There is an advantage to smoking

Quitting Smoking - How To Do It

Tips, benefits, and withdrawal symptoms

It's worth quitting smoking (Photo: fongbeerredhot | Shutterstock)


In this article:


the essentials in brief:

  • Tobacco smoke, whether from a cigarette or a cigar, a cigarillo or a pipe, is one of the main causes of lung cancer and cardiovascular diseases worldwide.
  • Tobacco use is one of the main risk factors for heart attacks and strokes.
  • Cigarettes are not just made of tobacco. Usually different substances are added, which make the smoke tastier, but also more dangerous.
  • As far as we know today, the e-cigarette is less harmful than the tobacco cigarette. But it is not harmless.
  • There are many and very different smoking cessation programs out there. A combination of behavior therapy and drug support is most effective.

Smoking is bad for your health, that is now common knowledge. Still grab it still more than a quarter of Germans between the ages of 18 and 64 to the cigarette.1 Why are cigarettes so addictive? What are the health consequences of smokers? Which factors favor quitting smoking? And what about the e-cigarette as an alternative to tobacco?

Tobacco as part of a cigarette

Cigarettes largely consist of tobacco, to which - depending on the manufacturer - more or less additives are added. But what actually is tobacco and what happens when it burns?

Tobacco is a plant that originally only grew in America and was used there by the locals for rituals from time to time. Tobacco was only brought to Europe with the conquest of America in the 16th century.2 Since then, its cultivation and consumption has repeatedly been banned in different countries. Nevertheless, tobacco continued to spread. Smoking was prohibited on German streets until 1848.

When smoking, however, the danger 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.

Carcinogenic substances

There are more than 90 substances in tobacco smoke that, according to scientific research, are classified as carcinogenic with a high degree of probability.

These substances cause damage to the human genome (DNA). The body is often able to repair this damage. However, these “self-healing powers” ​​are limited. This increases the risk that the DNA of individual cells will change. This can be done without noticeable consequences. However, if the DNA is changed at a point that is responsible for regulating cell division, health risks arise.

It can happen that the cell divides further in an uncontrolled manner and passes this misinformation on to all cells that emerge from it. This uncontrolled growth of diseased cells, which ultimately displace healthy tissue, is called cancer designated.

Substances damaging the lungs

Tobacco smoke contains substances such as hydrogen cyanide or ammoniawhich damage the cilia in the lungs. These actually have the task of clearing foreign bodies from the lungs. 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 from there are absorbed into the blood.3

I support the fight against stroke
Serious health information and empathetic support are worth a donation to me.

DONATE NOW

Donation account: IBAN: DE27 6905 1410 0007 0871 66 BIC: SOLADES1REN Bezirkssparkasse Reichenau

Additives

In addition to tobacco, manufacturers can add other substances to the cigarettes. The German Cancer Research Center (DKFZ) and the Dutch National Institute for Public Health and Environment (RIVM) as part of the EU project Public Information Tobacco Control (PITOC ) documented:

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. However, these substances burn in the cigarette, creating new substances that toxic or carcinogenic could be.

Toxic substances include acrolein and 2-furfural, which irritate the eyes and the upper respiratory tract. Toluene and phenol are also harmful to the body.

Acetaldehyde and styrene are classified as potentially carcinogenic by the International Agency for Research on Cancer (IARC). Acetaldehyde can also promote addiction.

Polycyclic aromatic hydrogens, formaldehyde, benzo [a] pyrene and benzene can also be produced when the additives are burned. It is known that these substances are carcinogenic.

These additives can be added together almost a quarter of the “tobacco” contained in the cigarette.4

The menthol cigarette

The use of additives in tobacco has been repeatedly and critically discussed in recent years. Not only because of the direct harmful effects of many of these substances on health, but also because they make the smoking experience more pleasant. Since the flavoring substances mask the actual tobacco taste, is particularly Adolescents getting started with smoking facilitated.

Additives - data: DKFZ

After more and more attention was drawn to this problem, the EU Commission decided in 2016 that “cigarettes and tobacco products that you can roll yourself may in future not contain any flavors such as menthol or vanilla that mask the taste and smell of tobacco.”5 This provision came into force in 2020 for menthol cigarettes. Legislation has not yet had any influence on the additives mentioned above; they may continue to be added to tobacco.

How does nicotine work?

