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Family Health Magazine - PHARMACY CARE

Quit Smoking
It's challenging, but help is available

If you have tried to quit smoking and been unsuccessful, take heart! Most smokers attempt to quit smoking several times before finally quitting. Past failures do not mean that you are unable to quit. Instead, they are part of the normal journey towards becoming a non-smoker.

You may believe that you just like to smoke. Tobacco companies have promoted the idea that smoking is a matter of personal choice. However, there really isn’t as much choice as consumers might believe. Ask yourself, and be totally honest: Am I addicted to tobacco? Am I truly making a free choice when I smoke? You may find that you need to have a cigarette. You’re not alone. Studies have shown that nicotine addiction is as hard to break as heroin or cocaine addiction.

Why nicotine is addictive

Nicotine is the most prominent addictive substance found in cigarettes. (There may also be others.) Nicotine reaches the brain about 10 seconds after you inhale cigarette smoke. The effect lasts only a minute or two. Drugs such as nicotine that are felt quickly and have a short-term effect tend to have the highest potential for abuse. Other addictive drugs that share nicotine’s quick action include narcotic street drugs such as crack cocaine and heroin.

How does nicotine affect the brain?

Nicotine causes a rapid release of dopamine, a neurotransmitter or brain chemical. Dopamine creates feelings of pleasure in the brain and helps people remember certain pleasures. These feelings and memories can also cause addiction to other activities like eating, drinking, and even sex. Since smoking is often easier and more frequently available, the pleasurable sensations produced through nicotine are constantly reinforced. Dopamine’s effect on memory is thought to be part of why people crave cigarettes even after they have quit for a year or more.

What are the benefits of quitting?

The health benefits of smoking cessation (quitting) are immediate and important. Almost instantly, blood circulation improves and the levels of carbon monoxide in your blood begin to decline. Your pulse rate and blood pressure, which may be abnormally high while smoking, begin to return to normal. Within a few days of quitting, your sense of taste and smell will improve while breathing becomes easier.

People who quit smoking live longer than those who continue to smoke. Ten to 15 years after quitting, your risk of premature death is close to that of someone who has never smoked. About 10 years after quitting, your chance of dying from lung cancer is 30 to 50 per cent less than the risk for those who continue to smoke. Women who stop smoking before becoming pregnant or quit in the first three months of pregnancy can reverse the chance of a low birth weight for the baby. Other risks associated with pregnancy and smoking will also be reduced. Quitting also decreases the threat of other diseases related to smoking, including heart disease and chronic lung disease.

Even people who are sick or have already developed cancer benefit by quitting. Stopping smoking cuts down the risk of developing infections like pneumonia, which often causes premature death in people with existing diseases.

Preparing to Quit

Before you decide to quit, you must know what you are getting yourself into and what to expect. There are many different stop smoking aids and methods that work for different types of people. They include the following.

• Nicotine replacement therapy (NRT) - available as a gum or patch
• Buproprion - a stop smoking medication
• ‘Cold turkey’ method
• Counselling, group therapy
• Hypnosis
• Motivational tapes
• Books

Most successful quitters use a combination of supports. These include nicotine substitutes (patch or gum) and buproprion, along with assistance from health care professionals (nurses, pharmacists and doctors) and help from family, friends and support programs.

Before you choose a treatment, do your homework and prepare for what lies ahead once you quit. Here are some recommended steps.

• Understand when and why you smoke. What are your tendencies, triggers and weaknesses?
• Research various methods and find information about quitting smoking. The Internet is a good source.
• Decide which method fits your lifestyle and would work best for you.
• Set a quit date and leave enough time to prepare for it physically, socially and mentally.

Nicotine Replacement Therapy (NRT)

Nicotine replacement by any method has been shown to double the quitting success rate. Currently, the two forms of nicotine replacement available are the patch and gum. These products can help ease your body off nicotine in a slow, controlled manner. Both have the advantage of meeting nicotine cravings while freeing smokers of the thousands of other toxic compounds found in tobacco smoke.

NRT makes it easier to avoid smoking by replacing some of the nicotine obtained from tobacco. With this type of therapy, nicotine blood levels are not at the accustomed height. Withdrawal symptoms like the cravings caused by not using tobacco are still reduced. NRT supplies nicotine more safely, without the harmful ingredients contained in tobacco smoke. NRT is available in Canada in the form of nicotine gum and nicotine patches.

Should I avoid nicotine replacement therapy (NRT)?

People with the following conditions should not use NRT products, according to the manufacturers.

• People recovering from a heart attack that occurred within the previous four weeks
• People recovering from stroke
• People with severe cardiac arrhythmia (irregular heat beat)
• People with unstable or severe angina pectoris (heart or chest pain)
• Pregnant women
• Breastfeeding women
• Young people under 18
• People with an allergy or sensitivity to diachylon (an ingredient only found in the patch)

Nicotine transdermal (skin) patches are often preferred to gum because they are simply easier to use. Several patches with different recommended doses and lengths of treatment are now on the market.

Skin patches provide nicotine at therapeutic levels in a way that is not obvious. Nicotine passes through a membrane and is absorbed by the skin and into the circulation system. The membrane in the patch controls the rate at which the nicotine enters the body. The patch is particularly recommended for people who have strong morning cravings for nicotine. Since nicotine is absorbed through the skin during sleep, morning cravings are reduced or eliminated.

