2007-07-25T21:59:00.002-07:00

Methods of Smoking Cessation

Methods of quitting

Cold Turkey method
Nicotine Replacement Methods (Patch, Gum, Nasal Spray)
Behavioral Methods
Cognitive Therapy Method
Other Methods and adjuncts (acupuncture, hypnosis, medications)
Factors for relapse while in the process of quitting
Predictors of successful quitting

Cold turkey method

This is the prefered method used by so called self changers, people who quit on their own and without any nicotine replacement by gum, patch or nasal spray. Little is known about this method as any research study would influence the results as it would no longer be a spontaneous process. Strong motivational factors are believed to play the foremost role in successful quitting using this method.

Nicotine replacement therapy

In this method the nicotine delivered by the cigarette is replaced with nicotine delivered through the skin (transdermal nicotine or nicotine patch) , the nasal mucosa (nicotine nasal spray) or the buccal mucosa (nicotine chewing gum). Several well designed clinical trials have shown the efficacy and safety of nicotine replacement the goal of which is to reduce cravings and ease withdrawal symptoms.

Transdermal Nicotine Patches

The nicotine patch is usually well tolerated, and provides constant, steady nicotine blood levels throughout the day and night when worn. They are quite simple to use, help prevent weight gain, cravings, and nicotine withdrawal symptoms and are socially acceptable

Side Effects of the patch

Patches may cause a local skin reaction,and insomnia with nightmares may occur.

Overdosing in nicotine is possible, especially if a person smokes while wearing the patch. Smoking while wearing a patch is dangerous and may lead to stroke or heart attack.
Use of the patch requires abstinence from tobacco products...i.e. no smoking or chewing tobacco.

Cost

Patches are expensive and cost close to $100 per month of use.
However bear in mind that smoking 1 ppd costs $1000 per year, which multipied by 10 years approximates the price of a car.
Some people are tempted to cut the patch to save money. Nicoderm is the only patch that can be cut without destroying the patch's ability to deliver nicotine through the skin to the bloodstream reliably.. It is not unsafe to cut the other patches as far as I know. However cutting the other patches impairs the transdermal drug delivery system, and may not provide reliable blood levels of nicotine. the key word here is reliable.

The total dose of nicotine in the patch does not correlate at a milligram to milligram equivalency to the dose delivered to the bloodstream. The drug delivery system of the patch ensures that nicotine is transported thru the skin at a constant rate, and e ach manufacturer uses a different patented technology to do this. Only a portion of the total nicotine contained in the patch is transported thru the skin. Individual differences in skin thickness, location of the applied patch, and other related factors play a role in the total dose delivered.

It is important to individualize the tapering method . . . Some people require longer periods of use, others shorter. If cravings intensify , return to the next higher dose of the patch.

Types of nicotine patches

Nicotrol

15,10,5 mg 16 hour patches
useful if a patient has insomnia on one of the other patches due to the absence of nightime nicotine delivery.

Habitrol

21,14,7 mg 24 h patches, comes with a kit

Prostep

22, 11 mg 24 h patches

Nicoderm

21, 14, 7 mg 24 h patches, can be cut for fine tuning of dose and cost savings.

Efficacy of the patch

When use of the patch is combined with a behavior modification program, sustained 12 month abstinence rates range from 12-25%

Effectiveness of Nicotine Patch for Smoking Cessation: A Meta-analysis

Compare these rate to the less than 5% of patients that will stop without the patch following simple advice to quit by a doctor.

Other types of nicotine replacement

Nicotine polacrilex chewing gum

Remarkably effective in reducing cravings and in promoting abstinence however is not practical, requiring a person to keep the gum in a corner of the mouth and only chewing once or twice to stop an intense craving. Some authoroties recommend using it in addition to the patch or after stopping the patch in selected individuals to address residual cravings and urges not controlled by the patch. It tastes bitter and may upset the stomach somewhat. It is available in 2 and 4 mg dosages.

The Nicorette gum homepage

Nicotine Nasal Spray

Shown to be as effective as the gum in reducing cravings and promoting abstinence when used over a 6 week period of time. A single dose is delivered to the nasal mucosa when cravings occur.

FDA approves nicotine nasal spray

Nicotrol nasal spray

Nicotrol inhaler

Cognitive Behavioral Therapy

What is Cognitive Behavioral Therapy ?

Behavioral therapy strategies for smoking cessation

Look for factors in the environment that predispose to smoking behavior

Remove triggers and cues from the home (ashtrays, matches, posters, etc) and establish smoke free zones at home, work, in the car and make access to cigarettes difficult . . .

identify situations and feelings that reinforce pleasure of smoking...oral, manual, respiratory pleasure...socializing with smoking friends or spouse...

identify high risk situations for desiring a cigarette: alcohol, after meals, while driving, particular mood states, etc...

measure and monitor smoking behavior which can help identify the relationship with triggers, cues, high risk situations...keep a smoking diary!!!

