Chapter 4
Nixing Nicotine

There are many benefits to quitting tobacco use, and even more to never starting. Almost 90 percent of smokers who started smoking as teenagers wished they had never begun. Even more wish they knew an effective way to quit. But it is not easy to quit permanently. In fact, author Mark Twain purportedly once said that quitting smoking was easy—he had done it hundreds of times.

There are many different resources available as well as a variety of methods to help people quit using tobacco. For instance, quitting smoking depends on the smoker. No one method works for every person because the situations that trigger their smoking are different. Even the reasons smokers want to quit can differ.

Many programs are targeted for the age or characteristics of the specific tobacco user. Some methods work well for adults but do not work as well for teenagers. Teens have very different needs than adults, and women have different needs than men. Cessation programs should be customized for the gender and age of the tobacco user. Usually, a combination of methods and approaches works better than a single method. The methods chosen, combined with a very strong desire and commitment, will help a tobacco user quit. Madeleine Armstrong, who has been a nonsmoker for fifteen years, says,

If I could quit, anyone can. There is a secret. I will share the secret with you because I feel that smoking is so detrimental to one's health and if anyone wants to quit, they can….

The secret? The secret is that you have to want to. That's all there is to it. You really, really, really, really, really have to want to! You have to manifest what you believe. You have to change your way of thinking. You have to change what you are doing. You have to change the way you feel about why you are smoking. You have to become a witness of your life.²⁹

After Quitting

Quitting tobacco can cause a number of changes in the body. Some people wonder if quitting would be of any benefit, since their bodies have already been damaged from tobacco use. However, there are a number of changes that happen immediately, and after time, some of the damage is reversed.

Twenty minutes after the last tobacco use, body temperature in extremities, the pulse, and blood pressure return to normal. After

eight hours, oxygen and carbon monoxide in the blood return to normal levels. The chance of heart attack diminishes in twenty-four hours. After two days, smell and taste start to return to normal. After three days, shortness of breath decreases and lung capacity increases. Within three months, circulation improves, lung function improves dramatically, and cholesterol levels plummet. Within nine months, energy levels increase and coughing and lung infections decrease.

After one year, the risk of coronary heart disease for former smokers is half that of smokers. Within two years, the risk of heart attack nears that of nonsmokers. After five years, stroke risk is reduced and risks of lung, mouth, throat, and esophageal cancers is half that of smokers. Lung cancer risk is near that of nonsmokers after ten years, and, after fifteen, the risk of coronary heart disease is near that of nonsmokers.

So quitting, even after long-term usage, can help former tobacco users become healthier. It is for precisely that reason that many people choose to quit.

Quitting Cold Turkey

To quit cold turkey is to stop using tobacco abruptly and with little or no preparation. Kathleen Purcell, a newspaper editor, says "My father quit 40 years ago when he fell asleep and awoke to find the chair he was sitting in was in flames. He quit cold turkey."³⁰

People have a number of explanations about the origin of the phrase cold turkey. Some say that in the state of drug withdrawal the blood is directed toward vital organs, often giving addicts goose bumps. Their skin resembles that of a cold, plucked turkey. Others attribute this phrase to the idea that cold turkey is a food that needs very little preparation.

Whatever the origin of the phrase, quitting tobacco cold turkey does not work well. Studies have shown that less than 5 percent of smokers who quit in this manner are able to remain smoke-free after a year, but smokers who have a compelling reason to quit, such as a severe illness, have more success with the method. Jodi Waxman was diagnosed with lymphangioleiomyomatosis (or LAM), a serious and often-fatal lung disease often initially misdiagnosed as asthma or emphysema. LAM affects young women of childbearing years. Abnormal muscle cells grow in the lungs, closing off the air space, and causing lung collapses and other serious complications. Many LAM patients eventually find themselves on a lung transplant list. Waxman says, "I quit smoking last February when my doctor suspected that I had LAM. I quit cold turkey because she told me that smoking limited my lung capacity more than it already was."³¹

Although quitting cold turkey can work, people often start using tobacco again. One of the most common reasons that people who quit cold turkey gave for going back to tobacco was the intense nicotine craving, an almost irresistible urge to use tobacco. These cravings, combined with withdrawal symptoms like irritability and depression, can make it more likely for former tobacco users to resume their habits. A combination of quitting cold turkey and nicotine replacement therapy (NRT) can help make the cravings more manageable and allow these people to remain tobacco free.