Nicotine is a neurotoxin and is addictive. It binds to receptors that are distributed throughout the body and triggers many different reactions. The effects on the body and brain are so severe that many people become addicted to this substance.

In the brain

Just a few seconds after inhaling the cigarette smoke, the nicotine has reached the brain. 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, brain areas that are responsible for alertness and increased attention are also activated.

This combination makes smoking particularly attractive for people who suffer from severe stress at work or in everyday life. It helps you to keep a “cool head” and increases your performance.

Nicotine also helps you lose weight through three different mechanisms. On the one hand, nicotine increases the release of adrenaline, which stimulates the breakdown of fat. In addition, digestion and the vomiting center are activated. The latter leads to a decrease in appetite.6

In the rest of the body

Nicotine binds to the so-called nicotinergic acetylcholine receptors, which are located throughout the human body and are responsible for very different processes. That explains the versatile, sometimes even contradicting effects of nicotine.

Nicotine increases the secretion of a hormone called vasopressin. This ensures that the blood vessels constrict and the blood pressure rises. It also inhibits urine production and thus the urge to urinate. In addition, nicotine increases the breathing rate and sensitivity to pain.

Because of the relaxing effects of nicotine, many believe that smoking helps them calm down. However, this is a misconception. The brain relaxes because its corresponding receptors are activated, but the rest of the body is activated by the increased adrenaline output in an "alarm state" offset.7

How does addiction come about?

A dependency is described in the current international classification of diseases as follows:

“There is a strong desire or even compulsion to consume the substance, whereby the ability to control the use of the substance is reduced. The body develops a tolerance towards the substance, so that an ever higher dose has to be administered in order to achieve the desired effect. If the substance is not administered, withdrawal symptoms occur. The substance is consumed even though the user is aware of its harmful effects. Social and professional activities are neglected in favor of substance use. In the course of the past year, three out of six of these criteria must have been met in order to diagnose an addiction. "

Physical dependency

One speaks of physical dependence when the body changes through repeated consumption of the substance and tolerance is built up as a result. If consumption is then interrupted, the person concerned suffers from withdrawal symptoms.8

Nicotine binds to receptors in the brain's reward center. With continued consumption, the brain adapts to the constant stimulation by creating more receptors. So now more receptors have to be stimulated so that the person affected can feel the same pleasant feeling. However, since the body does not produce that many messenger substances on its own, the person concerned becomes dependent on nicotine.

If he now quits smoking, his reward center is less stimulated than that of a non-smoker. That can too Withdrawal symptoms such as irritability, anxiety, anxiety, bad mood, difficulty concentrating, increased hunger and appetite, constipation and craving for tobacco. These symptoms are usually most severe within the first week after the last cigarette is smoked and then gradually decrease. This is because the brain adapts to the lack of stimulation of the reward center and excess receptors are broken down again.9

Mental addiction

A psychological dependence, on the other hand, is characterized by the strong urge to consume a substance over and over in order to achieve a feeling of pleasure. If consumption is interrupted, however, there are no withdrawal symptoms.

Psychological dependence is also caused by continuous smoking behavior. This is because certain situations are linked to smoking. Examples of this are the cigarette after getting up, or the smoking break at work. These links can last for years. However, it helps if you consciously avoid them. So after getting up, take a short walk or drink a cup of tea instead of a cigarette.8

Test: How strong is the nicotine addiction?

To get to the bottom of this question, the Fagerström test was developed with 5 questions:

When do you smoke your first cigarette after getting up?

  • 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 quit smoking in places where smoking is prohibited?

  • yes (1 point)
  • no (0 points)

Which cigarette would you not want to do without?

  • on the first one in the morning (1 point)
  • other (0 points)

How many cigarettes do you generally smoke a day?

  • 31 and more (3 points)
  • 21 - 30 (2 points)
  • 11 - 20 (1 point)
  • up to 10 (0 points)

Do you generally smoke more in the morning 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 of the Fagerström test

  • 0 - 2 points represent a low level of physical dependence. If you decide to quit smoking, you have a good chance of going smoke free. You should set a day to quit smoking as soon as possible.
  • 3 - 4 points indicate moderate physical dependence. You should plan your quitting smoking carefully and, if necessary, seek advice from experts who will help you develop strategies for managing smoking cravings and the risk of relapse.
  • 5 - 6 points speak for a strong physical dependence. In any case, you should get advice from experts and help you quit smoking.
  • 7-10 points indicate a very strong physical dependence. Medicinal support or the use of nicotine replacement products should be considered to cope with the desire to smoke.

