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Chapter 9

Like most smokers, she has tried to quit repeatedly, only to bump into the wall of her dependence on nicotine.

"If I don't have it, my personality changes, until I have completed withdrawal. I cry a lot," she explains. "Then once I'm done with the withdrawals and I just have to deal without having a cigarette in everyday life, I tend to get a little snappy."

She tends to be a little snappy sometimes anyway, she muses.

"The first few days after I quit, I cry—at nothing! I cry at nothing. I can be sitting here talking to you one second, and I'll burst into tears the next second, for no reason at all. There's no emotion—it's just a physical reaction. Boom, I'm crying, and I can't stop. There's no external force. I don't feel pain.

"I'll give you an interesting example of this happening. I quit for—it was my second day after quitting, and I went out with my friends to play darts. I was standing there playing darts, having a grand old time, and we were laughing and joking around. I wanted a cigarette, but, hey, this was my second day, and I was gonna be fine.

"It was my turn to throw the darts. I stepped up, I positioned myself, I went to throw the dart, and boom, I start sobbing. Uncontrollable sobbing. I couldn't stop. I could not stop. Boom. Done. It was the weirdest thing.

"Looking back on it, I know that it was just my body reacting to the nicotine withdrawal. So I wasn't feeling emotion, but I was really trying to curb that desire to smoke.

"My best friend came over. I kept sobbing and babbling for about ten minutes. Finally she said, 'Here, have a cigarette.' I just could not stop crying. That time, I'd quit cold turkey. The next time I decided I'd better use the patch."

So, what triggers a relapse, with or without the patch?

"I think I let down my guard. Usually I can have one drink and I feel that I'm okay, but the second that I have that second drink, if there's anyone around me smoking, then GOD! I WANT A CIGARETTE!

"I have to quit drinking to quit smoking. Even after six or seven or nine months, I'll decide one night that I want a glass of wine with dinner. Beer. Whatever. With friends. I don't go out on a drinking binge or anything. I just have a glass of something, and that's it.

"And if I have one drink and I manage to not smoke, then in a couple of weeks I do it again. Each time I do it, my resolve to not smoke gets less and less.

"And I always smoke more on opening night. Every chance I get, I smoke on opening night. Opening day. Opening day, if I'm at work during the day, I tend to take more breaks. Go outside more. As soon as I get to the theater, whenever I can get a break, I go outside and smoke.

"So, yeah, high stress will do it too."

Learning to Quit

They started coming in 1986, a group of health professionals visiting a small village in the southwest corner of Viti Levu, the main island of Fiji. They came only a few days at a time, yet the more than 200 villagers sensed the commitment of the medical team. They set up a dispensary and a system for safe water catchment. They helped eradicate scabies, trained village health care workers, and set up a local health care committee.

Then in 1990 they noticed that smoking had increased dramatically among the 238 Fijians in the village of Nabila. As tobacco advertisements had lured the Fijians into spending as much as a fourth of their small salaries on cigarettes, nearly half of all adult males in the village had become smokers. Almost a third of the entire adult population of the village smoked. Smoking had doubled in about five years. Health effects were becoming chronic: Hypertension was at an epidemic level. Asthma, vascular disease, and degenerative diseases were common.

The medical team had been advising villagers against smoking, handing out American Cancer Society posters and pamphlets, and warning villagers about the adverse health effects of smoking. The village minister set an example by abstaining from tobacco. It helped, but it wasn't enough. The visiting health team considered numerous strategies. What would work best in this population? Rapid inhalation? Social contracting? A reward system? The health team considered offering to build the village a community center if every smoker in the village would abstain. Team members were concerned, however, that they were imposing their own value system on another culture. Would this alienate youth from their elders? Would it undermine village authorities? How would it affect village smokers who later relapsed? The team expressed their concerns to the village spokesperson, who relayed them to the village elders.

The spokesperson made an announcement as the team's visit concluded: The entire village had decided to abstain from smoking. The idea had actually been proposed by the village youth. The money saved by not buying cigarettes would be contributed toward a community center. The medical team offered a donation toward the center; the village matched the funds. The elders declared that, soon, smoking would be forbidden by a formal tabu.

Was it too ambitious a plan? How could an entire village quit, when the chance of relapsing is 70 to 80 percent in well-designed community smoking cessation programs? The medical team departed, hoping for the best. Three months later, the village health committee sent the medical team a letter declaring that Nabila was now a nonsmoking village. The village had designed and implemented its own cessation program.

