Smoking harms health, this is now common knowledge. Nevertheless still more than a quarter of Germans between 18 and 64 years old to the cigarette. 1 Why do cigarettes have such an addictive effect?? What health consequences smokers must expect? What factors favor a smoking cessation? And what about the e-cigarette as an alternative to tobacco?
Tobacco as a component of a cigarette
Cigarettes consist mainly of tobacco, to which – depending on the manufacturer – more or less additives are added. But what is tobacco and what happens when it burns??
Tobacco is a plant that originally grew only in the Americas and there by natives now and then for rituals was used. Only with the conquest of America in 16. Tobacco was brought to Europe in the nineteenth century. 2 Since then, its cultivation and consumption has been banned again and again in different countries. Nevertheless, the tobacco spread further and further. Smoking was banned on German roads until 1848.
The danger in smoking does not come from the tobacco itself, but from the smoke that is produced when it is burned. This contains over 5.300 different substances, of which at least 250 toxic or carcinogenic are.
There are more than 90 substances in tobacco smoke which, according to scientific research, have a high probability of being classified as carcinogenic.
These substances cause damage to the genetic material (DNA) of humans. Often the body is capable of repairing this damage. However, these "self-healing" substances are limited. This increases the risk of altering the DNA of individual cells. This can happen without noticeable consequences. However, if the DNA is changed at a point that is responsible for regulating cell division, health risks arise.
In this way, the cell can continue to divide uncontrollably and pass on this misinformation to all cells that emerge from it. This uncontrolled growth of diseased cells, which ultimately displace healthy tissue, is known as Cancer denotes.
Tobacco smoke contains substances such as hydrogen cyanide or ammonia, which damage the cilia in the lungs. These actually have the task of clearing the lungs of foreign bodies. If they are damaged by smoking, they can no longer effectively remove the particles of tobacco smoke, so that these harmful substances remain in the lungs and are absorbed into the blood from there. 3
In addition to tobacco, manufacturers can add other substances to cigarettes. The German Cancer Research Center (DKFZ) and the Dutch National Institute for Public Health and the Environment (RIVM) have documented which substances are involved and how large their share in the total weight of a cigarette can be as part of the EU project Public Information Tobacco Control (PITOC):
Tobacco additives (data: DKZF)
It has been shown that many of the added substances are used in the food industry, among others. Their consumption is considered safe. In the cigarette, however, these substances burn, creating new substances which Toxic or carcinogenic can be.
Toxic substances include acrolein and 2-furfural, which irritate the eyes and upper respiratory tract. Toluene and phenol also harm the body.
Acetaldehyde and styrene are classified as possibly carcinogenic by the International Agency for Research on Cancer (IARC). Acetaldehyde can also promote addiction.
Polycyclic aromatic hydrocarbons, formaldehyde, benzo[a]pyrene and benzene can also be produced when the additives are burned. It is known that these substances are carcinogenic.
Taken together, these additives can Almost a quarter of the "tobacco" contained in the cigarette. 4
The menthol cigarette
The use of additives in tobacco has been the subject of critical debate in recent years. Not only because of the direct harmful effect on health of many of these substances, but also because they make the smoking experience more pleasant. Since the flavoring agents mask the actual taste of tobacco, especially young people to start smoking facilitates.
Additives – Data: DKFZ
After increasing attention was drawn to this problem, the EU Commission decided in 2016 that "cigarettes and tobacco products for rolling will in future not contain flavors such as z.B. May contain menthol or vanilla, which mask the taste and odor of tobacco." 5 For menthol cigarettes, this provision came into force in 2020. The legislation has not yet had any effect on the above-mentioned additives, which may continue to be added to tobacco.
How nicotine affects?
Nicotine is a neurotoxin and is addictive. It binds to receptors distributed throughout the body and triggers many different reactions. The effects on the body and brain are so strong that many people become dependent on this substance.
In the brain
Nicotine reaches the brain just seconds after inhaling cigarette smoke. There it activates the so-called "reward center", in which it stimulates the production of dopamine. This leads to pleasant feelings such as relaxation and serenity. At the same time, it also activates brain areas responsible for alertness and increased attention.
