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Chapter 10

So, I ask her, how many times have you quit?

"I couldn't even tell you." She shakes her head and shrugs. "Dozen? I've quit for nine months twice, six months two or three times." She speaks with an air of confession. "These are times I've gotten past the physical addiction. Anywhere from three to nine months. Three months, many times. I can't even tell you how many times I've quit for two or three months.

"I've quit, oh, probably 16, 20 times. I quit every night."

And do you learn something each time? I expect her to explain what triggers her into relapsing, or what temptations are just too intense to withstand.

"Yeah, actually I've learned that autumn is the best time for me to quit. If I quit right around Thanksgiving, I tend to stay quit longer. I don't know why. Couldn't tell you. Thanksgiving, Christmas—maybe it's the change of season, change of temperature.

"I never have wanted to smoke. I've never pictured myself smoking ten years from now. Getting to it is difficult. I keep trying! I keep trying!"

When I ask what methods she's tried, she laughs.

"I don't consider any of them successful, because obviously I still smoke. The times that I quit for nine months, it's like a paradigm shift. You kinda have to brainwash yourself into the fact that you don't smoke. Like, if you're out and somebody says, 'Do you want a cigarette?' you say, 'No thank you, I don't smoke.' Or if somebody asks you for a cigarette, you say, 'No, I don't smoke.' You don't smoke. You tell yourself, 'I'm not a smoker. I don't smoke.' And then when that settles in, then you're not a smoker. You've gotta brainwash yourself that you are not a smoker."

So part of it is redefining yourself? But before she can answer, I interrupt myself with another notion: Maybe all of your quit attempts have just been rehearsals, and you're still waiting to quit for real?

"I know I just can't have that first one. I know the second I break down and have it, that's it! I've lost! The thing is that I can't drink," she explains. "When I quit smoking, I can't drink. When I drink, I want a cigarette. My craving increases. When I have hard alcohol, I don't have as much of a craving as if I have beer or wine. Different alcohols affect me differently. I get different reactions to them."

And which quit attempt was the most successful?

"I'd been using a half a pack a day—no, not even that much. A quarter of a pack. Five. And my best friend didn't smoke. She didn't like it. She talked me into quitting, so I quit. I stayed quit for nine months. Clove cigarettes were the big things. Nine months after I quit, she started smoking clove cigarettes. She'd have one every few days, so I decided to try one. Pretty soon I was smoking five clove cigarettes a day. I switched back to cigarettes. And then I was smoking clove cigarettes and regular cigarettes. Soon, I was up to a pack a day."

Her highest rate of cigarette consumption occurred over a five-month period in college, when she found herself surrounded by smokers and smoking two packs a day. "I hadn't realized it. As soon as I realized it, I cut back down."

"Everybody smoked in the Theater Department," she recalls. "Things are getting better now working in theater, since people are quitting smoking. But it's strange to be working with an actor who's out there belting away this incredible song with a beautiful voice, great set of lungs—then he goes outside on his break and he's having a cigarette."

Smoking will always surround her, she knows.

"I'll just have to deal with it. Have to be strong," she declares. The theater will be a hard place to avoid smoking, "just because there's a huge incentive to smoke. More there because it keeps me awake, and focused. I read about the studies that say that nicotine increases your focus. And it works! It works great! When you're really tired, and you're getting spacey, and you know that you need sleep, but you can't, it works great. I'll just have to find other ways.

"I haven't quite figured out all the bugs yet."

As hard as she has found it, she has quit smoking during the production of a play. Sometimes, she says, quitting isn't that hard. Once she sought help in stopping smoking through a health maintenance organization. "They make you go to this class and do all this stuff—it's great! Stupid little class works great!" That time, she didn't smoke for three months.

She stops to calculate. The diamond solitaire on her left ring finger is a continual reminder: This year, she and her fiancé will be married. Soon after that, they hope, they'll start a family. They have decided that their children will not have parents who smoke. On this point they are united and firm.

No matter the cost in discomfort and aggravation, her days as a smoker are numbered.

Gimmicks, Gizmos, and Grit

For $95, a mail-order company in Waco, Texas, will send you Mr. Gross Mouth, a three-times-life-size hinged model of a mouth plagued by residual effects of using snuff tobacco. It is designed, apparently, to both deter potential tobacco users and terrify current users. If Mr. Gross Mouth's gingivitis and oral carcinoma aren't convincing enough, there's an even bigger model—Giant Mr. Gross Mouth. Weighing in at $135 and 12 inches wide open, Giant Mr. Gross Mouth has a four-inch-wide "cancerous" tongue made of realistic Biolike material.