The benefits of a smoke-free life

There are many benefits to quitting smoking. The most serious are probably health factors, but financial and psychological aspects should not be ignored either.

Health benefits

Smoking increases the risk of developing various diseases. Cancer and cardiovascular diseases in particular are more common among smokers. In return, quitting smoking can reduce the risk of illness again.

illnessIncreased risk
Cancers
Lung cancer100 times
Throat cancer20 times
Esophageal cancer3.5 times
Oral cancer2.5 times
Colorectal cancer2.5 times
Pancreatic cancer2.2 times
Stomach cancer2-way
cervical cancer1.75 times
Cardiovascular diseases
Peripheral arterial disease13-fold
stroke6-fold
Heart attack3.5 times
Aneurysm bleeding3.5 times
Ischemic heart disease3.1 times
Eye diseases
Orbitopathy (in people with Graves' disease4-way
Cataract3-way
Age-related macular degeneration2-way
Neurological diseases
Alzheimer's dementia1.6 times
vascular dementia1.6 times
multiple sclerosis1.5 times
Metabolic diseases
diabetes1.6 times

Data sourcesTCSC Indonesia, ASH, PeerJ, ASH, ASH, ASH

How is the risk to be understood?

The risk indicates the factor by which heavy smoking behavior increases the likelihood of contracting the disease mentioned. The The risk of a stroke, for example, is 6 times higher. This means that for every non-smoker who suffers a stroke, 6 smokers will suffer a stroke.

That the risk of developing lung cancer by 100 times is increased does not automatically mean that a smoker is most likely to develop lung cancer. The initial risk is taken into account.

In general, the initial risk of cardiovascular diseases is higher than, for example, cancer. Since this already increased risk is further increased by smoking, smoking has its greatest negative impact on the cardiovascular system.10

Why does smoking pose a health risk?

Cancer and cardiovascular diseases, in particular, 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 them multiplying in an uncontrolled manner. In particular, the tissues that come into direct contact with it when inhaling the smoke are at risk. As soon as these substances have been absorbed into the blood through the lungs, however, they are distributed throughout the body and can thus also damage other organs.

Smoking and cardiovascular disease

Smoking contributes to the development of cardiovascular diseases through different mechanisms.

On the one hand, it promotes the development of arteriosclerosis, as it exposes the body to so-called "oxidative stress". This happens, for example, through substances that are contained in cigarette smoke. These substances can then react with nitric oxide (NO), which actually protects the blood vessels from arteriosclerosis. This not only leads to the fact that the protective function of nitrogen monoxide is no longer available. The new substances that result from this reaction actually damage the blood vessels.

In addition, when there is increased oxidative stress, the “bad” LDL cholesterol in the blood vessels is increasingly oxidized. This is also an important factor in the development of atherosclerosis. In addition, slight inflammation of the vessels occurs more frequently in smokers, which permanently damages them and contributes to arteriosclerosis. The doctor can detect this inflammation in the blood count by an increased number of white blood cells (leukocytes). The body produces more leukocytes in order to fight the causative agent of a disease.

It is also known that platelets (thrombocytes) are more likely to clump together in people who smoke regularly. Ultimately, he can do that Triggers a heart attack or stroke be.

The nicotine contained in cigarettes not only causes addiction, it causes it also increases blood pressure. Increased blood pressure puts a strain on the blood vessels and the heart, which promotes the development of cardiovascular diseases.11

Smoking and fertility

Studies have shown that both male and female fertility are at risk from smoking. During pregnancy, women who smoke actively or passively have more complications than non-smokers.

The ejaculate of men who smoke contains fewer sperm on average than that of non-smokers. The remaining sperm are more often deformed, so it can be assumed that they are only functional to a limited extent. Even occasional smoking has been linked to decreased potency in men.

Women who smoke have greater problems becoming pregnant than women who do not smoke. The probability that a fertilized egg can implant in the uterus is halved in smokers. In addition, the risk for female smokers of miscarriage is more than doubled.

The pill to prevent pregnancy inherently harbors a health risk, which is exacerbated by smoking. Under these circumstances, even young women can develop a thrombosis or a stroke. It is therefore advisable to avoid 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 becomes clear during pregnancy: the more the mother smokes, the higher the risk of miscarriage. This was shown by a meta-analysis from the American Journal of Epidemiology.13

It should be noted that the pregnant woman does not have to smoke herself. Passive smoking is also harmful to the unborn.

