Physical Addiction
Within just 7-10 seconds of inhaling cigarette smoke, nicotine begins affecting your brain.  Nicotine acts on cells in the “reward center” of the brain.  This results in feelings of pleasure and alertness- the "hit" that your body comes to expect.  When bloodstream nicotine levels are at their peak, the brain is highly stimulated.  However, within just 30 minutes, your body has cleaned out most of the nicotine.  You then feel tired, jittery, depressed, or fatigued.  You begin to crave another cigarette, and the cycle continues.  This cycle, which increases in intensity and frequency over time, is part of what makes cigarettes so addictive.  Essentially, smoking becomes a never-ending battle of trying to stay within the ‘comfort zone’.

Psychological Addiction or “Habit”
Ever wonder how cigarettes got to be such an important part of your life?  Here’s one explanation:

Ivan Pavlov was a Russian physiologist who studied behavior change in the early 1900s.  He observed that dogs normally salivate when they are given food.  In his experiments, he rang a bell just before he fed his dogs.  As a consequence, the dogs began to associate the bell with the presentation of food.  Over time, they would salivate if he simply rang the bell without putting out any food.  They had learned “Hey… when the bell rings, it means I’m going to be fed.”

The same thing can happen with smoking.  After smoking many, many cigarettes, various things become “paired” with cigarettes and can bring on the urge to smoke.  For example, if you smoke every time you drive in your car, simply getting into the car can trigger powerful cravings.  It’s like your brain says, “Hey, I’m in the car now, looks like I’m getting nicotine soon!”  Likewise, if you smoke each morning when you first get up, this time of day can lead to powerful cravings for cigarettes, even long after you’ve quit smoking.  For most people, breaking these connections is one of the most important steps in quitting.

Want a few other explanations for your habit?  B.F. Skinner did a series of animal experiments to study how habits are formed.  Although it doesn’t seem like rocket science these days, Skinner found that when behavior is reinforced or rewarded, it is more likely to be repeated; similarly, if a behavior is punished, it is less likely to be repeated.  This makes it easy to see why smoking is tough to stop: there are many powerful “reinforcers” involved in smoking.  The “kick” of nicotine is probably the strongest reinforcer, but social acceptance from other smokers and the perception that smoking is relaxing are other reinforcers to consider as well.  Likewise, many people who try to quit are “punished” by withdrawal symptoms and give up their efforts to quit.

Understanding the Smoking Equation:
People have varying difficulties with either the physical or psychological aspects of quitting smoking.  Maybe you smoked to experience the “hit” of nicotine or to avoid strong withdrawal symptoms.  If so, physical addiction will underlie many of your triggers.  Or… perhaps being in certain places or experiencing certain emotions often made you want to smoke; thus, psychological or behavioral elements will be behind your triggers.  Most likely, though, you’ll find both areas are involved in your smoking patterns to some degree.  It is important to think about why you smoke each time you have a cigarette.  QuitNet members use the “Why do You smoke” tool to figure this out. This will help you identify your triggers.  Once you have identified your reasons for smoking and your triggers, you can go about breaking them one by one.  Nicotine replacement medicines can be an important part of this process.

Methods Of Quitting
The two keys to quit-success are: Commitment- you make up your mind to quit and are willing to go to any lengths to do so; and: Preparation- you take the time to develop a quit-plan that works for you, and to prepare for nonsmoking life.  What we know from over 30 years of research is that different combinations of quit-tools work for different people. The people who succeed are likely to use many tools together, not just one thing.

 A panel of physicians and researchers appointed by the Surgeon General of the United States reviewed more than 6000 studies of quitting and issued a set of guidelines in June 2000.[22] They made some powerful conclusions and recommendations.

They said "Use medicine:"
Research has shown that Zyban™ and nicotine replacement therapy helped people succeed more than trying without medication. Nicotine replacement therapy comes in a number of forms: gum, a skin patch, inhaler or nasal spray.

They said "Get counseling and support:"
Counseling and behavioral approaches are especially effective and should be used by all people trying to quit smoking. The experts said: Don’t quit alone. Get expert counseling and social support. In fact, they found a strong “dose effect”; that means the more support people had the more likely they were to succeed. We have found the same thing on QuitNet. Members who used its support and counseling more frequently were more likely to report success in quitting than those who used it less. Research has also shown that people who took medications and also participated in a support program were more likely to succeed than people who just took medicine. Specific behavioral approaches that help people quit include problem solving and skills training, and using social support.

Medicine & Behavioral Interventions:
We’ll review different kinds of medicine and behavioral interventions first since they are the most effective treatments available.  For people who are interested in other types of quit smoking methods, we’ll review these as well.

·Nicotine Replacement Therapy
Nicotine replacement therapy is an effective way to “wean” yourself off nicotine.  Although not the “magic pill” that it was thought to be when first introduced, nicotine replacement therapy (NRT) has been shown to be very effective and is now recommended for all smokers attempting to quit (when medically appropriate).  On average, all nicotine replacement products are equally effective, roughly doubling the chances of quitting successfully.

