The butt stops here

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Twelve days ago, John Richards vowed never to smoke another cigarette. As he stubbed out the last fag of 2003, while the seconds of the old year ticked away, he informed the loved ones gathered around him that never again would he - or they - inhale the lethal fumes from his 30-a-day habit. It came as no surprise to the rest of his family that the following morning, he was back puffing on the weed. As long as anyone in the family can remember, he has been pledging to give up smoking on New Year's Eve.

Twelve days ago, John Richards vowed never to smoke another cigarette. As he stubbed out the last fag of 2003, while the seconds of the old year ticked away, he informed the loved ones gathered around him that never again would he - or they - inhale the lethal fumes from his 30-a-day habit. It came as no surprise to the rest of his family that the following morning, he was back puffing on the weed. As long as anyone in the family can remember, he has been pledging to give up smoking on New Year's Eve.

And he is not alone. It's estimated that more than a million people will have made a New Year's resolution to give up smoking, and that by now, day 12, considerably more than half of them will have already have fallen to temptation.

Although the number of smokers has dropped dramatically over the years as the evidence has been mounting that tobacco is linked to half of all cancers, heart disease, infertility, and a wide range of other problems, there is still a hard core of puffers who cannot, and in a minority of cases, will not, give up the habit. It is estimated that more than 11 million people in Britain have quit smoking, and that each year another three million try. On average, those who finally succeed will have made about three or four unsuccessful attempts to stop.

For the seven out of 10 smokers who want to quit, it has never been easy, at least in theory. Where once there was only cold turkey, there is now a huge choices of aids, including pills, capsules, sprays, patches, antidepressants, counselling, hypnosis, acupuncture, and shock therapy, as well as cigarette substitutes, laughing gas, special moist snuff, glucose, and a battery of alternative remedies.

The dilemma for smokers is finding the quitting aid that suits them best and one where there is a high chance of success. For some aids, especially drugs, there is the considerable solid research on effectiveness and safety that is needed for licensing, but, even here, success rates hover around the 30 per cent mark. That is six or seven times the rate for cold turkey, but it still means that the majority will resume smoking. Some of the methods which claim high success rates - up to 100 per cent in some cases - are often supported by little empirical evidence.

The main obstacle to giving up smoking is the addictive nature of nicotine. Dr Michael Fiore, director of the international Centre for Tobacco Research and Intervention at the University of Wisconsin Medical School, says that tobacco use is a powerful addiction that warrants medical treatment.

One of the reasons it is so addictive is that the smoker gets a very rapid and effective dose of nicotine by inhaling the smoke. Within seconds of inhaling, a cigarette, nicotine enters the lungs and travels directly to the brain.

Dr Fiore says people who smoke more than 10 cigarettes a day and want to quit are likely to need a smoking cessation aid, and stick with it: "Most people who abstain from smoking for three months can be cigarette-free for the rest of their lives. Your risk of heart disease and lung cancer drop steadily after you quit.''

Quitting: the options

Acupuncture

What is it? Tiny pins are used to stimulate points on the outer ear which have connections with area of the body associated with smoking.

The evidence: Auriculotherapy, a key component of Chinese acupuncture, is a highly developed system of diagnosing disharmonies in the body by stimulating 300 points on the ear corresponding to different parts of the body. One trial of auriculotherapy found that 38 per cent had given up smoking after two months of treatment. "Auriculotherapy is a useful aid for giving up smoking. It is easy and painless,'' say the authors.

The verdict: May work, but many experts are sceptical.

Cold turkey

What is it? The method used by people that Americans call self-changers, those who quit with the help of nothing but willpower.

The evidence: Studies show that it may take several tries before smokers, especially those on 20 a day or more, are able to finally quit. Stress, habit and cigarette cravings are common reasons for failure. The success rate is reckoned to be around 5 per cent for each attempt. Heavy smokers - more than a packet a day - may have a difficult time and probably need to use an aid as well.

The verdict: If it works, it can be the best way - and the cheapest - but strong motives are needed, and the odds are 20-1 against success.

Cognitive behavioural therapy

What is it? Embraces the concept of taking personal responsibility for thoughts, changing the beliefs about the barriers to success, and identifying irrational thought.

The evidence: A sort of thinking man's cold turkey, it involves changing the mindset to realise that smoking is bad. Cognitive behavioural psychotherapy highlights beliefs, interpretations, and perceptions of life events that determine our feelings, moods, and our actions. Tricks include removing ashtrays, matches, and so on, keeping smoking diaries, and ignoring cravings.