At birth, children of smokers are smaller and lighter than those of non-smokers. Your risk of dying within the first four weeks of life is increased by 40 percent.

Later children from smokers' households suffer twice as often from respiratory diseases (respiratory diseases)12 and 2.5 times as likely to suffer from asthma14compared to children who are not exposed to cigarette smoke.15,16

But diseases such as otitis media or inflammatory bowel disease also occur more often in children who smoke in their surroundings than in those who are not exposed to cigarette smoke.

Recommendation: It is not enough to stop smoking during pregnancy if it resumes after giving birth. For the benefit of the child, both parents should stop smoking before the pregnancy begins.

In addition to the physical influences that parental smoking can have on the child, the role model function of the parents must not be neglected. They are the child's first caregivers; they learn from them what is “normal”. So when he sees his parents smoke, he thinks it is good and right from an early age. Even if he learns later that he shouldn't smoke himself, the risk is still higher. This assumption is also confirmed by a study by the Official Journal of the American Academy of Pediatrics. The study also showed that children whose parents quit smoking are less at risk than those whose parents do not quit.17

Financial benefits

Another reason to quit smoking is for cash. A person who smokes a pack of cigarettes a day spends around 6-7 euros on it. That doesn't sound like a lot of money at first. However, if you extrapolate it over a whole year, that's up to 2,500 euros.

tip: If you want to quit smoking, put the money you would otherwise have spent on cigarettes in a money box. In this way you can see in concrete terms how much money you have already saved. Use this money to reward yourself for your discipline. Eat well or treat yourself to a day of wellness. Make yourself so aware that by quitting smoking you will not only have abstract health benefits in the distant future, but that it will also offer you benefits in the here and now.

Mental relief

Many people who have given up smoking perceive it as 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 proud of themselves and of what they have achieved.

The e-cigarette as a healthy alternative?

Relatively new to the market, the e-cigarette and its impact on society's health have already led to controversial discussions. It is hailed by some as an effective means of helping people quit smoking. Others see it as an “entry-level cigarette” that 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 a nebulizer (propylene glycol or glycerine), water, ethanol and various aromatic substances. In addition, in most liquids, as in conventional cigarettes, Contain nicotine.18

The e-cigarette is generally advertised as being “healthier” than regular cigarettes because it contains fewer carcinogenic or toxic ingredients. That may be true. Since the e-cigarette has not been on the market for too long, there are hardly any studies that prove its harmfulness - that but does not automatically mean that it is harmless.

A first American long-term study on this topic was published in 2019. The scientists were able to show a clear connection between the consumption of e-cigarettes alone and respiratory diseases.19

But short-term consequences such as respiratory irritation and inflammatory reactions of the bronchi are already known.18

Another important point to note is that almost half of all smoking-related deaths are due to cardiovascular disease. The cardiovascular damage is caused by the nicotine, which is still absorbed by the e-cigarettes.20 Even pregnant women should not consume nicotine, as it can damage the lungs and brain of the unborn child, regardless of the form in which it is consumed.21

E-cigarettes as an aid to smoking cessation

The e-cigarette as a means of smoking cessation is discussed very controversially. On the one hand, they have the potential to help smokers quit tobacco cigarettes by simply replacing them. Since it is currently assumed that e-cigarettes are the lesser evil compared to conventional cigarettes, this intervention would have taken the first step in a good direction.

However, there is a risk that the consumer will find themselves in false security weighs and neglects the health risks of the e-cigarette. Therefore, the smoker must also part with the e-cigarette in a second step.

The most effective is weaning with nicotine-free e-cigarettes, because here the physical dependency is broken directly. In the next step, the consumer can free himself from psychological dependence by also giving up the e-cigarette.

Successful cessation can only be considered successful if the smoker is neither dependent on conventional nor on e-cigarettes after weaning.

A phenomenon: Many people who want to quit smoking with the help of the e-cigarette end up consuming both. So you can't get away from tobacco and smoke an e-cigarette as well. With this double consumption, the health risks increase considerably.22

E-cigarettes in a social context

One major criticism of e-cigarettes isthat they make smoking socially acceptable again.
The clean image of e-cigarettes tempts young people who would not use a normal cigarette to try “vaping”. These adolescents are at an increased risk of trying tobacco cigarettes and getting stuck on them.23

The discrepancy between knowledge and action - and how it can be overcome

Most smokers are aware of the health risks this habit poses and many want to quit. Still, this is often easier said than done. In addition to physical and psychological dependence, there are other psychological factors that keep the smoker cigarette.

