"Habit is habit, and not to be flung out of the window by any man, but coaxed downstairs a step at a time."
Even in the face of withdrawal symptoms that can challenge the strongest of wills, millions of Americans have conquered their smoking "habit," step by step. According to the U.S. government's Agency for Health Care Policy and Research (AHCPR), for every one of the 46 million American smokers, there is an ex-smoker who has successfully quit.
True, it's not easy. The nicotine in cigarettes can command both a physical and mental hold that can be tough to overcome. For some, nicotine is as addictive as heroin or cocaine, according to AHCPR.
"There's no question about it; sometimes when you're trying to give up cigarettes, you think 'I've got to have one,'" says Denis Brissette of Madison, Wis., who smoked about three packs a day for 30 years before quitting four years ago.
For many smokers who want to quit, willpower alone isn't enough to beat the yearning. For them, smoking cessation products the Food and Drug Administration has approved may reduce the cravings and other withdrawal symptoms. To help him quit, Brissette used the nicotine patch, which is now available over-the-counter along with nicotine gum. Other stop-smoking aids, available only by prescription, include nicotine nasal spray and the nicotine inhaler, as well as a stop-smoking product in pill form.
While these products can ease the symptoms resulting from the physical addiction to nicotine, group or individual counseling and encouragement from family and friends are critical to help address the mental dependence.
"You really have to be committed to quitting," says Celia Jaffe Winchell, M.D., a psychiatrist and FDA's medical team leader for addiction drug products, "and when you've made the decision to stop smoking, commit to using whatever it takes to quit."
Imagine: Two jumbo jets crash every day and not a single person walks away alive. That, then-Surgeon General C. Everett Coop told Americans in 1989, is the number of people who die each day from smoking.
Cigarettes alone kill more than 400,000 Americans each year--more than AIDS, alcohol, car accidents, murders, suicides, illegal drugs, and fires combined. And smoking can harm not just the smoker, according to the Environmental Protection Agency and other experts, but also family members and others who breathe "secondhand smoke."
Given that cigarettes are known killers, why do so many Americans continue to smoke?
Seventy percent of adult smokers want to quit completely, according to a survey by the national Centers for Disease Control and Prevention. But the nicotine in cigarettes is an addictive drug that makes quitting difficult, as confirmed by the 1988 Surgeon General's report on smoking and health.
"There is little doubt," wrote smoking researcher M.A.H. Russell in 1974, "that if it were not for the nicotine in tobacco smoke, people would be little more inclined to smoke than they are to blow bubbles or light sparklers."
As with other addictive drugs, people can experience withdrawal when they get less nicotine than they are used to. Symptoms can include irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, and craving for tobacco.
One reason cigarettes in particular are so addictive, Winchell says, is that a person gets a "very rapid and effective dose" of nicotine by inhaling the smoke. Within seconds of inhaling a cigarette, nicotine enters the lungs and then travels directly to the brain.
Tobacco use "is not just some bad habit, but a powerful addiction that warrants appropriate medical treatment," says Michael Fiore, M.D., director of the Center for Tobacco Research and Intervention at the University of Wisconsin Medical School.
As a rule, Fiore says, people who smoke more than 10 cigarettes a day and want to quit should use an FDA-approved smoking cessation product.
Most medical aids to smoking cessation are nicotine replacement products. They deliver small, steady doses of nicotine into the body to relieve some of the withdrawal symptoms, without the "buzz" that keeps smokers hooked.
Nicotine replacement products are available in four forms: patches, gum, nasal spray, and inhaler. Like cigarettes, the products deliver nicotine into the blood, but they don't contain the tar and carbon monoxide that are largely responsible for cigarettes' dangerous health consequences.
Studies show that the nicotine replacement therapies as much as double the chances of quitting smoking. Smokers should choose the method that appeals to them and try a different method if the first one doesn't work.
"It's an individual decision," Winchell says. "You really can't say that one of these products works better than another." (See "Which Nicotine Replacement Product Appeals to You?")
Like the nicotine substitution products, the newest option--an anti-smoking pill--seems to reduce nicotine withdrawal symptoms and the urge to smoke. But Zyban (bupropion hydrochloride), approved by FDA in May 1997, has one thing that sets it apart. It contains no nicotine.
