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.
3 Step Tapering Method of using the patch
- The 21 mg patch is worn daily for 6-8 weeks for quitters who smoked an average of 1 ppd
( 2 ppd quitters may require 2 patches to alleviate cravings and withdrawal symptoms)
- The 14 mg patch is then worn daily for the next 2 to 4 weeks if the ex smoker
remains confident in his or her ability to not smoke and if urges or cravings to
smoke are controlled.
- The 7 mg patch is then worn for 2-4 weeks if the same criteria as above are met.
- In the absence of cravings and urge to smoke the patch is then stopped entirely.
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
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.
21,14,7 mg 24 h patches, comes with a kit
Prostep
22, 11 mg 24 h patches
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
Benefits some people in the process of quitting smoking...contact a local acupuncturist for more information.
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
while quitting you may not be at your best socially, but this is not
the time to become a loner...a network of supportive people in times
of doubt and need goes a long way....there are on line support groups
as well but nothing replaces live human contact...
the earth will get you back to the top
of my homepage! 