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Healthy Living December Issue
DYING FOR A CIGARETTE? KICK THE HABIT AND LIVE


The Cumulative Impact of Smoking

Although the majority of smokers express a desire to quit smoking, only a minority have real plans to take that step in the near future. What are the factors that lead up to someone finally saying, "It is time for me to kick the habit"? And of equal importance, what factors will help a person who makes that decision be successful? This chapter is dedicated to helping nonsmokers remain nonsmokers, helping smokers see that the best time to quit is today, and giving everyone the tools to be free of tobacco in all its forms.



Motivation to Quit

There is no question that the knowledge of smoking’s physical harms can provide some of the most powerful motivations to quit. Such information has helped motivate many to kick the habit, as shown in Figure 1: Information on the Dangers of Smoking Helps Smokers kick the Habit.2

The trends following the Surgeon General’s announcement provide strong evidence that knowledge of smoking’s dangers can help a smoker decide to quit. Some of the information in this chapter on the physical harms of smoking will be familiar. However, much of it will not be. The full scope of smoking’s damage has not been well publicized. In a 1983 Harris survey, health professionals rated "not smoking" as the very first priority among activities that Americans could do to protect their health. The public, however, rated "not smoking" a distant 10th on the list of important health-protective behaviors.3

Public health professionals often stand amazed at how complacent we are as a society regarding smoking. For nearly 20 years, influential public health voices have called smoking the most dangerous public issue that we face. In 1979, the U.S. public health service called smoking "the largest single preventable cause of illness and premature death in the United States." C. Everett Koop made a bold pronouncement three years later during his tenure as Surgeon General. He pronounced smoking "the most important public health issue of our time." Dr. Ronald Davis, in citing such statements, points out, "Future historians will look back with amazement that it took society so long to control the use of tobacco."4

Why does the public seem to have a different view of this addiction than professionals? Part of the reason relates to tobacco industry practices of exercising a type of censorship against bad press regarding nicotine and smoking. They accomplish this by influencing the coverage of information in magazines that are dependent on tobacco advertising dollars for their existence.5 Actual research studies show that magazines that depend largely on cigarette advertising are less likely to feature articles dealing with smoking’s hazards. This is particularly noticeable in women’s magazines.6

There are other risks from smoking besides those that affect the personal health of smokers. We will also examine these issues in this chapter. Each can play a role in helping a smoker see more clearly the negative aspects of the smoking habit. This will help each smoker advance in the process of ultimately quitting for good. Some of these other risks include the damages of secondhand smoke, the costs of smoking-not only to the individual-but to his or her family and employer, and the smoker’s personal example and its effect on the next generation of Americans.



Prevention Efforts Must be Focused on Youth

We need to focus a good share of our prevention efforts on children and adolescents for a number of reasons:24
  1. It is easier for young people never to start smoking than to stop once they become addicted.

  2. The earlier individuals start smoking, the more years they are exposed to the injurious effects of tobacco, and the greater the risk of serious diseases.25

  3. Smoking has immediate physical and social effects that can undermine health, impair performance, and weaken career opportunities.

  4. The tobacco industry is actively targeting young people as their hope for the future;26 we must actively focus on this age group to help empower them to determine their own future.

  5. If we really believe in prevention, we will start with the group who has not yet taken up the habit-this is the greatest way to minimize the health risks of smoking.
All told, of those 3000 young people who start smoking today, at least 750 of them will die prematurely from a smoking-related illness.27 Furthermore, each of those 750 victims will lose 21 years of life on average. This translates to a figure of 15,750 life-years lost-a total that is 5 to 6 times that exacted by traffic accidents and murders combined.

The dangers of youth smoking do not relate to merely the damage wrought by the host of toxic chemicals in cigarette smoke. Many experts look at tobacco as a "gateway drug." What this means is that smoking (and other forms of tobacco use) often opens the gate to the use of illicit drugs later on. Research suggests that children who use tobacco are more likely to go on to use in sequence alcohol, marijuana, and then other illegal drugs.28

The emphasis throughout this book is on preventing diseases as opposed to treating them after they become problems. The approach in this chapter is no different. The best way to prevent diseases caused by smoking is to help individuals avoid nicotine addiction in the first place. This fact has not been lost on the public health community. Nonetheless, there are indications that we may be losing the war. Recent statistics indicate that smoking among high school seniors is on the increase, rising from 17 percent to 22 percent in four years (1992 to 1996).29 Currently about 30 percent of American youth drop out of school before becoming high school seniors, and dropouts are three to four times more likely to be smokers than their peers who complete high school.30 All told, more than three million U.S. children under the age of 18 are regular tobacco users. More than two million others are actively experimenting with tobacco products.31

The stakes are high. Not only are lives involved, but an incredible amount of money also hangs in the balances. Estimates in 1989 indicated that the tobacco companies collectively were taking in some $1.25 billion dollars per year from the sale of their wares to minors.32 The tobacco industry spends $265 million dollars (1988 statistic) giving free cigarette samples through coupons. This is an effective way to put cigarettes in the hands of young people at no cost to them, and with little chance of their being caught. A recent Camel advertisement was obviously directed at youth. Along with the coupon it suggested that you have a friend or a "kind looking stranger" redeem the coupon for you if you were "uncomfortable."33

And the free sample strategy works. Consider the case of Sean Marsee. This Oklahoma youth got his first taste of tobacco as a minor when a tobacco company representative gave him a free pack of snuff at a rodeo. Sean’s habit carried a heavy price, however. At the age of 18 he died from mouth cancer caused by smokeless tobacco.34 In those who have objectively studied smokeless tobacco marketing, there is no question that the tobacco industry has been targeting minors in their placement of advertising as well as in their distribution of free samples.35 How can we help our teenagers and younger children avoid this deadly habit? For children 3 to 11 years old, the task may be as simple as convincing them that smoking is dangerous to their health.36 However, by the time they reach puberty, most researchers feel that knowledge of health consequences is not enough. Part of the problem is the tendency of young people to view themselves as "immortal." Even if they acknowledge that smoking is dangerous, they often do not see it as a personal risk.37

A great variety of factors seem to play a role in youth smoking, such as the influence of friends, poor scholastic performance, etc. Some experts feel that efforts focusing on tobacco alone are doomed to fail with this age group. They argue that messages to quit smoking will only be broadly effective if they are part of more comprehensive efforts to address some of the social conditions that feed into smoking behavior.

Parental smoking is one factor that influences children to smoke. Parents are role models whether they recognize it or not.38 In fact, Dr. Flay, in his comprehensive chapter on youth tobacco, says that many studies demonstrate that parental smoking is the very strongest predictor of whether or not a child will smoke.39 This role-modeling effect is especially important with younger children. Children may get the message from their parents that smoking is acceptable, and that it is a legitimate way to deal with stress or boredom. This point emphasizes that a parent stopping the smoking habit is one of the most important strategies for preventing tobacco use by their children.

An approach to the social aspects influencing youth smoking involves more than the example provided by parents and other adults. Research indicates that classroom-based programs are most effective when they address social influences in a structured way. Such programs obtain far better success than programs that only impart knowledge about smoking’s health effects.40 Some of the elements that the most successful programs utilize are enumerated in Figure 7: Elements of Successful Youth Smoking - Prevention Programs.41, 42

Clearly, for children and youth who see themselves as immortal, a good case can be made for emphasizing the short-term detriments of smoking. These may include decreased athletic endurance, cost, stained fingers, premature graying and baldness, bad breath, cough, phlegm production, shortness of breath, body odors, cigarette burns, and risk of starting a fire.43, 44 Even armed with this knowledge, it is still important to impart an awareness that smokers are in the minority, and to dispel myths about tobacco’s benefits. In the face of all of these good reasons not to smoke, experts then recognize a need for special training in refusal skills.45 Young people need to learn to say no in a way that they feel is acceptable to their peer group. Giving reasons to peers may actually be one of the most effective ways to legitimatize their stance. The child may say, "No thanks, it makes my clothes smell", or "No thanks, it will interfere with my playing sports."