Nicotine Replacement Therapy and Behavior Modification

NRT usually consists of some means other than the use of tobacco to deliver nicotine to the body. Nicotine can be added to chewing gum, delivered into the bloodstream by means of a patch affixed to the skin, a nasal spray, or delivered in an inhaler similar to a cigarette. Colleen Brady, a pharmacist, said in an article for Chatelaine, a Canadian women's magazine: "Nicotine replacement therapies work by providing the brain with a controlled amount of nicotine either through the mouth or the skin. The amount of gum chewed and the strength of patch used is slowly decreased over a period of time, about three months for the gum and eight to 12 weeks for the patch."³² During all types of NRT, the amount of nicotine in the replacement product is gradually reduced until it is completely eliminated.

People using NRT are trying to minimize the effects of sudden withdrawal from nicotine. During nicotine withdrawal, studies

have shown that there are specific mental functions that are impaired. Although there is no change to complex cognitive functioning like logical reasoning, people who are withdrawing from nicotine often have problems with tasks requiring sustained attention. The patch or gum can help them gradually get used to changes in thinking processes. Furthermore, nicotine replacement can help the user focus on the behavioral and coping aspects of quitting tobacco without having to deal with the immediate problem of nicotine addiction or withdrawal.

People who want to quit smoking have to deal not only with the addictive nature of the drug but with their habits as well. Sometimes they will change their habits entirely, such as avoiding places in which they used to smoke, in order to break the habitual aspects of smoking. Smokers often want to have something in their hands, or even in their mouths, so people quitting smoking are often advised to chew cinnamon sticks or carry raw vegetables around as a substitute for cigarettes.

Being able to make decisions and be firm about them helps. Judith Stock, a freelance writer and editor, has been a nonsmoker for one year. When she quit, she took decisive action and removed all smoking-related items from her home. She says, "I just started thinking of myself as a nonsmoker as opposed to a smoker. I took all the ashtrays out of the house, tossed out the lighters. Everything that had anything to do with smoking, I tossed out. When I wanted to smoke I would take a walk around the block."³³

A combination of NRT and behavioral modification techniques can be very helpful for many adults. However, several studies have shown that NRT is not an effective treatment for adolescents. In one study, which used a combination of minimal behavior modification and NRT, smoking abstinence was only 10.9 percent at six weeks and 5 percent at six months. This is not much better than the success rate of quitting smoking cold turkey.

Those teens who used NRT and started smoking again said it was because of stressful situations in their lives or pressure from their peers. NRT helps with the cravings so the person quitting can focus on other issues, but it does not eliminate those other issues. Other techniques may be needed to address those problems.

Hypnosis

One technique used by many people to quit using tobacco is hypnosis. Some people think hypnosis is a type of hocus-pocus or a way to control someone's mind. Actually, hypnosis is a state of concentration. If someone is intensely watching a television show, he or she can be so focused on the program that the outside world seems to "go away." A hypnotized person is in the same state—a state of intense concentration.

During that state of concentration, patients can look inside themselves and find, for example, what voids tobacco is filling. If, for example, a person was using nicotine to fill a void left by an absent parent, that person could use hypnosis to help heal feelings of emptiness. Using guided imagery techniques, that person could imagine feeling loved and wanted—by a parent, by a higher power or God, or by a friend. Using that image or experience, a person can reimmerse him- or herself in that feeling of being loved at any time and use those positive feelings to help overcome nicotine cravings.

Hypnosis can help people deal with other reasons they use tobacco. It can help establish better coping techniques and can help people learn to fill other types of voids, such as not feeling accepted, appreciated, or liked at school. In addition, since hypnosis is a heightened state of concentration it can help people stop ignoring the negative physical effects of the tobacco in the body—the lightheadedness, the searing lungs. Essentially hypnosis may make someone more cognizant of the effects happening in his or her body every time nicotine is taken into the body—which can lead to a desire to stop using tobacco.

