As a pulmonologist, one of my main roles is to try and help patients to quit smoking. Quite often a patient will come to my office and proudly offer that he is “cutting down on his smokes.” He or she will often ask, “Isn’t that kind of quitting?
Actually, it’s not, according to a new study out of the University of Oxford, England. The researchers looked at 700 smokers and compared sudden complete cessation of smoking with gradual reduction. They looked at the impact in each group after four weeks, and then again, after six months. After four weeks and six months they noted a significant difference between the two groups, with greater abstention achieved in the group that quit suddenly and completely. Unfortunately, even in the best of outcome, with all the smoking aids available to support those who choose to quit smoking, only 25 percent remained abstinent from smoking after six months.
Why is it so hard to quit smoking?
Nicotine, the naturally occurring substance in tobacco is highly addictive. Smokers become both emotionally and physically dependent on cigarettes and their active ingredient. There are somewhat unpleasant withdrawal symptoms when you try to quit. If you are just cutting down, the number of cigarettes that are cut often depend on the withdrawal symptoms you experience and the degree to which you can tolerate those symptoms. The symptoms can also vary from day to day.
Why is nicotine so addictive?
Inhaled nicotine is rapidly absorbed into the bloodstream and reaches the brain faster than many other drugs, even when they are administered intravenously. Nicotine directly stimulates the brain reward system to release dopamine, the neurotransmitter that stimulates the pleasure center. This pleasure sensation is behind the mechanism of addiction and the lure of nicotine and other drugs. The search for pleasure has been a very powerful driver of behavior as demonstrated in numerous animal studies. That level of pleasure also promotes risk-taking behavior.
It is also perhaps the reason why cutting down doesn’t work as well as quitting completely. When you cut down the number of cigarettes you smoke (without quitting), you keep the memory of the pleasure alive and constantly crave it. When you quit smoking abruptly and completely, in about thirty days most of the strong pleasurable memories diminish and dissipate.
What medicinal aides are available to help stop smoking?First, there is nicotine. The culprit so-to-speak is available in nicotine gum, patches or lozenges. Using a nicotine-based aid may help to remove the unpleasant symptoms of nicotine withdrawal. Many argue that this approach merely prolongs the chemical addiction while successfully achieving the goal of sparing the lungs of smoke. It is important to remember that nicotine (in the aids) is still harmful to the cardiovascular system. NEVER use nicotine products if you continue to smoke - you will get very sick. My recommendation is to use the patches, and taper their use over a six week period. The patches usually come in seven, fourteen, and twenty one mg dose. Take each dose for two weeks and then at the end of six weeks there should be cessation of use of the aids and clearly no more smoking. Only use the patches during the daytime—remove them when you go to sleep.
Varencicline also known as Chantix, is the “new(est) kid on the block.” Though it has been on the market for nearly 10 years, it’s still one of the most recent and predominant aids to help smokers quit. It works by inhibiting the dopamine receptor in the pleasure center of the brain. So it doesn’t make you stop smoking; it simply limits and blocks the pleasure. This is an important distinction when deciding which smoking cessation aids to choose. Some individuals suffer with psychiatric illness in which pleasure (or the lack of it) is a marker of their disease. To suddenly take the pleasure away with a drug like Chantix (especially in someone who has been smoking for years) may drive that individual into an acute psychological crisis. That is why this drug is contraindicated in patients with depression or psychiatric illness who do want to quit smoking.
How effective is Chantix?
The studies show mixed results. The typical program is to take Chantix for twelve weeks, gradually increasing the dose depending on how well it is tolerated. The studies that Pfizer, the maker of Chantix, presented to the FDA showed that after twelve weeks of usage, smoke abstinence was 29 to 31 percent, compared to 8 to 9 percent in those who took placebo. Personally, I don’t consider success until abstinence lasts for a year, and no studies have tracked patients for that duration. Furthermore, I don’t consider 30 percent success after 12 weeks something to boast about - even though it was superior to placebo.
Equally as important to be aware of are possible side effects of Chantix, such as: abnormal dreams, bloated of full feeling, change in taste, dry mouth, headache, nausea, trouble sleeping and more. If you are taking Chantix and experience any of these symptoms you should talk with your doctor immediately.
What about Zyban?
Zyban is an antidepressant also known as Bupropion or brand name Wellbutrin. It works on the dopamine system in the brain, again impacting the pleasure center. It’s used to treat depressed patients whose main feature is “lack of pleasure” (“anhedonia”). Patients usually start using it two weeks before they stop smoking and continue its use typically longer than the three month period of cessation to try to prevent going back to smoking. Zyban is contraindicated in individuals with a history of seizure disorder.
Just as Chantix, you should be aware of possible side effects and alert your doctor if you experience: anxiety, dry mouth, hyperventilation, irregular heartbeats, involuntary shaking, trouble sleeping or more.
What about using Chantix and Zyban together?
Studies have been encouraging, but caution should be maintained. The combo should not be used by individuals with a history of seizures, those who consume large amounts of alcohol and those with active liver disease. Usage should be monitored by a psychiatrist.
What are some non-medicinal aids to quit smoking?* ** Hypnosis**is the most often used method. There is no standard for hypnotherapy and few studies on success rates. Most reports of success are anecdotal in nature. Always use a licensed therapist.
Acupuncture has also been used but there’s little verified evidence that it works. It is usually performed on certain parts of the ears. I advise patients who are interested to search for a practitioner in the American Academy of Medical Acupuncture database.
Magnet therapy, another option, is done by placing magnets opposite each other on either side of the ear. There is no scientific evidence to date that suggest that magnet therapy works.
What is the ultimate _stop smoking solution _?These are all aids to help you to stop smoking. You have to make a decision, commit to it, and show that you are serious, by setting a date. That is why cutting down usually doesn’t work - there is no date and there is no definitive commitment event.
What can help is a formula that I use with my patients. The day before they plan to stop, I tell them to smoke as usual but to start a diary. They write down all the times they light up a cigarette, the place and their thoughts at the time. I then tell them to use that information the next day when they have the urge to smoke. Identifying the weakest moments and places that instigate the desire to smoke allows you to connect, identify and refrain from the urge mindfully. It can also help to do things that occupy your hands so you can’t “stop and smoke.” Avoid places where smoking is still allowed and try to minimize interactions with smokers.
It is SO worth the effort to kick butt – your health and your family will thank you.
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Eli Hendel, M.D., is a board-certified internist/pulmonary specialist with board certification in Sleep Medicine. An Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations, his areas include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases. Favorite hobby? Playing jazz music. Find him on Twitter @Lung_doctor.