Articles & ProceduresOffice LocationsPatient InformationHospital AffilliationsPrivacy PolicyFormsServicesJobs

Smoking Cessation

Introduction

Of all the hazardous activities that people participate in, cigarette smoking is one of the worst. Most people start smoking young, as teenagers or in their early twenties. As smoke enters the blood stream through the lungs, the nicotine from the cigarettes stimulates receptors in the brain. This results in a physical addiction that is felt to be at least as strong as what one sees with heroine or cocaine. While a nicotine addiction occurs, substances within cigarette smoke such as tars, are carcinogenic (cause lung cancer), are destructive to lung function (cause emphysema), and promote hardening of the arteries (atherosclerosis) which leads to heart attacks.

It is estimated that approximately 5 million deaths worldwide are caused by cigarette smoking. This number includes 400,000 deaths in the United States alone. In addition to this, exposure to second hand smoke is felt to cause 40,000 deaths each year from heart disease.

Most people who smoke are well aware of the risk of heart and lung disease they subject themselves to by continuing this practice. Many smokers have actually tried to quit, sometimes several times in the past. However, overcoming the addiction to nicotine is difficult. Withdrawal symptoms can include difficulty sleeping, irritability, frustration, anger, anxiety, difficulty concentrating and restlessness.

Despite the large barriers to quitting cigarette smoking, help is available. Your doctor can provide help by using several different drugs which all help break the nicotine addiction which makes this process so difficult. Our staff will also work with you to implement techniques to modify your behavior. These techniques will train you to avoid situations that encourage continued cigarette smoking and make it very difficult to stay quit. Finally, you will be given hot line numbers to call that provide support to you while you go through the quitting process.

Let’s begin.

Behavioral Approaches

Because nicotine is such a powerful psychoactive drug that causes physical dependence and tolerance, a typical withdrawal syndrome occurs when one tries to quit. The smoker becomes conditioned to smoking with activities such as drinking their morning coffee, finishing a meal or while drinking alcohol.

Based on this difficulty, it has been shown that the smoker has to be prepared psychologically for the task of quitting and staying quit. ( See http://www2.pmusa.com/en/quitassist/quitting/index.asp )
One can expect that the symptoms of withdrawal when one stops smoking will peak within the first 3 days. They generally will improve over the next three to four weeks. However, during this period of time cravings for cigarettes can be intense and sometimes persist for months. It can be expected that these times commonly result in relapse. It is also well recognized that smoking cessation can result in depression. This can be significant enough to cause one to start smoking again. Another problem is weight gain. A weight gain of two to five pounds in the first two weeks is common, and is frequently followed by a gain of four to seven pounds over the next four to five months. (See http://www.uptodate.com/patients/content/topic.do?topicKey=~zbQz5uZ7uWwMb&selectedTitle=2~18&source=search_result)

Based on these challenges, it is very important to prepare psychologically to quit. One should not resolve to quit on New Year’s Eve and stop smoking cold turkey on New Year’s Day. Instead, it is helpful to set a quit date. Ideally, this would be sometime within the next few weeks. However, other options include waiting for a special date. These include birthdays, anniversaries, or the Great American Smokeout (See http://www.anti-smoking.org/patrick.htm?gclid=CJv_oMba4p8CFUcL2godiVXBGQ).

It will help to ask for the support of family, friends and coworkers. One should make plans to avoid smoking in places where a lot of time is spent such as in the car or at home. It’s important to review in one’s mind the successes and failures that were experienced with previous quit attempts. Try to embrace previous pitfalls and to attempt to avoid these in your current plan. If you smoke during breaks at work, plan your quit date during a vacation.

Give thought to developing new skill sets. One thing to consider is getting involved in an exercise program. As one gets more involved with exercise the improvement in one’s sense of well being becomes re-enforcing. It can also help reduce the weight gain that happens frequently with quitting.

