7.1 Health and other benefits of quitting

Last updated: October 2016 

Suggested citation: Greenhalgh, EM, Stillman, S, & Ford, C. 7.1 Health and other benefits of quitting. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-2-health-and-other-benefits-of-quitting

A substantial body of research has established that quitting smoking has immediate as well as long-term health benefits for men and women of all ages, reducing risks for diseases caused by smoking and improving health in general.1-4 

The strongest evidence for this comes from a landmark 50-year follow-up of 34,000 British male doctors first studied in 1951.5-7 Many participants quit as the evidence on smoking and health accumulated from the 1950s onwards, providing a natural experiment demonstrating the impact of number of years smoking on health and eventual mortality. The study showed just how hazardous tobacco is and estimated that almost two-thirds of persistent smokers were killed by their smoking. Among those who quit, the greatest benefit was seen in those who quit earliest in life.7 Quitting at age 50 halved the risk of smoking-related death, but cessation by age 30 avoided almost all of the excess risk. Stopping at age 60, 50, 40 or 30 resulted in gains, respectively, of about 3, 6, 9 or 10 years of life expectancy.7, 8 A number of more recent studies have supported these findings. A 2015 Australian study that explored tobacco smoking and all-cause mortality found that past smokers who quit prior to age 45 did not significantly differ in mortality from never-smokers. Mortality diminished gradually with increasing time since cessation. Current smokers lost an average decade of life compared with non-smokers.9 Similarly, Italian researchers found that the more cigarettes per day a person smokes, and the earlier the person quits, the more years of life gained. For men that smoked 10-19 cigarettes per day, cessation at age 30, 40, 50, or 60 led to a gain of about 7, 7, 6, or 5 years of life respectively, and for women, 5, 5, 4, or 3 years of life, respectively.10

Changes in disease risk following cessation can be measured in different ways. A common measure is relative risk, as in the studies cited above, where the likelihood of developing or dying of disease in a population of former smokers is compared to either current or never smokers. At a population level, relative risk represents the fraction of disease attributable to smoking. However this measure is influenced by the rates of disease in the reference population, which should be taken into account when examining the influence of cessation on disease risk. Another measure is absolute risk, where the actual rates of disease in former smokers are compared to those of current or never smokers. Rates can be directly compared, or the excess rate of disease caused by smoking in smokers can be calculated as can the excess disease rate in former smokers. Another measure is cumulative risk of disease, which enables the cumulative risk for those who quit at different ages to be compared to that of continuing smokers.

A more complete discussion of changes in risk following cessation can be found in a handbook published in 2007 by the International Agency for Research in Cancer.3 i In general, the risk of disease is lower in former smokers than in otherwise similar current smokers. Smoking results in both acute and chronic changes to the body and progression towards disease. Cessation results in reversal of acute changes and slowing of disease progression and provides the potential for damage reversal.3

Many harmful effects of smoking are arrested or begin to decline as soon as a person stops smoking.1, 2 Many disease risks in former smokers continue to decrease with prolonged abstinence, compared to continued smoking. The risk for some health effects decreases more rapidly than for others, and improvement may continue for years after quitting. Some disease risks return to the level of never smokers after a long period of abstinence, but others do not, even after 20 years of abstinence.3

The extent of damage to health and risk for smoking-related disease is related to how much the person has smoked and for how long.3 For some health effects, for example inflammation of the lung, the reversal process is not yet well understood.3

However, while some damage may be irreversible or less reversible, there are substantial benefits to be gained from quitting at any age, regardless of smoking history.1, 2 Benefits accrue to persons both with and without smoking-related disease.1

7.1.1 Health problems that may be temporarily exacerbated by quitting

While there is no question of the overall long-term benefits of cessation, quitting is associated with a number of bothersome short-term problems such as mouth ulcers and cold symptoms, weight gain and constipation.11

Mouth ulcers and colds

There is evidence that smokers and users of smokeless tobacco are less likely to develop aphthous stomatitis (common mouth ulcers). Individuals commonly report a short-term increase in mouth ulcers and cold symptoms on quitting smoking.12

Mental health problems

Many smokers appear to have an increase in depressed mood and associated negative affect as part of nicotine withdrawal, but for the majority of people who quit this is temporary.13, 14 A common belief is that smoking cessation will exacerbate mental illness.15 However, recent evidence suggests that the reverse is true; quitting smoking for at least six weeks actually improves mental health, mood, and quality of life, both among the general population and among people with a psychiatric disorder.16 (See Section 7.12)

