Smoking Cessation, Lapsing and Relapsing

Smoking cessation is the act of no longer smoking. However, this state may last one day or it can last a lifetime. Lapsing is when you have 1 or more cigarettes during a quit or cessation attempt. Relapse occurs when you are no longer trying to actively quit and have returned to a regular habitual smoking routine.

So the question is this, can you get back on the wagon after you've fallen off? Can the quit attempt remain in place even though you had a 'bad day' and smoked half a pack of cigarettes? The answer is absolutely 'yes'! That's why it is important to review the definitions above. Lapsing does not have to lead to relapsing.

A recent study in the journal Addiction, looked at this phenomena and how to treat the lapse before it became a full blown relapse. Interestingly, they looked to the good old nicotine patch to see if it could promote recovery to abstinence.

As we all know, one of the effects of nicotine withdrawal is the craving. Nicotine patches were designed to counteract that craving with a dose of nicotine replacement to the brain using a far more clinical platform.

What happens when you relapse? You smoke for a day or two; you feel like a failure; you throw your hands up, put away your stop smoking aids and figure you've completely relapsed. This 'give-up' is one reason why smoking has such a high rate of recidivism. But it is possible to climb back up on that horse and start riding again without waiting two or three months.

The researchers discovered that using the patch increased the tendency to re-initiate abstinence at the critical 6 and 10 week interval, after lapsing. They conclude that continuing treatment with active patches does promote recovery from lapses and helps smokers regain their cessation 'mo-jo'. Let's face it, when you're trying to quit, you've got to have mo-jo and it looks like patches might be able to help you find it after a lapse.

Auricular Therapy for Smoking Cessation

On this blog, we like to bring the latest scientific information to the reader with respect to smoking cessation. Sometimes, we even learn something along the way. Such is the case of a novel treatment idea called auricular therapy or auriculotherapy as it is also known. Yeah, we hadn't heard of it either. But I'm sure there will be con artists trying to sell this type of therapy to unsuspecting smokers, hoping to make a quick buck or two.

What is auricular therapy? Good question. This therapy involves the delivery of electrical pulses to specific points on the outer ear. Now, why anyone would think this would help people quit smoking in the first place, is beyond me. It probably came about as an extention of acupuncture. But regardless of how this connection came about, it is out there as a possibility for people who are desperately looking for a way to quit smoking.

Some researchers looked to see if there was anything to this therapy for smokers. They published their findings in the Journal of Addictive Diseases recently. So did this therapy help? Nope, not one bit. The nicotine dependence scores were the same for smokers in the control group and those who received the electrical pulses. Abstinence rates were also the same for both groups, reported as "low".

So if you ever hear people talking about auricular therapy for smoking cessation, then you can tell them not to waste their time or money. Better yet, send them over to our website where they can learn about a quitting smoking timeline, health benefits of cessation, and even learn how to develop a quit smoking plan. Sorry for the shameless plug.

Texting As A Smoking Cessation Tool

The 21st Century has officially arrived. Not only can we talk to a missionary on a cell phone in Africa as clear as if they're sitting next to us, but we can also help people stop smoking by texting them messages. This is not my dad's technology for sure.

I came to the texting world fairly late, by today's standards. I'm in my forties and I just recently purchased a cell phone and plan that included texting. I had to have the Verizon wireless sales-lady teach me how to text. But my nephew can send a 2 paragraph text message with less than 40 characters in 30 seconds flat, and he includes a picture with it. Just amazing!

Well, smoking cessation is evolving with technology. A recent study looked at texting as a smoking cessation tool for college students. Apparently, there is a resurgence of smoking in this young population - despite the wealth of knowledge that details how dangerous smoking is. Researchers enrolled college smokers to see what affect texting would have on their quit outcomes. Although, they study didn't go far enough in establishing the effect on long term cessation, it did seem to offer help with short term cessation in this population.

So texting may be a tool that can be used by cessation professionals as they look for novel approaches to assist them in their efforts. It obviously isn't a stand alone tool, but just one more resource available to encourage and lift up someone who is trying to quit.

Smoking and Quitting Smoking

It is a viscious cycle for some people, smoking and quitting smoking. Just when they think they've got it licked, the craving hits and they decide, "one cigarette won't hurt". Ah, but that one cigarette then leads to another and another.

Smoking has one of the highest rates of recitivism or relapse. Several studies say it may take up to 7 quit attempts before finding lasting cessation success. Yep, smoking and quitting smoking are link the ying and yang of addiction.