Not to mention Mr. Dip Lip, whose flesh-like lips retract to show stained, deteriorated teeth and gums resembling those of smokeless tobacco users. Also made from Biolike is the Itty Bitty Smoker, a model of a ten-week-old fetus smoking a cigarette, "a hard-hitting reminder that pregnant mothers have special responsibilities," the company asserts. These educational products and an array of models of diseased lungs, folding displays, and "durable polyester" body-part models "painted in gory, realistic detail" are focused on developing an aversion to tobacco use, often among those who already use it.

The stop-smoking marketplace has no end of gimmicks and gizmos purported to help curb tobacco use. Among the most interesting are these:

Nor is the attack on smoking limited to gadgets. A small notice in a local newspaper advertises a hypnosis clinic, where your smoking can be cured for $40. Because the hypnosis clinic will be conducted at a local hospital, the notice carries the imprimatur of the medical facility. But will it work? The same question comes up every time you see an ad for losing weight quickly and permanently: If it's so easy to lose weight, why are there so many overweight people? And if stopping smoking is as easy as being hypnotized, why do so many people still smoke?

To Quit or Not to Quit

40% current smokers not considering quitting in the foreseeable future
40% current smokers ambivalent about quitting
20% current smokers intending to quit in the next few months
50% nicotine-dependent adults who attempt to quit
more than 90% quit attempts made without formal treatment
33% those attempting to quit who are abstinent for at least 2 days
2.5—5% quitters who stay quit for 1 year

Other quitter-hopefuls take a more circuitous route to quitting, by cutting back. Some people switch brands as they prepare for a pending quit date, going from a higher-nicotine to a lower-nicotine cigarette. This process is called nicotine fading. It has been used successfully in conjunction with several other stop-smoking methods. This technique is not applicable for smokers already using low-nicotine brands. Some smokers find smoking reduced-nicotine cigarettes to be aversive in and of itself. Also, smokers switching to a lower-nicotine brand may be taking in about the same amount of nicotine anyway if they compensate by smoking more cigarettes or inhaling and puffing differently.

Some smokers attempt to quit by switching to another form of tobacco, such as oral snuff, cigars, or pipes. At least one book and several scientific publications have promoted the use of smokeless tobacco as a supposedly safer alternative to smoking, which is satisfactory only for those not worried about the numerous health risks that smokeless tobacco entails. Other smokers switch to cigars, assuming that because they inhale cigar smoke less than cigarette smoke, and because they smoke cigars less frequently than they would smoke cigarettes, cigars are safer. Both of these switching techniques carry their own risks, which are substantial.

Techniques termed aversion strategies are also in the stop-smoking armamentarium. These approaches, based on what psychologists term a "behavioral" model, typically involve developing an aversion to cigarette smoke. The aversion technique that has been studied the most is rapid smoking, in which the smoker puffs every six to eight seconds until puffing is no longer bearable. This can be done several times at a series of sessions. Another technique involves doubling or tripling the usual smoking rate for several days prior to quitting, to achieve satiation in the smoker's home environment. Clinicians recommending these techniques must be careful to avoid introducing additional cardiovascular risk in patients. A low-risk aversive technique involves the smoker's saving cigarette butts in a sealed jar before quitting; when the temptation to smoke strikes, one sniff in the jar may be enough to deflect a potential lapse back to smoking.

Currently at the head of the class among smoking cessation aids are several pharmacologic treatments, including a nicotine replacement delivery device called "the patch," a small, adhesive bandage-like system that provides a slowly delivered, steady amount of nicotine to replace the nicotine that otherwise would be acquired from smoking cigarettes. Preceding "the patch" was "the gum," a vaguely neutral-tasting substance that delivers a fixed amount of nicotine if it is chewed and "parked" in the mouth correctly, which can be used to curb cravings and urges to smoke during cessation. Other nicotine delivery devices include a nicotine nasal inhaler, which has been tested both in Europe and in the United States. Nicotine replacement was designed to be a short-term means of weaning oneself off tobacco while dealing with the behavioral changes necessary for quitting smoking. However, long-term use can have its own negative consequences and thus is not recommended.