Another element that may help deter youth from smoking is by confronting them more squarely with the addictive nature of nicotine. Recent research confirms that young people who smoke daily tend to smoke for the same reason that adults do-they are addicted. Furthermore, statistics also illustrate the deceptive powers of cigarettes. Many young smokers apparently take up the habit thinking that they can remain "in control."46 But here is where they are deceived. That small paper roll of tobacco contains nicotine-a powerfully addictive chemical. Dr. Louis Sullivan, former U.S. Secretary of Health and Human Services, sums up the relationship between teenagers and smoking as quoted in Figure 8:



Expectations of Teens.

Even if we can halt the emerging trend of an increase in youth tobacco use and keep smoking initiation at its present level, the future still looks bleak for our children. Figure 9: A Smoking Catastrophe expresses the grim realities.47

The death of five million children is a catastrophe that we must do our utmost to prevent. The information in this chapter can play a pivotal role in preventing this epidemic. If smokers take these messages to heart and quit now, and if all parents can impart this information to their own children, we can make a significant impact.



The Dollar Costs to Society of Smoking

When you think of the human devastation caused by smoking, any financial costs tend to pale in significance. However, in an environment of shrinking health care resources, we must look at the financial impact of this habit as well. What are the health care costs for smokers? Figure 10: Healthcare Costs of Lifelong Smokers illustrates some of the best current estimates.48

We have seen startling escalating health care costs each year in America. One of the major reasons is the huge price tag that tobacco carries. Many patients that I take care of in our hospital intensive care unit on a daily basis are there because of the effects of tobacco. If you have not been a patient in an intensive care unit, consider yourself fortunate. The diseases that land you there are usually serious and the daily price tag is very high. Heart attack patients typically are taken into intensive care units for a number of days. Other smokers find themselves in the intensive care unit because they need a ventilator (a mechanical breathing machine). Although these machines can be lifesaving, they are probably among the most difficult procedures for the patient to tolerate. Just imagine lying awake with a large plastic tube going through your nose or mouth, down your throat, and into your windpipe. On top of all this, the machine breathes for you. In many such circumstances, you are actually unable to take a breath on your own, even if you want to.

What is the best way to end up on a ventilator? Continue smoking. As your lung effectiveness deteriorates, normal recovery from surgery or normal improvement from pneumonia may well elude you. When you get into such situations, part of your recovery may take place in the intensive care unit on a ventilator.

Not only are those intensive care stays demanding on the patient physically; they are, to repeat, extremely costly. Where does all the money come from? From Medicare funds, medical insurance companies, and, yes, even from patients’ own personal bank accounts. Regarding illnesses due to smoking, all of the expense arises from wholly preventable conditions brought on by an individual’s own actions. It was a voluntary act by the individual in adopting the smoking habit that collectively totals 50 billion dollars per year in health care costs.

If we could eliminate the smoking problem in America, we would certainly relieve the crisis in health care costs. The problem of escalating costs or the need to cut those costs would be diminished. The need to close down our hospitals or medical research programs for lack of funds would be diminished or even disappear. Fifty billion dollars of savings each year would surely go a long way. Certainly, the pressure to make "Medicare cuts" would disappear entirely.

Some have framed the financial argument in other terms. When the additional costs of things like disability and premature death are added into the equation, every family of four in our country is probably paying close to $1000 per year (in taxes and increased insurance premiums) so that other Americans can have the "privilege" of smoking.49 In view of this, many citizens are concluding that it is wrong for the American taxpayer to, in essence, be subsidizing the tobacco companies and smokers.

Others have made even bolder suggestions. One of the boldest is the proposal to restructure Medicare such that all smokers are totally barred from Medicare benefits. I mention this radical proposal because it highlights the economic issues. Merely discussing some of these more eccentric proposals may help smokers better realize that in the present U.S. system they are not only harming their health, but they are asking someone else to pay for many of the related costs.



Smoking and Cancer

As was previously stated, in 1964 the Surgeon General accurately and emphatically stated that tobacco causes lung cancer. It is hard to find a smoker today that does not accept that fact. The lung cancer message has been heard loud and clear by smokers. What has not been publicized is that smoking increases the risk of many other cancers. There are at least 16 other cancers related to smoking. They are listed in Figure 12: Smoking Causes More than Lung Cancer.54, 55, 56, 57, 58

These cancers are in 16 critical areas of the body. All told, estimates indicate that every year in the U.S. some 150,000 smokers die from cancers that are a direct result of their smoking.59, 60 Nearly one-third of all cancer deaths are due to smoking.61 Some of the cancers that smoking causes tend to be rapidly fatal, such as cancers of the esophagus, lung, pancreas, and liver. Others offer more chance for cure, but all are potentially devastating if not fatal.



Dozens of Carcinogens in Tobacco Smoke

Tobacco smoke contains a veritable witches’ brew of compounds that almost seem purposely designed to cause cancer. Of the 4000 identified chemicals, 43 are known to be carcinogens. Carcinogens are able, in and of themselves, to cause the beginnings of cancer. For this reason they are sometimes referred to as cancer initiators. Also, tobacco itself contains a variety of carcinogens. These compounds are unable to cause cancer themselves, but when they are present in the company of full-blown carcinogens, they increase the risk of cancer.62 There are still other chemicals in the smoke that are called tumor accelerators. As their name indicates, these speed up the growth of cancer once it has begun.

The information in this section regarding the devastation wrought by smoking is massive. It is consistent-there are no contradictions in the data. Cigarettes cause disease, destruction, and death. Being a nonsmoker is the most powerful way to prevent cancer. If you smoke, yet love life and want to live, the very best decision you can make is to kick the habit now.



Smoking, Heart Disease, and Other Diseases of Blood Vessels

Many are aware that tobacco causes cancer, but few of my patients seem to realize that smoking causes diseases of the heart and blood vessels.98 Coronary heart disease (heart disease caused by blockage of the heart arteries) is the number one killer in America today partly because of the large number of people who are addicted to tobacco. Another top killer, stroke, is also related to smoking.99 Diseases of the blood vessels of the arms and legs, known as peripheral vascular disease, are also dramatically increased by smoking.100 The common denominator in all of these diseases is a process called atherosclerosis, which is greatly accelerated by smoking.101

How many Americans die of diseases of the heart and blood vessels? When added together, strokes, coronary heart disease, and peripheral vascular disease claim nearly a million lives each year. Close to 300,000 of these deaths are the direct result of cigarette smoking and its effects upon the blood vessels.102 Simply put, if these people had not been smokers, they would probably still be alive today.

It is well established that a singular factor, smoking, is the cause of a massive number of deaths each year because of its effect on the blood vessels alone. The whole world should be made aware of this tragic news. A number of years ago, the Surgeon General sent a letter to every American about the AIDS virus. I received one, as did every other American who had a mailing address. The letter served a good purpose: it told us how to avoid dying of AIDS. However, comparing the high number of heart disease deaths caused by smoking with the much smaller number of AIDS deaths every year, the Surgeon General should have sent out five letters to each American to warn us of the cardiovascular evils of smoking.



How Much Does Smoking Increase the Risk of a Heart Attack?