Listen, if you are smoking and desire to quit, then realize there will be times during the quit attempt when the cravings will get intense. You can't quit as easily as you started. There's a video of some little kid smoking, so it doesn't take a rocket scientist to start the nasty habit. However, it does take dedication to the decision to quit to be successful.

Smoking and quitting smoking may be a tough cycle for you to get out of, but you can do it. Just stick with it and you'll find lasting success. Just be prepared and keep telling yourself the reasons why you want to quit.

First Line Pharmacologic Smoking Cessation Drugs

A recent article in the Current Pharmaceutical Design by Aubin and others [Apr 2011] discusses first line smoking cessation drugs. It's kind of a where are we now article. It's called "Pharmacotherapy for Smoking Cessation: Present and Future".

In it, they mention the three FDA-approved smoking cessation medications: Nicotine replacement therapy, sustained-release bupropion (Zyban) and varenicline (Chantix/Champix). They state these are recommended for all smokers, even those with psychiatric or addictive co-morbidities. I guess that kind of sums up everything we've said here at Unbiased...

However, they do realize the limited success of these first line smoking cessation drugs. Because of the rather high relapse rate, they go on to mention alternative pharmacotherapies like clonidine and nortriptyline. These would be classified as second line stop smoking medications. Later on in the article, they discuss what is in the pipeline, like the nicotine vaccine.

However, there really isn't anything too new to talk about in this article. Sadly, there just doesn't seem to be any magic bullet in the stop smoking aid arsenal to guarantee the smoking cessation success that so many people desire.  Which means only one thing. It's up to the individual to want to stop bad enough, that it doesn't matter which method they use - they'll quit in spite of the method they choose because they are so determined to succeed or so disgusted by the habit. Once you get to that point, it doesn't really matter any more.

Can the Internet Help you Stop Smoking

There are many internet sites that offer some sort of stop smoking remedy. But do they really work? We need to first differentiate what is available on the web for smoking cessation. First, there are blogs. Some are written by people trying to stop smoking, others by former smokers and then there is mine. Mine is written by a respiratory therapist (me) who tries to give information to the public to help them understand what is involved with smoking and what the science says about smoking cessation.

Second, there are smoking cessation websites that are simply trying to sell smoking cessation aids like nicotine replacement, supposed herbal remedies, etc. I think these have a place, but they usually don't offer viable information that is useful to the one who is trying to become smoke-free. People who frequent these sites are really not getting the information they need to make the right decisions for their situation. However, even a blind squirrel finds a nut, so I'm sure there is a small portion of the population that quits because of these type of sites.

Third, there are social support sites where people can link up with other people trying to stop smoking. Here, they form support groups and encourage one another as they all try to reach for that same goal. These sites can range from being simple forums to affiliate marketing sites for branded products. You have to kind of pick and choose the information off these sites, because some of them are only using the forum to get the visitor and then they try to sell them their "branded" stop smoking aid. Then you have to wonder if the advice you get on the forum is real or someone just trying to sell you something. But it's not too hard to figure out after you've visited a few of them.

Lastly, there are tailored content sites like www.smokefree.gov and www.stopsmokinghelper.org . These sites offer scientifically-based information to empower the smoker to stop smoking. The goal isn't so much to sell the visitor something, as much as it is to set expectations and guide the visitor through the complex process of overcoming nicotine addiction. (Disclosure: I operate stopsmokinghelper.org)

But what does science say about these type of websites? Are they any good at helping people stop smoking? Before we answer that question, I want to point out the cold turkey success rate is anywhere between 3 and 7%. Okay, now let's see what the literature says about websites and smoking cessation.

The Archives of Internal Medicine published a study called "A Randomized Trial of Internet and Telephone Treatment for Smoking Cessation". The researchers wanted to determine the effect of Internet (by itself) and Internet plus telephone treatment for smoking cessation. Their study had 3 components: Basic Internet (BI); Enhanced Internet with tailored content (EI); and EI plus proactive telephone counseling (EI+P). The participant demographics had an average age of 36 years, were 51% female, and 86.5% caucasian. The participants had to smoke at least 5 cigarettes a day to be included.

By 18 months, the 30 day multi-point abstinence rate across all follow-up intervals (3, 6, 12, 18 months) was as follows: the BI group was 3.5%; the EI group was 4.5%; the EI+P groups was 7.7%.

So what does this tell us? Well, it tells us that the first two types of stop smoking internet sites don't really help people that much. It also tells us that tailored content stop smoking sites (and those with social support) are much better, but only when combined with proactive telephone counseling. Something you are sure to read on these type of sites.

