How to Stop Smoking

John Fitzgerald was interviewed for an article (Confessions of an ex-smoker: Winning the battle against nicotine by Terri Brown) on the website Moms Today. Although excerpts appear in the article, below are more complete answers to the questions asked in the interview.

Do you have a particular program you recommend for those who wish to quit
smoking?
Yes. I have developed a general process whereby people can resolve any addiction, including smoking. It involves five steps:

Deciding to change: Most smokers are in a state of precontemplation or contemplation, meaning they either have no motivation to quit at all, or they are stuck in a state of ambivalence where they know they should stop but continue to smoke. The first step in helping a smoker is to explore their motivation for change (or lack thereof), and help them increase it in the direction of wanting to stop. Often motivation can be increased when people realize  the benefits of quitting, including: 1) food tastes better, 2) get sick less, 3) chance of living longer, 4) increased energy, 5) breathe easier, and 6) lower risk for heart attack, stroke, and cancer. Once a commitment to change is reached, then the various methods of change can be explored. In the last ten years researchers have developed a way of working with people called motivational interviewing that has been shown in multiple studies to effectively move a person in the direction of positive behavior change.

Changing addictive behavior: Extensive research has shown that a combination of behavioral and pharmacological treatments for nicotine addiction work best when a person is ready to change. Behavioral therapies are an essential component of change, and include (1) learning new coping responses in place of smoking (2) monitoring smoking behavior and change over time (3) developing aversions to smoking (4) learning to avoid smokers and high risk environments and (5) developing a support network. Pharmacological therapies include nicotine replacement treatments such as Nicorette gum, the patch, and nasal sprays and inhalers. All appear equally effective. I will also advise patients to consider non-nicotine prescription drugs like Zyban and Chantix as aids to quitting that help reduce cravings and improve outcomes. I also think it is important for patients to recognize that there are many paths to changing addictive behavior, and no one right path for everyone. I have many patients who have successfully stopped smoking with the help of self-help groups, diet changes, meditation, exercise, and spiritual activities.

Note: A compound called Nic VAX is entering clinical trials as a new vaccine that prevents nicotine from reaching the brain. If the trials are successful, it would be the first medication useful as an inoculation against nicotine addiction, and prove useful for those trying to quit.

Preventing Relapse: Research is clear that most people who try to stop smoking relapse a number of times before finally succeeding – and most in the first three months after quitting. The most common relapse triggers include drinking alcohol, being around other smokers, weight gain, and having a negative mood. Relapse prevention typically involves helping people develop both behavioral and cognitive skills to (1) prevent relapse from occurring (2) manage a relapse after it happens and (3) help a person not continue in the addictive behavior after a relapse. I find often that once a smoker relapses they will feel defeat and want to continue smoking for a while until their motivation to quit comes back. In the end, preventing relapse is really about developing a healthy lifestyle.

Resolving Core Issues: Probably among the most significant reasons so many people struggle to quit an addiction like smoking is they fail to address underlying core issues. Robert Bly said it best: "We spend our life until we're twenty deciding what parts of our self to put into the bag, and we spend the rest of our lives trying to get them out again." Core issues are a universal feature of being human and afford us all the opportunity for continued growth and development if we are open to exploring their message and meaning in our lives. Core issues take many forms, but among the most common include: (1) mental health issues like depression and anxiety disorders – and other addictions like gambling, sex and drugs (2) trauma in all its forms – sexual, physical, emotional (3) developmental deficits and constrictions – such as an inability to think emotionally or self-regulate emotion (4) relationship issues - 67% of first time marriages end in divorce over a 40 year time span! (5) overweight/obesity – now with 55% of the US population qualifying it has become an epidemic and (6) grief and loss – losing someone unexpectedly and not properly grieving their death. I find resolving core issues to be at the heart of helping a patient permanently stop an addiction because often it has been used as a coping mechanism. Resolving these issues can be simple or very complex depending on the nature of the problem. There are many things that can help a person resolve core issues, but like smoking a person starts with deciding to change. The actual process of change takes many paths and may or may not involve professional therapy.

Living Optimally: The final stop involves the continual process of optimizing how we live. In most change programs once the behavior ceases so does the program. This is unfortunate because I have had many patients who work incredibly hard to stop smoking (or some other addiction), take the time to resolve core issues, and then find themselves feeling lost and without a sense of direction or purpose. Helping people find their own compass and passion is the best insurance against a return to an addiction like smoking. Often this work takes on a spiritual quality, but it can also be very practical as well.

