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Let’s Quit Smoking
The New Year Resolution

December 30, 2003

By Louis Wittig : eCureMe Staff Writer
December 26th, 2003 : Physician Reviewed


Sue knew she wasn’t getting any younger. She had lit up her first cigarette when she was 14, in her friend’s garage. "It was bad, taboo," she remembers, "I didn’t think I’d actually become a smoker." By 17 she was buying her own. Throughout her twenties she was smoking a pack of Malboro 100s every day. In her early thirties, she started waking up with a sore chest after nights of heavy smoking. It was different than when she started; years ago every place she went had a smoking section. Now, new state laws were making it difficult for her to light up anywhere. Her doctors told her she had to. It all came together when she was 35. Sue decided to quit smoking. It’s a decision made millions of times each month. It’s not as often seen through. It takes the average smoker between five and seven tries to stop smoking. Still, more are trying and more are succeeding. The number of Americans who have quit smoking has been slowly and steadily growing for the last forty years. Along with more quitters have come more ways of quitting.



Cold Turkey

Sudden cessation - better known as ’going cold turkey’ - is the preferred route of the majority of smokers trying to quit, according to the Food and Drug Administration.

It’s the cheapest option on the market, and the most flexible. There are no books, tapes or pills to buy and no rigid plans to get caught in. Cold turkey relies entirely on the will and self-knowledge of the quitter. However, what little research there is suggests that, however admirable, these may not be enough. Less than 10% of smokers who try cold turkey have long-term success with it.

The decision to try and succeed, cold turkey style, is one that depends heavily on how much confidence a quitter has in their ability to resist temptation. Sue never gave it really serious thought. "I’d never even try," she says almost bashfully, "I have really weak will power."



Therapy

Nicotine may keep smokers physically hooked, but the addiction is just as much a psychological one, an accumulation of habits, learned behaviors and social responses. When some smokers insist they only smoke when they go out to drink or after they have a cup of coffee, they’re admitting that their smoking is as much related to their habits as it is to nicotine.

Smoking went with almost everything Sue did. She became accustomed to smoking after she ate, when she drank, when she went out with her friends and when she met with her smoking co-workers. Deciding to quit meant that Sue had to change the way she behaved in almost every workplace and social setting.

Changing behavior is the focus of smoking cessation therapy - an intensive option that few quitters use. It focuses on helping smokers who want to quit formulate and stick to plans, increase their motivation and help them cope with the temptation to light up. Like most psychological services, smoking cessation therapy can come in many forms. One-on-one counseling is offered by many psychologists and psychiatrists, but most who do bill at their usual rates: usually $50 an hour and up. Many community organizations run local group sessions that brings together a number of smokers to help support each other’s efforts. These are often offered at a lower cost (to find out where these resources are in your community, contact the American Cancer Society at 1-800-ACS-2345 and ask for the number of their smoking Quitline in your state) but not everyone is comfortable with the approach.

Sue, for one, couldn’t see her way past the stigma of therapy. If she did make an appointment, she says, "my friends might think I was a freak or something."



eQuitting

Sue’s feeling is what keeps Dr. Steven Goldband in business. Goldband, a clinical psychologist, runs Smoke Clinic (www.smokeclinic.com) an Internet based company that offers online behavioral counseling. " A fair number of people aren’t inclined to talk to a counselor, " says Goldbrand, of his clients "they like the anonymity."

Smoke Clinic’s strategy is to keep their clients away from the types of behaviors that trigger smoking; essentially mirroring, in an online environment, the mechanisms smoking cessation clinics have been using for years. For $50, clients receive daily, structured lessons for just over a month. The Clinic records their individual trigger behaviors, helps them devise coping mechanisms and advises clients on putting together an action plan. After clients have smoked their last cigarette, they keep in routine contact with the Clinic, filling out questionnaires that let the site monitor their withdrawal symptoms and suggest further coping mechanisms.

