Introduction

Smoking (quitting)
Smoking (quitting)

If you smoke, giving up smoking is one of the greatest single steps you can take to improve your health. Smoking continues to be the biggest preventable cause of ill health and premature death globally, killing half of all smokers placing a huge financial burden on the National Health Service. Tobacco remains the number one cause of preventable illness in Wales resulting in one in two smokers dying from their tobacco use with many more suffering smoking related ill health.

In the latest Welsh Health Survey, 2015 it was estimated that 19% of the Welsh adult population are currently smokers with 21% of men and 18% of women smoking. The Welsh Health survey also indicates that smoking rates are three times higher in the most deprived communities.

The results from the Welsh Health Survey, 2015 highlights that two out of three smokers in Wales say that they want to stop smoking with around 40% actively trying to stop.

Smoke free laws

Since 2nd April 2007, virtually all enclosed public places and workplaces in Wales have been smoke free. It is against the law to smoke inside pubs, bars, nightclubs, cafes and restaurants, lunch rooms, membership clubs and shopping centres. The smoke free law was introduced to protect employees and the public from the harmful effects of passive smoking (secondhand smoke).

Under the smoke free law, you are unable to smoke inside, at work, including in smoking rooms. Public transport and work vehicles that are used by more than one person are also smoke free. No-smoking signs have to be displayed in all smoke free premises and vehicles.

Anyone who smokes in a smoke free place may face an on the spot fine of £50 (or up to £200 if the matter goes to court). Anyone in charge of smoke free premises, or vehicles, can face fines for two separate offences; failing to prevent smoking in a smoke free place, and failing to display no-smoking signs.

During May 2017 the Public Health (Wales) Bill had legislative updates on tobacco and e-cigarettes. These planned legislative changes in smoke free laws will see the banning of smoking on hospital ground, in school grounds, public playgrounds and the outdoor areas of registered childcare settings. There will also be a ban on tobacco and nicotine products being handed over to under 18s by home delivery or collection services as well as the creating of a national register of tobacco and nicotine product retailers.

Smoking in Cars Carrying Passengers Under the Age of 18

As of October 1st 2015, a new law was introduced in Wales which now means that it is illegal to smoke in a private vehicle carrying passengers under the age of 18. See the Welsh Government website for more information.

Tobacco and Related Products Regulations 2016

Additional to the retrictions already in place around the selling of tobacco products, from May 2017 there will be additional retrictions on the selling of tobacco products. Restrictions included on tobacco;

  • banning the sale of small packets of cigarettes such as packets of 10
  • banning the sale of smaller packets of rolling tobacco (under 30g)
  • the standardisation on the sale cost of the cheapest packet of 20 cigarettes to be retailing at £8.82
  • the sale of menthol cigarettes will gradually be phased out with a full ban in place by 2020
  • all cigarettes will be sold in plain packaging with graphic images from 21st May 2017 and there will be a ban on the sale of other flavoured cigarettes and rolling tobacco.

How old do you have to be to purchase tobacco?
Since October 2007, in England, Scotland and Wales, it has been illegal to sell tobacco to anyone under the age of 18. The age limit was previously 16. This includes the sale of cigars, rolling tobacco, rolling papers, and cigarettes from vending machines. This change in the law brings the age restriction in line with the purchase of alcohol.

The reason for the age change is to try and deter young people from starting smoking. The earlier you start smoking, the more likely you are to be addicted later on in life. For example, if you start smoking at 15, you are three times more likely to die of cancer than if you started smoking in your mid-20s.

For more information on tobacco control legislation visit ASH Wales.

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Facts

Tobacco smoke contains nicotine which is highly addictive. However, there are over 7,000 known chemicals found in tobacco including tar and carbon monoxide.

Some of the poisonous substances that are found in tobacco smoke, and the ways in which they harm your body, are listed below.

Poisons in tobacco smoke

Nicotine

When you smoke a cigarette, nicotine affects your brain within seconds of inhaling. It increases your heart rate and causes a surge in the hormones noradrenaline and dopamine in your brain, which creates a positive effect on your mood and ability to concentrate. In between cigarettes, the levels of these hormones drop, leaving you feeling irritable, anxious, and in need of another cigarette.

