Background
Smoking cessation is an effort by a person who regularly uses tobacco products to establish a plan to reduce, and eventually eliminate, tobacco use. Tobacco contains nicotine, a highly addictive drug, in addition to the 69 chemicals known to cause cancer. All major medical institutions acknowledge that quitting smoking greatly increases a person's health prospects.
Smoking cessation may be accomplished by many different approaches. The pharmacological approach often contains various nicotine replacement therapies, such as the patch, nicotine gum or lozenges, or even a nicotine inhaler. Some alternative therapies include certain herbal combinations, such as kava and chamomile, acupuncture, hypnotherapy, psychotherapy, and relaxation therapy. Some individuals simply pick a quit date and stick with it.
In the past few decades, the medical community has come to recognize the enormous health risks of smoking. Though governmental and health related organizations have conducted extensive campaigns to address the hazards of smoking, less information is available on strategies a smoker can use to quit.
According to the American Lung Association, smoking is the leading preventable cause of increased morbidity (increased risk for disease) and mortality (death) in the United States. Approximately one of every five deaths (438,000 deaths) each year can be attributed to smoking including deaths from lung cancer, emphysema, and heart disease. Causes of death from cigarette smoking include: stroke, lung cancer, coronary heart disease, chronic lung disease, other cancers, and other conditions
An estimated 20.9% of all adults (age 18 or older), or approximately 44.5 million people, smoke cigarettes in the United States. Cigarette smoking is more common among men than women.
Among current adult smokers in the United States, 70 percent report that they want to quit completely. In 2004, an estimated 14.6 million, or 40.5% of adult smokers, had stopped smoking for at least one day during the preceding 12 months because they were trying to quit. Nearly 54% of current high school cigarette smokers in the United States tried to quit smoking within the preceding year.
Technique
A doctor's edict is often not enough to help a person through the difficult process of quitting. Support from family and friends greatly increase a person's likelihood to abide by their decision to quit. Even if a person has developed one or more medical conditions from smoking, they can prevent the onset of other medical conditions and slow the progress of the one they have by quitting.
Individuals who make a plan to quit are twice as likely to succeed, according to the American Cancer Society (ACS). The ACS sponsors a website, called the Great American Smokeout, to provide resources to individuals who wish to stop smoking. No one method to quit smoking will work for every person. Individuals wishing to quit will increase their likelihood of success if they consider all of the options available.
Cold turkey: An individual picks a "quit day," or day to stop smoking. Many individuals choose to quit in honor of a loved one who died from smoking complications.
Hypnotherapy: The process of hypnotherapy can be divided into pre-suggestion, suggestion, and post-suggestion phases. The pre-suggestion component may include selective focusing of attention with distraction, imagery, and relaxation methods. An aim is to reach an altered state of consciousness in which the conscious mind is relaxed and the unconscious mind is more accessible, therefore making the subject susceptible to suggestion. In the suggestion phase, specific goals or impressions are presented. This is where the therapist would suggest the goal to quit smoking. The post-suggestion phase occurs after a return to a normal state of consciousness, and new behaviors based on hypnotic suggestions may be practiced. The therapeutic goals of hypnotherapy vary, and may include the treatment of psychological or medical conditions or alteration of behaviors/habits. Self-hypnosis techniques may be used as an adjunct to sessions with a hypnotherapist. There is wide variation in the training and credentials of hypnotherapists. Certification is granted by multiple organizations, with different requirements. In the United States, there is no universally accepted standard or licensing for hypnotherapists. Although many therapists are not licensed medical professionals, some doctors, dentists, and psychologists are trained in hypnotherapy and may use hypnosis in their practices. Books and audiotapes are available for training in self-hypnosis, although these have not been well evaluated scientifically. Group sessions may also be offered. Hypnosis sessions may vary from a brief encounter to multiple, continuous sessions.
