Breaking Free: Expert Tips To Quit Smoking For Good

As National Non-Smoking Week (January 19-25) is in full swing, many Canadians are tackling the challenging journey of quitting smoking as part of their 2025 health goals. With success often requiring over 30 attempts, experts Dr. Leslie Phillips and Dr. Milan Khara share their insights on conquering nicotine addiction, navigating misconceptions about quit strategies, and creating personalized plans for lasting change. —Noa Nichol

Dr. Leslie Phillips, clinical pharmacist, smoking cessation expert and professor at Memorial University  

What are the most common misconceptions Canadians have about nicotine replacement therapies (NRTs), and how do these misconceptions impact their quit attempts?

There are several misconceptions that I hear from individuals who are either contemplating or already using NRT when they come to clinic. I sometimes hear them from healthcare providers as well. These are important to address because they often sabotage a quit attempt, sometimes even before it gets started.  Here are my top 5 in order of most important/common:

1. “If I smoke with the patch on, I’ll have a heart attack or stroke!” :  I think the most common misunderstanding about NRT is that you cannot smoke with the patch on because it will cause a heart attack or stroke.   Consequently, individuals may put off using the patch, because they believe that they must quit right away and are very anxious about the thought of not being able to smoke once the patch goes on.  Some may never make the decision to even try NRT as a result and miss out on a very effective treatment.  This belief can also cause what might have been a minor slip-up in someone who has been quit, to turn into a full-blown relapse, as they often chose to take the patch off versus butting out. Once the patch is removed, more severe nicotine withdrawal sets in, increasing the odds of further tobacco use.  The evidence is clear, NRT is not associated with any increased risk of heart attack, stroke or death. Individuals with pre-existing cardiovascular disease are also at much higher risk if they continue to smoke.  It is okay to smoke with the patch on for a period under the guidance of a health care provider. NRT products can be used before quitting to help individuals gradually reduce over a few weeks to quit day. Advising an individual who has a slip up and is smoking to remove the patch (why do they do this instead of advising them to stop smoking???) has sabotaged many a quit attempt.
2. “I can’t use more than one NRT product, it will be too much nicotine!”:   It is okay to use more than one NRT product and it’s also more effective.  Using a single NRT product such as a patch, doubles your chances of quitting. Using combination NRT, such as a patch plus a short-acting NRT  product like gum, lozenge, inhaler, or spray when needed for cravings, will triple your chances. Using a short-acting NRT product allows the individual to temporarily boost nicotine levels to manage sudden cravings or other withdrawal symptoms and stay quit.
3. “ If I use NRT, I will just be replacing one addiction with another!”:  Many individuals are reluctant to use NRT because of concerns they will be addicted to it instead. There are two important messages that health care providers need to discuss to address this concern.  Firstly, nicotine in the form of a NRT product is not re-enforcing in the way that nicotine from a cigarette is.  The difference has to do with how these products are delivered to the brain. The faster a substance like nicotine arrives at the brain’s reward centre, the more dopamine is released and therefore the better it feels, and the more addictive it is.  Inhaled nicotine is delivered very quickly to the brain in about 7-10 seconds. NRT products by contrast are delivered to the brain much more slowly and are far less re-enforcing.  Secondly, carbon monoxide and tar ride along with nicotine in a cigarette, whereas NRT products only contain nicotine.  Carbon monoxide and tar are the more dangerous ingredients in a cigarette for adult smokers.  Tar may include more than 7000 different chemicals, at least 80 of which are carcinogens.  It is useful to help the individual see the difference between inhaling a chemical soup in the form of a cigarette multiple times a day until it likely causes their death versus using just nicotine for a few months. 
4. “Take the patch off before bed so you don’t get nightmares!”:  Healthcare providers can be guilty of giving this advice. Having vivid or more realistic dreams is common when using NRT, but nightmares are not.  Individuals should be advised to keep the patch on overnight unless intolerable insomnia or persistent nightmares develop.  Taking the patch off before bed, will likely translate into nicotine withdrawal by morning, increasing the risk of cravings and slip-ups. Individuals who do have to take the patch off before bed, should be advised to make use of  short-acting NRT products in the morning if needed, while waiting for the new patch to take effect.
5. “I can stop using NRT as soon as I quit!”   Many individuals are not aware that NRT products should be maintained for at least a couple of months to ensure they quit and stay quit.  A minimum duration of treatment is generally 10-12 weeks, with evidence that longer periods of treatment up to 6 months may be preferable for many. Over the treatment period the amount of NRT used is slowly tapered and discontinued. Some individuals may opt to keep a short-acting NRT product on hand for any emergent cravings for a while after coming off the patch.

