ADVICE TO SMOKERS WHO

WANT TO QUIT

JAMES K. ROTCHFORD, MD, MPH

Nicotine is clearly one of the most addicting substances known to man. I consider myself addicted to the nicotine in cigarettes-this despite difficulty remembering the last time I smoked and never having smoked more than ten in a day.

A. SMOKING IS NOT AN ISOLATED BEHAVIOR. Studies of addictions show that addictive behavior is not isolated behavior. Having a cigarette becomes intertwined with other personal ways of responding to life. The smoker will often say that a cup of coffee, a big meal, emotional stress, a beer or a lonely moment-any number of cues-will prompt a desire for a cigarette.

These cues, however, are just the tip of the iceberg. Without outside help and a willingness to be introspective, the smoker will likely not appreciate the degree to which smoking is associated with other aspects of their life.

PRACTICAL POINT: To increase the odds of successfully stopping smoking and remaining abstinent, I suggest smokers also change some other behaviors at the same time they stop smoking. I encourage patients to adopt healthy patterns rather than to overeat, overwork, over drink, or the like. Near the end of this paper are some examples of healthier patterns to adopt.

B. ADOPT A WIN-WIN APPROACH.

Question the win-lose absolute proposition. Instead, see stopping smoking as a process that will likely involve years of effort. The first step, physically stopping, does not mean you're no longer a smoker.

Here's a helpful analogy. Say an immigrant comes to the United States from Russia. She intellectually knows and believes that she's better off as an American. She spends years making the necessary preparations to get American citizenship. When all is said and done, she thanks God for being an American. But that doesn't mean that she is no longer a Russian.

Being an ex-smoker can be as difficult as changing nationalities. And the win-win approach comes from the awareness that becoming an ex-smoker is a process, not an absolute change. The only way to lose the bet is to give up trying and thus end the process. If you have a setback, learn from it so that next time you will be better prepared. The rules of this game are such that, if you keep trying, you are a winner. Statistics support the notion that the people who are successful in smoking cessation are those who tried and failed in several previous attempts.

PRACTICAL POINT: A friend or a loved one might not be helpful during your setbacks. They might say such critical remarks as, "I thought you were going to quit smoking." I suggest that you respond with comments that let them know that stopping is a process; for example, "I'm having a hard time now and I'd appreciate your support. I may have suffered a setback but the war isn't over yet."

For a lucky few stopping smoking is easy. For many, however, only the relentless desire to be free allows them to continue the fight and to finally win.

The win-win proposition can be strengthened by the knowledge that in entering the process of stopping smoking you will likely enhance other aspects of your life as well.

C. BE KIND TO YOURSELF. Many of us have learned the old put-down tactic, or nasty comments, as a way of changing behavior in ourselves or others. "What's the matter with me? Smoking is a dirty, ugly habit. I must be a real jerk. I should know better." Such negative self-talk doesn't help in the long run.

Remember to monitor such abusive cliches. Your cigarette addiction doesn't define who you are. Indeed, I believe just a greater awareness that you are much more than what you do creates a context in which the urge to smoke evaporates.

Wonderful and loving people have been smokers. There is nothing inherently wrong with taking pleasure in smoking. The issue is addiction and the desire to be free of it, whether for health, family, spiritual, financial, or other reasons. Although telling yourself you're nasty might be effective in the short run, in the long run you will be healthier and happier if you are kind to yourself.

PRACTICAL POINT: Accentuate the positive. Learn new ways to reward yourself other than with a cigarette. See the list at the end of this paper.

D. GET HELP. Smokers have a typical pattern of reacting to life with isolation. Their cigarettes become their best friend. Hurt, happy, lonely, or sociable-every mood engenders reaching for a cigarette rather than reaching out to a friend. I don't believe professional help is always necessary but it can be quite helpful. Your physician also has a number of options available to mitigate the symptoms of withdrawal from nicotine and this help may, in turn, promote continued support from friends and loved ones. Professional help also may guide you through the onslaught of feelings that can be intense and confusing during the recovery from addiction-feelings of anger, anxiety, depression and other painful emotions.

Change, even for the better, is often painful. "No pain, no gain" is a popular reminder of this paradox. To have your painful feelings validated by a professional can be a great help. I believe that in conquering any addiction a person must ultimately accept pain, and be willing to stop trying to fix and relieve and relieve pain right away. A listening ear can go a long way in allowing uncomfortable feelings to be and to pass away without any need of fixing.

PRACTICAL POINT: In dealing with addictions I've found it helpful to remind myself that it is okay not to feel good all the time. Our culture conveys the misleading message that if we have our lives in order, we don't ever have to suffer. Addictions flourish in such simple-minded denial. I've come to appreciate more and more the paradox, "In weakness there is great strength."

