What is the Single Best Thing You Can Do to Quit Smoking?

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Dr. Mike Evans is founder of the Health Design Lab at the Li Ka Shing Knowledge Institute, an Associate Professor of Family Medicine and Public Health at the University of Toronto, and a staff physician at St. Michael's Hospital.

This video was made possible by the Canadaptt Project (The Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment), Prinicpal Investigator Dr. peter Selby. Canadaptt was funded by Health Canada, Tobacco Control Programme. The views do not necessarily reflect those of Health Canada.

Written and Narrated by Dr. Mike Evans
Executive Producer, Dr. Mike Evans
Illustrations by Liisa Sorsa
Produced, Directed, and Photographed by Nick De Pencier
Editor, David Schmidt
Story/Graphic Facilitator, Disa Kauk
Whiteboard Construction, James Vanderkleyn
Production Assistant, Chris Niesing
Script Consultant, Hilary Cousins

©2012 Michael Evans and Mercury Films Inc.

>> Hi, I'm Dr. Mike Evans and I
think quitting smoking is a journey.

For some, it's a short journey
full of resilience.

But I think for most it's a long journey, a long
affair, if you will, of quitting and relapse.

A complicated relationship that can have
as much to do with a person's relationship

with themselves, as with the cigarettes.

What starts as a pleasant sensation, an
opportunity to rebel or even to belong,

is replaced by less pleasure
and a feeling of being trapped.

A daily or hourly ride of nicotine withdrawal
and then another cigarette, which brings relief.

Most teens who smoke, think they will in their
twenties and actually don't until their forties.

Stopping smoking is about making a change
and that is something we're not too good at.

When I think of change, I think of two concepts.

Where you are at and the
mechanics of how we change.

So, we should start where you are at.

When I started medical school, I thought I
could take somebody who smoked and convert them

into a non-smoker in one fell swoop.

Now I see it differently.

I focus on where the person is at.

You may be in what we call pre-contemplation,

where you're not really even
thinking about change.

Approximately 75% of smokers want to quit.

But 25% are not interested.

Maybe you're at the contemplation stage,
thinking about it, but not quite ready to act.

Next is preparation.

This is critical with smoking, especially in the
likely event that you've tried to quit before.

What has worked in the past and what hasn't?

What caused the relapse?

Maybe you're at the action stage.

This is when you're ready to make your move.

There's never a perfect time to quit.

And at one point you just have to jump.

I'll tell my patients, "Hey,
it's going to be a challenge now

and it's going to be a challenge in five years.

So, why not do it now?"

And then finally, there's the maintenance stage,

where you become a non-smoker
and are trying to stay that way.

[cheers]. When we make changes
it's critical to stop and think,

how important is this change to me?

And how confident am I in making this change?

What we call your self-efficacy.

Your job is to be honest.

My job is to see if I can
move your score towards ten.

The second concept is about
the different parts of change.

So, there's the what.

What are we changing?

With smoking, I suppose it is
straight forward, stopping.

But if you think about it, you
might be changing lots of things.

And I think it is like a relationship breakup.

You start by just keeping
things simple and low risk.

You might breakup your routine a little bit.

Avoid certain places.

Maybe use that juicer every
morning to distract yourself.

But you will need to change more than
your smoking, to stop your smoking.

The next is the why.

Why change?

I feel like I could do a ten-minute video just

on all the medical reasons why
not to smoke and they are legion.

But I'm going to spare you.

Partly because you already know.

Partly because you don't need anymore guilt.

And partly because in clinic, I actually
spend more time asking people what they

like about smoking.

Which sounds funny, but I think we have

to recognize there are positives
or at least perceived positives.

And I think it's important to reframe these
perceptions, if we are to make a change.

So, let's run through a few of the common ones.

Cigarettes are my friend.

They destress me.

They relax me.

Hmm, I'm not going to deny that
you may feel a sense of relief

and satisfaction, when you have a cigarette.

But I see it a bit differently.

You have a nicotine addiction.

The nicotine in tobacco is highly addictive.

Within a few seconds of inhaling, it travels to
your brain causing you to have a temporary high.

Over time, your brain changes, causing
you to smoke more to get the same effect.

We rate your addiction to nicotine
with a few simple questions.

Do you smoke more than 15 cigarettes a day?

Or smoke within 30 minutes
of getting up in the morning?