"We don't know exactly how Zyban works," Winchell says, "but it seems to have an effect on the chemicals in the brain associated with nicotine addiction."
Bupropion was previously approved as a prescription antidepressant under the brand name Wellbutrin. In studies of the drug for smoking cessation, there were no noticeable changes in people's moods. "Antidepressants make depressed people feel normal; they don't make non-depressed people feel happier," Winchell says. "The people who entered the trials weren't depressed, and the drug didn't make them euphoric."
Some common side effects from Zyban are dry mouth, difficulty sleeping, shakiness, and skin rash. As many as 3 in 1,000 people taking Zyban may have an allergic reaction--such as itching, rash and hives--severe enough to require medical attention.
About 1 out of every 1,000 people may have a seizure, which may involve convulsions and loss of consciousness. People should not use Zyban if they have a pre-existing seizure condition such as epilepsy or an eating disorder such as anorexia nervosa or bulimia, or if they are taking other medicines containing Zyban's active ingredient, bupropion hydrochloride. These circumstances can increase the chance of a seizure.
Zyban is not recommended for women who are pregnant or breast-feeding.
While it can be used with a nicotine substitution product, the supervising doctor should monitor the Zyban user closely for a possible rise in blood pressure. It is not physically dangerous to smoke while using Zyban, but continuing to smoke after deciding to stop significantly reduces the chance of successfully quitting.
Despite the availability of Zyban and the other medical aids for smoking cessation, Winchell says, "If someone is serious about quitting, the drugs alone won't do it. They must have some kind of support, whether it's from a formal stop-smoking program or at least informal support from their friends and family."
This, Winchell explains, is because nicotine addiction isn't all physical. Smokers come to enjoy the smoking behavior and are used to lighting up in certain situations. "A smoker's whole day," Winchell says, "is filled with cues that could trigger the desire for a cigarette: the first cup of coffee in the morning, sitting down to check the e-mail, opening the paper, finishing a meal."
Before quitting, a person should change his or her environment. A good way to start, according to AHCPR, is by getting rid of cigarettes and ashtrays in the home, car, and workplace.
Setting a quit date, and sticking to it, is another important step toward successfully giving up cigarettes. A good date might the day of the annual "Great American Smokeout." Each year, millions of Americans participate in the American Cancer Society event, which is designed to encourage people to give up the deadly pastime for at least a day.
Because being around smokers, being under stress, and drinking alcohol are some of the most common smoking triggers, AHCPR recommends that people avoid such difficult situations whenever possible while trying to quit.
As a distraction from thoughts of smoking, the agency says, taking time for a fun activity may help. Exercising may be an especially useful distraction. And exercising, along with eating healthier, low-fat foods, can minimize the weight gain (not more than 10 pounds on average) that sometimes goes along with quitting smoking.
Quit-smoking programs, self-help materials, and hot lines are available throughout the United States. (See "Help When You're Ready to Quit.")
Also, family, friends, or a health-care provider can offer encouragement and support when the going gets tough. "The buddy system helped me," Brissette says. "My mother-in-law quit at the same time I did. We supported each other through it."
Some people have found hypnosis and acupuncture helpful in quitting, but these methods have not been proven to work.
Cigars and smokeless tobacco should not be viewed as safe alternatives to cigarettes. They, too, can be addictive and can cause serious health effects such as cancer and heart problems.
Not Even a Puff
Regardless of the method you decide to try, Fiore says, "hang in there." Most people who abstain from smoking for three months can be cigarette-free for the rest of their lives, he says.
Your risk of heart disease and lung cancer drop steadily after you quit. Three years after quitting, your risk of dying from a heart attack is about the same as if you had never smoked, according to the American Heart Association. And the American Lung Association estimates that in 10 years, the risk of lung cancer declines to about 30 to 50 percent of a continuing smoker's risk.
So when you try to quit, keep the rewarding health benefits in mind. Don't be discouraged if the first quit attempt doesn't succeed, because experts say it usually takes two or three tries. Think about what seemed to help during past quit attempts and what didn't, and each try will carry a better chance of success.