Before the formal tabu commenced, smokers collected all the cigarettes in the village. At a meeting, the villagers who used tobacco chain-smoked until they were nauseated. The remaining cigarettes were ceremonially destroyed. That night, the village commenced a six-hour ceremony in which they drank kava, a powdered root that is mildly relaxant, euphoriant, and hallucinogenic. Drinking kava is a sacred experience that can help create change or enforce a tabu. Most Fijians believe that breaking a tabu can result in bad health or injury.

You Quit, but It Doesn't

6 — 12 hours how soon withdrawal symptoms start after the last use of tobacco
1 — 3 days period in which withdrawal symptoms are the worst
3 — 4 weeks how long withdrawal symptoms usually last
more than 40% smokers whose withdrawal symptoms last longer than 3 to 4 weeks
(Hughes, Higgins, and Bickel, 1994.)

The "evil spirits" of the cigarettes were allowed to enter the kava that remained unused, and the kava was thrown to the ground. The villagers believed that this would help eliminate the desire to smoke. At this point, the tabu commenced.

The village's nonsmoking pledge was posted permanently. Fijian news media carried reports of "the village that quit smoking." Even some 50 Nabilans who smoked but no longer lived at Nabila honored the tabu by quitting smoking. Three-fourths of the young people in a neighboring village also quit smoking, in a gesture of solidarity.

Most of the ex-smoking villagers reported having little trouble quitting. Those who had problems quitting sucked on lollipops or reinforced their commitment through another kava ceremony. Four relapsing smokers did experience negative consequences. One tripped and cut himself, another was attacked by a dog, a third developed testicular swelling, and the fourth became unconscious after smoking during a kava ceremony. They all sought forgiveness and quit smoking.

Nine months after the tabu started, almost no one in the village smoked. About two years after the tabu, smoking rates remained very low. Four elderly persons and a youth visiting from another village were allowed to smoke.

The researchers reporting this account remarked about the medical team's joint trust, understanding, and commitment with the village. Australians Gary Groth-Marnat and Simon Leslie, and Mark Renneker of the University of California at San Francisco, also noted that the repeated visits of the medical team added the expectation of accountability to their relationship with the village. The nature of Fijian society and culture also enhanced the plan's possibility of success. Nabila was a cohesive community where Fijian beliefs in group harmony and respect for authority were beneficial. Additionally, the villagers expected their cessation attempt to be successful, in part because they believed in the power of the kava and the tabu. Also, the negative emotions, interpersonal conflicts, and social pressure often contributing to relapse in Western cultures were minimized in Fijian culture. The Fijians did not hesitate to consider cigarettes as evil and immoral, and thus the "powerful motivator of morality" helped reinforce their commitment to quitting.

The health team proposed several suggestions for health workers in similar situations:

Fijians' communal decision making provided a contrast to Western society's focus on individualism. This is not how most people in Western cultures quit smoking. Attempts to develop a sense of community among quitting smokers in the West have not resulted in dramatic quit rates. However, successful Western community-based treatment programs have involved the community in making decisions and designing the program, have considered cultural issues, and have offered long-term help.

As the story of the Fijian village illustrates, the initial act of quitting smoking is not enough to ensure that a person will remain a nonsmoker. Equally important is the necessity of staying quit over the following months and years.

A brief return to smoking, involving perhaps one or two cigarettes, is termed a lapse. It is common for smokers attempting abstinence to indulge in a lapse episode. Often, however, a lapse leads to a full-blown relapse, in which the individual returns to ongoing smoking or other tobacco use. The nature, prediction, and prevention of relapse constitute an entire realm of study within the larger field of tobacco cessation research. Scientists know, with some imprecision, who is likely to relapse, and what can help prevent it. Researchers also know that it is important to distinguish between lapse and relapse, since they have different impacts on quitting.

At what point does a lapse episode become a relapse? A task force of the National Working Conference on Smoking Relapse deliberated this issue in an attempt to find sufficient unity to allow comparability of research studies, as reported by Sally A. Shumaker and Neil Grunberg. The task force determined that seven consecutive days of smoking at least one puff per day would constitute a relapse. Obviously, this definition does not imply a return to baseline smoking levels, but it does imply a return to regular, repeated smoking.

Consider these accounts of lapse and relapse:

An unmarried man in his twenties quits smoking, with the help of a cessation treatment program. His co-workers, friends, and family are supportive and encouraging. One night, he goes to a bar. Although most others there smoke, he refrains. He reunites with a woman he has known intimately for some time. Late that night, they go to her home, where they spend the night. Early the next morning he wakes up, rolls over in this familiar setting, takes a cigarette out of the woman's cigarette pack on the nightstand, and smokes it. A few minutes later, as the fog clears from his mind, he remembers that he is a nonsmoker.

