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Tobacco Cessation

Best Practices and Programs for Quitting Tobacco

Volume 9, Number 2 – Spring 2005

Editors: Carol A. Rice, Ph.D., RN, Professor and Extension Health Specialist, and Janet M. Pollard, MPH, Extension Associate-Health

 

Download PDF version of this newsletter and 3 handouts

Inside HealthHints....

• Tobacco Cessation
• Key Factors for How to Quit
• Deciding to Quit
• Setting Your Quit Date
• Environmental Changes
• Discovering Your Tobacco Triggers
• Methods for Quitting
• Smokeless Tobacco…Unique Aspects of Quitting
• What About Medications?
• A Quick Reference to Quit Tobacco Medications
• Get Support: Increase Your Chance for Success
• Talking with Family and Friends
• Being a True Support
• What to Look for in a Cessation Program
• Self-Help Materials
• Quitlines
• Other Approaches to Quitting
• Weight Control
• Activity Ideas
• Resource Guide
• References

Tobacco Cessation: Best practices and programs for quitting tobacco

There are about 47 million smokers in the United States (about 1/4 of the population)—most say they would like to quit, but only about 5% manage to do so each year¹.

“Quitting smoking is easy. I’ve done it a thousand times.”² –Mark Twain

Quitting smoking, chewing tobacco, snuff, or any other type of tobacco product is hard. That’s because nicotine (a drug found naturally in tobacco products) is highly addictive—as addictive as heroin or cocaine.²

The reality is, we could spend an entire newsletter, or an entire textbook, talking about the statistics—the negative health consequences related to tobacco use and those exposed to it, as well as the financial consequences for the individual and the nation. Some of these reasons might even convince a person or two to consider quitting tobacco, but most people who smoke will make the decision to quit for their own reasons—be it their own health, the health of a loved one, or some other circumstances, such as no smoking policies at work, in the community, etc.

“Don’t tell my why to quit, tell me how.”²

Though talking about these elements may provide a bit of insight or motivation, for the most part we don’t want or need to be told why to quit, we want and need to know how.

Key Factors for How to Quit: Beginning the Fight for Freedom from Tobacco

The problem with describing how to quit tobacco is that there isn’t one right way or one magic pill that will work for all tobacco users. In fact, what works for one may not work for another and vice versa. Additionally, what works for someone who smokes may or may not work as well for someone who chews tobacco. Still, there do seem to be some key factors that help most people quit. Let’s start with these key factors for quitting and staying quit:

• Make the decision to quit.
• Set a quit date.
• Get ready – This is the time to get prepared and make some plans about how you will quit. Choose the method by which you will quit (e.g., nicotine fading, cutting down and tapering off, cold turkey). Change some things about your environment and your daily routine. Plan how you will deal with obstacles to quitting (e.g., withdrawal, cravings, social situations, etc.).
• Get support (e.g., friends, family, one-on-one support, group support, support from a former smoker, telephone help line, etc.).
• Get medication (if needed), and use it correctly.
• Stay quit – This involves dealing with relapse and maintaining your quit status.^2,5 See the “Steps for Quitting Tobacco” (PDF) handout in this issue of HealthHints.

Deciding to Quit: Are You Ready?

Research says that you will be more likely to quit smoking if you:

• believe you could get a tobacco-related disease, and that worries you.
• believe that you can make an honest attempt at quitting.
• believe that the benefits of quitting outweigh the benefits of continuing tobacco use.
• know someone who has had health problems as a result of their tobacco use.²

Do any of these situations apply to you?

You may also go through stages of contemplation about quitting. First, you may not be thinking seriously about quitting. Then you’re thinking about it, but you’re concerned, for example, that the stress at work is too much, you’ll gain weight, you’ll be anxious all the time, or you’re just not sure you can do it. Finally, you will be prepared and ready to quit within the next month—making a plan for how you will quit.

It is normal to go through these stages of contemplation. If you are stuck contemplating quitting but not moving on to prepare to quit, read on in this newsletter as we will look at how to deal with some of the elements that might be holding you back. Perhaps you have even tried to quit before but aren’t sure how to go about it again. If you didn’t make a plan for quitting before—try it this time (we’ll show you how). Many people try quitting at least 2–3 times before they are successful. Some people try 5–7 times or more before they reach the goal. Others can go “cold turkey” and quit the first time. Don’t be discouraged. Not quitting the first time is NOT failing. Look at your attempt as a positive experience—progress toward quitting for good—you are trying and learning what triggers your tobacco use along the way (we’ll talk more about “triggers” later). Don’t give up; get ready for your next attempt to quit for good.

Find reasons to quit that are important to you. Try to think of more than just health reasons. For example, consider the following ideas (adapted from the National Cancer Institute’s Clearing the Air booklet):⁶

• the amount of money you’ll save by not buying tobacco;
• the time you’ll have for yourself instead of taking cigarette breaks, rushing out to buy tobacco, or searching for a light;
• not being short of breath, coughing as much, or fighting sores in your mouth; and
• setting a better example for your children, grandchildren, or others.⁶

Write down all of your reasons for wanting to quit. Ask former smokers their reasons for quitting. Keep the entire list, or at least the top five on your list,⁷ where you will see them often, such as:

• where you keep your cigarettes or other tobacco products,
• in your wallet or purse,
• in the kitchen,
• in the bathroom,
• in your car,
• attached to the TV remote, or
• beside your bed.⁶

Setting Your Quit Date: Making Your Mark

You’ve decided to quit tobacco. Unless there is a critical health reason that causes you to need to quit immediately, give yourself time to make some important changes and make a plan. The first thing you need to do is to set a quit date. When choosing a quit date, try these recommendations:

