“Habit is habit, and not to be flung out of the window by any man, but coaxed downstairs a step at a time.” –Mark Twain
Even in the face of withdrawal symptoms that can challenge the strongest of wills, millions of Americans have conquered their smoking “habit,” step by step. According to the U.S. government’s Agency for Health Care Policy and Research (AHCPR), for every one of the 46 million American smokers, there is an ex-smoker who has successfully quit. True, it’s not easy.
The nicotine in cigarettes can command both a physical and mental hold that can be tough to overcome. For some, nicotine is as addictive as heroin or cocaine, according to AHCPR.
“There’s no question about it; sometimes when you’re trying to give up cigarettes, you think ‘I’ve got to have one,'” says Denis Brissette of Madison, Wis., who smoked about three packs a day for 30 years before quitting four years ago.
For many smokers who want to quit, willpower alone isn’t enough to beat the yearning. For them, smoking cessation products the Food and Drug Administration has approved may reduce the cravings and other withdrawal symptoms.
To help him quit, Brissette used the nicotine patch, which is now available over-the-counter along with nicotine gum. Other stop-smoking aids, available only by prescription, include nicotine nasal spray and the nicotine inhaler, as well as a stop-smoking product in pill form.
While these products can ease the symptoms resulting from the physical addiction to nicotine, group or individual counseling and encouragement from family and friends are critical to help address the mental dependence.
“You really have to be committed to quitting,” says Celia Jaffe Winchell, M.D., a psychiatrist and FDA’s medical team leader for addiction drug products, “and when you’ve made the decision to stop smoking, commit to using
Imagine: Two jumbo jets crash every day and not a single person walks away alive. That, then-Surgeon General C. Everett Coop told Americans in 1989, is the number of people who succumb each day from smoking.
Cigarettes alone perish more than 400,000 Americans each year–more than AIDS, alcohol, car accidents, crime related losses, illegal drugs, and fires combined.
And smoking can harm not just the smoker, according to the Environmental Protection Agency and other experts, but also family members and others who breathe “secondhand smoke.” Given what cigarettes are known for, why do so many Americans continue to smoke? Seventy percent of adult smokers want to quit completely, according to a survey by the national Centers for Disease Control and Prevention.
But the nicotine in cigarettes is an addictive drug that makes quitting difficult, as confirmed by the 1988 Surgeon General’s report on smoking and health.
“There is little doubt,” wrote smoking researcher M.A.H. Russell in 1974, “that if it were not for the nicotine in tobacco smoke, people would be little more inclined to smoke than they are to blow bubbles or light sparklers.” As with other addictive drugs, people can experience withdrawal when they get less nicotine than they are used to.
Symptoms can include irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, and craving for tobacco. One reason cigarettes in particular are so addictive, Winchell says, is that a person gets a “very rapid and effective dose” of nicotine by inhaling the smoke.
Within seconds of inhaling a cigarette, nicotine enters the lungs and then travels directly to the brain. “Tobacco use in 1997 is not just some bad habit, but a powerful addiction that warrants appropriate medical treatment,” says Michael Fiore, M.D., director of the Center for Tobacco Research and Intervention at the University of Wisconsin Medical School.
As a rule, Fiore says, people who smoke more than 10 cigarettes a day and want to quit should use an FDA-approved smoking cessation product.
Most medical aids to smoking cessation are nicotine replacement products. They deliver small, steady doses of nicotine into the body to relieve some of the withdrawal symptoms, without the “buzz” that keeps smokers hooked.
Nicotine replacement products are available in four forms: patches, gum, nasal spray, and inhaler. Like cigarettes, the products deliver nicotine into the blood, but they don’t contain the tar and carbon monoxide that are largely responsible for cigarettes’ dangerous health consequences.
Studies show that the nicotine replacement therapies as much as double the chances of quitting smoking. Smokers should choose the method that appeals to them and try a different method if the first one doesn’t work. “It’s an individual decision,” Winchell says. “You really can’t say that one of these products works better than another.”
Like the nicotine substitution products, the newest option–an anti-smoking pill–seems to reduce nicotine withdrawal symptoms and the urge to smoke. But Zyban (bupropion hydrochloride), approved by FDA in May 1997, has one thing that sets it apart.
It contains no nicotine. “We don’t know exactly how Zyban works,” Winchell says, “but it seems to have an effect on the chemicals in the brain associated with nicotine addiction.” Bupropion was previously approved as a prescription antidepressant under the brand name Wellbutrin.
