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Strategic lAlithdrawal from Cigarette Smokiig ,Arden G Christen, D.D S Kenneth H. Cooper, M.D s Whoever urdderstonds the human mind, knows that hardly anything rS harder ja a man to give up than a p/eosure he has once experienced. Actualfj; we can never give anything upt we onry• earchange one thing for arAother. What app4rs to be a renunciatiort is reolly the;Jonatation of a substitute or surrogate. Sigmund Freud' Cigarette smoking is an enigma. In light of the weU-known, thoroughly publicized health hazards of smoking; why does this habit continue to have such wide- spread appeai? Why is it so difficult for many persons to quit smoking once hav- ing become habituated? Can a person really do anything to control this tena- cious habit? To help understand these questions and see the overall picture, one should consider two imperctant gener- alirations about the use of tobacco prod. ucts: o Smoking provides powerful, immediate satisfactions for the individual-phar- macological, psychological, emotional, and social. • Miliions of Americans hhve success- fuliy quit smoking. lt can be done. Dr. Christen is Chief, Dental Invesripuion Ser• vice, United States Air Force Sehool of Aero• spaa Medicine, Brooks Air Force 8ase, Texas. Dr. Cooper ts Er<eeotive Director;r Aerobic Cen• ter of Preventive Medtcine, ~il~t, ~aas. Pharmacologleal SatlsfaeHons The pddictive agent in tobacco is nicotine. Ctol~it.Ns, a colorless, bitter liquid. Ciga- rette smokang allows for the absorption of S0•10 µg of nicotine per puff, or one to two mg pcr cigarette.s Most smokers re- quire the rsicotine effect characteristit of ttmoking (i.e., "nicotitte-seeking behav- ior°). As Russell states, •'If it were not for the inicotiate in tobacco smoke, people would be 'ittle more inclined to smoke cigarettes than they are to blow bubbles at light sparklers."' Nicotine can simultaneously act on various pgs•ts ot the brain as a stin..iant (euphoriaotl, depressant, or ttanquilizer, depending on the dosage. The level of nic- otine in the brain is er cial for the heavy and highly dependent smoker and he will unconsciously modify his puff rate until that intake level has been reached. Depen- dent smokers need a brain level boost of nicotine about every 20 to 30 minutes thrqughout their waking hours ? ` Much of the dependence•producing potency of nicotine is due to its almoit in- ttant absorp.-OK fra^t the lungc followinR inhAlation. It is practically impossible to smoke without inhaling: in fact, the ••re- ward°' for smoking is inhaling. A slower nicotine effect can be obtained without in- halation from pipes, cigars, or chewing tobacco, by absorption through the oral mueosa! ~ 5gnekiwa~ seldom a take-it-or-Itave• I i~ I' re ,n' ava, r,1RC.'WCIaI;S

it activity. It has, immediate reinforcing Why Continue to Smoke? I consequences and considerably delayed adverse consequences. Only about two percent of smokers are intermittent or oc- casional users of Cigarettes] and the most gtable, well•adjusled person can become a regular, dependent ttnoker. The reasons why one staru to smoke, and why one progresses and continues int the habit, are not always related. After oae has become habituated, a new set of learned.psychological and social needs are activated. To identify these factors, the Smoker's Se{J Test was developed by Psychic and Social Effects of Smoking Daniel Horn, Ph.D., Director of the Na- tional Clearinghouse for Smoking, and Smoking can be realistically viewed as pri- Health, Public Health Service, from Tom- marily a psychologicai habit °7 The per- , kins'mode)!6-t•TestNo.3("WhyDoYou son who has never smoked cannot possibly Smoke?") covers factors perceived by the understand the depth of affective satisfac- smoker relating to the psychotogical satis- tion derived from this habit. factions. he derives from this habit Why Start to Smoke? There is no innate need for tobacco. Smoking is almost entirely a learned be- havior, primarily in response to direct and indirect social pressures.3 The two major influences for predicting early smoking behavior are: (1) smoking of one or more parents; and (2) peer pressure.