Unrealistic optimism

Several studies from the 1990s have shown that many people have what is known as “unrealistic optimism”. They believe that bad things can only happen to others, not to themselves.

It has been shown that smokers rate the health risk of an average smoker as high as non-smokers. However, they estimate their own risk to be lower. This is a protective mechanism of the psyche that helps those affected to worry less about their own health. However, this mechanism is a double-edged sword. After all, the person affected could actually protect their health. However, his unrealistic optimism leads him to believe that everything is fine and that the unhealthy behavior will continue.

In the case of quitting smoking, this unrealistic optimism must first be resolved. This can be very stressful at first. Knowing about your own risk and trusting your own abilities to quit smoking are the basis for successfully quitting smoking.

Confidence in your own abilities

Quitting smoking takes a lot of confidence. After all, quitting is a major challenge in which discipline and perseverance are regularly tested.

tip: In preparation for the X day you quit smoking, think about the following: What are the obstacles I can face? What solutions will help me to get around these hurdles? Answering these two questions not only increases your self-confidence, but also increases your specific chances of success.

Prepare for day X

Prepare for quit smoking as well as if you were taking an important exam or giving a presentation at work. It is important to be as specific 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", he is unlikely to have much success.

Questions from Mr. Maier: When do I want to stop? And why? What will be easy for me? What hard? In what situations will it be liberating to stop being a smoker? In which situations does it become difficult not to take up a cigarette after all? How do I want to deal with it? What do I want to do to celebrate my first week of smoking free? The first month? The first year?

Again, it can be frightening to plan so far into the future. Doubts can arise, “What if I don't last a week?”.

These doubts provide important clues. Why shouldn't he last a week? Maybe because his best friend smokes too and he would feel tempted to join in around him. How good that he thinks about it now and not just when the time comes. How does Mr. Maier want to deal with it now? Does he want to initiate his friend? Maybe he would even take part? Or is the friend a staunch smoker and would find it ridiculous to try to quit? Maybe Mr. Maier should avoid contact for a week or two.

Even if smoking is still allowed as usual while preparing to quit smoking, the following question is worthwhile: Why do I need a cigarette right now? Is it the stress? The habit? Or the feeling of solidarity with your colleagues?

tip: Bring back to mind the very personal reasons for quitting smoking. Visualize what it would be like not to smoke right now. What can you do instead?

It's like the presentation: the better prepared you are, the safer you feel. Maybe one day you will even look forward to the big day X. It should be at the beginning of a relaxation phase. Maybe after a big project or at the beginning of your vacation.24

Possible withdrawal symptoms

Withdrawal symptoms occur very individually. While some have severe physical withdrawal symptoms, others have no problems at all.

The most common withdrawal symptoms are:

  • increased irritability and frustration
  • fatigue
  • Bad mood
  • increased appetite
  • strong desire to smoke

The withdrawal symptoms are due to the fact that the body has got used to the influence of nicotine. Over time, however, he will get used to the situation without nicotine. After a week most of them got through the worst.

In the meantime, the following tips can make withdrawal tolerable:

The right time: In order to cope with the withdrawal symptoms as well as possible, it is advisable to quit smoking as stress-free as possible, such as on vacation.

Accept what is happening in your body right now: Make yourself aware that your tiredness or irritability is completely normal at the moment and that you cannot help it.

Treat yourself to something: Give yourself and your body exactly what it needs. When you're tired, rest or take a short walk in the fresh air. When you have excess energy, exercise.

Sports: Exercising helps with many withdrawal symptoms, such as irritability or increased appetite. Exercise helps your body balance. It is particularly advisable to go running in the fresh air. Any activity that makes you comfortable is good.

Initiate your fellow human beings: Explain to your friends and family that irritability or bad moods are normal withdrawal symptoms when you quit smoking. Ask for understanding and, if it gets too much for you, take some time for yourself.

Talk to like-minded people: Perhaps you know someone who has already quit smoking and understands how you are doing. Or maybe you met someone in a forum who is also just quitting smoking. Give each other support.