• Choose a date 2–4 weeks away (within the next month) to give yourself time to prepare, but not so long that you lose your drive to quit.
• Choose a date that is special to you (e.g., birthday, anniversary, holiday, New Years Day, Independence Day, World No Tobacco Day (May 31st), or the date of the Great American Smokeout (3rd Thursday in November each year; see http://www.cancer.org/docroot/PED/content/
  PED_10_5_Great_American_Smokeout_History.asp?sitearea=PED for more information). Choosing a random date is fine, too.
• If you use tobacco at work, choose a quit date on the weekend or a day off. That way you’ll already be tobacco-free when you return.
• Mark the date on your calendar.
• Make a strong personal commitment to quit that day, and stick with it.^2,5,6

Environmental Changes: Making a Clean Getaway

Make some special plans for your quit date. Plan to make a clean break with tobacco on the date you quit. Change your usual routine and environment to increase your chances for success by following these suggestions:

1. Remove all tobacco products from your home, car, and work. Throw away all your cigarettes, snuff, chew, cigars, etc. Throw away or give away your matches, lighters, and ashtrays (if an item has sentimental value, ask a friend to store it for you). Don’t forget the ones in your makeup bag, junk drawer, tackle box, golf bag, or other places outside the home.
2. Do NOT save just one pack of cigarettes or chew, one cigar, or one can of snuff. Some smokers like to do this “just in case” or to “prove” they have the willpower not to use tobacco. Don’t! Saving just one pack of tobacco makes it easier to start again.
3. Schedule an appointment on your quit date to have your dentist clean your teeth to get rid of tobacco stains. See how great they look, and try to keep them that way.
4. Make things clean and fresh at home, work, and in your car. Clean your drapes and clothes. Wash your car—inside and out. Buy flowers for your home and/or workplace—you’ll enjoy their scent as your normal sense of smell returns.
5. Don’t let people smoke in your home. Ask other members of your household who smoke to quit with you. If they won’t, just ask them if they would be willing to smoke outside, or at least not to smoke around you.
6. Change your normal routine. If you normally have a cigarette with your coffee in the morning, try juice or a bowl of cereal instead. Avoid places or change routines where you normally drink alcohol—alcohol and tobacco use typically go hand-in-hand. If you smoke when you take a bath, try a shower instead. If you always take a tobacco break at the same time and place each day at work, change the time and place you take your break, and replace tobacco with a walk around the grounds, hallway, or spend the time getting a healthy snack. If you always smoke in the car, try riding with a friend who doesn’t smoke or place gum, toothpicks, etc. in your car to chew on instead.^5,6,8,9

Discovering Your Tobacco Triggers: Keeping a Record

Certain things trigger, or turn on, our need to use tobacco. These things can be moods, feelings, places, or things we do. Examples include:

• feeling stressed
• feeling down
• talking on the phone
• drinking alcohol
• watching TV
• driving your car
• finishing a meal
• playing cards
• taking a work break
• being with other smokers
• drinking coffee
• seeing someone else smoke
• cooling off after an argument
• feeling lonely
• other_______________________.⁶

Knowing your pattern for tobacco use, such as, which triggers are the strongest; which cigarettes are the “must haves”; and where, when, or with whom you’re most likely to use tobacco can help you begin to break the pattern.¹⁰

Before you quit tobacco, make a sincere effort at keeping a written record of each time you use tobacco and under what circumstances. Try to do this for at least 3 days; if possible, keep recording your tobacco use for a couple of weeks. This record will be extremely useful in uncovering what triggers your use of tobacco most often. Many people find while doing this exercise that they use tobacco without even thinking about it. Most importantly, this record will help you prepare how best to fight the urge to use tobacco when you quit.

The National Cancer Institute (NCI) and the American Lung Association have already done some of the work for us by creating tools to make keeping a record of our tobacco use easier:

National Cancer Institute’s Craving Journal can be copied from page 11 of the Clearing the Air: Quit Smoking Today booklet at http://www.smokefree.gov/pubs/clearing_the_air.pdf. Make a copy of the journal page for as many days as you would like to keep a record. This journal will give you a place to write down the following information for every cigarette you smoke:

• date,
• time of day,
• where you were,
• what you were doing,
• who was with you, and
• your level of craving (1=just a little; 2=some; 3=a lot).

If you use other forms of tobacco, just substitute chew, dip, snuff, cigar…etc. for “cigarette number.”

American Lung Association’s Pack Tracks can be copied from the “Module 2: Triggers” section of the on-line Freedom from Smoking program at http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=39197 and are sized to fit on a pack of cigarettes. There are 9 pack tracks on each page. Copy enough pack track cards to place 1 on each pack of cigarettes you will have over the next 3 days–2 weeks (depending how long you plan to keep record). If you use other forms of tobacco, the pack tracks are a great size to put in your back pocket, wallet, purse, or on your car’s dashboard or console. The Pack Tracks give you a place to write down and check off:

• 20 uses of tobacco per day,
• time of day,
• your felt need for the tobacco (?, yes, or YES),
• your mood at each use (identified by checking happy face, “blah” face, or unhappy face).
  • If you identify your tobacco use with mostly happy faces, you most likely use tobacco to relax, feel good, and enjoy good times. Think about where and when you use tobacco and who is with you at these times.
  • If you identify your tobacco use with mostly “blah” faces, you most likely use tobacco out of boredom or habit. Think about where and when you are when you use tobacco and check the “blah” face.
  • If you identify your tobacco use with mostly unhappy faces, you most likely use tobacco when you are tense, angry, or upset. Think about why, when, and where you use tobacco under these circumstances.¹¹

Once you know what triggers you to use tobacco, you can start preparing how you will handle these circumstances when you quit. See the handout “Quitting Tobacco Tips” (PDF) in this issue of HealthHints for ideas on how to cope with your tobacco use triggers.

Methods for Quitting: What’s Right for You?

Some people may argue that quitting “cold turkey”—abruptly and totally—is the only way to quit tobacco. That just happens to be the way most people who use tobacco prefer to quit.² They use tobacco until their quit date and then stop all at once. The truth is, there is no one right way to quit for everyone. So, if you are concerned about quitting abruptly on your quit date, you might want to try nicotine fading or tapering off for a few weeks prior to your quit date.