Pharmacological therapies: These include nicotine replacement products like herbs, gums, inhalers and patches or non-nicotine medications, such as bupropion SR® (Zyban). Nicotine replacement therapies are intended to help a patient deal with withdrawal symptoms, cravings, and urges associated with nicotine withdrawal, by replacing nicotine through various forms of administration. These forms include inhalers, patches, gums, nasal sprays, and lozenges. Most of these forms of nicotine replacement are available over the counter, and the directions for usage vary according to which method a person chooses. It is important not to smoke while using nicotine therapy, as to avoid harmful nicotine overdose.
Proactive telephone calling: Nurse counselors that call smokers receiving pharmacotherapy may be an effective method of enrolling smokers into a cessation quitline. This approach involves counseling and advice administered over the phone. Some individuals ask for family and friends to call during the initial stages of withdraw.
Psychosocial therapy/behavior therapy: Brief clinical interventions by health care providers may increase chances of successful cessation, as may counseling and behavioral cessation therapies. Treatments with more person-to-person contact and intensity (more time with counselors) may be more effective. Individual, group and telephone counseling are available. Behavior therapy, which is a form of counseling, may help change behaviors and thoughts that contribute to anxiety and possibly addiction. Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). Its purpose is the exploration of thoughts, feelings, and behavior for the purpose of problem solving or achieving higher levels of functioning. This therapy may help a person to: attain a better understanding of personal anxiety triggers, develop coping skills, and/or learn relaxation techniques to aid in smoking cessation. Generally, sessions range from 50 minutes for individuals to 90 or 120 minutes for groups. The number of sessions varies widely depending on the problems being addressed. An hour of therapy may range from $5 or $10 an hour at a community or non-profit mental health center to over $200 an hour for a doctoral level practitioner in private practice.
Relaxation techniques: This method aims to reduce stress level, and may include meditation or breathing exercises. Meditation, like many relaxation techniques, involves focusing on a word or object in a quiet environment to provide relaxation. Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation, but it can be used in cases of addiction to aid in a patients' abandonment of harmful or undesirable habits. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), adoption of a passive attitude towards intruding thoughts, and return to the focus. Relaxation techniques may be taught by various complementary practitioners, physicians, psychotherapists, hypnotherapists, nurses, clinical psychologists and sports therapists. There is no formal credentialing for most relaxation therapies.
Support groups: In this method, individuals share stories and find a feeling of common struggle from other individuals who are struggling with or who have overcome the urge to smoke.
Theory/Evidence
Nicotine is the psychoactive component, or the drug, which affects the brain in tobacco products, thus producing dependence. Most smokers are dependent on nicotine, and smokeless tobacco use may also lead to nicotine dependence. Research suggests that nicotine may be as addictive as heroin, cocaine, or alcohol. Examples of nicotine withdrawal symptoms include irritability, anxiety, difficulty concentrating, and increased appetite. Quitting tobacco use is difficult and may require multiple attempts, as users often relapse because of withdrawal symptoms. Tobacco dependence is a chronic condition that often requires repeated intervention.
Smoking damages nearly every organ in the human body. Tobacco smoke carries more than 60 cancer-causing chemicals, tiny amounts of poisons such as arsenic and cyanide and more than 4,800 other substances, some of which may be harmful, to the human body. These toxins cause cell death, cell damage and cell mutation.
The list of diseases caused by smoking has been expanded to include: abdominal aortic aneurysm, acute myeloid leukemia, cataract, cervical cancer, kidney cancer, pancreatic cancer, pneumonia, periodontitis, stomach cancer, cardiac diseases, lung diseases, and stroke. Smoking may also have a negative impact on the health of both unborn and newborn children.
Stopping smoking may greatly reduce the risk of dying prematurely. Benefits may be greater for people who stop at earlier ages, but cessation is beneficial at all ages. Cessation may lower the risk for lung and other types of cancer. The risk for developing cancer declines with the number of years of smoking cessation. Risk for coronary heart disease, stroke and peripheral vascular disease is reduced after smoking cessation. Coronary heart disease risk may be substantially reduced within one to two years of cessation. Cessation may also reduce respiratory symptoms such as coughing, wheezing, and shortness of breath. The rate of decline in lung function is slower among persons who quit smoking as compared with those who continue to smoke.
