Quitting Smoking

“Giving up smoking is easy … I’ve done it hundreds of times.” - Mark Twain

With all due respect to Mr. Twain, for most people who smoke, quitting is one of the hardest things they will ever do.  Trying to quit can cause a flood of negative emotions such as anxiety, irritability, panic, fear, shame, guilt, regret and doubt.  Deciding to quit means facing those emotions and choosing to make yourself uncomfortable.  The good news is that quitting is possible, and there are now more people who have quit smoking than there are people who still smoke.  Hopefully, this short blog will help you find a reason to quit – your “why”, explain why quitting is so hard, and give you some strategies for getting there.

Why Quit Smoking?

According to the CDC, nearly 7 in 10 people who smoke want to quit, and more than half of adults who smoke make a quit attempt each year.  Unfortunately, just under 8% of people who attempt to quit succeed.  If quitting is so hard, why bother trying.  There are a lot of great reasons.

• Smoking is responsible for 80 – 85% of lung cancers.
• Smoking contributes to heart disease, stroke, emphysema and bronchitis.
• On average, people who smoke die 10 years earlier than those who don’t.
• Cigarette smoking is responsible for more than 480,000 deaths in the US annually.
• 41,000 deaths annually in the US are linked to second hand smoke.
• Smoking is linked to more than $240 billion dollars in healthcare costs.
• $185 billion in lost productivity from smoking related illnesses
• Almost $180 billion in lost productivity due to premature death.
• $7 billion in lost productivity due to premature death from secondhand smoke

Those are grim statistics, but they may help you find a reason to quit.  Smoking robs people of health, productivity, time, and life.

Why is Quitting So Difficult?

When it comes to smoking, it’s the smoke that causes the damage to your body.  There are more than 7,000 chemicals in cigarette smoke, and at least 70 of those chemicals are known to cause cancer.  But it’s the nicotine in tobacco that causes addiction.  Nicotine occurs naturally in tobacco, and it’s naturally addictive.  In fact, research indicates that nicotine is one of the most addictive substances inexistence.  One study published in the journal Nicotine and Tobacco Research found that nicotine was more addictive than cocaine, alcohol, or cannabis, and was similar to heroin and morphine in its addictive potential.  Tobacco companies amplify the addictive quality of nicotine during the growing and manufacturing process in multiple ways.

• Flavors are added to dull the harshness of cigarette smoke making it easier to inhale.
• Ammonia is added to create a free base form of nicotine that reaches the brain faster.
• Tobacco crops are genetically modified to contain twice the amount of nicotine found in unmodified tobacco.
• Companies change the design of cigarettes to increase the amount of nicotine delivered.

When nicotine is inhaled, it stimulates the release of dopamine, a neurotransmitter that plays a key role in feelings of pleasure and reward. This creates a positive reinforcement loop that encourages people to continue smoking. What’s more, nicotine “hijacks” the survival center of the brain. This part of the brain relies on memories, emotions, and information from the five senses to let you respond to threats quickly enough to keep you alive, or to let you know that everything is OK. When you try not to smoke, a low nicotine level is seen as a threat, and your own brain may cause you to feel fear, anxiety, even panic to try and force you to smoke. When you give in, this same area in the brain will send signals that the threat has been eliminated, and you’re safe again. Your own brain becomes the enemy. It increases the motivation to keep smoking, and decreases the motivation to quit!

Nicotine is able to hijack your survival system because communication in the nervous system takes a combination of neurotransmitters and receptors. The transmitter is like a key and the receptor is like a lock. In the “survival center”, the main neurotransmitter is dopamine. The receptors are nicotinic acetylcholine receptors. Nicotine fits the lock about as well as dopamine does. It’s the wrong key, but it works. And to make the situation worse, the brain develops more nicotinic receptors in response to smoking. It can take years for those extra receptors to go away.

Strategies for Quitting

Identify Your Triggers

After many years of smoking, your brain may associate smoking with certain activities like drinking coffee, finishing a meal, driving, talking on the phone, visiting with family and friends, or drinking alcohol. These normal everyday activities become “triggers”. Your brain has come to expect nicotine at these times. Like a spoiled toddler, if you don’t give it what it wants when it wants it, it might throw a tantrum by once again activating the survival mechanism. 

