Immediate and delayed quitting

Last week I attended the 4th annual meeting of the Society for Research on Nicotine and Tobacco (Europe) in Madrid. This is a conference where the top researchers present their latest research findings. As you can imagine a lot of fascinating stuff was presented. One that I particularly liked was presented by David Gonzales of the Health and Sciences University in Portland. He presented data on immediate quitting (i.e. those who succeeded in quitting on their target quit date with no lapses) and delayed quitting (i.e. those who had some lapses after the initial target quit date but then managed to get quit and stay quit) among patients treated with either varenicline (Chantix), bupropion (Zyban), or placebo.

For me the interesting thing was that Chantix and Zyban each improved the proportion who initially quit (over placebo), but Chantix also increased the proportion who managed to achieve abstinence after their initial target quit date. Dr Gonzalez presented a nice diagram showing that the number of patients achieving abstinence continued to increase across the first 12 weeks among those on Chantix or Zyban (although it increased faster among those on Chantix).

Colleagues have remarked that patients taking Chantix are less focused on the target quit day (typically day 8 of taking Chantix) than we are used to. We think that’s because almost all of the patients we treated before Chantix were also using nicotine replacement therapy (sometimes combined with Zyban/bupropion). The NRT (patch, gum etc) is typically started on the target quit day and so patients are very aware of the importance of that day. We don’t typically combine Chantix with NRT (as the Chantix is supposed to block the nicotine receptors in the brain) and so on Chantix its easier to see the target quit date as less distinct from any other day and just continue reducing cigarette consumption rather than quitting completely.

The take-home message for patients is that it still makes sense to select a target quit-date (day 8) and to try to quit smoking completely on that day. However, if you don’t immediately get quit, don’t give up on yourself or on the medicines. The evidence suggests that if you keep trying you will likely achieve abstinence, and that Chantix improves your chances, so long as you keep trying and keep taking the medicine. On the other hand, its important to be clear that the aim of the game is to quit completely, and its better in the long run to throw away the cigarettes and get on with it.

Labels: bupropion, Chantix, cigarette smoking, quit, varenicline, Zyban

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Getting through the first few weeks

When people quit smoking it is very common for them to experience a temporary increase in certain unpleasant symptoms. The most common nicotine withdrawal symptoms are:
1. Irritability
2. Restlessness
3. Poor concentration
4. Depression
5. Increased appetite
6. Anxiety
7. Insomnia

I discussed these symptoms in previous posts:
What is nicotine withdrawal syndrome? 3/6/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/what-is-nicotine-withdrawal-syndrome.html

Ten tips for coping with nicotine withdrawal. 3/7/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/ten-tips-on-coping-with-tobacco.html

However, I’m bringing this topic up again because I’m noticing a number of people trying to quit smoking by using Chantix who are still experiencing some of the symptoms mentioned above but are concluding that these symptoms are caused by the medicine. Of course with any individual person the best way to figure out the cause of a new or worsening symptom is to discuss the problem in detail with your health professional. But in general, if someone has just quit smoking and they experience one of the symptoms mentioned above, the first explanation to consider is that it is a temporary nicotine withdrawal symptom caused by stopping smoking, rather than a symptom caused by a smoking cessation medicine.

Sometimes similar symptoms can be caused by smoking cessation medicines. For example, insomnia and vivid dreams can also be caused by the 24 hour nicotine patch and by bupropion (Zyban or Welbutrin). Chantix has also been known to cause vivid dreams. Generally, the heavier a smoker the person is, the more likely they will be to experience strong withdrawal symptoms, and the less likely their symptoms are caused by their medication. The opposite is also true. So if a 40-a day smoker experiences insomnia 2 days after quitting smoking while taking the standard dose of a smoking cessation medicine it is more likely to be due to nicotine withdrawal. If a 10 cigarettes per day smoker who never wakes at night to smoke and doesn’t smoke within half an hour of waking in the morning experienced the same insomnia it is might be caused by the medicine. In the case of the patch, they might want to try taking it off a few hours before going to bed, and in the case of Zyban or Chantix they might want to make sure they don’t take the second pill just before going to bed.

My main point here, however, is to caution against blaming the medicine for symptoms that it may actually be helping with, and then stopping using the medicine too soon. Any change in timing or dosage of a medicine should be discussed with your doctor first.

Similarly, it is tempting when a medicine is not giving complete relief of unpleasant symptoms like insomnia, anxiety or cravings to want to try another medicine as well. As always, a decision on what medicines are most likely to help you in any specific situation is best made after a full discussion between you and your doctor. However, when one of the symptoms mentioned above is the problem, and particularly if you were a heavy smoker and have recently quit, then the symptom is likely caused by nicotine withdrawal and will resolve by itself gradually over a couple of weeks. Medicines that have not been approved by the FDA or a similar medicines regulatory authority for smoking cessation will be unlikely to help much.

To tell if you are a “heavy smoker” check out my previous posts on that topic:
How addicted are you to cigarettes? (1) 5/19/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/how-addicted-are-you-to-cigarettes-1.html

How addicted are you? (2) 5/19/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/how-addicted-are-you-2.html

If you are a heavy smoker and are having a rough time quitting I’d strongly encourage you to get as much support as you possibly can. As well as speaking to your own personal health professional, I’d recommend a specialist face-to-face tobacco treatment service if there is one near you (they will have experts in smoking cessation counseling and medicines), as well as use of smoking cessation telephone helplines and internet sites, that were also discussed in previous posts:

Telephone quitlines: do they help smokers to quit? 4/19/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/telephone-quitlines-do-they-help.html

Can smoking cessation internet sites help you to quit? 4/21/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/can-smoking-cessation-internet-sites.html

Key things to remember during the rough times are:
A. Nicotine withdrawal symptoms are worst during the first couple of weeks after you completely quit tobacco and gradually calm down to be almost gone by the 4th week.
B. Each individual episode of craving for a cigarette typically lasts a few seconds, and rarely longer than a couple of minutes. Keeping yourself busy and actively switching your mind onto other things will help get rid of cravings more quickly.
C. Cravings are stimulated by being around tobacco and other people smoking. If you have any in the house, get rid of it. If you are hanging out in a place where people are smoking, hang out somewhere else!

You have probably put in quite alot of effort by the time you found this web-site. Don't throw it away by having a smoke. Keep going. It is tough but you can succeed.

Labels: Chantix, cigarette smoking, nicotine, patch, quitting, side-effects, symptoms, withdrawal, Zyban

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