Cigarettes, Cut the Habit

No doubt smoking is a major health scourge, and given that success rates with various interventions are surprisingly low, few patients come to our office seeking help for the serious addiction that smoking represents. Regardless, patients who come for other reasons often allow us to talk about it.

Just the other day, a woman came in for a routine medication check. She is stable overall and had been treated for PTSD. At this point in her life she is wrestling with more ordinary concerns: worries about what it will be like to confront an empty nest as her son moves off to college, reflections on how deeply she loves and anticipates missing her grandchildren, and growing personal health concerns involving circulatory problems in her legs.

Mid session as she was talking about the health concerns, a light bulb went off in my mind as I remembered noticing the smell of cigarettes on her clothing as she entered the office at the beginning of our session.

Timing is everything. Here was a woman with poor circulation, growing concerns about her health and longevity, and likely a strong motivation to make changes in her life so she could remain a lasting presence in the lives of her grandchildren. As I brought up smoking cessation I was confident that I was talking to a woman whose ears were primed to listen.

One technique I sometimes advise is for patients to gradually reduce the size of the cigarettes they smoke, cutting roughly a tenth off each day. Over a period of about 10 days, the size of the cigarettes, and therefore the nicotine delivered from them, declines in a gradual and visually satisfying way. At the beginning of the procedure it is important that patients count and lay out their daily cigarettes as they may unconsciously cheat as their nicotine levels drop.

During the transition as the cigarettes are getting smaller on a daily basis patients can begin experimenting with nicotine gum. Knowledge is power, so it is important to teach patients about the different behavior of gum compared to cigarettes.

With a cigarette, when a person has a sudden hankering for nicotine, it takes only seconds to raise nicotine levels. A smoker can therefore remain somewhat “behind the cart,” so to speak, without the catch-up being terribly uncomfortable. Nicotine gum is slower, taking as long as 20 minutes for it to reestablish nicotine levels. So patients using gum need to stay ahead of the cart, using it with a rhythm that simulates maintaining the nicotine levels they have been used to.

Not much needs be attended to regarding safety issues. It is a paradox that nicotine is quite toxic yet people almost never overdose because they experience immediate feedback when they inhale such as significant nausea before things get out of hand.

There is no guarantee that this protocol for smoking cessation will work but it is a good way to start; patients feel in control with the procedure and can visualize their progress. Regardless of method, motivation to change is the most important variable in success.

In addiction medicine it holds: where there is a will, there is almost always a way If a doctor or therapist can make a contribution to a patient quitting it is likely to be one of the most significant health interventions of the patient's lifetime.