“I’ve tried the gum, I’ve tried Chantix, I’ve tried cold turkey, and nothing works!”
“I’ve been smoking for too long, there’s no point in quitting now, the damage is done.”
“It’s the only way I can manage stress.”
“It keeps me from eating everything.”
“It’s just a bad habit.”
Sound familiar? These are some of the most common responses I hear when I begin to work with someone on quitting their tobacco use.
While these responses are valid, what the person doesn’t know is that most of the strategies they’ve tried in the past are not the most effective ways of quitting tobacco OR they aren’t done in the way that is most effective.
A few months back I went through a tobacco treatment specialist training which was a collaborative effort of Duke and the UNC Chapel Hill. Many of the clients I see for therapy smoke, and many (such as pregnant women) are high risk and desperate to quit.
The week-long intensive training was eye-opening for two reasons:
Tobacco is even more harmful than I initially believed.
The standard of care for treatment, which is based on strenuous research, is not well known by medical professionals.
The research on the best treatments is clear and voluminous, and yet few (if any) behavioral health and medical providers know about it, which is why I’m writing this article.
Before I get into the best treatment for nicotine dependency, I’d like to de-mystify it and explain why it’s more than a “bad habit”.
Why smoking is more than a bad habit:
Nicotine, the addictive chemical in all forms of tobacco, is a powerful drug. A neurochemical in our brains called dopamine is released when we get a hit of nicotine. Dopamine is known as the pleasure chemical. It’s the same chemical that is released when we eat something delicious, have great sex, or do other drugs (see graphs below). It keeps us wanting more because it feels good.
Another neurotransmitter, serotonin, is also released when we use nicotine. Serotonin is the chemical that gives us a sense of well-being and is implicated in depression. When we use nicotine regularly, our brains become accustomed to having regular releases of dopamine and serotonin. As a result, our brains produce less of these chemicals on their own.
When we first quit using nicotine we often feel edgy and anxious because we have a deficit of serotonin and dopamine. The neurochemical changes that happen in the brain resulting from regular nicotine use prove that it is more than "a habit".
Habit, however, is a large contributing factor to maintaining addiction.
We get use to smoking with our morning coffee, after meals, when we’re stressed or bored, etc. Changing any behavior takes time and practice, especially if it has been a part of our lifestyle for decades.
As a hiker, I find the analogy below to be helpful in understanding nicotine addiction:
When you’ve used tobacco for a while it’s like you’ve been walking on a well-cleared trail. The more you walk the path, the easier it gets, the less weeds and sticks are in your way. It becomes automatic. You smoke without thinking.
When you start resisting the urge to use, it’s like clearing a new trial. You have to make new pathways, and it takes effort. The more you walk on the new pathway, the easier and faster It becomes. When you stop using tobacco, the old tobacco path starts to grow over.
Hacking a new trail is hard work, and it’s even harder work when you have physical and neurological cravings. THIS IS WHY the standard of care treatments I outline below are THE MOST EFFECTIVE ways to quit. They take care of the physiological dependence through nicotine replacement or medication so that you can focus on changing behavior. It’s nearly impossible to change behavior when you are going through nicotine withdrawals and cravings.
Evidence-based Standard of Care for Tobacco Treatment:
The standard course of treatment for tobacco addiction is 12 weeks or longer. Below I will outline the two most effective ways of quitting.
Varenicline (also known as Chantix) in combination with nicotine gum or lozenges for 12 weeks or longer. The medication is used to reduce cravings and withdrawal. Nicotine gum or lozenges are used additionally to manage immediate cravings. For example, if you know your strongest craving is upon waking in the morning, place a piece of nicotine gum on your bedside table and chew it upon waking. It’s the combination of these two things that yields the best results.
For a 1 pack per day smoker, here’s a sample treatment plan:
Days 1-3: 0.5mg 1x day while you continue to smoke
Days 4-7: 0.5mg 2x day while you continue to smoke
Day 8 until treatment end (typically 12 weeks total): 1 mg 2xday. Quit smoking.
For cravings- use 4mg nicotine gum or lozenge. If using gum- do not chew like normal gum. Chew a few times and then place gum between your teeth and gums. You should feel a tingling sensation.
For this treatment, you begin the medication one week prior to quitting. On day 8 of medication (your quit day) you no longer smoke but use gum or lozenges for cravings instead.
Nicotine replacement therapy aka the patch and gum or lozenge. Similar to the what I explain above, the patch is used 24/7 to ease withdrawal. As cravings arise, nicotine gum or lozenges can be used. For example, if you crave a cigarette most after a meal, wear the patch all day and chew a piece of nicotine gum after a meal to replace the cigarette. The patch can irritate skin, so move it on your body frequently.
Below is a sample of typical dosing Nicotine Replacement Therapy (Nicotine Patch + gum or lozenge) for 12 weeks or longer.