Nicotine fading is for those who smoke cigarettes. It involves switching to a cigarette with a lower level of nicotine so you can bring your addiction to nicotine down before you quit smoking. Here’s how it works:

• If you’re smoking a high-nicotine brand, switch to a medium-nicotine brand.
• If you’re smoking a medium-nicotine brand, switch to a low-nicotine brand.
• If you’re smoking a low-nicotine brand, just switch to a different low-nicotine brand.12

For a list of brands and their nicotine levels, go to the American Lung Association’ on-line Freedom from Smoking program Nicotine lesson at http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=39202, and click on the Nicotine Fading handout. If your brand is not listed, follow these guidelines:

• If it’s an unfiltered cigarette or if it’s filtered and does not contain the words “light” or “ultra light,” count it as a high-nicotine brand.
• If it’s a filtered cigarette and contains the word “light” or “mild,” assume it’s a medium-nicotine brand.
• If it’s a filtered cigarette and contains the words “ultra light,” assume it’s a low-nicotine brand.

If you decide to try nicotine fading, make sure you DO NOT:

• switch from a high-nicotine brand directly to a low-nicotine brand,
• smoke more cigarettes than you normally do, or
• inhale more often or more deeply.¹²

Tapering off works in a similar way, but rather than reducing the nicotine level, you reduce the amount of nicotine you’re using. Tapering off may look different for you than for another person depending on how much tobacco you use each day. Start gradually; then taper off as much as you can before your quit date, when you will quit tobacco for good. Tapering off can be used for all types of tobacco use, since you just reduce the amount (e.g., fewer cigarettes or cigars, less chew or snuff, etc.). This method also helps you gradually reduce the amount of nicotine in your body, preparing you for your quit date when you will stop using tobacco completely. Of course, “cold turkey” has been very successful as well—put the tobacco in the trash can on your quit date; say goodbye, and be done with it—that’s cold turkey.

What About Medications? – Double Your Changes for Quitting

Do you use tobacco within 30 minutes of waking up in the morning? Do you smoke 20 cigarettes (one pack) or more each day?
At times when you can’t use tobacco or don’t have any, do you feel a craving for it? Is it tough for you to keep from using tobacco for more than a few hours? When you are sick enough to stay in bed, do you still use tobacco?¹⁴

If you answered yes to two or more of the questions above, you may be at a level of nicotine addiction that warrants the use of medication as part of your quit smoking plan.¹⁵ In fact, “research has shown that using a quitting smoking medication, such as bupropion (Zyban) or the nicotine patch, gum, nasal spray, inhaler, or lozenges, can double your chances of successfully quitting.”¹⁶

The U.S. Food and Drug Administration has currently approved five medications to help you quit:

• Bupropion SR – available by prescription
• Nicotine gum – available over-the-counter
• Nicotine inhaler – available by prescription
• Nicotine nasal spray – available by prescription
• Nicotine patch – available by prescription and over-the counter.⁵

Bupropion (brand names Zyban and Wellbutrin) is a non-nicotine medication that helps reduce cravings and can relieve symptoms of depression for some people.^5,17 The other medications listed above are known as nicotine replacement therapy (NRT) products because they deliver small, safe amounts of nicotine to the body to try to help you with nicotine cravings and through nicotine withdrawal symptoms (e.g., irritability, difficulty concentrating, feelings of depression, difficulty sleeping, increased appetite cravings, headaches, etc.).¹⁸ The most effective time to start nicotine replacement therapy is at the beginning of an attempt to quit.² So, if you and your doctor find NRT is right for you, get prepared by getting your medication and keeping it on hand for your quit date through the appropriate length of treatment (see below for more information).

Talk with your health care provider (doctor, dentist, or pharmacist). If you are pregnant or thinking of becoming pregnant, you should not use nicotine replacement medications. If you have heart disease or other circulatory disease, eating disorder, or are a heavy drinker, these medications may or may not be safe for you depending on your individual circumstances—talk with your doctor.

If medication is an appropriate choice:

• Your provider may recommend one or some combination of these medications as part of your quit tobacco plan. He/she will make recommendations based on your individual needs, which may differ according to how much and what type(s) of tobacco you use.
• It is crucial that you use these medications correctly. Read the instructions, and talk with your health care provider. Start out using enough medicine. Use the full dosage suggested in the instructions or by your doctor. Don’t skip or forget to use your nicotine replacement medication(s) after you first quit tobacco.⁶
• Use the medication for an appropriate length of time. Often, it will be recommended that you continue to use the medication for a designated length of time (e.g., 8–12 weeks),¹⁸ even if you think you don’t need it anymore. Be patient, and stick with it. If you slip and use tobacco, don’t stop using your medication unless advised by your doctor to do so.
• Wait at least 1/2 hour after using the gum, lozenge, or inhaler before eating or drinking anything acidic. Acidic food items (e.g., tomatoes and tomato sauces, oranges, lemons, grapefruit, orange juice, grapefruit juice, coffee, soda, etc.) can keep these nicotine products from working.⁶
• Gradually taper off the medication. Don’t stop completely until you are ready. You can set up a plan with your health care provider. Keep some of the medication with you after you stop using it. This backup package may help you be ready for an emergency situation.
• DO NOT use nicotine replacement products if you plan to continue to smoke or use other tobacco products. The combined dose of nicotine could be dangerous to your health. Having a slip where you smoke one or two cigarettes is not dangerous (don’t quit using your medication if this happens), but continuing your old patterns of tobacco use with these medications could be dangerous.²

Remember, there is no single pill to cure smoking,¹⁹ but these medications may very well increase your chances for quitting tobacco.

Note: For ideas on how to save money on your medications, see the HealthHints issue on reducing prescription medication costs at http://fcs.tamu.edu/health/Health_Education_Rural_Outreach/
Health_Hints/2005/jan-feb/medications.php.

