Thinking of quitting? This article details the many options that are available to you, from stopping cold turkey to using nicotine replacement products like gum or patches to attending a support group.

At this time the most effective methods for quitting is a combination of nicotine replacement products and the antidepressant bupropion (Zyban) bolstered by counseling. Cold Turkey After a year only about 4% of smokers who quit without any outside help succeed. Nevertheless, most people try to quit alone and many have reported activities that can help the process of withdrawal [see Some Tips for Quitting, below]. The primary obstacle in trying to quit alone is making the behavioral changes necessary to eliminate the habits associated with smoking. Excellent books, tapes, and manuals are available and are strongly recommended to help people who want to quit without other assistance. Nicotine Replacement Nicotine replacement products provide low doses of nicotine that do not contain the contaminants found in smoke. They are proving to be twice as helpful as other standard quitting methods. Replacement products include nicotine patches, gums, nasal sprays, and inhalers. A 2000 English study indicated that about 20% of people who use nicotine replacement products and have some support from health professionals will abstain for at least a year and about 10% will remain nonsmokers. (Unfortunately this rate is not much better than using placebo, although adding the antidepressant Zyban is improving this rate.) (In spite of the obvious health benefits from nicotine replacement treatments, only about a quarter of HMOs reimburse smokers for these aids.) There is no evidence yet that one product is any better than another, but individual preferences vary. Tips for All Nicotine Replacement Products: Not cheating on the very first day of nicotine-replacement use increases the chance of quitting permanently by tenfold. No one should use these replacement therapies as a substitute for smoking. Any nicotine replacement therapy should be temporary and directed at quitting. In one study, use of nicotine gum for more than year was associated with insulin resistance, an abnormality that occurs in diabetes. Adding a counseling program may boost the effect of any nicotine replacement program. (One study reported a quit rate of 30.5% after a year in patients who wore the patch and attended a smoking program.) The antidepressant Zyban may be particularly useful in addition to nicotine replacement in ensuring long-term abstinence in people who suffer with depression because or independently of withdrawal. No one should smoke while using nicotine replacement. It can cause nicotine to build up to toxic levels. Nicotine replacement helps prevent weight gain while it is being used but people are still at higher risk for gaining weight when they stop all nicotine. Side Effects. Side effects of any nicotine replacement product may include headaches, nausea, and other gastrointestinal problems. People often experience sleeplessness in the first few days, particularly with the patch, but the insomnia usually passes. Patients using very high doses are more likely to experience symptoms, and reducing the dose can prevent them. Special Concerns. Certain individuals may need to be aware of some concerns with nicotine replacement products. Most studies have been conducted using the patch, but results may apply to other replacement products as well. People with Heart Disease. There has been some concern that the patch might be harmful for people with heart or circulatory disease, but studies are finding that it poses no danger for these individuals. In fact, it may help reduce angina attacks brought on by exercise. Nevertheless, unhealthy cholesterol levels (lower HDL levels) caused by smoking remain abnormal with the use of nicotine replacement (at least with the use of the patch). HDL levels improve when all nicotine is stopped. Pregnant Women. Nicotine replacement may not be completely safe in pregnant women. There is an increase in heart rates in fetuses of women who use the patch as compared with those who smoke. Because this may be an indication of fetal stress, pregnant women are cautioned to remove the patch before bedtime. Adolescents. Nicotine replacement is safe for adolescents. Small Children. Nicotine is a poison and all nicotine products should be kept safely away from small children. A parent should call a physician or a poison control center immediately if a child has been exposed to a nicotine replacement product, even for a short duration. Parents should also call the doctor if a small child has been exposed to a nicotine product and has any symptoms, including stomach upset, irritability, headache, rash, or fatigue. Nicotine Patches. Nicotine patches, or transdermal nicotine, can be an effective way to quit smoking. The quit rate for patch users is around 20% after six months, twice the