Or, rather, he remembers that he was a nonsmoker. Now that he has lapsed with this single cigarette, he is no longer sure whether he should consider himself a nonsmoker. At work that morning, he calls the clinician who has guided his stop-smoking group through cessation. He tells her of the cigarette he unthinkingly smoked. She assures him that it is only a lapse episode and does not need to lead to a full-blown relapse. He can continue his smoking cessation from this point.

Another situation: An engaged college-age couple decide to quit smoking together. It becomes a cornerstone of their commitment to each other. They plan their wedding and determine that they will honeymoon in their favorite remote, mountainous area. They decide that they will use their honeymoon as a time to quit smoking, together. They exchange vows and head off with their backpacks, throwing away their cigarettes as they embark on their backwoods honeymoon.

For a week, the hills are alive with the sound of their bickering. For the first time in their relationship, they fight and snip, spewing nicotine-free venom from the depths of their abstinence. It is no surprise that on their return to civilization, they also return to smoking.

And a third story: A psychology graduate student is enlisted to help lead a stop-smoking group. No one at his university knows that he secretly smokes. He learns the skills of helping smokers quit and becomes an effective interventionist. He helps dozens of smokers quit and stay quit; he learns every relapse prevention strategy, every tool of aversive conditioning, every problem-solving routine. He knows how to do it all for others but cannot do it for himself. He uses the nicotine patch and nicotine gum to get through times he cannot smoke openly.

Years pass; he graduates and does postdoctoral work. Finally, he quits using nicotine completely when he becomes a parent. He would never smoke around the baby, he explains.

Every ex-smoker's course through withdrawal and into abstinence follows a unique path. Not only do withdrawal symptoms vary greatly from ex-smoker to ex-smoker, but the risks for relapse are also individual. What tempts one smoker might not tempt another. Each smoker's capacity to cope with temptation, lapse, and relapse depends on a host of somewhat unpredictable factors.

"What worked for me was . . ." So the story starts, whenever we ask a long-time ex-smoker how he or she quit and stayed quit. The methods are so various as to be uncountable and difficult to catalogue. Even if we ask a current smoker who has tried to quit but failed, the wording isn't so different. "What worked the best for me was . . ."

Why Ex-Smokers Relapse

People who haven't "been there" can find it hard to understand why anyone would relapse, once a smoker gives up tobacco and gets past the withdrawal phase. If the abstinence symptoms are history, why is it so hard? The answer can be explained partly by a description of how nicotine works. Nicotine is a reinforcing substance, which means that using it results in sensations and conditions that are perceived as positive by the tobacco user. It can help a smoker regulate his or her mood. It can help curb appetite and can help keep body weight at least a few pounds lower. It can heighten thinking and reasoning skills, although not dramatically. Some people find that nicotine enhances memory, eases anxiety and tension, makes sensory experiences feel more intense, and makes pain easier to bear. Not all nicotine users report all these occurrences.

Since these effects are pleasurable, they are reinforcing. This means that they become psychologically and mentally linked to the act and circumstances of smoking. These linkages of what psychologists call stimulus and response operate on the same principles that led Pavlov's dogs to salivate when they heard sounds associated with being fed. They are the same processes that start your mouth watering when you see a picture of your favorite chocolate. A sequence of behavioral psychologists, including B. F. Skinner and Albert Bandura, have described these phenomena well and expanded on their meaning in our social lives. If anything in psychology has been demonstrated to the point where theory has become doctrine, it is these principles.

When we use tobacco in any setting at all, what we perceive as the positive effects of using the substance reinforces our use of it. Just as we shape a child's behavior with reinforcement ("That's a magnificent mud pie, and thank you for not bringing it in the house") we also shape our own tobacco-using behavior by our very use of tobacco. In a laboratory, a researcher can teach a pigeon to peck in a certain spot on a cage wall by reinforcing the bird's behavior with food as it pecks closer and closer to the designated spot. An animal trainer can teach a cat to dance, can teach an elephant to stand on two legs, or can train a dog to jump through hoops, by using the same principles of reinforcement. We likewise train ourselves to reach certain emotional and mental states through the reinforcing use of tobacco. This results in a different, and perhaps more pernicious, form of dependence than what we would commonly call "addiction" to nicotine. We learn not only to depend on nicotine, but also to look to tobacco for its reinforcing effects.