Get Support: Increase Your Chance for Success – Individuals, Groups, and Telephone Lines

Studies have shown that you have a better chance of quitting tobacco if you have some help in the form of support people.⁵ This support can come in many forms: individuals, family, friends, former smokers, one-on-one programs, group programs, health care providers, smoking counselors, or telephone quitlines. You may have some ideas of your own about who can best help you. Try seeking support through some or all of the following avenues:

• Tell your family, friends, and co-workers that you are going to quit and would like their support. Ask them not to smoke around you, or ask them to consider quitting with you.
• Talk with your health care providers. These can include doctors, dentists, nurses, pharmacists, psychologists, nutritionists/ dieticians, and smoking counselors.
• Seek out individual, group, or telephone counseling. “The more counseling you have, the better your chances of quitting.”⁵ Check with your employer, health insurance company, or local hospital for help finding support groups.

Talking with Family and Friends: What Can I Say?

“Many former smokers say a support network of family and friends was very important during their quit attempt.”² Still, well-intentioned friends and family often don’t know how to support you and can become more of a hazard than a help.

Talk with them. Tell them what is helpful to you as you quit. Read the section below, or go to the American Cancer Society link to Helping a Smoker Quit: Do’s and Don’ts at http://www.cancer.org/docroot/PED/content/
PED_10_3x_Help_Someone_Quit.asp?sitearea=PED. Mark the items that you find most helpful. Share a copy with family and friends.

Get help from a “buddy.” Remember the old “buddy system” from your school days? Well, try it out as part of your quit plan. Choose someone who is currently going through the quit process or who is a former smoker or tobacco user if possible. An especially helpful, supportive nonsmoking friend is fine, too. Just try to choose someone outside your household. Because your
“buddy” knows what you’re trying to do and how you’re trying to do it, he/she is someone who can help during those times when members of your household are unable to understand, tense, in a bad mood, etc.²⁰

It can be hard for family members to handle mood swings you may be having as well. Your “buddy” can be a help during these times. Use e-mail, or call them on the phone when needed. Ask them to provide you any information about things that have helped them in similar situations. Tell them what helps you most.

Being a True Support: How Do I Support Someone Trying to Quit?

If you know someone who is trying to quit tobacco, being truly supportive can be hard. People who use tobacco and try to quit go through withdrawal symptoms. They may get irritable, angry, depressed, lack concentration, etc., which can make them not so enjoyable to be around. Don’t give up on them. The worst of the withdrawal symptoms usually last two weeks, and the cravings usually lessen within three months. In the meantime, use the following tips as a guideline to help you be a true support (note: the following ideas are adapted from American Cancer Society’s fact sheet Helping a Smoker to Quit: Do’s and Don’ts. For the complete fact sheet see http://www.cancer.org/docroot/PED/content/
PED_10_3x_Help_Someone_Quit.asp?sitearea=PED):

• Respect that the quitter is in charge—not you. Listen to what he/she asks of you in terms of support, and try to honor that, even if he/she asks you not to do something that is suggested here. These are guidelines; people who quit are individuals who have their own support needs.
• Ask the person if he/she would like you to call, visit, or e-mail regularly to see how he/she is doing.
• Tell the person it is okay to call, visit, or e-mail you when they need some encouragement.
• Do NOT offer advice. Just ask how you can help with the plan or program they are using.
• Help the person get what they need to help them quit, such as picking up tobacco substitutes they like (e.g., straws or toothpicks to chew on, fresh vegetables cut up and refrigerator ready, sugar free hard candy to suck on, etc.) or going to get their nicotine replacement medicine.
• Spend time with the person to help keep his/her mind off tobacco—go to the movies or take a walk to get past a craving.
• Help the person with a few chores, occasional child care, cooking, or anything else that may lighten the stress of quitting.
• Celebrate along the way. Quitting is hard, and it is a big deal. Praise the person, and help him/her celebrate as they meet short-term goals, even if it is making it through one movie without having to go outside and smoke. This can be a major accomplishment for someone who has smoked regularly for years.
• Do NOT take any of the person’s grumpy moods personally during his/her nicotine withdrawal. Remember, this period usually will pass in about two weeks.²¹

If the person you care about fails to quit, don’t give up your efforts to encourage and support:

• Praise him/her for trying to quit for whatever amount of time was possible (4 days, 3 weeks, 2 months, etc).
• Encourage him/her to quit again. Don’t say “If you try again.” Say, “When you try again.” Studies have shown that most people who don’t succeed in quitting are ready to try again in the near future.
• Remember, the person may try to quit many times before quitting for good. Trying to quit 5–7 times is not uncommon. Encourage him/her to learn from each attempt. Things a person learns from a failed attempt can help him/her in the future.²¹

If you use tobacco, you can still be supportive of the person trying to quit:

• Smoke or use other tobacco products outside, always away from the person quitting.
• Keep your tobacco products, matches, lighters, etc. out of sight; they may be a trigger for the person trying to quit.
• Don’t ever offer the person tobacco, even in jest.²¹

What to Look for in a Cessation Program…and What to Watch Out For

Quit tobacco programs are designed to help individuals “recognize and cope with problems that come up during quitting and to provide support and encouragement in staying quit.”² Studies have shown that the most successful programs include either group or individual counseling. “There is also a strong association between the intensity of the counseling and the success rate. In general, the more intense the program, the greater the likelihood of success.”²

What to Look for in a Quit Program

Based on the information above, the things to look for in a quit tobacco program are as follows:

• Find a program that includes group or individual counseling. Be sure that the leader of the group is trained in tobacco cessation. Ask about their training or professional degrees. Ask if they have a diploma or some sort of certificate of training completion for verification. Health educators or other health, medical, or counseling professionals will often offer these types of services.
• Also, look for a program of adequate intensity. Sessions should:
  • last at least 20–30 minutes,
  • last for at least 2 weeks, and
  • have at least 4–7 total sessions.²

A good tobacco cessation program should also cover the following topics:

• developing a quit plan,
• understanding and dealing with withdrawal symptoms,
• information about the harmful health effects of tobacco and the benefits of quitting,
• social support,
• weight control, and
• maintenance plan for staying quit.²²

