Originally published in The Ottawa Citizen November 19, 2002
Original Title: Quitters are Winners

Most people know the risks of cigarette smoking. They often employ many strategies to quit, often with lukewarm success. An understanding of the addictive nature and the associated habits and triggers of smoking is essential before attempting a smoking cessation program.

Nicotine is one of the most addictive substances known: worse than heroin. It is strongly psychoactive, incorporating itself in the chemical processes of brain function. The term “addiction” is commonly misused. An addiction is condition wherein a person needs a particular substance or activity in order to continue to function. He/she will go to any length to procure the substance should it become scarce. The effect it has on the brain dictates their behaviour. In short, these people lose the ability to function independently compared to a non-addicted person.

To wit, how many smokers do you know who would not hesitate to head out into a stormy winter night to buy a pack of cigarettes should their supply be depleted? One only needs to look at the short-term nicotine withdrawal effects to understand how powerful a hold this drug has on behaviour and brain chemistry. True, some people can go without cigarettes for extended periods of time but the vast majority cannot.

There are two sides to nicotine addiction; the chemical addiction and learned behaviours. Indeed, think of the myriad of associations with cigarettes; coffee, alcohol, social gatherings, sex, peer group status, anxiety, and pleasure among the many others. Over the years these factors incorporate themselves into the fabric of a person’s day-to-day life. They become commonplace and achieve a status of normalcy as the person adapts to and accommodates the “smoking lifestyle”.

These triggering events or activities become so strong that people forget how the cigarette ended up in their hands. The conditioning of their behaviour is so insidious that their actions seem to be automatic without any forethought.

Some patients, fed up with smoking, will come to the office seeking the nicotine patch or Zyban to implement a quick-fix solution. Indeed the desire and motivation to quit smoking requires support and encouragement. However, an ad hoc approach to smoking cessation can lead to frustration and a greater chance of relapse.

Some people can quit cold-turkey, most cannot. How do you reverse years of conditioning and dependency?

The first and most important step is the motivation to quit. The smoker must want to quit, not for others, but for themselves.

The second step is to keep a written smoking log. The log should be in a table format with four columns; time, location, activity and mood. Each time a person lights up they enter this data. The log should include three consecutive work days and one day off. I ask patients to bring this record back a week later for review. Many will say they know when and where they smoke but the written record is often more accurate. It reveals smoking patterns and common triggers. Completing this log indicates a true motivation to quit.

Step three asks the smoker to create a list of personalized enjoyable activities (PEAs) to substitute for their cigarette smoking time. The smoking log provides the template. What can the smoker do at this particular time of day in this location that will be close to or just as enjoyable as smoking a cigarette?

For example, an ashtray (clean and pristine) is set on the desk filled with a low fat salad dressing or dipping sauce. Next to it are baby carrot sticks, celery, or other low fat food. The act of dipping the celery stick in the ashtray, taking a bite and placing it back in the ashtray mimics the act of smoking.

Preparing for a stop-date is step four. The PEAs have to be as available to the smoker as their cigarettes. They should be put in the locations (identified in the log) ahead of time. This preparation gives the smoker a sense of control. They are aware that they will have an alternative when the craving hits them.

The final preparatory step is addressing the chemical addiction. Two products are available to help reduce or eliminate the nicotine craving. By virtually eliminating the burdensome effects of nicotine withdrawal, the smoker has a window of opportunity to incorporate new habits in response to their smoking triggers.

Your doctor can help set up a program for you. Based on your state of health, he/she will review whether the nicotine patch or Zyban is safe for you to use. Both can be a useful adjunct to smoking cessation. Using both concomitantly does not significantly increase the success rate. Indeed, using them as step one instead of step five will invariably lead to relapse.

This five-step approach is an open-source guideline. Tailor it to your own needs. When used within a comprehensive smoking cessation plan, about 50 to 60 percent of quitters remain so after a year. Most smokers with the motivation to quit will eventually succeed. With each effort they learn a little bit more about themselves and fine tune the strategy for next time. Take the time to learn to quit. You already know the advantages of doing so.
© Dr. Barry Dworkin 2002