The effects of reinforcement are multifaceted. When we smoke in a social setting, we are not only continuing our dependence on nicotine and experiencing tobacco and nicotine's many physiological properties, but we also are linking the experience of smoking to the setting. Tobacco use becomes tied to chatting with friends, sharing conversation, flirting, solidifying relationships, or whatever else. We engage in much more than just a physically reinforced action; we also reinforce our smoking or other tobacco use with the effects of the setting in which we use tobacco.

In addition, repeated exposure to nicotine leads to a physical dependence, such that the nicotine-dependent person requires nicotine to avoid experiencing adverse effects. A dependent smoker who does not get the dose of nicotine that the body expects and needs will begin experiencing withdrawal symptoms. The symptoms vary considerably between individuals, but they generally involve some constellation of the following effects:

Not every nicotine-dependent person will get all the symptoms, or will get them all at once. The symptoms may change throughout the course of withdrawal. A nicotine-dependent person using nicotine replacement (e.g., the patch or the gum) to help quit using tobacco may experience symptoms to a lesser degree, but may still experience them somewhat. Some clinicians have reported success with enhanced doses of nicotine replacement, through application of multiple patches or combinations of gum and patch. A smoker in withdrawal will begin to feel the symptoms fading within minutes after he or she uses nicotine. This is evident from subjective self-reports as well as from computerized testing administered to smokers deprived of nicotine.

Not only will the nicotine-deprived smoker undergo withdrawal symptoms during abstinence, but he or she will also notice the absence of nicotine's purportedly enhancing qualities. For instance, the mind may feel dulled because of the effects of withdrawal, but also because of the absence of the nicotine that provided the mild enhancement. In addition, the lack of nicotine may affect how medications and other substances are taken into the body, perhaps resulting in symptoms secondary to withdrawal but noxious nonetheless.

The First Month after Quitting

heart ratedecreases
thyroid function decreases
caloric intake increases
craving for cigarettes increases
difficulty concentrating increases
metabolism of some drugs increases
nocturnal awakening increases
resting metabolic rate increases
sweet/fat food intake increases
taste for sweets increases

The experience of going without nicotine, resulting in withdrawal symptoms and other unpleasantness directly or indirectly caused by the absence of nicotine, can be a powerful precursor of relapse. Withdrawal, however, is over within a few weeks of cessation. Why, then, do many ex-smokers relapse long after that?

An answer to that question lies in the behaviors surrounding tobacco use. The modern cigarette is a particularly effective means for providing rapid reinforcement, which sets it up as a coping response in many situations. Inhaled nicotine, delivered through tobacco smoke, is rapidly absorbed by the body. About the time the cigarette is snuffed out, blood levels of nicotine have peaked. Behavioral scientists have long known that immediate and rapid reinforcement can create a powerful link between situations and behaviors. If the reinforcement were to come hours or even minutes later, the sensations and events would not be tied so tightly to the use of tobacco. Because smoked tobacco is rapidly reinforcing, the reinforcement from nicotine in cigarettes becomes a powerful mechanism, independent of its addictive potential.

Smokers can come to feel dependent on nicotine to help them maintain their normal state of functioning. A tobacco user who has relied on nicotine throughout many times of high stress may come to believe that he cannot manage stressful events without nicotine. Someone who uses nicotine in conjunction with alcohol in social settings may feel inadequate without a cigarette, because he is used to the way nicotine helps him relieve anxiety, or because he is used to the combined interaction effects of nicotine and alcohol.

Such highly reinforced use of tobacco creates a high potential for relapse in people who use it to maintain a normal state. The nicotine delivery system we call a cigarette affords the smoker a range of emotional and mental effects. A smoker quickly learns to vary the rate and intensity of smoking to maximize his or her preferred effects.

