 no matter how slowly I tried to taper them off nicotine replacement, they couldn't do it," says Sachs. "They were literally using it for years. Before you start tapering the dose, you should be cigarette-free for at least 30 days."
His clinical experience leads him to believe that 10 to 20 percent of smokers are so dependent that they may always need to get nicotine from somewhere. One study of people using the gum found that two years later, 20 percent of those who had successfully remained cigarette-free were still chewing. The idea of indefinite, even lifetime, nicotine maintenance sounds offensive to some. "Clearly, the goal to aim for is to be nicotine-free," says Sachs. "But if that can't be reached, being tobacco-free still represents a substantial gain for the patient, and for society." And getting nicotine via a patch or gum source means a far lower dose than you'd get from a cigarette. Plus, you're getting just nicotine, and not the 42 carcinogens in tobacco smoke.
Although the once-a-day patch has largely supplanted the gum first used in nicotine replacement, Sachs thinks that for some, the most effective treatment could involve one or both. The patch may be easier to use, but the gum is the only product that allows you control over blood nicotine level. Some people know they'll do better if they stay in control. And would-be quitters who do fine on the patch until they run into a stressful business meeting may stifle that urge to bum a cigarette if they boost their nicotine level in advance with a piece of gum, Sachs says.
However nicotine replacement "is not a magic bullet," says Fiore. "It will take the edge off the tobacco-withdrawal syndrome, but it won't automatically transform any smoker into a nonsmoker." Other requisite needs vary from person to person. A standard approach teaches behavioral "coping skills," simple things like eating, chewing gum, or knitting to keep mouth or hands occupied, or leaving tempting situations. Ways people cope cognitively are as important as what they do, says Shiftman.
He advises would-be quitters at times of temptation to remind themselves just why they're quitting: "My children will be so proud of me," or "I want to live to see my grandchildren," for example. Think of a relaxing scene. Imagine how you'll feel tomorrow if you pass this crisis without smoking. Or simply tell yourself, "NO" or "Smoking is not an option."
Coping skills, however, are conspicuously unsuccessful for people who are high in negative affect. Supportive counseling works better. Depression or anxiety may interfere with the ability to use cognitive skills.
One exercise that Brandon teaches patients asks them to inventory—and treat themselves to—things that make them feel good, a substitute for the mood-elevating effect of a cigarette. These might include exercising, being with friends, going to concerts, reading, or taking a nap. "Positive life-style changes that improve mood level" are particularly useful if you use cigarettes to deal with negative emotional states, he says.
Depression treatment is particularly important for those trying to quit smoking. One study found that cognitive therapy significantly improved quit rates for people with a history of depression. Various antidepressants have been effective in small studies, and a large double-blind trial using the drug Zoloft is underway.
Fiore has found that having just one cigarette in the first two weeks of a cessation program predicted about 80 percent of relapses at six months. Even when the withdrawal symptoms are gone, a single lapse can rekindle the urge as much as ever.
In the critical first weeks without cigarettes, a key to relapse prevention is avoiding, or severely limiting, alcohol, which not only blunts inhibitions, but is often powerfully bound to smoking as a habit. Up to one-half of people who try to quit have their first lapse with alcohol on board.
Watch your coffee intake, too. It can trigger the urge to smoke. And nicotine stimulates a liver enzyme that breaks down caffeine, so when you quit, you'll get more bang for each