••s These influences obviously operate strongly in our culture. Recent data show that ig to 2V percent of teenagers are currently smoking cigarettes on a regular basis.a Many of them use smoking to counteract [telings of inferiority and gain acceptance by the "in" erowd ° Smoking thus.be- comes a social requirement. When parents smoke they teach their children two important things: (!) "This is the way to iive;" and (2) •'ignore med- ical advice." Adolescents may feel more grown-up when smoking sz:t use it tc de- "The reasons why one slarts to smoke, and why one progresses and continues in the habit, are „ .o! Plways !e!ated " ~~ L •~ . t.: fiantiy dsim adult status. Moreover, pop- ular advertising has portrayed smokers as being active, attractive, and sophisti- cated. For the teenager, these effects are highly egointegrative and socially facili- tative. (Table 1). For Tomkins,10 smoking is a learned response that can be associated with any positive, negative, or neutral affect. Six Psychological Reasons for Smoking (Horn's Test) Each person's habit is unique. Thus,,there is no truly "typical" smoker. However, according to the American Cancer Soci- ety, smokers do fit roughly into one or more of six smoking types, depending on how their habit has developed. H'orn's test shows how smokers use their ciga- rettes to manage their emotions. Smoking may be characterized by one, or a cmmbi- nation of, these factors.tt • Stimulation (10 percent). This type of smoker is stimulated by the cigaa'ette. It helps him to wake up in the morn- ing, to organize his energies, and to keep him going. Many smokers re- port that while smoking they experi- ence a sharpening of inteit:itual ca- paeity and an @a*rease in rmpulse control. a Handling: Sensorimotor Manipulation (10 percent). This type enjoys manip- ttlating the cigarette with his hands, watching the smoke eurl as he ex- hales, and making a production of lighting the cigarette, holding it, and flicking the ashes. 'The Smoker's Self Test is available from local umu of the Ameriean Cancet Society an from the National Office on Smoking and ealth, Depanmmt of Health. Education and W'elfare. I

i i .. . . . .~. .. .~: o Pleasurable Rela.xation (15 percent). This smoker geta real, honest plea- sure from smoking, especially after a dinner or with a kocktaii. He tends to smoke to accentuate or enhance pleasur- able feelings accompanying a state of well-being. Comment: Tlpe above stimulation-~ handling-relaxation positive-affect smokers characteristically smoke un- der pleasant circumstances that are relaxing. They usually require an ade- quate substitute fot quitting and often find that it is not, too difficult to stop. t Crutch: Tension Reduction (30 percent). This negative-affect type of smoker uses cigarettes for the sedative or tranquil- izer effect in moments of stress, fear, shame, disgust, discomfort, or pressure. He uses cigarettes to help him cope with problems. Substitutions wip generally not help this smoker, and success is gained from tearning how to properly manage the situations that produce the bad feelings in the first place. • Craving: Psychological Addiction (23 percent). This type of smoker feels to- tally dependent upon his eigarettes, and alternates between an inerease of posi- tive feelings and a decrease of negative feelings. He is constantly aware when be is not smoking and begins the eraving for the next cigarette when he puts out the present one. Tapering off doesn't seem to work; the only solution is to quit "cold turkey." • Habit p0 percenR). The habitual smok- er gets very littie satisfaction from his habit and J tfmas it somewhat auto- matically. He nta•v smoue a cigarette without realirinq it ot •ven wanting it. There is very littlcrmel:onal component to his smoking activity nnd a minimal amount of awareness. It is important for him to develop this awareness and to ur.derstand tl.t pattern of his smo}ring. Dynamics of Oulltlnp It is not for Everyone Not everyone should stop smoking. It is unlikely that most individuals will be able to give up smoking during a period of emotional turmoil or life crisis, and it is particularly inappropriate to ask a severe• ly depressed person to quit smoking when he is still working through another loss•" People who are mentally ill and/or undec active psychiatric oare probably should not attempt to quit smoking berause they may be relying on their psychological need for dgarettes. The precipitous cessation of smoking can be a profoundly disorga- nir.ng experience and it may throw a per- son into frank psychosis. For those who cannot stop abruptly, we can offer advice of safer ways to smoke. Some heavy smok- ers, howtver, are resistant to smoking ces• sation programs. They may be excessively fmpukive, reixiiious, or deager-seeking: they may experitaue self-0issatisfactions, or even have strong self.destructive ten- dencies. Ochsner, the sioted surgeon, de- scribed patients who, following surgery for carcinoma of the larynx or lung, con- tinue to smoke through a tracheostomy:a The "Myth^ of Sutxess • Smokers am often an unforgiving lot. They frequently feel that quitting is aa ali- or-nothing proposition, and fail to under- stand the significance of the dose response relationship: the less one smokes, the less the harard. 