But even after you've abstained for a while, cautions Fiore, don't be lulled into letting your guard down. Because the nature of nicotine addiction makes it impossible for most people to be occasional smokers, "you need to treat cigarettes the way an alcoholic treats booze," he says. "Don't take even a single puff."
Which Nicotine Replacement Product Appeals to You?
Although they have nicotine in common, the four nicotine replacement products have some important differences.
Known generically as the nicotine transdermal system, this method has been available in the United States by prescription since 1992 and over-the-counter since July 1996. It is sold under the brand names Nicoderm, Nicotrol, Habitrol, and Prostep.
Each day, a new patch that looks like a big bandage is applied to a different area of dry, clean, non-hairy skin and left on for the amount of time recommended in the product's labeling.
A mild itching, burning or tingling at the site of the patch when it is first applied is normal, but should go away within about an hour. After removing the patch, the skin might be red for up to a day. If the skin develops a rash or becomes swollen or very red, a doctor should be consulted.
The patch may not be a good choice for those with skin problems or allergies to adhesive tape.
FDA approved Nicorette gum (nicotine polacrilex) for prescription sale in 1984, and began allowing its sale without a prescription in February 1996.
Chewing Nicorette releases nicotine into the bloodstream through the lining of the mouth. Unlike gum chewed for pleasure, Nicorette requires a measured routine--it is chewed slowly until a slight tingling occurs or a peppery taste comes out, then placed between the cheek and gum until the taste or tingling is almost gone. The cycle is repeated for about 30 minutes per piece.
Most people find that chewing 9 to 12 pieces a day controls their urge to smoke, but the maximum number of pieces that can be safely chewed in a day is between 20 and 30, depending on the type of Nicorette.
Chewing nicotine gum may not be the right choice for those with temporomandibular joint disease (TMJ) or for those with dentures or other vulnerable dental work.
FDA approved the Nicotrol nicotine inhalation system for smoking cessation in May 1997.
The nicotine enters the user's mouth through a mouthpiece attached to a plastic cartridge. Although the product is called an "inhaler," it does not deliver nicotine to the lungs the way a cigarette does. Almost all of the nicotine travels only as far as the mouth and throat, where it is absorbed through the mucous membranes.
Side effects from the inhaler can include cough or throat irritation. Anyone with a bronchospastic disease such as asthma should use it with caution.
Nicotine Nasal Spray
FDA approved Nicotrol-brand nicotine nasal spray in March 1996, for sale by prescription only.
The nicotine is inhaled into the person's nose from a pump bottle and absorbed through the nasal lining into the bloodstream.
Nasal and sinus irritation is a common side effect of the nicotine nasal spray. While most people can tolerate the irritation, the spray is not recommended for people with nasal or sinus conditions, allergies, or asthma.
Generally, people should not use the nasal spray for longer than six months. The manufacturer is continuing to gather data on use of the nasal spray to ensure that neither smokers nor nonsmokers are abusing it.
If you decide you want to try one of the four nicotine replacement products, you need to remember the following:
- Keep nicotine replacement products, including those that have been used and thrown away, out of reach of children and pets. Even very small amounts of nicotine can cause them serious illness.
- Don't smoke, chew tobacco, or use snuff or other nicotine-containing products while using any of the four therapies. It is possible to get an overdose of nicotine. Signs of overdose include headaches, dizziness, upset stomach, vomiting, diarrhea, mental confusion, weakness, or fainting.
- Depending on how much you smoked, you may still experience some withdrawal symptoms, or you may feel some side effects from the nicotine, such as headache, nausea, upset stomach, dizziness, or disturbing dreams.
- Consult a doctor before beginning any nicotine replacement therapy, even one that is available over-the-counter, if you have a medical problem such as heart disease or high blood pressure.
- If you take any medications, especially drugs for asthma or depression, speak to your doctor. The dose of a medication may need to be adjusted because, with or without nicotine replacement, the body changes when one stops smoking.
- If you are pregnant or breast-feeding, speak to your doctor before trying a nicotine replacement product.
Help When You're Ready to Quit
Programs are offered by the following groups as well as many local hospitals and health centers:
Agency for Health Care Policy and Research
American Heart Association
American Cancer Society
American Lung Association
Office of Smoking and Health
Centers for Disease Control and Prevention