Ask The Doctor: Smoke Cessation

Question: My husband has been prescribed Chantix to help him stop smoking.  It doesn’t seem to be working.  Can you tell us the pros and cons of the various medications that are used to help a person quit smoking?  Is there one you would recommend over the others? Carmen McIntyre What advice would you have for a person wanting to quit smoking?
I can’t begin to tell you how happy I am that a question has come up about smoking cessation.  Smoking-related illness accounts for more than 1,300 deaths in the U.S. every day. That’s about 480,000 deaths per year that were preventable.  On average, every cigarette takes 11 minutes off your life, and smokers die at least 10 years younger than non-smokers.  Cigarette smoke contains more than 7,000 chemicals, at least 70 of which can cause cancer.  Some of those chemicals include lead and carbon monoxide, which we all know are hazardous to our health.
So I am excited to know that people are trying to quit, and want to know more about how to stop.  First thing for me to say:  Never stop trying.  Most people who succeed in giving up tobacco tried multiple times, so don’t be a quitter in quitting!
Let’s take a moment to talk about some of the things a person who is giving up tobacco might experience as they reduce or give up cigarettes. The Centers for Disease Control has a great timeline for what happens after you stop smoking.  Twenty minutes after you quit your heart rate will start to drop back towards normal levels.  Two hours without a cigarette and your heart rate and blood pressure will be down to almost normal levels, and your circulation will improve.
This is when early withdrawal symptoms start, including craving; anxiety, tension or frustration; trouble sleeping or drowsiness; and increased appetite.  The craving is what usually drives people to pick up their next cigarette.  Some of this is physical due to withdrawal of nicotine.  Some of it is psychological too.  Most people who smoke have a pattern — after meals, when talking on the phone, on a break from work, when drinking alcohol. So when you engage in these activities you will trigger your urge to smoke.  The key here is you need to retrain you brain and body that these activities aren’t linked to smoking.  The only way to do that is  not to smoke when you do those things. It will take practice and repetition for you to learn this new pattern.
Twelve hours after quitting, carbon monoxide decreases and your blood oxygen levels increase to normal.  Twenty-four hours after your last cigarette, your risk for heart attack starts to drop.  Forty-eight hours after you stop smoking, your nerve endings to your nose and mouth start to regrow, improving your sense of smell and taste.
Three days after you quit, nicotine is completely out of your body, which means a peak in physical symptoms such as headaches, nausea and cramps or vomiting, along with the other symptoms mentioned above.  Now is great time to use that money you saved from not buying cigarettes to reward yourself with something nice. By two-three weeks, withdrawal symptoms have ended and your body is really showing signs of healing.  You can be more physically active without being short of breath because your lungs are recovering.
Psychological symptoms are pretty much gone over the next five-six months. One year after quitting, the risk for heart disease is 50 percent lower than when you were still smoking.
So how do people quit?
Some people are able to simply make the decision to stop, and just do it.  These folks are rare, and those who cannot are not weak and they don’t lack willpower.  They just need some help. First, most people need some sort of support.  That may be informal, such as getting those around you, your family, co-worker, and especially smoking buddies, to help you.  This means they don’t offer you cigarettes, they are your cheerleaders and help distract you when you are tempted, and they find healthier activities for you to engage in.  For example, if your work break is stepping outside to smoke, maybe you can step outside for a quick walk around the block.  You get fresh air, exercise and good conversation instead of a lungful of chemicals.
Support may also be formal, through smoking cessation groups or counseling.  There are even telephone quit line counseling services. There are also medications that can help.  The first group are nicotine substitutes, such a patches, gums and inhalers. The point of these is to slowly wean yourself off nicotine, the primary chemical that results in the withdrawal symptoms and physical craving. They are safer than cigarettes in that you don’t have all of the other toxic chemicals, and are most helpful for heavy smokers for whom the withdrawal effects are the worst. Prescription medications are typically in two categories.
First are medications that were originally used for depression and anxiety. Buproprion was originally approved and marketed for depression as Wellbutrin, but has also been used for smoking cessation under the brand name Zyban. It makes smoking less pleasurable, so people stop smoking because it is a waste of time. A plus for buproprion, and other antidepressants that have been used such as nortriptyline, are that they also help with depression and anxiety which are sometimes present in addition to the nicotine addiction, or might arise as side effects. The “cons” are that they don’t work for everyone and have their own side effects.
Buproprion is not associated with weight gain, which is attractive to some smokers due to the increased appetite that is a side effect of quitting cigarettes. Chantix (generic name varenicline) tablets are the first medication specifically developed and approved for smoking cessation that isn’t nicotine-based. In order to be most effective, it must be taken after eating a meal, and with a full glass of water. Side effects include nausea and vomiting, trouble sleeping, strange dreams, constipation, and gas. Some people have changes in behavior, aggression, anger, hallucinations, paranoia, depressed mood and suicidal ideation. It may be hard to differentiate between the short-term effects of tobacco cessation, side effects of Chantix, and a worsening of an underlying mood or anxiety disorder.
Therefore, people taking Chantix must make sure to be on the lookout for these symptoms, and see the prescribing doctor regularly, reporting any of these symptoms right away. The studies show that counseling and medication are more effective when used together than either alone. Also, the nicotine replacement treatments can be safely combined with the other medication treatments if necessary. Both brief treatment and long-term treatments have been shown to be effective. Some people respond quickly and others, often those who are heavier smokers and have other diagnoses such as major depression, require longer treatment. Finally, I want to repeat that tobacco dependence is a chronic disease that may require repeated interventions, and smokers may require multiple attempts to quit. So don’t give up, instead, get help.
Dr. Carmen McIntyre is chief medical officer at the Detroit Wayne Mental Health Authority. She is committed to ensuring that the Authority meets the mental health needs of those with sub- stance use disorders, children with serious emotional disturbance, mental illness, and persons with intellectual and/or developmental disorders in Wayne County.

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