1he smoker who has gone from three or four packs a day to one pack a day should teralice that he has made great strides. Many people appear to quit in graduated fashion ova a prolonged peri- od, and some have reported that a taper- ing-off Proeess is rhe preferable way to "People wtta sre mentally ill and/or under active psychiatric care probably should not attempt to qWt smoking..:" WL IY quit. As Mark Twain said,'rl•tiia bit is habit, and not to be flung out the window by a_n;y man, but coaxed downstairs a step at a time." Of the many who have succeeded quitting, about 50 percent reported that

r ~.Ti'rsA . . . . . . . PrwF I I .. •~ •~~ t+.;r:' •~rY~.•~--s e_E~t~.a.r~. Important: Answer every question. tra• t~~o 1tea'1;•/ C e/eNys ouently slOnatly slldoan nerer A. {mOke Crgarettes m or er to eep mysel /romslowmgdown 5 4 3 2 ~-1 sn rmg a cigarette 1{ part o t e enloy ment ot itnos,n p 5 4 3 2~ •$moa.ng ugerettes a oreasant and ceiaKvng 4 2 I , 1 rgnt up a cigarette wnen 1«i angrv about - somethmg 5 4 3 2~ 1 en t w run om o e gerettet 12nd rt • almost unbearable until I Gen get tnem 5 4 3 2 1 F. I tmoke eigaretles automat4any wrthout t even berng aware of .t 5 4 3 2 . 1 smoKe Ngartltes to strmulate me. to oerk myserr up 5 4 3 2 1 Vait or theenloyment ot smo.mg a ugarette +j, - comes lrom the Steos 1 take to hgM uo 5 4 3 2 1 1 ,no ooarettes p~easarabre 2 1 nen ee uncomrohep e or upset about tomahmg, l hght up a a rette 5 4 3 2' 1 K. 1 sm very mucn swere o1 tne act wnen I am n011m010. mgeagarene 5 4_ 3 2 1 ~~p~t up a agareoe witnout reanenng 1 eau have one burnm in the ashtray 5 4 3 2 1 S . I smoke Crqveves to g,va me arnt •. 5 4 3 2 en smokea ugarate, parl O the enroy mem rs watchin the imo4e as I etrlare rt ~ 4 3 2 1 0. I want a crgnene most wnen I am comror• table end reNastd 5 4 3 2 1 P. hen I ee• e or want to take my mmd off cares and wornee, / smoke e renes 5 4 3 2 1 . I get a real gnawmg nunger 1or a uparatte when I haven•t tmOked SOr a whde 5 A 3 21 . 1 ee IOunO a GgHetle in my mouth an0 didn't remember puttmg rt there. 5 4 , 3 2 1 Now to Store: j. Fnter the numbers you have circif0 to the Test 30uett•ons rn the CpaMS below. putt.ng the number you hafe dtCleo c0 Ounttion Aover line A. to Quetlron 8 over hne B. etc 4• Total the 3 trores on each lrne to Ael your totals For eeamph, the sum or your scores over lines A, G, an0 M grw{ you your score on SlUmu/apon-hnn 8. N, and N grve tna TeMls ~" + + n ~ e ~ rrwaM _'er" + ~'g'~- + Cwrar, wnneameu• ~T- + Crwne ewwwiw aee.eon r + rwn.t SCoyeS of 11 Ot above rndiCate that this fettor it an important s0urc@ Of satltfeCtion for the sTOker. Scores of T Ot less ate IOw an0 probably rndtcate ihet thrs (OCtor does not apply to you Scoree in bnween are mergreel, Kore on Nandimy, etc NL . 117Trr 9;

a,...,~...;.cs.?~t . .- . .. . . they stopped suddenty and 50 percent that they stopped gradually.'r For some, the very idea that they could stop smoking is one that evolves very slowly. Many persons are not quite sure how to approach stopping. It is an awk- ward habit to leave behind, especially since it has been so carefully built into a lifestyle. For smoking die-bards who refuse to quit, Adams's has suggested five simple steps that can lessen the hazards: (1) smoke fewer cigarettes each day; (2) take fewer puffs on each-cigarette; (3) reduce the depth of inhalation; (4) smoke less of each cigarette; and (S) choose a brand low in tar and nicotine. Research indicates that for many heavy smokers, there is a"reduc- tion floor rate" of approximately 10 ciga- rettes per day that can be reliably met but not surpassed." Patients must be taught procedures for maintaining this low rate, or they will relapse. Each smoker who wants to quit has two problems that must be solved: physi- ological and psychological withdra~ai. Horn6 suggests that there are at least four nteessary conditions for engaging in self- protective health behavior. These condi- tions are: (1) an awareness of the threat; (2) the acceptance of the impoitance, of the threat in a personal sense; (3) the rele- vance of the threat to the individual; and (4) the confidenee that one can do sorne- thing about smoking. Physiolopical Withdrawal pronounced •-rebound" effect during withdrawal. Moderate to severe head- aches, irritability, muscle aches and cramps, anxiety, visual and sleep d'utur- bances, and a distorted sense of time per- ception-along with an intense craving for tobacco-have been reported com- monly by those who are quitting smoking. Gen,crally the peak in severity of sytnp- toms is reached by the