Studies show that those who are between the ages of 45 and 54 and smoke more than one pack per day increase their risk of a heart attack by over four times.103 Older smokers increase their risk between 70 and 200 percent depending on their age.104 Moreover, when combined with other risk factors such as high cholesterol and hypertension, the effect of smoking is even greater, according to a summary of studies on smoking published by the Pooling Project Research Group.105 The findings are listed Figure 18: Impact of Smoking, High Blood Pressure, and High Cholesterol on the First Major Heart Attack .

Notice that 23 of 1000 nonsmokers with diastolic blood pressures below 89 and cholesterol levels below 249 had their first heart attack before they were 59 years old. For those who smoked (with neither of the other risk factors), the risk was more than doubled, at 54 heart attacks. On the other hand, those nonsmokers with high blood pressure and high cholesterol had a risk four times that of someone without those risk factors. However, if those persons add smoking to their lifestyle, the risk jumps to eight times that of the low-risk individual. Those with all three risk factors are obviously in the most dangerous group; they are living on the brink of having their first major heart attack. In the Pooling Project data, within 10 years, nearly 1 in 5 of these relatively young individuals (30 to 59 years old) had a heart attack. This is a greater risk than expected, when compared to totaling up the risk of each factor separately.

The conclusions drawn from this and a host of other studies are compelling. Some of the key points are listed in Figure 19: Smoking and Coronary Heart Disease.106

Many find the strong relationship between smoking and heart disease deaths hard to accept. Nonetheless, the statistical research is clear. Among Americans who are under 65, smoking is responsible for fully 45 percent of male heart attack deaths and 41 percent of female heart attack casualties. In younger women, the risks may be even greater. One researcher suggests that about 76 percent of heart attacks in young women are due to cigarette smoking.107

Similar relationships are found in other Western nations. For example, a recent British study found that smokers in their 30s and 40s were, remarkably, five times more likely to suffer heart attacks than nonsmokers.108 This research indicates that, in the United Kingdom, tobacco is to blame for the majority of heart attacks striking those younger than 50 of both sexes. Young women who smoke can further increase their risk of heart attack if they also use the oral contraceptive pill. These striking relationships are shown in Figure 20: The Pill, Smoking, and Heart Attacks.

Notice that combining smoking with pill usage causes a much greater increase in heart attack risk than expected when compared to the effect of either one alone.



Fatal Heart Attacks Caused by Smoking

Not only are smokers more likely to have a heart attack, they are more likely to die from one. Furthermore, they are at higher risk from sudden death due to heart disease. When death occurs within 24 hours of some distinct change in an individual’s state of health, it is called sudden death.109 It can happen to an apparently healthy individual while on the job, enjoying leisure time, or with the family. It typically comes suddenly, without warning; life may slip away in a matter of minutes. Figure 21: Smoking Elevates Sudden Death Risk quantifies the increased risk of sudden death in smokers.110, 111

Notice that smokers have up to four times the risk of sudden death compared to nonsmokers. Fortunately, however, the risk diminishes dramatically when a person stops smoking. In fact, so quickly does the risk fall, that within one year the risk of sudden death from a heart attack has dropped 50 percent.

Why is there such a rapid decrease in sudden death risk? One of the answers seems to lie with nicotine. Nicotine in cigarettes increases the risk of sudden death by predisposing to fatal heart rhythm problems. In other words, if a smoker has a heart attack, sudden death is more likely because nicotine in the blood renders the heart more irritable. Nicotine, however, is rapidly cleared from the blood once a person stops smoking. Within just a few days of the last cigarette, we would therefore expect a person to be at much lower risk of death from a heart attack. Your clotting system also rapidly changes when you stop smoking. One of the key actors in this process is the platelets. What are the platelets and what is their function? Platelets are very tiny substances in our bloodstream that are smaller than white or red blood cells. They go into action when a blood vessel is cut. Without platelets, a cut would continue to bleed until it was fatal. Platelets prevent this from happening by clumping together and sealing off the cut. The clump (or clot) grows until it is large enough to seal the broken blood vessel, stopping the bleeding. Platelets do a wonderful work for the body in sealing off broken blood vessels, usually within minutes.

These clotting cells become more sticky and tend to clump in an unnatural way when a person smokes.112 They tend to clump inside a vessel where there is no cut, usually at places where the blood vessels narrow down. If the narrowing is located in a coronary artery or the blood vessel that carries blood to the brain, clumped platelets may stop the flow of blood. This may affect the control of limbs, affect speech, or even result in sudden death. When a person stops smoking, platelet function begins to return to normal-in just a matter of days.113 Since the average platelet only lives 10 days,114 in less than two weeks you will have a whole new population of normal platelets in the body. These changes seem to play a significant role in decreasing heart disease risk within a short time of stopping smoking.

The facts regarding heart rhythm stabilization and normalization of clotting function should provide further encouragement for smokers to kick the habit. The rapid change in risk of sudden death is just one example of the body’s marvelous ability to repair itself and return to a normal state of functioning. I will cite more examples of how the body can bounce back from smoking-related damage later in the chapter.



Dangers of Passive Smoking

Passive Smoke Increases Heart Disease Risk

It is bad enough that smoking affects the smoker. In addition, it increases the risk of heart attack deaths in nonsmokers by 20 to 30 percent. Drs. Glantz and Parmley of the University of California at San Francisco identified a number of reasons for increased heart risk in nonsmokers in their comprehensive review of the subject.128 Other studies have added to this body of information.129,130,131 Secondhand smoke damages nonsmokers as shown in the following list.

EFFECTS OF PASSIVE SMOKING
  1. Reduces the blood’s ability to deliver oxygen to the heart
  2. Compromises the heart muscle’s ability to use oxygen
  3. Lowers HDL levels as much as in active smokers
  4. Increases platelet activity
  5. Damages the lining of blood vessels
  6. Impairs dilation of blood vessels that normally occurs during exercise and other conditions
  7. Causes blockages in heart blood vessels to form faster
  8. Increases the amount of heart damage following a heart attack
We see that smoking affects the cardiovascular system of the passive smoker and the smoker in the same way. The clear message as enunciated by Glantz and Parmley is "Nonsmokers exposed to secondhand smoke in everyday life exhibit an increased risk of both fatal and nonfatal cardiac events."132

An entire chapter of Drs. Orleans and Slade’s definitive book on nicotine addiction is devoted to "tobacco smoke pollution." There they quantify the number of deaths caused by secondhand smoke each year in our country.133 Their estimates are listed in Figure 27: U.S. Deaths per Year fom Passive Smoking (Est.).

About 50,000 passive smoking deaths from heart disease and cancer is a significant number. The tragedy of passive smoking is that it hurts innocent people, those who themselves have chosen not to smoke. Outcries against this infringement on the rights of nonsmokers have largely been responsible for legislation prohibiting smoking in public areas.



Do Smokers Cause Cancer in Friends and Loved Ones?

The Journal of the National Cancer Institute reported on a study of 210 women who developed lung cancer but never smoked. Results are shown in Figure 28: Cancer Risk from "Passive Smoking".134

The risk of developing lung cancer more than doubled for those nonsmoking women who lived with one or more smokers. This is only one of many studies that show the same results: "passive smoking" is dangerous to your health. Of course, it is not as dangerous as "active smoking;" that is, smoking your own cigarettes rather than those of someone else’s. Remember, active smokers can increase their own lung cancer risk 10 to 20 or more times, compared to the doubling or tripling in risk seen with passive exposure. It is noteworthy that other smoking-related cancers also may be increased by the smoke of those around you. For example, published reports link cancer of the cervix (the opening of the womb) not only with active smoking, but also with secondhand smoke.135

Another message from the medical studies on secondhand smoking is that it is most devastating for the most defenseless: the young and the unborn. Recalling the study published by the National Cancer Institute, smoke exposure in childhood and adolescence was nearly twice as potent at increasing cancer risk as exposure in adulthood.136 An even more chilling report was published by Dr. Dale Sandler and colleagues at the National Institute of Environmental Health Sciences. Their research indicated that childhood exposure to parental smoking (either in the womb or after birth) increased cancer risk years later when the child became an adult. One group of cancers that was markedly increased was the hematopoietic cancers. These are cancers of the blood-forming tissues and include the infamous leukemia. When one parent smoked, risk of these devastating cancers jumped 70 percent. However, when both smoked, the risk increased 360 percent.