rate of those who try to quit cold turkey. Nicotine patches are available over the counter, but it is best to consult a doctor before using them, particularly people with any medical problems. They are probably the best nicotine replacement products for people with asthma or other chronic lung problems. The patch products available have different approaches: NicoDerm CQ includes patches that come in three strengths (21, 14, and 7 mg), which are used in a step-down program over a period of 8 to 10 weeks. The initial set of large patches is replaced after about three weeks with a smaller, less potent set. For heavy smokers, this process is usually repeated one more time using an even smaller patch. Using these patches for 8 weeks provides the maximum benefit. Nicotrol is a single-step patch and can be taken off after 16 hours and replaced 8 hours later. It can only be taken for six weeks. Perigo offers two strengths and does not require tapering. The 22 mg patch is for those who smoke more than 16 cigarettes per day, and the 11 mg patch is for those smoking 15 or less each day. The patches are all applied in similar ways: A single patch is worn each day and replaced after 24 hours. To avoid skin irritation it is applied to different hairless locations above the waist and below the neck each day. (Transparent patches are now available, which allows greater area for application.) People can wear the patches for 24 hours, but some have reported odd dreams and have disliked the sensation of the patch during the night. People who wear the patch all the time, however, have fewer withdrawal symptoms and slightly better abstinence rates than those who take it off at night. Patches should be stored and discarded safely, particularly in homes with small children. Small children have been poisoned (not fatally so far) from wearing, chewing, or sucking on nicotine patches. The FDA recommends the patch for three to five months, although some studies suggest that using it for eight weeks is just as effective. Special precautions should be made if children are exposed to the patches: Children should not come in contact with the patches, even while the smoker is wearing them. If the child has worn the patch, the affected skin should be washed right away. Urgent medical care may be required if the child has eaten nicotine or worn a patch for a prolonged time. (The hazard increases if the child has been exposed to more than one patch or one that has not been used.) Nicotine Gum. Nicotine gum (Nicorette), available over the counter, has also been effective for a number of people. Some prefer it to the patch because they can control the nicotine dosage and chewing satisfies the oral urge. Long-term dependence may be a problem with this method. Although such dependence is probably safer than smoking, research is needed to confirm this and experts recommend chewing the gum for no more than six months. Some tips for using the gum are as follows: Patients starting to quit chew one to two pieces each hour. A smoker should not chew more than 20 pieces a day. The goal is to stop using the gum by six months, but about 3% of people continue to use it long after they have quit smoking. The gum must be chewed slowly until it develops a peppery taste. It is then tucked between the gum and cheek where it is stored so that the nicotine can be absorbed. Coffee, tea, soft drinks, and acidic beverages may interfere with nicotine absorption, so people should wait at least 15 minutes after drinking before chewing a piece of gum. Some people prefer other methods or cannot use the gum for the following reasons: They find gum unpleasant tasting. Side effects specific to the gum that may include upset stomach, mouth ulcers, hiccups, and throat irritation. They are embarrassed chewing gum. They wear dentures. The Nicotine Inhaler. The nicotine inhaler resembles a plastic cigarette holder. It comes with a number of nicotine cartridges that are inserted into the inhaler. It requires a prescription in the U.S. Four studies have reported that the inhaler triples abstinence rates (between 17% and 28%) compared with placebo (6% to 9%) for a six-month period. It has some specific advantages over other slower nicotine replacement products: It provides varying doses of nicotine on demand (as opposed to continuously with the patch or the gum). It satisfies the oral urges. Most of the nicotine vapor is delivered in the mouth (although some people experience throat irritation). The Nicotine Nasal Spray. The nasal spray satisfies immediate cravings by providing doses of nicotine rapidly, and thus may play a useful role in conjunction with slower acting nicotine replacement therapies. The spray can irritate the nose, eyes, and throat, but most people can tolerate the side effects that usually subside within the first few days. Unfortunately one small study found that at the end of the year, only 16% were still abstaining. Nicotine