Within 24 hours, withdrawal from nicotine can cause the following side effects:

  • depressed mood,
  • difficulty sleeping,
  • irritability,
  • frustration, or anger,
  • anxiety,
  • difficulty concentrating,
  • restlessness,
  • decreased heart rate,
  • dizziness, and
  • increased appetite.

As well as being addictive, nicotine can be dangerous if you have high blood pressure (hypertension). It increases the risk of accelerated hypertension, which is a sudden rise in already high blood pressure that can cause headaches, blurred vision, and vomiting.

Nicotine also slows down your body's ability to heal itself by making your skin dehydrated (lacking in water).

Tar

Every breath of tobacco smoke taken deposits tar in your lungs. The tar in cigarette smoke contains chemicals called carcinogens, which encourages the development of cancer cells in your body.

Carbon monoxide

When it is inhaled, the poisonous gas carbon monoxide binds itself to the haemoglobin in your bloodstream and prevents it from carrying enough oxygen around your body. This is particularly dangerous for pregnant women because it causes a severe lack of oxygen in an unborn baby (known as foetal hypoxia). Foetal hypoxia is thought to be the main cause of the harmful effects that smoking can have on unborn babies.

Oxidant gases

Oxidant gases are gases which react with oxygen. They make your blood more likely to clot, which increases your risk of having a heart attack, or stroke.

Other harmful substances

In addition to the above, there are many other poisonous substances found in tobacco smoke. These substances can have harmful effects, such as thickening and fatty degeneration of your arteries, which causes heart disease.

Tobacco smoke can also increase the acidity of your stomach acid, putting you at risk of peptic ulcers (ulcers in your stomach or small intestine).

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Risks

Smoking is bad for your health and, if you smoke, you increase your risk of getting many serious, and often fatal, diseases.

Some of the most harmful conditions that smoking can cause are detailed below.

Premature death

A medical study on smoking found that, on average, men who smoked throughout their lives died 10 years younger than those who had never smoked. Most of these men died from smoking-related illnesses, including:

  • lung cancer.
  • chronic obstructive pulmonary disease (COPD) - long-term lung diseases, such as chronic bronchitis (infection of the main airways in the lungs) and emphysema (damage of the small airways in the lungs), which can occur together.
  • heart disease.

Cancer

As well as lung cancer, smoking can cause cancer of the throat, oesophagus (the tube between your mouth and stomach), bladder, kidney, stomach, and pancreas. Smoking can also cause myeloid leukaemia, which is a form of cancer that affects your white blood cells that help to fight infection.

Pneumonia

Smoking can cause pneumonia, a potentially fatal infection which causes inflammation of your lungs.

Cerebrovascular disease

The arteries that supply blood to your brain can be damaged by smoking. This is a condition which is known as cerebrovascular disease. This can lead to heart failure due to a lack of oxygen, or it can cause an aortic aneurysm (a dangerous swelling of the main artery leaving your heart).

Buerger's disease

Smoking causes Buerger's disease, which is a severe condition that affects your blood circulation, and causes your arteries and veins to close.

Chronic (long-term) health problems

Some of the conditions smoking can cause can be life-long, including:

  • angina - chest pains caused by a lack of oxygen to your heart,
  • peripheral vascular disease - damage to your blood vessels,
  • macular degeneration - breakdown of the retina (light sensitive layer of the eye), causing gradual blindness,
  • impotence,
  • infertility - in both men and women,
  • skin wrinkling, and
  • osteoporosis - weak and brittle bones.

Smoking can also worsen the symptoms of certain conditions, and make them more prolonged, including:

  • asthma,
  • respiratory tract infections, and
  • diabetic retinopathy - loss of sight caused by diabetes.

 Risks of passive smoking

When you smoke, it is not just your health that is put at risk, but the health of anyone who breathes in cigarette smoke (including those around you). The smoker only inhales about 15% of the smoke from a cigarette, with the other 85% being absorbed into the atmosphere, or inhaled by other people.

Breathing in this secondary smoke is known as passive smoking, or secondary smoking. Those who are exposed to passive smoking also have an increased risk of smoking-related diseases, particularly lung cancer, and heart disease.