The basic idea is to give you time to break the cigarette habit before attempting to actually get off nicotine.  NRT minimizes withdrawal symptoms and helps control cigarette cravings to allow you to concentrate on using behavioral techniques to stay smoke-free.  There are 4 different types of nicotine replacement therapies: the nicotine patch and nicotine gum are available over the counter without a prescription, while the nicotine spray and nicotine inhaler require a prescription from your physician.

What NRT does not do:
·       It doesn't work equally well for everyone.
·       It doesn't eliminate withdrawal symptoms entirely.
·       It doesn't give you any more willpower.
What NRT does do:
·       It does let you concentrate on your habit before breaking the physical addiction to nicotine.

·Zyban:™
Zyban is a prescription medication that was originally used to treat depression.  The idea to use it for smoking came from physicians who saw that their patients being treated for depression spontaneously quit smoking.  Numerous trials have shown Zyban to be at least, if not more, effective than the nicotine patch.  Zyban is thought to work by blocking nicotine withdrawal, making smoking less reinforcing by stimulating certain centers of the brain, and improving mood.  Use of Zyban should begin 2 weeks before quitting smoking to allow blood levels to reach a therapeutic level.  Side effects can include tremor, rash, headache, insomnia and dry mouth. 

Behavioral Interventions:
Counseling – Individual or Group, Telephone or Internet:
Many smokers find it helpful to have the support of other smokers who are trying to quit. Properly run group, telephone and internet  programs help you understand your smoking habits, develop new coping strategies, and set a target quit date; they’re also a good way to learn tips and strategies that other smokers find helpful.  Most good group programs meet for a few weeks after the quit date so members can get support before, during, and after quitting.  One-year quit rates for group programs usually range from 25% - 40%.  The cost of these programs varies, and can range from $15 to several hundred dollars.  Remember… more expensive programs are not always more successful.

There is a strong association between the duration of treatment and also the length of each session.  The more intensive and longer the program, the more likely you are to succeed. When choosing a  counseling  program, look for one that has sessions that are at least 20 to 30 minutes long; offer at least 4 to 7 sessions; and last for at least 2 weeks.  The group leader should be specifically trained in smoking cessation.  The QuitNet National Directory can give you information about programs in your community.

Good telephone programs usually make between three and five followup calls to provide support during the months after a quit date.

QuitNet members participate in the online program an average of 13 times, for about 20 minutes each visit, during the first three months of their quit; they return frequently after that to help others, celebrate their success or reinforce their quit.

Nicotine fading:
Rate fading and brand fading are two strategies of gradually reducing the amount of nicotine in your system before you quit.  They are different than the approach of cutting back since the ultimate goal is quitting, not continued smoking at a lower level.  Smoking fewer cigarettes and smoking low nicotine cigarettes are still hazardous to your health.

Many people use these strategies to prepare for quitting using medicines like the nicotine patch or nicotine gum.  There are a number of benefits of these strategies: they may make withdrawal symptoms less intense after quitting, and they provide mini practice opportunities for coping with mild withdrawal symptoms and for giving up cigarettes which may help later on.  The downside to these strategies is that people often go too slow or too fast: reducing nicotine intake by more than 30% at any time may lead to intense withdrawal symptoms and relapse, whereas reducing nicotine too slowly may result in a loss of motivation and relapse.  If you decide to try nicotine fading, follow the instructions below carefully and use the NICOTINE FADING CHART[2] to help you track your progress.

Other Approaches:

Cold Turkey
Some people swear by this approach.  It’s a no-nonsense, low-cost approach… the “Just Do It” method for quitting smoking.  About 85% of smokers who try to quit do it “cold turkey”; however, this strategy has been shown to be far less effective than active approaches like nicotine replacement therapy and behavioral counseling.  The problem is that, for most people who quit cold turkey, nothing changes except the smoking.  Daily routines are still the same, methods of coping with stress and frustration are still the same, and the body’s dependence on nicotine is still the same.  With all these powerful triggers to deal with throughout the day, it’s no surprise why many people relapse within just 3 days after trying to quit cold turkey.

Cutting Back
Many smokers believe that just cutting back on the number of cigarettes is enough to avoid the dangerous health problems associated with smoking.  It just doesn't work that way.  There is NO safe level of smoking.  Over time, most people go back to smoking their regular amount anyway.  Cutting back is not an effective or recommended approach to quitting smoking.