This combination makes smoking particularly attractive to people who suffer from severe stress at work or in everyday life. It helps them to keep a "cool head" and increases their performance.
In addition, nicotine helps people lose weight through three different mechanisms. On the one hand, nicotine increases the release of adrenaline, which stimulates the breakdown of fat. In addition, it activates the digestive system and the vomiting center. The latter leads to a decrease in appetite. 6
In the rest of the body
Nicotine binds to the so-called nicotinic acetylcholine receptors, which are located throughout the human body and are responsible for very different processes. This explains the has a wide range of effects, some of which are even contradictory From nicotine.
Nicotine increases the release of a hormone called vasopressin. This ensures that The blood vessels constrict and thus the blood pressure increases. It also inhibits urine production and thus the urge to urinate. In addition, nicotine increases respiratory rate and pain sensitivity.
Because of the relaxing effect of nicotine, many believe that smoking helps them to calm down. However, this is a misconception. Although the brain relaxes because its appropriate receptors are activated, the rest of the body is affected by the increased release of adrenaline into a "state of alarm" displaces. 7
How does dependence occur?
Dependence is described in the current international classification of diseases as follows:
"There is a strong desire or even compulsion to use the substance, with a diminished ability to control the use of the substance. The body develops a tolerance to the substance, so that an ever higher dose must be administered in order to achieve the desired effect. If the substance is not taken, withdrawal symptoms occur. The substance is consumed even though the user knows about its harmful effects. Social and professional activities are neglected in favor of substance use. Three out of six of these criteria must have been met in the course of the last year in order to diagnose a dependency."
Physical dependence is when the body changes as a result of repeated use of the substance and a tolerance is built up as a result. If consumption is then interrupted, the person suffers from withdrawal symptoms. 8
Nicotine binds to receptors in the brain’s reward center. With continuous use, the brain adapts to the sustained stimulation by forming more receptors. Now more receptors have to be stimulated so that the person can feel the same pleasant sensation. Since the body does not produce so many messenger substances on its own, the person becomes dependent on nicotine.
If he now stops smoking, his reward center is stimulated less than that of a non-smoker. This can lead to Withdrawal symptoms such as irritability, inner restlessness, anxiety, low mood, concentration problems, increased hunger and appetite, constipation, and tobacco cravings. These symptoms are usually strongest within the first week after the last cigarette is smoked and then gradually decrease. This is due to the fact that the brain adapts to the lack of stimulation of the reward center and excess receptors are broken down again. 9
Psychological dependence, on the other hand, is characterized by a strong urge to consume a substance again and again in order to achieve a feeling of pleasure. However, when the consumption is interrupted, withdrawal symptoms do not occur.
Psychological dependence is also caused by continuous smoking behavior. This is because certain situations are associated with smoking. Examples include having a cigarette after getting out of bed, or taking a smoke break at work. These links may persist for years. However, it helps if you consciously avoid them. So after getting up, instead of having a cigarette, take a short walk or have a cup of tea. 8
Test: How strong is the nicotine dependence??
To get to the bottom of this question, the Fagerstrom test with 5 questions was developed:
When after getting up you smoke your first cigarette?
- after 5 minutes (3 points)
- after 6 – 30 minutes (2 points)
- after 31 – 60 minutes (1 point)
- after more than 60 minutes (0 points)
Do you find it difficult to refrain from smoking in places where smoking is prohibited?
- yes (1 point)
- no (0 points)
Which cigarette would you not want to give up?
- on the first one in the morning (1 point)
- other (0 points)
How many cigarettes do you smoke per day in general?
- 31 and more (3 points)
- 21 – 30 (2 points)
- 11 – 20 (1 point)
- to 10 (0 points)
Smoke in the morning generally more than the rest of the day?
- yes (1 point)
- no ( 0 points)
Does it happen that you smoke when you are sick and have to stay in bed during the day?