In studies of the drug for smoking cessation, there were no noticeable changes in people’s moods. “Antidepressants make depressed people feel normal; they don’t make non-depressed people feel happier,” Winchell says. “The people who entered the trials weren’t depressed, and the drug didn’t make them euphoric.”
Some common side effects from Zyban are dry mouth, difficulty sleeping, shakiness, and skin rash. As many as 3 in 1,000 people taking Zyban may have an allergic reaction–such as itching, rash and hives–severe enough to require medical attention.
About 1 out of every 1,000 people may have a seizure, which may involve convulsions and loss of consciousness. People should not use Zyban if they have a pre-existing seizure condition such as epilepsy or an eating disorder such as anorexia nervosa or bulimia, or if they are taking other medicines containing Zyban’s active ingredient, bupropion hydrochloride.
These circumstances can increase the chance of a seizure. Zyban is not recommended for women who are pregnant or breast-feeding. While it can be used with a nicotine substitution product, the supervising doctor should monitor the Zyban user closely for a possible rise in blood pressure.
It is not physically dangerous to smoke while using Zyban, but continuing to smoke after deciding to stop significantly reduces the chance of successfully quitting.
Despite the availability of Zyban and the other medical aids for smoking cessation, Winchell says, “If someone is serious about quitting, the drugs alone won’t do it.
They must have some kind of support, whether it’s from a formal stop-smoking program or at least informal support from their friends and family.” This, Winchell explains, is because nicotine addiction isn’t all physical. Smokers come to enjoy the smoking behavior and are used to lighting up in certain situations.
“A smoker’s whole day,” Winchell says, “is filled with cues that could trigger the desire for a cigarette: the first cup of coffee in the morning, sitting down to check the e-mail, opening the paper, finishing a meal.” Before quitting, a person should change his or her environment.
A good way to start, according to AHCPR, is by getting rid of cigarettes and ashtrays in the home, car, and workplace. Setting a quit date, and sticking to it, is another important step toward successfully giving up cigarettes.
A good date might be Nov. 19, the day of this year’s “Great American Smokeout.” Each year, millions of Americans participate in the American Cancer Society event, which is designed to encourage people to give up the deadly pastime for at least a day.
Because being around smokers, being under stress, and drinking alcohol are some of the most common smoking triggers, AHCPR recommends that people avoid such difficult situations whenever possible while trying to quit.
As a distraction from thoughts of smoking, the agency says, taking time for a fun activity may help. Exercising may be an especially useful distraction.
And exercising, along with eating healthier, low-fat foods, can minimize the weight gain (not more than 10 pounds on average) that sometimes goes along with quitting smoking. Quit-smoking programs, self-help materials, and hot lines are available throughout the United States
Also, family, friends, or a health-care provider can offer encouragement and support when the going gets tough. “The buddy system helped me,” Brissette says.
“My mother-in-law quit at the same time I did. We supported each other through it.” Some people have found hypnosis and acupuncture helpful in quitting, but these methods have not been proven to work.
Cigars and smokeless tobacco should not be viewed as safe alternatives to cigarettes. They, too, can be addictive and can cause serious health effects such as cancer and heart problems.
Not Even a Puff
Regardless of the method you decide to try, Fiore says, “hang in there.” Most people who abstain from smoking for three months can be cigarette-free for the rest of their lives, he says. Your risk of heart disease and lung cancer drop steadily after you quit.
Three years after quitting, your risk of dying from a heart attack is about the same as if you had never smoked, according to the American Heart Association. And the American Lung Association estimates that in 10 years, the risk of lung cancer declines to about 30 to 50 percent of a continuing smoker’s risk.
So when you try to quit, keep the rewarding health benefits in mind. Don’t be discouraged if the first quit attempt doesn’t succeed, because experts say it usually takes two or three tries.
Think about what seemed to help during past quit attempts and what didn’t, and each try will carry a better chance of success. But even after you’ve abstained for a while, cautions Fiore, don’t be lulled into letting your guard down.
Because the nature of nicotine addiction makes it impossible for most people to be occasional smokers, “you need to treat cigarettes the way an alcoholic treats booze,” he says. “Don’t take even a single puff.”
Tamar Nordenberg is a staff writer for FDA Consumer. (http://www.pueblo.gsa.gov/cic_text/health/quittin-time/797_smoke.html)