This article originally appeared in the October 2003 Harvard Heart Letter and is provided courtesy of Harvard Health Publications.

Let the butt stop here

Any time is the right time to stop smoking. A host of stop-smoking aids can boost your odds of success.

In the old days, when smoking was just a bad habit, willpower was the only way to shuck it. But sheer willpower didn’t work well then, and it doesn’t work any better today, even when almost everyone knows the health hazards of smoking.

Fortunately, there’s no need to go it alone. Smokers who want to quit can now choose from a variety of tools that double or triple their chances of succeeding. The best approach uses medication to quell cravings for nicotine along with some sort of support or counseling to break the patterns that make a smoker reach for a cigarette.

Know the enemy
Smokers tend to underestimate the hazards of smoking, the benefits of quitting, and the barriers to quitting, says Dr. Nancy A. Rigotti, an associate professor of medicine at Harvard Medical School and director of the Tobacco Research and Treatment Center at Massachusetts General Hospital.

Hazards: Most people know that smoking increases the chances of developing lung cancer. But many aren’t fully aware it’s also a key cause of heart attack, stroke, and other cardiovascular problems. Smoking also contributes to many types of cancer besides lung cancer, as well as emphysema and other breathing problems, tooth and bone loss, ulcers and acid reflux, sleeping problems, and a host of other ills.

Benefits: Quitting improves the chances of living longer, reduces the odds of developing the problems listed above, and slows the spread of tobacco-related diseases. These benefits hold true even if you stop smoking after age 65 or if you’ve already developed a smoking-related illness. For example, smokers who quit after having a heart attack tend to live longer than those who keep smoking.

Barriers: Many things get in the way of stopping smoking. The two biggest barriers are the physical addiction to nicotine and the psychological addiction to the habit of smoking. Others include stress, a mistaken belief that it’s too late to stop, and the influence of other smokers.

Tools for quitting
When a panel appointed by the U.S. Public Health Service reviewed smoking cessation methods, it made two clear recommendations: Use medicine, and get counseling and support.

Nicotine is a powerfully addictive substance. It stimulates the brain’s “reward center,” creating a sense of pleasure and alertness. Yet these feelings fade as the body washes nicotine from the system. They’re replaced by other sensations that aren’t so pleasurable (see Withdrawal symptoms), which nudge a smoker to light up again. Smoking is basically an effort to keep the brain in its nicotine comfort zone.

Easing the craving for nicotine is a key part of stopping smoking. Several aids can do this (see Stop-smoking aids). Nicotine patches, gum, lozenges, nasal spray, and cigarette-shaped inhalers deliver enough nicotine to satisfy the body without the tar, carbon monoxide, and other harmful chemicals found in cigarette smoke. An antidepressant known as bupropion (Zyban, Wellbutrin) also alleviates the symptoms of nicotine withdrawal, even in people who aren’t depressed. Combining bupropion and nicotine replacement may work the best of all.

Nicotine replacement is safe, even after a heart attack. Just as important, patches, gum, and other nicotine delivery systems are safer than continued smoking. They don’t increase the clotting potential of blood or damage the fragile but important lining of blood vessels, as smoking does.

By itself, nicotine replacement isn’t enough. Two thousand years ago, the Roman poet Ovid wrote, “Nothing is stronger than habit.” Although he was speaking about love, his words apply perfectly to smoking. Over time, smokers link having a cigarette with other activities or feelings. For some, the smell of coffee or the sound of a rustling newspaper triggers the urge to smoke. For others it’s getting into the car, finishing a meal, or feeling stressed.

Breaking these ingrained links is essential to successfully stop smoking. Here’s where counseling and social support come in. These can help you figure out your smoking cues, devise plans to break the link between cues and the act of lighting up, learn to identify and cope with the symptoms of withdrawal, and anticipate situations and problems that might make you start smoking again.

The most effective — and most expensive — way to do this is by working one-on-one with a smoking cessation counselor. Group counseling or support groups run by hospitals, national organizations, and state or local health departments work almost as well. Counseling from a telephone quit line is helpful. And a growing number of people are finding virtual counseling and support via the Internet. (See More information.)

A plan
If you want to stop smoking, a game plan will help you succeed. Here are some steps to consider:

• Pick a “quit day.” Look at your calendar and decide on a good day to quit.

• Prepare for it. Choose a method for controlling nicotine cravings that you think will best fit you. Talk with a smoking cessation counselor about strategies for coping with tobacco triggers.

• Talk to your doctor. Smoking speeds up how quickly the body processes some medications. Quitting may mean you’ll need a lower dose of some drugs.
• The day before. Toss out cigarettes, lighters, ashtrays, and other smoking paraphernalia.

• Quit day and beyond. If you’ve chosen to use some sort of nicotine replacement, start it up. Keep busy, so you don’t dwell on the important change you’re making. When the urge to smoke creeps up on you, chew some gum, chomp on a carrot stick, drink a glass of water, or breathe deeply for a minute or so. Use the habit-breaking tips you’ve learned.

• Get moving. Starting an exercise program, or exercising more, can help you avoid the weight gain that often follows quitting. It can also burn off quitting-related restless energy and low moods.

• Seek support. Get help from a counselor, doctor, friends, or others who can give you moral and physical support.

Slip, don’t slide
There’s an important distinction between a slip (a mistake) and a slide (a relapse). You slip when you smoke once or twice after your quit date. You relapse when you go back to your former smoking pattern. Slipping is common and doesn’t make you a smoker again. If you slip, try to figure out what went wrong and how to fix it the next time. Above all, don’t let one slip lead to another cigarette, then another...

The same holds true for a return to smoking. It’s not a catastrophic failure. You may have to quit two, three, or even more times before you stop smoking for good. Not succeeding may just mean you need more help.

“ I see lots of people who tell me they can’t quit even though they’ve tried everything,” says Dr. Rigotti. “But most haven’t tried counseling, which is enormously helpful, especially when combined with other approaches.”