E. ACCOUNTABILITY WORKS. In all areas of human endeavor, being accountable to something or someone promotes positive outcomes. The endeavor to stop smoking is no different. If you are willing to become accountable to someone other than yourself, you are more likely to attain your goals. Although I believe we are all ultimately accountable to God, I think that smokers will have better results with quitting if they become accountable to another person.

PRACTICAL POINT: In my opinion this person should not be the spouse but obviously someone who you feel comfortable with and has some compassion and understanding when it comes to dealing with an addiction.

F. PRAY. Prayer can be a great help. Gerald May, M.D. in his book Addiction and Grace argues that conquering addictions most likely requires spiritual growth. Current research also indicates that different forms of meditation might also assist addicts to be free. None of this is to imply that smokers are less spiritual than non-smokers-and everyone can benefit from techniques that foster spiritual growth-only that prayer and meditation are valuable tools to acquiring peace and freedom.

G. HELPFUL BEHAVIORAL TECHNIQUES

a. Avoid having cigarettes too readily available. I've heard of smokers who, after some time of abstinence, start smoking again without even thinking about it; they just wake up and grab a cigarette because it's there, before they remember that they've quit. A new strategy is to crumple up your pack of cigarettes. That way, it would be difficult to take one without making a conscious choice to do such. The point here is not to encourage a feeling of deprivation.

b. Plan to reward yourself with something special after the first week, first month, and every month smoke-free.

c. Stop any behavior that you know triggers an increased desire to smoke, like drinking coffee.

d. Start to limit times, places, and people with whom you are willing to smoke. Avoid situations where everyone smokes.

e. Listen to music or play an instrument.

f. Take up yoga or karate.

g. Get into a vigorous aerobic conditioning program. (With appropriate health precautions.)

h. Spend more time with ex-smokers.

i. Slow down and enjoy your meals more.

j. Take a trip to a flower store and enjoy smelling.

k. Learn and practice an effective relaxation response technique twice a day.

l. Make a list of things you'll do or say to yourself the next time you have an urge for a cigarette.

m. Call a friend everyday and talk about how thankful you are to have gone another day without a smoke. If you do have a setback call at least two friends/supporters and let them know of your setback but also that you are going to keep trying.

n. Put up signs with encouraging thoughts in places like your refrigerator, your bedroom, your car, your bathroom mirror, etc.

o. Daily visualize yourself as a non-smoker.

p. Intensive smoking cessation programs have been proven to be helpful and cost-effective in helping smokers quit. Sign up for one.

In Preparation for Stop Day:

* Inform family, friends, and co-workers of quitting and request understanding and support. (This is controversial, some state in increases anxiety about stopping.)

* Remove cigarettes from your environment. Prior to quitting, avoid smoking in places where you spend a lot of time (e.g., home, car).

* Review previous quit attempts. What helped you? What led to relapse?

* Other smokers in the household - The presence of other smokers in the household, particularly a spouse, is associated with lower success rates. Patients should consider quitting with their significant others and/or developing specific plans to stay quit in a household where others still smoke.

* Abstinence - Total abstinence is essential for successful quitting. "Not even a single puff after the quit date."

* Alcohol - Drinking alcohol is highly associated with relapse. Those who stop smoking should review their alcohol use and consider limiting/abstaining from alcohol during the quit process.

References:

Hooked but not Helpless, Kicking Nicotine Addiction by Patricia Allison. This book outlines five steps to take when the urge to smoke hits. These steps make sense and have helped many ex-smokers to stay stopped. The book emphasizes "cognitive" skills/patterns to help in stopping smoking. The suggestions for preventing relapse are helpful. I believe there is more to stopping smoking and dealing with the addiction than learning how to think "right". Nonetheless, the book is clearly worth reading. Unfortunately, it doesn't support interventions with "proven" benefits and a discussion on dealing with addiction through spiritual growth is absent.

Overcoming Addictions by Deepak Chopra, MD. This book clearly takes another slant on addiction and what to do about it. I'm sure that it would be of help to some smokers. By discussing ayurvedic medicine's approach/appreciation of addiction it confirms the need to individualize approaches for smokers. Dr. Chopra doesn't overlook the need for spiritual growth in dealing with addiction of any sort.

WWW

http://www.well.com/user/woa

This web site is called the Web of Addictions and has links to several sites that are involved in addictions of all sorts. The list of links relating to nicotine addiction is quite comprehensive. Doing a search for "smoking cessation" will help you find a number of other resources on the web.

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