Most smokers need some type of accountability, encouragement and guidance. They also need sound information so they can make better decisions about how to progress in their journey to their goal. So use the tailored content sites, like mine, and then find out what will help you stop smoking. That's why it was created in the first place. Also, call 1-800-Quit-Now to find a phone counselor who can give you that proactive support you need.

"I want to quit, but I enjoy it too much" - Sound Like You?

I've talked about (and blogged about) how addiction works - both the physical and behavioral components. Anyone who is trying to stop smoking must understand the nature of addiction in smoking. They must also have a grasp on any underlying factors that might cause them to pick up that cigarette. Perhaps, they struggle with depression or have some kind of emotional baggage that continues to project smoking as a viable alternative or escape from this unsettling circumstance.

The feeling of satisfaction found with smoking can have a profound influence on a person's psyche. When all else is falling apart, smokers can always count on that old friend to provide a calming oasis in the middle of their troubles. But this begs the question which comes first, the enjoyment or the addiction? It's the old chicken and the egg argument.

Well, scientists in London published their research on this very topic in Drug and Alcohol Dependence. They looked at the enjoyment of smoking versus the urges to smoke as predictors for successful smoking cessation. They surveyed 2,257 smokers. Enjoyment and strength of urges were assessed, as was smoking status, quit attempts and quit success. The results showed that only enjoyment of smoking predicted whether a smoker would actually attempt to quit or not; while the strength of urges predicted whether the quit attempt would be successful.

This provides insight for us to are trying to help people stop smoking. By addressing the "enjoyment" part of the equation, we can help motivate people to journey toward a quit attempt. Then, once they choose to quit, we then need to help them face down the urges to smoke. I would imagine, every former smoker will tell you this is how they went about the process of smoking cessation. They first had to have a reason that was greater than their enjoyment and then, they had to overcome the urges. It seems like a relatively simple formula, I know. But don't some smokers get overwhelmed with the prospect of quitting. Don't they "overthink" it sometimes and then relapse?

The message seems pretty clear and simple. Anyone can quit if they follow this formula. The key though, is to follow it. So, pass this formula on to somebody you know who smokes. They'll be glad you did.

Cigarette Cravings - Where Do They Come From?

If you read this blog frequently, then you know I always talk about the two parts of the nicotine addiction. First there's the physiological addiction of nicotine and then there's the behavioral component of the addiction. Both are equally powerful and make it difficult for smokers to quit smoking.

Researchers at Duke University recently published that some smokers are genetically pre-disposed to the physical addiction found in nicotine. They characterized smokers their genome. So if your DNA code looks like this, you'll struggle with quitting; but if it looks like that, you may have no trouble quitting.

Well now, Mahler and de Wit have published a fascinating article in PloS One, that looks at the second part of the addiction, but from the same genetic standpoint. Let me explain this behavioral or classic conditioning before I get too far ahead.

Classical or Pavlovian conditioning is characterized by the association of a response with a neutral stimulus. The association develops because it is paired with a significant stimulus that does bring about a specific response. For example, his dogs began to salivate when given food. He then introduced the neutral stimulus which was the bell. The bell and food became paired to the salivating response. Hence, the conditioned stimulus (bell) brought about a conditioned response (salivation).

So with a smoker, lets say he smokes a cigarette with coffee in the morning and then again after dinner. The coffee-drinking by itself does not trigger the smoker to want a cigarette at first. But the coffee drinking eventually becomes paired with smoking. Now the smoker drinks a cup of coffee while at work and suddenly finds himself craving a cigarette. He now has a new conditioned stimulus (coffee) the triggers a conditioned response (cigarette craving).

These researchers actually found what they call a "cue-reactive phenotype" among smokers who are more sensitive to conditioned stimuli than others. This means, they are more likely to develop classic conditioning cues to neutral stimuli. As a side note, they also point out that the subjects who rated as having stronger behavioral triggers for smoking, also had stronger triggers for food craving too.

This isn't necessarily earth shattering news, but it does help us realize the importance of conditioning on smoking cessation (and diet too, I suppose). It cannot be overlooked when developing a method to stop smoking. Many would-be ex-smokers relapse because they underestimate, or never consider, the environmental cues that often trigger the smoking response.

The Cost of a Pack of Cigarettes and Smoking Rates

What are you willing to pay?

How much does smoking cost? If you don't take into consideration the health costs, then the answer is still the same - it's expensive. (Click for some fun smoking facts ) The cost of the cigarette isn't really the issue here, so much as the tax that is levied on them. The old "sin tax" is often used to help fund many state or local municiple projects. Anything from education to hiring more police can be found wrapped up in the tax that smokers pay at the five and dime.