Aversion Therapy

Some people use aversion therapy to quit smoking. Aversion is avoiding a thing or a behavior because it has been associated with something disgusting, unpleasant, or painful. Aversion therapy helps people learn to associate things they wish to avoid with a feeling of disgust or physical and emotional discomfort. Because of this negative association, those using aversion therapy to quit smoking modify their behavior and avoid tobacco products.

Imagining all the terrible effects tobacco has on the body is a way of using aversion therapy to stop smoking. When smokers think back to the first time they started cigarettes, they can recall the nausea, dizziness, and other negative effects they may have experienced and imagine they are experiencing those discomforts again during each cigarette. If this is imagined often enough, smokers tend to associate the cigarette with negative feelings and will not want to smoke.

Another way of using aversion therapy is to imagine that the cigarette is something physically disgusting. For instance, a smoker might imagine that the cigarette is filled with bugs or worms instead of tobacco. The guided imagery of hypnosis can greatly enhance aversion therapy as well. Because someone under intense concentration can often create vivid mental images, there can be a strong association between the negative images and the use of tobacco.

Smoking-Cessation Groups, Mentors, and Community Help

While hypnotists and aversion therapists help smokers with specific techniques to quit smoking, smoking-cessation groups and support systems help people help themselves. It can be helpful to have a friend who has had similar experiences. Smoking-cessation groups might be offered through schools, hospitals, and churches. These groups provide education and guide new nonsmokers by helping them through the rough times. Many smoking-cessation programs also teach methods to manage anger and stress and teach ex-smokers how to keep a handle on their emotions. This can be critical because many people use tobacco to cope with anger or stress, and when they stop using it they need to learn new methods for coping.

Mentors are people who teach and guide other people, often through a difficult process. They can provide insight, inspiration, and aid to the struggling ex-smoker. For example, mentors may make themselves available to talk whenever someone experiencing

intense cravings is worried about relapsing. Mentors can be contacted in person or online. Some mentors guide people one-onone, others offer e-mail mailing lists through which they assist many smokers or soon-to-be-ex-smokers at once.

Nicotine Anonymous is modeled after the highly successful Alcoholics Anonymous (AA) program. Participants meet with others struggling to rid themselves of nicotine in their lives. They share experiences, strength, and hope with each other. Utilizing twelve-step programs originally developed for AA, participants help each other on a path toward achieving personal responsibility and remaining nicotine free. Some Nicotine Anonymous groups have a religious character; others do not.

Religious organizations can also provide a network of support for the smoker, who may be going through one of the most difficult times in his or her life when quitting. Scientists have found faith to be helpful in a number of health situations. Meditation or prayer can help people with the urges and cravings they experience. Dave Waddle, a contractor, describes his experience in praying for help in quitting smoking. "I said a prayer, and that was five days before my son was born. My dad smoked for years and died recently of lung cancer. I didn't want my son to see me that way, lying in a hospital bed, slobbering on myself. I held my dad's hand as he took his last breath. After my prayer, the urge for smoking went away. My son is a month old now."³⁴

Medical Help

Besides finding help from religious organizations, people wanting to quit using tobacco may seek help from physicians and other medical practitioners. Physicians often talk to smokers at yearly physicals or when they are ill. They usually counsel patients on the health risks of smoking. Large health maintenance organizations (HMOs) like Kaiser Permanente or Group Health Cooperative of Puget Sound offer smoking-cessation programs. Some programs like this are even free to the consumer—the HMOs believe that it is cheaper to pay for a program to stop smoking than it is to pay for the treatment of many of the diseases and the complications that can arise from a lifetime of nicotine abuse.

Physicians can offer some treatments that are only available with prescriptions. Bupropion is a medication (Zyban) authorized by the FDA to be used for smoking cessation. The same medication is also marketed as an antidepressant under the brand name Wellbutrin. "Bupropion helps curtail the cravings," says pharmacist Frederick Nehser. "It helps take away the need [for nicotine.]"³⁵ Medications such as clonidine and nortriptyline can help with the side effects of withdrawal, but bupropion is the most commonly prescribed medication because it alters the brain chemistry so the nicotine cravings are reduced.

