Beating the craving

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Willpower
Nicotine Replacement Therapy
Prescription Drugs (Zyban & Champix)

When you quit there are four main negative side effects that most people experience:

Mood changes – on average these last up to four weeks. Typical manifestations include being irritable, restless and depressed.
Difficulty in concentrating – on average this lasts less than two weeks
Urges to smoke - These will last for about four weeks, as the nicotine ‘craving’ only lasts four weeks if you have stopped smoking. As time goes on they will decline in frequency, but may increase in intensity. Don’t be surprised if you have a really strong urge for a cigarette quite a few months, even a year, after stopping.
Increased hunger and weight gain – the urge to smoke is similar to feeling hungry so people often eat to take away the urge. Body weight can increase, putting on 6 kilogrammes (a stone) is not unusual, until the new body weight stabilises. One of the things you can do to both take the edge off these hunger pangs, and also lessen the urge for a cigarette, is to buy and use glucose tablets (Lucozade make some). Each tablet is only around 2 calories.

In addition to these, there are other less common symptoms:

Mouth ulcers – in around 30% of quitters in the first two weeks
Light headedness – in around 10% of quitters in the first few days
Increased coughing – in around 15% of quitters in the first three to four weeks
Disturbed sleep patterns – in around 25% of quitters in the first two weeks

You can find information on this site about ways to reduce these negative side effects.

There are three recognised ways that you can beat the urge to stop smoking: relying on your willpower; using nicotine replacement therapy (NRT); and using prescription drugs. Below we have provided information about each method, but ultimately it is for you to decide which method you think would be most suitable for you.

Willpower

Some people are able to go ‘cold turkey’ and quit using willpower alone, but this is probably the least successful method. Only a small proportion of people who attempt to stop smoking using willpower alone are successful on their first attempt.

Using the information on this site, getting support from your friends and family, and thinking about why you want to quit will help you to stop, although you will improve your chances of success if you use NRT, one of the new stop smoking drugs that are now available on prescription, or if you access a stop smoking group.

Nicotine replacement therapy (NRT)

Nicotine replacement therapy is the use of various forms of nicotine delivery methods intended to replace nicotine obtained from smoking. NRT helps deal with withdrawal symptoms and cravings caused by the loss of nicotine from cigarettes. There are several forms of NRT including the nicotine patch, inhaler, nasal spray, gum, sublingual tablet, and lozenge.

It is not the nicotine in cigarettes that do harm, but rather the other chemicals in tobacco smoke, such as Carbon Monoxide and tars. NRT delivers nicotine to the smoker's brain in a much slower way than cigarettes. It helps to damp down the urges to smoke that most smokers have in the early days and weeks after quitting, rather than remove them totally. It gives the smoker the chance to break smoking cues in their daily lives, and might provide a more comfortable exit from the smoking habit. NRT however is best used with some form of support, ideally from groups or a smoking cessation specialist.

Pointers on using Nicotine Replacement Therapy (NRT)

First of all, don’t worry if you have already tried NRT. Quite a few people have tried it before and failed with it. In the vast majority of cases this is because they were not using it properly, or gave up at the start because it tasted bad. Often they might have had unrealistic expectations, like they would slap on a patch and never even think of smoking again.

NRT is not a magic bullet, it needs work. You have to be motivated to quit and you will still have to wrestle with the urge to smoke but NRT will take the edge off the urge to smoke and make it more manageable.

Different types of NRT will work for different people, depending on their smoking habits. Consider such things as:

Heavy smokers should use 4mg strength gum, not 2mg strength to begin with. Microtabs and lozenges are equivalent to 2mg gum, so heavy smokers probably won’t want them.
It is OK to change from one sort of NRT to another if you find it is not working very well for you. You can also combine NRT products i.e. patches to give a gradual stream of nicotine over a long period, use the gum, lozenge or spray to deal with any strong ‘urges’ to smoke you have.
The key to success is perseverance. All of the NRT products take some getting used to, and switching around in the first week is not advisable, just in case you might not have given it a proper chance.
The recommended dosage on packets is quite low. The gum packet says use 10 to 15 pieces a day, but clinics recommend doubling that. Also, it is OK to use different NRT products in combination. The only nicotine you shouldn’t take while on NRT is from a cigarette, not just because you’re supposed to be quitting, but because the high nicotine content from a fag added to the NRT will make you feel quite sick.
If you don’t use NRT properly you will continue to get urges to smoke. Don’t try to “give up” NRT – make full use of it.
NRT should be used for up to three months after Quit Day, but if you feel the need to carry on for a bit longer, that’s OK, or if you want to wean yourself off by switching strengths of gum or patch, or switching to a lower dose product that’s OK too.

