Smoking

Description

Alternative Names

Quitting Smoking

Quitting is extremely difficult. No one should be discouraged if they relapse. Everyone should keeping trying to quit. With continued efforts, many people succeed.

At this time perhaps the most effective method for quitting is a combination of the following:

• Nicotine replacement products for reducing withdrawal symptoms and craving.
• The antidepressants bupropion (Zyban) or nortriptyline (Pamelor, Aventyl). These agents reduce emotional effects and also cravings associated with withdrawal and improve abstinent rates.
• Professional counseling or support organizations. Outside help may be very effective in concert with the other agents in helping people maintain abstinence.

Cold Turkey

About 4% of smokers who quit without any outside help succeed. Nevertheless, most people try to quit alone and many have reported activities that can help the process of withdrawal. The primary obstacle in trying to quit alone is making the behavioral changes necessary to eliminate the habits associated with smoking. Excellent books, tapes, and manuals are available and are strongly recommended to help people who want to quit without other assistance.

Nicotine Replacement

Nicotine Replacement Products and Success Rates. Nicotine replacement products provide low doses of nicotine that do not contain the contaminant found in smoke. They relieve cravings for nicotine and ease the symptoms of withdrawal. Nicotine replacement products include over-the-counter products (nicotine patches, gum, lozenges) and prescribed brands (nasal sprays, inhalers). They generally benefit moderate to heavy smokers most but appear to have little effect for light smokers (less than 15 cigarettes a day). Evidence to date suggests that all nicotine replacement products are equally effective. The different forms can also be used together, which might improve quitting rates.

Between 10% and 20% of people who use nicotine replacements alone will abstain for at least a year. However, only about half of these will remain nonsmokers indefinitely--about the same rate as a placebo (a sham agent). Simply reducing withdrawal symptoms, then, is insufficient for long-term abstinence.

Adding specific antidepressants, such as bupropion (Zyban) or and nortriptyline (Pamelor, Aventyl), may be critical for improving these rates.

Tips for All Nicotine Replacement Products:

• Not cheating on the very first day of nicotine-replacement use increases the chance of quitting permanently by tenfold.
• The more cigarettes a patient smokes, the higher the dose of nicotine replacement may be required at the start.
• Adding a counseling program may boost the effect of any nicotine replacement program. One study reported a quit rate of 30.5% after a year in patients who wore the patch and attended a quit-smoking program.
• No one should smoke while using nicotine replacement. It can cause nicotine to build up to toxic levels.
• Nicotine replacement helps prevent weight gain while it is being used, but people are still at higher risk for gaining weight when they stop all nicotine. It should be noted that a small study suggested that caffeine enhanced nicotine's energy expenditure and so may help prevent weight gain. Moderate caffeine intake may also have antidepressant properties.

Side Effects. Side effects of any nicotine replacement product may include headaches, nausea, and other gastrointestinal problems. People often experience sleeplessness in the first few days, particularly with the patch, but the insomnia usually passes. Patients using very high doses are more likely to experience symptoms, and reducing the dose can prevent them.

Special Concerns for Specific Individuals. Certain individuals may need to be aware of some concerns with nicotine replacement products. Most studies have been conducted using the patch, but results may apply to other replacement products as well.

• People with Heart Disease. There has been some concern that the patch might be harmful for people with heart or circulatory disease, but studies are finding that it poses no danger for these individuals. In fact, it may help reduce angina attacks brought on by exercise. Nevertheless, unhealthy cholesterol levels (lower HDL levels) caused by smoking remain abnormal with the use of nicotine replacement (at least with the use of the patch). HDL levels improve when all nicotine is stopped.
• Pregnant Women. Nicotine replacement may not be completely safe in pregnant women, although it has been used successfully in this group without ill effect. There is an increase in heart rates in fetuses of women who use the patch as compared with those who smoke. Because this may be an indication of fetal stress, pregnant women are cautioned to remove the patch before bedtime.
• Adolescents. Nicotine replacement is safe for adolescents.
• Small Children. Nicotine is a poison and all nicotine products should be kept safely away from small children. A parent should call a physician or a poison control center immediately if a child has been exposed to a nicotine replacement product, even for a short duration. Parents should also call the doctor if a small child has been exposed to a nicotine product and has any symptoms, including stomach upset, irritability, headaches, a rash, or fatigue.