Each nicotine delivery approach has its own virtues. Some smokers prefer using nicotine gum because it allows them to regulate their nicotine replacement dose. Others prefer the patch because of its ease of use. The inhaler is preferred by some because it delivers nicotine via puffing, and thus shares some of the sensory characteristics of smoking.

Another pharmacologic smoking cessation aid is an antidepressant medication, bupropion, marketed as Zyban. In May 1997, this drug was approved by the U.S. Food and Drug Administration. A nonnicotine medication, it went through extensive clinical trials, as did all the nicotine replacement devices and the gum, before it was approved for use as a prescription medication.

Since the late 1980s, the same drug was marketed as the antidepressant Wellbutrin, or Wellbutrin SR. A scientist monitoring depressed patients who were using Wellbutrin noticed that some patients quit smoking. A multi-site trial of bupropion reported by Richard D. Hurt and colleagues in 1997 examined effects of three bupropion dosage levels and a placebo in more than 600 subjects who were quitting smoking. Smoking was reduced significantly in the groups of subjects who were given either of the two highest doses of bupropion, but not in those given the lowest dose or the placebo. Those subjects receiving the highest dosages of the medication also gained the least weight as they quit smoking. Even with that success, many of the participants in the study were smoking one year later. This medication currently is being evaluated further in multiple clinical studies.

The Zyban formulation of bupropion differs from Wellbutrin SR in two significant ways. The upper limit of use of bupropion for smoking cessation treatment is 300 milligrams; for depression treatment, it is 450 milligrams. Smokers are encouraged to use Zyban for cessation rather than Wellbutrin SR, because the higher bupropion dosage of Wellbutrin SR could unnecessarily increase the risk of seizures.

Ironically, the pharmacologic interventions, including those containing nicotine, must go through extensive testing for both safety and efficacy before they can be marketed, while tobacco remains a readily available and relatively inexpensive source of nicotine. In fall 1997, an international panel of tobacco experts urged governments throughout the world to ease restrictions on nicotine replacement as a way to help millions of smokers quit. As David Sweanor, a legal counsel for Canada's Non-Smokers' Rights Association, was quoted by Reuters news service, most of the world's 1.1 billion smokers want to quit but are addicted to nicotine. Quitting "is very difficult for them . . . because regulation of nicotine substitutes is far tougher than for cigarettes. The whole thing is upside down and it has to be corrected." In some countries, nicotine replacement requires a doctor's prescription. Because the limitations make the market small, the cost remains high. Smokers in developing countries thus have virtually no access to nicotine replacement.

A necessary part of successful tobacco cessation is modification of behavior. A small percentage of tobacco users will seek help through structured stop-smoking programs. The majority of those attempting to quit will try to do it by themselves, without help. To smokers, particularly the do-it-yourselfers, the array of devices and approaches can be bewildering. Many who have quit repeatedly, only to resume repeatedly, know what has worked for them, at least temporarily. They also know that tobacco is difficult to leave behind.

Cold Turkey on Wry

Some smokers believe that the best way to quit smoking is stop abruptly, or (as North Americans phrase it) to quit "cold turkey." They insist on gritting their teeth and toughing it out. This approach does work for some people. Similarly, it is a fact that most ex-smokers stopped without any formal help, although it typically takes many attempts before they finally succeed. In any case, the statistics predicting success for any given quit attempt aren't on the side of the cold-turkey quitter. Studies with thousands of smokers have shown repeatedly that the best way to quit smoking is to have help, and that cessation rates are higher among those who use nicotine replacement correctly.

Smokers who attempt to quit without any help, any support group, any gum, or any patch tend to have limited success. A group of leading cessation researchers, led by Sheldon Cohen, reported a decade ago on the quit-rates of more than 5,000 smokers who attempted to quit without help from a "change agent" (e.g., therapist, nurse, doctor, or support group), and without any personalized assistance. Some of the smokers received self-quit manuals and other printed materials through the mail or through their place of employment. The report responded to published assertions that those who quit by themselves meet with more success than those who have help quitting.

