Methods of Smoking Cessation

Smokers trying to give up the habit should first realize that they are not alone. In fact, over 75% of adult smokers would like to stop, and at least 60% have tried to quit in their lives. However, smoking is a highly addictive habit and 97% of all attempts to quit are met with failure. This is discouraging for both the smokers and others helping the smoker quit. The fact is that most successful quitters, quit and relapse multiple times before obtaining permanent remission. Approximately 20% of ex-smokers report quitting on their first attempt, while only 50% succeeded after 6 tries. Of successful quitters 90% used individual methods of smoking cessation rather than organized programs; with 'cold turkey' being the method most often used (Taylor).

There are multiple methods of smoking cessation, and smokers that do not succeed to stop on their own can always make use of different approaches such as self-help groups, hypnosis and aversion therapy. The use of pharmacological intervention, especially nicotine replacement therapy, has also been shown to be of great benefits for certain smokers. Doctors and other health care professionals are in great position to help their patients quit smoking, and their involvement in the quitting attempt will increase a smoker's chances of success. Lastly, multiple smoking cessation trials have shown that smokers using multiple quitting methods at the same time have a greater chance of success.

Whether I smoker is trying to quit alone of with the help of a smoking cessation program, there are multiple steps a smoker can take to improve his or her chances of success:

• Understand why people smoke, the consequences of smoking, and the benefits of smoking cessation. Motivation is an important predictor of quitting success. The smoker that understand smoking and wants to stop for themselves have a better chance of quitting.
• Be prepared to deal with the inevitable craving for smoking that will come after cessation. Anticipate the situations that will provoke craving and prepare specific strategies to deal with them. Avoid people or situations associated with smoking. Make smoking more difficult for yourself (throw away cigarettes, lighters and ashtrays).
• Choose a method of quitting and develop a quitting plan. Set a quit date and stick to it.
• Reward yourself for not smoking. Make a list of things you wish to buy, put the money previously used for smoking aside to purchase these presents.
• Substitute smoking for another habit such as jogging.
• Make use of the multiple resources available to help smokers quit. Self-help in the form of pamphlets and kids can be obtained from a doctor, local medical societies, and a varied of other sources. Tobacco road has references to some of the resources available in Canada and on the web.
• In case of relapse do not get discouraged. Understand that most successful quitters relapse multiple times before obtaining lasting abstinence. Learn from the relapse and try again.

Cold Turkey

Most successful smoker quit 'cold turkey'. That is to say, they stop smoking cigarette from one day to the next without the help of any specific therapy or pharmacological intervention. Smokers planning to quit cold turkey should set a quit date no more than one month away. The smoker will have a better chance of success if this quit date is not during a stressful time as this will decrease the chances of success.

Cutting Down Smoking Day by Day

Tapering off slowly the number of cigarettes smoked is an alternative to going 'cold turkey'. The choice between the two methods is a matter of personal preference, although there is evidence that most successful quitters use the 'cold turkey' approach. Smokers using the tapering method should keep the following principal in mind: First, plan in details the gradual reduction in smoking. For instance, plan to cut down on smoking by one cigarette per day. To increase the chances of success the smoker should only carry during the day the number of cigarettes allowed for that day. Second, begin to decrease the amount of smoking approximately two weeks prior to quit day. Ideally, by quit day the smoker should be smoking no more than half as many cigarettes as he or she smoked at the beginning of the preparation period. Lastly and most important, it is essential for the smoker not to allow the gradual tapering of cigarettes to become an excuse to procrastinate quitting.

Nicotine Replacement Therapy

Nicotine replacement therapy has proven to be a useful tool in smoking cessation. This especially true for patients that are highly addicted to nicotine. Withdrawal symptoms associated with the rapid discontinuation of nicotine is one of the main reason associated with relapse after quitting. Nicotine replacement therapy prevent the physical withdrawal by providing an alternative source of nicotine until psychological withdrawal can be managed with behavior modification in three to six months. The available forms of nicotine replacement do provide nicotine serum levels high enough avoid withdrawal but too low to provide 'reward'. The Fagerstrom Test predicts the level of nicotine dependence and helps indicate the need for nicotine replacement therapy, as well as, the nicotine replacement dosage (Danis

While nicotine replacement therapy can be of great help in smoking cessation it should be prescribed appropriately. First, nicotine replacement therapy does not substitute smoking cessation advice. The rate of cessation for smokers on nicotine replacement therapy alone is not usually effective. Providing nicotine replacement therapy for smokers who are at the precontemplation stage is inadequate. Smokers should be committed to smoking cessation in order to provide the full benefit from nicotine replacement. Furthermore, smokers on nicotine replacement therapy also benefit from structured smoking cessation advice from their doctors and other methods of smoking cessation. Second, smokers should not smoke any cigarettes while using nicotine replacement. Third, smokers should follow carefully the prescribed dosing regiment. There are few contra indication to nicotine replacement therapy. It appears that it is safe in people with coronary artery disease. However, nicotine replacement should not be used in smokers with a recent myocardial infarction, in smokers with worsening angina, and in pregnant women. There is also a significant risk of the smoker becoming dependent on the nicotine medication. The risk of dependence is higher for formulation that allow for rapid delivery of high doses of nicotine, such as nasal sprays. Up to 5% of patients prescribed the nicotine gum continue to use it for more than one year, and 20% of successful abstainers use the medication for more than one year (Henningfield).