Warnings Against Long-Term Use. No one should use these replacement therapies as a long-term substitute for smoking. Any nicotine replacement therapy should be temporary and directed at quitting. In one study, use of nicotine gum for more than a year was associated with insulin resistance, an abnormality that occurs in diabetes. Some studies have now suggested that nicotine itself may have properties that increase the risk for cancer, independent of carcinogenic chemicals in smoke. More studies are needed, however, and nicotine replacement therapy is still a better alternative to smoking.

Nicotine Patches. Nicotine patches, or transdermal nicotine, delivers nicotine through the skin and is effective in reducing symptoms during withdrawal. They are available over the counter. They are probably the best nicotine replacement products for people with asthma or other chronic lung problems, but it is best to consult a doctor before using them, particularly people with medical problems.

The many methods of quitting smoking include counseling and support groups, nicotine patches, gums and sprays, and incremental reduction.

The patch products available have different approaches:

• The Step-Down Approach. The step-down approach (e.g., NicoDerm CQ) employs patches that come in three strengths (21, 14, and 7 mg), which are used in a step-down program over a period of 8 to 10 weeks. The initial set of large patches is replaced after about three weeks with a smaller, less potent set. A 21 mg patch, for example, is about equal to 15 cigarettes. A heavy smoker may therefore need to wear two patches at first.
• Single-Step Approach. The single-step patch (Nicotrol) can be taken off after 16 hours and replaced 8 hours later. It can only be taken for six weeks.

In both approaches, the patches are applied and used in similar ways:

• A single patch is worn each day and replaced after 24 hours.
• To avoid skin irritation it is applied to different hairless locations above the waist and below the neck each day. (Transparent patches are now available, which expand the body areas for application.)
• People can wear the patches for 24 hours, but some have reported odd dreams and have disliked the sensation of the patch during the night. People who wear the patch all the time, however, have fewer withdrawal symptoms and slightly better abstinence rates than those who take it off at night.
• Patches should be stored and discarded safely, particularly in homes with small children. Small children have been poisoned (not fatally so far) from wearing, chewing, or sucking on nicotine patches.
• The FDA recommends using the patches three to five months, although some studies suggest that using it for eight weeks achieves the maximum benefits.

Special precautions should be made if children are exposed to the patches:

• Children should not come in contact with the patches, even while the smoker is wearing them.
• If the child has worn the patch, the affected skin should be washed right away.
• Urgent medical care may be required if the child has eaten nicotine or worn a patch for a prolonged time. (The hazard increases if the child has been exposed to more than one patch or one that has not been used.)

Nicotine Gum. Nicotine gum (Nicorette) is available over the counter and has helped many people to quit. Some prefer it to the patch because they can control the nicotine dosage and chewing satisfies the oral urge. (A new fast-acting gum, not yet released, relieves cravings more quickly and may help reduce early relapse rates.)

Some tips for using the gum are as follows:

• Patients starting to quit chew one to two pieces each hour. A smoker should not chew more than 20 pieces a day.
• The goal is to stop using the gum by six months, but about 3% of people continue to use it long after they have quit smoking.
• The gum must be chewed slowly until it develops a peppery taste. It is then tucked between the gum and cheek where it is stored so that the nicotine can be absorbed.
• Coffee, tea, soft drinks, and acidic beverages may interfere with nicotine absorption, so people should wait at least 15 minutes after drinking before chewing a piece of gum.

Some people prefer other methods or cannot use the gum for the following reasons:

• They find the gum unpleasant tasting.
• Side effects specific to the gum may include upset stomach, mouth ulcers, hiccups, and throat irritation.
• They are embarrassed chewing gum.
• They wear dentures.

Long-term dependence may be a problem with the gum. Although such dependence is probably safer than smoking, research is needed to confirm this, and experts recommend chewing the gum for no more than six months.

