People quit smoking every day. There are more former smokers than current smokers. (16) Many smokers make an average of four to six quit attempts before they quit for good, but it is important to recognize that each quit attempt builds upon previous experience. An analogy can be made to learning to ride a bicycle. One may fall a few times, before riding smoothly. One or two falls does not mean that one will not learn to ride. Patients learn what worked for them, and what didn't. The authors like to think of these as practice for the final and permanent quit attempt. It is important to advise patients to quit, and do so in a kind, caring, nonjudgmental manner. Quitting can be difficult for the smoker. Most likely the patient will experience physical symptoms of nicotine withdrawal once he or she stops smoking. There are also many triggers or rituals the patient associates with his or her smoking habit, and despite the cessation of cigarettes, there will be continued presence of those triggers. Common triggers include: coffee, alcohol, completion of a meal, work breaks, smoking "buddies," etc., and all the other behaviors that are associated with cigarette use. Withdrawal from nicotine is easier if the patient is aware of his or her triggers, tries to avoid them, and knows how to better cope with them when they occur. A plan of action will help promote the patient's success in unlearning the rituals of his or her smoking behavior.

There are several effective approaches to smoking cessation. These include going "cold turkey," nicotine replacement therapy, (17) or the use of a newly released non-nicotine medication, such as Buproprion HCL (ZYBAN (®)). (18) A patient's desire to stop smoking is one of the most important indicators for successful cessation. Other tips that assist the patient in the quit process are:

• identify a support person
• advertise the quit attempt
• make the home smoke-free (this discourages a relapse)
• get rid of tobacco, matches, lighters, ashtrays, and all things associated with the cigarette habit.

Cold Turkey

Quitting "cold turkey" involves selecting a quit date. On that date, the smoker completely stops the use of any and all sources of tobacco. With the removal of the nicotine source, it is important for the patient to be aware that he or she will most likely experience withdrawal symptoms, which may last for a few days, but often up to two weeks. (19) The withdrawal symptoms are a response to nicotine deprivation and other aspects related to smoking, and may include irritability, fatigue, dizziness, difficulty concentrating and cravings for cigarettes. Encouraging the patient to drink plenty of water may assist with nicotine elimination.

Nicotine Replacement Therapy

Nicotine replacement products help to reduce the physical withdrawal symptoms that occur when the patient stops tobacco use. Over time, proper use of nicotine replacement therapy will help to wean the patient off nicotine. (17) Nicotine replacement therapy comes in the following forms: gum, patch, oral inhaler, and nasal spray. Please refer to Table 3 for more information. Nicotine replacement therapy should be started on the selected quit date, and only after your patient has completely stopped the tobacco source. Certain brands of these medications are now available over-the-counter, while some continue to be available by prescription only. The AHCPR guidelines caution the use of the nicotine replacement patch in patients within four weeks of a myocardial infarction. (12) The oral inhaler is the latest replacement product to be released and is meant to serve two purposes: providing nicotine replacement and also providing a substitute for the hand-mouth routine so commonly experienced by the smoker. The nasal spray has been found to provide the fastest delivery of nicotine due to rapid absorption through the nasal mucosa.

Buproprion HCL (Zyban (®), Welbutrin SR (®),)

This non-nicotine medication, Buproprion HCL, available for a number of years as an antidepressant, has been found to be effective in reducing the cravings smokers experience when they stop smoking. (18) The manner of its action is unknown, but it is thought to work on certain pathways in the brain that are involved in nicotine addiction and withdrawal. Buproprion HCL is available only by prescription and should be started approximately one week before the patient's quit date to achieve adequate drug levels in the bloodstream to prevent craving. This medication is taken once daily for three days and then increased to b.i.d. dosing for the duration of therapy, which is usually three months. It is crucial for patient success that this medication does not be discontinued if the patient is wavering to return to smoking once this medication is stopped. Current research is being done on duration of this therapy. A patient may also use this therapy along with nicotine replacement therapy for additional relief from nicotine withdrawal symptoms. Buproprion HCL is contraindicated in patients with a history of seizures or disorders that may promote seizure activity (alcoholism, unstable diabetes, altered metabolic state, such as in eating disorders), and also for patients currently taking MAO inhibitors, or one of the other Buproprion HCL preparations, such as Welbutrin SR (®).

Behavior Modification

The use of tobacco often becomes a learned behavior reinforced by the redundant triggers we discussed earlier. Patients who are aware of their triggers and develop a personalized quit plan will achieve more success in unlocking the rituals associated with their smoking habits.

Alternative options for smoking cessation also include: hypnosis, acupuncture and aversion therapy (smoking a large quantity of cigarettes until becoming ill). For the purposes of this article, these options will only be mentioned. Evidence to support their efficacy is insufficient at present.