When all cancers were looked at, risk was actually greater if the father smoked than if the mother was a smoker. Risk of cancer across the board was increased by 50 percent.137 Other research has demonstrated that children whose mothers smoked during pregnancy are at increased risk of childhood cancers.138 Interestingly, if the child’s father (but not mother) smoked, the child was at increased risk of brain cancer.139

Upon discovery of these and other dangerous effects of secondhand smoke, citizens throughout our nation have passed legislation prohibiting smoking in restaurants, airplanes, and the work place. After all, the public reasoned, who has the right to endanger the health of innocent bystanders by lighting up a cigarette? Such an act is one of "people abuse." In the wake of all the attention directed at passive smoking, a newspaper cartoon pictured a horse lying on its back in a hospital bed. The animal was ill and emaciated. It was receiving medication by vein labeled "chemotherapy." The caption under the cartoon said "all those years with the Marlboro Man." The horse was a victim of his master’s smoking-a victim of passive smoke exposure.

Smoking kills far more people from heart disease and cancer than from any other single health-related problem. Similarly, when we look at passive smoking, many casualties come at the hands of these two leading killers. However, in many minds, secondhand smoking’s greatest emotional impact comes from the damage it does to our children and grandchildren, with some being affected throughout their lifetime.



Parental Smoking and Sudden Infant Death Syndrome

Perhaps most frightening, however, is the statistic that infants exposed to tobacco smoke are two times more likely to die of SIDS-the "sudden infant death syndrome." The link between maternal smoking and infant death is outlined in Figure 29: Mom's Smoking Linked to Sudden Infant Death Syndrome.148

Sudden infant death syndrome occurs in apparently healthy babies. Everything about the child seems normal. The mother and baby are bonding well; she is so happy to have the little one. The child is put in the crib for a nap; when the mother returns to the crib at the usual wake-up time, the baby is dead. The pain and suffering of the parents are indescribable in such a death. The baby of a mother who smokes during pregnancy and after is three times more likely to become a victim than the baby of a nonsmoker. Even if a woman stops smoking at the time she delivers, her baby who was exposed to her smoking in the womb is twice as likely to be a SIDS victim. Yes, kicking the habit at birth reduces the risk, but it is still greater than for the baby of a nonsmoking mom. It is clear that smoking should cease before a woman becomes pregnant.

Research published in the British Medical Journal presented similar findings. In their research, a mother who smoked during pregnancy increased the risk of her child dying with SIDS before eight weeks of age. The risk of death jumped by 55 percent for every 5 cigarettes per day that she smoked.149 Amazingly, the father’s smoking was an even more powerful risk factor; however, the results were only apparent in infants older than 24 weeks old. Every five cigarettes that dads smoked each day essentially tripled their child’s risk of SIDS.150 Clearly, the risk of SIDS appears to be related both to parental smoking around the infant as well as to the parents’ smoking habits during conception and pregnancy. These considerations call attention to the fact that parental smoking first exerts its effects on children long before they are born. Other kinds of damage that can be done to an infant whose mother smokes during pregnancy are listed in Figure 30: The Smoking Mom Causes Multiple Damage.



Smoking Parents - A Form of Child Abuse?

For reasons such as these, obstetricians and pediatricians have become champions of smoking cessation. Almost all obstetricians inform their pregnant patients to quit smoking. Pediatricians generally give the same advice to the smoking parents of their young patients. Truly, it is tragic enough that smokers damage their own bodies, but the tragedy takes on much greater proportions when the habit harms their own children and grandchildren. No normal parents would want to deliberately threaten the health or well-being of their child, but it is happening daily in our society. When parents realize the damage their smoking inflicts on their innocent children, would it provide enough incentive for them to kick the habit? In America today, child abuse has become a major issue. Some are suggesting that a smoking parent is guilty of a subtle form of child abuse.



Chronic Lung Diseases Caused By Smoking

About 60,000 Americans die each year of chronic lung conditions such as emphysema and chronic bronchitis caused by cigarette smoking.175 These lung conditions are often collectively referred to as chronic obstructive pulmonary disease (COPD). Another published statistic is that smoking causes 85,000 deaths per year in our country from various pulmonary diseases, including both COPD and pneumonia.176 A whole host of changes in body functions induced by smoking sets the stage for chronic lung problems. Smoking causes widespread damage to the lung’s defense systems. These changes also set the stage for chronic obstructive lung disease.



The Cause of "Smoker’s Cough"

Chronic bronchitis is one of the lung conditions that occurs under the influence of cigarette smoking. This illness seems to be a direct result of two of smoking’s effects: paralysis of the cilia and irritation of the lung lining tissues. You will recall that in nonsmokers, microscopic cilia help to keep the lung clean. But because of chemicals like formaldehyde, hydrogen cyanide, nitrogen dioxide, and ammonia, the cilia of smokers are paralyzed. To make matters worse, there are a host of irritant chemicals in tobacco smoke that cause the lung to make more mucus and thicker mucus. The result is greater mucus buildup in the lung. With deficient cilial function, the only way that the body can clear this mucus is by coughing. Thus, the hallmark of chronic bronchitis is a persistent "smoker’s cough." A cough may sound harmless enough, but chronic bronchitis is a progressive disease. In its advanced stages it can cause severe impairment and even death.



Smoking Degrades the Quality of Life

As Americans get older, many fear disability more than they fear death. The good news is that medical research has found that paying attention to good health habits now decreases our risk of disability later. One of the key factors in preventing disability is avoiding smoking. Some of the most convincing research comes from studying individuals between 60 and 94 years old from Alameda County, California.180, 181 Ongoing research on that population has determined that cigarette smoking significantly increases the risk of disability. Healthy eating habits and regular exercise also helped to decrease the likelihood of disability as the participants’ aged.182

There is no question that smoking causes life-threatening diseases. It also increases our risk of disability and decreases the quality of life in a number of ways other than disability; they are listed in Figure 35: Smoking Decreases Quality of Life.



Smoking Weakens Bones

The strength of our bones depends on their density. The more dense our bones, the stronger they are. A decrease in bone density and strength is undesirable: risk of fracture escalates. We have known for some time that cigarette smoking contributes to the loss of bone density. There is a host of other risk factors that contribute to bone loss; however, smoking is a major one to reckon with.183

Many research studies have conclusively demonstrated that smoking women have less bone density. Problems, however, usually do not surface until they go through menopause and suffer further bone density losses. At that point they become much more likely to suffer a hip or other fracture as a result of osteoporosis (thinning of the bones). Hip fractures are serious in older Americans. The risk of the most serious complication, death, increases with the age of the patient. In older Americans, within one year of the hip fracture, roughly 20 percent of the victims will die. In the next year, another 13 percent will die.184 Thus, roughly one third of older hip-fracture patients do not survive two years following the episode. The good news, however, is that after those two years the risk of death is similar to those who have never had a hip fracture.185

Even if a broken bone does not cause death, it certainly degrades the quality of life. Anyone who has been incapacitated by a hip fracture recognizes the impact on life’s quality. The inconvenience and misery of surgery, healing, recovery, including physical therapy to learn to walk again, can be a discouraging experience that stretches out for months. The statistics suggest that in many cases all this misery could have been avoided had that victim chosen not to be a smoker.