The Nicotine Inhaler. The nicotine inhaler resembles a plastic cigarette holder. It comes with a number of nicotine cartridges, which are inserted into the inhaler and puffed for about 20 minutes, up to 16 times a day. The dose is gradually decreased. It requires a prescription in the US. A number of studies have reported that the inhaler triples abstinence rates (between 17% and 28%) compared with placebo (6% to 9%) after six months. It has some specific advantages over other nicotine replacement products:

• The inhaler provides varying doses of nicotine on demand (as opposed to continuously with the patch or the gum) and is relatively fast-acting. Blood nicotine levels peak about 20 minutes after using the inhaler, comparable to the gum and faster than the two to four hours seen with the patch.
• It satisfies oral urges.
• Most of the nicotine vapor is delivered in the mouth, not into the lung airways (although some people experience mouth or throat irritation and cough).

Using a combination of the inhaler and the patch may be particularly effective. In one study, the combination led to an abstinence rate of over 60% after six weeks. While this percentage dropped off over time, it was still a marked improvement over the use of the inhaler and a placebo patch.

The Nicotine Nasal Spray. The nasal spray satisfies immediate cravings by providing doses of nicotine rapidly and thus may play a useful role in conjunction with slower-acting nicotine replacement therapies. (Nicotine levels peak within five to ten minutes after administering the spray). The spray can irritate the nose, eyes, and throat, so it may not be suitable for those with allergies or sinus infections. Most people, however, can tolerate the side effects, which usually subside within the first few days.

Nicotine Lozenge. A nicotine lozenge (Commit) is now available over the counter. It is made from pressed tobacco and comes in two strengths for heavier or lighter smokers. In a large 2002 study, 15% to 18% of smokers who used it remained smoke free, compared to 6% to 10% who were given a dummy lozenge. Side effects included heartburn, hiccups, nausea, headaches, and cough. It also contains phenylalanine, a chemical that certain people may need to avoid.

Antidepressants

Evidence to date suggests that the antidepressants bupropion (Zyban) and nortriptyline (Pamelor, Aventyl) have specific actions that may help reduce nicotine action and can be very effective, even in people without depression. Quit rates with either of these agents are as high as 30%. Long-term abstinent rates are more than twice those of placebo. Most other antidepressants, including fluoxetine (Prozac), perhaps the best known antidepressant, have no additional benefits for smokers.

Bupropion (Zyban). The unique antidepressant bupropion (Zyban) is proving to be a strong aid in the quitting process. It differs from most other antidepressants because it increases the effects of dopamine, the brain chemical that appears to play a strong role in nicotine addiction. People should take Zyban only as directed by their physician.

The usual recommended dosing is 150 mg tablet twice a day. No single dose should be higher than 150 mg. In one comparative study reported by the manufacturer, quit rates were with abstinence rates at 12 weeks ranging from 20% with 100 mg/day to 25% at 300 mg/day. (It should be noted that other studies report significantly higher quit rates, particularly in combination with nicotine replacement.) Zyban is equally effective in African American and Caucasian smokers. Many people quit smoking one to two weeks after starting, although the drug is typically prescribed for seven to 13 weeks.

In people who are not depressed, there is no noticeable effect on mood. People who are depressed generally report better spirits and more energy, although in a few cases depression worsened.

People tend to maintain their weight after quitting while they are on the drug. A 2001 study indicates that Zyban is most effective while it is being taken, and some people may need to take it for a year or longer to increase the duration of abstinence and perhaps maintain weight loss.

Studies are mixed on whether Zyban is effective for relapse. In one 2001 study, those who were retreated with the drug still had a significantly better abstinence rate (20% at 12 weeks) than those on placebo (3%). Not all studies are as positive, however.

Side effects include gastrointestinal problems, headaches, insomnia, dry mouth, and irritation. In very rare cases, seizures have occurred, although usually in people who exceeded the recommended dose or who already had risk factors for seizures.

Nortriptyline. Antidepressants known as tricyclics may also be beneficial, since they have additional effects, independent of reducing depression, that may help smokers. The tricyclic nortriptyline (Pamelor, Aventyl) has been specifically studied for helping smokers. It is best to start taking the medication 10 to 28 days before the quit date. Studies have reported quit rates of between 14% and 24%. Side effects of this drug include dry mouth and changes in taste. It should be noted that in rare cases, tricyclics can have serious side effects, and overdose can be fatal. Tricyclics may pose a danger for some patients with certain types of heart disease.