Diabetes

People with diabetes who quit smoking have a lower risk of death and cardiovascular events compared with those who continue to smoke.17 However, recent research has shown while quitting generally decreased the risk of diabetes overall, smoking cessation is associated with an increased risk and deterioration in blood glucose control in the first 2-3 years of abstinence.18, 19 A recent review similarly found that cessation can cause weight gain and can be associated with diabetes or obesity onset.20 Therefore, it is important that quit attempts are accompanied by preparation, extra care, and careful monitoring to keep the person's blood glucose well controlled during this time.18, 21

7.1.2 Quitting and weight gain

While smoking cessation usually results in some level of weight gain, there is disagreement about the extent and how long it lasts.

Smokers' average weight is about 3 to 4 kg less than that of non-smokers.14, 22 Smoking appears to attenuate weight gain over time, in part due to increasing metabolic rate.22, 23 The difference in weight between smokers and non-smokers is more marked in older long-term smokers while the average weight of younger smokers is similar.23-26 The weight difference, however, is further complicated by the finding that despite their lower weight and body mass index (BMI), smokers have a greater waist-to-hip ratio than non-smokers. Increased waist circumference is a stronger predictor of cardiovascular disease than BMI.27

When smokers quit, the majority experience some weight gain.1 Estimates of weight gain associated with cessation vary depending on the sample, study design and follow-up period.28 Most excess weight gain occurs in the first year after cessation, after which the rate of weight gain slows.22, 24, 29-33 One study found that increase in body weight may continue for longer.34 Estimates of the mean weight gain in people continuously abstinent for a year are about 5 to 6 kg.30-33 Results from a 2015 meta-analysis showed that on average, quitters gained 4.1 kg and continuing smokers gained 1.47 kg over an average of 5.15 years follow-up.35 Individual experience of weight change after quitting is quite broad, ranging from weight loss to a minority gaining over 10 kg.24, 31, 33, 36-39 Increase in waist circumference per kilogram gained is smaller in people who quit than in continuing smokers, indicating that recent ex-smokers gain less visceral fat.37, 40

Limited research suggests that some of the weight gained during the first few years after quitting may be lost with continued abstinence,41, 42 however more research is needed to resolve this issue.43 Large cross-sectional studies show that long-term former smokers have a mean waist-to-hip ratio and a mean BMI similar to or approaching that of people who have never smoked.27, 36, 39, 44 Research in New Zealand that followed a cohort of people from age 15 to 38 concluded that on average, quitters do not experience greater weight gain than never-smokers.45

Reasons for the association between smoking cessation and weight gain are not fully understood. Predictors of weight gain include younger age, lower socio-economic status and heavier smoking, with some influence of underlying genetic factors.29 Weight gain after smoking cessation is related to a transient increase in food intake,46 changes in metabolic rate,47 and minimal physical activity.48, 49 There is some evidence that smoking and obesity are independently associated with specific food cravings and mood states.50 Smokers who have a higher BMI also experience more weight gain after quitting.51, 52 A person's gender may also influence post-cessation weight gain. One study found that among light smokers, men gained more weight on average than women one year after quitting, while the opposite was observed among heavy smokers. Young women who were heavy smokers had the highest risk of weight gain after quitting.53

The health benefits of smoking cessation far outweigh the health risk from extra body weight, unless the weight gain is extraordinarily large.1 Even in cases of significant post-cessation weight gain and/or high prevalence of obesity, diabetes, and hypertension, sustained tobacco abstinence appears to substantially reduce cardiovascular risk.54, 55 The risk of death is smaller in overweight or obese ex-smokers than in normal-weight smokers.56 One study concluded that cessation related weight gain may actually be beneficial, as it is associated with increased muscle mass, muscle strength, and bone density.57 Nonetheless, fear of weight gain is a significant factor in discouraging quitting and provoking relapse in smokers.29, 58-66

(See Chapter 3, Section 3.29 for further information on the health effects of smoking in conjunction with and compared with those associated with obesity, and Section 7.8.3 for further information on managing weight gain.)