Patched Up

2 hours time it takes for nicotine in nicotine patch to plateau in the bloodstream
44% increase of daily nicotine intake with 4-mg nicotine patch, vs. 2-mg nicotine replacement
10—20% those using nicotine gum who will still be using it 9 months after quitting smoking
98—99% those using nicotine gum who will eventually quit using it

Using data from ten long-term studies, the research group determined that self-quitting is not a panacea, and that those attempting to quit by themselves have no greater success than those attending formal programs. Those who smoke more than a pack a day are less successful at self-quitting over the long-term than are those who are considered light smokers. Those who smoke the most tend to have the most difficulty quitting in any setting, with or without assistance.

In the current climate of smoking cessation aids, the question has shifted from a discussion of self-quitting versus group treatment to the choice between using or not using the available medications. In addressing this question, groups of scientists have offered some valuable guidance.

Guidelines for Quitting

Many tobacco users who go through years of quitting and relapsing find specific approaches that work for them. Until recently, however, approaches to treatment of nicotine dependence were anything but standard. Every program, whether it was designed by the American Heart Association or a local hospital's nursing staff, had a somewhat different twist. Even though those differences in approach are likely to remain, two sets of guidelines issued in 1996 now help both interventionists and smoking consumers identify a successful approach to cessation.

These sets of guidelines were compiled by two separate blue-ribbon panels. The more comprehensive guideline was assembled by a panel of 19 specialists assigned to the task by the Agency for Health Care Policy and Research (AHCPR), a Public Health Service entity established in 1989 to conduct and support health service research. The AHCPR guideline (titled Smoking Cessation) was based on extensive searches of scientific and medical research. Hundreds of research reports were reviewed and synthesized. When scientific literature was incomplete or inconsistent, the panel and their consultants recommended what they believed to be sound practices.

Physician and public health specialist Michael Fiore, chairman of the panel that drafted the guidelines, called their publication "a critical event." Addressing a 1996 conference introducing the guidelines to the scientific and clinical communities, he elaborated: "This document, for the first time, provides clinicians, administrators, and smokers alike with a definitive, research-based answer to the question: what actions are necessary to improve the likelihood of successful smoking cessation for people already addicted to tobacco?" He deemed the dissemination of the information a "defining [moment] in reaching a goal that finally appears achievable: the elimination of tobacco addiction from our society."

Within a few months of the AHCPR recommendations, the American Psychiatric Association published a complementary guideline focusing on three target populations: (1) smoking patients being seen by psychiatrists for disorders unrelated to nicotine use; (2) smokers whose initial attempts at cessation failed and who need intensive treatment; and (3) smoking psychiatric patients confined to inpatient units or residential facilities where smoking is not allowed.

Worth a Try

15 — 20 years it takes, after quitting smoking, to reduce the risk of cancer and likelihood of mortality; they never reach that of a never-smoker
1 — 3 years it takes, after quitting smoking, to reduce risk of recurrent myocardial infarction, sudden death, and stroke to levels approximating those of a never-smoker
1 days it takes after quitting smoking for carbon monoxide levels to return to those of a nonsmoker

The two sets of guidelines combine to outline the best that science can offer the tobacco user who wants to quit. Together, they provide the most comprehensive descriptions to date of what works and what doesn't. This does not mean that other approaches might not work, but rather that they have not yet been demonstrated to work as well as the methods the guidelines list. Also, it does not mean that every smoker who uses these approaches will be successful. To the contrary, only a portion of those who attempt to quit using even the best combination of methods will succeed in any given quit attempt. The guidelines recognize that the process of learning to quit can span many years. Most youth who start smoking try to quit within a year. Most successful quit attempts come after repeated failures. Those who succeed generally are those who have learned from their earlier attempts.

A physically fit professor once described how he lost a considerable amount of weight. One day, during a time when he was seriously overweight, he went to a health club to sit in the sauna. As he basked in the heat, he noticed, with a glance, a man sitting across from him. He was immediately appalled by how fat the man was. Then he realized that he was seeing his own reflection in a mirror. That unguarded look at himself prompted him to start an exercise program. Within months, he was running several miles a day. He dropped to an ideal weight and stayed there. That unexpected vision forced him to confront a reality he had been denying.

Many cultures and nations have not yet had such a jolt. It is true that public health advocates have made considerable headway, and that the world of tobacco politics shifts daily, sometimes hourly. Even so, the world has not yet taken that unexpected glance in the international mirror that would motivate serious changes in smoking prevalence. What science knows about quitting smoking has not yet been translated into programs, policies, practices, and norms. We know how to help people stop smoking. We know what constitutes effective strategies and interventions. However, they are not yet available to the general population, at least not uniformly.

