Good Reasons to Quit
Nature of Tobacco Addiction and Widthdrawal
Methods of Cessation
Effects of Cessation
Smoking Cessation and Weight Gain
Handling a Relapse
People smoke for a variety of reasons. Some of the reasons are: (1) it provides a sense of increased energy or stimulation; (2) it is a pleasurable feeling which often accompanies a state of well-being; (3) it reduces tension or feelings of anxiety; or (4) it has become automatic or addictive.
Unfortunately, although many find smoking to be enjoyable, it is a very deadly habit. Over 400,000 Americans die each year from tobacco-related diseases, and many thousands more suffer illness and disability directly attributable to smoking.
It is therefore not surprising that of the 50 million Americans who continue to smoke, approximately two-thirds say that they would like to quit (Gallup Poll, May 31, 1990). In fact, more than 38 million American adults have already quit smoking; nearly half of all living adults who ever smoked cigarettes have quit.
The most important element in tobacco cessation is that the smoker must truly desire to quit, and consideration of some of the benefits of quitting may encourage him or her to do so.
GOOD REASONS TO QUIT
Some of the health and life-saving benefits of quitting have been listed in the U.S. Surgeon General's Report for 1990. They include the following:
Quitting has unique benefits for women:
Quitting is also good medicine for smokers who are already sick. If smokers with heart disease quit, risk of repeat heart attacks and death from heart disease is reduced by 50 percent or more. Smokers with peripheral artery disease who quit have an improved ability to exercise and an increased overall survival rate. Smokers with ulcers who quit reduce the risk of recurrence and enjoy an improved rate of healing.
There are also purely economic benefits of quitting. A daily expenditure of $5.00 per day on cigarettes results in a yearly sum of $1,825.00.
TOBACCO ADDICTION AND WITHDRAWAL
Quitting smoking is usually very difficult, and many ex-smokers go through the quitting process several times before becoming permanent quitters.
People begin to smoke for a variety of reasons: pleasurable sensations, relaxing effect of nicotine, desire to appear more grown up or sophisticated, peer pressure from friends, etc. Over time, however, with the repeated smoking of thousands of cigarettes, smoking becomes a strongly ingrained habit that is difficult to give up: smokers become "hooked."
It is useful to think of the smoking habit as having two primary components: one physical and one psychological, although the distinction between the two is sometimes difficult to make. The physical aspect of addiction is a result of continued exposure to nicotine. All tobacco products contain substantial amounts of nicotine, a powerful drug, which acts in the brain and throughout the body. With each cigarette smoked, this powerful drug exerts its effects.
The pharmacologic and behavioral processes that determine nicotine/tobacco addiction are similar to those which determine addiction to other drugs. According to the U.S. Surgeon General's 1988 Report, nicotine is more addictive than any other drug, including cocaine, heroin, opium, and marijuana.
Nicotine exerts a wide variety of complex effects on a smoker's system, but some of the more common effects are that it can promote relaxation, help control hunger, and increase mental alertness. Over time smokers become physically dependent on nicotine and need to smoke just to feel normal.
The second factor that helps maintain the smoking habit is what psychologists call "conditioned association." A one-pack-a-day smoker smokes over 7,000 cigarettes per year and over 100,000 cigarettes after 15 years. Over time, consistent patterns of smoking develop. For example, a smoker may find that he or she typically smokes when driving, when talking on the phone, when having a cup of coffee or a drink of alcohol, when feeling angry, or sad, etc. These patterns become strongly ingrained and the activities, thoughts, feelings, etc. that often accompany smoking become automatic "triggers" that elicit a craving for a cigarette. If you ever found yourself reaching "automatically" for a cigarette, without thinking, or suddenly had a strong urge for a cigarette when you were in a setting where you normally smoke, you have experienced a "conditioned craving." This is a very powerful effect which can make it difficult to quit and can cause a relapse to smoking even years after quitting.
Because smoking is maintained both by nicotine addiction and conditioned habit, the most effective methods of cessation are those that attack both factors.
METHODS OF CESSATION
Although literally hundreds of different smoking cessation methods have been devised, they all can be categorized by where they fall on three dimensions: 1) how and where they are implemented (self-help vs. clinic-based interventions); 2) whether or not some type of drug is involved (pharmacologic vs. non-pharmacologic); and 3) whether they involve abrupt (cold turkey) or gradual quitting.