What to Watch Out for in a Quit Program

There are also some programs to watch out for. Not all programs are ethical. Be very careful of programs that do the following:

• Promise instant or easy success with little effort on your part. If it sounds too good to be true, it probably is.
• Claim high quit rates but follow participants for less than 6 months. Quit rates measured 6–12 months after the end of a program are considered the standard.
• Claim high quit rates but do not include those who dropped out of the program or with whom they could not get in touch or follow-up in the measurement.
• Use injections or pills, especially those that have “secret ingredients.” If you choose to use medication, use only those that are FDA-approved, and talk with your health care provider about the best choice for you.
• Charge a high fee. Check with the Better Business Bureau if you have doubts.
• Are not willing to provide references from people who have taken the class.^2,22

Self-Help Materials: Finding What Works for You

Did you know that you don’t have to leave the comforts of your own home to participate in some programs? There are many
excellent self-lead programs and self-help materials available either on-line, through the mail, and even at local libraries and book stores. These programs offer you flexibility and privacy. Many of these are free. You can use these materials to learn how to:

• prepare for your quit attempt,
• deal with withdrawal symptoms,
• develop strategies to help with cravings, and
• prevent relapse once you’ve quit.

Self-help programs and materials can be an easy-to-follow way of keeping your motivation high. The following programs and materials are a good place to start:

• Clearing the Air: Quit Smoking Today – Available from the National Cancer Institute at http://www.smokefree.gov/pubs/clearing_the_air.pdf.
• Freedom from Smoking On-Line – Available from American Lung Association. Sign up for this program at http://www.lungusa.org/.
• I Quit: What to do when you’re sick of smoking, chewing, or dipping – Available by calling the Centers for Disease
  Control (CDC) Information Center at 1-800-232-1311.
• Out of Ashes – Available by calling the CDC Information Center at 1-800-232-1311.
• You Can Quit Smoking Consumer Guide – Available from U.S. Department of Health and Human Services (USDHHS) at http://www.cdc.gov/tobacco/quit/canquit.htm.

See the “resource guide” section of this newsletter for more information on some of these and other resources. Also, ask your health care providers for other reputable resources, or contact your health insurance company, local hospital, or local health clinic to see if they offer other self-help programs and materials.

Quitlines: Support at Your Fingertips

Another great way to gain support without leaving the conveniences of home is to use a telephone quitline. In fact, “quitlines
have been proven to double your chances of successfully quitting.”¹⁶ A quitline is a telephone number you call to get personal support, counseling, encouragement, etc. to help you through the tough spots and keep you quit. The advantage of using a quitline is its convenience. Most quitlines are available any time you choose to pick up the phone and call.

USDHHS has created a national, toll-free quitline number that will route you to a state-sponsored quitline or to the National Cancer Institute’s quitline if a state-sponsored line is not available. The USDHHS number is 1-800-QUIT NOW (1-800-784-8669).

Other national quitlines available include:

• National Cancer Institute (mentioned above)
  1-877-44U-QUIT (1-877-448-7848)
• American Cancer Society
  1-877-YES-QUIT (1-877-937-7848)
• American Lung Association
  1-800-LUNG-USA (1-800-586-4872)
• American Legacy Foundation: Great Start (for pregnant women)
  1-866-667-8278

For more help in locating a quitline, try these locating services:

• American Cancer Society’s Find a Quitline or Other Support at http://www.cancer.org/docroot/PED/PED_10_3x_Find_Support.asp.
• North American Quitline Consortium’s Quitline Map at http://www.naquitline.org/map_us.php.

Other Approaches to Quitting: Live-in, Conditioning, Hypnosis, Acupuncture

There are a number of non-traditional and/or more expensive methods for attempting to quit tobacco. While methods such as self-help, group approaches, and quitline counseling work for many, there may be reasons you want to try another approach, such as if you are a very heavy smoker or have found other approaches ineffective. Keep in mind that the methods listed in this section have limited research, and though some have shown effectiveness, others may have limited effectiveness or only psychological results.

Live-in Programs

Some hospitals and clinics offer live-in quit tobacco programs. In these programs, you live in the hospital or clinic for several days or a week and participate in quit smoking activities (e.g., group support, counseling, conditioning, fitness and exercise, changes in diet, and education about the health risks of tobacco and benefits of quitting).

If you are a heavy smoker, you may benefit from a live-in program, which puts you in a nonsmoking environment. The limited research available on live-in programs shows they can be quite effective; however, it can be difficult to go back to a normal environment, and the cost is expensive. For an example of a live-in program and what it entails, see the website for the Mayo
Clinic’s 8-day live-in program in Rochester, Minnesota at http://www.mayoclinic.org/stopsmoking/residentialprogram.html.

Conditioning

Conditioning is another approach to quitting tobacco. The idea in conditioning is to condition your body to feel sick when you use tobacco; thus, leading you to quit. Rapid smoking and satiation are the two most common methods of conditioning. In rapid smoking, you inhale from a cigarette once every few seconds for the length of the cigarette or until you feel sick. In satiation, you smoke 2–3 times your usual number of cigarettes in a day. These methods have shown limited results. Studies show rapid smoking to be the more effective of the 2 methods.

These methods also tend to be more expensive. There are higher health risks with these methods. Never use these methods without consultation and supervision of your doctor.

Hypnosis

Hypnosis therapy is designed to help you focus on your tobacco use patterns and to change your attitude about smoking. While you are hypnotized, your therapist gives you suggestions to help you quit smoking. If hypnosis works for you, these suggestions stay in your mind after the session and help you avoid tobacco in the future.

There is little evidence that hypnosis helps people quit beyond the effects of the counseling (“suggestions”) provided by the therapist. If you choose to use this method, be sure your therapist is qualified—either a psychiatrist, psychologist, or accredited social worker.