Missed Opportunities

70% smokers who see a physician each year in the United States
more than 50% smokers who see a dentist each year in the United States
2 million estimated additional smokers who would quit annually if 100,000 health care providers helped 10% of their patients quit smoking
11% estimated U.S. health insurance carriers that provide coverage for treatment of nicotine dependence

Prior to relapsing, many ex-smokers think that they are in control of their smoking behavior. When they slip, they may feel aspects of self-blame, guilt, self-criticism, depression, and hopelessness. Rather than pushing them back toward abstinence, these feelings actually increase the likelihood that the ex-smoker will relapse. The complex cognitive process involved in this unfortunate twist of direction has been called the abstinence violation effect. According to behavioral scientist George Marlatt, a high-risk situation that may result in relapse includes these three aspects: (1) the expectation of the positive effects from a lapse, (2) the actual reinforcement from the lapse, and (3) the pressure pushing the ex-smoker toward lapsing. In other words, an ex-smoking woman facing a sudden, unexpected stress might think that a cigarette surely would help her cope. Then the cigarette does help her feel as if she's coping. In a situation where smoking would be tolerated or even encouraged, she could find herself lapsing, perhaps lapsing again, and eventually relapsing. She might then feel negative about her inability to keep from smoking. Feeling depressed and discouraged, she might not find it easy to return to abstinence. Instead, she might return to her precessation level of smoking. And if she feels bad about that, another cigarette surely would help her cope.

Looking into the Statistical Ball

There's no magical crystal ball that enables us to see who will quit and stay quit. There are, however, some common traits among those who are successful, as well as among those who fail on a given quit attempt. Also, some life situations, traits, and behaviors seem to predispose people not only to smoking, but also to quitting and to staying quit.

Just how powerful a preventive or therapeutic intervention can be depends on many factors. The degree of dependence on nicotine can influence the success of quitting and the likelihood of relapse. A smoker's tobacco-related health problems can provide motivation to quit, but can also complicate quitting. The smoker's lifestyle has a profound effect on the possibility of quitting successfully. A person with supportive family and friends, nonsmoking home and work environment, low social stressors, and a stable life is likely to find it easier to stay quit than someone who is immersed in financial problems, strained relationships, stressful situations, and a social environment where smoking is tolerated or encouraged.

Who would be the ideal candidate to stop smoking for good? He (the person would be male, according to the statistics) would be a light smoker who hasn't smoked long, who does not have a history of failed quit attempts, who is not particularly overweight, who is willing to comply with treatment instructions, and who is capable of learning and using coping strategies and techniques. Swedish researchers Per Tillgren and colleagues found that the best predictors of success among nearly 13,000 Swedes who quit smoking were lack of quitting attempts during the previous year, participating of one's own volition rather than being recruited by a nonsmoker, and being married or cohabiting. If we consider the inverse of most of these criteria, we are envisioning someone who would be likely to have far more trouble quitting. Heavy smokers, women, overweight smokers concerned about gaining weight after quitting, and people unwilling or unable to employ coping techniques are less likely to succeed.

Men and women experience smoking and quitting differently. Overall, women appear to be less responsive to nicotine replacement as part of smoking cessation. If this finding is supported by further research into cessation for women, it is possible that sex-specific treatment approaches could be developed. It may be that women will benefit less from nicotine replacement, but will have greater success by learning to cope with the nonnicotine reinforcement of smoking, such as the sight, smell, and taste of tobacco. Even so, Ken Perkins emphasized in 1997 that women do experience nicotine withdrawal, which can be relieved to some extent by nicotine replacement. However they may benefit from much more than just replacing nicotine.

For both men and women ex-smokers, the most common triggers to relapse center around negative emotions and abstinence symptoms. Gary Swan and colleagues at SRI International related in 1996 that ex-smokers who reported heightened anger, depressed mood, and craving for cigarettes were more likely to relapse quickly. When other quitting-related factors were taken into consideration, the prominence of craving for cigarettes still significantly predicted a higher rate of relapse among ex-smokers.

A smoker's beliefs as he or she considers quitting can markedly affect the chances of success. A research team from American University in Washington, D.C., interviewed 100 people who had recently quit smoking, asking them why they believed they would or would not be able to stay quit for a year, and what benefits they expected. David A. F. Haaga and his colleagues then coded the responses according to dimensions of belief about success in abstinence, including health factors, the experience of quitting, external factors that could influence staying quit, the role of nicotine addiction, and personal attributes. Subjects' responses regarding the benefits they expected from quitting included reduction in inconvenience, lower expense, reduction of health problems, diminished health risk for themselves or someone else, improved health, and improved feelings of psychological and physical well-being.

The most commonly cited reason for the expectation of continued abstinence was the belief that the ex-smokers' own personal traits would determine their success. About half of the people who gave this response mentioned the concept of willpower or self-discipline. Few of them thought that specific actions or tactics would help prevent relapse. Improved physical health was noted most often as an expected benefit.

Worse Than Hard Drugs?