Quitting smoking may have immediate as well as long-term benefits including reduced risk for diseases caused by smoking and improved overall health. Many clinical studies have been demonstrated that reductions in smoking rates may substantially improve health outcomes and reduce health care costs, even in the short term. Some clinical studies have suggested that COPD (chronic obstructive pulmonary disease) patients felt better after quitting smoking.
Hypnotherapy: The mechanism of action of hypnosis is not well understood. Some physiologic changes have been associated with hypnosis, including alterations in skin temperature, heart rate, intestinal secretions, and immune response. The mechanism of such changes is not clear. During hypnosis, decreases have been noted in heart rate, blood pressure, body temperature, and brain wave patterns (alpha waves). Similar changes have been reported with other forms of relaxation. Hypnosis is associated with a deep state of relaxation. Whether this represents a specific altered state of consciousness is the subject scientific debate. There are reports that suggestion alone, without the process of hypnosis, can achieve many of the same results, although research in this area is not conclusive. It is not known why some individuals are more susceptible to hypnotic suggestion than others.
Pharmacological therapies: Findings from a recent Cochrane review of controlled trials testing nicotine replacement therapy (NRT) products indicated that smokers using NRT were 1.5 to 2 times more likely to be abstinent from smoking at follow-up than those in the placebo or control treatment condition. However, some studies show NRT success rates at six months to be less than 10%, actually lower than the 11-12%success rate using the "cold turkey" method.
Psychosocial therapy/behavior therapy: Several studies suggest that group therapy, psychotherapy or behavior therapy, may be more effective than self-help for quitting smoking. However, there is not enough evidence to show that group therapy is as effective or cost-effective as intensive individual counseling. More research is needed to determine effectiveness.
Relaxation techniques: Early research reports that relaxation with imagery may reduce relapse rates in people who successfully completed smoking cessation programs. Better study is needed in this area before a firm conclusion can be reached.
Safety
Hypnotherapy: It has been suggested that there is a risk of false memories (confabulation) as a result of some types of hypnotherapy, although scientific research is limited in this area. The safety of hypnotherapy has not been thoroughly studied. Practitioners sometimes discourage hypnosis in people with psychiatric illnesses such as psychosis/schizophrenia, manic depression, multiple personality disorder, or dissociative disorders, due to a proposed risk of exacerbation. Hypnosis is sometimes discouraged in people with seizure disorder, although study is lacking in this area.
Pharmacological therapies: Pharmacological therapies for smoking cessation are generally considered to be safe with appropriate supervision by qualified health professionals. Side effects to pharmacological therapies may include nausea, vomiting, headache, insomnia, and dizziness. Mild adverse effects may be indicative of more serious problems and patients should consider discontinuing current treatment and contacting a physician. Patients may also consider switching to other available products. If the replacement therapy is discontinued, nicotine withdrawal symptoms may include: cravings for tobacco, anxiety, irritability, restlessness, difficulty concentrating, headache, drowsiness, stomach upset, constipation, or diarrhea. People with certain medical conditions, including but not limited to high blood pressure or recent cardiac infarction, need to consult with a health care provider before starting nicotine replacement therapy. However, it is believed that using these forms of nicotine replacement is significantly less harmful than using cigarettes or snuff. Smoking while using a nicotine replacement therapy may lead to a harmful overdose of nicotine.
Psychosocial therapy/behavior therapy: Some forms of psychotherapy may induce strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions.
Relaxation techniques: Most relaxation techniques are non-invasive, and generally are considered to be safe in healthy adults. Serious adverse effects have not been reported. It is theorized that anxiety may actually be increased in some individuals using relaxation techniques, or that autogenic discharges (sudden, unexpected emotional experiences including pain, heart palpitations, muscle twitching, crying spells, or increased blood pressure) may occur rarely. Scientific evidence is limited in these areas. People with psychiatric disorders such as schizophrenia/psychosis should avoid relaxation techniques unless recommended by their primary psychiatric healthcare provider.
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