Behavioral Methods

Smokers who use outside help have the best record for quitting, with success rates of between 25% and 35%. (Those who are counseled in addition to using nicotine replacement and Zyban have the best chance.) Behavioral methods can be very helpful, including changing specifically or indirectly related to smoking and learning ways to cope and solve problems associated with smoking. Telephone hotlines offering counseling also help, especially when smokers receive follow-up calls. Brochures, audio tapes, and other self-help materials are often ineffective when used alone but may be helpful in conjunction with a counseling program.

The following are descriptions of some behavioral approaches that may help.

Problem Solving or Coping Strategies. Smokers who learn thinking (cognitive) and behavioral techniques for breaking the link between certain cues and smoking, stress management techniques, and ways to handle the symptoms of withdrawal and the urge to relapse are more likely to be successful in quitting. The more intense the counseling program, the better. Smokers should look for programs that include the following:

• 20 to 30 minute session lengths.
• Four to seven sessions.
• Two week program duration.
• An additional two weeks or more of follow-up contacts.

The Staged Approach. The intent of the staged approach is to plan quitting intervention customized for each individual rather than imposing some general method for quitting. The approach takes the smoker through six stages with behavioral interventions at each point:

• Precontemplation.
• Contemplation.
• Preparation.
• Action.
• Maintenance.
• Termination.

Although some studies report this approach is significantly more effective than non-staged methods, an analysis of 23 trials did not find the staged approach to be any more effective than other methods. Most studies, however, were weak and better research is needed on this approach.

Stages for Adopting Healthy Behavior

For a person to successfully adopt a more healthy behavior -- whether it's to exercise more, lose weight, or stop smoking -- it's not as simple as just deciding to do it. Behavior change expert James Prochaska and his colleagues outlined a theory, which has been supported by numerous studies, showing that people cycle through a variety of stages before a new behavior is successfully adopted over the long term. It may help you to understand how this works. As you read the description of each stage -- specifically as it relates to smoking -- you may find yourself nodding and saying to yourself, "Yes, that's me!"

Stage 1: Pre-Contemplation.

People at this stage have no plans or desire to stop smoking. They aren't even considering quitting. People at this stage are generally unaware of the specific benefits that quitting can bring. Or, they may simply have "failed" in the past and have given up. There's no point in talking about how to start a cessationprogram if you are at this stage. Instead, it is important to think about why quitting might be good for you personally -- by helping you to feel better, have more confidence, or live longer. The benefits must be identified before a person will consider quitting. If you are at this stage, a good activity is to ask several friends or family members why they quit. That may unveil real-life benefits and inspire enough interest to compel you to take the next step.

Stage 2: Contemplation.

A person at this stage is thinking, "I think I should probably quit, but I need help getting started." People at this stage know that quitting is good for them, but it seems like a daunting task or they don't think they can pull it off. Some may have tried and "failed" in the past, but they are still receptive to another go-round. It's important for people at this stage to consider some of the truths and falsehoods of quitting. There is no such thing as "failure" -- it is never too late to try again. If you are at this stage, a good activity is write down (brainstorm) all your potential roadblocks -- the things that you believe make quitting difficult -- and to learn strategies for overcoming or side-stepping those hurdles. There are many ideas available on the internet. People at this stage might benefit from making a pledge, contract, or other commitment that they are going to get more active in the near future. Prochaska and his colleagues write that people in this stage are "aware of the pros of changing but are also acutely aware of the cons. This balance between the costs and benefits of changing can produce profound ambivalence that can keep people stuck in this stage for long periods of time. We often characterize this phenomenon as chronic contemplation or behavioral procrastination." Thus, the goal is to get un-stuck by identifying the roadblocks, ways to overcome these hurdles, and making a commitment.

Stage 3: Preparation.

These folks are primed and motivated. They are ready to quit. The goal of this stage is to create a specific action plan that takes all factors into account, so that the "smoke out" is successful. People at this stage need to know what methods work and what support exists to help them. If you are at this stage, you should consider some backup plans -- what to do when the urge to smoke hits you. That way you are prepared to overcome that hurdle when it happens. And you should be aware of what to realistically anticipate how you'll feel at the beginning.

Stage 4: Action!