Patches are usually tolerated well. Some people do report allergies to the adhesives or have irritation around the patch area. Smoking while using the patch can lead to serious side effects, since too much nicotine is introduced into the body. Taking the patch off to have a cigarette won’t help since the nicotine is already in your system. Another side effect is nightmares or vivid dreams.

Nicotine gum is available in two different doses - 2 and 4 milligrams. The 2-milligram gum is recommended for people who smoke up to 20 cigarettes per day. Heavier smokers should start with the stronger gum. The gum should be used on a regular schedule of about one piece per hour while awake. No more than 30 pieces of the 2-milligram gum or 20 pieces of the 4-milligram gum should be used in a 24-hour period.

To avoid problems, the gum must be chewed a certain way. Chew two or three times, then ‘park’ the gum between the cheek and the gums for one minute while the nicotine is absorbed. Repeat the same process for 30 minutes while chewing each piece of gum. To absorb the nicotine effectively, it is important not to eat or drink anything other than water for 15 minutes before and throughout chewing.

Side effects such as oral pain or irritation, hiccups, stomach acid reflux (backward flow), and jaw pain are usually mild and temporary. They usually disappear when users achieve the proper ‘chew and park’ technique. Nicotine gum may work well for those concerned about weight gain caused by quitting. When nicotine gum is used, the weight gain often associated with stopping smoking does not occur until the end of treatment.

Health Canada approved buproprion HCl for use as a stop-smoking medication in 1998, in the form of a sustained-release (SR) tablet. Sustained-release provides gradual but continual release of the medication. It is the first non-nicotine-based pill approved by government for quitting smoking. Buproprion appears to block the breakdown of dopamine in the brain. The level of dopamine in the brain increases and becomes more constant. The cravings associated with low levels of dopamine from cigarettes are reduced. Many people find that after a few weeks on buproprion, the cravings for cigarettes slowly subside or go away.

For this treatment to be effective, you must begin taking buproprion before you quit smoking. Buproprion therapy is usually started in a dose of 150 milligrams per day for three days. The dose is then increased to 150 milligrams twice a day. The quit date should be set for one to two weeks after buproprion therapy is started. Medication should be continued for a total of 10 to 12 weeks.

Although it is quite effective, buproprion is not for everyone. People on anti-depressant medications or with a history of seizures should talk to their doctor before taking this drug. It should not be combined with alcohol because of the increased risk of seizures. The most common side effects include nausea, insomnia, disturbed sleep, headache, and skin rash.

Combination Therapy: Buproprion and the Patch

While you may choose to use either NRT or buproprion alone, combining the two may be more effective. In theory, using buproprion and the patch together makes sense. Buproprion works on chemicals in the brain while NRT tapers the body’s physical need for nicotine. Recent studies suggest that using the patch with buproprion at the start of therapy is more effective than using one method alone. Smokers who wore a low dose patch for the first few weeks of quitting had a higher success rate than those using just the patch or just buproprion.

One concern with using them together is the risk of increased blood pressure.

Be sure to discuss combination therapy with your doctor before you start. Do not smoke at any time when using the patch. Since cost is a factor combination therapy is not an option for everyone, and may not suit the needs of those who smoke less than seven cigarettes a day.

Other Drugs

Newer, more effective treatments such as Zyban™ and NRT have phased out other prescription drugs. Some past treatments and reasons why they are no longer used are listed below.

Silver Acetate, which causes cigarettes to have a bad taste, was used as a stop smoking aid for many years. However, research does not support its use.

Alprazolam (Xanax™) and other benzodiazepines have been used to reduce anxiety associated with nicotine withdrawal. However, treatment with these medications has not been shown to improve rates of quitting smoking.

Clonidine (Catapres™) seemed at first to be useful in the treatment of nicotine withdrawal, but long-term quit rates did not improve when this drug was used alone.

Buspirone is a non-benzodiazepine tranquilizer that may help patients with tobacco withdrawal anxiety. It is generally used early to support therapy.

Coping with psychological cravings

NRT and buproprion help you control your body’s physical nicotine addiction. However, you must also cope with the mental habit. You likely associate certain activities or times with smoking. A cigarette with your morning coffee, or with a drink at the bar, may have become part of your routine. Unless you change your lifestyle to avoid these associations, it is easy to fall prey to old habits. So to quit successfully, you must also mentally break the habit.

For instance, if you usually smoke after dinner, try going for a walk instead. If idle hands crave a cigarette while watching TV, keep them busy with knitting. You are the only one who can change triggers related to your smoking habits.

Even after you have quit successfully, expect the temptation to arise even more than a year after your last cigarette. If this happens, remind yourself that you are a non-smoker. If you are experiencing a moment of weakness, leave the situation and find something else to do. Thinking it’s possible to have ‘just one’ is the main reason why people start smoking again.

If you have the will, there are many different ways to help you successfully quit smoking. While over-the-counter and prescription products can help make things easier, you must want to be a non-smoker.

Just as there are many effective methods for quitting smoking, there are many different people who quit smoking. You have your own special requirements and needs. Decide which option is best for you. Regardless of what method you use, you must first be ready to quit.

Becoming smoke-free is challenging, but with determination and assistance you can be successful. Quitting smoking offers a new sense of freedom and personal achievement, and the health benefits will last a lifetime.

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While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specifid medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physican promptly. Copyright 2012, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 0S1  [PC_FHa04]