BREVAgen was validated only in comparison to Gail score. Being that the Gail score is the least sensitive scoring tool available and that it is widely considered inadequate, it is hard to have confidence in the validation process. In addition, the risk calculation that depends on multiplying SNP risks by Gail raises its own questions of accuracy. Finally, there is no prospective evidence that BREVAgen produces clinical evidence.

For Professional version see here

After radical cystectomy, NCCN recommends:

Urine cytology, liver function tests, creatinine, and electrolytes every 3 to 6 mo for 2 y and then as clinically indicated
Imaging of the chest, upper tracts, abdomen, and pelvis every 3 to 6 mo for 2 y based on risk of recurrence and then as clinically indicated
Urethral wash cytology every 6 to 12 mo, particularly if Tis was found within the bladder or prostatic urethra
If a continent diversion was created, monitor for vitamin B12 deficiency annually.

ACR has similar recommendations: CT is recommended at 6, 12, and 24 months for follow-up of patients with minimal muscle invasion (T2) who elect either cystectomy or other types of therapy without cystectomy, since most recurrences become evident within the first 2 years after surgery.

NCCN, BLadder Cancer, BL-E, 2013

CMS Guidelines National Coverage Determination (NCD) Computed Tomography (220.1)
2013

Leyendecker JR, Francis IR, Casalino DD, Arellano RS, Baumgarten DA, Curry NS, Dighe M, Fulgham P, Israel GM, Papanicolaou N, Prasad S, Ramchandani P, Remer EM, Sheth S, Expert Panel on Urologic Imaging. ACR Appropriateness Criteria follow-up imaging of bladder carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. 10 p. [80 references]

Tamoxifen has a variety of bothersome side effects, related mostly to forced early menopause.
In addition, a rare complication of tamoxifen is uterine lining overgrowth, which can proceed to endometrial bleeding. Abnormal uterine bleeding occurs in more than 50% of premenopausal women taking tamoxife and in this group of women, up to 23% will have an underlying endometrial abnormality such as polyps, hyperplasia, or EC. However, the incidence of endometrial disease is not markedly different compared with that in premenopausal women with breast cancer and AUB who are not taking tamoxifen. However, two meta-analyses found the risk of uterine/endometrial cancer nearly doubled with tamoxifen use. In the great majority of the cases, these are early stage cancers that are curable with hysterectomy. Unfortunately, there are no effective or generally accepted ways to monitor endometrial overgrowth. Given the higher rate of endometrial disease in premenopausal women taking tamoxifen who have development of  uterine bleeding, further evaluation is warranted via endometrial sampling with an office biopsy or with operative curettage (with or without hysteroscopy). There are no guidelines that recommend preventative hysterectomy or cystoscopy.

Recently, USPTF recommended ten years of adjuvant tamoxifen instead of five. This greatly increases concern for the development of endometrial caner over this longer period. The ASCO guideline* (Visvanathan et al) has this to say: “Follow-up should include a baseline gynecologic examination before initiation of treatment and annually thereafter, with a timely work-up for abnormal vaginal bleeding.”
H.F. Kennecke,New guidelines for treatment of early hormone-positive breast cancer with tamoxifen and aromatase inhibitors, BCMJ, Vol. 48, No. 3, April 2006,  121-126

Kala Visvanathanet al, American Society of Clinical Oncology Clinical Practice Guideline Update on the Use of Pharmacologic Interventions Including Tamoxifen, Raloxifene, and Aromatase Inhibition for Breast Cancer Risk Reduction, JCO July 1, 2009 vol. 27 no. 19 3235-3258

Bushnell CD wt al, (2004) Risk of ischemic stroke with tamoxifen treatment for breast cancer: A meta-analysis. Neurology 63:12301233.

Jamie N. Bakkum-Gamez et al, Challenges in the Gynecologic Care of Premenopausal Women With Breast Cancer, Mayo Clin Proc. 2011 March; 86(3): 229–240.

For the Lay version see here

A recent article in the Journal of American Medical Association suggests that in BRCA positive patients there is a benefit to bilateral prophylactic mastectomy. Prophylactic surgery  reduced the high risk of breast and ovarian cancer among BRCA mutation carriers and improved survival, researchers affirmed. Similarly, all-cause mortality dropped from 10% without salpingo-oophorectomy to 3% with it (hazard ratio 0.40, 95% confidence interval 0.26 to 0.61). Even before theis information, ESMO was recommending bilararl mastectomy and oophorectomy. The American College of Obstetricians and Gynecologists’ guidelines on “Hereditary breast and ovarian cancer syndrome” (ACOG, 2009) stated that “risk-reducing salpingo-oophorectomy should be offered to women with BRCA1 or BRCA2 mutations by age 40 or after the conclusion of child-bearing”.