7.1.3 Immediate health effects of quitting

Upon cessation, the nicotine and carbon monoxide levels in the body decline rapidly. Nicotine levels drop to very low levels within a few hours, and the main metabolites of nicotine are largely eliminated within a week.1, 3, 67 After 24 hours the level of carbon monoxide in the blood has decreased substantially.1 After a year blood pressure returns to normal levels (this means it generally stabilises at whatever the person's new blood pressure is) and small airway function improves, with further improvements after six months.68 After two months, improvements can be seen in blood viscosity, blood flow to the limbs and blood levels of high-density cholesterol.1, 69, 70 Within six months the immune system improves greatly. Within a few months the cilia in the lungs and airways improve at sweeping mucus and debris from the lungs (as long as irreversible damage has not taken place).71 Lung function improves and the presence and severity of respiratory symptoms reduces.11 Symptoms of chronic bronchitis, such as chronic cough, mucus production and wheeze, decrease rapidly, and lung function in asthmatic patients improves within a few months after stopping smoking.3, 72, 73 Rates of respiratory infections such as bronchitis and pneumonia also decrease, compared to continued smoking.1

7.1.4 Short to medium-term reductions in health risks following quitting

7.1.4.1 Problems during pregnancy

It is extremely dangerous for a woman to smoke during pregnancy. (Refer to Chapter 3, Section 3.7 for a more detailed discussion of health effects, and Section 7.11 for a more detailed discussion of interventions aimed at pregnant women and their partners.) The US Surgeon General has stated that ‘smoking is probably the most important modifiable cause of poor pregnancy outcome among women in the United States'.1 Stopping smoking before or during pregnancy is important and has benefits for both the baby and the mother.74 Encouraging women to quit before they become pregnant or early in pregnancy is important because the critical period may be quite early.23

There is limited evidence that reducing consumption to fewer than eight cigarettes per day can improve birthweight75 and reduce preterm birth.76 However, complete abstinence is the only proven way to maximise health benefits. Women who stop smoking either before becoming pregnant or in the first three to four months of pregnancy have infants with a similar birthweight to those infants born to women who have never smoked.1, 77 Women who stop smoking any time up to the 30th week of pregnancy have infants with higher birthweights than those who smoke throughout pregnancy. Women who quit smoking before or during pregnancy reduce their risk of pregnancy complications, including preterm premature rupture of membranes and preterm delivery (birth at less than 37 weeks gestation).1, 23 Smoking cessation reduces the risk of infant death.78

7.1.4.2 Diseases for which the risk quickly declines

Heart disease

Smoking cessation reduces the risk of cardiovascular disease and death for male and female smokers of all ages with or without existing heart disease.4 One study found that smoking cessation is beneficial for people even after the age of 65 in reducing the excess risk of cardiovascular events and mortality.79 There are immediate and long-term benefits of cessation.80 After one year the increased risk halves and after about 151, 81 to 2082 years the rate is similar to that of a non-smoker for most former smokers. However, one study found that these cardiovascular benefits did not extend to former heavy smokers who smoked more than 3.2 packs per day, although they did have lower risk of death relative to current smokers.81 Quitting helps to improve peripheral vascular tone83 and to prevent atherosclerosis (the narrowing and hardening of the arteries due to build-up of plaque on the artery walls) advancing to heart disease and stroke.2, 3, 84 Smoking is a known risk factor for sudden cardiac death (SCD),2 and quitting smoking results in a significant reduction in SCD risk.85 Quitting is also associated with improved exercise tolerance among middle-aged men and women, with physical fitness being a protective factor against cardiovascular disease.86

Stroke

There is a marked reduction in risk within two to five years of quitting.3 After 15 years the risk of stroke is the same as a non-smoker.1

Oral health

Stopping smoking can reduce the risk of oral diseases associated with smoking including cancer, and improve the health of the mouth, gums and teeth.2, 87-89 Stopping smoking reduces the risk of leukoplakia, and after one to five years about half of leukoplakia disappears.90 Cessation reduces the risk of developing periodontitis, slows down the progress of existing disease, and quite quickly improves wound healing.2, 87, 91-93 Following cessation, gum colour gradually returns to normal88 and so-called ‘smoker's palate' can disappear.87, 88 Stopping smoking improves the success rate of dental implants.89 Smoking cessation may be associated with relatively rapid improvement in periodontal health in young adults.93

7.1.5 Medium to long-term health benefits of quitting

Successful cessation appears to stop the progressive increase in the use of health services associated with continued smoking within a few years.94

Specific long-term health benefits include:

