“Doc, I’m down to one cigarette a day”. That’s great, but you have to stop altogether. “I don’t want to gain weight if I quit. What do you think about e-cigarettes?”

Over the past several years, the number of people who smoke has dropped to an all time low. About 13% of US adults smoke, but that still represents about 37 million active smokers. The risks of smoking are well known. Heart attack, stroke, lung disease and cancer all increase with more smoking: the greater the number of cigarettes smoked and the longer a person smokes, the higher the risk for problems. Many people believe that cutting from smoking 20 to 25 cigarettes per day to only one or two per day will cut their risk. The idea is that a cigarette a day can’t be harmful. What is the data?  Researchers examined 5.6 million people and found that cutting the number of cigarettes from 20 per day to one per day reduced the risk for cancer, but the risk for heart disease persisted.  Compared to a nonsmoker, smoking 20 cigarettes per day increased the risk for heart disease in men by 100% (doubling the risk) and by 184% in women. Compared to those who never smoked, smoking only one cigarette per day increased the risk for heart disease by 50% in both men and women.  In addition, there is an excess risk for stroke with only one cigarette a day. The conclusion was that even one cigarette per day puts a person at significant risk for a heart attack or stroke. The goal must be zero cigarettes.

One of the barriers to quitting is that smokers don’t want to gain weight when they stop smoking. Given the fact that both smoking and obesity put people at risk for heart disease, which is worse, smoking or weight gain? Weight gain in quitters is the result of an increased appetite and lower energy levels.  The amount of weight gained after quitting is usually less than 10 pounds, but can be as high as 30 pounds. Weight goes up for about 5 years after smoking cessation and then slowly comes down.  In a recent study, it was found that stopping smoking reduced the risk for cardiac deaths regardless of weight gain.  This reduction occurred in those who gained weight and those who didn’t gain weight; the weight gain didn’t offset the benefits of smoking cessation on the death rate. The patients who gained weight also had more diabetes than those who didn’t gain weight. Even with weight gain and diabetes, there were less cardiac deaths. This data shows that smoking is worse than weight gain. 

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What is the best way to stop smoking?  The main determinant is the smoker’s desire to quit. If you don’t really want to stop, then quitting will be nearly impossible. Some people can stop cold turkey. Most, however, need help in some form. Smoking cessation aids (such as nicotine patch, Chantix and Wellbutrin) can help people quit.  How safe are they? The cardiovascular safety of these aids has been tested in the general population of smokers and they do not increase the risk for heart attack and stroke.  The safety in patients with heart disease is not yet known. How effective are they? In a recent large trial only 3% of people using these aids were smoke free at six months. An emerging method of quitting is the use of the electronic cigarette (e-cigarette) or “vaping”.  The e-cigarette is a battery-powered device that heats liquid nicotine and flavorings (such as vanilla or cinnamon) into a vapor cloud that is inhaled. The data on e-cigarettes are still evolving, but preliminary studies show that they are less harmful than traditional cigarettes. Less harmful does not mean safe, however the degree of harm has not yet been defined. By altering the amount of nicotine in the device, smokers can titrate the nicotine down and quit slowly. However, a recent study showed that smoking cessation with e-cigarettes was not any better than other smoking cessation aids. The other major concern with e-cigarettes is their use in the adolescent population. Vaping has exploded among teens. Many studies have shown that e-cigarette use in young people doubles the odds of smoking traditional cigarettes. The FDA is now cracking down on e-cigarette manufacturers, trying to stop their advertising and sale of these products to teens.

In summary, the number one priority for any smoker is to stop smoking, using any means (going cold turkey or using smoking cessation aids or e-cigarettes) and then work to lose the weight that is gained.