Do you find it difficult to go more
than four hours without a smoke?

The power of nicotine comes from the repeated
small doses you give yourself when you smoke.

It may seem innocent at first, but if you
take 15 puffs from a cigarette and smoke, say,

20 cigarettes a day, that's
300 drug doses a day.

You think smoking relieves
your stress or is satisfying.

But it actually isn't.

The cigarette is just making
your nicotine addiction go away.

Smoking doesn't make your concentration better.

It just calms your nicotine
receptors cry for more.

Smoking makes your heart beat faster.

Increases blood pressure and breathing.

These are all symptoms of
stress, not stress reduction.

Let me repeat that.

The cigarette just reduces your
nicotine stress, not your real stress.

I've got a lot of trigger times.

Coffee, sex, meals, certain people.

Break times, telephone calls, the car.

There are a lot of triggers you're
going to have to prepare for.

You got to change your coffee routine.

Plan something to do right after meals.

Throw out your car ashtray.

I have no advice on sex,
but make a plan for breaks

or the telephone, with lots of distractions.

Know that when you have a hunger or
caffeine or other types of pangs,

you also have a nicotine pang
that needs to be satisfied.

You have associated these,
but they're actually separate.

Alcohol and parties double the
risk, as you have the association.

Plus, you're imbibing something
that intends to lower your resolve.

I want something in my hand.

Yes, you are making maybe
300 hand motions a day.

You may need to replace this by chewing gum
or chewing on a straw or a cinnamon stick.

Or playing on your cellphone, to keep your
hands busy, to replace this daily habit.

I will gain weight.

Yes, you might.

But I think this is actually
more marketing than reality.

What I call the Virginia Slims effect.

On average, people who quit, gain
about 2.5 kilograms or five pounds.

So, two thoughts on this.

Firstly, if this is a concern for you,
you might want to focus on strategies

that affect calories in and calories out.

Such as your new daily routines
might focus on walking.

A special emphasis on being
mindful of emotional eating.

Or that your hand mouth routine
includes carrots or celery sticks.

My second point is about perspective.

A possible five pounds may be
important from a vanity perspective.

But from my doctor perspective,

the health return is spectacularly
higher, when you stop smoking.

Remember, we said smoking was a relationship.

Part of the healing of stopping
a damaging relationship,

is start a new healthy relationship.

So, now it's the time to start a deeper
relationship with your bicycle or salads

or walking or gardening or
your support of friends.

Next is the how.

What do the skills require to change?

How do I change, with the emphasis on I?

So, what works?

Well, let's start with willpower.

It's a strange word.

On the one hand, it permeates behavior change
and all of the interventions we talked about.

It's also a word I don't love, as
people see it as black and white.

If a person succeeds, they have willpower
and if they fail, they have no willpower.

The science of willpower and
smoking gives a mixed message.

Approximately 5% of smokers
who try to quit cold turkey,

achieve prolonged abstinence
for six to 12 months.

With most relapsing in the first
eight days of attempting to quit.

And the other hand, most people
who quit, do so unassisted.

Maybe 2/3 to 3/4 of people do so by themselves.

Reconciling these two stats reveal the natural
history of smoking cessation, that quote,

"failures" are part of this process.

And can be seen as dress
rehearsals for the eventual success.

Another key pearl here is the data
which tells us that a perception

of the quitting smoking experience
is often much darker than reality.

In a British study of people who were
surveyed about their quit experience,

53% said that it was not
at all difficult to stop.

Twenty seven percent said
it was fairly difficult.

And the remainder found it very difficult.

So, to summarize, you can do it by yourself.

And it may be less difficult than you think.

On the other hand, it looks like your chances
are better if you layer on some other tactics.

So, if you fail, try again.

And think about adding another strategy.

Some say there are two types of cigarettes.

Those that are dealing with your
nicotine addiction and those

that have become part of a routine.

So, let's see what works for
both these types of cigarettes.

Let's start with treatments that
have not been proven affective.

And where you may be wasting your money.

Now, some of my patients have found they help.

And to be honest, if they stop your
smoking, I suppose I don't really care.

But under this category I put laser
therapy, acupuncture and hypnosis.

When we compare these treatments to a placebo
or just compare them to the quit rates

on waiting lists, the rates
don't appear to be improved.

Next is medications to help stop smoking.