To deal with triggers you have to identify them. If the activity has been part of your daily routine for years, you may not even be aware that it’s creating a desire to smoke. Everyone is unique. What triggers you to smoke may be no problem for someone else. One person realized they lit a cigarette every time they passed a certain landmark on their way to and from work. Several others realized they smoked more when they sat in certain chairs. People who don’t smoke in the house tend to have one place outside where they like to smoke. That place can become a trigger. Morning coffee and after meals seem to be the most common triggers.

Change Your Behavior

Once you identify your triggers, change your patterns. Humans are creatures of habit. We like to do the same things in the same way day in and day out. It’s comfortable and predictable. It gives us a sense of control. It feels safe. Changing your patterns can let your brain know that something is different, and if you don’t smoke when it expects you to smoke, it’s not the end of the world. For example, if you smoke with your morning coffee, move the coffee maker, change the cup you drink it out of, and sit in a different chair to drink it. It can be as simple as moving from one side of the table to the other. If you smoke when you drive and take the same route every day, change your route if possible. If you smoke after eating, and you normally stay at the table, then get up, go to a different room or even outside. If you normally go outside to smoke after eating, then hang around inside. If you only smoke outside and have one place set up for it then avoid that place if possible. Move the chair, table or ashtray that are there. Be creative. Again, your situation is unique, and nobody knows you as well as you do.

Five Minute Distractions

Cravings to smoke are going to hit you. When they do, it’s a good idea to have a preplanned distractions ready to go. These can help take your mind off wanting to smoke and keep you in control of your survival instincts. Read a book or magazine. Check headlines on your phone. Play a computer game. Call a friend. Go for a walk. Do puzzles like crosswords and word finds. The more concentration the activity takes the better.

Nicotine Replacement Therapy

Nicotine replacement therapy (NRT) is the backbone of the medications used to quit smoking. There are five common NRT products – patches, gum, lozenges, nasal spray and an inhaler. Patches, gum and lozenges are over the counter. You don’t need a prescription to get them, but some insurance companies will provide them to you for free if you do have a prescription. Some insurance companies will give you an allowance to buy them or send them directly to you. It’s always worth a call to the customer service line to see if your insurance will help with the cost of NRT. State Medicaid programs are normally very good at covering these medications. Calling the national Quit Line is also a good idea. The number is (800) QUIT NOW or (800) 784-8669. They will put you in touch with your state’s tobacco cessation program will and send you a limited supply of free patches and gum or lozenges. Nicotine nasal spray and inhalers require a prescription. The only active ingredient in these products is nicotine. The only difference is the way you use them.

Patches

Nicotine patches come in three strengths, 7mg, 14mg and 21mg. They deliver a steady dose of nicotine through the skin. They are a long acting form of nicotine replacement, and can be used alone or with other medications. Change your patch every 24 hours and rotate the site so the glue doesn’t irritate your skin. The upper arms and chest are good choices.

Nicotine Gum and Lozenges

Nicotine gum and lozenges are short acting forms of nicotine replacement. They can be used alone, or with patches. Usually, people will choose to use one or the other. They work the same way so it’s just a matter of preference. One piece of gum or one lozenge can be used per hour up to 16 pieces per day. Place them against the cheek and let them sit there. The thin mucous membrane and the great blood supply there will let the medicine get into your system. Chew the gum just long enough to get it soft, them put it against your cheek. If you chew it like regular gum, the nicotine may go into your stomach where it can’t be absorbed, but may cause nausea.

Nicotine Inhalers and Nasal Spray

These are also short acting, but they are only available by prescription. The inhaler looks like a plastic straw. A nicotine cartridge is placed inside and punctured. Take rapid, shallow puffs for up to twenty minutes per hour up to 16 cartridges per day. Try to use a minimum of six cartridges per day. A cartridge that isn’t completely used can be saved for later and used until empty. The nasal spray is used by spraying 1- 2 sprays per nostril per hour up to 80 sprays per day. Inhalers and nasal spray can also be used with patches. Nicotine isn’t meant to be inhaled deeply when using these medications. Just like the gum and lozenges, the nicotine in these products is meant to be absorbed through the mucous membranes of the mouth or sinuses.

Can I Get Too Much Nicotine?

