SMOKING CESSATION: Part III

EDITOR’S NOTE:  This is the final article in a three-part series on smoking cessation. In the first article, Dr. Owens gave you an overview of the psychological and physical obstacles that individuals face in their attempts to quit. In this issue, he will describe the medical treatments, and in the final installment he will discuss psychological and behavioral methods, including counseling, hypnosis and biofeedback.

Smoking Is An Ingrained Habit

Dr. Henry Owens

SMOKING IS A HABIT difficult to break because it involves both physical addiction to nicotine and many different aspects of a person’s emotions and social life. Physically, the body reacts to the absence of nicotine. Mentally, the smoker is giving up an ingrained habit, which calls for a major change in behavior. Successful treatments need to address both the psychological and physical aspects of the smoking habit.

There is a wide variety of smoking cessation treatments that are available. These include medications and nicotine replacement therapies; behavioral and psychological smoking programs; group and individual counseling; and other approaches such as acupuncture, hypnosis, herbs. If you’re considering trying any of the treatments check with your physician.

Nicotine Replacement Therapy
NRT is designed to help alleviate unpleasant withdrawal symptoms by providing nicotine without the other harmful chemicals in tobacco. Currently, there are five types of nicotine replacement therapies (NRT) approved by the FDA, as well as two medications used for smoking cessation.

• Nicotine Patches (transdermal nicotine systems): Patches work by giving a measured dose of nicotine through the skin, with subsequent gradual weaning off nicotine by switching to lower nicotine dose patches over time. Patches can be bought with or without a prescription, with different types and strengths available. The 16-hour patch works well for light-to-average smokers and is less likely to cause side effects like skin irritation, racing heartbeat, sleep problems, and headache. However, because it does not deliver nicotine during the night, it is not helpful for early morning withdrawal symptoms. The 24-hour patch provides a steady dose of nicotine, avoiding peaks and valleys, but may cause more side effects.
• Nicotine Gum (nicotine polacrilex): Nicotine gum is a fast-acting form of replacement in which nicotine is taken in through the mucous membrane of the mouth. It is available over the counter and comes in 2 mg and 4 mg strengths. If you smoke a pack or more per day, smoke within 30 minutes of waking up, or have trouble not smoking in restricted areas, you may need to start with the higher dose (4 mg). Nicotine gum is usually recommended for one to three months, for a maximum of six months. An advantage of nicotine gum is that it allows you to control the nicotine doses. However, long-term dependence is one possible disadvantage of nicotine gum.
• Nicotine Nasal Spray: Available only by prescription, the nasal spray delivers nicotine to the bloodstream as it is quickly absorbed through the nose. It relieves withdrawal symptoms quickly and reduces nicotine cravings. However, the FDA warns that it can be addictive and recommends that the spray be prescribed for no longer than six months.
• Nicotine inhalers: Also available only by prescription, the nicotine inhaler is a thin plastic tube with a nicotine cartridge inside. When you puff on the inhaler, the cartridge puts out a nicotine vapor. Unlike other inhalers, which deliver most of the medicine to the lungs, the nicotine inhaler delivers most of the nicotine vapor to the mouth. To smokers, nicotine inhalers may be the closest thing to smoking a cigarette. At this time, inhalers are the most expensive forms of NRT available.
• Nicotine lozenges: Nicotine-containing lozenges as an over-the-counter aid in smoking cessation are the newest form of NRT on the market. As with nicotine gum, the Commit® lozenge is available in two strengths: 2 mg and 4 mg.
• Other NRT: While not FDA approved, there are some “experimental” forms of NRT, such as combination of the patch and other nicotine replacement products, as well as High-Dose Nicotine Replacement Therapy.  However, these are new therapy regimens and should be considered only with a doctor’s guidance and supervision.

Medications

• Bupropion (Zyban®) is a prescription antidepressant that reduces symptoms of nicotine withdrawal by acting on chemicals in the brain that are related to nicotine craving. Bupropion works best if it is started one or two weeks before the quit date.
• Varenicline (Chantix™) is a newer prescription medicine that works by interfering with nicotine receptors in the brain. Several studies have shown varenicline can more than double the chances of quitting smoking and that it may be more effective than bupropion, at least in the short-term.
• Other Medications: Some smoking cessation clinics use shots of anticholinergic drugs (atropine and scopolamine) to help reduce nicotine withdrawal symptoms. These drugs block the action of acetylcholine. However, there is insufficient independent research to establish effectiveness.

Other Methods
There are many other cessation tools and methods that may have helped some people, but have not been proven effective in independent research. These include acupuncture, low level laser therapy, hypnosis, herbs and supplements, smoking deterrents  (over-the-counter products that change the taste of tobacco, stop-smoking diets that curb nicotine cravings, and combinations of vitamins), and filters. In fact, filters that reduce tar and nicotine in cigarettes are generally not effective since studies show that smokers who use filters actually tend to smoke more.

IN THE U.S., among adult smokers, 70 percent report that they want to quit completely, and more than 40 percent try to quit each year. Nearly 21 percent of U.S. adults (45.3 million people) are current cigarette smokers.

Which Medical Treatments Works Best?
The Agency for Health Care and Policy and Research, after two years of extensive investigation, reported these findings:

• The Nicotine Patch approximately doubles the 6-12 month abstinence rate when compared to a placebo.  It is found to be even more effective when combined with psychological support.
• Nicotine gum improves cessation rates by 40 to 60 % when compared with other interventions, notably, nicotine patch, spray, or medication.  Psychological support resulted in even better abstinence rates.
• Counseling:  Analysis of 57 studies showed that when counseling was added to nicotine replacement therapies, results were better than those of using NRT alone and concluded that optimal outcomes for smoking cessation require a combination of counseling and NRT.

There is insufficient data to draw conclusions regarding the effectiveness of nicotine nasal spray and nicotine inhalers; and anti-depressants and anxiety medications.

Which May Be Right for You?
When choosing which type of treatment to use, here are some important points to consider:

• Nicotine gums, lozenges, and inhalers are oral substitutes that allow you to control your dosage to help keep cravings under better control.
• Nicotine nasal spray works very quickly when you need it.
• Nicotine inhalers allow you to mimic the use of cigarettes by puffing and holding the inhaler.
• Nicotine patches are convenient and only have to be applied once a day.
• Both inhalers and nasal sprays require a doctor’s prescription.
• Some people may not be able to use patches, inhalers, or nasal sprays because of allergies or other conditions.

Remember that NRT deals only with the physical addiction. Studies have consistently shown that combining NRT with individual or group psychological counseling can double your chances of successfully quitting. In the next article I will share what I learned from my personal journey in successfully overcoming smoking.

Henry Owens, Ph.D. is a licensed psychologist and director of the Owens Center for Biofeedback & Psychological Services. He received his doctorate in Psychology from St. John’s University in New York. Treatments include psychological counseling and testing, biofeedback, sex therapy, EMDR, hypnosis, and parent training, stop-smoking. Specialties include ADHD, anxiety and mood disorders, child behavior and learning disorders, alcohol and substance use. His proudest accomplishments include quitting an over-two-pack-a-day smoking habit and being the proud father of two daughters.  He can be reached at 321-757-6321 or www.OwensCenter.com

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