Supportive therapies

Since most people find it difficult to quit smoking through sheer discipline, various therapies have been developed to assist them in this process. It has been shown that a combination of behavior therapy and drug support is most effective.25

Nicotine replacement therapy

The best-known support for quitting smoking is nicotine replacement therapy. The patient takes nicotine in the form of patches, chewing gum, nasal spray or tablets. The nicotine helps against the withdrawal symptoms, but the physical dependence remains. This is only broken when you are weaned from nicotine.

Listen using nicotine replacement therapy 50-70 percent more people with smoking than without.26

Medication

There are two drugsthat are approved in Germany to help people quit smoking. They are bupropion and varenicline. Since both can lead to severe side effects, they require a prescription.

Bupropion is an antidepressant that increases the levels of dopamine and norepinephrine in the brain. So it mimics the effect of nicotine, but without binding to the associated receptors, so that they can regress. Possible side effects include dry mouth and difficulty sleeping.

Varenicline was specially developed for quitting smoking. It occupies the nicotine receptors so that smoking is no longer rewarded. The most common side effect of varenicline is nausea.27

Cognitive behavioral therapy

While nicotine replacement therapy and medication help manage physical addiction, cognitive behavioral therapy focuses on psychological addiction and the "smoking habit".
There are different behavioral therapy programs, for example from Rauchfrei - an initiative of the Federal Center for Health Education.

Studies have also proven the effectiveness of such programs.28

What do the health insurance companies cover?

To help smokers quit, most health insurance companies offer online courses that are free for their members. These courses help smokers to break their behavioral patterns and thus to dissolve psychological addiction. In addition, the courses are held in groups so that problems can be discussed directly and the participants can support one another.

Some private health insurances also cover the costs of acupuncture and hypnosis therapies.

However, the cost of prescription drugs and nicotine replacement products must be borne by the smoker himself.29

more on the subject

Share or print this article

author


with the cooperation of stud. med. Katharina Püchner

Dr. med. Jürgen Kunz is a resident specialist in neurology at the Ravensburg Neurocenter. One focus of his work is the treatment of patients after a stroke. When treating a stroke, cross-sectoral collaboration with other doctors and therapists is very important to him. [more]