Try to identify situations in your life that provoke stress. Make plans to avoid these types of encounters wherever possible. It may help to learn relaxation techniques. (See http://www.mayoclinic.com/health/relaxation-technique/sr00007)

Learn to deal with the cravings that will inevitably occur during the quitting process. Avoiding alcohol during these periods of time can be helpful. Have oral substitutes available such as sugarless gum, carrots, or sunflower seeds for when the cravings occur.

Self help is an important concept for the person who is attempting this difficult task. There are multiple materials such as pamphlets, booklets, videos, audiotapes, counselors, telephone hotlines, the internet and support groups that one can take advantage of. (See http://www.helpguide.org/mental/quit_smoking_cessation.htm)

Drug Therapy

There are currently three classes of drugs that are used to relieve the symptoms of nicotine withdrawal. These agents lessen the rewarding feelings one obtains when smoking. The rationale behind the use of these drugs is that it makes it easier for the smoker to stop the habitual use of cigarettes.

The following are different drug classes that have been used for smoking cessation:

Pharmacotherapy for smoking cessation


 

Advantages

Disadvantages

Dosing schedule

Non-nicotine based therapy

Bupropion HCl

Non-nicotine.
May be used in combination with patch for greater efficacy.
Provides therapy forco-morbid depression (anti-smoking effect independent of this).

Use relatively contraindicated in smokers with a history of seizures, head trauma, heavy alcohol abuse, or anorexia.
Multiple drug-drug interactions, esp. with anti-HIV meds.

300 mg/day (in 2 divided doses to minimize side effects).
Start two weeks prior to anticipated quit date and continue for 7 to 12 weeks
Optimal duration of treatment not well defined.

Varenicline

Non-nicotine

Not assessed in combination with other medications

One 0.5 mg tablet daily for three days, one 0.5 mg tablet twice daily for the next four days, one 1 mg tablet twice daily starting at day seven.

Nicotine replacement

Nicotine polacrilex (gum or lozenge)

Accessible over-the-counter. May satisfy oral behavior.

Low nicotine levels. Requires multiple dosing, thus, compliance may be affected.

Start on quit date <25 cigarettes/day use: 2 mg tab.
[Greater than or equal to]25 cigarettes/day use: 4 mgtab.
1 to 2 tab/hour for 6 weeks, taper over 6 weeks.

Nicotine patch

Easy dosing (QD) may improve compliance Over-the-counter.

Local skin irritation in up to 50 percent of users.
Insomnia with 24-hour dosing.
Requires 30 to 60 minutes for maximum effect.

Precaution: pregnant women (Category D), smokers with recent MI (within four weeks), or serious arrhythmia.
Nicoderm CQ: 21 mg/day for 6 weeks, then 14 mg/day for 2 weeks,then 7 mg/day for 2 weeks (may be used for either 24 or 16 hours toavoid insomnia).
Nicotrol: Use single dose patch for 16 hours/day for 6 weeks (no tapering recommended).

Nicotine nasal spray

Higher/quicker nicotine levels.

Initial adverse effects (nasal and throat irritation,sneezing, rhinorrhea, coughing, and eye irritation) may discourage users before tolerance occurs.

1 to 2 doses per hour for 3 months.
Most patients require from 7 to 40 sprays over 24 hours.

Nicotine inhaler

Substitutes for behavioral aspects of smoking.

Low nicotine levels similar to those achieved with gum.

10 mg cartriges used over 20 minutes.
Six to 16 cartriges per day.

Nicotine Replacement Therapy

When one stops smoking, typical withdrawal symptoms such as depression, insomnia, irritability, frustration, anger, anxiety, reduced attention span, restlessness and nicotine craving can occur. The purpose of nicotine replacement is to provide some stimulation of nicotine receptors in the brain so as to decrease withdrawal symptoms during the quitting process.

There are several types of nicotine replacement drugs as outlined above. These all have individual advantages and disadvantage. Of note, use of some combination of these agents is possible, thus providing help with the symptoms of withdrawal over a prolonged period of time.