Tablet. A nicotine tablet that is held under the tongue is also being investigated. Reduced-Smoke Cigarette: Special Warning? A new cigarette (Eclipse) is a reduced-smoke cigarette. It works in the following way: The smoker lights a carbon rod at the tip of the cigarette. The heat passes from the carbon rod through a layer of tobacco. The carbon rod is insulated by glass fiber mat, so the tobacco is heated rather than burned. The smoker inhales. Nicotine and other substances in the cigarette are delivered to the lungs similar to using an aerosol device. It should be strongly noted, unlike nicotine replacement products, this cigarette has undergone no rigorous independent studies. In spite of massive advertising efforts, this product should not be regarded as a safer form of smoking. To date no independent studies support manufacturer claims that Eclipse poses less risk for cancer or lung disease. One potential danger, in fact, is that the glass insulating fibers can become dislodged and inhaled into the lungs. Their carcinogenic effects in the lungs may be similar to asbestos fibers. Even the manufacturers do not claim any lower risk for heart disease than conventional cigarettes. In fact, Eclipse may increase carbon monoxide levels, a danger to the heart. Bupropion (Zyban) A unique antidepressant called bupropion (Zyban) is proving to be a strong aid in the quitting process. This agent increases the effects of certain neurotransmitters, particularly dopamine, that may play a strong role in nicotine addiction. Success Rates. Taking the drug alone produces higher smoking rates than placebo and taking it along with nicotine replacement is even more successful. In one 2000 study, after a year the following people were still not smoking: 5.6% of people on placebo. 9.8% of those on the nicotine patch. 18.4% of those treated with Zyban alone. 22.5% of those treated with Zyban and nicotine replacement. Temporary weight loss is a possible side benefit of the drug, although people generally regain it after they stop the antidepressant. In people who are not depressed, there is no noticeable effect on mood. People who are depressed generally report better spirits and more energy. (In a few cases, people have experienced increased depression.) Typical Regimen. A typical regimen for quitting smoking using Zyban is the following:* The smoker takes Zyban twice a day for five days before the quit date. On the day the smoker quits, the dose is increased to three times a day. The smoker may or may not choose to take nicotine replacement at that time. Generally people take Zyban for about 8 weeks in total, although some researchers are investigating longer use of the antidepressant to increase the duration of abstinence and perhaps maintain weight loss. Side Effects. Side effects include gastrointestinal problems, headache, insomnia, dry mouth, and irritation. In very rare cases, seizures have occurred, although usually in people who exceeded the recommended dose or who already had risk factors for seizure. Outside Support People who have such outside help have the best record for quitting, with success rates of between 25% and 35%. (Those who are counseled and use nicotine replacement and Zyban have the best chance.) According to recent research the two most successful behavioral interventions are supportive care by a clinician, or training in problem-solving or coping. Telephone hotlines offering counseling also help, especially when smokers receive follow up calls. The more intense the counseling program the better. Smokers should look for programs that include the following: 20 to 30 minute session lengths four to seven sessions two-week program duration Even brief advice by a physician (three minutes or less) can help, however. In one study this modest intervention increased the long-term quit rate from 7.9% to 10.2%. (In spite of this, less than half of primary care physicians and even fewer specialists counsel their patients on quitting.) Other Investigative Agents Nortriptyline. Antidepressants known as tricyclics may also be beneficial, since they have additional effects, independent of reducing depression, that may help smokers. The tricyclic nortriptyline (Pamelor, Aventyl) has been specifically studied for helping smokers. In one study, after six months 14% taking the drug had quit compared to 3% who hadn't used it. Side effects of this drug include dry mouth and changes in taste. It should be noted that tricyclics can have serious, although rare, side effects, and overdose can be fatal. Tricyclics may pose a danger for some patients with certain heart diseases. Vigabatrin. Vigabatrin (Sabril), a drug used for epilepsy, administered in very low doses, is being investigated for treating nicotine addiction. The drug blocks nicotine-induced increases in levels of dopamine, the primary chemical in the brain that causes smoking pleasure. Animal studies show promising