swell

  1. Smoking - facts and figures - ONKO Internet portal of the German Cancer Society - Url: https://www.krebsgesellschaft.de/onko-internetportal/basis-informationen-krebs/bewusst-leben/rauchen-zahlen-und-ffekten.html
  2. Tobacco history - German headquarters for addiction issues V. - Url: https://www.dhs.de/suechte/tabak/geschichte
  3. Toxic mixture tobacco smoke - toxic substances in tobacco smoke - German Cancer Research Center - Url: https://www.dkfz.de/de/rauchertelefon/Zusatzstoffe.html
  4. Increased health risk from tobacco additives - German Cancer Research Center (DKFZ), Heidelberg, and National Institute for Public Health and Environment (RIVM), Bilthoven, Netherlands - Url: https://www.dkfz.de/de/tabakkontrolle/download/PITOC/PITOC_Zusatzzstoffe_Tabakprodukte_combined_pdf.pdf
  5. New tobacco rules apply in all EU countries - European Commission - Url: https://ec.europa.eu/germany/news/neue-tabak-regel-gelten-allen-eu-l%C3%A4ndern_de
  6. Pharmacological effects of nicotine - German Cancer Research Center - Url: https://www.dkfz.de/de/rauchertelefon/Nikotin_Wirkung.html
  7. Misinformation about smoking - German Cancer Research Center - Url: https://www.dkfz.de/de/rauchertelefon/Fehlinformationen_zum_Rauchen.html
  8. Dependence, physical and psychological - Lexicon of Psychology - Spektrum Akademischer Verlag, Heidelberg - Url: https://www.spektrum.de/lexikon/psychologie/abhaengigkeit-physische-und-psychische/37
  9. Tobacco addiction - German Cancer Research Center - Url: https://www.dkfz.de/de/rauchertelefon/Nikotinabhaengigkeit.html
  10. The future worldwide health effects of current smoking patterns - Authors: Richard Peto and Alan D Lopez - publication: Tobacco and Public Health: Science and Policy - Oxford University - ISBN: 0 19 852687 3
  11. The Pathophysiology of Cigarette Smoking and Cardiovascular Disease - Authors: John A Ambrose and Rajat S Barua - publication: Journal of the American College of Cardiology, 43.10 (2004), 1731–37 - DOI: 10.1016 / j.jacc.2003.12.047
  12. Smoking and Reproduction - ASH fact sheet - Url: https://ash.org.uk/wp-content/uploads/2019/10/Smoking-Reproduction.pdf
  13. Systematic Review and Meta-Analysis of Miscarriage and Maternal Exposure to Tobacco Smoke During Pregnancy - Authors: Beth L. Pineles, Edward Park, and Jonathan M. Samet - publication: American Journal of Epidemiology, 179.7 (2014), 807-23 - DOI: 10.1093 / aje / kwt334
  14. Increased Incidence of Asthma in Children of Smoking Mothers - Authors: Fernando D. Martinez, Martha Cline, Benjamin Burrows - Publication: Pediatrics Vol. 89, Issue 1, Jan 1992 - Url: https://pediatrics.aappublications.org/content/89/1/21.short
  15. Children and Passive Smoking: A Review - Authors: A. Charlton - publication: The Journal of Family Practice, 38.3 (1994), 267-77
  16. Passive Smoking Is Associated with an Increased Risk of Developing Inflammatory Bowel Disease in Children - Authors: B.A. Lashner et al. - publication: The American Journal of Gastroenterology, 88.3 (1993), 356-59.
  17. Parental Smoking Exposure and Adolescent Smoking Trajectories - Authors: D. Mays et al. - publication: PEDIATRICS, 133.6 (2014), 983–91 - DOI: 10.1542 / peds.2013-3003
  18. Electronic cigarettes - e-cigarette - a supposedly harmless alternative - smoke-free - Federal Center for Health Education - Url: https://www.rauchfrei-info.de/informieren/tabak-tabakprodukte/tabakprodukte/electric-zigaretten/
  19. Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis - Authors: Dharma N. Bhatta, PhD, MPH, Stanton A. Glantz, PhD - publication: American Journal of Preventive Medicine - DOI: 10.1016 / j.amepre.2019.07.028
  20. Smoking cessation: smokers can't do it alone - Author: Lenzen-Schulte, Martina - publication: Dtsch Arztebl 2018; 115 (31-32): A-1436 / B-1214 / C-1206 - Url: https://www.aerzteblatt.de/archiv/199361/Tabakentwoehnung-Raucher-schaffen-es-nicht-allein
  21. E-cigarettes: stop smoking at full steam - Author: Lenzen-Schulte, Martina - publication: Dtsch Arztebl 2019; 116 (7): A-314 / B-258 / C-258 - Url: https://www.aerzteblatt.de/archiv/205575/E-Zigaretten-Mit-Volldampf-zum-Rauchstopp
  22. Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis - Authors: Dharma N. Bhatta and Stanton A. Glantz - publication: American Journal of Preventive Medicine, 58.2 (2020), 182–90 - DOI: 10.1016 / j.amepre.2019.07.028
  23. E-Cigarettes and the Use of Conventional Cigarettes - Authors: Matthis Morgenstern et al. - publication: Deutsches Aerzteblatt Online, 2018 - DOI: 10.3238 / arztebl.2018.0243
  24. The gap between knowledge and action: empirical and theoretical approaches, ed. By Heinz Mandl, Jochen Gerstenmaier, and Adrian Bangerter (Göttingen Bern Toronto Seattle: Hogrefe, Verlag für Psychologie, 2000).
  25. Smoking cessation: smokers can't do it alone - Author: Lenzen-Schulte, Martina - publication: Dtsch Arztebl 2018; 115 (31-32): A-1436 / B-1214 / C-1206 - Url: https://www.aerzteblatt.de/archiv/199361/Tabakentwoehnung-Raucher-schaffen-es-nicht-allein
  26. Nicotine Replacement Therapy for Smoking Cessation - Authors: Lindsay F Stead et al. - publication: ed. by Cochrane Tobacco Addiction Group, Cochrane Database of Systematic Reviews, 2012 - DOI: 10.1002 / 14651858.CD000146.pub4
  27. Nicotine replacement and other drugs to quit smoking - German Cancer Research Center - Url: https://www.dkfz.de/de/rauchertelefon/NRT_Medikation.html
  28. Behavioral therapy - Unlearn smoking - Smoke-free - Federal Center for Health Education - Url: https://www.rauchfrei-info.de/informieren/rauchstopp/lösungen-zum-rauchstopp/lösungenstherapie/