT) to quit smoking, there are 7 keys to cope with difficult situations:

It is about overcoming the problem, not about repressing it

• Entertain yourself with something else when you feel like smoking.
• Change your routines
• Develop some activity to reduce emotional stress.
• Plan to do something every day that you enjoy, that gives you pleasure.
• Find people who can support you. Many times, people who have already quit smoking becomes one of the main motivations for those who decide to end their addiction.
• If necessary, seek professional support.
• Know how to enjoy the improvements that the ex-smoker begins to experience, starting from the first moment he abandons tobacco.
• The key is to have the command. The first thing to remember is that the anxiety disappears and the best way to combat it is to face it. And that is achieved by making an action plan that includes alternative activities in which there is no room for cigarettes. It is important to eliminate the thought of smoking and try to keep the mind occupied with other things.

Nicotine disappears from the body in 48 hours and the physical dependence on nicotine lasts only about a week. This first week will be the hardest, so it is important to choose the right time to start quitting. Once it has been overcome, the most important step will have been taken.

Exit does not mean relapse

Parties, meals, bars ... these situations can be especially hard for ex-smokers. For many people, the weekend is the hardest time. However, there are tricks that can make partying enjoyable when you are quitting smoking:

• Turn the challenge into a campaign: tell friends that you are quitting smoking so that you do not smoke in front of you and to have more support.
• Approach walking to the place where you have stayed. If it is too far, get off one or two stops and walk a while. In this way, exercise is done.
• Always remember, in a moment of weakness, all the advantages of quitting tobacco both in the short term thinking about the well-being of the morning after the party, and in the long term knowing that each day that passes less depends on the cigar.
• Improve stress: sleep well

A restful sleep is one of the aspects of your life that can be significantly improved when you stop smoking. Improve rest hours can be achieved by trying to go to bed at the same time every night and avoiding coffee and exciting drinks before bedtime. It is advisable not to eat during the last hour before going to bed so that the digestive system does not work while you try to sleep and, above all, do not take the worries.

Fighting impulses: tricks to eliminate temptations

Brushing your teeth often: it will not only improve your oral health but it will eliminate the desire to light a cigarette.
Take a relaxing bath or practice relaxation techniques.
Drinking water or juice: helps accelerate the elimination of nicotine from the body. Creates a feeling of satiety that decreases the craving for cigarettes and does not make you fat.
Do sport: not only will keep you in shape but the body will increasingly ask for less nicotine.
Avoid the abundant meals: you will eliminate the sensation of having to finish the lunch with a cigar.
Look for pleasant sensations to taste, sight or smell: every time you smell the smoke of snuff you will hate more.
Have at hand substitutes: candy, chewing gum, sunflower seeds ...
The feeling that you need a cigarette only lasts a few moments. If you are able to resist the first impulses every time the desire to smoke appears and eliminate your temptations, you will be able to leave it with ease.

Some tricks that will help:

When the temptation to smoke seems to be winning the game remember that every cigarette smoked are 7 minutes that you are subtracting the only life you have. If, in spite of everything, the problems related to the withdrawal syndrome persist, do not hesitate to go to your doctor: he will help you and give you support at critical moments.

Advances in the treatment of smoking

As smoking is considered by many professionals as a "mental disorder", methods to stop smoking often resort to psychological therapies, along with some type of pharmacological help; however, the mechanisms of action of these drugs can be very different:

Nicotine Replacement Therapy (NRT): consists of the supply of certain amounts of nicotine in the body in a continuous and controlled manner. In this way, the withdrawal syndrome is eliminated with an amount that is decreasing until the consumption of cigarettes ceases completely. The possible ways of administration of nicotine are through chewing gum, transdermal patch, nasal spray, oral inhaler or tablets to suck.
Bupropion: It was the first non-nicotinic medication, but it is an atypical antidepressant with stimulating properties, which acts at the level of the central nervous system. It is thought that it acts on brain reward systems in the same way that nicotine would, although less intensely, which would reduce the intensity of the symptoms of the withdrawal syndrome. It is administered orally.

Varenicline: This is an innovative drug that does not replace nicotine, but acts specifically on the receptors of this substance in the brain. When a person smokes, these neuronal receptors release substances, such as dopamine, which generates a sensation of pleasure, which is one of the main neurotransmitters involved in addiction processes. The great novelty that varenicline contributes is that, on the one hand, it stimulates the release of dopamine partially, to attenuate the craving for smoking and the symptoms derived from withdrawal, and on the other hand, it blocks the union of nicotine with brain receptors, to reduce the feeling of well-being associated with tobacco consumption.