The panel that developed the AHCPR guidelines noted that some 70 percent of smokers say they would like to quit and have tried at least once. Also, they stated that a physician's advice can motivate smokers to stop using tobacco. But between those demonstrated facts and the reality of patient-physician contact is a sizable disconnection. Only about half of current smokers say that they have ever been asked about their smoking status or encouraged to quit. Even fewer have been offered advice on how to do so successfully.

The panel listed four solid suggestions that would increase clinicians' impact on smokers:

The central theme of their report is that brief, effective help for smokers should be offered at each clinical visit. Every time a patient visits a doctor, dentist, or other care provider, stop-smoking help should be provided. It need not be an intensive program, although that might be more effective for some patients. The panel recommended that every medical student and other clinician in training be educated in smoking cessation. This would not only "transmit essential treatment skills," the panel noted, "but also inculcate the belief that cessation treatment meets the standard of good practice."

Moreover, the AHCPR panel recommended including questions about smoking cessation treatment in licensing and certification exams for all clinical disciplines. They also proposed that specialty societies adopt a uniform standard of competence in smoking cessation. They even recommended that clinicians who smoke should enter treatment programs so that they can stop smoking permanently themselves. This is important because clinicians serve as models for their patients.

How would this work in the typical visit to a doctor or other clinician? First, the clinician would determine whether you smoke. A report of your current and former tobacco use would be listed as a "vital sign," along with blood pressure and body temperature. (The concept that smoking should be assessed as a "vital sign" has been described by researcher Michael Fiore.)

If you smoke, you would be strongly advised to quit. The message should be clear, strong, and personalized. The clinician would offer to help you, would explain why it is important that you quit, and would describe how your smoking affects your medical condition and affects your family members. The message and encouragement would come not only from the clinician, but also from the clinic staff.

The clinician would then determine your willingness to attempt quitting, and would provide a motivational intervention to encourage you to quit. It might be as simple as asking you a question: "Are you ready to make a quit attempt at this time?" If you are ready, the clinician would offer help. If you want more intensive treatment than the clinician offers, he or she would refer you to a treatment program, and then would follow up with you. If you aren't motivated to quit at that time, the clinician or the staff could perform any of several motivating interventions, including offering you information about the relevance of quitting smoking, explaining the risks of smoking, and discussing the rewards of quitting. If you still aren't motivated to quit, the message might be repeated every time you visit the clinic.

Once you are willing to quit, the clinician would ask you to set a date for quitting, and would help you prepare for quitting. This might involve encouraging you to tell your family, friends, and others about your pending quit date. You would need to remove cigarettes from your environment, and stop smoking in places you routinely smoke, such as in your car. The clinician might talk to you about your previous attempts at quitting, and might work with you to anticipate anything that could challenge your coming quit attempt.

If your clinician follows the advice of the AHCPR panel, he or she would recommend that you use nicotine replacement therapy, unless you have a medical condition that might preclude its use, such as pregnancy or cardiovascular disease. Even in those cases, your physician would help you decide whether the relative benefits and risks of nicotine replacement would warrant your using it. And your clinician would make it very clear that you must not use tobacco while you use nicotine replacement.

Does this sound intrusive? If a patient is only seeking medical help because of a skin rash or an ear infection, why should she have to put up with all that commentary about her smoking? Why would her physician risk losing business?

Let's just say that clinicians have an interest in seeing their patients survive.

Intensive Treatment

As with all other human variables, the intensity of addiction can vary dramatically from person to person. Regardless of strength of character or willpower, a tobacco user's capacity to quit can be influenced by many other factors as well. Some smokers are able to quit smoking on their own, particularly if they use nicotine replacement carefully. Some smokers have better success in an intensive treatment program. This could be an outpatient program in which they have either group or individual counseling, or could involve their participation in an inpatient setting where their condition is monitored frequently and they receive a wealth of instruction and support. Intensive treatment is effective across most groups, regardless of sex, race, ethnicity, or health condition such as pregnancy.

The AHCPR panel reported a strong relationship between the intensity of counseling and success in quitting. More intense counseling resulted in a higher rate of cessation, overall. Intensity can be increased by lengthening each counseling session or by increasing the number of sessions and the number of weeks of treatment.