Different types of Nicotine Replacement Therapy

Below are tables for the different products of NRT available. You can buy brand names or some pharmacists sell their own brand. They are both as effective but “own brands” are usually cheaper.

Product	Gum 2mg and 4mg strengths flavours: original, mint, liquorice and fruit
How quickly it works	Takes 30 minutes to reach plateau (that is, enough nicotine in blood to satisfy brain demand).
How it works	The nicotine is absorbed through the lining of the mouth. Each piece is effective for up to 30 minutes then the nicotine is gone.
Usage tips	Use 15 to 30 pieces per day to maintain continuous levels. Chewing technique is different from regular gum – a few chews then park it in the side of your mouth. Swallowing the nicotine may make you feel nauseous, and the nicotine won’t be absorbed.
Negatives	Doesn’t taste too good, but then it’s ‘medicine’ not a sweetie. Can make you hiccup if you overchew because the nicotine is released too quickly. This is a skill that has to be taught in the workshop. Can give you a sore throat at first.

Product	Lozenges 2mg and 4mg flavours: original, mint,
How quickly it works	Takes 20 – 30 minutes to reach plateau (that is, enough nicotine in blood to satisfy brain demand).
How it works	The nicotine is absorbed through the lining of the mouth.
Usage tips	Use 15 to 30 per day. Suck in short bursts and leave to dissolve.
Negatives	Probably the worst tasting.

Product	Microtabs 2 mg micro tablet
How quickly it works	Takes 20 – 30 minutes to reach plateau (that is, enough nicotine in blood to satisfy brain demand).
How it works	The nicotine is absorbed through the lining of the mouth.
Usage tips	Use 15 to 30 pills per day. Dissolve pills under tongue in about 20 minutes.
Negatives	Not a great taste, but better than lozenges.

Product	Patches 16 or 24-hour patches Clear patches available
How quickly it works	Takes 8 hours to reach plateau (that is, enough nicotine in blood to satisfy brain demand).
How it works	Different strengths for ‘weaning’ you off, but the effectiveness of this is unproven. Absorbed through the skin ( transdermal absoption). Takes up to 8 hours to reach plateau.
Usage tips	24-hour patches are for people who fear waking up in the morning dying for a fag! Vary the place you put the patch and avoid hairy areas!
Negatives	If you use the full strength patches and you’re not a heavy smoker, they can make you dizzy and nauseous. 24-hour patches can disrupt sleep with insomnia or weird dreams / nightmares. Can react to sensitive skin.

Product	Inhalator
How quickly it works	Takes 20 – 30 minutes to reach plateau (that is, enough nicotine in blood to satisfy brain demand).
How it works	Looks like a cigarette holder/biro with a replaceable cartridge. Absorbed through the buccal mucosa (lining of the mouth). 10 puffs equals one puff of a cigarette.
Usage tips	Gives you that hand action or oral fixation substitute. Recommend vigorous puffing for 10 to 20 minutes. Each cartridge lasts for three puffing sessions.
Negatives	Lot of hard work and you may look silly. You don’t get very much out of one puff.

Product	Nasal Spray
How quickly it works	Takes 5 - 10 minutes to reach plateau (that is, enough nicotine in blood to satisfy brain demand).
How it works	Takes just a few minutes to reach plateau. Gives quite a big hit of nicotine, but not as much as a drag on a fag.
Usage tips	Good for craving relief – works rapidly One to two shots up each nostril hourly.
Negatives	Only available on prescription. Can cause adverse reactions on first usage – eyes water, runny nose, sneezing.

Product	NiQUITine PreQuit
How quickly it works	Takes 5 - 10 minutes to reach plateau (that is, enough nicotine in blood to satisfy brain demand).
How it works	Takes just a few minutes to reach plateau. Gives quite a big hit of nicotine, but not as much as a drag on a fag.
Usage tips	Good for craving relief – works rapidly Use on it’s own at start and then with NRT of choice (apart from Champix or Zyban.
Negatives	It’s a supoort NRT, it won’t help you to quit on it’s own.

Prescription drugs

There are two prescription drugs which can help you beat the urge to smoke – Zyban and Champix. All websites such as this can only offer limited advice and it should not be read as medical advice. All decisions on prescribing Zyban and Champix must be made by a GP. Doctors will normally expect you to be part of a smoking cessation programme before they prescribe either of these drugs.

Zyban

Zyban tablets contain the active ingredient bupropion hydrochloride. Zyban was originally developed as an antidepressant. It acts in the brain but is not the same as nicotine replacement therapy.

It is not fully understood how this medicine works to help people stop smoking, but it is thought that bupropion helps people to quit smoking by increasing the amount of neurotransmitters to act in the brain.

