Although everyone realizes the health benefits of quitting smoking, people often fail to quit because the nicotine in cigarettes is addictive. Fortunately, new treatments are available to help decrease nicotine withdrawal symptoms and increase the chances of success. These treatments work best when combined with a counseling program. Counseling is available from your doctor or in support groups. It would be very helpful for you to make an appointment with your doctor to discuss quitting. Smoking is a major health problem and physicians are eager to help.

Going It Alone
There are several ways you can quit. Many people quit for good through their own efforts alone, and the desire to quit is the most important ingredient in a successful attempt. First figure out why you want to quit and make a plan of action. Set a quit date and tell your friends and family. Avoid other smokers and tell people you are quitting. Then throw away your cigarettes and ashtrays. Avoid places where you normally would smoke. Make other plans, such as drinking coffee, chewing gum or walking outside instead of a cigarette. Have a support system in place, such as a friend you can call if you feel tempted to smoke. You can also join a support group in your community. With the money you save, start planning a vacation. And remember; every attempt at stopping is a step in the right direction.

Nicotine Replacement
Addiction to nicotine is one of the primary reasons people have difficulty in quitting smoking. Nicotine is a drug that effects the heart and the brain as well as other body systems. Once a person becomes used to nicotine in their blood, they will have withdrawal symptoms if they stop smoking. Some of the withdrawal symptoms include anxiety, poor concentration, restlessness, and hunger.

Nicotine replacement treatment substitutes the nicotine in your cigarettes with lower amounts of nicotine to decrease the cravings. There are several forms of replacement and selecting the best one for you depends on the kind of smoker you are. All are safe, but you must check with your doctor if you have any medical problems, especially if you are pregnant or if you have heart disease. You may be a good candidate for nicotine replacement if you are a heavy smoker, that is, you smoke more than 20 cigarettes per day, you need to smoke the first cigarette of the day within 30 min of waking up, or if you strongly crave tobacco during the first week when trying to quit. When buying nicotine replacement medications at the drug store, be sure to consult the pharmacist and read the package directions carefully.

The nicotine patch is familiar to most people. It is available over the counter at drug stores and is convenient because you can put it on in the morning and leave it on. There are different strengths available depending on how much you smoke. The actual dose of nicotine you need should be decided by you and your doctor or pharmacist. The package directions will also help you decide what strength you need. There are also two different patch schedules available. Both work equally well. The 16 hour a day patches seem to be better in that they do not disturb sleep as much as the 24 hour a day patches do. You may have heard of step down therapy. Step down therapy is helpful for people who are heavy smokers who require high dose patches early in their treatment. They can step down to a lower dose patch and therefore avoid cravings. The downside is that this will cost more since you will wear the patches for a longer period of time.

A disadvantage of patches to consider is that it takes over an hour for enough nicotine to reach the blood and stop withdrawal. Also you cannot adjust the patch’s dose by small amounts because it comes in preset packaging. Other problems include skin irritation under the area of the patch. Finally, some people may develop tolerance when their bodies get used to the nicotine in their blood. You must not smoke while wearing the patch because you can get a nicotine overdose when your blood level gets too high. Nicotine overdose may give you a headache, upset stomach, sweats, dizziness, confusion, and weakness. Call your doctor if you have any problems.

A second type of nicotine replacement is the gum form. You can also buy it at the drug store without a prescription. The most important thing about the gum is that it must be used correctly to get an effect. It must be chewed slowly and allowed to rest against the inside of your cheek. This allows the nicotine to be absorbed by the blood vessels in your mouth. The main advantage of the gum is that it works quickly, usually within 30 minutes, so it can be used to stop sudden cravings. You must carry it with you to use during the day. The disadvantages are that it has to be used correctly to work, it can taste bad, and should not be used with dental work. You can expect to continue to use the gum for several months after you quit.

A newer product that requires a prescription is the nicotine nasal spray. This product is sprayed into the nostrils when you have a craving for cigarettes. The advantage of the spray is that the nicotine reaches high enough levels in your blood in minutes, helping to stop cravings quickly. This action mimics a cigarette in its speed of action. This can be very helpful for heavy smokers or people who still crave cigarettes while wearing a nicotine patch. Disadvantages are that it must be used repeatedly throughout the day. It must be used correctly and it requires a prescription. People with active nasal allergies or sinusitis also should not use it.

A very new form of nicotine spray, released in May 1997, is an oral inhaler. This product was designed to replace the hand to mouth sensation of a cigarette with the end piece of the inhaler. The advantages are similar to the nasal inhaler. It takes a short time to start working. The downside is that it may upset the stomach, especially if you have ulcers.

Bupropion (Zyban™)
Bupropion is a medication that has been used for years to treat depression. This drug is now also approved for smoking cessation and is available by prescription from your doctor. It seems to work on brain chemistry to reduce craving for cigarettes. Zyban is the trade name for the long acting form of this drug. Success with Zyban is once again dependent on participating in a counseling program. The medication is used twice a day for one week before the quit date. It should be continued for 7 to 12 weeks. Side effects may include difficulty sleeping, headache, and dry mouth. People with a history of seizures, eating disorders, or currently using other antidepressants should avoid Zyban. The drug offers an alternative to using nicotine replacement and causes less trouble with weight gain. The disadvantages are cost and twice a day dosing.

Cost
Quitting smoking will help you save money, and your insurance may help you pay for prescription medications. The cost of a month’s supply of patches is about $120, and the gum costs about $50 for 100 pieces (each piece substitutes for one cigarette). Compare this with the cost of smoking a pack per day, which is approximately $90 per month and about $1100 per year. Considering most medications are needed only for a few months, you can save a lot of money.

Summary
You must overcome two obstacles in order to succeed in your goal of smoking cessation. These are the lack of motivation to quit and the withdrawal symptoms once you have stopped. The second of these problems is now a little easier to solve thanks to new medications. See your doctor for more information about these products. He or she can help you with the first step, which is to determine if you are motivated to give up smoking. When you are ready, he or she can counsel you and help you determine which treatment is best. And congratulations; you are on your way to becoming an ex-smoker.

Other Resources
There are other organizations that have web pages and hotlines that can help you quit.

• American Cancer Society:   (800) ACS-2345
• American Lung Association:   (800) LUNG-USA
• American Association of Retired Persons:   (800) 434-2300.

Dr.Virmani is a resident in medicine at the Boston University Medical Center with a special interest in women's health issues. Dr. Freund is the Section Head in Women's Health.