Researchers have identified factors predisposing a smoker to relapse, including dependence on nicotine, existence of a psychiatric problem, and low motivation to quit. These factors can be used to the smoker's advantage if they become the basis for matching the smoker to a suitable treatment. An example of such "treatment matching," as the practice is known, could be providing a depressive smoker with antidepressant treatment such as bupropion, if the drug is an appropriate prescription for that patient.

Another way to provide intensive treatment is to involve a variety of care providers, including perhaps a physician, a nurse, a dentist, a psychologist, or a pharmacist. Each might provide a unique perspective that could help a smoker in a different way.

Matters of Life and Death

one-sixth proportion of all deaths attributed to tobacco use in developed countries
35 years age at which smokers begin to have a higher death rate than nonsmokers
one-half proportion of all smokers who will eventually die from smoking
28 minutes amount of life expectancy lost for each pack of cigarettes smoked
25 years years of life expectancy a typical pack-a-day smoker loses

Additionally, a smoker could participate in group or individual counseling, or both. The most effective content of counseling sessions would involve problem solving and skills training, to help the smoker deal with temptations and high-risk situations that will arise after quitting. Support during treatment also helps boost cessation success. In addition, a smoker's chances of quitting can be enhanced through learning several self-administered aversive techniques, such as rapid smoking. Smokers in intensive treatment also are likely to be encouraged to use nicotine replacement therapy, since it consistently enhances cessation rates, independent of any other therapy that accompanies it.

How exactly should such programs be tailored? The panel recommended at least four to seven treatment sessions lasting at least 20 to 30 minutes. The sessions should be offered for at least two weeks, preferably more than eight weeks. Either individual or group counseling can be effective. It is important to provide follow-up assessments as well. The content should deal with motivation to quit and with relapse prevention. Every smoker, except those with special circumstances, should be offered nicotine replacement.

What the Health Care Industry Can Do

Of course, the onus for quitting smoking rests on the smoker. Even so, health care administrators, insurers, and purchasers can do much to make quitting smoking more feasible, and to make help more accessible. The AHCPR panel suggested a variety of approaches the health care industry could implement to encourage quitting:

Tobacco use is spread across most demographic groups. Both men and women smoke, although there are differences in how they smoke and how it affects them. People of various racial groups smoke, although the preferences may differ. Nonetheless, the AHCPR panel determined that their general guidelines are applicable for virtually all groups. Tobacco use causes disease and death across all demographic groups; cessation can be successful with all groups. Both men and women, for instance, can benefit from the same basic cessation treatment. Women may confront different problems in quitting, including a greater possibility of depression and greater concern about weight gain. Even so, the panel identified no consistent evidence of differences between men and women in their success in smoking cessation treatment.

Some groups may have particular needs, although the evidence is weak that these groups would benefit from specially tailored programs. Disease and death related to tobacco use are more common among some U.S. minority groups, including African-Americans, Native Americans, Alaskan Natives, Asians, Pacific Islanders, and Hispanics. Even so, little research has studied interventions tailored only for particular groups, and there is no evidence that tailored programs lead to higher quit rates. In fact, smoking cessation programs developed for the population at large have been effective with minority groups.

Some tailoring makes logical sense, such as providing self-help materials in a language the smoker understands, or offering culturally appropriate models or examples. The panel noted that little work has been done to identify hindrances to successful quitting in groups with such problems as low education levels or lack of access to medical care. Clearly, such topics need to be studied.

Pregnant women constitute one group of smokers who should be strongly encouraged to quit using tobacco. Since it is common for pregnant smokers to play down or deny their smoking, the panel recommended offering intensive counseling treatment to pregnant smokers. Obviously, quitting before conception or early in a pregnancy is preferable to quitting later, but quitting at any point can be beneficial. Since it also is common for women who quit during pregnancy to relapse back to smoking after the child is born, the panel recommended educating women about the risks of smoking around an infant or child.

The question of whether a pregnant woman should use nicotine replacement has never been studied in a clinical trial, but pregnant women who cannot stop smoking without the help of nicotine replacement might benefit from using it, since it poses a reduced risk to health. Nonetheless, it would be preferable for a pregnant woman not to be using nicotine at all. In any case, pregnant women who participate in cessation counseling during pregnancy have higher quit rates than those who do not have such help. Even minimal counseling may be beneficial.