Scientists and researchers concerned with nicotine addiction are regularly looking for new ways to help people quit or to help prevent them from becoming addicted in the first place. Scientists are exploring medication and vaccines that help block the action of nicotine in the brain. If nicotine cannot bind with the receptors in the brain responsible for addiction and pleasure, then the smoker will not experience the pleasurable effects of the nicotine. When the internal reward for tobacco use is gone, smokers will find little reason to continue.

Facts About Quitting

When people are first seeking to quit, they most often try medication or NRT in addition to either a support group or behavior therapy. This combination of counseling and NRT is probably the most effective in helping people quit and stay smoke free for the long term. Many existing therapies are more effective when used in combination with other therapies. One study showed that the success rates (3 to 5 percent) for cold turkey double for those receiving brief advice and triple for those receiving behavioral therapy. Hypnosis, aversion therapy, and smoking-cessation groups generally average success rates of about 10 to 15 percent. Most of these therapies work to modify behavior and have success rates similar to traditional behavioral therapy and counseling. However, teens often drop out of group treatment programs, perhaps because they are fearful of having to disclose to their parents that they smoke. Some treatment programs require parental consent. Groups that assure anonymity can be more effective in helping teens stop using tobacco, as can online help and individual mentoring.

For those tobacco users receiving medication, 10 percent were able to quit. Twenty percent of those receiving medication and

Weight Gain

Nicotine affects the appetite. There is some truth to the idea that smokers can control their weight with nicotine. This effect happens for a number of different reasons. First, smoking impairs taste and smell. With impaired taste, appetite can be diminished. Second, nicotine use can speed up metabolism, so the body works harder and burns more calories in general. Third, nicotine itself decreases the appetite. In fact, the chemicals in tobacco interfere with the absorption of many food substances and nutrients. This makes smokers more likely to have disorders such as osteoporosis, since tobacco interferes with the absorption of calcium.

Tobacco users who want to quit should expect that they might gain weight. Most who quit gain just a few pounds, which disappear relatively soon. About 10 percent of quitters gain more weight, which tends to be more difficult to take off. However, the negative health effects of excess weight are less than the negative health effects of tobacco. If someone has to make a choice between being overweight or smoking, it is often better to be a few pounds too heavy.

One way to help with the weight issue is to make certain the diet is wholesome by eating fruits and vegetables, rice, millet, or potatoes without toppings; reducing the amount of meats and fatty, refined, or processed foods; and snacking on carrots, celery sticks, or unsalted seeds and nuts. Other ways to control weight gain include joining a health club, starting an exercise program, or getting a dog. Studies have shown that dog owners who walk their dogs regularly walk more than other pet owners and are in better health and condition overall.

brief advice quit, as did 30 percent of those receiving medication and therapy. The success rate with NRT doubles when combined with counseling or behavioral modification.

The success rates for NRT vary depending on the type of nicotine used. In a 1999 article in the Journal of the American Medical Association, it was reported that people using the nicotine patch alone have a quit rate of 5 to 11 percent. Those using nicotine gum have a success rate of 13 to 15 percent. The nicotine inhaler, which uses a cigarette holder attached to a nicotine cartridge, has a success rate of 17 to 21 percent. The nicotine nasal spray has a success rate of 25 to 35 percent. Some recent studies have indicated that a combination of nicotine replacement strategies also improves the chance for success. Success rates are higher when combining the patch, which delivers a steady dose of nicotine, with nasal spray, which provides bursts of nicotine that move quickly into the bloodstream and the brain.

However, these success rates are just percentages and do not indicate which method will be most successful for any given tobacco user. Some people will try a number of different methods before finding one that works for them. The truth is that quitting tobacco use is difficult. As with most other addiction-cessation programs, the overall success rates of long-term abstinence from nicotine are low. Only half of those who attempt to quit smoking succeed for more than two days. Most people who successfully quit make five to seven attempts before they succeed. Jennifer Nelson, a nonsmoker for two years, says, "This last time [I quit] I used the patch. I found it very effective in taking the edge off those first shaky few weeks of withdrawal. This is my sixth time."³⁶

Once Addicted, Always Addicted?