The data shows that medications, especially
when combined with behavioral support,

can double your chance of success.

Many patients are resistant, which I get.

But I also see an irony in the
fact that people are willing

to inhale chemicals much, much worse for them.

But they won't take a medication
for a few weeks or months

to stop smoking for the rest of their life.

If we use nicotine replacement therapy
as an example, it allows people to deal

with the addiction of nicotine, without having

to inhale the other 7,537
chemicals in cigarettes.

And that's what I worry about.

People die, two full 747's of people a
week in Canada, from smoking, not nicotine.

Nicotine replacement therapy
comes in multiple forms.

And there is usually less nicotine
then what you get in a cigarette.

You can put on a patch, which
is easy and discreet.

You can chew gum, although in a
different way than you usually chew gum.

You can suck on a lozenge
or you can use an inhaler.

The patch gives you a nice baseline
nicotine level to lower your cravings.

The latter three, offer the
advantage of flexible dosing,

when you have a nicotine craving.

And a familiar routine of opening packages
and putting something in your mouth.

The important thing people need to know about
nicotine replacement therapy are, firstly,

you can design your own nicotine program.

You do not need a prescription.

Prefer the patch and then the gum or lozenge
or inhaler for breakthrough cravings?

Great. Maybe you smoke under
ten cigarettes a day

and just want to use the gum when you need it.

Your pharmacist can really help here.

People get a bit confused with the cost.

NRT is generally cheaper than smoking,
but you might be buying a month at once.

Moneywise, of course, it's a no brainer.

A pack a day is maybe $3,600 a year.

imagine what you would do with that money.

Imagine what you would do with
ten years of that savings.

Secondly, with nicotine replacement,
you can stop cold turkey

or you can wean down your smoking.

Taking nicotine and smoking together,

does not increase your risk of
heart attacks, smoking does.

You probably started smoking gradually.

And I guess the same can be true of stopping.

If you feel you need another
month of NRT, then that's fine.

I'm not going to go into details
of pills for smoking cessation.

But I will give you a quick
overview of the two most known ones.

The first is Zyban or bupropion.

This started just as an antidepressant.

And then users found their desire for smoking
dropped and they were able to quit more easily.

Champix or Chantix, in the U.S., is varenicline.

It is a newer option that may be even more
effective, but also has some side effects

that may make it not for everyone.

You can discuss these options with your
doctor or other healthcare providers.

The counseling needs to be individualized.

The final approach is the
behavioral interventions.

I covered some of this ground, but I don't think
people realize how many fantastic resources are

out there for them.

Governments make a lot of
money from people who smoke.

And they fell into superb programs.

You want a text message, a supportive e-mail?

You want expert counseling, want to
be connected with other people going

through the same thing or
who have just been there?

Or maybe you just want to talk to someone?

Go online.

Call the help line.

Buy the book.

Get the message.

In the first months following
quitting, I want you to prepare

for the roadblocks of risk and stress.

So, avoid high-risk situations.

You know what they are.

You might want to tell the
people involved in advance.

And then I want you to focus
on stress reduction.

Stressful things are going to happen
to you, but you create the stress.

Tell people, "Hey, I'm quitting
smoking this month."

So, what's the least stressful
strategy that works.

I also get people to think about the three A's.

Avoid situations you know are stressful for you.

Alter expectations.

So, when you look at your
to do list, be realistic.

Manage the expectations up
front before it's stressful.

And the final A is acceptance.

If we use driving as an example, traffic
jams, bad drivers and flat tires happen.

Take a deep breath.

Focus on what you can control.

And accept what you can't.

Now, let's say you quit smoking,
that's excellent.

You've broken up.

So, what now?

Well, first of all, you're great.

Secondly, there's going to
be some ups and downs.

More ups, especially after you
get through the first month.

But some of the things to expect with
nicotine withdrawal are cravings.

And these don't follow a perfect line.

Headaches, nervousness, irritability,
trouble sleeping.

And you may want to eat more.

So, have some healthy foods ready.

And then also people tend to have more
of a cough, as their lungs self-clean.

Finally, the Japanese have a
proverb that success is falling

down seven times and getting up eight times.

If you get derailed, don't feel guilty.

As I said in the beginning, this is a journey.

Come back and see us.

This is the best thing I can do for you.

Don't learn helplessness.

Learn about yourself and get
ready for the next round.

And thanks for listening.