Other fractures due to thin bones can also rob life’s quality. Consider vertebral compression fractures. These fractures of the backbones are not only generally painful, but they also cause a decrease in height and can cause a humpbacked posture. A study at Melbourne University measured the loss of bone density caused by smoking. The results are shown in Figure 36: Smoking Robs Bones.186 This study of twins on smoking and bone density is significant. Since identical twins have identical genes, the possibility of genetic differences was eliminated. One pack per day is enough to cause dangerous weakening of the bones.



Smokers Have More Back Pain

Back pain is costly for the individual and for his or her employer. In fact, back pain costs employers over 10 billion dollars each year. Nearly half of all days missed from the workforce are due to back pain-and the condition affects 80 percent of the working population at some time in their careers.187 Among the risk factors for back injury are the obvious things: poor posture, poor lifting techniques, being overweight, lack of fitness, and excessive stress.188 However, also on the list is cigarette smoking.189

Cigarette smoking is an important and often unrecognized risk factor for back pain. A study of workers in Maine found that smokers of more than 1 pack per day had triple the risk of significant back pain. Other studies have found that cigarette smokers are more likely to suffer from serious spinal disk disease. And following successful surgery for low back pain, smokers have a greater risk to again experience disabling low back pain.190 One serious form of back pain is caused by problems with the disk structures that provide cushioning between the backbones or vertebrae. A leading theory is that smoking limits blood supply to the disks so that they become more susceptible to everyday wear and tear and ultimately sustain damage sooner.



Smoking and Hormonal Function

Current evidence indicates that smoking can alter a host of hormonal factors. Sex hormone levels are affected, including the important follicle-stimulating hormone (FSH) and luteinizing hormone (LH).191 It is likely that these hormonal effects play a role in the premature menopause that tends to occur in smokers. Parathyroid hormone is a critical hormone involved in mineral balance; it is decreased in smokers.192 Furthermore, evidence indicates that smoking may worsen mild thyroid deficiency. A recent Swiss study evaluated over 80 women with mild thyroid problems.193 Those who smoked had worse thyroid function and significantly higher cholesterol levels (28 percent higher total cholesterol values and 16 percent higher LDL levels). In fact, the more the women smoked, the more their cholesterol levels rose. The research suggests that smoking may interfere with the action of thyroid hormones.



Aging, Early Skin Wrinkles are Accelerated by Smoking

Those smokers who live to see the age of 65 are likely to function at a poorer level than their nonsmoking peers. A study of nearly 10,000 women 65 and older demonstrated that those who smoked had a hastened aging process. More rapid declines in physical performance were documented in a number of tasks, as listed in Figure 37: Smoking Lowers Agility and Hastens Aging.194

Physical performance in smoking women over 65 is reduced to a level often found in women five years older. Their "health age" is thus significantly greater than their chronological age. The profound reduction in muscular strength and balance would also tend to make those women more prone to falling and other accidents. This particular effect of smoking does not necessarily translate into an earlier death, but it surely takes the fun out of life during the much-anticipated years of retirement. Truly, smoking can rob a person of the joy of those "golden years." In 1992, researchers at the University of California at San Francisco analyzed five studies that looked at smoking and skin wrinkling. The conclusion was undeniable: in white men and women, skin wrinkling was measurably increased by smoking.195 Once smokers reach middle age, they tend to look much older because of skin wrinkling. The reports are not pretty.

One group of researchers studied 244 women who ranged between 35 and 84 years of age. They described what they called "cigarette skin;" a pale, grayish wrinkled skin with thick skin between the wrinkles. These unbecoming changes were found in 79 percent of smokers and only 19 percent of the nonsmokers.196

A more recent British study found a pattern of prominent wrinkling, gaunt facial features, and skin color changes in 46 percent of smokers, 8 percent of ex-smokers, and none in the nonsmokers.197 I have become so accustomed to a smoker’s skin appearance that I usually do not need to ask a patient if he or she smokes. Those wrinkles tell the story. Anyone who wants to avoid early skin wrinkling should quit the habit now.

Why do smokers get more wrinkles? Drs. Grady and Ernster have provided a compelling explanation.198 They point out that cigarette smoking causes a decrease in blood flow through the tiny skin blood vessels. They suggest that a chronic lack of adequate blood supply may be one of the reasons for increased wrinkling. Smoking hast

ens other processes that affect the smoker’s appearance. Smoking increases the likelihood of early baldness and premature graying.199 A study of over 600 individuals found that smokers faced approximately four times the risk of premature graying as nonsmokers. And when compared to nonsmoking men, those who smoked were almost twice as likely to go bald. The researchers speculate that this and other studies indicate that smoking speeds up a person’s biological clock.



Eye Diseases More Prevalent among Smokers

The rapid aging effects of smoking are not limited to the nerves, muscles, skin, and hair; they affect the eyes as well. Cataracts, age-related clouding of the eye lenses, are more prevalent among smokers; treatment usually involves surgery. Smokers also increase their risk of an untreatable eye disease that can lead to blindness. The condition is called macular degeneration, and there is no medical treatment for it. The Harvard University-sponsored Nurses’ Health Study has followed 60,000 female nurses for 12 years. A similar study of 21,000 male doctors for 14 years has come to similar conclusions. Namely, that cigarette smoking can more than double the risk of blindness from macular degeneration. Although most lay people are unfamiliar with this condition, the disease is surprisingly common. Each year in the U.S. macular degeneration causes 1.7 million cases of vision loss. Almost all of those affected are 65 or over.



Smoking Decreases the Quality of Sleep

Sleep quality appears to suffer in smokers. Recent research from the Department of Preventive Medicine at the University of Wisconsin has demonstrated that smokers have more problems falling asleep and more difficulty with non-restorative sleep.200 The researchers suggest a number of factors that may contribute to these problems. First, the stimulant effects of nicotine make it more difficult for the average smoker to get to sleep. Second, as nicotine levels drop in the blood, smokers begin to go through subtle withdrawal symptoms. They may not awaken, but interference with sleep quality is the rule. Third, smokers’ tendencies to respiratory problems may also interfere with their sleep quality. Ironically, all of the sleep problems caused by smoking may actually keep the smoker coming back for more. In order to compensate for the results of impaired sleep quality such as fatigue and mild feelings of depression, the person often turns to smoking. This behavioral "vicious cycle" is best broken by stopping smoking "cold turkey." However, be persistent. During early withdrawal, sleep difficulties often get worse before you see improvement.



Smoking Aggravates the Digestive System

Are you troubled by heartburn? Burning pain in the mid-chest or stomach area can occasionally be a sign of serious disease. Usually, however, heartburn occurs when stomach acid travels back up the swallowing tube known as the esophagus. Irritation of the esophagus as a result of this backwards acid movement causes the pain. Technically it is called reflux. Unfortunately, heart disease, ulcers, and even cancer can masquerade as simple heartburn. For this reason, a medical evaluation is wise if you have a new or recently worsened heartburn problem. If your discomfort turns out to be due simply to reflux, then some relatively simple lifestyle solutions may go a long way toward curing your problems. One of the cornerstones is to stop smoking. Like alcohol and caffeine, nicotine tends to increase stomach acid production. Total avoidance of all tobacco products is therefore the best approach.