- yes (1 point)
- no (0 points)
Evaluation Fagerstrom test
- 0 – 2 points represent a low physical dependence. If you decide to stop smoking, you have a good chance of becoming smoke-free. you should set a quit day as soon as possible.
- 3 – 4 points indicate moderate physical dependence. You should plan your smoking cessation carefully and, if necessary. Seek advice from experts to help you develop strategies for managing smoking cravings and for dealing with relapse risks.
- 5 – 6 points speak for a strong physical dependence. In any case, you should seek expert advice and support in quitting smoking.
- 7 – 10 points indicate a very strong physical dependence. To cope with the urge to smoke, you should seek medical support or. consider the use of nicotine replacement products.
The benefits of a smoke-free life
Leaving smoking behind has many advantages. Health factors are probably the most serious, but financial and psychological aspects should not be ignored either.
Smoking increases the risk of suffering different diseases. Cancer and cardiovascular diseases in particular occur more frequently among smokers. In turn, the cessation of smoking can reduce the risk of disease again.
|Esophageal cancer||3.5 times|
|Pancreatic cancer||2.2 times|
|Cervical cancer||1.75 times|
|Peripheral arterial occlusive disease||13 times|
|Heart attack||3.5 times|
|Aneurysm hemorrhage||3.5 times|
|Ischemic heart disease||3,1-fold|
|Orbitopathy (in people with Graves’ disease||4-fold|
|Age-related macular degeneration||2-fold|
|vascular dementia||1.6 times|
|Multiple sclerosis||1.5 times|
How to understand the risk?
The risk indicates the factor by which heavy smoking increases the probability of contracting the named disease. The Risk of stroke is bspw. increased by 6 times. This means that for every non-smoker who suffers a stroke, 6 smokers suffer a stroke.
That the risk of developing lung cancer is increased 100-fold is elevated, however, does not automatically mean that a smoker is most likely to develop lung cancer. The baseline risk is taken into account.
In general, the baseline risk of cardiovascular disease is higher than, for example, the baseline risk of smoking. for cancerous diseases. Since this already increased risk is further increased by smoking, smoking has its greatest negative influence in the area of the cardiovascular system. 10
Why smoking endangers health?
In particular, cancer and cardiovascular diseases occur significantly more often in smokers than in non-smokers. The causes of this are already known.
Smoking and cancer
Many carcinogenic substances are absorbed into the body through tobacco smoke. In the cells, they damage the genetic material, which can lead to uncontrolled multiplication. In particular, the tissues that come into direct contact with smoke when it is inhaled are at risk. However, once these substances are absorbed into the blood through the lungs, they spread throughout the body and can damage other organs as well.
Smoking and cardiovascular disease
Smoking contributes to the development of cardiovascular diseases through different mechanisms.
On the one hand, it promotes the development of atherosclerosis, as it exposes the body to so-called "oxidative stress". This is due, for example, to substances contained in cigarette smoke. These substances can then react with nitric oxide (NO), which actually protects blood vessels from arteriosclerosis. This not only leads to the protective function of nitric oxide being lost. The new substances that result from this reaction actually damage the blood vessels.
In addition, increased oxidative stress leads to increased oxidation of the "bad" LDL cholesterol in the blood vessels. This is also an important factor in the development of atherosclerosis. In addition, mild inflammation of the blood vessels occurs more frequently in smokers, which permanently harms them and contributes to atherosclerosis. The doctor can recognize these inflammations in the blood count by an increased number of white blood cells (leukocytes). The body produces more leukocytes to fight the pathogen of a disease.
It is also known that platelets are more likely to cluster together in people who smoke regularly. This may ultimately triggers a heart attack or stroke Its.
The nicotine contained in the cigarettes not only causes dependence, but also increases blood pressure. Increased blood pressure puts a strain on the blood vessels and the heart, which favors the development of cardiovascular diseases. 11
Smoking and reproductive ability
Studies have shown that both men’s and women’s reproductive capacity is at risk from smoking. Complications during pregnancy are also more frequent in women who smoke actively or passively than in non-smokers.
