By Angela Spivey

What are cigarette smokers hooked on? You know the answer. Even tobacco companies concede that a cigarette is basically a delivery system for an addictive drug: nicotine.

But to a smoker, a cigarette is much more than that. A smoker craves not only nicotine, but all the tiny things he or she has unconsciously learned to associate with it -- the feel of a lighter in a pocket, the smell of burning tobacco, the sensation of smoke in the throat.

“A smoker who has smoked a pack a day for twenty years has inhaled a cigarette over a million times,” says Robert Shipley, PhD, former director of the Duke Center for Nicotine and Smoking Cessation Research. “Each time, they have associated that inhaling of a cigarette with something pleasurable.”

Research shows that those associations are so strong that the cigarette’s power lies just as much in its sensory effects as in the nicotine, says Jed Rose, PhD, the center's current director.

Understanding the intricacies of addiction to cigarettes is key to helping smokers kick the habit -- a goal that has proved frustratingly elusive for both the health care community and smokers themselves.

Most current smoking-cessation methods are only moderately helpful, with overall quit rates 25 percent or less after one year, Rose says.

Timing Is Everything

The mainstay of smoking-cessation treatment is nicotine replacement therapy (NRT), which can help relieve some of the irritability, hunger, and other withdrawal symptoms that smokers feel in the first weeks of quitting.

Patients who use NRT are more successful than those who don’t. Initial quit rates on NRT are about 25 percent -- without, 5 to 10 percent.

Recent research conducted by Rose, a co-inventor of the nicotine patch, suggests a simple way to modify NRT to dramatically increase those success rates. The modification helps NRT not only relieve withdrawal, but actually weaken smokers’ dependence on the cigarette itself.

In one study, Rose had a group of smokers start using a nicotine patch on their target quit date, just as the labeling directs. Another group began the patch early -- two weeks before they stopped smoking. Those who used the patch while still smoking were twice as successful at quitting.

Why? Using NRT and cigarettes at the same time appears to “devalue the experience of smoking,” Rose says.

If the physical need for nicotine is met by the patch, but the person still smokes, then each time he lights up, the cigarette itself provides less of a reward.

Gradually, the smoker’s body and brain learn not to associate cigarettes with pleasure. The cigarette loses some of its power.

Strategies for Success

Once smokers are ready to quit, they are more successful if they have strategies for handling cravings.

Arming smokers with a plan is a major part of the QuitSmart smoking cessation program, developed by Duke’s Robert Shipley.

In one study, 66 percent of smokers using QuitSmart were still smoke-free at six months, versus just 16 to 30 percent in four comparison treatments.

The program uses multiple methods: gradually switching to low-nicotine cigarettes before the quit date, various forms of NRT, hypnosis, and behavioral treatment such as encouraging smokers to reward themselves.

“Smokers spend a lot of their life in the actual smoking ritual. Now they have time on their hands,” Shipley says. “We want them to use that time not to clean the cupboard, but to do something to feel good -- take a walk, a bubble bath -- so they don’t feel deprived, which could lead them back to cigarettes.”

These approaches tackle not just the physical addiction to nicotine, but the smoker’s emotional dependence on the whole habit.

Shipley says that, for most smokers, giving up cigarettes is like giving up a good friend.

“If a smoker is lonely, they smoke. If they’re bored, they smoke,” he says. “While you and I can see it as a false friend, to a smoker, day by day, hour by hour, it’s been a very good friend to them.”

The Best Stop-Smoking Strategies

If you’re ready to quit, try these strategies to help yourself succeed.

• Try, try again. It’s common for smokers to make more than one quit attempt before succeeding for good.
• Try nicotine replacement, which comes in a gum, a transdermal patch, a nasal spray, an inhaler, and a lozenge. Smokers could use the patch primarily but add the gum or inhaler when cravings strike.
• Ask your doctor about higher doses of nicotine replacement. One nicotine patch delivers the equivalent amount of nicotine as one pack of cigarettes a day. But someone accustomed to smoking four packs a day may need higher doses to relieve withdrawal. Use of doses of nicotine replacement higher than 21 milligrams a day isn’t approved by the FDA, but it has been found useful in research studies.
• Try varenicline (Chantix), which releases dopamine into the brain, making the smoker feel as if he or she has already had a hit of nicotine. The presence of dopamine in nicotine receptors also makes smoking a less rewarding experience, reducing cravings.
• Also consider Zyban, a form of the antidepressant bupropion (Wellbutrin) approved for use in smoking cessation. Duke psychiatrist Kishore Gadde, MD, found in 1999 that the same compound also helps people lose weight. Though Chantix was found more effective in a clinical trial, studies have indicated Zyban may help those who are particularly worried about gaining weight when quitting.
• Try behavioral therapy or counseling. Telephone counseling has been shown effective for adults in several studies, as have printed materials tailored to specific needs, such as what to do when seeing friends who smoke.