However, kicking the habit provides other benefits to your esophagus. Nicotine has direct effects on a band of muscle that lies between the stomach and esophagus. This muscular band is called the lower esophageal sphincter. It is designed to be closed at all times except when food passes from the esophagus downward into the stomach. It normally closes immediately after food passage to prevent reverse flow of acid and other stomach contents. Nicotine, however, weakens the sphincter muscles, causing the sphincter to stay open.201 This, in turn, allows stomach acid to flow upward into the swallowing tube. The combination of a weakened sphincter with more acid sets the stage for heartburn in susceptible individuals. Although there are a variety of medications that can treat this condition, stopping smoking is a most prudent first step. Kicking the habit decreases acid production and allows the sphincter to tighten up and work more normally, often ending the heartburn. Stomach ulcers are also much more likely to occur in smokers. Some studies indicate that smokers have from two to three times the risk of such problems.202 Ulcers can cause bleeding with or without accompanying pain. It can be difficult to heal an ulcer and keep it from recurring if an individual continues to smoke, even when potent medications like Zantac, Tagamet, Prilosec, and Carafate are taken. However, if the ulcer victim kicks the habit, the cure is often not difficult.



Smoking Diminishes Vitality and Other Qualities of Life

I could continue to document on many pages further details of quality of life issues that are related to cigarette smoking. Some of those issues would be extensions of information we have already presented in this chapter. Examples may include suffering from a cancer that is ultimately cured but renders a person disfigured; disability from a non-fatal, yet crippling smoking-related heart attack or stroke; or the mental anguish of an adult smoker living with a child who is mentally or physically disabled due to the effects of the smoker’s habit.

Recent work by Dr. Ronan Lyons and colleagues put all of these factors into perspective when they used a special survey to measure quality of life.203 The questionnaire employed was an established evaluation called the SF-36. It asked 36 questions that provide a useful way of measuring quality of life in eight categories. Among the more important areas measured were physical functioning, pain, general health perception, and vitality. When those who ever smoked were compared with those who never smoked, the results were startling. They are depicted in Figure 38: Effects of Smoking on Four Quality of Life Areas.204

The values stated in this figure mean that the physical functioning of 44-year-old people who ever smoked is equal to the physical functioning of 50 year olds who never smoked. The ever-smokers are over 6 years older than their actual age in this regard. Regarding pain, general health perception, and vitality, the ever-smokers are 14 to 15 years older than their actual age. If these were the only detrimental effects of smoking, they should be enough to motivate smokers to quit, and for nonsmokers to keep their distance from tobacco.

Lyons’ work provides an eloquent capstone to this segment of this chapter. Tobacco is not just a killer. It can do things that are worse in the eyes of some-stealing life’s quality, destroying happiness, and inducing disability. Every smoker can significantly increase the probability of a full quantity and quality of life by choosing today to become a nonsmoker.

Many people fail in their multiple attempts to quit this powerful addiction because they do not use the right methods. A description of the keys to become a successful ex-smoker is found in Section VIII. I do not stop there, however; the section also includes practical solutions on how you can kick the misery out of kicking the habit. Before I cover that vital material, we must examine one other indispensable topic. All of the documented problems with cigarette smoking have led some to abandon cigarettes in favor of other tobacco products or other addictive substitutes. If health is your goal, those cigarette "alternatives" are not viable options.



"Alternatives" To Cigarettes Are Also Health Hazards

When people give up tobacco, there is a danger that they will gravitate to alternatives that are perceived to be safer, but may be equally or more dangerous in certain respects. A detailed presentation of such alternatives is beyond the scope of this chapter. However, it is important to mention several popular "alternatives" to tobacco cigarettes.



Marijuana - Dangerous Drug - Not an Alternative to Tobacco

One popular alternative seems to have the reputation of being harmless and simply a youthful pleasure-marijuana. However, marijuana is a dangerous and addictive drug. Marijuana smoke, like tobacco smoke, includes a host of chemicals. Even some lay people can spew out the name of tetrahydrocannabinol (THC) which is the main active constituent of marijuana.205 Few realize that this drug is just one of over 60 cannabinoids (a class of drugs) that are found in marijuana.206 Just as tobacco smoke is more than a few chemicals, so it is with marijuana smoke. There is a host of drugs in this illegal substance.

Just as nicotine exerts deleterious fetal effects, so does marijuana. Marijuana, like its cousins alcohol and nicotine, has now been demonstrated to harm the brain of the developing fetus. A mother who uses marijuana gives her child a lifelong legacy of brain impairment.207 Animal tests demonstrate that decreased oxygen delivery occurs when mothers are exposed to marijuana, similar to that noted with nicotine exposure.208 Of note, with marijuana, the decrease in oxygen delivery to the fetus is prolonged, lasting long beyond any effects on the mother. Furthermore, after birth, marijuana can also interfere behaviorally, diminishing the mother’s desire to care for her newborn. 209 It also tends to decrease breast milk production and release.210

Some of the greatest fears about marijuana are not the effects on others but the effects on the long-term user. Tetra-hydrocannabinol bears a striking chemical similarity to corticosterone, one of the cortisone-type hormones of the body.211 Current research indicates that because of this similarity in structure to the cortisone type family of drugs, THC exerts toxic changes in a central part of the brain known as the hippocampus. In fact, both the natural stress hormones of the body and THC have been demonstrated to accelerate aging of the brain. For example, in one animal study, rats exposed to marijuana showed a doubling in the progression of brain aging. At the end of the study, the marijuana-treated rats had brains that tested twice as old as their age. All of this is extremely important. The hippocampus is one of the most vulnerable structures to brain aging. It is particularly hard hit in brain-deteriorating conditions such as Alzheimer’s disease.212 Current research suggests that the huge numbers of Americans who habitually use marijuana may be putting themselves at significantly increased risk of brain deterioration as they age. Recent statistics indicate that 4.8 percent of the entire U.S. population smoke marijuana at least once per month. More than 3 million are daily or "almost daily" users.213

As covered in Chapter 12, "The Frontal Lobe: The Crown of the Brain," marijuana also affects day-to-day mental performance. For example, recent research funded by the National Institute on Drug Abuse found that college students who were regular marijuana users had defects in their attention, memory, and learning even 24 hours after their last use of the drug.214 Marijuana use measurably affected brain performance long after the user thought the effects had worn off.

Marijuana also appears to pose a threat to the heart and blood vessels. When combined with exposure to everyday stresses, marijuana significantly increases the heart rate and blood pressure responses to those stresses.215 Since blood pressure is a significant risk factor for both heart disease and stroke, switching from cigarettes to marijuana is not a protective move for your heart.

Marijuana also appears to increase cancer risk. Cannabis has been identified as a source of carcinogens as well as being an immune system suppressant.216 Recent research on the subject has come from the University of California at San Francisco and other centers. These reports show that marijuana and tobacco smoking cause similar lung changes-with one difference-marijuana has a much more potent effect. In terms of lung damage, one joint is equivalent to a full pack of 20 cigarettes.

Compared to tobacco, our national experience with marijuana is relatively brief-but the current results suggest that it adversely affects unborn children. The drug leads to short term and long term mental deterioration. It is also a powerful respiratory poison, a cancer-causing agent, an immune system suppressant, and a drug that likely increases heart disease risk. Clearly, marijuana is not a safe alternative to tobacco.



Cigar and Pipe Smokers Have Increased Risk of Death

There are other supposed alternatives to smoking cigarettes than illicit drugs. There are a number of other tobacco products that seem to have acquired the reputation of being safe ways to enjoy a nicotine high. Cigar smoking is one; some mistakenly believe that cigars are safer than cigarettes. However, cigar and pipe smokers do put themselves at increased risk of death because of their habit. Some studies suggest their mortality rates are 20 to 40 percent higher than nonsmokers.217 However, the more often an individual smokes a pipe or cigar, the greater the risk. It is important to note that, as a group, those who have previously smoked cigarettes tend to smoke more if they switch to a pipe or cigars.218 Current cigarette smokers clearly should make a clean break with all forms of tobacco.