There was a recent article in the NY Post that detailed how a pack of cigarettes was now selling for $14.50 thanks to an abrupt increase in the tax. One smoker interviewed said she realized it was something tatamount to an idiot tax, but she'd have to go right on paying it. Another commenter said the tax hike was outrageous and how dare the government demand more money for cigarettes.

Tobacco friendly states add very little in the way of tax, for instance, Virginia adds only $0.30 to their packs of cigarettes while New York adds a hefty $4.35 on average to a pack. This is quite a wide range and points to the political pressure that Big Tobacco can exert on local state representatives.

So how does the price of cigarettes effect smoking cessation? Do people eventually hit a point where the immediate cost of smoking becomes too great and they are finally "forced" to quit? The journal Addiction published an article that looked at this very issue. The researchers looked at 2000 smokers and evaluated their motivation to quit, cigarette prices, nicotine dependence and health knowledge. The title of the article is "Do cigarette prices motivate smokers to quit? New evidence from the ITC survey."

Ross and others, found that higher cigarette prices increased the likelihood that smokers would quit, however, they achieved statistically significant results in only 1 of the 2 models evaluated. They also discovered that having access to cheaper cigarette sources did not slow down smoking cessation. But they did say current smokers would be more responsive to quitting if these cheaper sources were not available. Still though, they concluded that smoking cessation was associated with higher cigarette prices; even when there were cheaper sources of cigarettes available.

One last little caveat, in preparing for this blog post, I ran across a newspaper article out of Spain where researchers tried to find the real cost of a pack of cigarettes that was inclusive of the health costs. Their cost was $149 per pack. Now multiply that by 365 days and you get a "real cost" equal to $54,385 per year per smoker.

Hum...I wonder what would happen to our Medicare tax spending if nobody smoked?

Perception of Quality of Life

The European Journal of Public Health published a new study by Hays, et al that discusses the changes in the quality of life for smoking cessation participants. However, inbedded within this study is a little peak into how well some of the more popular stop smoking aids work.

 

Choosing Your Quality of Life

The researches looked at smokers who were placed into 3 groups. The first group received Chantix, the 2nd received Zyban and the third was given placebo. The smokers all smoked greater than 10 cigarettes per day and there were almost 2100 people in the study group altogether, divided fairly equally into the 3 groups listed.

The participants were then given a questionnaire prior to the study, 12, 24 and 52 weeks into the study. As usual, it doesn't take a rocket scientist to figure out what the results were. Those who took Chantix and Zyban had a significantly improved sense of health/well-being (compared to baseline) and self-control than those who received the placebo. It should be no surprise that the longer the participants were abstinent, the better they felt about their overall health and ability to control their habit. What does this mean? Well, when you have cessation success, it builds a self-fulfilling prophecy within the person. They now believe with each passing day of abstinence, that they can go another day, and then another, etc., until they are smoke free.
However, the smokers in the placebo group had a more difficult time with abstinence and hence, did not feel better about their health at weeks 12, 24 and then 52.

Now to discuss that imbedded fact found within the study. Those who took the Chantix, had an even greater sense of what they call health transition and self control than did those who were in the Zyban group. This correlates with what we already know about these two methods. Chantix has a significantly higher quit rate than does Zyban.

So nothing knew learned here. But it's always nice to get confirmation from well designed studies that are not sponsored by the drug companies.

It's a Head Scratcher!

The government seems to be wanting to make inroads with the American smoking public. "How so?", you may ask? Well, they've changed their stance on what they will pay for in regards to smoking cessation. They have always paid for smoking cessation medications and now it looks like they are willing to pay for smoking cessation counseling as well.

Now we haven't talked too much about counseling, but here's the upshot. It works! Think of the success rates for nicotine replacement therapy and Zyban - only in the 6 to 10% range, depending on which article you read. Chantix boasts around a 20% success rate. So how does counseling fit it with all these magic pills? Well, add a simple smoking cessation counseling program to your method of choice and you increase the success rate to the twenties. That is astounding! Basically 4-5 times more successful than quitting cold turkey.

In the past, Medicare would only pay for counseling if you already had contracted a smoking related illness. Now they have removed that condition. This makes perfect sense, since most people have a smoking related illness in the pipeline when they reach Medicare age.

This is a move that shows how the government is hoping to move us from a treatment based healthcare system to a prevention based model. So congratulations to the US Federal Government on this one. I know, I can't believe I said it either.