The verdict: Can work, and research in Australia suggests success rates of up to 30 per cent.

Glucose

What is it? Glucose is the simple sugar obtainable from food.

The evidence: Researchers found that the craving to smoke drops dramatically after eating glucose tablets. "Heavy smoking changes the way that carbohydrate intake is regulated in the body, so during periods of abstinence there is an increased need for carbohydrates which smokers will normally relieve by smoking a cigarette. Glucose could be helpful because it satisfies the carbohydrate craving and reduces the desire for a cigarette," says Professor Robert West.

The verdict: More and bigger trials are needed.

Zyban

What is it? The trade name for buproprion, it was developed as an antidepressant but is thought to have an effect on nicotine addiction.

The evidence: Bupropion was previously approved as a prescription antidepressant, but doctors noticed that patients using it were able to stop smoking more quickly. Research suggests it interferes with cravings for nicotine and that those who used Zyban gain less weight than those who quit with other methods. Some studies suggest success rates of 49 per cent can be achieved with Zyban, alone or in combination with NRT.

The verdict: One of the best performers.

Shock treatment

What is it? Also known as aversive condition, involves conditioning the mind to associate smoking with negative experiences.

The evidence: One form of treatment - the Schick Shadel - involves a self-administered mild electric shock from a nine-volt battery as you smoke. Another is based on the idea of chain smoking until you are sick. Focused smoking uses the idea of imagining negative consequences like lung cancer while smoking.

The verdict: Some, very small, studies suggest a 95 per cent initial success rate, dropping to 50 per cent after a year, but there are many sceptics.

Nicotine replacement therapy (NRT)

What is it? Nicotine is delivered through the skin with patches or sprays, or via chewing gum, capsules or lozenges.

The evidence: Nicotine patches have been around for a decade and there is evidence that they work for some people. They deliver small doses of nicotine into the blood to relieve some of the withdrawal symptoms, without the hazardous tar and carbon monoxide. The patch provides steady nicotine blood levels throughout the day and night. Chewing gum releases nicotine into the bloodstream through the lining of the mouth.

Verdict: Success rates for NRT with counselling range from 20 to 40 per cent. Other research suggests that for NRT alone the success rate is around 10 per cent.

Combinations

What is it? Combinations of different aids that can increase the chances of success.

The evidence: Research in France suggests that smokers may have a better chance to quit with a nicotine inhaler, and a patch instead of just an inhaler. At six weeks, 60 per cent of those who used the combination had quit, compared to only 47 per cent of those who used an inhaler.

The verdict: Research in America found that the combination of antidepressant, nicotine replacement and counselling resulted in 40 to 60 per cent being smoke-free after a year.

Hypnosis

What is it? Designed to weaken the desire to smoke or strengthen the will to stop.

The evidence: Mixed verdicts range from unproven to 100 per cent success. One research review by Leicester University concluded: "We have not shown that hypnotherapy has a greater effect on six-month quit rates than other interventions or no treatment.'' There are variations on techniques used, including self-hypnosis and neurolinguistic programming (NLP), which works by transferring the enjoyment of smoking to another habit.

The verdict: May work for some people, but others may need extra help from aids like skin patches.

Others

Mecamylamine: Works on the nicotinic receptors in the central nervous system, and there is a some evidence that it may help in promoting abstinence when combined with use of patches.

Snus: Oral moist snuff, it is widely used in Sweden, which was the only country in Europe to reach the World Health Organisation's goal of fewer than 20 per cent smokers.

Low tar: Many people switch to lower tar cigarettes with the idea that they are a halfway house to cessation. Not so, say researchers at the University of Vermont; evidence suggests that switching does not increase the likelihood of quitting.

Substitutes: Various in-mouth devices that are said to help the smoker give up or provide healthier smokes, such asfilters which cut down tar and nicotine, and cigarettes which heat rather than burn tobacco.

Nitrous oxide: Doctors discovered that when they gave laughing gas to smokers as a withdrawal aid, four out of 10 quit completely. It is thought that nitrous oxide works on brain transmitters that are unbalanced by nicotine withdrawal.

Surgery: Anaesthetists in Swansea have got people to stop smoking with the power of suggestion during general anaesthesia. Women who were given messages encouraging them to give up smoking were significantly more likely to quit than women who were exposed to the same voice counting numbers.

Quitline: 0800 002200; NHS Smoking Helpline: 0800 169 0169

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