Hospitalized patients who smoke are another group who require consideration. The panel recommended that hospital staff ask all new patients about their tobacco use. Smoking status would be listed on the admission problem list and on the discharge diagnosis. The panel proposed that hospitals help all smokers quit during their hospitalization, including giving them nicotine replacement when appropriate. Since continued tobacco use could disrupt a patient's recovery, it is vital that hospitalized patients attempt to quit. Research evidence indicates that stop-smoking interventions can help hospitalized patients quit.

All hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are now required to be smoke-free. This provides tobacco-using patients an opportunity to quit smoking in a smoke-free environment. Hospitalized smokers could experience nicotine withdrawal symptoms if they are not allowed to smoke in the hospital. As with other groups of smokers, nicotine replacement may be appropriate for these patients.

Conditions such as depression, substance abuse, or other psychiatric problems are more common among smokers than among the general population. Between a third and half of patients seeking help to stop smoking may have a history of depression. At least one-fifth of those seeking help may have a history of problematic alcohol use. Going through nicotine withdrawal may worsen such conditions, and may put such individuals at greater risk for relapse. Nonetheless, smoking cessation treatment can help them quit and stay quit. Since the presence or absence of nicotine can affect how the body processes and uses some medications, such as antipsychotic drugs, clinicians need to monitor the effects and side effects of medications in smokers who are attempting to quit.

The experts reported that the best strategy is to quit smoking without attempting to diet at the same time. Once a smoker is confident that he or she will not relapse, and once the nicotine abstinence symptoms have passed, then it is appropriate to deal with the weight gain. Overall, what is most important is to maintain or establish a healthful lifestyle. The bottom line is this: Compared with the health risk of continuing smoking, any risk from postcessation weight gain is negligible.

The panel explained that dentists, in particular, are well positioned to help users of smokeless tobacco quit. Findings from a handful of research studies suggest that stop-smoking techniques are also effective with users of smokeless tobacco. It is possible that nicotine replacement may help smokeless tobacco users quit, although this has not been studied thoroughly.

Tobacco is not only an adult problem. Many grade-school children and adolescents appear to be as dependent on nicotine as adults are. Even so, in many communities little help exists for pediatric smokers. Cessation in young persons has not been studied extensively; consequently, the effectiveness of counseling and nicotine replacement for young people is undetermined. Some young people who attempt to quit using tobacco on their own quickly relapse. Clinicians such as physicians, nurses, and dentists can be an immediate source of help. The AHCPR panel suggested that clinicians consider nicotine replacement for young users of tobacco, as long as the degree of dependence and body weight are taken into consideration when determining dosage.

The panel's many recommendations were based on evidence of what works. As they emphasized, "an absence of studies should not be confused with a lack of efficacy." They did not report, for example, on the use of bupropion, since they conducted their analyses before bupropion was approved for smoking cessation treatment. In cases where evidence was thin or inconclusive, the panel rendered no opinion about a treatment approach. Sometimes, data were inadequate or unavailable, as in a comparison of nicotine patch and nicotine gum. No adequate, published studies had compared the two methods; consequently, the panel did not compare them. The panel also avoided ranking therapies in order of superiority. They did note, however, that longer person-to-person therapeutic interactions have a greater impact than minimal contact, and are superior to having no contact.

A Process

Stephen King's tale Cat's Eye portrayed a stop-smoking method that could make even the most addicted smoker throw away the cigarettes for good. A smoker who agreed to participate in the stop-smoking program and then sneaked a cigarette had much to lose, including a finger or a family member. Effective as draconian measures may be, they are neither legal nor necessary. Stopping smoking may take repeated tries, but it is feasible. The secret is in learning to quit.

Quitting smoking is a process, not a single event. Many users of tobacco find that they must learn to quit before they can succeed permanently. Learning to quit can involve learning to manage lapse and relapse episodes, turning them from catastrophe to beneficial experience. Some tobacco users are more successful in quitting when they focus on reducing their risk for relapse. Ex-smokers learn that they are tempted to relapse in certain situations. The "triggers" that lead them back to smoking are individual. For some, just going to a gathering where others will be smoking is enough to trigger a relapse. For others, it is the quiet moment after a meal, or an unexpected high-stress crisis at work.

Hundreds of scientific studies report that a host of factors influence success in quitting, just as many individual factors lead to tobacco use. Although first-try failures are discouraging and common, the odds are high that a smoker determined to quit can eventually do so. Many have, and many more can.

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Copyright 1998 National Academy Press