third or fourth day. However, symptoms, when present, are highly individualized, and a significant number of those who stop state that they have few•, if any, symptoms. For example, some persons state that they have yrob- Iems with daytime drowsiness and lethar- gy, while others relate thet they suffer from insomnia and feel like "bouncing off the walls:" Virtually all physical effects should subside within a week. After this period, withdrawal symptoms are con- sidered psychological. Psychological Withdrawal The residual effects of a habit of xhis magnitude are hard to imagine. As inmost forms of habituation, the psychological component of withdrawal is of much greater importance and is often extremely complex. Psychological withdrawal can last for weeks, to years. Women have greater problems than men in stopping smoking because most of them use ciga• renes for a tranquilizer affect, whereas men smoke for pleasure 6 Studies show that the fitst two td three months after stopping is a critical period; Physiological withdrawal is easier to deal with than 3s psychological withdrawal, and requires about a week. Nicotine, the addictive substance in tobacco, is large!y eliminated from the bloodstream hnd body tissues via the tiidneys.s To prom,ote this flushing effect and decrease the crav- ing for cigarettes, high liquid intake- especially fruit juices-is destrabte. The first three to four days are the most diffi- cult, since the bulY of nicotine is being eliminated; most individuals will experi• ence the worst withdrawal symptoms dur- ing that time.' Most of these symptoms nre related to the effects on the automatic nervous system, which appears to have a "COmerelve, seare-type approaches or those based an nuessire judgment, mtionaiity, and ctiiticism have little place in a quft•smoking program " N 117g2.. it is then that people who go back to their habit will do so.'! The rate of success has been similar for most quitting ntethods: about one-third of the subjects stop smok• ing immediately and about one-third of

J <t;~ar :: :,='a~.a>•r:_s~.u_ .: cYx?3t++a>Z~.lrasr=~'„~, the quitters resume smoking at a later time. Occasionahy, some who no longer consciously desire cigarettes have vivid satisfying dreams of smoking. atsliting as a Process The cessation of smoking is best consid- ered not as a single, isolated event but rather as a continuing, extended process 6 It requires persistent expenditure of ef- fort. Schematically, and perhaps some- what simplistically, let us examine the quit-smoking process from a psychologi• cal point of view (Fig. i). The short-time quitter (X) can.either return to his habit by the front door (A) by means of a conscious decision, or he can attempt to overcome numerous hidden and entrenched psychological obstacles (8). These obstacles (the list is by no means complete) provide strong unconscious mechanisms that can act forcefully upon the individual so that he is "off the hook" and free to enter the smoking habit via the rationalized back door (Ct. Long- term quitting (D) is a complicated, lengthy process, and coming to grips with the ob- stacles to quitting involves a great deal of unconscious, constructive and painful in• ner conflict. Obstacles to Quitting Social Pressure The atmosphere around the quitter may not be conducive to his stopping.' Smok- ing has a strong social-facilitative effect "... the psychological component of withdrawal is of much grealer Importance and is often extremely complex " that is also tied to one's lifestyle, friend- ships, habit patterns, etc. Smokers have more friends who smoke than do non• smokers. If one lives with a social group of smokers, it is rather doubtful that one can be induced to stop by anything less than other, equally strong social pressures and supports. It may be necessary to change one's circle of friends. Many quit- ters have expressed the feeling that some people dose to them really do not want them to succeed. Lack oJo Plan Although there is no right or easy way for everyone to quit; it is important that each person find an appropriate private method to fit Ir, atrnation.