Originally created 06/07/01

No magic in kicking the smoking habit



The addiction gripped Allison Blakebrough in ways that surprised her. A smoker since she was 13, the Durham, N.C., woman was taken aback when, a week into her most recent attempt to quit, she cried.

"It was like losing a buddy," Blakebrough said. "There was a real loss for me, an emotional loss. I probably cried every day the first week. I wanted to smoke."

But Blakebrough managed to make it through that first week, and despite two relapses, has been smoke-free since March.

She credits her success with a program offered by the American Lung Association, which uses a diverse approach that, in essence, unleashes the entire scientific arsenal against nicotine addiction.

And there's much more in that arsenal now than even five years ago. The science of smoking cessation has advanced to such an extent that some multi-therapy programs can claim success in up to 70 percent of cases. The key lies in a combination of therapies, outlined last year by the Agency for Healthcare Research and Quality:

- Zyban, a drug originally prescribed as an anti-depressant, has been shown to help reduce cravings for cigarettes by affecting the chemicals in the brain. It must be prescribed by a doctor and works best when taken before, during and awhile after the attempt to quit.

- New nicotine replacement therapies beyond gum and the patch. Duke University researchers recently announced they have developed a nicotine liquid that can be added to the smoker's favorite beverage. Other recent tools include an inhaler that is shaped like a cigarette and delivers nicotine without the other harmful compounds in tobacco, and a nicotine nasal spray, which delivers a blast of nicotine that is quickly absorbed.

All help to ease nicotine withdrawal, but they also give smokers a hands-on substitute for their cigarettes.

- A counseling model that incorporates proven steps to help smokers quit. So important is this component of a cessation plan that even Zyban's manufacturer, GlaxoSmithKline, notes that the drug works best in combination with a behavioral therapy. So much of smoking is beyond habit - it's a lifestyle, an identity - that smoking cessation requires a wholesale change that the smoker must embrace.

Even with all the breakthroughs and developments that science has provided in recent years, no single cessation plan or program is guaranteed to work.

"If we could take a magic potion and quit, we'd all be non-smokers," says Eleanor Blackwell, area director with the American Lung Association in Raleigh, N.C. "Smoking becomes such a part of how we live every day. We can't just put the pack of cigarettes down and go along the way we've become accustomed."

But finding a magic potion is exactly what researchers at Duke University, along with the Veterans Affairs Medical Center in Durham, N.C., are trying to do. The goal is nothing less than the Holy Grail of nicotine addiction.

"We hope that by developing the magic pill, doctors will want to use it because it will be so easy," said Dr. Eric Westman, a researcher at Duke and the VA. "We know in a doctor's office that there is going to be minimal behavioral support, so we try to develop treatments to solve everything."

Westman said researchers learned this lesson from tests of the nicotine patch. Early studies, done with counseling, showed great success rates. "Then, applied in the real world from the doctor's office, lo and behold, the success rates weren't as high," Westman said.

But the magic pill remains an elusive goal, making counseling programs a necessity. While this component of a cessation plan is highly effective, it has to be done right. And that's not always the case, even when doctors are involved.

Westman and others don't blame doctors for this failure to counsel patients in the finer points of smoking cessation. It's time-consuming, highly individualized and often unsuccessful. Furthermore, it's systematically discouraged.

Until very recently, no health plans reimbursed doctors when patients came to them about smoking. Health plans also seldom paid for smoking cessation classes or drug therapies, which can be expensive. A month's prescription of Zyban, for example, can cost as much as $90.

Changes are afoot. Over the past two years, North Carolina Prevention Partners, a health advocacy group, has persuaded 64 percent of the state's health insurers and managed care plans to cover smoking cessation. This month, Doctors Health Plan will become the latest group to add smoking cessation to benefits packages it offers employers.

But even as the financial hurdles are removed, there are others that trip up smokers interested in quitting. Just finding a smoking cessation class these days is difficult.

Yet rounding up just eight fed-up smokers at once isn't easy, despite the fact that 70 percent of smokers wish they could quit. Often, the lung association cancels classes for lack of interest.

Hard-core smokers require a skilled approach. Many are scared they'll fail again. They have experienced withdrawal symptoms and know what's ahead. They're skeptical of the very measures that can help them. But what many do not realize is that becoming a non-smoker takes, on average, four failed attempts to quit.

"I tell my patients that they ought to go ahead and quit three times real quick to get that behind them," said Dr. Adam O. Goldstein, a leader in anti-smoking campaigns at the University of North Carolina at Chapel Hill.

And while failed attempts actually offer the smoker practice, they also necessitate the counseling sessions that are labor- and time-intensive. Goldstein said few doctors are truly prepared. Simply writing a prescription for Zyban or a nicotine replacement therapy is not enough, and too often, that's all that's done.

Unless or until researchers develop a magic bullet, such pharmacological aids are best coupled with therapy. And research has found that the hallmarks of a good therapy program are, remarkably, consistent.

First, people who want to quit should be advised to set a quit date two to three weeks ahead, and then prepare themselves psychologically for what that will mean. The real nub is learning why a person smokes - which cigarettes are especially good, or what circumstances compel a person to reach for the pack. Then, smokers must identify why they want to quit, and constantly remind themselves of these reasons.

Even though 1 million Americans quit smoking each year, about 75 percent to 80 percent start back up after six months. In the end, only 6 percent of smokers manage to stay smoke-free for a year.

But scientists are working to ensure that one day, it will be easy for even the most addicted.

"We are making really important inroads," says Cathy Melvin, director of child health services at the University of North Carolina at Chapel Hill and one of the authors of last year's smoking cessation guidelines. "... (T)here are effective ways of helping people quit. We don't have to throw our hands up and say nothing works."

Cigarettes and other nicotine products are directly responsible for 430,000 deaths a year in the United States. As a result, tobacco is the No. 1 cause of death and disease in this country. The costs of caring for tobacco-related diseases is estimated to be $50 billion annually.

Some of the diseases directly linked to tobacco include:

- CANCERS: Lung; oropharangeal, including mouth, tongue, pharynx and larynx; bladder, and endometrial

- CARDIOVASCULAR DISEASES: Coronary heart disease, vascular disease.

- RESPIRATORY DISEASES: Chronic obstructive pulmonary disease; pneumonia and influenza; bronchitis; emphysema, and chronic airway obstruction

- REPRODUCTIVE AND DEVELOPMENTAL PROBLEMS: Fertility impairment; spontaneous abortion; placental complications; pre-term delivery; low birth weight; sudden infant death syndrome (SIDS); congenital malformations; cognitive and behavioral deficits in childhood, and abnormal fetal lung development

- OTHER HEALTH PROBLEMS: Peptic ulcers; inflammatory bowel disease; rheumatoid arthritis; periodontal disease; osteoporosis and delayed bone healing; eye diseases, notably cataracts and macular degeneration; premature wrinkling and skin degeneration; kidney disease, and depression.