Helping Quitters Quit

Quitting one of the world’s most addictive substances isn’t easy, as the many smokers who have tried and failed can attest. But finding a way to stop smoking is particularly important to the health of cancer survivors: Recent studies have shown that smoking reduces survival time for all forms of cancer and can affect other aspects of healing.

Indeed, whether smoking caused the initial cancer or not, lung cancer patients who continue to smoke experience a lower quality of life compared with their peers who quit, and separate studies of smokers with lung cancer and head and neck cancers found that the habit increases the risk of developing a second primary tumor.

Smoking also aggravates side effects of cancer treatment such as dry mouth, and research shows smokers are more likely to develop infections such as pneumonia. In addition, smokers’ wounds heal more slowly.

Despite this, 20 percent of cancer survivors continue to smoke (compared with 23 percent of the general population). And among survivors who are able to quit during their cancer treatment, many relapse as soon as treatment ends.

Overall, most smokers who try to quit fail at least once, says Joy Schmitz, PhD. “Twenty to 30 percent will achieve long-term abstinence,” says Schmitz, a professor in the department of psychiatric and behavioral sciences at the University of Texas Medical Research Center. “We always tell our patients, if you try once and relapse, that’s just a sign that you need to try again. Relapse is inherent in the definition of tobacco dependence.”

quitting smoking.

Part of the reason so many smokers feel hopeless is that they’ve tried the most common quit-smoking method, going “cold turkey,” which is also widely considered the least effective method. Research shows the cold turkey approach doesn’t address a smoker’s addiction to nicotine or the psychological challenges associated with

Jed Rose, PhD, director of Duke University’s Center for Nicotine and Smoking Cessation Research, says the cold turkey approach — sudden, total abstinence — is “like climbing a mountain and not taking any rope or climbing tools. Given the statistics, it isn’t wise to invest the effort in quitting cold turkey and then fail.”

No matter how hard it is to quit, experts stress that it is possible to succeed with the help of a doctor and the right combination of individualized tactics.

Medicines are among the tools available to help a smoker who wants to quit climb that mountain. Pharmacotherapy (often prescribed for at least 12 weeks) can double the odds of smoking abstinence compared with the use of a placebo, according to an analysis by the Mayo Clinic published this spring.

Zyban, released in 1997, became the first non-nicotinic prescription medication approved by the U.S. Food and Drug Administration for tobacco dependence. Zyban was created when researchers found that the antidepressant Wellbutrin had the serendipitous side effect of helping smokers quit (Zyban, known generically as bupropion, is a modified dose of Wellbutrin).

While it’s not clear exactly how Zyban works, research has shown it partially blocks norepinephrine, serotonin and dopamine, chemicals in the brain that regulate, among other things, alertness, mood and feelings of pleasure. This blocking may help reduce cravings and alleviate some of the symptoms associated with nicotine withdrawal, as well as ultimately reduce the brain’s perception of nicotine as a “reward."

Besides helping smokers quit initially, Zyban appears to reduce or delay relapse, the Mayo Clinic analysis found. Zyban is the most commonly prescribed non-nicotinic treatment for smoking cessation because it has been shown to be effective in smokers with a high risk of relapse or with other medical ailments, and because it can be safely taken with nicotine replacement therapies, noted the analysis, contributed by Amit Sood, MD, an assistant professor of medicine at the Mayo Clinic.

Another prescription medication for nicotine dependence, released in June 2006, appears to double the odds of quitting compared with Zyban, and quadruple the odds compared with a placebo, researchers have found. The drug, Chantix (varenicline), mimics nicotine, partially stimulating nicotine receptors in the brain, a 2007 study by Canadian researchers found. This helps relieve withdrawal and cravings and prevents relapse by blocking smoking’s rewarding aspects.

Chantix might also stimulate dopamine release in the brain, making the smoker feel good about not smoking. The long-term effects of Chantix, however, are still being studied, although there is evidence that staying on the treatment prevents relapse months after quitting.