The ejaculate of smoking men contains fewer sperm on average than that of non-smokers. The remaining sperm are more often deformed, so that it can be assumed that they have only limited functionality. Even occasional smoking is associated with reduced potency in men.
Smoking women have greater problems getting pregnant compared to non-smokers. The probability of a fertilized egg implanting in the uterus is halved in smokers. In addition, the risk of miscarriage is more than doubled for smokers.
The contraceptive pill already poses a health risk in itself, which is exacerbated by smoking. Under these circumstances, even young women can get thrombosis or stroke. Therefore, it is advisable to eliminate at least one of the two risk factors. 12
Disadvantages for the child
Since children are still developing, cigarette smoke is particularly harmful to them. This is already evident during pregnancy: the more the mother smokes, the higher the risk of miscarriage. This was shown in a meta-analysis published in the American Journal of Epidemiology. 13
It should be noted that the pregnant woman herself does not have to smoke. Passive smoking also harms the unborn child.
At birth, children born to smokers are smaller and lighter than those born to non-smokers. Their risk of dying within the first four weeks of life is increased by 40 percent.
Later, children from smoking households are twice as likely to suffer from respiratory diseases 12 and 2.5 times as likely to suffer from asthma 14 , compared to children not exposed to cigarette smoke. 15, 16
But diseases such as middle ear infections and inflammatory bowel disease are also more common in children who smoke than those who are not exposed to cigarette smoke.
Recommendation: It is not enough to stop smoking during pregnancy if it is resumed after birth. For the good of the child, both parents should stop smoking, even before pregnancy begins.
In addition to the physical influences that parental smoking may have on the child, the role model function of parents should not be neglected. They are the first caregivers for the child, from them he learns what is "normal". So when it sees its parents smoking, it thinks it’s good and right from a young age. Even if it later learns not to smoke itself, the risk is still increased. This assumption is also confirmed by a study in the Official Journal of the American Academy of Pediatrics. The study was also able to show that children whose parents quit smoking are less at risk than those whose parents don’t quit. 17
Another reason to stop smoking is the money in cash. A person who smokes a pack of cigarettes a day spends approx. 6-7 euros out. At first, that doesn’t sound like a lot of money. However, if you extrapolate it to a whole year, that’s up to 2.500 euros.
TipIf you want to quit smoking, put the money you would have spent on cigarettes in a piggy bank. Here’s how to see specifically how much money you’ve already saved. Use this money to reward yourself for your discipline. Go out for a good meal or treat yourself to a spa day. Thus, make yourself aware that by quitting smoking, you will not only have abstract health benefits in the distant future, but that it also holds benefits for you in the here and now.
Many people who have given up smoking find it a psychological relief. They feel more independent because they no longer have to worry about when they can smoke the next cigarette at work, for example.
In addition, many are rightly very proud of themselves and what they have achieved.
The e-cigarette as a healthy alternative?
E-cigarettes, which are relatively new to the market, and their impact on community health have already generated controversy. Praised by some as an effective way to help quit smoking. Others see it as a "gateway cigarette" that first opens the doors to smoking, especially for young people.
How harmful are e-cigarettes?
The so-called liquid, which is inhaled when using an e-cigarette, consists of nebulizer (propylene glycol or glycerine), water, ethanol and various flavorings. In addition, in most liquids, as in conventional cigarettes, Nicotine contained. 18
E-cigarettes are generally advertised as being "healthier" than regular cigarettes because they contain fewer carcinogenic or toxic ingredients. This may be true. But since e-cigarettes have not been on the market for too long, there are hardly any studies proving their harmfulness – the But does not automatically speak for their harmlessness.