Why is personalized dosing and tailoring NRTs to individual needs so crucial for quitting success?

Individualizing NRT product selection and dosing is crucial to success.   Quit journeys are like snowflakes, no two are the same.  Even individuals who smoke the same amount daily may have very different NRT requirements.  Any individual who reports that NRT did not work for them, was likely under-dosed or not using the products correctly.

Some individuals struggle to quit more than others and as a result may need a higher dose of NRT or a longer duration of treatment to quit, remain comfortable, and stay quit.  It is critical for clinicians to regularly reassess the efficacy and tolerability of these products,  and make any necessary adjustments to ensure best results.

Using a combination of a long acting NRT product (patch) plus a short acting product (gum, lozenge, inhaler, or spray) is more effective than either alone.  Individuals may have different preferences for which short acting agent/s they would like to try.  For example, some prefer an inhaler because it helps to satisfy the hand-to-mouth ritual of smoking, others may prefer the spray because it is more discrete and faster acting. Demonstrating the individual pros and cons and proper technique for using NRT products can help an individual decide which agent/s they would prefer to try and ensure their effectiveness.

What role does a clinical pharmacist play in helping patients develop an effective quit-smoking plan?

Pharmacists can play an important role in helping patients develop an effective plan to quit smoking and to stay quit.   They serve most communities and are often available without appointment and for extended hours, including evenings and weekends.  They are a great way to extend the reach of smoking cessation services.  As drug therapy experts, they are trained to recommend and monitor quit medications for adherence, efficacy and tolerability.  Pharmacists in most provinces can prescribe for all quit medications. They can complete a thorough assessment of an individual’s tobacco use, quit history, current medications and medical conditions, reasons for quitting, and triggers and use that information to work with the individual to develop a comprehensive quit plan that may include both medication and behavioural therapies or non-drug ways to manage triggers, cravings and withdrawal.  Studies have documented the effectiveness and cost-effectiveness of pharmacist-led smoking cessation programs.

How do you address the psychological and emotional challenges that smokers face when attempting to quit, in addition to managing the physical addiction?

Quitting smoking is hard.  Individuals who smoke can experience psychological and physiological challenges when quitting and both can contribute to inability to quit and relapse. Quit medications such as NRT products lay the foundation of a successful quit by managing the physical discomforts of nicotine withdrawal and allowing individuals to better focus on some of the psychological impacts of smoking such as maladaptive or negative thinking and low self-esteem (e.g. I cannot quit, I’m a failure, I have no will power, I cannot cope without a cigarette), and the emotional ups and downs that accompany the journey. 

Behavioural therapies can help individuals to navigate many of the psychological impacts associated with quitting.  They help individuals to set achievable, realistic goals, stay motivated, develop coping strategies and manage triggers and build confidence.  Behavioural therapies help to “rewire” the longer-term impacts of nicotine on the brain by correcting maladaptive thinking and responses to triggers and establishing new coping skills. For example, thinking about reasons for quitting or engaging in activities like hobbies, gardening, or puzzles to keep distracted, or brushing one’s teeth, applying chapstick chewing veggie sticks to help satisfy the hand-to-mouth ritual of smoking can help an individual resist a craving.  Journaling, yoga, mindfulness and meditation can help individuals develop new coping strategies.   Having a support network such as health care providers, in-person or on-line support groups, friends and family, can also play a critical role in supporting and encouraging individuals on their quit journey and helping them remain accountable.  When used together these strategies create the best chances for a successful quit.

What advice do you have for someone who has tried to quit smoking multiple times but has not succeeded?