Children are at particular risk from the effects of passive smoking because they have an increased risk of developing chest infections during their first five years. Babies who are exposed to cigarette smoke are also at a greater risk of sudden infant death syndrome (SIDS), which is also known as cot death.

As well as making children more vulnerable to ear infections, such as otitis media, passive smoking makes children more likely to develop asthma.

Risks of smoking during pregnancy

Smoking can make you less fertile. Therefore, not smoking can improve your chances of conceiving. If you smoke, there is a greater chance of complications occurring during pregnancy and labour, such as sickness, miscarriage, and bleeding. Smoking while pregnant can also increase the risk of premature birth and stillbirth.

Smoking during pregnancy can also affect your developing baby. Your baby may have a lower birth weight, be weaker, and grow more slowly, throughout their childhood. Research suggests that children exposed to smoke in the womb may also go on to do less well at school.

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Why should it be done?

Giving up smoking increases your chances of living a longer and healthier life. It instantly reduces your risk of death or serious illness due to smoking-related diseases, such as lung cancer, chronic obstructive pulmonary disease (COPD), and heart disease.

Health benefits from the moment you stop

When you stop smoking, the benefits to your health begin straight away. As your body starts to return to normal, you will start to feel healthier, and within a few weeks you will also start to notice the benefits. For example:

  • After one month - your skin will be clearer, brighter and more hydrated.
  • After 3-9 months - your breathing will have improved, and you will no longer have a cough or wheeze. Your lung function may have improved by up to 10%.
  • After one year - your risk of heart attack and heart disease will have fallen to about half that of a smoker.
  • After 10 years - your risk of lung cancer will have fallen by half.
  • After 15 years - your risk of heart attack and heart disease will be the same as someone who has never smoked.

Research into smoking shows that people who quit smoking before the age of 35 have a life expectancy only slightly less than people who have never smoked. Those who quit before they are 50 years of age reduce their risk of dying from a smoking-related disease by 50%.

As well as the immediate and long-term benefits to your health, there are many other good reasons to quit smoking, such as those outlined below.

  • No longer causing harm to others through passive smoking, particularly babies and children, who are at risk of sudden infant death syndrome (SIDS), asthma, and ear and chest infections.
  • It is less likely that your children will go on to smoke. Research shows that children living with parents who smoke are almost three times more likely to start smoking themselves.
  • Limiting harm to your unborn baby. Although smoking at any stage of pregnancy can harm your baby, most of the harmful effects of smoking occur in the second trimester (weeks 14-26) and third trimester (week 27-birth). Therefore, if a woman quits smoking during her first three months of pregnancy, she will have a similar risk of giving birth to a low weight baby as a non-smoker.
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Treatment

NHS Stop Smoking support - Help Me Quit

If you want to give up smoking a good first step is to contact Help Me Quit on 0800 085 2219.

Help Me Quit makes it easier for smokers to access NHS stop smoking support in Wales from the range of free NHS service providers. Many people try to stop smoking on their own but research tells us this is the least effective way. Combining NHS help with a stop smoking medication is the best way of quitting.

The Help Me Quit contact centre team will help you shape your 'quit journey' and offer you a choice of support from group, 1:1 or telephone support from the range of service providers in your area such as at local community pharmacies, hospital based services and through Stop Smoking Wales.

Regardless of the service you choose to use it will be delivered by a NHS stop smoking expert, provide you weekly support sessions, access to stop smoking medication and carbon monoxide screening to monitor your progress.

You can find out more about the different NHS stop smoking services available on the Help Me Quit website that provides a comparison table of services and also information on what support is in your area via an interactive Google map.

To find out which sevice is best for you in your local area, contact a member of the Help Me Quit team by:

  • calling: 0800 085 2219
  • Texting: HMQ to 80818
  • Requesting a call back

Nicotine replacement therapy (NRT)

Nicotine is highly addictive, and it is the nicotine in cigarettes that causes people to become addicted to smoking. Nicotine replacement therapy (NRT) works by releasing nicotine steadily into your bloodstream at much lower levels than in a cigarette, without the tar, carbon monoxide and other poisonous chemicals you get from tobacco smoke. This helps to control the cravings for a cigarette that occur when your body starts to miss the nicotine that smoking provides.