According to Goldband’s research, 38% of those who sign up with Smoke Clinic finish the program tobacco-free: a number comparable to what face-to-face behavioral therapy delivers.
Building on this success, Dr. Goldbrand expects Internet quitting programs to grow into the future. Already Smoke Clinic is competing against sites like www.quitnet.org and the American Lung Association’s Freedom From Smoking Online site (at www.lungusa.org/ffs).

The site’s hallmark behavioral approaches are only half the equation for some clients though. "We absolutely believe that pharmacological methods are complementary to behavioral ones," says Goldbrand. By pharmacological methods, he means nicotine replacement.



Patches, Gums and Nasal Sprays

The premise is simple, but the details can get fuzzy. Up to 90% of smokers say that the only reason they haven’t already given up already are the irritating withdrawal symptoms. Withdrawal symptoms - nervousness, insomnia, exhaustion and a host of others - are caused by a lack of nicotine. Figure out a way to keep providing smokers with nicotine while they quit, the withdrawal will go smoother and more people will kick the habit.

But exactly how? Since the FDA first approved nicotine gum in 1984, the market has been flooded with ways to get nicotine in the bloodstream: nicotine patches, inhalers, prescription drugs, nasal sprays, lozenges and even nicotine lollipops and lip balms.

Sue finally settled on the patch after running into a friend of hers who was on it. It was a fit for the part of her personality that couldn’t see a therapist. "Admitting I have a problem is something I don’t like to do, with the patch, no one has to know."

The patch, the most popular choice among quitters using nicotine replacement, works by delivering a measured dosage of nicotine through the skin and into the bloodstream. Patches are designed to be switched daily and come in 16- and 24-hour dosages; the first supplies nicotine for most of the day and the second supplies it around the clock. Sue started out with the 16-hour, but found that she still woke up craving a cigarette and switched to the 24.

After month and a half of wearing one, she hasn’t noticed any side effect. But depending on the strength (patches come in various strengths, to accommodate smokers with various tolerances) brand and length of use, side effects can include skin irritation, dizziness, sleep problems and nausea, among others. Despite the fact that over 17% of patch users succeed with it, Sue still has cravings sometimes.

Used correctly, nicotine gum can tackle those cravings. Where the patch delivers slow and steady nicotine, gum delivers a fast-acting punch. Designed so that the nicotine quickly penetrates the mucous membranes of the mouth, the gum also allows for more user control than the patch. Delivered one piece at a time, quitters can cut down on their dosage as feels appropriate.

Nicotine gum’s strengths are also its weaknesses. Fast acting and scalable, the craving relief it offers can disappear just as quickly as it arrives. Sue tried a couple pieces before she started on the patch, but wasn’t impressed. "Once you chew it and get rid of it, the urge comes back." Additionally, studies have found that 15% to 20% of quitters who use the gum end up addicted, still chewing it long after they’ve quit smoking.

Some quitters use both; patches to keep them on an even keel throughout the day and occasionally popping a couple pieces of gum when their cravings become acute. Initial research has held out promise for this hybrid method, but it has yet to be approved by the FDA.

Fewer than 1% of quitters use the nasal sprays and lozenges. Nicotine lollipops and lip balms, sold occasionally in pharmacies across the country, were pulled from shelves in 2002 because they contained an unapproved ingredient. Zyban, a prescription antidepressant drug, affects the chemicals in the brain related to nicotine withdrawal - thus easing withdrawal symptoms - has been shown to be effectively, but is also comparatively rare.



The One?

The patch has been working for her, but Sue still hasn’t completely quit smoking. Though she’s been wearing the small white circle on her arm for more than a month, she still allows herself a cigarette or two a day. She thinks it will be a while until she has complete gone off them. "Right now, I’m thinking day-to-day," she says, "it might take a year."

No strong evidence that would clearly indicate which method of quitting is the most effective yet exists. As new products continue to roll off the line, weary smokers will have even more to contemplate. While there might not be any one "right" way to quit, there’s also no wrong way. With the amount that’s at stake, the only way to really fail is to not try at all.




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