Quitting tobacco use is very emotional. The nicotine has changed the way the brain works with every dose. Its loss makes the tobacco user feel incomplete. As a result, some people experience intense mood drops. In an article that examines the current and potential state of cessation therapy, one new nonsmoker said: "It was like losing a buddy. There was a real loss for me, an emotional loss. I probably cried every day the first week. I wanted to smoke."³⁷ The depression or mood drops may be because of an emotional or chemical withdrawal from the cigarettes or tobacco use. Depending on the severity of these depressions, some people may be inclined to start up again. In fact, research has shown that if there are severe mood disturbances within five days, the quit attempt will probably fail. Most people who are affected this way will resume their tobacco use within two weeks. Antidepressants are sometimes used as short-term therapy to help tobacco users weather this period of time.

Some people experience this emotional withdrawal immediately after quitting, and then again after some time has passed. Often after a month or two, the ex-smoker will experience an acute desire for nicotine and another serious mood drop. This, too, can put the quit attempt in jeopardy. Thomas Stanislao, a nonsmoker for six years, says,

Five months [after I quit], I was at a conference in Palm Springs and had a little too much bourbon. Several people were smoking and I bummed one, expecting it to taste awful, to make me dizzy. It tasted wonderful, and I bummed another one. Then I thought, once an addict, always an addict. I know a woman who quit for 16 years and then started again. I was determined that would not be me. I've been clean ever since and never even think about it.³⁸

The longing for nicotine often does not go away with time. The ex-user is still subject to nicotine addiction even years after quitting. Ten or fifteen years after people quit, they may still desire the chemical and to feel it acting in their brains. However, it does frequently lessen and people who experience the desire learn how to cope with the urges without using nicotine. Sometimes the desire can be enhanced by circumstances—when other people are smoking or the ex-smoker is in a situation in which he or she used to smoke, the desire may seem to be overwhelming. Once someone is addicted to nicotine, they are always addicted. However, just because the addiction remains does not mean they have to give in to that desire.

Tobacco is legal because it was in use centuries before the birth of the U.S. government. But perhaps if tobacco were discovered

A Five-Day Plan for Quitting Tobacco Use

The U.S. surgeon general's office publishes a five-day plan for quitting tobacco use on their website, available at www.surgeongeneral.gov. They recommend that first, a person must decide to quit. Then they should contact a health-care provider or a tobacco-cessation clinic to discuss options. And before starting the plan, a person should set a quit day.

Quit Day Minus 5: List all of your reasons for quitting and tell your friends and family about your plan. Stop buying cartons of cigarettes or pouches of tobacco.

Quit Day Minus 4: Pay attention to when and why you use tobacco. Think of habits or routines you may want to change. Make a list to use when you quit. Think of new ways to relax or things to hold in your hand instead of a cigarette.

Quit Day Minus 3: Make a list of the things you could do with the extra money you will save. Think of who to call when you need help, like a smoking support group.

Quit Day Minus 2: Buy the over-the-counter nicotine patch or nicotine gum, or get a prescription for the nicotine inhaler, nasal spray, or the non-nicotine pill, bupropion SR. Clean your clothes to get rid of the smell of cigarette smoke.

Quit Day Minus 1: Think of a reward you will get yourself after you quit. Make an appointment with your dentist to have your teeth cleaned. At the end of the day, throw away all matches, cigarettes, and other tobacco products. Put away lighters and ashtrays.

Quit Day: Keep very busy. Change your routine, and do things differently so you're not reminded of tobacco. Let family, friends, and coworkers know this is your quit day, and ask them for help and support. Avoid alcohol. Celebrate, or buy a treat for yourself.

Quit Day Plus 1: Congratulate yourself. When cravings hit, do something not connected with tobacco, such as walking, drinking water, or taking deep breaths. Call your support network. Find snacks like carrots, sugarless gum, or air-popped popcorn.

today, it would be regulated as strictly as any other type of potent pharmaceutical. Perhaps it would never make it onto the market because of its negative health impacts. In the last century, particularly the time from 1964 on, the U.S. government has taken an increasing role in the relationships between the consumer, medical experts, and the tobacco industry.