Smoking side effects sneak up on you. You don’t feel crummy in the beginning. By the time you notice the rasping cough that never seems to go away, you’re addicted. If you are one of the more than 34 million Americans who smoke, you likely got hooked very quickly. It probably took only a few cigarettes to make nicotine a huge part of your life, and that’s because nicotine is highly addictive. Cigarettes are deliberately designed to deliver high levels of nicotine to the brain in six to 10 seconds.

That’s a major reason why smoking is so difficult to stop. The faster the delivery of nicotine to your body, the greater the addictive effect on your brain. Another reason that it’s tough to stop smoking is the desire to ease the discomforts of withdrawal. And the rituals associated with smoking may be even more addictive than nicotine.

Smoking rituals are part of the addiction

“The behavior addiction of smoking may be far more compelling than just the short-term withdrawal symptoms of a hard drug.” says Jed Rose, the director of the Duke Center for Smoking Cessation in North Carolina. “Every move a smoker makes: the lighting of the cigarette, the inhaling, all the feelings and sensations of it, the whole package becomes highly addictive,” Rose tells CNN.

What’s behind the psychological need to smoke? “The chemicals in cigarettes work on the structures deep within a smoker’s brain, literally rewiring it so the habit becomes deeply ingrained,” says Rose.

And, of course, smokers suffer extreme discomfort from withdrawal when they stop. Shortly after smoking their last cigarette, many smokers start to feel uncomfortable and become anxious, irritable and restless. Their mood changes because they are not getting what the brain feels it needs to work well. As soon as they start smoking again, smokers usually feel relief.

You lose freedom of choice

Most who start as adolescents or young adults don’t believe they will be long-term smokers. They think they can easily quit whenever they want. “Ultimately, they will lose their capacity to make a free choice to smoke,” says Rose. “Then 30 years later, that’s when we typically see them in our program desperately trying to quit, because now they can’t go a single day without (a cigarette).”

Rose said his organization has found a patch or lozenge or drug combined with behavioral change techniques can be most successful in helping smokers quit. The Center for Smoking Cessation is also exploring e-cigarettes as a tool for quitters.

American Lung Association doubts the usefulness of e-cigarettes. The association says the Food and Drug Administration has not found any e-cigarette to be safe and effective in helping smokers quit. If smokers are ready to quit smoking for good, they should call 1-800-QUITNOW, according to the association. Or smokers should talk with their doctor about finding the best way to quit using proven methods and FDA-approved treatments and counseling.

Smoking is the No. 1 killer

Smoking is still the No. 1 cause of preventable death in the United States. It kills more people than obesity, substance abuse, infectious disease, firearms, and traffic accidents, according to the CDC. The U.S. Department of Health says some 443,000 Americans die from smoking-related illnesses every year. More than 16 million Americans live with a smoking-related disease.

In 1965, 42 percent of the U.S. population smoked. Current smoking declined from 20.9 percent or nearly 21 of every 100 adults in 2005 to 14 percent or 14 of every 100 adults in 2017. This means an estimated 34.3 million adults in the United States currently smoke cigarettes.

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