Please Stop Smoking







Although my blog is dedicated to opioid use disorder and its treatment with medications, this blog is about the importance of stopping smoking.

I was listening to the American Society of Addiction Medicine’s annual review course from 2018, and while I listened to the lecture of nicotine use, became convinced I must do more to promote smoking cessation among my patients and readers of this blog.

In the ASAM lecture I listened to by Dr. Abigail Herron, she remined me of some bleak facts about smoking: it is the leading cause of preventable deaths worldwide, and it accounts for 20% of deaths in the United States. Half of all smokers will die from tobacco-related illness.

Smokers die, on the average, of ten years earlier than they would if they never smoked.

That last bit of data stopped me. If you are a smoker who is reading this, what would you do to be given the gift of ten more years of life? For me, it would also depend on the quality of those years, but then, stopping smoking is likely to increase the quality too.

Rates of cigarette smoking are going down in the U.S., but as smoking is being promoted in the developing world, we will see more problems in these areas. By 2030, it’s expected that 80% of all smoking deaths will be in developing countries.

Deaths from smoking are usually from cardiovascular disease (heart attack or stroke), lung cancer, and chronic obstructive pulmonary disease (COPD) like asthma and emphysema.

Nicotine causes blood vessels to constrict, and smoking also causes blood to clot more easily, causing vascular disease of all types. We usually think of smoking causing lung cancer, but smoking increases the risk of cancers of the esophagus, kidney, pancreas, stomach, liver, urinary bladder, and uterine cervix. Smokers also are more likely to develop Type II diabetes, osteoporosis, erectile dysfunction, cataracts and macular degeneration, and early menopause.

And wrinkles. Lots of wrinkles, because nicotine cause blood vessels to constrict, limiting blood flow and depriving skin of oxygen and nutrients. I dabbled with smoking when I was younger but stopped after a few months when I thought I saw wrinkles developing. Vanity saved me from nicotine use disorder, and I’m happy about this.

It’s not only the nicotine that does the damage with cigarettes; they also contain harmful ingredients like hydrogen cyanide, ammonia, benzene, formaldehyde, and particulate matter like lead, cadmium, and nitrosamines. Cigarettes contain around forty-eight hundred compounds, and eleven are known carcinogens.

The active product, nicotine, is quite physically addicting. It stimulates the release of dopamine in the brain, producing feelings of pleasure, but nicotine also stimulates other neuro transmitters.

In the past, patients entering substance use disorder treatment programs weren’t asked to quit smoking, because we worried quitting both cigarettes and drugs (including alcohol) would be too hard and people needed something to fall back on. We worried patients would do worse in substance use treatment if they were asked to quit smoking too. Now, we have good evidence that shows the opposite may be true.

Most of the studies done in this area show better outcomes in patients who quit smoking early in their recovery from substance use disorders. Smoking cessation may improve the likelihood of longer-term sobriety. (Gulliver et al., Alcohol Research and Health, 2006) Several studies showed that patients entering addiction treatment were 25% more likely to maintain abstinence from alcohol and other drugs if they also stopped smoking (Prochaska et al, 2004, Joseph et al., 2004).

Patients’ brains may recover more quickly if they quit smoking. A study of patients with alcohol use disorders (Durazzo et al., Alcohol Clinical Experience Research, 2014) showed patients recovering from alcohol use disorder who quit smoking at the same time they stopped drinking rapidly improved on measures of learning and mental processing speed during their first month. Patients who continued to smoke had slower recovery of these mental functions.

Smoking during pregnancy has well-known risks. Moms who smoke are more likely to have miscarriages, low birth weight, ectopic pregnancies (pregnancy in the Fallopian tubes instead of in the uterus), placental abruption (when the placenta tears away from the uterine wall), and increased risk of Sudden Infant Death syndrome. Given these known problems, many moms chose this time to quit smoking.

I already talk to patients about smoking cessation, but after I listened to Dr. Herron’s lecture, I vowed to redouble my efforts, and talk to everyone about quitting.

Here’s what we know about quitting smoking: though not easy, it can be done. If you have a failed attempt, don’t give up. As with other substance use disorders, learn what you can from each relapse. Learn what does work for you and what doesn’t. Pay attention your triggers.

Medications can help, and double quit rates. The three first-line medications are bupropion (brand names Wellbutrin and Zyban), varenicline (Chantix) and all the nicotine replacement therapies (NRT). NRT comes in patches, gum, lozenges, inhalers, and nasal sprays.

Each of these products have some drawbacks; the gum can stick to dentures, making it less desirable for some patients. The patches can cause a skin rash, and the inhalers can potentially cause breathing problems, so patients may want the advice of their primary care provider.

I’d like to educate readers about e-cigarettes and vaping, but that’s difficult, due to the many products on the market. One product may have significant carcinogenic particulate matter in what is being vaped, and another product may not. Overall, vaped products have fewer cancer-causing substances, but still contain things other than nicotine. At a minimum, e-cigs and vapes contain flavoring and humectants. Since people tend to puff longer with a vape or e-cig, these substances may still be harmful to the heart and lungs.

Though smoking rates in the U.S. have dropped significantly over the past decades, down to around 15% of the population, adolescents use of e-cigs and vapes has increased rapidly. Manufacturers make products targeted towards adolescents, for example, with cotton-candy flavored products.

Thus far, no electronic nicotine delivery systems are FDA approved for smoking cessation. These products might be helpful if they are used as a complete substitute for tobacco. However, people who both smoke cigarettes and use vape products, called dual users, are no more likely to quit smoking than people who aren’t trying. That’s discouraging data about using e-cigs and vapes to quit.

There’s good news for people who want to quit smoking. Circulation improves after only a few weeks of smoking cessation, and lung function can increase up to 30% within the first three months. After one year of stopping smoking, the cardiovascular risk drops to half that of someone who continues to smoke. Ten years after quitting smoking, the risk of developing lung cancer drops to half that of a smoker.

Talk to your doctor to form a plan to help you quit. Consider accessing the free North Carolina quit line for help:

They have a 24-hour hotline, and even have coaches available to help you.

I’m writing this because I have many friends in recovery from substance use disorders, and some of them still smoke. I like these people, and don’t want them to die early. I want them to quit and be around for many more years, sharing their experience, strength, and hope with the rest of us.

2 responses to this post.

  1. Posted by Alan Wartenberg MD on May 20, 2019 at 3:02 am

    There is only ONE field in medical practice where you can go to a conference for practitioners of that field (like the Cape Cod Symposium on the Addictions, which I love), and find, of the 1300 or so people gathered at the conference, somewhere around 300 (and maybe more) hanging around outside, smoking (which I hate). Our program in Boston was the first to go smoke-free, and that is one of our proudest achievements. One of the problems in our field is that a higher percentage of people with SUD’s still smoke cigarettes While it has gone down to 18% or so of the general population, it is still around 50% of people with SUDs. Unfortunately, even when they get into recovery from their drug-of-choice, they continue this other drug-of-choice. And that includes counselors, therapists of all kinds with recovery histories and even doctors and nurses. And we will have a hard time convincing our patients to stop if we don’t. Shame on us.


  2. Posted by jp on October 5, 2019 at 12:57 am

    Great article.
    As a Pain Physician I also tell my patients there is evidence that smoking reduces the effectiveness of analgesics AND worsens pain perceptions.


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