Lung cancer. Quitting is beneficial for lung cancer risk.95 Quitting at age 30 reduces the risk of lung cancer by several times compared to a lifetime smoker. Even quitting at 50 more than halves the risk over the next 25 years compared to continued smoking.96 The absolute annual risk of developing or dying from lung cancer does not decrease, but by stopping smoking the much greater increase in risk that would result from continuing to smoke is avoided.3

Chronic obstructive pulmonary disease (COPD). Smoking cessation remains the only proven strategy for reducing the disease-causing processes leading to COPD.4 Cessation reduces decline in lung function.97 In smokers without COPD, stopping smoking improves lung function by about 5% within a few months of cessation. The accelerated decline in lung function in smokers stops within five years of smoking cessation, returning to the far slower rates of decline that naturally occur with ageing.1, 3 Existing emphysematous damage to lung tissue caused by smoking is permanent1 however cessation slows the progression of COPD.11 Symptoms of COPD will be less likely in the short and long term.1 However, even after many years of abstinence, COPD risk still remains elevated in comparison with never smokers.1 Statistical modelling has estimated that about 35% of the excess risk still exists after 20 years of quitting.98 In people diagnosed with COPD, stopping smoking reduces the rate of lung function decline, decreases the risk of hospitalisation for COPD,3, 71, 99 and results in fewer physician visits and less use of COPD medications.100

Other cancers. Smoking cessation is the only proven strategy for reducing the disease-causing processes leading to cancer.4 The risks of cancers of the mouth, throat, larynx, oesophagus, stomach, bladder, kidneys, pancreas and cervix are reduced after quitting compared to continued smoking, and continue to decrease over time.1, 3 The risk of pancreatic, oral and cervical cancers quite quickly become similar to people who have never smoked, but the risks for the other cancers remain higher than never-smokers even after 15 to 20 years.1, 3

Peripheral vascular disease. Quitting slows down the build-up of plaque on artery walls, so that the risk of the disease is substantially reduced. For those who already have the disease, amputations are less likely.1, 101

Blindness. Cataract development and macular degeneration risks and progression are reduced.2, 67

Male erectile dysfunction is reduced when smokers quit.2, 67

Female fertility. Missed and painful periods are reduced after quitting, as is the risk of delayed conception and early menopause.23, 102 The higher risk of heart disease and stroke among women smokers who use the contraceptive pill is reduced.103

Overall health and quality of life improve, with some evidence that heavier smokers report greater improvement in quality of life after quitting and report feeling happier compared with when they were smoking.1, 2, 104-107 Ex-smokers also appear to experience a meaningful increase in subjective well-being (i.e. satisfaction with life) from quitting.108 A 2014 meta-analysis reported that smoking cessation is associated with reduced depression, anxiety, and stress, and improved positive mood compared with continuing to smoke.16 Quitting has also been linked with less financial stress among women.109

7.1.6 Cutting down: are there health benefits?

Cutting down the number of cigarettes smoked each day is a common strategy used by smokers to reduce harm, to move towards quitting, or to save money.110-113 However, research shows no noticeable improvement in health outcomes or lifespan among smokers who are able to cut down on a long-term basis.4, 114-116 This is largely because smokers primarily seek a consistent level of nicotine. Those who cut down therefore tend to smoke the remaining cigarettes harder by taking more and larger puffs, and holding each puff longer. Thus they do not reduce their intake of toxins as much as the reduction in the number of cigarettes suggests.111, 117 For a detailed discussion on smoking reduction, see Chapter 18, Section 18.3.

7.1.7 Other benefits of quitting

There are other benefits of quitting smoking. Financial savings for a 20 cigarette pack-a-day smoker are about $7500 per year (2016 prices).118 Smokers who quit reduce their likelihood of financial stress and are likely to enhance their material wellbeing.119 As more public and private places become smokefree, ex-smokers avoid the inconvenience of having to find somewhere to smoke. Quitting avoids further smoking-related damage to skin, and slows the development of wrinkles.120 Life insurance is often cheaper,121 the risk of smoking-related fires is reduced122, 123 and people who quit have fewer sick days.2

Recent news and research

For recent news items and research on this topic, click here (Last updated October 2016)  

 

References

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17. Qin R, Chen T, Lou Q, and Yu D. Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: Meta-analysis of observational prospective studies. International Journal of Cardiology, 2013; 167(2):342-50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22251416

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