Smoking/ Vaping/ Marijuana
By: Meldon Kahan MD, Valeria Ramirez Lombana MD, Muhammad Adnan Haider MD, Jonathan Kahan MD
What you need to know
Smoking directly leads to cardiovascular disease such as heart attacks and strokes. You do not realize how sick you are until you finally stop for good!
Quitting smoking at any age is one of the best things you can do for your health
There are multiple effective tools to help quit smoking. Using a tool to help quit smoking increases your chances over cold turkey
The average smoker attempts to quit at least 6 times before stopping for good, do not give up!
Smoking has evolved into a widespread social habit over centuries, deeply intertwined with cultural, economic, and social aspects of societies around the world. However, it is now known to have profound implications for public health. Aside from the well documented association with respiratory ailments and cancer, smoking is a main modifiable risk factor for cardiovascular disease. As of today, 11% of adults aged 18-24 vape, 17% of US adults use vape/smoke marijuana and 11.5% of adults smoke cigarettes/tobacco. These numbers are increasing in every category annually [1].
What are modifiable risk factors?
These are factors that individuals can change or influence through lifestyle choices or medical treatment. For example: smoking, physical inactivity, unhealthy diet, obesity, high blood pressure, high cholesterol, and type II diabetes.
What are non-modifiable risk factors?
These factors are beyond individual control and cannot be altered. They include age, sex, and genetic predisposition. For instance, the risk of CVD increases with age, and men are at a higher risk at a younger age compared to women, though the risk for women increases and can surpass that of men as they age.
Why is smoking bad?
Smoking is a leading cause of CVD-related morbidity and mortality, responsible for a substantial proportion of preventable deaths worldwide. The detrimental effects of smoking on cardiovascular health involve mechanisms such as oxidative stress, inflammation, endothelial dysfunction, and alterations in lipid metabolism [2].
What is oxidative stress?
Oxidative stress occurs when there's an imbalance between the production of free radicals (reactive oxygen species or ROS) and the body's ability to detoxify these reactive products or repair the resulting damage. Cigarette smoke contains a high concentration of free radicals, heavy metals and other reactive oxygen species. When inhaled, these substances can overwhelm the body's antioxidant defenses, leading to cellular damage. This damage is a result of the oxidation of cellular components like lipids (see cholesterol section), proteins, and DNA, which can lead to various diseases, including cardiovascular diseases, cancer, and chronic obstructive pulmonary disease (COPD) [3].
How does smoking cause inflammation?
Cigarette smoke can trigger an inflammatory response in the body. The chemicals in smoke activate immune cells, such as macrophages and neutrophils, leading to the production of inflammatory cytokines and mediators. This chronic inflammatory state not only damages tissues but also promotes the progression of atherosclerosis (the buildup of fats, cholesterol, and other substances in and on the artery walls) as well as other inflammatory diseases. The persistent inflammation can further exacerbate oxidative stress, creating a vicious cycle that contributes to disease progression [4].
What is endothelial dysfunction?
The endothelium is the thin layer of cells lining the inside of blood vessels, playing a key role in maintaining vascular health by regulating blood pressure and blood flow, and preventing clotting. Smoking can cause endothelial dysfunction, which is an early and critical step in the development of atherosclerosis (plaque or blockages in the arteries). The chemicals in cigarette smoke can damage the endothelium, leading to reduced production of nitric oxide (NO), a molecule essential for vasodilation (the widening of blood vessels). Additionally, the oxidative stress and inflammation induced by smoking further impair endothelial function. This dysfunction promotes the development of plaques in the arteries, leading to cardiovascular diseases such as heart attacks, strokes, erectile dysfunction, peripheral artery disease [5,6].
How does smoking affect lipid (cholesterol) metabolism?