In 2019, the first long-term American study on this topic was published. Scientists were able to show a clear link between the sole use of e-cigarettes and respiratory diseases. 19
However, short-term consequences such as respiratory irritation and inflammatory reactions of the bronchial tubes have already been reported. 18
Another important point is that nearly half of all smoking-associated deaths occur because of cardiovascular disease. However, the cardiovascular damage is caused by the nicotine that continues to be ingested through the e-cigarettes. 20 Pregnant women should also avoid nicotine, as it can damage the lungs and brain of the unborn child, no matter what form it is consumed in. 21
E-cigarettes as a smoking cessation aid
The e-cigarette as a means of smoking cessation is discussed very controversially. On one hand, they have the potential to help smokers quit tobacco cigarettes by simply replacing them. Since e-cigarettes are currently believed to be the lesser of two evils compared to traditional cigarettes, this intervention would have been the first step in a good direction.
However, there is a risk that the consumer in false sense of security Weighs and neglects the health risks of the e-cigarette. Therefore, in a second step, smokers also have to part with the e-cigarette.
The most effective way to quit is with nicotine-free e-cigarettes, as the physical dependence is directly broken. In the next step, the consumer can then break free of the psychological dependence by also giving up the e-cigarette.
Only if the smoker is not dependent on either conventional or e-cigarettes after cessation can one speak of successful cessation.
One phenomenonMany people who want to quit smoking with the help of e-cigarettes end up using both. So they do not manage to get away from tobacco and now smoke e-cigarette in addition. With this dual consumption, the health risks increase significantly. 22
E-cigarettes in a social context
A major criticism of e-cigarettes is, that they make smoking respectable again.
The clean image of e-cigarettes tempts young people who would not reach for a regular cigarette to give "vaporizing" a try. These young people have an increased risk of also trying tobacco cigarettes and getting hooked on them. 23
The discrepancy between knowledge and action – and how to overcome it
Most smokers know about the health risks of this habit and many want to quit. Nevertheless, this is often easier said than done. In addition to physical and psychological dependence, there are other psychological factors that keep smokers with cigarettes.
Several studies from the 1990s have shown that many people have what is known as "unrealistic optimism," and that this optimism. They believe that bad things can only ever happen to others, but not to themselves.
Thus, it was shown that smokers consider the health risk of the average smoker to be as high as non-smokers. However, they estimate their own risk to be lower. This is a protective mechanism of the psyche that helps people worry less about their own health. However, this mechanism is a double-edged sword. Finally, the individual might actually be protecting his or her health. However, his unrealistic optimism deludes him into thinking that everything is fine, and the unhealthy behavior continues.
In the case of smoking cessation, this unrealistic optimism must first be dispelled. This can be very stressful at the first moment. However, knowing one’s own risk and having confidence in one’s own ability to quit smoking are the basis of successful quitting.
Confidence in your own abilities
To quit smoking, it takes a lot of self-confidence. Finally, quitting is a major challenge in which discipline and stamina are regularly put to the test.
Tip: In preparation for day X when you quit smoking, think about the following: What hurdles may get in my way? What solutions help me get around these hurdles? Answering these two questions will not only increase your confidence, but also your concrete chances of success.
Prepare for day X
You should prepare for the day you stop smoking as if you were writing an important exam or giving a presentation at work. Here it is important to be as concrete as possible.
Mr. Maier is preparing for day X
Suppose a certain Mr. Maier wants to quit smoking. If he just says to himself, "I should quit smoking sometime," he will probably have little success.
Questions from Mr. Maier: When do I want to quit? And why? What will be easy for me? What hard? In which situations will it be liberating not to be a smoker anymore? In which situations will it be difficult not to reach for a cigarette again?? How do I want to deal with it? What do I want to do to celebrate my first smoke-free week? The first month? The first year?
Again, it can be scary to plan so far into the future. Doubts may arise, "What if I can’t even make it through a week??".
These doubts give important clues. Why he should not last a week? Maybe because his best friend smokes as well and he would feel tempted to join in in his presence. How good that he is thinking about it now and not when the time comes. How would Mr. Maier like to deal with it now? Does he want to initiate his friend? Maybe that would even go along? Or perhaps the friend is a convinced smoker and would find such an attempt to quit ridiculous? Maybe Mr. Maier would be better off avoiding contact for a week or two.
Even if smoking is still allowed as usual during the preparation for quitting smoking, it is worth asking the following question: Why do I feel the need for a cigarette right now?? Is it the stress? The habit? Or the sense of connection with colleagues?