The importance of making a clean break with all forms of tobacco becomes apparent when we look at heart disease risk. Cigar and pipe users put themselves at significantly increased risk of this leading cause of death among cigarette smokers. One classic study from Copenhagen, Denmark, looked at a group of middle-aged men between the ages of 40 and 59. Among the group were 3,772 smokers that were categorized by the type of tobacco they used and 1,440 men who had never used tobacco.219 The results are illustrated in Figure 39: Seven-Year Incidence of First Heart Attacks in Tobacco Users and Tobacco Abstainers.

Over the course of seven years, there were 170 heart attacks in this combined group of over 5,000 men. The results showed more than double the risk for smokers of cigarettes, cigars, pipes, and cheroot. Pipe smokers’ risk was increased by 50 percent.



Snuff and Chewing Tobacco Increases Cancer Risk

Smokeless tobacco also carries the seeds of death. Most notably, use of these products is a potent cancer risk factor. In 1992, then Health and Human Services Secretary, Dr. Louis Sullivan stated, "It is time that smokeless tobacco take its rightful place next to cigarette smoking...as a serious health risk that must be stopped." Dr. Sullivan’s strong language seemed appropriate when you realize his statement introduced a scientific book of over 300 pages that detailed the hazards of smokeless tobacco.220

The subject represents no small problem. Over 30,000 new cases of oral cancer occur in the U.S. each year. Researchers have now identified 28 different cancer-causing chemicals in chewing tobacco and snuff.221 It is no wonder that users of smokeless tobacco increase their risk of oral cancer several-fold. The risk increase is even greater for some sites in the mouth; long-term snuff use increases a person’s risk of cancer by over 50 times.

Like cigarettes, the use of smokeless tobacco products typically starts at a young age. The far-reaching effects of this habit should not be underestimated. In some parts of the U.S., 25 to 35 percent of adolescent males admit to the use of smokeless tobacco.222 Young people should realize that even adolescents have died from mouth cancer as a result of smokeless tobacco.223 Whether it is marijuana, cigars, pipes, or smokeless tobacco, none are an alternative to cigarettes if a person is seeking to maximize health. Clearly, the best option is to make a clean break with cigarettes and all of its cousins. All forms of nicotine delivery have long term detrimental effects. No nicotine-containing product is safe.



How to Kick the Habit

"Cold Turkey" - the Most Successful Method

The method most likely to succeed is called the "cold turkey" method-you stop smoking immediately, with no taper-off. There are 46 million adult Americans who continue to smoke.231 However, almost as many have quit over the years since the 1964 announcement by the Surgeon General linking smoking to lung cancer. In fact, more than 3 million Americans stop smoking every year. The success of quitters is summarized from the 1991 Centers for Disease Control and Prevention data in Figure 41: Most Quitters use "Cold-Turkey" Method.

There are several important points in this figure. First, it is possible to quit, and that anyone who quits has lots of company. Second, most of the successful quitters used the cold turkey method, and have accomplished it on their own without the benefit of a smoking cessation clinic.232 However, twelve months later, only 8 to 25 percent were still free from smoking. Third, individuals that took advantage of smoking cessation clinics had a greater likelihood of remaining nonsmokers.

The first reaction of many smokers to the thought of quitting abruptly is, "It takes too much will power to quit by the cold turkey method. I am not sure I can do it." Whether you taper off or quit abruptly, will power is required because there likely will be withdrawal symptoms. The weakness of the tapering off method is that it is too easy to relieve the symptoms by lighting up. The nicotine rush brings relief, and you feel much better again. You sense that everything is going to be all right. But the urge returns, followed by other symptoms. You give in and smoke another cigarette. Progress toward your goal is minimal. Each day you hope to smoke a little less. This torturing process generally continues until you finally quit cold turkey or ultimately fall back into your unrestricted habit.



Withdrawal Discomfort More Short-lived With Cold Turkey Method

When you quit smoking abruptly, it is not necessarily easy. However, withdrawal symptoms do not last as long with the cold turkey method. Although most smokers have some uncomfortable withdrawal symptoms, about 25 percent go through no significant physical withdrawal. Others have a very difficult time with these physical symptoms. In my private medical practice and in conducting smoking cessation clinics for the general public, I have often observed withdrawal symptoms first hand. The American Psychological Association notes that within 24 hours of abrupt smoking cessation it is common to have withdrawal symptoms like those listed in Figure 42: Common Nicotine Withdrawal Symptoms.233

If you experience these withdrawal symptoms, how long will they last? For many smokers within 24 hours of quitting "cold turkey," the worst of the withdrawals are already behind them. For others, their worst day without cigarettes is day number two. However, almost without exception, at the end of 72 hours the worst of the withdrawal symptoms are history for those who make a complete break with cigarettes. Although the most severe symptoms pass within a few days, other symptoms can linger for several weeks. Some of these bothersome symptoms include increased irritability and having trouble concen-trating. For the majority of smokers, all of these remaining effects are gone by the end of a month. Statistics indicate that every smoker has finished with even the most subtle withdrawal effects by eight weeks.

Other annoyances are common when a person stops smoking. These are usually not classed technically as withdrawal symptoms; however, they often add to the physical difficulty of the quitting process. Some are very responsive to other lifestyle changes and usually last only a very short time. Others may take longer to run their course. They are detailed in Figure 43: Other Physical Effects of Kicking the Habit.234 235 Withdrawal symptoms and other physical changes are often feared as the worst part of quitting smoking. No one will say they are fun. However, they are actually a sign of the body beginning to heal itself.236 Despite the horrible destructive work that nicotine and other chemicals have been doing, your body has become used to-and even dependent on-nicotine. Withdrawal symptoms largely demonstrate that your body is getting back to the healthy state of living that it experienced in the days before you smoked. Just as your body probably rebelled against smoking when you had your first cigarette, now the body is agonizing again to readjust to the way it was designed to work-without nicotine and those other 4000 chemicals.



Will I Gain Weight?

One pressing concern of many who are contemplating quitting is, "Will I gain much weight?" Others who have tried to quit respond, "I know I will gain weight because it happened before when I stopped smoking." It is true that 80 percent of those that stop smoking put on some pounds.258 However, that statistic is deceptive because of the rate at which all Americans are enlarging their girths. About 56 percent of those who continue to smoke also gain weight.259 Furthermore, the average weight gain after quitting is only about five pounds.260

And not all of that weight stays with the person. Most smokers lose some of the excess weight they put on during the early phase of quitting. Only 40 percent of smokers gain and retain more than about four or five pounds. The negative effect of this amount of weight gain on health is negligible compared to the huge benefits of kicking the habit. Some experts estimate that you would have to gain 100 pounds to even come close to some of the health damage that smoking has been doing.261

But the best news is that 20 percent of smokers do not gain weight. Although they are the minority, they constitute a group of millions of living witnesses who testify that you can indeed stop smoking without gaining a pound.

It is a fact, however, that most people do not even want to gain one pound, let alone four or more. How can it be avoided? Before that question is answered, we will examine the cause of weight gain when kicking the habit. There is a number of reasons for this tendency. Let us look at four of the more important ones. First, foods often taste better. Within hours or days of stopping smoking, your nose becomes more sensitive. Commonly, ex-smokers discover a new appreciation for scents and tastes. Unfortunately for some, the stage is set for overeating. Second, there is often a tendency to substitute foods for cigarettes. The ex-smoker often turns to food to substitute for the oral pleasure that smoking brought. Third, metabolism slows down. Since nicotine functions primarily as a stimulant, the body’s engine has been revved up during all those years of smoking. Your metabolism slows about 10 percent when you kick the habit. If you do not eat fewer calories or exercise more, weight gain may well result.