You should start taking Zyban while you are still smoking and set a 'target stop date' for within the first two weeks of treatment, preferably in the second week. This is because the medicine needs time to start working. If you have not managed to stop smoking by the seventh week of treatment, your doctor will usually ask you to stop taking Zyban.

Side effects of Zyban

Using Zyban if you have certain medical conditions, are on some medications (including HIV treatment), use recreational drugs or drink large amounts of alcohol can increase the risk of damaging your health. Zyban is not recommended for people under 18 or over 65 or for people at risk of seizures. Due to substantial side effects, doctors are now far more likely to prescribe Champix than Zyban.

The following will be more risky if you are on Zyban:

Recreational stimulants (e.g. cocaine, speed, meth / crystal, ecstasy etc.)
Alcohol consumption which is consistently greater than safe limits
Alcohol consumption inside safe limits but on binges

If you suffer from any of the following conditions, Zyban is not recommended:

Epilepsy, seizures, fitting
Previous head injury
Eating disorders
Cirrhosis of the liver
Other chronic liver disorders e.g. hepatitis B or C
Depression treated with Monoamine Oxide inhibitors (MAOIs)
Bipolar disorder (manic depression)
Having significant renal or hepatic impairment (kidney or liver damage)

You are advised not to take Zyban if you already take any of the following medications:

Antidepressants (MAOIs and selective serotonin reuptake inhibitors - SSRIs)
Quinolones
Antipsychotics
Cimetidine
Betablockers
Antiepileptics
Antiarrhythmics (type 1c)
Levodopa
Theophylline
Orphenadrine
Systemic steroids
Cyclophosphamide
Antimalarials
Sedating antihistamines (Nytol)
Tramadol or Zydol (a type of very strong opiate-based pain killer)

Zyban and HIV

There is a small theoretical risk of an interaction between Zyban and the class of anti HIV drugs known as protease inhibitors (PIs), which might result in elevated levels of the PI Ritonavir in the blood. It is also possible that the PIs Nelfinavir, Saquinavir and Amprenavir might react similarly, leading to an increase in the levels of Zyban in the blood.

An increase in the level of the PI would do no damage to the HIV treatment’s effectiveness, but might make the PI’s side effects more severe. An increase in the level of Zyban could be more dangerous as a possible side effect of Zyban is seizures. Also, there is a slight risk of seizure from Ritonavir, so combining the two drugs might increase that risk.

There is no indication of any interaction between Zyban and the other main classes of anti HIV drugs (NRTIs and NNRTIs).

There is more information on HIV medication on our positive men’s site.

Champix

Champix (varenicline) is the newest smoking cessation prescription drug on the market, approved by the Department of Health and launched by Pfizer in the UK on 5th December 2006.

Varenicline acts in the brain, but is not the same as nicotine replacement therapy or Zyban. Varenicline works by stimulating the nicotinic receptors in the brain. This produces an effect that relieves the craving and withdrawal symptoms you can get when you stop smoking. At the same time, varenicline blocks nicotine from acting on the nicotinic receptors. This prevents any nicotine inhaled in tobacco smoke from having a rewarding and enjoyable effect.

You should set the date on which you will stop smoking and start taking this medicine one to two weeks beforehand. This is because the medicine needs time to start working. The dose is increased gradually in the first week of treatment (follow the instructions given by your doctor or pharmacist) and the medicine should then be taken twice a day for 12 weeks. If you have successfully managed to stop smoking at the end of 12 weeks, your doctor may offer you a further 12 week course of treatment.

In trials Champix was seen to help more people quit than Zyban.

Champix and side effects

About a quarter of Champix users may experience mild nausea for a period of about 30-45 minutes after taking the medication. This reaction normally tails off after a week’s use. Taking Champix after a meal reduces the chance that you will feel sick.

Other side effects noted in trials were, difficulties sleeping, vivid dreams and flatulence. Many of these adverse effects were also experienced at similar levels by those in placebo groups during the trials, and as such are normal side effects of stopping smoking. It is currently thought that a very small percentage of users may experience ‘mood change’ and stop using Champix.

There have recently been a number of reports purporting to link Champix with an increased risk of depression, psychosis, suicidal thoughts or in the worst case scenario, suicide. So far, a definitive causal link has not been established, although further research is needed. It could be that stopping smoking itself is the trigger for the suicidal thoughts. However if you start to take Champix and you begin to feel depressed, agitated or have suicidal thoughts you should inform your doctor immediately and stop taking the drug.

Champix is not recommended for smokers under the age of 18 or anyone with end stage renal disease. As with Zyban, it is recommended that you stop or limit recreational drug use (especially cocaine) as they work on similar receptors in the brain to Champix.

There are no known contraindications between Champix and any HIV medication.