Quitting smoking is a process, not an event

March 9, 2015

Read this interview about quitting smoking with Dr. Peter Selby, Clinician Scientist, Addictions and Director, Medical Education at the Centre for Addiction and Mental Health in Toronto

Tell us about the work you do at the Centre for Addiction and Mental Health’s Nicotine Dependence Clinic?

I am the physician lead around nicotine dependence. I also develop research and knowledge translation programs around the treatment of smokers who find it particularly difficult to quit.

We hear a lot about smokers and nicotine addiction in the media. Can you talk about the science behind nicotine addiction?

Nicotine becomes addictive depending on how you use it. If you smoke it like a cigarette, cigar or pipe, or if you chew it like tobacco, then it is addictive. However, when you take it through your skin, like the patch, then it isn’t addictive.

Nicotine activates parts of the brain that have to do with reward, attention and memory. The memory part is tough because we can detoxify somebody in a day or two, and within a week all the nicotine’s out of the system, but that’s not why people relapse. They relapse because of the way cigarettes ingrain themselves in their minds.

Men and women smoke for different reasons. In general, men tend to smoke for the reward and when they quit they tend to have an easier time quitting. In women, smoking is more about the perceived social and coping benefits. Although they do respond to NRT, they do not respond as well as men. When they quit they tend to have a harder time and some of that may also be attributed to female sex hormones.

You’re the principal investigator of the STOP study, which is investigating the effectiveness of nicotine replacement therapy (NRT) for Ontario smokers. What have you found so far?

The quit rate with NRT is 10 to 30 per cent. We can compare that to the real-world quit rate, if you didn’t use NRT, of about three per cent. So we are almost tripling the quit rate. From that perspective, it’s proving to be effective and safe in the real world – that’s something that can help inform policy. We can say smokers should be offered NRT because it does help them to quit.

Speaking of NRT, e-cigarettes have been in the news quite a bit lately, and they seem to be gaining in popularity, but not necessarily to help people quit smoking. What are your thoughts on this?

Researchers, clinicians and policy-makers need to pay very close attention because smokers are more willing to try e-cigarettes than they are approved medications to quit smoking. Many of them anecdotally tell us that they use them to get away from cigarettes and find them an acceptable alternative. That’s good on one level, but not good on another because we really don’t know what’s in these e-cigarettes. They haven’t been subjected to the same consumer product regulations or inspections as NRT.

What about smokers themselves? What do they need to know or do to help themselves quit smoking?

It’s basically a four step plan to help the smoker quit called STOP:

• Strategy (before the quit date – managing the environment, monitoring smoking intake, choosing and starting medications)
• Take action (stopping completely and committing to not take even a puff)
• Optimize (tweaking the plan if you experiencing cravings or lapses to prevent full blown relapses)
• Persevere (staying quit and committing to not taking another puff, adopting the identity of a non smoker)

Is there anything that friends or family members can do to help a smoker quit smoking?

Family members should ask the smoker how they can be helpful. They should not nag, but they should clearly hold people accountable for smoking. The person who is quitting should feel comfortable being honest about the difficulties they might have in quitting and the friend could be a sympathetic ear. They could just listen, provide support and really take the lead from that person as to what would help them not have that next cigarette. Most important is to not jeopardize the quit attempt by offering cigarettes, having cigarettes around or telling that person to go back to smoking because they are irritable and anxious.

Fewer Canadians are smoking. Why, do you think? What has worked?

I would attribute the reduction primarily to some very good national tobacco control strategies that had to do with smoke-free places, and the price and availability of cigarettes. Unfortunately, in the last five years that reduction has plateaued and we need to start looking at ways we can reinvigorate the decline so that fewer people take up smoking and current smokers quit and stay quit. That requires policies that will shift the norm so that smoking is a non-normative behaviour and that if you are still smoking in this day and age and you can’t stop on your own there should be help available to you.

What does a smoker look like in 2013, compared to 10 years ago? Have you noticed demographics changing?

The current smoker is much more likely to not have completed high school, to work in a blue collar job and to be a male, although women are catching up. They tend to be smoking about one cigarette per waking hour and are more heavily addicted to cigarettes. They tend to be much more likely to have some comorbidity, whether it’s psychiatric, another addiction or a medical problem. Often all of those comorbidities are combined, which can also lead to social isolation.

Then you have this other group that’s developing that calls itself “social smokers.” They’re not daily smokers, but they are still smoking. It’s an interesting young demographic who are early enough in their problem that they will not develop into lifelong smokers if we help them change.