Acupuncture

Acupuncture is based on the Chinese science of connections in the body. Nerve endings near the surface of the body are said to be connected to certain organs and functions in your body. Acupuncture treatment involves inserting needles or staples into these skin surfaces. Acupuncture may have only a psychological effect (not a true physical effect) and only after a number of treatments. This approach is also expensive.²²

Weight Control: One Step at a Time

Did you know that the average weight gain among those trying to quit tobacco is only about 5 pounds?^22,23 Weight gain is
often a concern among people trying to quit tobacco, especially among women. Still, the average weight gain for quitters is only about 5 pounds.

Focus on the task at hand—quitting tobacco. Don’t let weight gain concerns be your reason for not quitting. You can help control your weight by eating low-calorie snacks, exercising, and drinking plenty of water. For more information, see the “Weight Control While Quitting” (PDF) fact sheet provided in this issue of HealthHints.

Activity Ideas: Strengthening Ideas for Quitting

The following activities can be used to help strengthen a person’s commitment to quit tobacco and help individuals take first steps in seeking social support in the quit process.

Smoking Practice

Supplies needed: Pencil, paper, calculator

Introduction: Most people start tobacco use to fulfill a need. Perhaps the need started when you were younger as a way to feel accepted or grown-up. Maybe it was to help you feel as if you had something to do in situations where you felt uncomfortable or anxious. Whatever the reason, each time you used tobacco and felt that need fulfilled, you practiced and strengthened your tobacco habit.

Say: Think about how many times you have lifted a cigarette to practice using tobacco and making it a habit. Each cigarette is about 10 inhalations (or puffs). If you smoked 1 pack a day for 20 years, that’s 10 inhalations times 20 cigarettes or 200 practices per day. Multiplied by 365 days, that’s 73,000 practices a year. Multiply that times 20 years and you have practiced 1.5
million times to strengthen your smoking habit.

Activity: Have participants take some time now to figure out how they have practiced strengthening their smoking habit. Here’s the equation to figure it out:

• 10 inhalations × # cigarettes smoked per day = # of practices per day
• # of practices per day × 365 = # of practices per year
• # of practices per year × # of years smoked = # of times you have strengthened your habit.

Ask: Are you surprised by your number? Remember that it took time and effort to form your current habit. Quitting tobacco takes time and effort because creating the habit took time and effort. Make the commitment to quit, knowing that it will take time and effort, but that it will be well worth it.²⁴

Squeamish about Support

Supplies needed: Pen, paper

Activity: Grab your pen and a piece of paper. Stand up and put the pen in your non-dominant hand (the hand you don’t write with). Put the other hand behind your back. Now write your name and phone number on the paper.

Ask: What was this experience like? (Common responses include: awkward, hard, feeling unable or incompetent.) Would it have helped if you could have used your other hand? How? (Common responses include: gives them help, balance, strength; generally makes it easier.)

Explain: There are two reasons I wanted you to do this. First, the way you feel about doing this is often how you will feel about quitting tobacco. You may feel different, awkward, or inadequate. These feelings are not uncommon anytime someone does something new. You will initially think you don’t do it well. Like the activity, having support and time practicing makes it easier. That’s the second reason for the activity; asking a “buddy” for support may feel awkward and uncomfortable, but most people find it is helpful to have a person who agrees to provide mutual support while quitting.²⁰

Resource Guide: Programs, Websites…Designed to Help You Quit

There are many wonderful resources available to meet individual needs. Some are for adults, some for teens, some for those
looking for a group program, and others for those wanting private or individualized help. We want to highlight a few of these resources and/or places to turn for more help.

CONTACTS

If you want to quit smoking and need help, contact one of the following organizations:

• American Cancer Society
  Telephone: 1-800-ACS-2345
  Internet address: http://www.cancer.org/
• American Heart Association
  Telephone: 1-800-AHA-USA-1 (1-800-242-8721)
  Internet address: http://www.amhrt.org/
• American Lung Association
  Telephone: 1-800-586-4872 (1-800-LUNG-USA)
  Internet address: http://www.lungusa.org/
• Centers for Disease Control and Prevention
  Office on Smoking & Health
  Telephone: 1-800-CDC-1311 (1-800-232-1311)
  Internet address: http://www.cdc.gov/tobacco/
• National Cancer Institute
  Cancer Information Service
  Telephone: 1-800-4-CANCER or 800-422-6237
  Internet address: http://www.cancer.gov/
• U.S. Department of Health and Human Services
  Smokefree.gov
  Telephone: 1-877-44U-QUIT (1-877-448-7848)
  Online materials, including info on state Quitlines
  Internet Address: http://www.smokefree.gov/

RESOURCES

Books and Audio Books

Fresh Start: 21 Days to Stop Smoking – Created by the American Cancer Society, this book (also available in audiocassette) is based on the American Cancer Society’s Fresh Start Smoking Cessation Program (see below) designed for face-to-face group classes. Contact your local library, bookstore, or on-line bookstore for availability.

7 Steps to a Smoke-Free Life by Edwin B. Fisher – In association with the American Lung Association, this book (also available on audiocassette) is based on their Freedom from Smoking Program and leads you through the 7 steps/modules:

1. Understanding your habit
2. Building your motivation to quit
3. Developing your quit plan
4. Preparing for your quit day
5. Quitting
6. Fighting temptations (the first 2 weeks)
7. Staying focused (the first 6 months).

Contact your local library, bookstore, or on-line bookstore for availability.

Quit & Stay Quit: A Personal Program to Stop Smoking by Terry A. Rustin, M.D. – Contact your local library, bookstore, or on-line
bookstore for availability.

Face-to-Face Programs and Support

Fresh Start Smoking Cessation Program – Created by the American Cancer Society (ACS), this is a 4 week (meets once per week), face-to-face, group program. Available to adults and teens (with parental permission). Call your local ACS to see if this course is available in your area.

Freedom from Smoking – Created by the American Lung Association, this is a 6 week, face-to-face, group program. There is usually a fee to cover expenses of materials and facility only, if necessary. This fee is also considered an incentive to participate,
since people who invest their money in something tend to be more committed to it or feel more obligated to participate and make the most of their investment. Call your local ALA to see if this course is available in your area. This program can also be accessed on-line for free to anyone who wants to register and go through the course on their own (see below).