Smoking affects lipid metabolism in several ways, leading to unfavorable changes in blood lipid profiles. It can increase the levels of low-density lipoprotein (LDL) cholesterol (often referred to as "bad" cholesterol) and decrease levels of high-density lipoprotein (HDL) cholesterol ("good" cholesterol). This alteration in lipid levels contributes to the development of atherosclerosis. The mechanisms behind these changes include oxidative modifications of lipoproteins, alterations in the activity of enzymes involved in lipid metabolism, and changes in the liver's metabolism of lipids. These lipid profile changes further elevate the risk of cardiovascular diseases [7].
What is the prevalence of Tobacco, Nicotine and E-Cigarettes use in the USA?
Quitting smoking is crucial for your health, given the high prevalence of tobacco use. According to the National Institute on Drug Abuse, in 2021, about 22% of people aged 12 or older reported using tobacco products or vaping nicotine in the past 30 days, equating to 61.6 million people. Of these, 15.6% (43.6 million people) smoked cigarettes, and 4.7% (13.2 million people) vaped nicotine in the last month.
Among young students, the trend is concerning. In 2022, about 8.7% of 8th graders, 15.1% of 10th graders, and 24.8% of 12th graders reported using nicotine in the past 30 days. The numbers for cigarette use were lower, with 0.8% of 8th graders, 1.7% of 10th graders, and 4% of 12th graders reporting use. However, vaping nicotine was notably higher, with 7.1% of 8th graders, 14.2% of 10th graders, and 20.7% of 12th graders reporting vaping in the past 30 days [11]
What are the different types of smoking?
Cigarettes: Combustion of tobacco generates a complex mixture of toxic compounds, including tar, carbon monoxide, heavy metals and numerous chemicals that cause cancer and damage the heart.
Light Cigarettes: Marketed as a 'healthier' alternative, light cigarettes typically contain lower levels of tar. However, smokers of light cigarettes often compensate by inhaling more deeply. Studies suggest that light cigarettes confer a similar risk of CVD as regular cigarettes.
Alternative Forms of Tobacco: Among these products are cigars, cigarillos, hookahs (water pipes), smokeless tobacco, and powder tobacco. All carry similar risks as traditional forms of tobacco use.
Electronic Cigarettes and Vaping. Electronic cigarettes, or e-cigarettes (ECs) or vaping (they are the same) heat a liquid solution containing nicotine, flavorings, and other chemicals, producing an aerosol or vapor that users inhale. ECs send nicotine to the brain within seconds, satisfying the brain’s craving for nicotine as completely as cigarettes do.
Secondhand and Thirdhand smoking: Secondhand smoke, also known as passive or secondary smoke, poses a significant public health risk. It is linked to a 20% increase in lung cancer risk among nonsmokers and is estimated to cause around 53,800 deaths annually in the United States Moreover, exposure to secondhand smoke at home is a risk factor for childhood asthma. [9] Thirdhand smoke, a lesser-known concern, refers to the chemical residue left on surfaces (eg. curtains) after smoking. These residues can persist long after the smoke has dissipated, posing a risk to anyone who might touch, inhale or ingest them.
Cannabis (marijuana/weed smoking/vaping): The cardiovascular effects of smoking cannabis are not as extensively studied as tobacco, but research indicates several potential risks. Cannabis smoking has been associated with an increased heart rate, fluctuations in blood pressure, and a potential increase in the risk of heart attack and stroke, especially in individuals with pre-existing heart conditions. The combustion products inhaled when smoking cannabis can also harm the cardiovascular system similarly to tobacco smoke, although frequency of use appears to be less than traditional tobacco.
If I quit, when will I feel/get better?
20 Minutes - Heart rate (HR) and blood pressure (BP) begin to drop toward normal. Peripheral circulation starts to improve.
8–12 Hours - Carbon monoxide (CO) in blood drops significantly. Red blood cells can carry more oxygen, increasing tissue oxygenation.
24 Hours - Risk of acute coronary events (e.g., heart attack) begins to decline as platelet stickiness and pro-thrombotic effects decrease.
2 Weeks – 3 Months - Circulation continues to improve, lowering stress on the heart and blood vessels. Exercise tolerance often increases.