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10 Steps to quit smoking

HOW TO STOP SMOKING SUCCESSFULLY?

In this article, our expert doctors in smoking cessation present you with 10 fundamental tips to stop smoking successfully . These are a series of methods to stop smoking that we believe are essential to understand how to quit smoking once and for all. 

1. Set a date to smoke your last cigarette
Mentalize: there are no tricks to quit smoking. You must set a date in which you say to yourself "I want to quit smoking" and fill it. Many more people have stopped smoking at once than doing reductions, which in the long run do not work. Think of your previous attempts and the best methods that worked well for you and those that did not .



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2. Change your routine to end up "cheating" your smoking addiction
Recover all those activities that you like and have forgotten. It is a good time to surprise yourself. Distract yourself from the urges to smoke. Plan something nice every day.

3. Do not look for excuses to leave it
Any day is a good day to stop smoking, not only for your health, but also for your family ... and your pocket.

4. Do not smoke any more cigarettes
For a cigarette or even for a puff falls, is the beginning of a great "friendship."   "For a cigarette nothing happens" should be "for a cigarette falls safely" ..

5. Think positively: "I want to quit smoking"
One of the best methods to stop smoking is noting the advantages, not only the physical ones, which are sure to be found from the beginning.   Seek support from your family, friends and co-workers.

6. Exercise. Stay active
It is not necessary to do an Olympic marathon. Sport is one of the examples of how quitting smoking can help you in your life.   Any small activity is a step to stop smoking:   It will relax you, help you control your weight and, above all, highlight the physical improvements of quitting.   You just need not take the car when you can walk, the stairs instead of the elevator ...

7. Drink lots of fluids
Drinking is one of the best tips while quitting smoking . Drink at least 1.5 liters a day since the body needs to hydrate. Try different flavors. Avoid alcohol.

8. Control what you eat
Avoid foods that get fat and if you need to snack, vegetables are your best allies. Under proper control, the person who stops smoking should not get fat.

9. Think of the day to day, not the never again
Think: "Today I do not smoke." This is your main goal when you want to avoid smoking a cigarette and being smoke-free today. You know you can get it.

10. Take advantage of the professional help that is being given to you
Ask health professionals how to stop smoking.   The different professionals that can help you will do everything possible to make smoking cessation a positive experience.

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Stop smoking in summer

Summer can be a good time to quit smoking. Discover tricks to do it if you want to go back to get a cigarette.

Summer is usually the time chosen to try to quit smoking . Out of the routine, we are more relaxed and calm, and those are moments in which we take advantage of to face challenges that due to the stress of the day to day, we would not face.



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•     Stop smoking this summer how to do it?
•     Mentalize
•     Find support
•     Short-term objectives
•     Avoid thinking
•     Try to change your habits

Stop smoking this summer How to do it?

Before considering the challenge, it is important to be aware. Change a habit with which we have been years is not easy. So we propose some guidelines to make it easier for you to achieve your goal.

1. Mentalize

This point is the most important, take the time you need but when you make the decision, there is no turning back. The subject is serious, so, choose the day you start and from there, for all.

2. Seek support

Quitting smoking is not an easy task, it is usually not achieved at first and several attempts are necessary, so finding support with family or friends is essential. Also, keep in mind that if you need extra help, there are pharmacies or centers that offer treatments for smoking cessation as well as psychological support or pharmacological reinforcement.

3. Short-term objectives

War is won day by day. Setting yourself small and realistic goals will make you feel better, more satisfied knowing that at the end of the day, you will be a little closer to your goal. In addition, you can reward yourself by giving yourself a whim that will reinforce your behavior. He thinks that proposing something forever is very complicated and professionals recommend doing it little by little, so, step by step.

4. Avoid thinking

By abandoning a habit, it can cause, especially at the beginning that we are continually thinking about it. Start a hobby is highly recommended, take the bike, go running, a little sport is always preferable. You will clear your mind, you will be distracted, and at the end, you will be avoiding thinking about tobacco continuously.

5. Try to change your habits

Identifying the habits with which we associate tobacco is vital. It is important to realize that tobacco consumption is linked to customs. Avoid situations like that cigarette during the morning coffee, the after-lunch, or when we are with friends, is key to not generate more stress than it already causes detoxification. Identifying those moments will make it easier to overcome the mental need of tobacco.

You follow these little tips and I'm sure they'll help you achieve it. Although it is a difficult road, the reward is worth it.