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Contrary to popular belief it is not generally difficult to stop, only 14% finding it 'very difficult'. But ex-smoker status is unstable and the long-term success rate of a smoking withdrawal clinic is rarely above 30%. The situation is summed up by the witticism, 'Giving up smoking is easy, I've done it many times'.

Though they are as aware of the risks of smoking as men, women find it harder to stop; they consistently have lower success rates. This trend crosses every age group and occupation. Women particularly dislike the weight gain.

Aids to giving up. The addictive effects of tobacco smoking are substantially due to nicotine, and it is logical to substitute nicotine for tobacco smoke as a pharmacological aid to quitting. Nicotine is available in a number of formulations, including chewing gum, transdermal patch, oral and nasal spray. When used casually without special attention to technique, nicotine formulations have proved no better than other aids but, if used carefully and withdrawn as recommended, the accumulated results are almost two times better than in smokers who try to stop without this assistance.19 Restlessness during terminal illness may be due to nicotine withdrawal and go unrecognised; a nicotine patch may benefit a (deprived) heavy smoker. Nicotine transdermal patches may cause nightmares and abnormal dreaming, and skin reactions (rash, pruritus and 'burning' at the application site).

Amfebutamone/bupropion may provide an alternative, or addition, to nicotine. When the drug was being investigated as an antidepressant, researchers noticed that patients gave up smoking, and it was developed as an aid to smoking cesation. Amfe-butamone selectively inhibits neuronal uptake of noradrenaline (norepinephrine) and dopamine and may reduce nicotine craving by an action on the mesolimbic system. Evidence from a small number of clinical trials suggests that amfebutamone may be at least as effective as the nicotine patch with which it may usefully be combined. It may cause dry mouth and insomnia, and is contraindicated in those with a history of epilepsy.

If the patient is heavily tobacco-dependent and severe anxiety, irritability, headache, insomnia and weight gain (about 3 kg) and tension are concomitants of attempts to stop smoking, an anxiolytic sedative (or (3-adrenoceptor blocker) may be useful for a short time, but it is important to avoid substituting one drug-dependence for another.

19 Lancaster T et al 2000 Effectiveness of interventions to help people to stop smoking: findings from the Cochrane Library.

British Medical Journal 321: 355-358.

There is ample evidence to warrant strong advice against starting to smoke but over-hasty and unreasonable prohibitions on patients' longstanding pleasures (or vices) do no good. The pliable patient is made wretched, but most are merely alienated.

My doctor's issued his decree That too much wine is killing me, And furthermore his ban he hurls Against my touching naked girls. How then? Must I no longer share Good wine or beauties, dark and fair? Doctor, goodbye, my sail's unfurled, I'm off to try the other world.

D G Rossetti, poet (1828-82)

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