Nicotine (Polacrilex) Gum:

The nicotine gum may be the less expensive form of nicotine replacement when used sparingly. There are two common strengths available in the market: 2 mg and 4 mg. The 4 mg strength may be more effective for highly addicted smokers. Proper chewing technique is essential when using the gum. The nicotine gum is used when the desire to smoke is bothersome. It should be chewed several seconds until a peppery taste or tingling sensation occurs. The user then stops chewing and 'parks' the gum between the cheek and gums until the sensation is nearly gone. The process is then repeated for approximately 30 minutes. The nicotine gum should not be used while consuming food or beverages as nicotine absorption may be impaired. Side effects are mild and include indigestion and stomatitis.

Transdermal Nicotine Patch:

The patch provide relatively constant concentrations of nicotine is more expensive than the nicotine gum. Nonetheless, this methods is usually preferred over the gum because of fewer compliance problems and less need for instruction for appropriate use. Patches should be worn for 16 to 24 hours per day. The site of application should be changed everyday to minimize skin irritation. Side effects usually include insomnia, vivid dreams and stomach upset, as well, as persistent urticarial eruptions after chronic use secondary to an allergy to the patch's adhesive.

Nicotine Nasal Spray and Oral Inhalers:

Nicotine nasal spray and oral inhalers are new alternative methods of nicotine replacement. These appear to be safe and effective for highly addicted smokers as they provide rapid nicotine absorption. The risk of dependence to the medication, however, is increased and up to 30% of users may become addicted. The proper dose of the nicotine spray is one spray (1 mg) in each nostril, no more than five times per hour or 40 times in 24 hours. Side effects include a hot, peppery sensation in the nose or throat, sneezing, coughing, watery eyes or runny nose.

By Supportive Group Sessions

These groups which were led by health care professionals met on several occasions providing information on health consequences of smoking and fostering support and encouragement in quitting smoking, and discussion of problems encountered.

Behavior Modification Therapy

Nonspecific approaches of behavior modification techniques which included (1) relaxation techniques as an alternative to smoking; (2) reward and punishment techniques; (3) visualization techniques (for instance, visualizing nausea and dizziness as a consequence of smoking); (4) identification of situations or stimuli associated with the urge to smoke and avoidance of them or finding substitute activities; (5) emphasizing the positive reasons to stop smoking. These trial were conducted in individual sessions with a psychologist, group sessions, and in self-help manual in which the techniques were outlined. The combined efficacy of these trials was 2%. These techniques, therefore, were felt not to be cost effective as its efficacy is no greater than advice and encouragement by a physician during one visit and they are several times more expensive.

Aversion therapy trials using either satiation smoking and silver acetate were analyzed. Satiation smoking trials involved asking the patients to take one puff of their cigarettes every 6 seconds, or to smoke a daily minimum of at least twice as much as they usual number of cigarettes. The aim was to induce symptoms of nicotine toxicity. This method was felt not to have proven efficacy, and it is now seldom used because of the potential hazards of excessive smoking. Silver acetate either in the form of a gun or a spray leaves a noxious metallic taste in the mouth after interacting with cigarette smoke. The efficacy of this method was not statistically significant.

Sensory deprivation techniques where smokers lay on a bed in a dark soundproof chamber for up to 24 hours, and anti-smoking advice and other interventions were delivered were found to be ineffective.

Hypnosis

The 10 randomized trials reviewed in the article had a combined estimate of efficacy of 23%. However, there was no measure of biochemical markers of tobacco use to confirm verbal claims of having stopped and there was significant heterogeneity between the results. The efficacy of hypnosis as a quitting method was, therefore, deemed to be unproven.

References:

Danis and Seaton. Helping your patients to quit smoking. American Family Physician 1997; 55(4):1207-13.

Henningfield. Nicotine medications for smoking cessation. The New England Journal of Medicine 1995; 333(18):1196-201.

Law and Tang. An analysis of the effectiveness of interventions intended to help people stop smoking. Arch Intern Med, 1993. 155:1933-1939

Taylor and Dingle. Prevention of Tobacco-Caused Disease. In: The Canadian Task Force on the Periodic Health Examination. Clinical Preventive Health Care.Ottawa: Canada Communication Group - Publishing, 1994:500-511.