For example, it is common to start with use of the nicotine patches. (See http://www.nicodermcq.com/) The advantage of patches is that nicotine is delivered to the blood stream at a steady rate and over a prolonged period of time. The amount of nicotine delivered to brain receptors is only a fraction of the dose obtained with smoking a cigarette. However, the amount of nicotine from the patch may be enough to decrease the intensity of the withdrawal symptoms that occurs when one is trying to quit.

The patch has the disadvantage of getting into the blood stream and site of action slowly. This can take up to 2 hours. Also, the patch alone many times does not deliver enough nicotine to the brain to deal with periodic cravings that occur when the smoker is attempting to quit. It is for this reason that nicotine gum or lozenges can be of great help in getting through instances of intense cravings.

The patch is applied to a non-hairy skin site. It can remain in place for 24 hours. However, may people prefer to remove it at night as it can cause insomnia and vivid dreams. The patch is placed on the skin on the first day of quitting. A different skin site is chosen daily to avoid skin irritation.

Many smokers are able to quit after 8 weeks of therapy, although this is quite variable. For most people, the starting dose is 21 mg/day for four to six weeks. The dose is then decreased to 14 mg/day for two to four weeks, and eventually to 7 mg/day for an addition two to four weeks. The exception to this would be for someone who weighs less than 100 lbs. or smokes less that one-half pack per day. They can begin use of the patch at the 14 mg/day strength.

Nicotine gum can be used alone as a strategy for quitting. However, many smokers find the use of the gum in combination with the patch to be more effective. (See http://www.aafp.org/afp/2001/0601/p2251.html) For the gum to be effective and to avoid side effects, it is important to use it properly. When one chews the gum, nicotine is absorbed through the lining of the mouth with peak nicotine levels in the blood seen in 20 minutes. However, if the gum is chewed too fast, only a fraction of it will be absorbed which will result in swallowing the nicotine. This can cause stomach irritation. Also, less nicotine will be available to reach the blood stream thus rendering the gum less effective.

The most effective way to use the gum is with the “chew and park” technique. This is done by chewing until a nicotine taste occurs. The gum is then “parked” on the lining of the mouth until the taste disappears. The gum is then chewed again until the nicotine taste reappears. The process is then repeated for a total of 30 minutes. The gum is then discarded.

Nicotine gum comes in two doses. The four mg dose is appropriate for those smoking twenty five or more cigarettes daily. Two mg gum might be better for lighter smokers, or possibly when it is used in combination with the patches.

When considering a combination of nicotine replacement therapy, think of the patch as providing a constant low level of nicotine. The gum is then used as needed for cigarette cravings.

Bupropion SR

Bupropion is an antidepressant drug that can be effective in smoking cessation. It also goes be the brand names of Zyban or Wellbutrin SR. When bupropion SR is used alone, it results in quit rates that are increased by a factor of two.

The starting dose is 150 mg daily for 3 days. The dose is then increased to 150 mg twice daily. A quit date is set for having been on the drug for two weeks. The bupropion SR is then continued for seven to twelve weeks. I f a smoker is successful at quitting, the drug can be continued for up to six months to prevent a relapse. Of note, there are some smokers who cannot tolerate the twice daily dosing of this drug. In those people there is evidence that 150 mg once daily can still be effective, and with fewer side effects.

Bupropion SR can be combined with nicotine replacement therapy. Using these two classes of drugs together may be more effective than using Bupropion SR alone. The combination also appears to minimize the weight gain that occurs with smoking cessation.

This drug is generally well tolerated. The most common side effects are insomnia, agitation, dry mouth and headache. Bupropion SR should generally be avoided in those with seizure disorders, head trauma, anorexia nervosa, bulimia or heavy alcohol drinkers. (See http://quitsmoking.about.com/od/zybanwellbutrin/Bupropion_as_a_Quit_Aid_Zyban_Wellbutrin_.htm)

Chantix

Chantix is the trade name for Varenicline. This drug has a unique mechanism of action. It binds partially to the nicotine receptors in the brain and stimulates them. When these receptors are blocked, they are not available to be stimulated by the nicotine from cigarettes. By partially stimulating these nicotine receptors, the rewarding aspects of cigarette smoke are blocked, thus decreasing withdrawal symptoms and cigarette cravings.

