How to Quit? What Happens When You Do?


Not so many years ago, the prevailing wisdom was that the ability to quit
smoking was a matter of simple willpower. This attitude implied that
smoking was not really an addiction, that no special techniques were
required for quitting, and that anyone who could not quit simply lacked
the internal fortitude to do so. We now know that none of this is true.
Nicotine is an addictive drug, and quitting is a complicated change of
behavior that is not easy.

Many former smokers report having quit on their own, but there are
also plenty of treatments available to help. Unfortunately, there is no one
treatment that works for everyone. Probably because the behavioral habits
of smoking are tied up with the physiological addiction to nicotine,
many people require a number of different treatment strategies to address
the whole problem. On the behavioral side, these can include educational
counseling, group or individual smoking-cessation training, hypnosis, or
stress-management training.  On the medical side, they can include the use
of nicotine chewing gum or nicotine skin patches.Also, a medication called
Zyban, which is also used as an antidepressant under the name
Wellbutrin, is sometimes used as one component of smoking-cessation
programs, and a number of other drugs are being actively studied or are
in initial clinical trials. Some of those trials contain some interesting
twists that might be of great value. It turns out that starting nicotine
replacement therapy (the patch, specifically) a couple of weeks before
one’s “quit date” can increase the likelihood of successfully quitting. Initial
studies sponsored by the National Institute on Drug Abuse have
demonstrated this, and ongoing studies are looking for the optimal time
at which therapy should begin relative to the quit date. Other studies are
exploring the value of taking a flexible view of which medications to use,
and when, in the quitting process. Some people have more success than
others with different treatments, and current studies are looking for the
best ways to “rescue” smoking-cessation patients who are not having success
with one approach by replacing it with another at just the right time
in the quitting process. Although these studies are still being conducted,
they show promise for helping clinicians to refine their treatments to give
patients their own personal best chance for success.

As smoking-cessation treatments become more sophisticated and the
options for treatment multiply, it becomes more and more valuable to
seek professional consultation about quitting. The best first step to quitting
is to get a referral from a physician, psychologist, or pharmacist to an
established smoking-cessation program. Sometimes these are run in hospitals
or clinics, but they may also be operated as part of a community
mental health clinic or by a private practitioner. In any case, the people in
charge of the program should be trained professionals prepared to discuss
the various options in detail.

The bad news is that although most of these programs can help people
quit for a brief time, many people return to smoking within six months. It
appears that programs that use multiple approaches (such as nicotine
replacement and/or other drug therapies, behavior training, and hypnosis)
have a somewhat better record of keeping people off cigarettes longer
than single-method programs do. Still, many people in multiple-approach
programs return to smoking within a year. Why is this the case? We’re
not sure, but it probably has to do with how much behavioral habit the act
of smoking involves, and how many places, people, and things out in the
real world the smoker has associated with the act of smoking over the years.
The very uncomfortable cravings for nicotine diminish rapidly within days of
quitting, and nicotine gum or skin patches can help during this time. The first
few days are clearly the worst, but most people report that by about two weeks
the cravings are mostly gone. What remain are all the cues that used to be
associated with smoking—the morning cup of coffee, the evening beer, the talk
with a friend on a break at work (the list can go on and on).  These are powerful
stimuli that can exert considerable control over behavior. Many people will report
that they felt well on their way to really kicking the habit when an old friend with
whom they used to smoke came back for a visit, or that they went back to a bar
where they used to smoke and drink and have fun, and before they knew it, the
cigarette was back in their hand. A smoking-cessation program must anticipate
these situations and provide strategies for dealing with them. It’s a valuable help
to schedule follow-up sessions to talk such things over, learn strategies, and
get support. This can be particularly helpful because it has been shown
that stressful conditions can lead to relapse as well.

Before leaving the topic of the behavioral and environmental cues that
perpetuate smoking and challenge those who try to quit, it’s important to
discuss e-cigarettes, which were initially developed as an aid for people
trying to quit smoking. As we mentioned, these are devices that deliver
nicotine to the lungs without burning tobacco. In fact, they contain no
tobacco at all. They look like cigarettes, right down to the red LED that
turns on and looks like a glowing cigarette ember when the user draws air
into it (although at least one brand comes in a slick-looking black color
with a blue LED). A sensor turns the device on when a drop in internal
pressure is created by the user taking a drag. Powered by a rechargeable
battery, an atomizer converts liquid nicotine (mixed with other chemicals
and flavorings) into a warm mist, allowing it to be drawn into the lungs.
The user then exhales a mist that looks a lot like smoke but is odorless.
Clearly, e-cigarettes allow the smoker to engage in most of the behavioral
aspects of smoking and may thereby turn out to be a very good quitting
aid, though their usefulness has yet to be thoroughly studied. But even if
they did not help anyone quit and just resulted in smokers switching over
to e-cigarettes, they would still have some value as a “harm reduction”
option for smokers. Essentially they amount to a nicotine delivery system
that mimics the actions associated with smoking without delivering any
known cancer-causing agents to the user. However, e-cigarettes should not
be viewed as risk-free. After all, users may remain addicted to nicotine, even
though they eliminate their exposure to carcinogens. Furthermore, the
cardiovascular stimulation that contributes to the cardiovascular disease risk
of smoking is still present. It’s analogous to switching heroin addicts to
methadone—the user may remain addicted, but to a less dangerous compound.


One final point on quitting: if at first you don’t succeed, try again.
Every person is different and every addiction is different. If trying on your
own did not work, a treatment program might. If one treatment program
did not work, a different one might. Enough types of help are available
that there is a good chance one will work for any motivated person who
wants to quit smoking.


On reporting for his first morning of smoking-cessation treatment after a required
day of abstinence, one of my patients summed up his feelings by saying, “I want to
hurt something.” As I scanned the room for sharp objects, I realized that he was in
nicotine withdrawal. Although not all smokers are so extreme (or honest) in their
feelings soon after quitting, most report powerful cravings and irritability during the
first two to three weeks after their last cigarette these are clearly symptoms of
withdrawal. As with tolerance, withdrawal from nicotine has both short- and longterm
aspects. For example, most smokers report that their first cigarette of the day is the
one that makes them feel best. This effect can be seen as the termination of a
mini-withdrawal after the overnight abstinence.


*Excerpted from Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy, Fully Revised and Updated Fourth Edition by Cynthia Kuhn, PhD, Scott Swartzwelder, PhD and Wilkie Wilson, PhD. Copyright 2014, 2008, 2003, 1998 by Cynthia Kuhn, Scott Swartzwelder and Wilkie Wilson.  With permission of the publisher, W.W. Norton & Company, Inc.  All rights reserved


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