NRT is the most common smoking cessation treatment and comes in many different forms including those outlined below:

  • Transdermal patches (which stick to your skin) and which are available in formulations that release nicotine for either 16 hours or 24 hours.
  • Chewing gum that is available with either 2mg or 4mg of nicotine.
  • Inhalators which look like a plastic cigarette and through which nicotine is inhaled (breathed in),
  • Tablets and lozenges which are placed under your tongue.
  • spray which works by passing nicotine through the lining of your nose.


If your GP prescribes you a form of NRT, it is likely you will need to use it for the recommended duration of between 8-12 weeks, before gradually reducing the dose and eventually stopping. Most people stop using NRT altogether within three months, although heavy smokers may need to use it for longer.

Side effects of nicotine replacement therapy (NRT)

NRT can sometimes cause side effects which may include:

  • allergic reactions, such as skin irritation from a patch, or irritation of your nose, throat, or eyes, from nasal spray,
  • disturbed sleep with or without vivid dreams,
  • upset stomach,
  • dizziness, and
  • headaches.

Side effects caused by NRT are rarely severe enough to stop the treatment, but if you experience side effects while taking NRT, your GP may alter your dose of nicotine.

Using NRT does not affect driving in general, but the nasal spray can cause sneezing and watering eyes for a short time after use. For this reason, if you are prescribed a NRT nasal spray, you should not use it while driving, or just before driving.

How nicotine replacement therapy (NRT) will be prescribed

If you feel able to, your GP will recommend stopping smoking completely as soon as possible, with the help of NRT. The form of NRT you are prescribed will depend on your personal preference, ease of use, and your level of addiction. For example, if you are a heavy smoker with a high level of addiction, your GP may prescribe an NRT nasal spray because it is the fastest acting form of NRT.

However, if you do not yet feel ready to stop smoking completely, your GP may suggest a method of quitting known as nicotine-assisted reduction to stop. This involves using NRT to progressively reduce the number of cigarettes you smoke, before eventually stopping smoking altogether.

If your GP suggests using nicotine-assisted reduction to stop, you will be prescribed either an NRT gum, or inhalator, to use in between cigarettes. These forms of NRT are best for use between cigarettes because they release a short burst of nicotine, rather than a steady, constant supply. It is necessary to use short-release NRT when you are still smoking because ingesting the nicotine from your cigarettes, combined with that from a steady-release NRT could make you feel very unwell.

For this reason, you must only use your prescribed NRT in between cigarettes to combat cravings. You should also try and prolong your smoke-free intervals for as long as you can, and steadily reduce the number of cigarettes you smoke. By six weeks of NRT treatment, you should aim to have cut down on your usual cigarette consumption by half.

With the advice of your GP, you can stop smoking whenever you feel ready, but this should be no more than six months after the start of your NRT treatment.

Nicotine replacement therapy and pregnancy

If you are pregnant, or breast-feeding, and you want to quit smoking, it is best for your health, and that of your baby's, if you to stop completely and immediately, without the help of any smoking cessation treatment.

However, if you feel that you cannot stop smoking without help from smoking cessation treatment, your GP may recommend that you stop smoking completely and use NRT to control your cravings. Nicotine is not good for your baby, but the greatest risk to an unborn baby's health from smoking is posed by carbon monoxide which can cause foetal hypoxia (a severe lack of oxygen). Therefore, while using NRT is not ideal in terms of your baby, it is better than continuing to smoke.

As with any other patient who wants to stop smoking, the form of NRT you are prescribed will depend on your personal preference, ease of use, and your level of addiction.

If you feel that you cannot stop smoking completely straight away, your GP may suggest that you use the nicotine-assisted reduction method. You will be prescribed a short-release NRT, such as gum, or an inhalator, to be used in between cigarettes. You must try and prolong your smoke-free intervals for as long as you can, and steadily reduce the number of cigarettes you smoke. In order to protect the health of your unborn baby, try to stop smoking completely as soon as you possibly can.

Please note that the following medications, Bupropion and  Varencicline, may not be available in all parts of Wales as some Local Health Boards have decided not to fund them as smoking cessation treatments.