Nicotine Anonymous – Like Alcoholics Anonymous, some communities offer a Nicotine Anonymous program following similar quit philosophies. There is no fee to attend. Ask your health care provider if they know of a Nicotine Anonymous program in your area,
or use the contact line or website at 1-877-TRYNICA (1-877-879-6422) or http://www.nicotineanonymous.org/.

Prenatal/Infant/Young Child Care

Great Start (http://www.americanlegacy.org/greatstart/html/aboutguide.html) – This is a national website with facts on maternal smoking and a plan to quit. You can contact them through the website or by calling 1-866-667-8278.

Healthy Beginnings – Created by the American Lung Association, the Healthy Beginnings program provides free environmental tobacco smoke information to mothers and expectant mothers.

The program targets clinics and local organizations that work with teen mothers and families with children ages 6 and under. Healthy Beginnings packets are available at no cost and include:

• “I’m a Born Non-Smoker” baby t-shirt
• “No Smoking, Baby Breathing” sign
• Secondhand smoke brochure
• Facts about smoking and pregnancy brochure
• Healthy Beginning brochure
• Pledge card for smoking parents committed to quitting or to keeping their homes and vehicles smoke free.

Materials are also available in Spanish. To find out if the Healthy Beginnings Program is offered in your area or how to become involved in this train-the-trainer program, contact:

• Yolanda Cotton, 214-631-5864 (Dallas), or
• Elizabeth Terrazas, 915-532-6776 (El Paso)
  

Quitline Resources

Breaking Away from the Pack – These self-help materials are available to those who qualify (18 years or older) and want to participate in phone counseling through the American Cancer Society’s (ACS) quitline at 1- 877-937-7848. The 3 Breaking away from the Pack booklets focus on:

• setting a quit date,
• getting through the initial withdrawal, and
• staying quit how to’s.

Tools for Teens

ASPIRE (http://www.mdanderson.org/departments/aspire/) – This interactive website for teens was designed by the MD Anderson Cancer Center and University of Texas Health Science Center at Houston to help teens quit smoking or make the wise decision to never start.

Not On Tobacco (N-O-T) – N-O-T is the American Lung Association’s school-based voluntary program designed to help high
school students quit smoking. This program includes a 10-session curriculum and booster sessions conducted by facilitators. N-O-T facilitators are identified through a set of selection criteria, and training emphasizes nicotine addiction, curriculum content and implementation, as well as group process.

N-O-T is gender-sensitive, separating participants by gender, and tailors content and delivery to the adolescent population. N-O-T emphasizes daily life management skills such as stress management and healthy lifestyle behaviors such as nutrition and exercise. It also offers awards and incentives to the teens and facilitators, and includes evaluation and mental health referral
protocols. For information on how to obtain this program, contact ALA at 1-800-LUNG-USA.

Worth It! (http://www.worthit.org/) – This website is targeted to Texas teens and is supported by the Texas Department of State Health Services. Resources for quitting smoking and smokeless tobacco are provided, as well as a class locator, answers to frequently asked questions, and a link to Quitnet (another option for support for those who want to quit tobacco).

Web-based Programs and Support

Breathe (http://www.sw.org/) – Available from Scott & White Health Clinic, this resource is a personalized plan based on your answers to a questionnaire developed with the latest research in smoking cessation. The Breathe program includes a personal plan sent to you immediately following questionnaire completion and 3 follow-up newsletters at 2, 10, and 21 days. To access Breathe go to http://www.sw.org/; then, click on “health plan” on the toolbar at the top; click on “lifestyle management tools” at the right; click on “get started” at the top left; then register for Breathe and other helpful lifestyle management programs.

Clearing the Air: Quit Smoking Today (http://www.smokefree.gov/pubs/clearing_the_air.pdf) – Available from the National Cancer Institute, this booklet offers steps to take you through the quitting process.

Committed Quitters (http://committedquitters.com/) – This is web-based, individualized stop smoking program provided by the makers of NicoDerm CQ, Nicorette, and Commit.

Freedom from Smoking On-Line (http://www.lungusa.org/) – Available from American Lung Association, this is a free program that is well-worth registering for. It is a comprehensive quit smoking program that takes you through 7 modules and provides hands-on experiences to help you get through the quit process. The Freedom from Smoking online program also offers social support and numerous self-help resources. It is based on a successful program history originally used in a group program setting.

I Quit: What to do when you’re sick of smoking, chewing, or dipping – Available by calling the Centers for Disease Control Information Center at 1-800-232-1311. This booklet is for smokers as well as those who use chewing tobacco and snuff.

Joe Chemo (http://www.joechemo.com/) – This website was designed by individuals and private groups with the assistance of the Centers for Disease Control, American Council on Science and Health, Tobacco Education Clearinghouse of California, California Department of Health, and other health organizations and institutions. The site offers quit smoking tips as well as an excellent list of resource links at http://www.joechemo.org/links.htm. The site also has fun features like e-cards and tobacco IQ tests, etc.

Out of Ashes – Available by calling the Centers for Disease Control Information Center at 1-800-232-1311. This booklet offers information on choosing a method for quitting, descriptions of different quit methods, and tips for staying quit.

Quitnet (http://quitnet.com/) – This website is operated in association with Boston University School of Public Health. It offers free cessation support 24/7, plus resources, professional counseling, social support, anniversary reminders, e-mails, clubs, medication information, etc. For a fee, you can sign up for premium services that offer personalized, tailormade services and support, as well as discounts on medications, and rewards.

Smokefree.gov (http://www.smokefree.gov/) – This on-line guide to smoking sponsored by the National Cancer Institute, Centers for Disease Control, National Institutes of Health, and U.S. Department of Health & Human Services offers how-to-quit materials as well as telephone support and instant messaging services for those trying to quit.

