Why it is so difficult to quit smoking: ‘Tobacco is a drug, and a lot of money is invested to make it hard to quit’

Tobacco kills up to half of its users. Each cigarette puff is harmful to a person’s health and goes through the body like a shock wave. Smoking causes hypertension, chronic bronchitis, heart attacks, strokes and various cancers (lung, esophagus, larynx, kidney and bladder cancers). And to make matters worse, experts admit that quitting smoking isn’t easy. But it’s also not impossible. Doing so is a question of will, motivation, behavioral changes, support from healthcare professionals and, if necessary, pharmacological help.

According to the American Cancer Society, the health benefits of quitting smoking are noticeable almost instantly. Within 20 minutes, heart rate and blood pressure go down; within 12 hours, the carbon monoxide level in the blood drops to normal; within three months, lung function improves; and within a year, coughing and shortness of breath decrease. Overall health continues to improve every day and the body recovers. In fact, a study showed that quitting smoking before the age of 35 reduces the risk of death to that of non-smokers.

But, despite the benefits, quitting is a difficult process for many smokers. Why is that? Anna Riccobene, a nurse at the Tobacco Control Unit at the Catalan Institute of Oncology (ICO), emphasized that “tobacco is a drug, and quitting drugs is hard. It is very addictive, and also a lot of money is invested to make it difficult” to stop smoking. A European study found, in fact, that half of smokers have tried to quit at some point.

Dependence on tobacco is threefold, according to Vidal Barchilón, coordinator of the Tobacco Dependence Group of the Spanish Society of Family and Community Medicine (Semfyc in Spanish): “There’s biological, psychological and social dependence.” The first is due to nicotine’s effect on the brain; this substance is what creates addiction. It enters the blood through the lungs and rapidly spreads through the body until it reaches the brain, where it stimulates the release of dopamine in areas that regulate pleasure. “There are also psychological reflexes, such as the number of times a cigar is brought to the mouth, and a social influence that associates tobacco with pleasure, such as smoking a cigar after a wedding,” both of which hinder smoking cessation, said Barchilón.

People who are addicted to nicotine “experience ambivalence; they want to quit, [but]they [also] don’t want to quit,” explained Josep Maria Suelves, the head of the Tobacco Prevention and Control Service of the Public Health Agency of Catalonia, Spain. They want to stop smoking for their health or for financial reasons, but they don’t want to stop because of the influence of their environments (if they’re surrounded by smokers, they’re more encouraged to continue smoking) or because of tobacco’s instrumental value as a tool for socialization.

The anticipatory anxiety around quitting because of a fear of the unknown and of not being able to quit, as well as concern about withdrawal syndrome, further contribute to the difficulty of smoking cessation. “Although it is true that quitting smoking is difficult, many people find that it wasn’t as hard as they expected. There are no easy fixes, but it is not [impossible],” Suelves said. The first weeks are uncomfortable. One experiences irritability, anxiety, difficulty sleeping and “the very strong need to reach for a cigarette,” Suelves explained. But the feeling passes, and in a few weeks, it goes away.

Quitting smoking is possible. “The early process and making the decision [to quit] are [the] most difficult [part] for [people]… They see tobacco as a lifeline, although if you have a problem and you smoke, you actually have two problems,” Riccobene said.

There is no magic pill or silver bullet

Experts say that motivation is the key to quitting. “They [must] have the conviction of wanting to quit,” Barchilón insisted. That is why motivational interviews are conducted in tobacco control units to reinforce that conviction, Riccobene said: “You have to motivate them because it is impossible to quit against one’s will. Treatment is not a silver bullet; the person has to want to [stop smoking].”

In smoking cessation workshops, Riccobene pointed out, they often stress that tobacco is the only drug that harms both the user and those around them. They start by trying to limit consumption in enclosed spaces and propose behavioral changes, such as delaying the first cigarette in the morning. “We tell them: ‘You know that smoking is bad, but what you may not know is how good it is to quit because you will regain your freedom.’ Smokers think they smoke because they want to, but in reality the cigarette rules [them].”

When they are motivated to quit smoking, patients can turn to the medication available to treat nicotine dependency. There are a number of products one can use and many are available without a prescription, such as nicotine patches and chewing gum. “People who want to quit smoking should use treatment, except if they are light smokers (less than 10 cigarettes), minors or pregnant women,” Barchilón said.

Barchilón admited that, among medical professionals, there is a “significant lack of knowledge” about smoking cessation treatments. “Smoking has long been considered a habit, not a disease. It is not studied in universities, and there have been no funded treatments for smoking cessation. The fact that there are [such medications] now is a success because it increases professionals’ desire to learn more about these drugs,” he said. However, Suelves believes that there are other factors at play. He argued that the drugs aren’t underused; “their use is promoted,” but cost can be a barrier to using them because the medications are often quite expensive.

While the treatments available help make the first days of quitting more bearable and alleviate some of the effects related to smoking cessation, they are not guaranteed formulas. “Drugs are part of the treatment strategy and can double success, but quitting smoking is a long process and behavioral measures are also required, such as strategies to help us overcome the urge to smoke,” Suelves explained.

In addition, one needs to employ anti-smoking aids successfully. “You have to know how to use nicotine. For example, the patches are slow-release and must be used with other rapid-release drugs, such as [nicotine] gum. But these must also be used properly so that they are absorbed through the mouth’s mucous membranes; if not, they go to the stomach and can cause fatigue. They are not recreational products,” Barchilón said.

A high risk of relapse

Medicinal support, individual motivation and follow-up with health professionals increase the likelihood of success. “Someone who quits on their own has a 5% to 7% chance of success,” Riccobene said. Relapses are common, but they are not a complete failure. It’s all about getting back on track. “An alcoholic knows that one drink is enough to cause a relapse. But after a while the smoker thinks that one cigarette won’t cause a relapse. But [the smoker] can never control it. And there are always good excuses to smoke a cigarette, from having an emotional problem to feeling any stress, even though tobacco is stimulating, not relaxing! But sometimes you don’t get it right the first time,” she added.

At this point in the process, professional monitoring can be highly valuable. Riccobene advises “positive reinforcement and not criticizing the failures” of the patient. “The important thing is that they follow [through with] the treatment to the end.”

There is no universal formula for quitting smoking: some will quit on their own on their first attempt; others opt for behavioral changes and still others will succeed only with drugs and after several relapses. Every smoker is different. However, experts are skeptical about the effectiveness of alternative therapies, like acupuncture and hypnosis. They are also leery of using the techniques that the tobacco industry promotes to reduce consumption, such as electronic cigarettes: there is no evidence that e-cigarettes are beneficial, and some scientific research says that they are actively harmful.

In the end, Barchilón argued, certain alternatives “cause confusion.” In the case of “electronic cigarettes, we know that between 60% and 80% of consumers end up using [both] these devices and conventional cigarettes. In addition, we do not know what damage electronic cigarettes will cause in the future,” he warned. Suelves agreed and noted that using them gets people into trouble: “A kid who starts [using] electronic cigarettes doubles or triples the likelihood of smoking traditional cigarettes within a year.” Riccobene emphasized that “everyone is looking for magic solutions, but there aren’t any.”

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