Look for ways to alter smoking behaviors

Delaying tactics:

await an increasing amount of time before lighting up, make sure you keep track of this in a notebook...i.e. when you had the craving how long did it last, how long did you wait before lighting up...

practice quitting for 1 day only

Fading techniques:

taper the amount of nicotine by using the patch, gum or by gradual lowering of the tar/nicotine content in the cigarettes you smoke with care to not alter smoking technique, such as inhaling longer or more strongly...changing brands also reduces the pleasure you get from smoking which is helpful ....

you might also consider cutting off half your cigarette before lighting up, so you will smoke half as much that way...

Substitute one behavior for another:

Carrot sticks

gum, cereal

toothpicks

exercise

To make anything a habit, do it
To not make it a habit, do not do it
To unmake a habit, do something else in place of it.
Epictetus 60-110 AD

Aversive Conditioning:

based on pairing a negative stimulus ( behavior or thought) with the behavior one wants to change.

Rapid chain smoking until vomiting occurs...
this is very effective but must be repeated until the very idea of smoking makes you nauseate, and vomiting can be risky from bleeding or aspiration...

Focused smoking where one smokes while imagining negative consequences such as physical or mental health problems, causing harm to others, encountering social disapproval, labeling oneself an addict or slave, thinking of smoking as a suicide equivalent . . .

Contingency contracting: make a contract with yourself to reach a goal of short term abstinence and if not money gets sent to your most hated politician!!!

Positive reinforcement

based on pairing a positive thought or behavior with the desired behavior

Focus on the goal

Identify and write down your personal incentives for quitting, focus and dwell on them as often as possible!!

Focus on the personal rewards

Plan out the rewards one will have with cost savings, imagine what you may be able to do with all that money...think about all the benefits of quitting, being able to live longer, breath easier , etc...

Focus on the social rewards

Social reinforcers: imagine yourself telling people you are a nonsmoker, asking for a nonsmoking table in a restaurant, giving tips to a friend about how to quit smoking, daydreaming about people coming to you saying WOW! how did you do it?!

Actively work on your self concept

Self-esteem enhancement

Coping skills training, social skills training are very useful

relaxation techniques

Maintenance sessions months later can help consolidate the new habits....whatever worked for you, do them some more from time to time to avoid relapses...

Cognitive therapy techniques

Uses the concept of taking personal responsibility for one's thoughts, helping change the way a person thinks, changing the beliefs about the barriers to success, and identifying irrational thought patterns and mindsets are focused on in this strategy.

Cognitions ( thought patterns ) can be re-engineered and reconstructed...first one has to carefully analyze current beliefs, thought patterns then look at the feelings and behaviors that accompany those thoughts... the second step is replace the thought by another, drawing on examples from your own life experience preferably.

For example someone who says I always fail... if challenged about the word always will undoubtably have at least one success story in their life somewhere ....thus the thought can be replaced by I sometimes fail or better yet, I have had plenty of successes in my life!!

Homework assignments:

Write these down and carry them around with you to read at times of craving...

list 5 reasons why you want to stop smoking

list 5 reasons why you want to smoke

make a list of all the things you will do when craving a cigarette

prior to your quit date, write down every cigarette you smoke and track the time and the circumstances, stress relief or desire for pleasure...

Self rating of control, mastery and pleasure

Using a 1-10 scale ... write down a number from 1 to 10 reflecting how much in control you feel, how much mastery or how much pleasure you are experiencing....

this can help you focus your thoughts on these themes, and you can identify times of greater and lesser vulnerability which can be invaluable information ....chart this stuff daily or weekly starting prior to your quit date until several weeks after quitting.

Cognitive rehearsal

...i.e. practicing dealing with high risk realpse situations. For example you could rehearse what you will say when offered a cigarette at a social gathering...
"no thanks I am a non smoker!!"

Common beliefs and barriers:

"I'll get fat . . . " A study of 20,000 quitters showed that 80% do gain weight versus 56% of continuing smokers. The average gain was only 4.6 Lbs. 20% will gain 10 lbs. And 4% will gain 20+ lbs. With care to watch diet and exercise, weight gain can be controlled.

"I have to die of something . . . " no one deserves a premature death, smokers are 1 1/2 times more likely to die in the next year as an ex-smoker of the same age and sex.

"I can't enjoy life without smoking"...fewer coughs, less shortness of breath, stronger immune function, longer life . . . won't that help you enjoy your life more?

"I'll cut down"... if you can do it, it will help but why have your risk be any higher than it needs to be?