The short answer is yes. In general, it’s a good idea to set a quit date for the day you start NRT. Side effects of too much nicotine include nausea, dizziness, lightheadedness, increased heart rate, increased blood pressure or a drop in blood pressure, headaches, and insomnia. It can take several adjustments to find the right dose of nicotine for you. Some people metabolize nicotine quickly, and will need a higher dose. Others may need a dose lower than first expected.

Prescription Medications

There are two prescription medications to help people quit smoking: varenicline and bupropion. Varenicline is the only medication designed specifically to help people quit. It works by blocking nicotine receptors in the brain and reducing the pleasure of smoking. The American Thoracic Society recommends varenicline plus nicotine patches as the most successful combination of medicines to help people quit smoking. The dose is gradually increased over the first week until you’re taking one tablet twice/day. The two most common side effects of varenicline are nausea and vivid dreams. About one out of three people with experience some nausea, but taking it with food seems to eliminate most of that. About one in ten people will experience vivid dreams, but taking the second table of the day as long before bedtime as possible can eliminate most of that. Varenicline is a very safe medicine and doesn’t interact with very many other medicines. Varenicline has to be cautiously if you have reduced kidney function.

Bupropion was originally developed to treat depression and released in 1985. Since then, it has also been approved to treat seasonal affective disorder, ADHD, and nicotine addiction. One tablet is taken twice/day. How it works is not entirely understood, but we know that it affects the level of dopamine in the brain. The most common side effects are insomnia and dry mouth. It tends to have more interactions with other medicines, and can’t be used if you have a history of seizures. To help people quit smoking, it’s best to use it with NRT.

Questions

What If I’m Not Sure If I Want To Quit or Tried Unsuccessfully In The Past?

That’s OK. If you’re not sure you want to quit you can experiment with short periods of not smoking. Maybe a few hours one day a week. Most people will try to quit smoking several times before they finally quit. Experimenting with short periods of quitting will help you get used to the medicines, gage what kind of withdrawal symptoms you might have, and give you a few successes. You’ll learn that you can quit and gain confidence for the next time.

What About Vaping?

Many people do quit smoking by vaping. But the nicotine addiction is exactly the same. They are still trapped by an industry whose only goals are to keep them addicted and separate them from their money. It’s also not clear that vaping is safe. E cigarettes and vaping are generally considered to be less harmful than smoking, but they are not risk free. E cigarette vapor contains harmful chemicals including nicotine, heavy metals and compounds produced by the heating of the liquid. There have also been cases of lung injury from vaping.

What About Hypnosis, Acupuncture, or Laser Therapy?

These methods work for some people. When it comes to quitting smoking, use the method that will work best for you. You can increase their chance of success by combing it with medications and counseling designed and proven to help you quit.

Will I Gain Weight?

It’s possible. As you stop using nicotine for comfort, you may turn to food. If possible, add exercise as a distraction technique to help you quit smoking.

If Nicotine is The Problem, Why Should I use Nicotine Replacement?

The addictive power of nicotine in tobacco is amplified by the way it’s delivered to the brain. When nicotine is burned and inhaled, it reaches the brain within 5 – 10 seconds. Nicotine patches, gum, lozenges, inhalers and spray deliver nicotine much more slowly with less addictive potential. They relieve the symptoms caused by nicotine withdrawal and put you more in control of whether or not you smoke.

Will The Chemicals In These Medications Hurt Me?

There is a potential for side effects or an allergic reaction with any medication. But what’s missing from these medications are the thousands of chemicals found in tobacco smoke. And dozens of those chemicals are known to cause cancer.

My Life Is Stressful. Will Trying to Quit Make My Stress Worse?

There is no doubt that some people face more stress, adversity, and obstacles than others. But for people who smoke, their stress increases in response to a dropping nicotine level that triggers the activation of their survival system. People who smoke aren’t smoking in response to external stresses so much as in response to the internal stress caused by their own brains. Medications used for quitting smoking can help you deal with that.

Conclusion

Quitting smoking may be the most difficult thing you ever do. It will also be the best thing you ever do for your health and the health of those around you. The Tobacco Cessation team at Baptist Cancer Center wants to help you find your why, and give you the tools to live a life free from nicotine addiction whether it comes from cigarettes, cigars, vaping, e-cigarettes, or smokeless tobacco. You are not a smoker. You are a human being who smokes, and you deserve to live a life free from addiction to nicotine.