It's Quittin' Time
Smokers Need Not Rely on Willpower Alone
by Tamar Nordenberg
"Habit is habit, and not to be flung out of the window by any
man, but coaxed downstairs a step at a time."
--Mark Twain
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."
Killer Addiction
 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 in 1997 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.
The Options
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.
Psychological Side
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 be Nov. 19, the day of this
year's "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."
Tamar Nordenberg is a staff writer for FDA Consumer.
Which Nicotine Replacement Product
Appeals to You?
Although they have nicotine in common, the four nicotine replacement
products have some important differences.
Nicotine Patch
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 OTC under the brand names Nicoderm and Nicotrol and by
prescription under the names 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.
Nicotine Gum
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.
Nicotine Inhaler
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.
T.N.
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