Introduction

Smoking remains the single greatest preventable cause of death, illness, disability and health care use. Every other person (1 in 2) who smokes will die due to smoking related causes. Smoking causes serious physical problems including: heart disease (smokers have more than twice the risk of coronary artery disease, sudden cardiac death and stroke), cancers of the lung (90% of lung cancers are caused by smoking), throat, mouth, kidney, pancreas, cervix, & bladder; respiratory diseases such as emphysema and chronic bronchitis; impotence in men and pelvic inflammatory disease and complications in pregnancy among women; and impaired wound healing and more frequent complications after surgery. In addition, there are serious health risks for children and others exposed to second hand smoke. Some other consequences of smoking include: increased risk of household fires, higher insurance costs, nicotine addiction, decreased physical endurance, persistent cough, stained teeth & fingers, wrinkles, gray skin, bad colds, and less money (direct cost of $20,000 over ten years smoking a pack a day), more absences from work due to illness, lost income due to illness and premature death. Clearly, each cigarette you smoke harms you and those around you.

Benefits of Quitting

The good news is that quitting lowers many health risks very quickly. After quitting, your risk of heart attack and cancer decrease, breathing becomes easier, smoker's cough disappears, physical activity will be easier, those around you will not be harmed by your smoke, and things will taste and smell better. Quitting lessens the chance of heart attack or stroke (one year after quitting, a smoker's increased risk of heart attack or stroke is cut in half) and, over time, reduces risk of cancer (15 years after quitting, a smoker loses the increased risk of cancer). Other benefits may include no longer being controlled by an addiction to nicotine, having lower life insurance premiums, improved self-image, and not being effected by limits and social sanctions that pressure smokers.

Challenges of Quitting

There is no denying that smoking has a strong hold on many people. Usually, this is for a combination of compelling reasons. First, nicotine is an extremely addictive drug. When you inhale from a cigarette, nicotine reaches your brain in seven seconds. This quick hit of nicotine makes you feel good and makes you want more. Studies have shown that nicotine is more physically addicting than alcohol, heroin or cocaine. Despite long denials to the contrary, tobacco companies have recently admitted to increasing the amount of nicotine in cigarettes to make them more addictive to smokers. Often, the strong cravings you may have for cigarettes are a physical reaction to low levels of nicotine in your body. A strong craving, such a first thing in the morning, is your body's way of telling you that it wants more nicotine. In short, being hooked on cigarettes reflects a real physical addiction to nicotine. Second, the behavior of smoking is a strong habit. After you have been smoking for awhile, the physical behaviors of smoking (lighting up, inhaling) become so well-learned and established that you can do them without thinking, they are an almost unconscious habit. Third, smoking is a strong social habit that can become linked to specific situations. For example, always smoking on a coffee break, at a bar, or after a meal, trains you to smoke in these situations. Smoking during these situations associates smoking with these positive events. Fourth, some people find that smoking is part of how they define themselves. Often, smoking began during adolescence when people were trying to establish their own adult identity. Fifth, some smokers may see cigarettes as a source of emotional support, a constant in their lives that sees them through various crises and life changes. These factors make quitting smoking extremely challenging. Fortunately, there are things you can do to meet these challenges and increase your chance of quitting.

Techniques for Quitting

It is a challenge to change any behavior. For the reasons outlined above, stopping smoking may be especially difficult. However, certain quitting techniques and combinations of treatments may be especially helpful in helping smokers quit. It should be noted that usually it takes more than one attempt to stop smoking. A comparison of verified six-month quit rates for single smoking cessation attempts using different methods suggest that you are eight times as likely to quit successfully if you participate in a behavioral program than if you simply tried to quit "cold turkey." Other interventions are also associated with an increased chance of quitting successfully. These include: nicotine replacement (which reduce withdrawal symptoms), physician advice and follow-up, and participating in a self-help program. However, participating in behavioral program was the single best predictor of successfully quitting.

Method	Quit rate	Description
None	3.0%	self-initiated quitting "cold turkey"; no formal assistance
Self-help	5.0%	individual education and self-guided nicotine fading
Advice	10.2%	physician or other professional advice & follow-up
NRT	14.4%	nicotine replacement therapy (prescribed or OTC)
Behavioral	24.0%	guided nicotine fading, stimulus control, reinforcement
*A quit rate to 29.2% was found when NRT + Behavioral methods were combined

Behavioral programs for smoking cessation may be provided to individuals or groups and are not associated with side-effects. They usually involve a multi-session course of self-monitoring, gradual nicotine reduction, stimulus control (developing new habits in smoking-associated situations), relaxation training and relapse management. The most effective programs may assess readiness for change and beliefs about quitting, and provide techniques to manage acute withdrawal symptoms.

Nicotine replacement therapy (NRT) provides nicotine to the body without the tar and carbon monoxide ingested with smoking. A much safer method of ingesting nicotine than smoking, nicotine replacement is an aid for those who have decided to stop smoking completely rather than just cut down. NRT is for nicotine dependent smokers (those who smoke within 30 minutes of waking, smoke 20 or more cigarettes a day and suffer nicotine withdrawal symptoms). Nicotine is absorbed slowly from the gums (reaching a peak level in 20-30 minutes) and very slowly from the patch (peaking in 2-6 hours). Do not smoke at all when wearing the patch. Nicotine gum is a medication - a patch that goes inside the mouth. Its nicotine is released after 3-5 chews and is absorbed directly through the lining of the inner cheek when the patient "parks" the gum. A fresh piece of nicotine gum should be chewed until a peppery flavor is tasted or a tingling sensation is felt. The gum should then be parked in the cheek until the taste/sensation disappears. This procedure should be repeated, keeping the gum in the same place for 20-30 minutes. Steady chewing and swallowing of the nicotine released will cause unpleasant gastrointestinal side effects from mild nicotine poisoning.

Medications available for smoking cessation (such as Zyban™ - buproprion HCl) originally used as an anti-depressant, may reduce some of the negative symptoms experienced in the early phase of smoking cessation and may improve your chance of quitting. However, such medication has been associated with serious side effects such as increased risk of seizure. Nicotine replacement and any medication should be discussed carefully with your physician. There is some evidence that using these pharmacological interventions in conjunction with a behavioral program may further increase your chance of quitting successfully.

Smoking is incredibly damaging to both you and to others. Quitting can be quite difficult, especially in the early going, but it is well worth the effort. Behavioral programs, alone or in combination with other interventions, can improve your chance of successfully kicking the habit.

Dr. David Aboussafy, Ph.D.
UCounsel Corporation
Vancouver Hospital and Health Sciences Center
University of British Columbia

Further Information and Support
For more information, contact David Aboussafy, Ph.D. at [email protected] or [email protected] or see the Stop Smoking Course at UCounsel.com

References
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