1. Self-Help vs. Clinic-based Programs
The vast majority of smokers prefer to try to quit on their own. The U.S. Department of Health and Human Services (HHS) recently reported that 90 percent of successful quitters have used a self-help strategy. Self-help strategies are popular because they are typically cheaper than clinic-based programs and more convenient because they do not require participation in meetings or group sessions.
Most smokers simply try to quit on their own with no assistance. Others rely on one or more of the many booklets, pamphlets, and tapes that are available from various agencies (e.g. American Lung Association or American Heart Association) or from commercial sources.
The most recent innovation in self-help programs is the LifeSign computer, which provides a gradual reduction program that is based on a smoker's unique habit. Click here to learn more about LifeSign.
"Clinic-based" is a generic term that refers to any program administered by a treatment professional (e.g., doctor, psychologist, or health educator). Programs can be administered either individually or in a group setting.
Smoking cessation clinics usually offer intensive support and involve multiple sessions. They may include a considerable variety of treatment components and tend to produce good long-term outcomes. However, they typically require a very significant investment in time and energy.
Commonly offered nonprofit programs include those of the Seventh Day Adventist's Five Day Plan, the American Lung Association's Freedom From Smoking clinics, and the American Cancer Society's Fresh Start program. Judging from the research reports, it appears that the American Lung Association's clinic is somewhat more effective than that of the American Cancer Society; however, the American Lung Association's program requires a substantially greater time commitment. Programs that require a greater number of sessions typically result in higher quit rates than those with fewer sessions.
Commercial programs are also available. SmokEnders, Smoke Stoppers, Smokeless, and Schick are among the most common smoking cessation clinics. Commercial programs are often substantially more expensive than the nonprofit programs and there is little evidence to demonstrate that the commercial programs are more effective than those of nonprofit organizations. Commercial vendors indicate correctly that, for many smokers, a substantial fee may represent their high level of commitment and serve as an incentive for quitting.
2. Pharmacologic vs. Non-Pharmacologic
Although many quitters succeed by going "cold turkey," for some smokers who experience significant withdrawal symptoms (e.g., irritability, frustration, anger, difficulty concentrating, increased appetite, and urges to smoke), drug therapy may be used to ease the transition to a smoke-free lifestyle. The two most common drug therapies involve "nicotine replacement" with either nicotine chewing gum or nicotine transdermal patches.
Both nicotine gum and transdermal nicotine patches deliver doses of nicotine that provide relief from withdrawal symptoms while the smoker works on breaking his or her smoking habit. Over time, the dose of nicotine is gradually reduced. It is important to note that both nicotine gum and nicotine patches are useful primarily as adjuncts to other behavioral interventions and are not typically very effective when used as the sole method of treatment.
In the United States, nicotine patches are available by prescription only; nicotine gum has recently been approved for over-the-counter sales by the U.S. Food and Drug Administration (FDA). Both the gum and patches have some fairly common side effects, and they are not appropriate for smokers with certain health problems. Side effects of gum use include dizziness, nausea and jaw muscle ache. There have also been rare cases of overdosing.
Recently, moreover, five heart attack patients wearing patches were brought into a Massachusetts hospital. An investigation found that they had been wearing the patch and smoking as well - four of them two packs of cigarettes a day. Since the amounts combined from each source constituted a massive overdose of highly toxic nicotine, the patients' reaction was not surprising but the incident underlines the extreme danger of using the patch and continuing to smoke.
In the past, a number of other drugs have been marketed over-the-counter to smokers including lobeline sulphate (Nikoban and Bantron), silver acetate (Healthbreak), lobeline sulphate with vitamins (Cigarrest) and cloridine (Catapres). None of these compounds have been proven effective and their use in smoking cessation products has recently been banned by the FDA.
3. Cold turkey vs. gradual quitting
The vast majority of smoking cessation programs, whether self-help or clinic-based, pharmacologic or nonpharmacologic, involve cold turkey quitting. The programs differ primarily with respect to how smokers are prepared for quitting (e.g., monitoring smoking, reading lessons, participating in groups, switching brands, etc.) and what they do after they quit (e.g., chewing nicotine gum or using a nicotine patch). Recently, however, some very interesting research has suggested that gradual cessation may provide a better approach for many smokers.
Many smokers find the concept of gradual cessation very appealing. It seems intuitively obvious that it would be easier to cut down a little bit every day, rather than to quit cold turkey. The good news is that this approach really does work. Recent research studies conducted at the M.D. Anderson Cancer Center at the University of Texas have shown that gradual quitting works better than cold turkey.