Another pharmaceutical option may one day be available — a nicotine vaccine. Such a vaccine would trap the nicotine that the body derives from cigarettes, preventing it from leaving the bloodstream and thereby blocking the effects on the brain. At least five companies are developing nicotine vaccines, according to a March 2007 article published in the Annual Review of Pharmacological Toxicology.

Nicotine replacement therapy, or NRT, the most commonly used drug treatment to help kick the habit, addresses a smoker’s addiction by administering nicotine without the other harmful chemicals present in tobacco. The smoker keeps getting the nicotine the addiction craves, reducing withdrawal symptoms.

prescription, yet the FDA recommends that a person’s doctor be contacted before he or she begins any over-the-counter NRT.

Different types of NRT deliver the nicotine slightly differently: In the gum, inhalers and lozenges, it is taken up by the saliva and absorbed through the lining of the mouth; the patch supplies nicotine through the skin; and the nasal spray delivers nicotine through the lining of the nose. The inhaler and nasal spray are available only with a

A recent study led by Duke University’s Rose, who holds several nicotine patch patents, tested the effects of NRT when used before the smoker stopped smoking. Rose found that half the smokers who started using the patch two weeks before their quit date were still smoke-free a month later, compared with 23 percent of the placebo group.

Rose says that lighting up while wearing a nicotine patch isn’t as rewarding as is usual smoking because the smoker has not been deprived of nicotine. “So they don’t get as intense a release or reward, and over several days of not getting that reward, the sensory characteristics become less appealing,” Rose says.

That lessening of the reward might make it easier for smokers to wean themselves off nicotine, Rose says, though the FDA has always discouraged using NRT while smoking, due to concerns about possible nicotine overdose.

The smokers in Rose’s study “didn’t exhibit symptoms of nicotine overdose,” he says, “but their biochemical levels of nicotine did go up about 50 percent over their baseline.” Because of the chemical change, Rose is investigating a treatment whereby smokers switch to reduced-nicotine cigarettes while they are using the patch.

Using the nicotine patch with another form of NRT could also help smokers quit, studies suggest, by maintaining a steady balance of nicotine to the body through the patch and allowing for self-dosing with a fast-acting NRT, such as nicotine gum. This sort of combination therapy has only recently been studied and is not approved by the FDA, and so should be attempted only under a doctor’s supervision.

Physical addiction to nicotine is only part of the problem when it comes to quitting smoking; other obstacles are the thoughts and behaviors that contribute to the habit of smoking. Cognitive and behavioral therapy attempts to change those thoughts — or cognitions — and the habitual behaviors that accompany them.

habitually smoke when they read the newspaper, at a bar, or when they feel stressed, the next time that mental cue occurs, they are likely to feel the urge to smoke.

Those habits are often triggered by an environmental “cue” — something the smoker has come to associate with smoking. If smokers

“The hardest things for many people to kick are the cue associations that smoking has been linked to — so many situations that it is almost a knee-jerk reflex,” Rose says. “Even though the physical withdrawal is not so bad, the cue associations are so strong it is very hard to break them.”

After a smoker has quit, those associations are often the cause of a relapse. “When somebody does quit, they should avoid those situations that would be a very strong trigger for them to smoke,” Rose advises.

A 2003 study also found that how much a person believes he or she is able to perform a task “predicts effort and persistence, especially when the behavior has implications for his or her health.” Smokers who believe they can’t quit probably won’t, concluded the study, published in Annals of Behavioral Medicine.

To counteract such expectation of failure, Schmitz, who works with smokers at the University of Texas Substance Abuse Research Center in Houston, focuses on building patients’ confidence as they try to quit. “You start with small goals; instead of going from two packs to zero, you go down half a pack,” she suggests. “Little baby steps, and focus on what has worked, and if something hasn’t worked, that means you have to try a different strategy. Focus on the positive.”

She also tells her patients to expect an occasional lapse. “Just about every smoker is going to have a slip,” she says. She encourages smokers to reframe the way they think about lapsing. “Is it so much that you are a failure? Or that this is a trigger that we didn’t plan for or a skill that we need to strengthen?”