° For some, the best plan is '•coid tu%key: • For the individual who is highly susceptible t:, gr:,up pres- sures, quit-smoking groups can be help- ful?az.iar: Social support from those close to him is very important, perhaps crucial, to one who is trying to stop smoking. These "significant others" provide origoing en- couragetrtent, reinforcement, and non- judgmental support. One has only to look at Alcoholics Anonymous and various successful weight control groups to see how social pressures can be harnessed in a creative direction. Merely placing people in a group, how- ever, will not necessarily inspre good re• suits. The'se groups should not be too large and must not attempt to effect extensive personality change. The more attracted an individual member is to the group, the more likely he is to conform out of a desire to be accepted and to avoidrejecdon. This can lead to a self-generating "reinforce- ment effect," a process that can be espe- cially effective within small social units such as families, circles of friends, clubs, or work groups.e.12 AlcoAol A high positive correlation exists between ssnoking and drinking behacior.1s This is *Man) voluntary health otganaauons disuibe ute "hoM•t4do•n" hterature. The American Cancer Societ) conducts quu-smoktng chnits in tnantcommunsties. These consist of tNtce•a• week sessions for four weeks. The Ftvrt)ay Qun•SmokmR Clinics conducted b% the Seventh Day Adven sts have been h qpetgttaneAe7n 1959 p• •~ At .L Y e t7 ce - I

especially true for alcoholics. For some individuals, smoking and drinking are so strongly associated that they may have to avoid one to cont.rol the other. Certainly during the initial,difficult quittingperiod, aicohos consumption should be kept to a tninimum, since willpower is the first Enental facility to be affected by alcohol. SsycAic Dejenses:l t•lebilitea Denial Coerciwe, scare-typx approaches or those based on excessive judgment, rationality, and criticism have little place in a quit- v;moking program. "Hard•selP' approach- rs, which attempt to induce guilt or shame in smokers, should be avoided because they may overwhelm the ego rather than inform, assist, or strengthen it. These approaches may leave the smoker afraid, ashamed, or guilt•ridden, and he may teach for another cigarette to soothe those painful feelings.9 Especially for the heavy smoker, these tactics will often merely raise snd mobilize his psychic defenses and affect the smoking behavior only temporarily. Some return to their habit within a few days, with increased inten- sity. They may bolster their original atti- tudeby minimizing, distorting, ordenying the eontent of the anti-smoking message.19 ;fniporiant Psychologicar Gains DJSmoking Smokers may ask themselves, "If this habit offers me so much satisfaction, why should I undergo such suffering? Is the cure worse than the disease?" • Feared Loss ojSe(jControl Many feel that smoking keeps thrrn on an even emotional keel. For them, cigarette smoking is a technique t a keep the lid over suppressed anger and hostility. Smokers have expressed fears of being unable to concentrate, organize their thoughts, re• membkr, or perform various tasks which, in the past, have been intimately associ• ated with smoking.r= When some individuals quit - or merely try to quit - they are unable to control their emotions. One young house- wife reported that when she tried to stop she became a "shrew" and her family practically tiegged, her to start smoking again. She r~cognized that she was using her bad terdper as an excuse to resume smoking. Most ex-smokers are surprised to fsnd that the expected loss of control lasted in most cases only a few weeks and was seldom as serious as was feared. Expectation oJFailure About 61 percent of current smokers have tried to quit, unsuccessfully, on one or more oocasions.' There are some who will not even try because they feel doomed to failure; the immensity of the task is over- whelming. lit reality, very few people suc- ceed on the fsrst try. Secret Smoking Some smokers go underground with their habit!•u Like hidden drinkers, they have been pressured Into a pattern of deception and secrecy. The person may smoke at work while denying at home that he smokes at all, or regress to the adolescent practice of surreptitiously smoking in the garage or bathroom. Many spouses have been highly critical of their mates' inabil- ity to stop smoking, and this inability fills the smokers with feelings of guilt, shame, and anger. Therefore, many of them have feelings of low esteem and believe that they are missing some qualities that others possess, e.g., "I want to quit, but I just don't h ekvhat it takes. Sne.esjulSiruLrion::AcraatdF~orAteJ 4 Some will use a9y personal stress or taii- ure as a legitimate reason to start smok;ng again. Heavy smokers tend to be more vulnerable to streas than light smokers. They also appear to have more personal problems and anxiety than nonsmokers. m Ex•smokers will even unconsciously pre- plan for a gtressfui situation to occur to legilimire their resumption of the habit. They may do this, for example, by taking on too many responsibilities at work, by failing to get enough rest, or by spending a great deal of time in high stress situations.