How do you work with people who want to quit smoking?
I first say "way to go." Deciding to change an addictive behavior like smoking can be incredibly difficult – often as tough as heroin and cocaine. Most people who smoke are stuck in a state of perpetual ambivalence where their internal dialogue says "I want to stop and I don’t want to stop." Resolving this conflict is critical to permanent change, and involves helping a person connect change with something important, something of intrinsic value. This may be improved health, living long enough to be a grandmother, or a personal goal like running a marathon. As a therapist I spend a great deal of time providing a safe environment for patients to explore the state of ambivalence, and work through in their own way what is most important to them. I also believe that a little education goes a long way. Researchers and clinicians have learned a great deal about nicotine addiction. For those who smoke, understanding gender differences, genetic influences, and various treatment approaches can be extremely helpful. Probably the most common question I hear is "why can’t I just quit?" I help patients understand that smoking physically alters the brain, and the neurochemical changes that take place are in an area of the brain that runs on auto pilot. It is a place where breathing, heart rate and our thermostat for hunger and sleep are found. Those addicted to smoking have in effect educated their brain to believe that it is a need as strong as oxygen, food and sleep. This is why for some people stopping seems to be an impossibility. It can be very empowering for smokers to understand that changes in the brain can be reversed, and the strong cravings eliminated in time. (Refer to the above answer for a general overview of how I help people stop smoking)

How does nicotine addiction, the many failures that come with that, affect
the human spirit?
Although some people are able to quit on the first try, most research studies indicate that it is quite common to experience multiple relapses (6-7) before finally succeeding. As humans we are much more comfortable with life when we are in the drivers seat – when we are steering our own course and in control of our behavior. I find for many of my patients that relapse adversely affects the human spirit because it leads to feelings of despair, helplessness and a sense that there is no control over the future. Relapse also has become overly identified with addictive behavior when really it is best understood as a human behavior undertaken at times by us all. Taking the shame out of relapse and reframing it as a natural step in the process of changing tough behaviors like smoking empowers our spirit instead of draining it.

Are there any special considerations women need to be aware of when trying to
quit?
Yes. Large research studies have shown that quitting smoking may be more difficult for women. They are less likely to initiate quitting and when they do, relapse is often more common. For women who utilize nicotine replacement methods such as the patch or gum, they should be aware that the nicotine does not seem to reduce craving as well as it does for men. In addition, women may experience withdrawal symptoms more intensely and appear more likely to gain weight upon quitting.

Pregnant women take a tremendous risk smoking. The combination of carbon monoxide and nicotine interferes with the oxygen supply to the fetus and can result in developmental problems in the fetus. Smoking can also be responsible for spontaneous abortions in the first trimester, and an increase in premature delivery rates and decreased birth weights in the final trimester. In all cases it is advisable that pregnant women not smoke.

What sort of behaviors need to be changed in order to be a successful quitter?
In addition to what I have already stated above, I think the following behaviors increase the likelihood that a person can successfully stop smoking:

• Stay away from smokers
• Maintain a healthy diet (helps manage weight gain)
• Exercise!!!!!
• Avoid alcohol
• Take one of the five FDA approved medications to help quit smoking
• Get professional therapy to deal with negative moods and underlying core issues
• Be willing to ask for support and attend self-help meetings
• Use the internet to find helpful information about quitting

How Exercise Helps Smokers Quit

Research consistently indicates that we all try to self-regulate our moods. When our feelings are negative, we turn to all sorts of substances and activities to make ourselves feel better. When we are in a good mood, we will often try to maintain or enhance it using the same substances of activities. The most common mood regulators include: food, substances (caffeine, nicotine, & alcohol are most common), watching television, use of the internet, various activity addictions (gambling, sex), listening to music and exercise (of course there are many more).

Smoking continually works as a mood regulator, often occurring at specific time intervals. A pack-a-day smoker will light up approximately every half-hour. When the routine is disrupted and a smoker is unable to light up, tension builds in the body both physiologically and psychologically. And it will continue to build until smoking resumes. For the person trying to quit, a major hurdle is how to handle negative moods and tension (stress) that builds in the body. A corollary hurdle is also how to address the weight gain. It turns out that the number one method for regulating mood and weight is exercise.

Why? Considerable research now proves convincingly that exercise increases energy levels, improves mood, and helps to keep the pounds off. In one study done at Concordia University and Wake Forest University, 93 women in their thirties regularly engaged in fitness activities lasting twenty minutes or longer for eleven weeks. The most significant finding was that the women reported feeling energized, refreshed, and revitalized from just simple bouts of exercise. The women also reported increased positive moods – related to the increased energy and reduced tension.

Moderate exercise, done consistently, raises energy levels, is associated with increased positive moods, and helps to curb the cravings for food. Yet when faced with the choice of returning to a cigarette or jogging around the block, many people prefer the former. This problem goes back to deciding to change (see above). In working with patients, I often find that most are unaware of their moods, or what drives them. They know little about exercise (particularly if they are smokers) and how it can produce significant results with very little effort. Often during a session if a patient complains of feeling down and having low energy – or wanting to smoke – I will offer them an experiment. I say "lets go walk in the park for ten minutes and then see how you feel." Surprisingly, they always find themselves more energized and in an improved mood.