Behaviors to address — either alone or with the help of a behavioral therapist — include setting (and sticking with) a quit date, avoiding tempting situations, and adopting alternative behaviors like sucking on hard candy. The Internet offers many resources where people can find tips to break the smoking habit.

Because smoking is a lifestyle, not just a physical addiction, breaking those patterns that promote the habit is key to success, some experts stress.

Smokers also want complementary and alternative, or CAM, therapies, according to a study conducted by the Mayo Clinic’s Sood. The study showed that a quarter of patients use alternative methods and two-thirds were interested in trying them.

That study, published December 2006 in the journal Nicotine and Tobacco Research, found that tobacco users were interested in the benefits of hypnosis, relaxation techniques, acupuncture, botanicals and meditation.

However, the effectiveness of those therapies remains in question. Hypnosis “might be useful for some people,” the American Cancer Society’s “Guide to Quitting Smoking” suggests. The guide also notes another popular therapy, acupuncture, isn’t backed by solid evidence. No CAM treatments are clearly effective, Sood says, because not enough large, thorough studies have been completed.

Whatever combination of therapies smokers choose in an effort to quit, they don’t have to go it alone. By sharing experiences and struggles, support groups can be essential tools to quit smoking.

In fact, the only problem with support groups, as Rose sees it, is “most people don’t take the time to do it. But if they do, it’s as effective as many over-the-counter medications.”

It is important to find a support group that meets your needs and that is led by someone trained in smoking cessation, experts advise. Be wary of programs that claim success is easy; studies have shown that the best programs are generally also the most intense.

Even without a traditional support group, a support network of family and friends can prove very important to a would-be former smoker.

“I see smoking cessation as landing an airplane; when you land a plane it has to be perfect, the wings have to go down, the pilots have to be focused and it needs to be a well-thought-out process,” Sood says. “When planning smoking cessation, smokers should try to surround themselves with supportive colleagues; have supportive physicians and psychologists; [and have] a family that understands that they will be a bit cranky through the process. Enough planning should go into a quit attempt; it should not be a hurried, impulsive decision.”

Experts agree that individualizing the smoker’s plan is the most important aspect of quitting. A quit-smoking plan tailored to the preferences and habits of the smoker is essential to help ensure that this quit attempt will be the last.

A person’s quit-smoking plan should be like a cafeteria, with a “menu” of options that can be blended to create the most beneficial plan for the individual, the experts suggest. No one therapy will be appropriate for everyone, they say; the best plan is to keep trying different techniques until something works.

Don’t get discouraged, Sood says. “When you shake a tree, the apples that are loosely attached fall off easily, leaving the hardier ones,” he says. “Similarly to smokers — the ones [for whom] it was easy to quit, have already.”

But the apples always eventually do fall. And in the same way, a determined smoker can quit.

Sood believes smoking is predominantly a lifestyle problem that can’t truly be corrected only with pharmaceuticals, so he advocates lifestyle solutions — including yoga, meditation, tai chi and other relaxation techniques as helpful additional therapies. Dietary supplements, he notes, have a limited role for smoking cessation. In the current state of science, “I would rather have 20 percent of Americans meditate than 20 percent of Americans taking botanicals to quit smoking,” Sood says, because a program like meditation is likely to have profound impact on overall well-being, whereas botanicals are just a “natural” variation on pharmaceuticals.

Smokers try CAM therapies because they are hoping to find that one therapy that can help them cross the line between relapsed smoker and former smoker, Sood says.

The most important thing, he notes, is to “be kind to yourself, to make yourself happy. If you are chronically stressed, you don’t sleep well, you have a difficult job, no amount of pharmacotherapy is going to fix that.”

The cold turkey approach — sudden, total abstinence —is “like climbing a mountain and not taking any rope or climbing tools. Given the statistics, it isn’t wise to invest the effort in quitting cold turkey and then fail.

I see smoking cessation as landing an airplane; when you land a plane it has to be perfect, the wings have to go down, the pilots have to be focused and it needs to be a well-thought-out process.