In many countries, including Australia, developed or developing, tobacco products remain the largest contributors to lifestyle-related death and disability.

The risks of smoking and using other tobacco products are very well known and highly publised. Despite the well known risks associated with using tobacco, like any drug use, people make choices about what they do.

The main difference between tobacco use and other drug use is that tobacco is a legal drug and it's taxed in Australia and elsewhere. This means that the government 'mediates' drug-related harm through policy measures for the sake of tax. Despite tobacco taxation as a strategy in most parts of the world, the black market in tobacco trade is amazingly active.

As the wealth of current information about the health risks of smoking continues to accumulate, the choice to smoke or not is your choice. Smoking is still one of the most poisonous activities we of and it's so addictive.

Nicotine and addiction

Addiction is a complex issue. Addictive behaviors exist in many facets of life and are certainly not confined only to areas related to alcohol or other drug use.

Nicotine is known to be a highly addictive substance that can be extremely difficult for people to stop using. Unfortunately, with smoking, some aspects of the addiction are closely related to the social patterns in which smoking has become ingrained.

'Breaking the habit' is physical and mental. To quit successfully, most people have to give a go quite a few times before they really stop.

The 'Stages of Change' model is often used to help describe people's mindset about changing their behaviours. It is also valid in the context of smoking as it is a useful aid to thinking about different peoples' preparedness to change their behavior.

It has been applied to various clinical situations to assess the potential for lifestyle modification through increasing knowledge, changing attitudes and, particularly in the case of tobacco, support for cessation methods (Cohen et al., 2002).

The model describes the following five stages:

• Precontemplation
• Contemplation
• Ready for change
• Action
• Maintenance

With reference to smoking, the precontemplative stage describes someone who is yet to consider any form of behavior change. The person may have been smoking for a short or long period of time, but has not as yet noticed any health deficits.

There is unawareness that smoking has affected them in any way and they are yet to acknowledge that there is any need to stop smoking. The subsequent stages are contemplative (thinking about change); preparation (acknowledging that action is needed and preparing to do something); action (making attempts to change); and maintenance (stopped and now trying to maintain progress). People can move either way along the five stages. The model can also be used in thinking about a number of other health-related behaviors.

Symptoms of tobacco withdrawal

Nicotine withdrawal symptoms include depression, irritability, anxiety, disturbed sleep, and weight gain. Many people experience cravings, which can last for months to years, but may disappear within weeks. But for some ex-smokers, it may take two or three years of perseverance and self-control to maintain desirable lifestyle adjustments.

Some people choose to stop smoking and one day they just stop. For the majority, however, the quitting process is much more gradual and episodic (numerous failed previous attempts). Various interventions are available to help this process.

Effective cessation methods are very much related to individual behavior, preferences, prior experiences and choices. There are many options and many health professionals who are able to help people stop smoking. Most people do not successfully quit the first time, so it is important to persevere and take small steps at a time.

Nicotine replacement and other drug therapy

Nicotine replacement methods come in a number of forms. These include skin patches, nasal sprays, inhalers, and gum. Such replacement is usually undertaken to allow the person to more easily avoid smoking cigarettes without experiencing severe and unmanageable cravings. Different people use nicotine replacement differently. It is never advisable to smoke and use nicotine replacement concurrently. Nicotine is a highly toxic substance, and in high dosage (such as occurs if one smokes while using patches etc) it is not infrequent for serious states of intoxication and illness to occur.

Most forms of nicotine replacement have slightly different actions because with different delivery systems the nicotine is absorbed and metabolized at different rates. This will affect the way one feels. Inhalers or nasal sprays deliver nicotine to the bloodstream very rapidly and in a fashion which is similar to that of a cigarette.

Early in the quitting phase, these may be most appropriate because blood levels rise and fall quickly and toxicity is less of a problem if smoking is still occurring. Once the person is able to avoid smoking cigarettes, the next step is to be in a position to maintain steady background levels of nicotine for a period, and then taper the use of nicotine off slowly to zero.

Patches or nicotine gum release nicotine steadily and slowly over the day. Getting used to not experiencing the 'hit' or surge of nicotine can be quite difficult. If replacement therapy has not worked in the past, or it has been very difficult to give up, there are medications available to help with this.

Medications

The following medications are prescribed to reduce withdrawal symptoms associated with smoking cessation. The notion supporting their use is that by eliminating the unpleasant withdrawal effects, there is less motivation for the person to revert back to smoking cigarettes once the decision has been made to stop.

Mecamylamine is a nicotine antagonist. This means that it blocks receptors in the brain so that one doesn't experience the 'hit' from the nicotine. Mecamylamine has shown quite a high degree of success, especially when used in conjunction with nicotine replacement patches and support.

Bupropion (Zyban/Wellbutrin) is a dopamine reuptake inhibitor and has been used in the treatment of depression and anxiety and to aid smoking cessation. The use of bupropion on its own has similar efficacy to the use of nicotine patches. Using both in combination improves success rates.

Perry (2001) suggests that the drug should be started about 1 week prior to the set quit date and continued for about 7-12 weeks after that time. It can cause side effects and interact adversely with various other drugs so its use requires medical supervision.

Psychological

Therapy or counseling can help some people to quit because they find the support and guidance useful. Various health professionals are well prepared to help people quit smoking by dealing with some of the psychological issues associated with the process. Although there are many useful supportive approaches to smoking cessation based on the short-term use of cognitive-behavioral therapy, people do not generally participate in extensive or long-term psychotherapy regimes for the sole purpose of quitting smoking.

Clinician assistance

Doctors are equipped to deal with smoking cessation and are able to prescribe medications, provide information and give support to people who wish to give up. Talking with a doctor about the range of options available to assist in the quitting process often helps people feel more confident about making a concerted effort, and to make real progress.

It is important to remember that stopping smoking is not easy and often takes a few attempts. The doctor is in the best position to help find an approach that works for the individual.

Some people may find it useful to make deals or contracts with family members or friends to encourage positive progress. It can be of assistance to have someone to talk to if experiencing cravings or having difficulties. Use such social support as much as possible, keep busy, and above all don't stop trying.

Hypnosis

Hypnosis has been around for a long time and it has become more credible because it is very effective for many people. Hypnosis techniques are also always changing. To see a professional therapist, as with most psychological work, is quite expensive.

CDs and others recordings are incorporating newer scripts and techniques all the time to increase their effectiveness. Hypnosis doesn't replace any of the other techniques, but it can be a useful strategy to assist in changing ones mindset.

References

Cohen, J. E., Pederson, L. L., Ashley, M. J., Bull, S. B., Ferrence, R., & Poland, B. D. (2002). Is 'stage of change' related to knowledge of health effects and support for tobacco control? Addictive Behaviors, 27(1), 49-61.

Karnath, B. (2002). Smoking cessation. The American Journal of Medicine, 112(5), 399-405.

Katz, D. L. (2001). Behavior Modification in Primary Care: The Pressure System Model. Preventive Medicine, 32(1), 66-72.

Perry, B. L. (2001). Smoking cessation: successful intervention. Primary Care Update for OB/GYNS, 8(1), 36-39.