Lostumbo L, Carbine NE, Wallace J. Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Rev. 2010;11:CD002748.

J. Balma, BRCA in breast cancer: ESMO Clinical Practice Guidelines, Ann Oncol (2010) 21 (suppl 5): v20-v22.

Easer an j, Lessons learned from genetic testing. JAMA. 2010 Sep 1;304(9):1011-2.

Susan M. Domchek; Tara M. Friebel; Christian F. Singer; D. Gareth Evans; Henry T. Lynch; Claudine Isaacs; Judy E. Garber; Susan L. Neuhausen; Ellen Matloff; Rosalind Eeles; Gabriella Pichert; Laura Van t’veer; Nadine Tung; Jeffrey N. Weitzel; Fergus J. Couch; Wendy S. Rubinstein; Patricia A. Ganz; Mary B. Daly; Olufunmilayo I. Olopade; Gail Tomlinson; Joellen Schildkraut; Joanne L. Blum; Timothy R. Rebbeck. Association of Risk-Reducing Surgery in BRCA1 or BRCA2 Mutation Carriers With Cancer Risk and Mortality. JAMA, 2010; 304 (9): 967-975

Laura Esserman; Virginia Kaklamani. Lessons Learned From Genetic Testing. JAMA, 2010; 304 (9): 1011-1012

Medical science has found that regular mild exercise has many positive health benefits. Mainstream media has brought this message to the broad public. Yet, exercise need not be hard work. A sedentary individual can benefit even from adding just a few physical activity routines to his or her day. Take the stairs instead of the elevator. Walk during your lunch break. Do jumping jacks during work  breaks. It is not all that difficult to incorporate exercise into your daily routine. Of course, sustained exercise, 10-20 minutes at a time, has greater benefit, but any physical activity helps to burn calories and improves health. 

There are two kinds of exercise. One, aerobic exercise, uses muscle working without a resistance and it stimulates the heart, the lungs and increases muscle’s efficiency in extracting oxygen from the blood. The other, anaerobic exercise is the one used for weight building. Anaerobic excercize uses muscles that work against resistance. It is called anaerobic (without using air). When muscles work against resistance they quickly use up the available oxygen and begin to draw on stored energy. Such activity increases strength and strengthens bones.

Physical activity has many benefits:

1. Exercise improves your mood.

Contemporary life is inherently stressful.  Physical activity stimulates brain chemicals that leave you feeling happier, more relaxed and feeling more fulfilled.  Feeling better boosts self-confidence and improves self-esteem. Studies show that regular physical activity can even help prevent depression.

2. Exercise combats chronic diseases.

As people are living longer, chronic diseases become of greater concern. Regular physical activity prevents, or helps manage high blood pressure better. It lowers cholesterol, boosts high-density lipoprotein (HDL), or “good,” cholesterol, while decreasing triglycerides and low-density lipoprotein (LDL), the “bad” cholesterol. This helps prevent heart disease and stroke. Regular physical activity helps prevent type 2 diabetes, osteoporosis and decreases the risk of certain cancer types.

3. Exercise helps you manage your weight.

When you engage in physical activity, you burn calories. The more intense the activity, the more calories you burn — and the easier it is to keep your weight under control. Exercise alone is unlikely to help you loose weight: you will simply eat more to compensate. However, a combination of exercise and diet is more effective than diet alone.

4. Exercise increases your endurance.

Physical activity increases your heart rate and delivers oxygen and nutrients to your tissues. In fact, regular physical activity helps the entire cardiovascular system — the circulation of blood through your heart and blood vessels — work more efficiently, and muscles become more efficient in extracting oxygen as well.  When your heart and lungs work more efficiently, you’ll have more energy to do the things you enjoy and more patience for the tings that you must do but may not enjoy.

5. Exercise promotes better sleep.

A good night’s sleep can improve your concentration, productivity and efficiency. Regular physical activity can help you fall asleep faster and deepen your sleep. One should, though, put some time between exercise and sleep. The wisest of all men, Shlomo Hamelech said: “Sweet is the sleep of a working man (Koheles 5:11).” However, if you exercise too close to bedtime, you may be too energized to fall asleep.