People at this stage have just quit. This stage is where the most behavior change occurs - these folks have recently quit, or cut down, but it is not yet a long-term, ingrained habit. Prochaska notes that this stage requires significant commitment and energy. If you are at this stage, keep talking to friends and family for inspiration. Review your backup plans. Reward yourself for small achievements. If you can find a friend to quit with, that can be a huge support as you get through this stage. You want to build and maintain momentum, because it gets easier once it is a habit!

Stage 5: Maintenance.

The folks at this stage have been smoke-free at least 6 months. The goal here is to prevent relapse. If you are at this stage, continue to be wary of roadblocks. Improve your backup plans. Think about what you have found most enjoyable about being smoke-free. What benefits have you gained? Keep reminding yourself of these perks.

One point about this theory is that people do not proceed from one stage to another in a simple, step-by-step fashion. They actually cycle or spiral back and forth, so that they may move from stage 1 to 2 to 3, and then back to 2 again. They may stay in maintenance mode for years and then fall back to stage 2. Remember that this is normal -- if you tried quitting in the past and didn't stick with it, don't consider yourself a failure. Just know that it's time to try again!

Scheduled Reduction. A simply behavioral procedure involves the following steps:

• Divide the number of minutes per day awake by the number of daily cigarettes; the result is the minute-long wait between smokes.
• Set up a schedule with time intervals based on this result and using a timer, smoke only at those intervals; if the "cigarette appointment" is missed by more than five minutes, the smoker must skip that cigarette.
• The following week, one-third fewer cigarettes are used and the smoking time is recalculated based on the lower number.
• During the third week the count is again reduced by a third, and the smoker quits in the fourth week.

(Those who are unable to smoke during working hours could try calculating the intervals based on the usual smoking times of the day.)

Although one study showed that people who used a scheduled reduction were twice as likely to quit as those who went cold turkey.

Alternative Methods for Quitting

Hypnosis. Although rigorous studies are lacking, some people report successful cessation from smoking when hypnosis is given in individual sessions. Group sessions appear to be worthless. The process is effective only if the subject trusts the therapist and can feel completely at ease in the vulnerable and passive state necessary for hypnotic suggestion. A typical effective session includes the following steps:

• The hypnotherapist uses various techniques (e.g., imagery, silent counting) to put the subject in a relaxed state.
• When the subject is very relaxed, but not asleep, the hypnotherapist quietly suggests motivations for not smoking.
• The hypnotherapist should also reinforce a positive self-image while the subject is in deep relaxation. This helps many people avoid the depression that accompanies withdrawal.
• The session usually takes about an hour.

The patient is taught methods of self-hypnosis to use at home, and there is usually one follow-up reinforcing session.

Acupuncture and Acupressure. The acupuncture technique for quitting smoking usually uses tiny curved staples attached to three different points around the edge of the ear. The procedure is painless. The patient is instructed to press each staple in sequence for a few seconds whenever the craving for a cigarette occurs. The acupuncturist may also use acupuncture points elsewhere on the body. There are no side effects except for some soreness if the acupuncture staple is pressed too hard. A related technique called acupressure involves simply pressing select points on the body when a craving hits. Some studies have reported good quit rates with acupuncture, but few rigorous studies have been conduced using this approach.

Investigative Agents

Investigative agents for smoking cessation include clonidine (Catapres), a drug used for high blood pressure drug, and naltrexone, a drug used in detoxification programs for opiate addiction and alcohol abuse. Naltrexone may be specifically useful in women and those with a history of depression. Studies on these agents have been mixed, however.

Public Health Efforts and Social Pressure (Denormalization)

Public health efforts are effective, mostly by creating the idea that smoking is no longer normal. This concept of denormalization is best instituted by laws and local regulations making smoking inaccessible in public places, raising prices, and putting stricter limitations on cigarette advertising. California, Delaware, Maryland, New York and Vermont currently have the strictest anti-smoking laws.

Increasing taxes on cigarettes may be one of the most important methods for reducing smoking in the population, and, particularly in younger people.

Evidence is suggesting that banning smoking in work and public places may be leading to a higher quit rate than in places where smoking is permitted. Studies also indicate that people who smoke have reported reductions in their smoking by over 25%.

Denormalization can also work on a personal level. A British study found that when one spouse makes healthy changes, including quitting smoking, the other one follows. In couples where smoking continues, it usually continues in both.

Even if smokers have all the public and professional support available, however, quitting is still a solitary and difficult process.