Alternative Therapies
Even though alternative therapies like acupuncture, hypnosis, and herbal remedies are more readily available and have gained some recent popularity, their effectiveness is still unproven in clinical studies. The Surgeon General’s Guidelines of June 2001 did not recommend any of the following approaches as effective ways to quit smoking.  Any effect that these therapies produce is most likely due to positive expectations… in other words, belief in the value of the treatment.  We review them here for informational purposes only and do not recommend any of these:

a)    Acupuncture
Acupuncture is based on ancient Chinese medicine.  Nerve endings located near the surface of the skin are thought to be connected to certain organs and body functions.  For example, specific spots on the ears, nose, and wrists are thought to be related to the urge to smoke.  The few studies that have been done on acupuncture have found few differences between “active” acupuncture and “sham” acupuncture.[23]

b)    Hypnosis:
Hypnosis tries to change your attitudes about smoking to help you quit.  While hypnotized, you’re given certain suggestions that might include: reminders to relax when you are having a craving and to feel good when you successfully resist the urge to smoke, or, ‘unconscious commands’ to be acutely aware of the stench of tobacco smoke, its harsh taste, etc.  In general, research studies have shown that while hypnosis may be credited anecdotally with helping in the early stages of the quitting process, it’s not an effective long-term strategy.

c)     Herbal remedies:
Tobacco-free cigarettes contain a mixture of various herbs like jasmine, ginseng, and clover.  Although they may seem like the ‘best’ of both worlds (smoking without the dangers), these products still contain damaging tar and carbon dioxide just like regular cigarettes, as well as many chemical compounds released by the burning process. 

In the past few years, herbal medications such as Kava Kava, a natural anti-anxiety medication, and St. John’s Wort, an anti-depressant, have been used by ex-smokers. Often touted as natural substitutes for other synthetic quit-tools like Zyban, clinical research hasn’t demonstrated the same degree of effectiveness for these medicines. However; some ex-smokers swear by them.  Remember… all medications, natural or synthetic, have side-effects and potential risks, so be informed and aware before you use them. If you're unsure about any medication, check with your physician.

Preparing For Quit Day
Getting prepared for your Quit Day is as important as the day itself.  The more prepared you are to quit, the more likely it is that you will quit successfully and comfortably.  All too often, people make the mistake of jumping into quitting, thinking that they have to sink or swim.  It doesn’t need to be like that, and shouldn’t be if you really want to quit successfully.  With a little preparation, you can make giving up cigarettes a lot less difficult.  Each of these strategies is designed to help you unlearn your smoking habit and quit safely.

Talk to Your Doctor
Smoking may impact the way your body processes certain medications. Nicotine and the other chemicals in cigarettes speed up the metabolism of many drugs.  This means when you are smoking, these medications are eliminated from your body more quickly than if you were not smoking.  Once you quit, your current dose of medicine may become too strong.  If you are currently taking any medications, especially for psychological problems, consult your doctor before you quit smoking.[24]  You should not change how you take your medications until you talk to your doctor first.

Get Support
Getting positive support from friends and family is one of the most important things you can do to improve your chances for success.  Unfortunately, many smokers pride themselves on being independent and strong-willed and try to quit smoking by toughing it out alone.  People who actively arrange a support system for their quitting efforts are more likely to succeed, and they succeed with greater comfort. . For example, QuitNet buddies exchange thousands of e-mail support messages every day and Q members help each other in the forums 24X7.  Ask for the support of several family members and friends.  Ideally, you should have a support person at home, at work, and in social situations.  Tell each of these people about your plan to quit and ask for their support.  It’s a good idea to tell them specifically how they can be helpful to you; some people may think that nagging and “checking up on you” is helpful, for example, when in fact this may cause you more stress.

Coping with Triggers
This is a two step process, sort of like fighting a battle.  First you have to know who your enemy is; then you have to plan an effective attack strategy.  By keeping a record of when you smoke, you can start to identify triggers.  Once you know what your triggers are, you can figure out how to manage triggers without smoking.

The Day Before
Quitting smoking is a big change in your life.  Don't downplay it -- in fact, you should have a clear line between your life as a smoker and your new life as a non smoker. Anything you can do to help draw this line will not only make quitting easier, but will also make it more likely that you stay smoke free.  Think of it as a clean start!

• Throw away all your cigarettes.  Look through every possible place you might have cigarettes: jacket pockets, the bottom of your purse, the glove compartment, your nightstand, etc.
• Throw away your ashtrays, give them away, or at least wash them and hide them away somewhere.
• Get a hair cut.
• Clean house.  The car, your clothes, even the furniture. You may not be able to smell the smoke right now, but you will after you quit.
• Drink lots of water -- it will help flush the nicotine from your system and reduce the intensity of withdrawal symptoms.
• Reduce your caffeine intake by at least half. Cut back some or start mixing in decaf well before you quit.  Nicotine makes caffeine metabolize much more quickly in the body.  If you consume the same amount of caffeine when you stop smoking, it can lead to caffeine toxicity… nervousness, anxiety, restlessness.  All powerful triggers for smoking again.
• Get some exercise.  Not only will it make controlling your weight easier, but it will also give you more energy and keep your mind off smoking.  Walking, running, even bowling are all very helpful.
• Visit QuitNet and find a buddy who has a quit date near yours.