6. How much should you do?

According to the 2008 Physical Activity Guidelines for Americans, you need to do two types of physical activity each week to improve your health–aerobic and muscle-strengthening anaerobic activity.  These guidelines recommend  2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week and muscle-strengthening activities, such as weight lifting or rowing on 2 or more days a week. Anaerobic activities should work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

 From pushing a lawn mower, to taking a dance class, to biking to the store – all types of activities count, as long as you’re doing them at a moderate or vigorous intensity for at least 10 minutes at a time.

Moderate-intensity aerobic activity means you’re working hard enough to raise your heart rate and break a sweat. One way to tell is that you’ll be able to talk, but not sing the words to your favorite song. Here are some examples of activities that require moderate effort:

• Walking fast
• Doing water aerobics
• Riding a bike on level ground or with few hills
• Playing doubles tennis
• Pushing a lawn mower

Vigorous-intensity aerobic activity means you’re breathing hard and fast, and your heart rate has gone up quite a bit. If you’re working at this level, you won’t be able to say more than a few words without pausing for a breath. Here are some examples of activities that require vigorous effort:

• Jogging or running
• Swimming laps
• Riding a bike fast or on hills
• Playing singles tennis
• Playing basketball

You can do moderate- or vigorous-intensity aerobic activity, or a mix of the two each week. A rule of thumb is that 1 minute of vigorous-intensity activity is about the same as 2 minutes of moderate-intensity activity.

Exercise has many health benefits and should be engaged in and enjoyed.

When Columbussailed  from Spain in search of spices and gold, he hardly expected that among his most treasured finds would be… tobacco.

On October 12, 1492, Columbuslanded on an island in the Bahamaswhich he named San Salvador, and on October 15 the natives brought him gifts of, as he wrote in his journal, “fruit, wooden spears, and certain dried leaves which gave off a distinct fragrance.” Not knowing what these leaves wereColumbus disposed of them.

Soon after, his ships reached the coast of Cubawhere two of his scouts, Rodrigio de Jerez and Luis de Torres, observed the natives walking around, “with a little lighted brand made of a kind of plant which was their custom to inhale.”

De Torres was a Marrano Jew for whom the Luis de Torres Synagogue (Reform) inFreeport,Bahamas, was later named. However, it was Rodrigio who took a puff of tobacco that day, becoming the first European to smoke. He brought the habit of smoking back toSpainand the spectacle of a man exhaling smoke so frightened neighbors that he was arrested by the Inquisition and imprisoned. Seven years later, however, smoking had become common inSpainand he was exonerated and released.

A Brief History of Smoking

It did not take long for tobacco to spread acrossEurope. By 1512, it was cultivated inPortugaland by 1556 it was brought fromBraziltoFrance, and soon thereafter toHolland. By 1570 it was grown inGermany,Switzerland,AustriaandHungary.

Yet, as tobacco spread, so did the opposition to it. In 1603, King James I ofEnglandstarted the first anti-smoking campaign with his treatise, “A Counterblaste to Tobacco.” James I saw the opposition to tobacco in the context of his persecution of witchcraft. He added a law against witchcraft to the English statute books and burned some 400 witches a year during the latter years of his reign. To him, smoking was an occult practice.

As in the rest ofEurope, James’ opposition to tobacco was based primarily on religious and moral grounds. At the same time, James I discovered that tobacco was good business. In 1615, he made importation and sale of tobacco a royal monopoly and taxed it 4000%, in this way sounding many of the themes that defined tobacco control ever since. In 1619, he forbade cultivation of tobacco aroundLondonand in the following year he extended the prohibition to the rest ofEngland.

Others did not rely on taxation alone. The first Romanoff Czar ofRussia, Mikhail Fyodorovich (1596-1645), declared using tobacco a crime, the punishment for which was slitting the lips or flogging; some offenders were castrated. InTurkeyandPoland, smoking became a capital offense. In 1650, the opponents of tobacco were able to persuade Pope Innocent V to issue a Papal Bull against smoking. Peter the Great (1689-1725) ofRussia, on the other hand, smoked and publicly supported smoking.

The anti-tobacco forces were ultimately unsuccessful and support for smoking gradually grew. By 1725, Pope Benedict XIII allowed snuff-taking even inside St. Peter’s Basilica. Smoking soon became a part of daily life for millions of Europeans. When World War I broke out inEurope, it became almost universal, spreading especially among the millions of ex-soldiers who found in tobacco an instant relief from the stresses of battle as well as relief for hunger that they often suffered on the front lines.

