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    What might work for those who have tried everything?
    Jonathan Foulds, PhD posted:
    Many smokers feel they have already tried everything…..cold turkey, hypnosis, patches, acupuncture…..but still find they are smoking heavily and have almost lost hope of being able to quit. Lets take a not atypical example….a 2 pack per day smoker who smokes their first one of the day within 5 minutes of waking, and sometimes wakes at night and smokes. This particular case is in their 60s, has already had cancer and cardiovascular problems and some prior quit attempts have lasted for as long as 6 months, but ended with relapse to cigarettes when they stopped taking the patch. If this type of smoker felt ready to have a serious attempt to quit, what might make this one succeed in the long term?

    The first suggestion would be to think of quitting as a process rather than a single event. But importantly, go into it with the view that they will continue with the process nomatter what. It doesn't end when they have quit for a month or for six, it doesn't end when they stop their meds, and it certainly doesn't end if they have a cigarette or a pack after a period of abstinence. You will succeed if you decide that you are going persist with this and keep on it…basically forever. Sure after six months, then a year then 6 years it will require much less effort, but from time to time it will require renewed effort to stay abstinent.

    My second suggestion is to initiate the quit attempt along with counseling from a reliable source. By "a reliable source" I mean a health professional who has been trained to help smokers quit, is familiar with all the smoking cessation meds and how they work, and who has been doing this kind of work for at least a year. I feel that quitting along with a group of other smokers is often the best way to get structured support in the first few weeks that are very important, but seeing a health professional for individual weekly appointments can also help, as can regular telephone contacts from a telephone "quitline" where face-to-face is not available. Many people are skeptical about "counseling" or "group therapy" but there is very good evidence that this can increase your chances of getting off to a good start. For the type of case I described above, quitting smoking may be a life-or-death intervention so you have to use all the help that you can get.

    Thirdly, a heavy smoker who has already tried most standard treatments should be speaking to their doctor about using "extended combination pharmacotherapy". This means rather than using just one of the effective medicines, like the patch or Chantix, for a couple of months, they should be considering using more than one medication for at least 6 months, and possibly longer. This could be a combination of the patch and 4mg gum or lozenge, or varenicline (Chantix) and bupropion, or bupropion plus patch plus nicotine inhaler. Dr Michael Steinberg and colleagues at UMDNJ in New Jersey conducted a randomized trial comparing standard duration nicotine patch with patch plus bupropion plus nicotine inhaler for up to 6 months. At 6 months the combination extended duration had a significantly higher quit rate (35% v 19%), and it was found to be safe even though all the trial participants had a pre-existing medical condition.

    So initiating a quitting process, with counseling plus extended combo meds is worth considering for smokers who have tried many of the standard methods. Keep at it and you will succeed.

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