Fourth, the stomach empties more quickly. Researchers have found that smoking can delay stomach emptying by up to 40 percent.262 If your stomach normally empties after a given meal in two hours without smoking, that same meal eaten while smoking would sit in your stomach for nearly three hours. This would be expected to increase your risk of heart burn and acid reflux. However, it also may help you to feel full for a longer period of time after eating.



How to Avoid Weight Gain

With all of these changes in mind, consider now a four-point program to avoid weight gain. It is described in Figure 49: How to Give up



Cigarettes without Weight Gain.

None of these points are difficult to accomplish. The first two have already been mentioned as helpful in kicking the misery out of kicking the habit, and are good health practices within themselves. The last two have been well publicized as good for the health. They represent a modest change in lifestyle.

The first point, increasing physical activity, not only helps to control stress and cravings as previously mentioned, but also speeds up your metabolism. This is an important point, since, as we have seen, metabolism slows when you quit smoking. Thus, the same type of exercise program that will help you kick the habit will help you keep off excess pounds.

The second point highlights alcohol. This subtly addictive beverage is a problem on a number of fronts. It is first of all a significant source of calories. More than this, however, it depresses will power and has been shown to make it easier to overeat.

The third and fourth points deal with food choices. An emphasis on foods that are low in fat and sugar is best accomplished by a diet that includes liberal amounts of fruits, whole grains, and vegetables. A given volume of these foods is much lower in calories than the higher sugar, higher fat standard fare. As a result, you can actually eat more food while taking in less calories. This is another important way to address the issue of metabolic slow-down. Incidentally, such a diet also helps to deal with constipation, which can be a problem when some individuals first "kick the habit."263 Avoiding the high fat and high sugar foods also eliminates the most common food choices that people use as oral substitutes for smoking. Clearly, the best option is to completely avoid substituting eating for smoking. However, in a time of weakness, it is much better to chomp on a celery stick than light up again.

The bottom line is simple: continue the lifestyle recommended for kicking the misery out of kicking the habit and you should have no problem with weight gain. For those who are interested in further pointers on losing weight, refer to the chapter on hypertension (Chapter 6, "One Nation Under Pressure").

Before leaving this subject, I should mention that there are a number of smokers who are underweight and actually need to put on pounds. Surprisingly, they can gain weight by kicking the habit and combining it with daily exercise, resulting in maintaining their ideal weight. Exercise helps to lose or gain weight according to the need. For those who are overweight, it helps them to lose weight; in those who are at their ideal weight, it helps to keep weight stable. For those who are underweight, it helps them to gain muscle mass and the needed pounds.



A Half Million Dollar Decision not to Smoke

The out-of-pocket costs to support a smoking habit are enormous-to the tune of over $500,000 in a lifetime. This is the amount of nest egg a person would have at age 65 if he invested instead of smoked. Investing the cost of two packs per day for 50 years (age 15 to age 65) in a good mutual fund, at $2.00 per pack at this writing, would result in a fund worth $538,000 in today’s purchasing power at the end of the 50-year period. This assumes that the fund earned an average of 10 percent per year.264



Wrapping it Up

I opened this chapter with the grim story of Melissa. There are literally thousands of "Melissas"-of both sexes-who go to their graves prematurely each year because of smoking. It is all so tragic-and so absolutely needless. Beyond this, the blame for all this suffering is often subtly laid at our Creator’s feet. "It just must have been her time to die," we often hear. However, God has nothing to do with the deaths caused by this poison. In fact, a loving God has been taking pains for decades to keep people from ever starting this health-destroying habit. Over a hundred years ago Ellen White was inspired to make people aware of the dangers of this habit-both to themselves-as well as to those exposed to secondhand smoke. Note her words found in Figure 50: Advanced Warnings Regarding Tobacco.265

White’s insights did not end there. She wrote about her concerns with tobacco over 800 times. Her broad knowledge of the effects of tobacco on the human system and her understanding of other aspects of health and lifestyle decades before they were scientifically proven are explored in Appendix X.

The basis for her persistence in agitating the subject she attributed to God’s revelation. When you see the accuracy of her words in the light of modern science, it is hard to doubt her claims as to the divine source of the information. Consider some of the other concerns she voiced, as recited in Figure 51: Other Harmful Effects of Tobacco Predicted.

I see God’s hand not in the death of smokers, but rather in the millions of individuals who have stopped smoking-or never began the habit-and are enjoying life as a result. Whether they made their decision based on information from Ellen White or because they were convicted by the research of those that God led to prove scientifically the dangers of tobacco is not really important. What is important is that many have not given God the credit for the misery He has prevented. Conversely, He has been blamed for the natural consequences of tobacco use.

Just as there are thousands of "Melissas," there are also thousands of people like Catherine. Catherine, at 91, lives on her own in comfortable surroundings. She still enjoys life and has special pleasure in seeing her great grandchildren grow up. Catherine would probably not be alive today if she did not make a decision years ago to become a nonsmoker. Her decision to stop smoking was made in her 60s, but it seems to have paid big dividends. This is an educated guess. I cannot be sure that Catherine would not still be alive and doing well today if she had not made the decision-but statistical studies indicate that it would be extremely unlikely.

Every day, every single smoker makes a solemn choice. Not choosing to quit today is making a choice to continue to embrace a destructive habit that is likely to kill, maim, or in some other way incapacitate you-long before your time. Unfortunately, there often are no warnings before the cancer diagnosis or the heart attack, or even the osteoporotic fracture or the realization that you look 15 years older than your nonsmoking peers. Can I implore you to stop playing Russian roulette? The loaded chamber is sure to come up sometime.

Some of you no doubt are saying, "Yes, Doctor Nedley, I know all that you are saying is true. I am gambling with my life. But I am powerless over this addiction." For those of you who only see your weakness and your failures, take heart-you can be successful. Follow the guidelines presented in this chapter; they can make all the difference between success and failure. Also be sure to read Chapter 18, "Dealing with Bad Habits and Addictions."

If you have tried to quit on your own and have given up, work with your physician or other health professional. Use the material in this chapter to undergird the practical counsel and encouragement you get from working with a professional. If that option does not sound feasible, then look into the Breathe Free program offered by the Seventh-day Adventist church or other outpatient stop smoking programs offered in your community. Group support from other smokers who are going through the same process of kicking the habit can really reinforce all that we have shared in this chapter.

If you have gone that route and lack confidence in an outpatient approach, let me make another suggestion: take a week off and treat yourself to a good live-in lifestyle program. The Centers for Disease Control have gone on record: "the limited research available suggests that these [live-in programs to stop smoking] can be quite effective."266 In fact, I can heartily recommend such a center in my region. The Lifestyle Center of America in Sulphur, Oklahoma267 draws people from all over the country to take advantage of their live-in programs that include smoking cessation. They actually use this chapter of my book as their primary written educational resource for their participants.

However you use this chapter, whether on your own, with your doctor, as an adjunct to an outpatient class, or in conjunction with a live-in program, I am convinced it can help you to be finally successful. The good news is that you can stop smoking. You can begin today on a new smoke-free path that will enable you to live a much higher quality life and enjoy the many benefits that we have presented in this chapter.






References

  1. Melissa’s story represents a montage of true stories combined into this single case history.
  2. Fiore MC, Newcomb P, McBride P. Natural History and epidemiology of tobacco use and addiction. In: Orleans CT, Slade J, editors. Nicotine Addiction: Principles and Management. New York: Oxford University Press, 1993 p. 89-104.
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