1 Year - Risk of coronary heart disease is less than half that of a person who still smokes. Overall cardiovascular health sees notable improvement.
5 Years - Risk of stroke approaches that of a non-smoker. Atherosclerotic changes in blood vessels can regress over time.
10 Years - Lung cancer risk is half of someone still smoking. Reduced risk of other cancers (e.g., mouth, throat, bladder, and esophagus).
15 Years - Overall cardiovascular risk profile is the same as non-smokers!
Tips for quitting smoking
Practical strategies for quitting smoking are listed below.
Set a quit date. You should choose a specific date to quit, usually 1-3 weeks in the future. This will give you time to mentally prepare for quitting. The quit date should preferably be during a time that your life is not too stressful.
Start anti-smoking medications on or before the quit date. These medications will make it much more likely that you will succeed in quitting smoking - see section below. E-cigarettes and the nicotine patch or gum can be started on the quit date. Bupropion and Varenicline should be started a week or two before the quit date.
Make a pact with your partner or close friend to quit at the same time. This is especially important if you live with someone who also smokes. If you quit together your chances of success are much higher.
Tell friends, family and coworkers about your commitment to quit. This gives you extra motivation to resist cravings.
Get rid of everything in the house that may remind you of smoking - e.g. ashtrays, the chair on the balcony where you used to smoke.
Avoid situations where you’re likely to want to smoke, or where you will encounter other smokers, e.g. bars, on a work break, or the convenience store where you bought cigarettes..
Avoid or cut down on alcohol if drinking makes you want to smoke. Alcohol is a common trigger for cravings.
Keep busy with things you enjoy, e.g. seeing friends who don’t smoke; spending time outdoors. Boredom is a trigger for smoking.
Take steps to reduce anxiety and depression. It is harder to quit smoking if you are anxious or depressed. Some practical steps you can take to improve your mood are: Exercise more; drink less alcohol; get more sleep; spend more time with friends and family. If your anxiety or depression is persistent and troublesome, talk to your doctor about medications that can help. Mindfulness programs have been shown to improve mood.
Give yourself a reward for every week you’ve not smoked, eg a nice restaurant meal.
Have a 20 minute time out between the decision to smoke and actually smoking. During that time, use nicotine gum or lozenges, call a friend or leave the room to do something else. Cravings often dissipate after 10-20 minutes.
Keep a written reminder of reasons for quitting, and look at it when you have cravings. The reasons should be meaningful to you, eg more energy, breathing better, better able to go on walks, food tastes better.
Call a phone help line. You can get advice and support from trained counselors by calling 1-800-QUIT-NOW (1-800-784-8669) or 1-877-44U-QUIT (1-877-448-7848). If you prefer online resources, you can visit https://smokefree.gov/ [30]
What should I do if I relapse? Is there any point trying again if I failed at previous quit attempts?
If you begin smoking again, start planning your next quit attempt. Most people who successfully quit do so after six or more attempts.
Identify the triggers for the relapse and take steps to avoid them in the future. Maybe you encountered a stressful situation, or unexpectedly were exposed to a strong trigger for smoking, eg a friend offered you a cigarette. Figure out a way to avoid these triggers.
Set another quit date.
Talk to your physician about changing your smoking cessation medications. The physician might prescribe a new medication, or adjust the dose of your current medication, or combine your current medication with another medication. There is evidence that combinations of medications are more effective than single medications.
Call a QuitLine, and consider enrolling in a formal smoking cessation program. The phone number for quit lines are listed above. The Affordable Care Act (ACA) covers in-person smoking cessation counseling. There are different forms of counseling, such as Cognitive Behavior Therapy (CBT) [16,17], or Motivational Interviewing (MI)[18]. Select the therapy that is readily available and feels right for you.
Why should I take medications to help me quit smoking?
Nicotine is a “chameleon drug”: If you are anxious and tense, nicotine calms you down, and if you are tired it picks you up. Smokers rely on cigarettes to improve their mood and get through the day. When you stop smoking, you will experience powerful urges (cravings) to smoke, especially at times when you used to smoke - for example, after meals.