Bupropion

Bupropion is a medication designed to help smoking cessation. The way in which it works is not completely understood, but it is thought to work on the brain pathways involved in addiction and withdrawal. It is available in the form of tablets.

Bupropion is not suitable for those under the age of 18, women who are pregnant, or breastfeeding, or those who are anorexic, or bulimic. It is also not suitable for those with a central nervous system tumour, or severe cirrhosis of the liver.

With bupropion there is a slightly increased risk of seizures which means that it is not suitable for anyone with an increased risk of having a seizure, such as those who have epilepsy, or bipolar disorder (a condition that adversely affects a person's moods). Bupropion is also not suitable for those who abuse alcohol, or anyone treating diabetes with hypoglycaemic medication, or insulin. The risk of seizures caused by bupropion is related to the amount taken, so it is very important never to exceed your recommended dose.

Side effects of bupropion

Bupropion can cause several side effects which can include:

  • dry mouth,
  • upset stomach,
  • insomnia (trouble sleeping),
  • headaches,
  • difficulty concentrating,
  • dizziness, and
  • drowsiness.

As taking bupropion can cause drowsiness, and affect your ability to carry out skilled tasks, you should not drive, or operate machinery, while you are taking it.

How bupropion will be prescribed

If you are prescribed bupropion, you will need to take one tablet a day for the first six days, before increasing the dose to two tablets a day, which should be taken at least eight hours apart. However, you cannot take two tablets a day and should continue taking one tablet a day, if:

  • you are over 65 years of age,
  • you have mild, to moderate, liver damage, or
  • you have kidney damage.

If you have not stopped smoking completely before starting bupropion, you should aim to do so within 7-14 days of starting treatment. You can only take bupropion for a maximum of 7-9 weeks because it is not licensed to be used for any longer than this.

Varenicline

Like bupropion, varenicline is available in tablet form, and is specially designed to help smoking cessation. It works by preventing nicotine from binding to receptors (parts of your brain which respond to nicotine), which eases cravings and reduce the rewarding and reinforcing effects of smoking.

Varenicline is not suitable for those under the age of 18, women who are pregnant, or breastfeeding, or those with epilepsy. It is also not suitable for those who have advanced kidney disease.

Side effects of varenicline

Varenicline can cause side effects which can include:

  • nausea and vomiting,
  • headaches,
  • insomnia (trouble sleeping),
  • unusual dreams,
  • increased appetite,
  • constipation, or diarrhoea,
  • swollen stomach,
  • slow digestion,
  • flatulence,
  • dry mouth,
  • tiredness,
  • dizziness, and
  • drowsiness.

As taking varenicline can cause drowsiness and affect your ability to carry out skilled tasks, you should not drive, or operate machinery, while taking varenicline, if it causes you to feel drowsy.

How varenicline will be prescribed

If you are prescribed varenicline you will need to take the following:

  • one 0.5mg tablet once a day for days 1-3,
  • one 0.5mg tablet twice a day for days 4-7, followed by
  • one 1mg tablet twice a day from day eight onwards.

If you have not stopped smoking completely before starting varenicline, you should aim to do so within 7-14 days of starting treatment. The recommended duration of varenicline is 12 weeks. If you are successful in stopping smoking completely in this time, you may be prescribed another 12 weeks of treatment to ensure that you do not start smoking again.

Visit Help Me Quit website to read more about licensed stop smoking medications.

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Using E-cigarettes to stop smoking

Over recent years, e-cigarettes have become  popular in the UK, with the Welsh Health Survey (2015) showing that 6% of Welsh residents are currently using an e-cigarette. Evidence is still developing on how effective they are, but many people have found them helpful for quitting.

An electronic cigarette (e-cigarette) is a device that allows you to inhale nicotine without most of the harmful effects of smoking.

E-cigarettes work by heating and creating a vapour from a solution that typically contains nicotine; propylene glycol ( a thick, colourless liquid) and/or glycerine; and flavourings. As there is no burning involved, there is no smoke.

E-cigarettes do not produce tar and carbon monoxide – two of the main toxins in conventional cigarette smoke. The vapour from e-cigarettes has been found to contain some potentially harmful chemicals also found in cigarette smoke, but at much lower levels.