OBSTACLES TO QUITTING o SNf pity. "moumrog•' • Switch to other forms of tobet:o • Nrtotinedependency • Weight gain, actual or anticipated e Stresslul srtuation,actual ar planned • Secret amOking e E><peetation of failure e Feared loss of seff control • Piych0lagrcal gains of smoking e PsYchic defenses. mobihted tlen e: • Alcohol e Laek of plan for quitting s Social pressure Long•term quitting (by using strategic w,tridrawa' and bridge burn mg I Fig t piagra'r+mat+c presehtation ot the owt-smoking process as seen trom ~ a pS,CnOtoQ'Ca vantage oolnt Note the Obsta: les that must beovecome ana strong fendencres fo' 1ne mo.w0~° to resume Srlokrng vwa uMo^SCIous meehan'sms Successful tong•term qum.!+c consksts 0' w0•.'ngthbughunto'15CrouS coI)sFuctweanOpeihfutintetna'conlactnvetanre1onpe e Pe'Wo

tA ..c+:~waa*ta~x,? ::aae^'~ ~L'".r^'aaF WeighrCain This is often used as an excuse for the re- sumption of smoking, especially by wom- en. In one study, 60 percent of men and 51 percent of women gained weight after they had quit smoking." Although with- out dieting it is norntal to gain five to nine pounds after quitting smoking, some per- sons feel that a one to two pound weight gain is entirely unacceptabie. Most per- sons must giveseriotos consideration to the weight problem early in the quitting pro- cess, lest they gain a quick 20-plus pounds. As for their relative danger, to present the same health hazard as smoking a pack of cigarettes a day, one must be 125 pounds overweight!" Nicotine Dependence When a smoker consumes a pack of ciga- rettes a day, over a year's time he has re- peated a chemically rewarding cycle of stimulus-response-reward (inhalation) 60,000 times.' It is not easy to leave such rewarding behavior. Switch to OrAerFoirns oJTobaeco Some who leave eigarettes search for at• ternative tobacco sources to satisfy their needs. Many are convinced that cigars and pipes are safer than cigarettes and believe that they can inhale with impunity. How- ever, one who switches to other forms of Mhp;co may be actually increasing his "At one of our cllnics a woraan was overheard to say that she saourned more when she quit smoking than she did when her husband died!" health risk.l2•21 Most persons who discon- tinue smoking cigarkttes and change to ci- gars continue to inhale, and havecarboxy- hemogiobin levels twice as high as those who inhale cigarettes. Increased carboxy- hemoglobin levels are associated with in- creased incidence of atherosclerotic dis- ease. Also, those who switch to other forms of tobacco can expect a higher in- ddence of oral diseases. Finally, switch- ing is at best a temporary diversion, often eventually leading back to cigarettes. Se/j-Piry: "9Nourning" The depth of psychological grief and emp• daess experienced by an individual after quitting can be remarkable. At one of out clinics a woman was overheard to say that she mourned more when she quit smoking than she did when her husband , died! Tamerin9 reminds us that for millions of smokers, cigarettes represent one of the few consistent and stable objects it6 their Gves. It is important to realize that the ha- bituated cigarette smoker needs a reason• able period ot time to mourn the loss of an important companion. 5tudies of nor• mal bereavement indicate that, in most instances, a three-month period allows adult grief to be worked through ti4 Tirk quitter seeks todisengagehimself fromthe cigarette-the lost love object. He must learn to reinvest his emotional capital in new and productive directiotts. In the process, these patients may suffer from anxiety or depression. StrateBlc Withdrawal and Bridge Burning To successfully quit smoking, one should attack the problem on as many fronts as possible. A person should develop impor• tani substitute activities that cari help fill the vacuum that is left after quitting. A defsnite, strategic plan of action, based on a thorough understanding of one's own habit, should be forrnulated-~-pref• eratdy in writing. The technique of "burning your bridges behind you"-i.e., using various means to cut off all means of retreating back to the habit-is a valuable aid to quitting. Here are some suggestions that physicians can offer their patients who wish to quit smoking•: 'The Help Qun fiit, a program to help physr eiens help their patants quit smoktng, is avad• able from i I units of the ~rtljnpsin~~r Socrctr. gl~ 1 g 8N