Smoking cessation medications have been shown to double or triple your chances of success at quitting. They work directly on the brain to reduce cravings for nicotine, by providing nicotine directly, by acting on the nicotine receptor in the brain, or by increasing the same brain chemicals that nicotine does.
What is Nicotine Replacement Therapy (NRT)?
Most people start with NRT, because NRT has minimal side effects and risks [20]. NRT is safe to take in people with heart disease. Studies suggest that NRT can boost quit rates by 50 to 70 percent [21, 22]!
NRT products are available over the counter - no prescription is needed. The two main types of NRT are the patch and the short acting NRT products - gum, lozenge, nasal spray and oral inhaler. See Table 1 in the appendix for more information on NRT.
How should I use the nicotine patch?
The patch comes in three strengths: 7 mg, 14 mg, and 21 mg. The 21 mg patch is recommended for people who smoke more than 10 cigarettes per day. A 21 mg patch and 7 mg patch can be combined if you smoke 29 or more cigarettes per day (CAN-ADAPTT 2011). Talk to your physician if you feel you need higher doses of the patch.
You can take the patch off at night if it causes vivid or unpleasant dreams. If you experience strong cravings on awakening, it is probably best to keep the patch on during the night.
You can keep the patch at the same dose for as many weeks as you need; a minimum of 4-12 weeks is recommended. Then you can taper by 7 mg every two weeks. If you experience strong cravings or start smoking again you should increase the patch to the previous dose.
If you continue to smoke heavily despite taking the patch and the gum or lozenge, talk to your doctor about adjusting the dose and/or combining the patch with another smoking cessation medication.
The patch can be used in combination with the gum, lozenge, nasal spray or oral inhaler. See Table 1 of the appendix for detailed information on how to use these products.
How should I use nicotine gum or lozenges?
Nicotine gum and lozenge come in two strengths - 2 mg and 4 mg, and a variety of flavors. If you need a cigarette first thing in the morning (within 30 minutes of waking up) you should use the 4 mg strength. Also, female smokers tend to do better with the 4 mg gum/lozenge. You should use no more than 24 pieces of gum or 20 lozenges per day.
The lozenge should be left to slowly dissolve in the mouth, over a period of 20-30 minutes. For the gum, use the “chew and park” technique: give two or three chews, then ‘park’ the gum between the teeth and inner cheek. When you know longer feel a tingling sensation from the gum, start chewing again. Each piece of gum should last about 20 minutes.
Use the gum or lozenge during those times when you would normally want to smoke, for example, on awakening, after a meal, or with coffee. You should not wait until you have a craving before using the gum or lozenge, as it takes several minutes for the nicotine in the gum to reach the brain. At first, you may also need to take the gum or lozenge every 1-2 hours throughout the day, as the patch alone may not provide enough nicotine to relieve cravings.
Thus, if you smoke 30 cigarettes a day (1.5 packs per day), your NRT schedule might be:
Patch - 21 mg + 7 mg
Four mg gum:
On awakening - one at 8 am and again at 8:30 am
Morning - one at 10 am, 11 am, 12 noon
After lunch - one at 1 pm and again at 1:30 pm
Afternoon - one at 3 pm, 4 pm and 5 pm
After dinner - one at 7 pm and again at 7:30 pm
Evening - one at 9, 10, and11 pm
Total: fifteen pieces throughout the day.
You should modify the schedule according to your urges to smoke. Remember, it’s safe to take up to 24 pieces per day.
Can Electronic Cigarettes AKA Vaping Help Me Quit Smoking?
There is growing evidence that ECs are at least as effective as other medications. For example, a review of 78 studies found that people are more likely to quit smoking using nicotine e-cigarettes compared to nicotine replacement therapy or varenicline [12]. Another systematic review reached the same conclusion [13].