I believe it was Mark Twain who said “quitting smoking is easy, I done it hundreds of times.”  The truth is quitting smoking is hard and staying quit is harder.  When an individual is feeling hopeless because they have tried and not succeeded, it’s a good time to remind them that they are not alone in this experience. Most individuals will make numerous attempts before they quit for good.  Smoking is an addiction, not a bad habit and individuals shouldn’t rely on will power to make it through. Or think they are weak if they do not succeed.    Cold turkey quits don’t work for the vast majority.  It’s important to instill hope and motivate the individual to focus on the small successes they achieved (e.g they managed to reduce how much they smoked or quit for a period of time) and view past attempts not as failures, but rather as opportunities to learn.  

The next important step is to complete a thorough review of past quit attempts including methods used, duration of abstinence if any,  and reasons for relapse. Often individuals don’t succeed because they don’t try a quit medication or the quit medication is not optimised – improper technique, underdosing, treatment duration to short, or combination therapies are not employed.  Under-estimating the power of a trigger such as having cigarettes on hand or being around other smokers, stress, and alcohol use are also common causes of slip ups and relapses.  Most often a thorough review will result in the development of attainable goals and strategies that will form the foundation of a new quit plan.  Follow up and support will help the individual stay on track and revise goals and plans as needed.  When it comes to quitting, the only failure is when you stop trying.

Dr. Milan Khara, clinical director at the Tobacco Dependence Clinic within Vancouver Coastal Health and the lead of the Smoking Cessation Clinic at St. Paul’s Hospital 

How does the strength of nicotine addiction complicate the process of quitting smoking, and how can individuals prepare for these challenges?

The addiction to nicotine is the main driver of continued smoking behaviour. What we mean by that is that those who would like to quit, and struggle to do so, are “dependent” on nicotine. When they stop smoking, they feel uncomfortable. Because of nicotine withdrawal which causes craving, irritability, appetite changes and other quite predictable symptoms.

The challenge of quitting is best done so with a plan. This might include using NRT or one of the prescription medications that we know will reduce this nicotine withdrawal to be more tolerable. But it’s not just about nicotine…the environment in which the habitual part of smoking has occurred needs attention too. Trying to minimize the triggers to smoking will increase the chance of success. Getting rid of ashtrays, changing routines and maybe even avoiding the people that someone smokes with will all help.

What strategies do you recommend for someone unsure whether to quit smoking abruptly or gradually?

In the past, we recommended choosing a “quit date” and abruptly stopping smoking. We can still do this as some people prefer a “black and white” approach. A full and immediate commitment to stopping is maybe a better fit for some. But others feel scared or overwhelmed by this prospect and may prefer “fading”, a gradual reduction that allows a transition to becoming an ex-tobacco user. Both approaches will work better with NRT or a prescription medication. Evidence suggests that gradual quitting is similarly effective to the abrupt approach. So “horses for courses”!!!

Can you share insights into how the Tobacco Dependence Clinic supports patients through their smoking cessation journey?

My clinical work is at the St. Paul’s Smoking Cessation Clinic. We try to individualize the approach but the mainstay of treatment is a combination of the two things we know work in smoking cessation: NRT/oral medications and behavioural counselling.

How do you approach patients who are skeptical about the effectiveness of NRTs or hesitant to use them?

The approach is always “patient-centred”. By that we mean that the patient is in control and has the final say on how we proceed. Many patients will express hesitation about NRT and this is often due to misconceptions. For example, some patients will be concerned that NRT will make them “more addicted”. We explain how these medications work: by reducing withdrawal and increasing the likelihood of successful cessation. And that the nicotine in a patch (for example) is delivered more slowly and at a lower dose than from a cigarette and is therefore not addictive. We also sometimes hear that people don’t want to use NRT because they fear the health effects. It is important for patients to understand that the harm from cigarettes is caused by smoke. Nicotine is the addictive component of the cigarette but it is smoke that causes the diseases we attribute to cigarettes.

What emerging trends or advancements in smoking cessation treatment do you see as most promising for helping Canadians quit smoking?

There is no “magic bullet” on the horizon for smoking cessation. But we do have quite good treatments available to us that we could use more optimally. For example, very few people are aware that combining two NRT types is more effective than using one. Nicotine patch plus some nicotine gum for curbing breakthrough cravings is supported by medical evidence as almost tripling the chance of success (compared to using nothing)! Our smoking rates have fallen but as they get lower, it maybe that we need to do a better job of treating those who are left behind.