i • Actively encourage and help others to stop smoking. • Identify with and personally associate with former smokers. • Leartt to avoid "triggers" of high value stimuli that encourage smoking. • Dispose of the paraphernalia of smok- ing. •]oin a group opposrd to smoking and read their literature. • Make a cash bet or social pact with a close friend or relative, specifying a cer- tain period of abstinence. Make a pub- lic ctlmmitment to a respected group or person. When a person verbalizes a be- lief or intention to others, he becomes more inclined to accept it himself. • Develop substitute activities or habits incompatible with smoking, e.g., aero- bic exercise regimen. • Place signs in homeand work areas ask- ing others to refrain from smoking. Alternatives to Smoking In a provocative article, Cohen states, •'Major inroads on drug abuse cannot be made by stressing the undesirability of drugs.. It can only be done by offering more desirable alternative involvements- activities, life-styles and satisfactions which are more rewarding than drug ex- periences and incompatible with depen- dence on chemicak."u He suggests that the quitting smoker become involved in activities that are en- joyablk and rewarding. The possibilities are endless and diverse, but all have cer- tain elements in common: they promote greater self-awareness, self-confidence and self-esteem. While all such pursuits- artistic, athletic, intellectual, spiritual, or social-are beneficial, we baieve activi• ties that promote physical self-awareness are particularly important (e.g., walking, running, dancing, gymnastics and group sports). Aerobic Exercises ant7 physicat Awareness One of the greatest natural (and legal) •'highs'• that one can experience is the sen- sation of a healthy body in motion.2 Our bodies were designed for activity, move- ment, -graa and rhythm.u €rserson rec- ognized this fact when he said, "First, be a good animati" Many individuals have noted that they couldn't break the ciga- rette smoking habit until they first started a jogging or aerob.ic program?s Exercise carries with it an Increase in prudent living habits. It is difficult to find even a half- serious runner who smokes, drinks in ex- cess or fails to keep a-watchful eye on his diet?' As Dr. George A. Sheehan, a noted heart specialist and long distance runner, states, "... for your muscles to celebrate, and you to move about freely, you have to pay attention to details like diet and c?i- mate and training. How can one play and think and Imdi truth when stu:fed with jelly doughnuts?"u Posirfve PsycRologicofF,jfecu oJFxercire It is well accepted that physical activity can change the state of the adult mind, causing distinct and rapid changes in per- sonality.p When a sedentary, middle-aged man decides to enter a long-term, strenu- ous physical conditioning program and disciplines hiroself to stick it out, he will often gain a sFnse of atxomplishment, in- dependence and a sense of control of his own life that he may never have had be- fore. He is also likely to become more res- olute, emotionally stable and imaginatfve, ••... an exercise health program can infiuencb how a person thinks and feels and what he does to promote his own health." ~ c N 11787 and this is an exhilarating experience.t'-N Physical activity has been prescribed fre- quently in noqt-specific ways as pan of the therapeutic milieu of psychiatric rehabili• tation programs (for example, with drug and alcohol abusers and juvenile delin- quents). It is commonly employed io help