results with doses 10 to 20 times smaller than those used for epilepsy. Methoxsalen. Methoxsalen (Oxsoralen), a drug used for psoriasis, blocks an enzyme that metabolizes nicotine. The effect increases nicotine levels in the blood, leaving smokers with fewer urges to smoke. It also helps prevent absorption of carcinogens in cigarette smoke. In a 2000 study, patients who took methoxsalen in combination with nicotine patches reduced their cigarette intake by 50%. Research indicates that little of the drug enters the bloodstream and that its side effects are minimal. Long-term safety studies are necessary. Anti-Smoking Mouthwash. A newly invented mouth rinse shows potential as an effective smoking deterrent. The rinse makes cigarettes taste terrible for five to eight hours after use. Anecdotal evidence indicates that it is quite effective in helping people quit smoking, but the product is still under investigation and not yet available. Alternative and Other Methods for Quitting Scheduled Reduction. One study showed that people who used a systematic withdrawal schedule were twice as likely to quit as those who went cold turkey. The procedure involves the following steps: Divide the number of minutes per day awake by the number of daily cigarettes; the result is the minute-long wait between smokes. Set up a schedule with time intervals based on this result and using a timer, smoke only at those intervals; if the "cigarette appointment" is missed by more than five minutes, the smoker must skip that cigarette. The following week, one-third fewer cigarettes are used and the smoking time is recalculated based on the lower number. During the third week the count is again reduced by a third, and the smoker quits in the fourth week. (Those who are unable to smoke during working hours could try calculating the intervals based on the usual smoking times of the day.) Hypnosis. Some people report successful cessation from smoking with hypnosis in individual sessions. Group sessions appear to be worthless. The process is effective only if the subject trusts the therapist and can feel completely at ease in the vulnerable and passive state necessary for hypnotic susceptibility. A typical effective session includes the following steps: The hypnotherapist uses various techniques (e.g., imagery, silent counting) to put the subject in a relaxed state. When the subject is very relaxed, but not asleep, the hypnotherapist quietly suggests motivations for not smoking. The hypnotherapist should also reinforce a positive self-image while the subject is in deep relaxation. This helps many people avoid the depression that accompanies withdrawal. The session usually takes about an hour. The patient is taught methods of self-hypnosis to use at home, and there is usually one follow-up reinforcing session. Acupuncture. The acupuncture technique for quitting smoking usually uses tiny curved staples attached to three different points around the edge of the ear. The procedure is entirely painless. The patient is instructed to press each staple in sequence for a few seconds whenever the craving for a cigarette occurs. There are no side effects except for some soreness if the staple is pressed too hard. Analysis of studies indicates, however, that acupuncture is no more effective than any other method for quitting smoking. Social Pressure (Denormalization) An effective overall current method for reducing smoking is the concept of denormalization. Essentially, this is the process of making the smoker feel that what he is doing is abnormal. It is best instituted by laws and local regulations making smoking inaccessible in public places, raising prices, and putting stricter limitations on cigarette advertising. Here are some examples of its success: In California, where public control of tobacco began in 1989, the prevalence of smoking dropped from 26% to 18.4% in 1998. A similar anti-smoking campaign in Massachusetts that began in 1993 has resulted in a 43% decline in smoking. Denormalization can also work on a personal level. An English study found that when one spouse makes healthy changes, including quitting smoking, the other one follows. In couples where smoking continues, it usually continues in both. Even if smokers have all the public and professional support available, however, quitting is still a solitary and difficult process. SOME TIPS FOR QUITTING Decide on a Specific Quit Date For some people, choosing a particular date to quit is helpful when no or low stress is anticipated for at least the first three days afterward. Women affected by PMS should avoid quitting right before their periods. (If smokers lose their nerve on the chosen day, they must not get discouraged but should simply choose another one as soon as possible.) Let the Body and Mind Heal during Withdrawal Retreat from the world when cravings become overwhelming: take naps, warm baths, or showers, meditate, read novels. Assist the