The risks and benefits of e-cigarettes

E-cigarettes are still fairly new and we won’t have a full picture on their safety until they have been in use for many years. However, on current evidence, they carry a fraction of the risk of cigarettes and they can help you stop smoking.

Before trying to quit smoking,  you’ll give yourself the best chance if you get expert support from the free NHS stop smoking services that are available locally.

You can find your nearest NHS stop smoking service by visiting the Help Me Quit website, or by calling Help Me Quit on 0800 085 2219.

There are a range of scientifically tested and proven nicotine replacement products available to help you quit smoking and if these are used alongside the support provided by NHS stop smoking servies, you’re four times more likely to successfully quit than trying to quit on your own and going ‘cold turkey.

 E-cigarettes on prescription

Currently, there are no e-cigarettes on the market that are licensed as medicines, meaning they are not available on prescription from the NHS.

Once medicinally licensed e-cigarette products come onto the market, they will be available on prescription, alongside other stop smoking medicines.

You can read about other e-cigarettes on the Help Me Quit website.

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Making changes

Quitting

Deciding to give up smoking and really wanting to succeed are important steps in becoming a non-smoker. There are three stages to giving up smoking:

  • preparing to stop,
  • stopping, and
  • staying stopped.

It can take up to three months to become a non-smoker, but it usually takes less time. The physical craving for a cigarette often disappears in less than a week, but the psychological craving can last longer.

Stage 1 - Preparing to stop

It is important that you stop smoking because you want to. Write down your reasons, and keep the list to hand over the next few months. Think of the the many benefits that you will gain by stopping smoking, including:

  • less coughing,
  • cleaner clothes,
  • better breathing,
  • feeling healthier,
  • more money, and
  • a significantly lower risk of you, and your family, developing smoking-related illnesses.

Try to remember that most of the pleasure you get from smoking comes from relief of your nicotine withdrawal, not the cigarette itself. Nicotine replacement therapy (NRT) can provide the same effect without the need for smoking, and helps you quit at the same time.

Do not expect giving up smoking to be easy, but remember that the first 3-4 days will be the most difficult. If you can, give up with a friend, or family member, who also wants to quit.

When you have decided to stop, you should make a plan which may include:

  • a specific date to give up, and cutting down on the number of cigarettes that you smoke before that date,
  • the support of your family and friends to help you give up,
  • a reward for the end of your first day, first week, first month, and
  • getting rid of everything smoking related, such as cigarettes, ashtrays, and lighters, on the day before you give up.

Stage 2 - Stopping

Your initial goal is to get through the first day without smoking. If you need to put something in your mouth chew sugar-free gum or something else that is healthy and non-fattening such as fruit. If you feel a strong craving, take some deep breaths and delay giving in to the urge. The feeling will usually pass within a couple of minutes.

If you need to do something with your hands, find something to fiddle with, such as a pencil, a coin, or a stress relief ball.

Stage 3 - Staying stopped

Take it one day at a time, and each day congratulate yourself on having made it so far. Keep reminding yourself of your reasons for giving up, and what you are gaining by not smoking. Think positively, remain determined and reward yourself. At the beginning it may help to change your normal routine, in order to avoid situations that you would normally associate with smoking. Avoiding alcohol for a while may also help.

After the first weeks, particularly if you have found it easy not to smoke so far, people may stop encouraging you, and even forget that you have stopped. This period is crucial, so you must try not to be complacent. Do not allow yourself to be tempted to smoke one cigarette, because this can easily lead to two or three cigarettes, increasing your risk of becoming a smoker again.

Saving the money that you would have spent on cigarettes is a great incentive to keep going. For example, if you smoke 20 cigarettes a day but stopping smoking you could save on average, £64 a week or £275 a month or £3,343 a year. In six months you would have saved £1,672 which you could put towards a holiday.

Most importantly, do not give up trying to quit, even if you do not succeed the first time. Most people need several attempts at quitting long-term before they stop smoking completely.

To find out the money you could be saving visit Help Me Quit - What is smoking costing me?

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.
Last Updated: 13/09/2017 09:36:11