Chantix has been the subject of several well done studies, and has been found to be effective in achieving smoking cessation. Compared with placebo (sugar pill), the odds of were increase by a factor of three. Chantix was found to be superior to buproprion SR in three clinical trials including one large study with 2052 patients. Chantix was also found to be superior to the patch in another study with 757 smokers.

The proper way to take Chantix is after eating with a full glass of water. A starter pack is used that gives a dose of 0.5 mg daily for three days. The dose is then increased to 0.5 mg twice daily for the next four days. The starter pack is then replaced with a full prescription for 1 mg twice daily.

The patient is instructed to try to quit smoking one week after starting Chantix. It is continued for twelve weeks at which time an assessment is made as to whether or not it is working. In many instances, continuing it for an additional three months is of benefit to prevent relapse.

Of note, Chantix is currently being studied in trials using combinations with nicotine replacement therapy and buproprion SR. Early studies suggest that the combination of Chantix with buproprion may be safe and effective.  

If use of Chantix is not successful after six months one can try continuing the drug while trying harder with behavioral modifications. Alternatively, selection of a different treatment may be appropriate.

The main side effects that can occur from Chantix include nausea and abnormal and vivid dreams. Of more concern are reports that came out in 2007 that there were instances of some patients experiencing suicidal thoughts and aggressive behavior while on the drug.

It is notable that smokers themselves are at risk for suicidal behavior. When one tries to quit smoking symptoms such as depression, anxiety, anger, irritability and difficulty concentrating can occur, even when Chantix is not being used. In other words, it is not clear if these symptoms can be attributed to the drug or smoking cessation alone. It is for this reason that in patients with a psychiatric history this drug should be used with caution. They should have careful follow up with their health care provider. (See http://www.chantix.com/about-chantix.aspx?chtxsrc=CHW10019334&source=google&HBX_PK=s_chantix&HBX_OU=50&o=23119569|166373525|0).

Support While Quitting

For many people, quitting smoking will be the most difficult thing they have ever have tried to do. Because of this, support while quitting can be extremely valuable.

The first thing to realize before one starts the quitting process is that smoking cessation is a relapsing condition. Most relapses occur in the first week of quitting. This is because withdrawal symptoms are at their peak during this time period. With this in mind, it is important to mobilize all available support resources.

Try to make your family and friends aware that you will be quitting and ask for them to help you during this difficult time. It may help to think of how much money you are saving by not smoking. In fact, consider using the money you would ordinarily spend on cigarettes to treat yourself to something you would enjoy such as a movie, dinner at a restaurant, a new outfit, etc.

In order to help prevent a relapse during the quitting process, numerous counseling services are now available to help you. These include in-person counseling, telephone counseling, computer programs and clinician counseling. The basis for all these techniques is the provision of support while quitting that is both frequent and available.

In- person counseling may consist of multiple visits. These may have to occur weekly and can continue for one to two months. Contact with a clinician allows delivery of both brief counseling and advice that improves quitting rates.

Telephone counseling is potentially a valuable resource due to its ready accessibility. These can take the form of telephone calls by a counselor to a smoker on a scheduled basis. Alternatively, numerous quit lines have now been established. When a person has quit smoking and is experiencing a significant urge to smoke, he can call one of these numbers for support.
(See http://www.health.state.ny.us/prevention/tobacco_control/quitline.htm)
(See http://bc.quitnet.com/)
(See http://www.chantix.com/about-chantix.aspx?chtxsrc=CHW10019334&source=google&HBX_PK=s_chantix&HBX_OU=50&o=23119569|166373525|0) This is the Chantix website. A telephone line is available from 8:00 AM to midnight 7 days a week: 1-877-242-6849.

Mark A. Rothschild, MD, FACC