body in getting rid of nicotine. Drink plenty of water, eat fresh fruits, vegetables, whole grains, and fiber-rich foods. Carrots, apples, and celery are good munching foods. When cravings occur, hold your breath as long as possible or take a few deep rhythmic breaths. Use meditation or relaxation and deep breathing exercises. In fact, taking deep breaths when the urge to smoke occurs is a good stop-gap measure. Get Family and Friends Involved Tell all your friends and family that you've already quit, so you'll be embarrassed if they catch you smoking. Pay a family member or friend if they catch you smoking. The amount should be large enough ($5 to $20) to be a deterrent, but not too large as to be ridiculous. If your partner smokes, try and persuade him or her to quit or at the very least not to smoke around you and others. Exercise An enjoyable exercise program is a great asset. Studies continue to show that smokers who exercise, vigorously if possible, can greatly increase their ability to quit smoking, while reducing their risk for weight gain. Move the muscles when craving occurs. Dance, run, walk, jump up and down, stretch, do push-ups. Yoga is an excellent exercise program for quitting. Maintain a Healthy Diet Eat plenty of fresh, crunchy fruits and vegetables. This is also a useful way of satisfying oral cravings without adding many calories. Drink plenty of water and healthy beverages. Weight gain is a problem in quitting. One study reported that a low-calorie diet during withdrawal and for the first few weeks helped women prevent weight gain and improved abstinence significantly compared to those on a normal diet, even when subjects went off this diet later on. Change Daily Habits Change the daily schedule as much as possible. Eat at different times or eat many small meals instead of three large ones, sit in a different chair, rearrange the furniture. Find other ways to close a meal. Play a tape or CD, eat a piece of fruit, get up and make a phone call, or take a walk (a good distraction that burns calories as well). Substitute oral habits (eat celery, chew sugarless gum, suck on a cinnamon stick.) One small study comparing men who had quit for 10 years with those who failed found that those who substituted other types of oral behavior were more likely to succeed in quitting than those who didn't. People who simply tried to distract themselves with busy activities were typical of those who relapsed. Go to public places and restaurants where smoking is prohibited or restricted. Set short-term quitting goals Set short-term quitting goals and reward yourself when they are met, or every day put the money normally spent on cigarettes in a jar and buy something pleasurable at the end of a predetermined period of time. Other Find activities that focus the hands and mind but are not taxing or fattening: computer games, solitaire, knitting, sewing, whittling, crossword puzzles. Avoid heavy drinking of alcohol, caffeine, or other stimulants or mood altering substances. Make an Oath Take an extreme "sacred" or superstitious oath. (Example: "If I smoke one more cigarette my dog will die.") Although this seems absurd, some people, even well-educated individuals who have failed all other methods have reported that they quit completely and successfully after taking such an oath. RECENT LITERATURE Improving the treatment of tobacco dependence. Simple messages and an infrastructure to deliver them are needed. BMJ. 2000 Aug 5;321(7257):311-2. Effects of the transdermal nicotine patch on normalization of HDL-C and its subfractions. Prev Med. 2000 Aug;31(2 Pt 1):148-52. Contemporary smoking cessation. Cancer Control. 2000 Jan-Feb;7(1):56-62. Review. Smoking reduction with oral nicotine inhalers: double blind, randomised clinical trial of efficacy and safety. BMJ. 2000 Aug 5;321(7257):329-33. Development of depression during placebo-controlled trials of bupropion for smoking cessation: case reports. J Clin Psychiatry. 1999 Jul;60(7):436-41. A clinical practice guideline for treating tobacco use and dependence. JAMA. 2000 Jun 28;283(24):3244-54. Effect of counselor and client education in nicotine addiction on smoking in substance abusers. Addict Behav. 1999 May-Jun;24(3):443-7. The efficacy of computer-tailored smoking cessation material as a supplement to nicotine polacrilex gum therapy. Arch Intern Med. 2000 Jun 12;160(11):1675-81. A pharmacologic strategy for the treatment of nicotine addiction. Synapse. 1999 Jan;31(1):76-86. Impact of the Massachusetts tobacco control programme: population based trend analysis. BMJ. 2000 Aug 5;321(7257):351-4. Drug treatment of multiple sclerosis. BMJ. 2000 Aug 19;321(7259):490-494. No abstract available. *Note From the Editor: Glaxo Wellcome recommendations for a typical regime differ from those in this article. Please visit http://www.gw-zyban.com/initiating.html for more information.

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