By 1931, the number of smokers increased so dramatically that Count Corti, in his book “History of Smoking,” could write as follows: “A glance at the statistics proves convincingly that the non-smokers are but a feeble and ever-dwindling minority. The hopelessness of their struggle becomes plain when we remember that all countries, whatever their form of government, now encourage and facilitate the passion for smoking in every conceivable way, merely for the sake of revenue which it produces.”

It took about 50 years to turn this statement on its head. Now, in every advanced country, tobacco is under an active and increasingly stifling assault of governmental regulation, and the numbers of smokers are shrinking. What accounts for this remarkable turnaround?

The Truth About Smoking

As smoking spread, a new anti-smoking movement sprung to life and the evidence of the negative effects of tobacco on health began to accumulate. The argument against tobacco was now couched in terms of science and health.

Epidemiologists, scientists who collect and analyze statistics about health and disease, in the 1930s, 1940s and 1950s began to notice increased lung cancer mortality in smokers as well as an increase in emphysema, asthma and heart disease. The increase in lung cancer was particularly striking. From being a medical curiosity that deserved a case-report in a medical journal, lung cancer became increasingly prevalent, going on to become the leading non-skin cancer diagnosis both among men and women by the 1980s. On June 12, 1957, Surgeon General Leroy E. Burney declared that the official position of the US Public Health Service was that the evidence pointed to a causal relationship between smoking and lung cancer.

However, the bombshell was to drop seven years later!

Already in June, 1961, the American Cancer Society, the American Heart Association, the National Tuberculosis Association, and the American Public Health Association addressed a letter to President John F. Kennedy, in which they called for a national commission on smoking, dedicated to “seeking a solution to this health problem that would interfere least with the freedom of industry or the happiness of individuals.”

In response, Surgeon General Luther L. Terry convened a committee of experts on June 7, 1962, to conduct a comprehensive review of the scientific literature on the smoking question. Meeting from November, 1962, through January, 1964, at the National Library of Medicine on the campus of the National Institutes of Health inBethesda,Maryland, the committee reviewed more than 7,000 scientific articles with the help of over 150 consultants. Terry issued the commission’s report on January 11, 1964, choosing a Saturday to minimize the effect on the stock market and to maximize coverage in the Sunday papers.

The Smoking and Health: Report of the Advisory Committee to the Surgeon General held cigarette smoking responsible for a 70 percent increase in the mortality rate of smokers over non-smokers. The report estimated that the average smoker had a nine- to ten-fold risk of developing lung cancer compared to the non-smoker; heavy smokers had at least a twenty-fold risk.

The risk rose with the duration of smoking and diminished with the cessation of smoking. The report also named smoking as the most important cause of chronic bronchitis and pointed to a correlation between smoking and emphysema, and smoking and heart disease. It noted that smoking during pregnancy reduced the average weight of newborns.

On one issue the committee hedged: whether nicotine is addictive. It insisted that the “tobacco habit should be characterized as a habituation rather than an addiction.” To explain, habituation is developing a physical dependence, so that stopping smoking would cause physical symptoms of withdrawal. Addiction, however, is a psychological state in which smoking is so well integrated into the personality and daily routine of an individual that he or she continues to crave and pursue smoking even after the physical symptoms of withdrawal have long been surmounted.

To understand this distinction, cancer patients are often treated with morphine and their bodies become habituated to it. However, they rarely become addicted. Once the morphine is slowly tapered off and their bodies recover from needing it to control pain, cancer patients almost never experience a craving for narcotics. Although the Surgeon General was correct in that nicotine by itself is not particularly addictive, a combination of nicotine with other psychoactive substances that burning tobacco generates is now known to be highly addictive.

The story was picked up by the media and served as the topic of discussion for months. It lead to increasing pressure on the tobacco industry in the form of regulation, lawsuits and restriction on advertising and sales, as well as punitive taxation. Many people stopped smoking.

The recent biography of Rabbi Moshe Sherer recounts how, during a meeting in Washington, the Surgeon General, after noticing that Rabbi Sherer was a smoker, took him aside and told him, “If you are so important to Senator Javits (who arranged the meeting), I am going to save your life.” He proceeded to show Rabbi Sherer photographs of healthy lungs and the lungs of smokers. From the time that Rabbi Sherer walked out of that room, he never smoked another cigarette (Rabbi Sherer: The Paramount Torah Spokesman of Our Time, by Yonoson Rosenblum, ArtScroll, 2009, p. 590).

