With so many options on the market for programs, pills and treatments to help you kick the habit, how can you tell which is the best method to use? TIME asked Dr. Michael Fiore, a professor of medicine at the University of Wisconsin School of Medicine and founder of the school’s Center for Tobacco Research and Intervention.
TIME: How can people know what the most effective methods are to help you quit smoking?
Fiore: The good news is that the United States public health services have reviewed the scientific literature on ways to quit smoking and has incredibly thoroughly, systematically and impartially analyzed those methods. They actually reviewed more than 8,000 scientific articles and they pulled them together to give what are called meta-analytical results, so not just one single story or one anecdotal report, but rather, the whole body of research on the most effective ways to quit smoking.
TIME: And what are their findings?
Fiore: Those guidelines really emphasize three core components to successfully quitting. The first is counseling, and counseling is always a pretty nebulous term, but there are quit lines across America (1-800-QUIT-NOW), which anybody can call and get the government services to help them to quit. What they’ll do is give you coaching—one-on-one personalized, individualized coaching to help you to quit. And that has been shown to substantially quit rates.
The second action that has been shown to really increase quit rates is systematically identifying smokers when they present to health clinics in America, having a system in place in those clinics to help them to quit, and having it brought up every time they visit. We know that seven out of 10 smokers visit a primary care doctor every year, so those physicians have unequalled access to smokers.
The third scientifically proven therapy is medicine. All three of these are important, they work additively, each of them by themselves boost quit rates, but when you combine them it reallyboosts quit rates.
TIME: What medications have been shown to work?
Fiore: The government identified seven medicines that the FDA has tested and endorsed. There are five nicotine medicines: the gum, the patch, the lozenge, the nasal spray and the inhaler. And then there are two prescription pills: Bupropion, some people know it by the brand name Zyban, and the other is called Varenicline, which people may know by the brand name Chantix. Those two have been shown to boost success rates. Of course, any medicine you need to talk to your doctor about. Each of these medicines have some people for whom they’re not appropriate, but for the most part the medicines can be used for most smokers.
TIME: How long should people be one these medications?
Fiore: The recommended treatment for nicotine medicines—in fact all five of them—is anywhere from eight weeks of the medicine up to six months. That’s the recommended course of therapy, and that’s pretty much across the board for all of them. People tend to use the gum and the lozenge longer and the nicotine patch shorter.
TIME: Can any of these methods used to quit be addictive themselves?
Fiore: Here’s the really core issue. Cigarettes contain 4,000 chemicals, of which about 40 are carcinogens, which can cause cancer. Nicotine is only one of 4,000. It happens to be the addictive one, but it’s only one of 4,000. What the idea is in designing these medications is that you get rid of your cigarettes with those 4,000 chemicals, you use nicotine as a bridge to then get to a point where you’re using no nicotine and no cigarettes. That is the goal.
The rub of course is the 5% of people who successfully quit with nicotine products, but end up using them long term. Is that a goal? Absolutely not, the goal is to be free of both cigarettes and nicotine, but if the alternative is, Do I use one chemical—nicotine—indefinitely, or do I return to cigarettes with 4,000 chemicals, many of which are deadly like arsenic and carcinogens? Without question I’d say to a patient, our goal is to get you off these medications, but if the only way you can stay free of cigarettes is to use them, then the risk of that nicotine is so minimal that it’s reasonable compared to the enormous risk of the 4,000 chemicals in cigarettes.
TIME: Nicotine gum, such as the brand Nicorette, is one of the methods people tend to stay on longer. Can extended use of the nicotine gum be harmful?
The jury is still out on that, there are at least some theoretical risks of nicotine in terms of the cardiovascular system. Some of these risks may be associated with the way it’s delivered—particularly if it’s delivered to the lungs in cigarettes it appears to be much more harmful than through a gum or a patch. The risks are possible, but probably minimal. But, realistically, it’s a no brainer when you match it up against the risks of smoking.
TIME: If people have kicked smoking, but are trying to ditch their quit method, is there anything you can recommend?
Fiore: There’s not a lot of science to guide that, but my clinical experience is that there are a few strategies that can be used. One is to take the gum on a more scheduled basis, a particular time throughout the day, and over a couple of weeks lengthen the time between pieces of the gum. The second approach is to cut the gum in half, and mix it with a piece of regular chewing gum. The third approach that we’ve used in our clinic is to buy a really spicy cinnamon gum like Big Red, and use that to substitute in between pieces of the Nicorette, and you get the same taste sensation that you’ve gotten used to, but you don’t get the hit of nicotine. You then increase the amount of spicy gum and decrease the amount of pieces of nicotine gum.
TIME: When you have a new patient trying to quit smoking, what method do you prefer?
Importantly, what I start with is coaching and counseling. This isn’t all about a medicine, it really is taking a person who has made a decision to quit and giving them some extra tools. So we talk about setting a specific quit date, some specific time over the next week when, on that date, you’ll start with not even a single puff. The second thing we do is review past experience. Almost every smoker has already tried to quit, but got into trouble and eventually relapsed, so how can they handle that situation differently? And also, what worked, and can we build on that?
The third point is to ask them to anticipate challenges to the upcoming quit attempt. Smokers know what’s going to get them into trouble, and if they practice coping strategies or plans before they quit, when they’re in withdrawal, they’re much more likely to implement those plans and make it through those dangerous situations. Another element to consider is alcohol—the leading factor that is associated with failing once you’ve started a quit attempt is drinking. 50% of people who try to quit and then relapse have some alcohol in their bloodstream when they have the first puff of smoke that leads to that relapse. So we urge them to, maybe for the first month or two, to totally abstain, so you don’t let your guard down in a way that will lead you to relapse. The link between drinking and smoking is a powerful one. And the last of the five points is smokers in the household. Probably the hardest thing is if you’re married to a smoker, you’re trying to quit, but your spouse is continuing to smoke. You really need to set up some ground rules for the house, and let them know that I won’t be at my best for the next couple of weeks and I’ll need a little slack.
We then link this type of coaching with one of the seven medicines, and which of the seven medicines we use depends on the person, and their history.
What ends up happening is you start with a person who feels helpless and overcome, and instead you have a person who has a really specific plan to quit.