Heating of the liquid solution in the EC creates chemical byproducts. However, evidence suggests that smokers who use ECs in place of cigarettes have a reduced risk of heart attacks and strokes (Izquierdo-Condoy 2024). Note “popcorn lung” (broncholitis obliterans) is actually from diacetyl in flavored e cigarettes and vaping pens and should be avoided. Figure 1 shows different types of electronic cigarettes:
When should I use ECs?
You should consider using an EC if other medications - NRT, bupropion or varenicline - have not worked well or caused side effects. ECs can be used alone or in combination with other medications.
How much nicotine is in an EC? How many puffs should I take? How should I use EC to quit?
The nicotine cartridge for the EC typically contains 2 ml with 20 mg of nicotine per ml. One cartridge will provide between 200 and 400 puffs.
You should use the EC whenever you crave or desire a smoked cigarette. You will probably need to take about as many puffs on the EC as you did when smoking, because each puff of an E cigarette contains around the same amount nicotine as a puff of a cigarette,
Once you’ve been using the EC for at least 4-12 weeks and no longer have urges to smoke, you can gradually cut down on the EC dose, over several weeks or months. ECs are safer than smoking (but not as safe as traditional NRTs), so there is no hurry in tapering. Increase your EC use if you taper too quickly and find that you are craving cigarettes.
When and how should I use bupropion (Zyban?)
Bupropion, an antidepressant, is as effective as nicotine replacement therapy (NRT) in helping people quit smoking [23]. It works by increasing a chemical in the brain called dopamine; dopamine produces feelings of pleasure, relaxation and energy. Nicotine also produces pleasant feelings by increasing dopamine. Bupropion reduces cravings by reducing the brain’s need for nicotine.
You can ask your doctor to prescribe bupropion when you first try to quit, or if other medications didn’t work. It can be used alone, or in combination with NRT, ECs or varenicline; combining it with other smoking cessation medications may increase its effectiveness.
Bupropion should be started one week before your quit date, as it takes a week to reach the right level in your blood.
Discuss side effects with your doctor. It can cause anxiety and vivid dreams. It should be used with caution if you have a seizure disorder.
When and how should I use Varenicline (Chantix)?
Varenicline attaches to the nicotine receptor in the brain, convincing the brain that it is getting nicotine. It also blocks actual nicotine from attaching to the receptor, so that if you smoke while on varenicline the nicotine in cigarette smoke will have no effect. Both these actions make varenicline a more effective medication than either NRT or bupropion [24].
As with bupropion, you can ask your doctor to prescribe varenicline at any time - when you first try to quit, or if other medications didn’t work. It can be used alone, or in combination with ECs, NRT or bupropion [25].
Varenicline should be started a week before your quit date. You should take it for at least twelve weeks. Some people need an additional twelve weeks.
Varenicline is safe in people with heart disease (Lo 2023). Side effects include nausea, insomnia and irritability. Your physician will review side effects with you.
Are smoking cessation medications safe and effective in pregnancy?
Many women are able to quit smoking during pregnancy, but counseling and medications are often required. Nicotine replacement therapy is effective during pregnancy, but should be maintained throughout the pregnancy and at an adequate dose (Ila-Frinas 2024). E-cigarettes are at least as effective as NRT during pregnancy, and women who use ECs during pregnancy appear to have better birth outcomes compared to those who continue to smoke (Przuli 2023); however, NRT should be tried first during pregnancy because of its proven safety profile.
Bupropion and varenicline are not recommended for use during pregnancy. To date there is no evidence that these medications harm the pregnancy or the baby, but further research is needed before they can be considered safe (ACOG 2020).
Smoking: Key Points
There is no safe level of smoke inhalation. Smoking directly leads to blood vessel damage, heart attacks, strokes and death.
You should take medications to help you quit smoking. The most effective medications are nicotine replacement therapy (nicotine patch, gum or lozenge), e-cigarettes, bupropion, and varenicline.
You should use proven strategies to quit smoking, such as setting a quit date.
The average smoker quits several times, do not give up, there are tons of resources to help, make this a priority.