"Not all smokers die young"...true enough, there are some lucky individuals, and its up to you to choose to have the odds stacked in your favor or to have them against you.

"I've failed in the past . . . " most long term abstainers fail 4 to 5 times before succeeding.

"Its too late, I'm already sick . . . " there are benefits in stopping at all ages. After a heart attack, continuing smokers have a 10-fold greater mortality than do ex-smokers.

" I'll quit later if I get symptoms"...the risk is cumulative and it takes years for it to develop and to decrease after cessation.

"I'm only hurting myself"...WRONG!!! Passive smoking harms those exposed to it and costs them their health and well-being.

Common cognitive distortions of addicted individuals...in this text alcohol is the object of discussion...the reader is invited to substitue the word tobacco or nicotine whenever alcohol is mentioned....

Other methods and adjuncts

Acupuncture

Benefits some people in the process of quitting smoking...contact a local acupuncturist for more information.

Hypnosis

Hypnosis has been shown to be helpful for some people...
Hypnotic scripts This series of links includes several designed for smoking cessation.

Pharmacological adjuncts:

clonidine

This blood pressure medicine is used in the treatment of heroin withdrawal due to it central nervous system locus of action as a pre-synaptic alpha2 adrenergic agonist. In other words, it inhibits the adrenaline system and reduces cravings in some individuals.

bupropion ( Wellbutrin® ; Zyban® )

An antidepressant used to reduce cravings and withdrawal and has recently acquired FDA approval for use as an adjunct to smoking cessation. It may help promote higher abstinence rates than use of the patch alone and helps to alleviate anxiety and depressive symptoms which are common in persons in the process of quitting smoking. The usual starting dose is 75 mg twice daily and the dose is gradually increased upwards to a total of 300 mg per day in divided doses.

Bupropion SR Together With Nicotine Patch

See also the Zyban homepage

Mecamylamine

This molecule acts as an antagonist to the nicotinic receptors in the central nervous system, and there is a meager clinical database suggesting it may be helpful in promoting abstinence from smoking due it blocking the euphoric effects of nicotine, whern used in combination with the patch.
For more information see:

 
     Mecamylamine combined with nicotine skin patch facilitates smoking cessation
  beyond nicotine patch treatment alone.  Rose JE, Behm FM, Westman EC, Levin ED,
   Stein RM, Ripka GV.; Clinical Pharmacology and Therapeutics 1994;56:86-99


  Nicotine/mecamylamine combination treatment for smoking cessation
  Jed E. Rose, Eric C. Westman1,Frederique M. Behm;  Drug Dev.Res. 38:243-256 ;1996


  Mecamylamine (a nicotine antagonist) for smoking cessation 
  Lancaster T, Stead LF. (Cochrane Review). In: The Cochrane Library, Issue 1, 1999.
  Oxford: Update Software.

Factors that influence relapse rates

Knowledge of these can help you come up with a relapse prevention program...planning ahead and giving some thought on how to deal with these situations and lessos learned from the past can help you negotiate these difficult passages on your path to success!!!

stress and negative emotional states

Look ahead at what could be stressful in your life... develop ways to cope using the above cognitive behavioral strategies, drawing upon your past successes in dealing with stress and knowing what works best for you. Anticipate that you may have periods of sadness, anger, frustration, irritability, a "who cares" attitude at times...these high risk times are transient, temporary, and if you find ways to get through them without a slip or relapse you will feel a sense of mastery and pleasure...

cravings from smoking cues and triggers

Urges and cravings can intesify at certain times and under certain circumstances...if you did the tracking sheets noting when and where you smoke and how strongly you desired that particular cigarette you will most likely have identified these situations... for some its upon awakening, or after a meal, or when angry or when around certain people... work on avoiding these situations and/or keeping busy with other things during them...

withdrawal symptoms, weight gain

These cause you to focus on the cost of quitting instead of on the rewards of quitting...go back to reminding yourself of the rewards!!

spouse smoking, social smoking, peer pressure

If at all possible try to quit at the same time as your spouse, and avoid situations initially where the social pressures will be hard to resist... rehearse your polite refusal when offered cigarettes, enlist your smoking friends to be considerate of your efforts and to support and encourage you.

alcohol use

Drinking is one of the most frequent causes for relapse...there are many reasons why this is so, but the bottom line is that you would be well advised to not drink alcohol for the first several months after your quit date...

Predictors of successful quitting

several prior attempts to quit

something is learned each time you have tried to quit...the more learned the higher your chances of success the next time around!!

confidence in ability to quit

this reflects a person's motivation and anticiaption of a successful outcome... a little spark of faith can make the difference!!

a good support system

on line support groups

stopsmoking