A similar story is told of Rabbi Yitzhak Isaac Schneerson of Lubavitch (1880-1950). One day during a regular checkup, his physician mentioned matter-of-factly that studies are coming out suggesting that smoking might be bad for your health. After the visit the doctor offered him a cigarette. The Rebbe declined and said that he doesn’t smoke. The doctor countered that everyone knows that the Rebbe smokes. The Rebbe replied, “I used to smoke, but I just learned it might be unhealthy, so as of now I don’t smoke.” And he never did again.

What’s in a Cigarette?

Smoking is not the only way of consuming tobacco. Snuff and chewable tobacco are popular in many countries. All methods of consuming tobacco rely on nicotine to produce its effects. Because it is absorbed into the blood stream through the lung, nicotine reaches the brain in just six seconds and its half-life, the time it takes for the levels to decrease by half, is two hours.

Nicotine is the active ingredient (the one that produces the desired effect) in tobacco and heightens heart rate, memory, alertness and improves reaction time. It releases chemicals called dopamine and endorphins from nerve endings and these substances produce the sensation of pleasant relaxation. These effects are particularly pronounced in the young; later in life the motivation becomes primarily the avoidance of withdrawal symptoms.

Nicotine is not the only ingredient in tobacco. Cigarette smoke contains over 4,000 chemicals, including 43 known cancer-causing (carcinogenic) compounds and 400 other toxins. These include tar and carbon monoxide, as well as formaldehyde, ammonia, hydrogen cyanide, arsenic, and DDT. There are also traces of pesticides that were used to grow the tobacco and chemicals such as arsenic, cadmium and many others.

The effects of the mixtures and combinations of these chemicals after they are exposed to heat in the process of smoking have never been systematically studied. Some of these ingredients, such as tar, are clearly carcinogenic and long-term effects of their daily ingestion are not well-understood. Of the 250 known harmful chemicals in tobacco smoke, more than 50 have been found to cause cancer. These chemicals include:

• arsenic (a heavy metal toxin)
• benzene (a chemical found in gasoline)
• beryllium (a toxic metal)
• cadmium (a metal used in batteries)
• chromium (a metallic element)
• ethylene oxide (a chemical used to sterilize medical devices)
• nickel (a metallic element)
• polonium-210 (a chemical element that gives off radiation)
• vinyl chloride (a toxic substance used in plastics manufacture)

Nicotine by itself has both positive and negative effects on the body. Nicotine enhances concentration and alertness, improves memory and reduces pain and anxiety. At higher doses, such as the ones achieved by deep puffing on a cigarette, it produces a calming effect.

Nicotine is a drug that has some positive health effects as well: people who smoke appear to have less Parkinson’s disease or Alzheimer’s and less gum disease than non-smokers.

However, these positive effects are far outweighed by the increased rates of lung and other cancers, emphysema and heart disease. Smoking causes stroke, chronic lung disease, hip fractures and cataracts. Smokers are at higher risk of developing pneumonia and respiratory tract infections. Secondhand smoke (smoke that bystanders or family members and co-workers of the smoking individual inhale) also produces many of these negative effects, although not to the same extent.

Smoking is a leading cause of cancer and of death from cancer. It causes cancers of the lung, esophagus, larynx (voice box), mouth, throat, kidney, bladder, pancreas, stomach, and cervix, as well as acute myeloid leukemia. A pregnant woman who smokes is at higher risk of having her baby born prematurely and with an abnormally low weight. A woman who smokes during or after pregnancy increases her infant’s risk of death from Sudden Infant Death Syndrome (SIDS).

Cigarettes present another public policy danger: they start accidental fires, especially when smoked when drinking alcohol. Snuff tobacco is not much safer. It has been associated with an increased risk of mouth and throat cancer.

Public Policy and the Efforts to Decrease Smoking

Efforts to control smoking center on taxation and restrictions on advertising, sales and lawsuits.

In June, 1967, the Federal Communication Commission ruled that television programs that discussed smoking and health were insufficient to offset the effects of paid advertisements for tobacco that were broadcast for five to ten minutes each day. In April, 1970, Congress passed the Public Health Cigarette Smoking Act that prohibited advertising of cigarettes on radio and TV starting on January 2, 1971. Similar measures were put into effect in Europe andAustralia. Subsequently restrictions on billboard advertising and advertising near schools were added.