You Can Quit Smoking Consumer Guide (http://www.cdc.gov/tobacco/quit/canquit.htm) – Available from U.S. Department of Health and Human Services, this booklet offers steps to take you through the quitting process.

Worksite and Community Events and Materials

Communities of Excellence in Tobacco Control – Contact the American Cancer Society at 1-800- ACS-2345 for a planning guide to help your organization or group develop plans, gain support, and achieve results. For more information, see http://www.cancer.org/docroot/PED/content/PED_1_5X_Communities_of_Excellence.asp.

Great American Smokeout – This event is the third Thursday in November of each year. For information about resources to encourage the Great American Smokeout in your community or worksite, see the American Cancer Society website at http://www.cancer.org/docroot/PED/content/PED_10_5_Great_American_Smokeout_
History.asp?sitearea=PED.

Kick Butts Day – Kick Butts Day is the Campaign for Tobacco Free Kid’s annual celebration of youth leadership and activism sponsored by the American Lung Association. For more information or to order an activity guide, see http://www.kickbuttsday.org/.

World No Tobacco Day – This is a worldwide event held May 31st of each year to draw attention to the impact of tobacco use on public health and to reduce individual tobacco dependence. For more information on World No Tobacco Day or to receive an activity kit, see http://www.wntd.com/about_index.cfm.

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References

1. Landers, SJ. (2003). Kicking butt: Primary care physicians can help smokers quit. Retrieved March 7, 2005. From http://www.ama-assn.org/amednews/2003/12/15/hlsa1215.htm.
2. American Cancer Society (2005). Quitting smoking. Retrieved March 3, 2005. From http://www.cancer.org/docroot/PED/content/PED_10_13X_
   Guide_for_Quitting_Smoking.asp?sitearea=PED.
3. American Heart Association (2005). Smoking cessation guidelines. Retrieved March 4, 2005. From http://www.americanheart.org/presenter.jhtml?identifier=4735.
4. American Lung Association (2004). Quit smoking. Retrieved March 11, 2005. From http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=33484.
5. United States Department of Health and Human Services (2000). You can quit smoking consumer guide. Retrieved March 9, 2005. From http://www.cdc.gov/tobacco/quit/canquit.htm.
6. National Cancer Institute & United States Department of Health and Human Services (2005). Clearing the air: Quit smoking today. Retrieved March 9, 2005. From http://www.smokefree.gov/pubs/clearing_the-air.pdf.
7. American Lung Association (2004). Building motivation to quit. Retrieved March 11, 2005. From http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=39201.
8. American Lung Association (2004). Planning ahead. Retrieved March 28, 2005. From http://www.lungusa.org/site/ pp.asp?c=dvLUK9O0E&b=39206.
9. American Lung Association (2004). Alternatives. Retrieved March 11, 2005. From http://www.lungusa.org/site/ pp.asp?c=dvLUK9O0E&b=39204.
10. American Lung Association (2004). Triggers. Retrieved March 11, 2005. From http://www.lungusa.org/site/ pp.asp?c=dvLUK9O0E&b=39197.
11. American Lung Association (2004). Plan ahead – part 1. Retrieved March 28, 2005. From http://www.lungusa.org/site/ pp.asp?c=dvLUK9O0E&b=40400.
12. American Lung Association (2004). Nicotine. Retrieved March 11, 2005. From http://www.lungusa.org/site/ pp.asp?c=dvLUK9O0E&b=39202.
13. American Cancer Society (2005). Quitting smokeless tobacco. Retrieved March 3, 2005. From http://www.cancer.org/docroot/PED/content/PED_10_13X_Quitting_Smokeless_ Tobacco.asp?sitearea=PED.
14. American Lung Association (2004). Are you addicted to cigarettes? Retrieved March 11, 2005. From http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=40382.
15. American Lung Association (2004). Nicotine addiction. Retrieved March 11, 2005. From http://www.lungusa.org/site/ pp.asp?c=dvLUK9O0E&b=39198.
16. American Cancer Society (2005). Double your chances of quitting smoking. Retrieved March 3, 2005. From http://www.cancer.org/docroot/PED/content/PED_10_3x_
    Double_Your_Chances.asp?sitearea=PED.
17. University of Wisconsin Medical School: Center for Tobacco Research and Intervention (2005). FDA-approved medications to help patients quit smoking. Retrieved March 7, 2005. From http://www.ctri.wisc.edu/Smokers/ smokers_FDA.Approved.Medications.htm.
18. American Heart Association (2005). Nicotine substitutes/nicotine replacement therapy. Retrieved March 4, 2005. From
    http://www.americanheart.org/presenter.jhtml?identifier=4615.
19. Cable News Network (2005). New anti-smoking drugs promising. Retrieved March 9, 2005. From http://www.cnn.com/2005/HEALTH/conditions/03/08/antismoking.
20. American Lung Association (2004). The buddy system. Retrieved March 11, 2005. From http:// www.lungusa.org/site/ pp.asp?c=dvLUK9O0E&b=39203.
21. American Cancer Society (2005). Helping a smoker quit: Do’s and don’ts. Retrieved March 3, 2005. From http://www.cancer.org/docroot/PED/content/PED_10_3x_
    Help_Someone_Quit.asp?sitearea=PED.
22. United States Department of Health and Human Services (1996). Out of ashes: Choosing a method to quit smoking. Available CDC Fax Information Service 1-800-232-1311.
23. American Lung Association (2004). Lifestyle changes. Retrieved March 11, 2005. From http://www.lungusa.org/site/ pp.asp?c=dvLUK9O0E&b=39219.
24. American Lung Association (2004). Figuring it out. Retrieved March 11, 2005. From http://www.lungusa.org/site/ pp.asp?c=dvLUK9O0E&b=39195.

Download PDF version of this Newsletter:

• Download Newsletter only: Tobacco Cessation
• Download Handouts only:
  • Steps for Quitting Tobacco
  • Quitting Tobacco Tips
  • Weight Control While Quitting
• Download this Newsletter and 3 Handouts in one PDF file

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Last updated: 6 January, 2008

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