TipRecall your own personal reasons for quitting smoking. Imagine what it would be like not to smoke now. What can you do instead?
It’s like giving a presentation: the better prepared you are, the more confident you feel. One may even eventually look forward to the big day X. This should be at the beginning of a relaxation period. Perhaps after a big project or at the beginning of a vacation. 24
Possible withdrawal symptoms
Withdrawal symptoms occur very individually. While some suffer from severe physical withdrawal symptoms, others have no problems at all.
The most common withdrawal symptoms include:
- Increased irritability and frustration
- bad mood
- Increased appetite
- strong desire to smoke
The withdrawal symptoms are due to the fact that the body has become accustomed to the influence of nicotine. With time, however, he will also get used to the situation without nicotine. After a week, most people have gotten over the worst of it.
In the meantime, the following tips can make withdrawal bearable:
The right timeTo cope with the withdrawal symptoms as well as possible, it is advisable to start in a time that is as stress-free as possible, e.g. on vacation, to stop smoking.
Accept what is happening in your body right nowBe aware that your fatigue or irritability is normal at the moment and that it is not your fault.
Treat yourself: Give yourself and your body exactly what it needs right now. If you are tired, rest or take a short walk in the fresh air. If you have excess energy, do sports.
SportsSports activities help with many withdrawal symptoms such as irritability or increased appetite. The sport helps your body to get into balance. It is particularly recommended to go for a run in the fresh air. All activities that make you feel good are good.
Inaugurate those around youExplain to your friends and family that irritability or low mood are normal withdrawal symptoms of quitting smoking. Ask them to understand and, if it does get to be too much for you, take some time for yourself.
Talk to like-minded peopleMaybe you know someone who has already quit smoking and understands how you are feeling right now. Or perhaps you have met someone on a forum who is also in the process of quitting smoking. Give each other support.
Since most people find it difficult to quit smoking through sheer discipline, various therapies have been developed to help them in this process. A combination of behavioral therapy and medication support has been shown to be most effective. 25
Nicotine replacement therapy
Probably the best known smoking cessation support is nicotine replacement therapy. In this process, the patient takes nicotine in the form of patches, gum, nasal spray or tablets. The nicotine helps with the withdrawal symptoms, however the physical dependence remains. This is broken only when you are weaned from nicotine.
Listen with the help of nicotine replacement therapy 50-70 percent more people quit smoking than without. 26
There are two medications, approved in Germany to support smoking cessation. The drugs in question are bupropion and varenicline. Since both can lead to severe side effects, they are available only on prescription.
Bupropion is an antidepressant that increases the concentrations of dopamine and norepinephrine in the brain. It thus imitates the effect of nicotine, but without binding to the associated receptors, so that they can regress. Possible side effects include dry mouth and sleep disturbances.
Varenicline was developed especially for smoking cessation. It occupies the nicotine receptors so that there is no more reward effect when smoking. The most common side effect of varenicline is nausea. 27
Cognitive behavioral therapy
While nicotine replacement therapy and medication help manage physical dependence, cognitive behavioral therapy focuses on psychological dependence and the "habit of smoking".
There are various behavioral therapy programs, for example from Rauchfrei – an initiative of the Federal Center for Health Education.
Studies have also shown the effectiveness of such programs. 28
What is covered by health insurance?
To help smokers quit, most health insurance companies offer online courses that are free to their members. These courses help smokers to break their behavioral patterns and thus dissolve the psychological dependence. In addition, the courses are held in groups, so that problems are discussed directly and the participants can support each other.
Some private health insurance companies also cover the costs of acupuncture and hypnosis therapies.
However, smokers must pay for prescription medications and nicotine replacement products themselves. 29
More on the topic
Did this information help you?
Dr. med. Jurgen Kunz is a resident specialist in neurology at the Ravensburg Neurocenter. One of his main areas of focus is treating patients who have had a stroke. When treating a stroke, cross-sector collaboration with other doctors and therapists is very important to him. [more]