However, gradual quitting is not as simple as it sounds. It does not work very well to simply decrease the number of cigarettes smoked per day. Although this approach does decrease nicotine intake, it does not weaken the conditioned smoking habit. In fact, it may actually strengthen it. People will continue to smoke during their favorite times (e.g., after a meal, with a cup of coffee), and these remaining cigarettes will become even more valuable to them than before, and consequently even harder to give up.
The key to successful smoking cessation is a concept called "scheduled, gradual reduction" (SGR). With SGR, smokers smoke on a time-based schedule, not whenever they want to have a cigarette. Gradually, the time between cigarettes is increased until complete cessation is achieved. The time-based schedule forces smokers to disrupt their usual smoking pattern, thus their habit is weakened. The increase in time between cigarettes results in fewer being smoked per day, and therefore nicotine intake is decreased.
In the M.D. Anderson studies, researchers used computers to develop SGR smoking schedules for subjects to follow. This technique was quite successful, although it was somewhat inconvenient for smokers because they had to refer to printed schedules to determine when to smoke.
Researchers at PICS, Inc., have developed a self-help program that implements the SGR method through the use of a tiny, hand-held computer (LifeSign). Click here for information on LifeSign.
Other smoking cessation tools have also tried to implement the SGR method. Nicotine reduction filters such as One Step at a Time, intended to allow smokers to gradually reduce their nicotine intake, have not proved to be a successful method of cessation. The major problem with filter products is that the smoker tends to continue smoking at the lower levels of nicotine reduction rather than achieving total abstinence.
EFFECTS OF CESSATION
When an individual stops smoking abruptly there are a variety of symptoms, both physical and psychological, which may be experienced. Most symptoms decrease sharply during the first few days of cessation and continue to decline gradually over the next two or three weeks. The most commonly reported withdrawal symptoms include: irritability (which is caused by the body's craving for nicotine); fatigue (which may result from the fact that nicotine is a stimulant and cessation takes away that stimulation); insomnia; occasional dizziness (which is caused by the extra oxygen the body is getting); difficulty concentrating (which comes from the lack of stimulation nicotine had been providing to the brain); hunger (which results when nicotine no longer acts as a stimulant that increases the body's metabolic rate); and craving for cigarettes. These symptoms are most frequent within the first two or three days after quitting. Gradual cessation can help reduce the frequency and severity of these symptoms.
SMOKING CESSATION AND WEIGHT GAIN
The fear of post-cessation weight gain may discourage many smokers from trying to quit, and this problem was considered by the Centers for Disease Control in preparing the U.S. Surgeon General's Report for 1990.
According to the Report's Executive Summary:
Fifteen studies involving a total of 20,000 persons were reviewed in this report to determine the likelihood of gaining weight and the average weight gain after quitting. Although four-fifths of smokers who quit gained weight after cessation, the average weight gain was only 5 pounds (2.3 kg). The average weight gain among subjects who continued to smoke was 1 pound. Thus, smoking cessation produces a 4-pound greater weight gain than that associated with continued smoking. This weight gain poses a minimal health risk. Moreover, evidence suggests that this small weight gain is accompanied by favorable changes in lipid profiles and in body fat distribution.
To help limit weight gain after quitting ex-smokers should eat a well-balanced diet and avoid the excess calories in sugary and fatty foods; satisfy cravings for sweets by eating small pieces of fruit, have low-calorie foods on hand for nibbling, drink 6 to 8 glasses of water per day, and build exercise into their lives by walking 30 minutes a day or doing the physical activity of their choice, such as running, cycling, swimming, or gardening.
HANDLING A RELAPSE
Former smokers start smoking again for any of several reasons - stress, withdrawal symptoms, alcohol, or boredom. One important lesson which smokers learn when quitting is that they can't test themselves by having a cigarette or two after quitting. If a relapse occurs, ex-smokers should not despair. A quitter should:
The long-term benefits of smoking cessation have been mentioned earlier in this pamphlet. There are also some immediate benefits which include: (1) decline in carbon monoxide level in blood; (2) heightened sense of taste and smell; and (3) better oral health. Also, the effects of nicotine on pulse rate and blood pressure are eliminated within 20 minutes of the last cigarette.
Thus, quitting smoking carries major and immediate health benefits for men and women of all ages, even those in the older age groups. Benefits apply to healthy people and to those already suffering from smoking-related diseases.
In the words of Dr. Antonia C. Novello, U.S. Surgeon General:
Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives.
Note: Portions of this document were abstracted from "Cessation and Quitting" published by Action on Smoking and Health (ASH), 2013 H Street, NW, Washington, DC 20006
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