Some countries also impose legal requirements on how tobacco products must be packaged. Many countries have imposed labels upon cigarette packs warning smokers of the effects of smoking, and they include graphic images of the potential health effects of smoking. Warning cards are inserted into cigarette packs inCanada. There are 16 of them, and only one comes in a particular pack. They explain different methods of quitting smoking.

Many countries, including theUnited States, make it unlawful to sell cigarettes to minors. In 46 states, the minimum age for being able to purchase cigarettes is 18, except for Alabama, Alaska, New Jersey, and Utah where the legal age is 19 (also in Onondaga County in upstate New York, as well as Suffolk and Nassau Counties of Long Island, New York). The rationale for these laws is that an individual cannot make an informed decision about subjecting him or herself to the risks of smoking until they are mature enough to understand its consequences.

Many countries also prohibit smoking in public places. In theUnited States, many states prohibit smoking in restaurants, and some also prohibit smoking in bars. Most hospitals in theUnited Statesas well as many governmental buildings are now smoking-free zones. By restricting where a smoker may light up, society not only protects non-smokers from the effects of second hand smoke, but it also drives down demand for smoking and reduces the consumption of tobacco. The restrictions on smoking induce some people to quit.

Only about 23 percent of adult men and 19 percent of adult women now smoke. This figure is down from 42 percent of men in 1965. Changes in smoking habits during the late 1960s, the 1970s and the 1980s have very likely contributed to the drop in heart disease and death that occurred at the same time in theUnited States.

Smoking Cessation

Stopping smoking is not easy. It is, however, important.

According to the 2004 Surgeon General’s Report, The Health Consequences of Smoking, stopping smoking can greatly reduce heart disease. Smoking cessation is important in the medical management of many contributors to heart attack. These include atherosclerosis (fatty buildups in arteries), thrombosis (blood clots), coronary artery spasm and cardiac arrhythmia (heart rhythm problems). Quitting smoking also can help manage several other disorders, especially buildups of plaque in peripheral arteries and chronic obstructive pulmonary disease (emphysema). According to this Surgeon General’s report, tobacco smoking still remains the number one cause of preventable disease and death in theUnited States.

People who stop smoking feel better almost immediately, after the withdrawal symptoms pass. The benefits include a decrease in blood pressure, improved breathing and increased lung capacity. Studies have shown that quitting at about age 30 reduces the chance of dying from smoking-related diseases by more than 90 percent. People who quit at about age 50 reduce their risk of dying prematurely by 50 percent compared with those who continue to smoke. People who quit at about age 60 or older live longer than those who continue to smoke. Even those who already developed cancer live longer and tolerate their treatments better, if they stop smoking, and their risk of developing a second cancer substantially decreases.

However, this comes at a price. The initial phase of withdrawal from nicotine often comes with the symptoms of anxiety, irritability or depression. Some might have difficulty sleeping. Weight gain is common. Although most smokers gain less than 10 pounds, some gain more. Regular exercise can prevent this weight gain.

Although many people can quit on their own, others benefit from assistance. There are many smoke cessation programs which provide counseling, support and, sometimes, medical therapy.

Nicotine replacement products deliver small, measured doses of nicotine into the body, which helps to relieve the cravings and withdrawal symptoms often felt by people trying to quit smoking. Strong evidence shows that these products can help people quit smoking. Nicotine gum, nicotine lozenges and nicotine patches are available without a prescription. Nicotine nasal spray and nicotine inhaler do require a prescription.

There are also non-nicotine medications that are approved expressly for smoking cessation. They include the anti-depressant bupropion (Zyban) and varenycline (Chantix). Although the anti-depressants nortriptyline and clonidine are not currently approved by the FDA for the treatment of nicotine addiction, doctors sometimes prescribe these drugs to help people quit smoking. A combination of a nicotine patch and nicotine gum or spray or combining the patch with bupropion works better in some studies than single nicotine products. Hypnosis, acupuncture, laser therapy or electro stimulation may help tolerate withdrawal symptoms, but their effectiveness is not supported by clinical studies.

Conclusion

While smoking can produce short-term, pleasurable effects, its long term price is substantial. It carries with it serious health threats, often produces social ostracism, is expensive and off-putting to others. There are now many approaches, both those based on medication and those that do not involve medications, that can make quitting much easier. The question then that must be asked is: “Why smoke?”