1-10 cig/day: 14mg patch
11-20 cig/day: 21mg patch
21-30 cig/day: 35 mg patch (21mg and 14mg patches)
31-40 cig/day: 42mg patch (two 21mg patches)
Over 40 cig/day: 63mg patch (three 21 mg patches)
Step Down process example for 1ppd smoker:
21mg patch, 1xdaily for 8 weeks (Rx for 56 patches) – begin on quit day
14mg patch, 1x daily for 2 weeks (Rx for 14 patches) – begin after completing 21 mg patches
7mg patch, 1x daily for 2 weeks (Rx for 14 patches) – begin after completing 14 mg patches
Nicotine Gum/ Lozenge dosing:
11+cig/day: 4mg lozenge or gum
10 or less cig/day: 2 mg gum or lozenge
12-week protocol for gum / lozenges:
Weeks 1-6: one lozenge or gum every 1-2 hrs
Weeks 7-9: one lozenge or gum every 2-4 hrs
Weeks 10-12: one lozenge or gum every 4-8hrs
Maximum: 20 lozenges per day or 24 pieces of gum/day
WHILE THE ABOVE REGIMENS ARE THE STANDARD OF CARE, BUPROPION (ZYBAN OR WELLBUTRIN) ALSO CONSIDERED A FIRST LINE TREATMENT.
Treatment should begin while patient is still smoking (delayed tx effect of 1 week)
Set quit date within first 2 weeks of tx with bupropion. Treatment can last from 12 weeks to 6 months.
Days 1-3: 150mg one time daily
Day 4 – End of treatment: 150 mg twice daily (at least 8 hrs between doses)
MEDICATIONS AND INSURANCE COVERAGE:
1st line Rx meds (Varenicline and bupropion) are covered by Medicaid, Medicare and private insurance.
1st line over the counter meds (nicotine patch, gum, lozenge): Medicaid DOES cover them – with $3 co-pay, Medicare DOES NOT cover them, private insurance may or may not covered.
Behavioral Tips for Quitting Tobacco:
As mentioned, the physiological piece is only one, albeit strong, component. Behavior change is necessary to really quit for good. The graphic below gives some behavioral strategies for setting a quit day and sticking to it.
Common Myths/ Misconceptions:
1) Is vaping healthier than smoking?
No. The level of nicotine in some vape pens (like the Juul) is stronger than in cigarettes, making them as addictive, if not more.
No evidence that vaping helps in smoking cessation.
Drastically increases likelihood of smoking relapse.
E-liquids (often flavored) are toxic if consumed and toxic enough to kill a toddler or small child if consumed.
1 teaspoon of e-liquid can kill an infant if ingested.
2nd hand aerosol (vapor) dangerous as nicotine passes through vapor as well as other chemicals – no current FDA regulation.
“Vape” is not water vapor- it contains nicotine, flavors, and toxins.
2) Myth: “Smoking relaxes me when I’m stressed.”
Truth: Nicotine releases dopamine and serotonin, which gives a sense of well-being and pleasure initially, which does not last long. Smoking is a stimulant and increases symptoms of panic and anxiety such as blood pressure and heart rate increase, tense muscles, and less oxygen getting into the brain.
3) Myth: “Tobacco use is not a priority compared to mental health or other substance use issues.”
Truth: Those in recovery form other substance use are 25% more likely to stay completely abstinent from substances when quitting cigarettes at the same time.
Truth: Quitting smoking can decrease depression, anxiety, and stress.
4) Myth: “Medications for stopping smoking are dangerous and I don’t need them.”
Truth: Less than 5% of people who try quitting “cold turkey” are successful. By using medications to reduce withdrawal, patients can start working on building new behavioral pathways (which is really hard to do while craving and in withdrawal).
5) Myth: “Smoking is a bad habit, and I don’t have the willpower to quit.”
Truth: Tobacco is a powerful physical and behavioral addiction, and willpower has little to do with it.
6) Myth: I don't inhale smoke from a pipe or cigar, so they aren't addicting.
Truth: Cigars contain more nicotine than cigarettes – tobacco is rolled in tobacco leaf, not paper.
Cigars, pipes, chewing tobacco – nicotine absorbed in the cheek.
Cigarettes have 10mg nicotine/cigarette, but only 1mg is absorbed VS smokeless tobacco which has up to 25mg nicotine/plug.
Nicotine levels peak with cigarettes at 5 minutes VS 30 minutes with smokeless tobacco
Higher levels of nicotine stay in the blood with smokeless tobacco than cigarettes.
7) Myth: Tobacco use only impacts my lungs.
Truth: tobacco does effect the lungs, leading to COPD and Chronic Bronchitis
Tobacco use and blood vessles: Builds plaque, makes plaque unstable (increased risk for stroke or heart attack). Even 2-3 cigs per day increased plaque instability.
Inflammation from tobacco use can worsening pain and autoimmune issues.
Tobacco use increases risk of cancer.
Tobacco use drastically decreases surgical outcomes.
Tobacco use decreases life expectancy by 10 years.
8) Myth: “I’ve smoked a long time, the damage is already done.”
If you quit, lung function stops declining and you will breathe better by reducing inflammation.
9)“I already have cancer, why should I quit?”
Lung cancer treatments are effective.
Tobacco use increases chemotherapy side effects (nausea, weight loss, hair loss)
Tobacco use decreases response to cancer treatment.
10: "I'm resigned to the fact that I'm going to get lung cancer."
Actual risk of getting lung cancer:
Non-smokers – 1% chance
Stop smoking by age 30 – 2% chance
Stop smoking by age 50- 5% chance
Stop smoking by age 75- 15% chance
The bottom line is this: it's never too late to quit. Talk to your primary care provider about support for quitting and share with them the above standard of care for treatment. If you need support or have questions email us at firstname.lastname@example.org
To learn more visit the Duke-UNC Tobacco Treatment Specialist program.