It seems that many smokers who have difficulty quitting console themselves with the knowledge that the abstinence symptoms experienced when quitting smoking are purportedly worse than those associated with quitting other addictive substances. This sentiment usually is expressed in a phrase such as, "I've heard that addiction to nicotine is the worst addiction you can have, even worse than heroin or alcohol." The unasked question ("Is this true?") can be approached from various angles. Exactly what makes dependence on a substance bad or makes it worse than dependence on another substance is a matter of judgment. Some might give more weight to the immediacy of the physical threat or to the nature of physical or cognitive impairment in determining the severity of an addiction. It is also possible that some judge the relative badness of a substance by the unpleasantness of the symptoms that arise when one is abstinent.

The most direct scientific comparisons between nicotine and other substances of abuse involve analyses of abstinence symptoms. British researchers Robert West and Michael Gossop in 1994 described a shift in emphasis from physical withdrawal syndromes to compulsive use, in efforts to define the concept of addiction. They outlined the basic difficulty scientists encounter in studying abstinence effects, which mirrors the confusion smokers may experience as they attempt to quit. Scientists' prior belief that physical withdrawal was "the defining feature of drug addiction" has matured into viewing addiction more as compulsive use. The features of withdrawal syndromes vary across classes of drugs, as well as across individual experiences.

John Hughes and colleagues of the University of Vermont's Human Behavioral Pharmacology Laboratory concluded in 1994 that nicotine has several commonalities with other substances of abuse, but the similarities and differences are difficult to make sense of because so much about nicotine withdrawal remains untested. They reviewed dozens of pertinent studies and noted these comparisons:

Is the possibility of severe abstinence effects part of what keeps someone using an addictive substance, and part of what leads to relapse in former users? Although these ideas make intuitive sense, the data do not always follow. The link between abstinence effects and relapse remains tenuous, awaiting more solid scientific replication and confirmation.

Studying abstinence effects and the potential for relapse is a venture into complexity. A basic limitation of this area of research is the problem of generalizability. People who volunteer to be part of nicotine cessation research, or who attend clinics for help in quitting, might not be representative of tobacco users as a group. Only a small minority of smokers seek formal help for quitting smoking. Of those smokers, not all will join or stay with a cessation program. Additionally, the process of being studied during cessation may affect the outcome in ways that are hard to predict or assess.

A related problem is the nature of withdrawal itself. The above-cited list contains many symptoms that are difficult to quantify, and that can also be influenced by other life factors. For example, one typical abstinence symptom is irritability. Many things can make us irritable; going through nicotine abstinence may be only part of the reason for increased irritability. Even more complex is the symptom of depression. A smoker who may be using nicotine to help curb the feelings associated with depression may find those symptoms worsening during depression. But is this due solely to the sudden lack of nicotine in the system? If nicotine has merely been helping mask feelings of depression, is nicotine abstinence actually increasing depression, or is it merely unmasking depression? Or is the equation even more complicated than that: Is depression at least in part the result of the social and emotional consequences of giving up a substance of dependence? Only the most cautious and careful research can tease apart such questions.

The best way that scientists work around the thorny issues of assessing withdrawal symptoms is by doing what West and Gossop described, which involves defining "a specific set of criteria for what counts as presence of withdrawal using a specified measure." Additionally, researchers have to "avoid falling into the trap" of overinterpreting their findings beyond the scope of their definition of a withdrawal symptom. Which is to say, if they are studying the emergence of anxiety symptoms in withdrawal, they must be careful not to draw conclusions about other aspects of anxiety beyond those symptoms.

What does this matter to the average smoker who wants to stop? It may not seem to matter much to someone who throws away his or her cigarettes one day and grits through withdrawal by raw force of will, regardless of the unpleasantness of the experience. It may matter greatly, however, to an ex-smoker who recently quit and who now feels irritable, hungry, and depressed, and who wants to know how long these feelings will last. It also matters if science hopes to alleviate or ameliorate withdrawal symptoms, or to develop strategies to help people avoid relapse.

Curiously, the nature of abstinence effects may affect the success of a quit attempt in unpredictable ways. Research indicates that those who are more dependent on nicotine have an increased tendency to relapse. However, sometimes severe abstinence symptoms become a deterrent to use of the substance itself. Also, severe symptoms that occur soon after cessation can heighten resiliency; a smoker who has had an easy time for the first couple of weeks can be blindsided by the sudden worsening of such symptoms as cigarette cravings or hunger that may emerge as abstinence progresses.

In any case, it is clear that the experience of withdrawal differs from individual to individual, and that some people have a higher tolerance for discomfort than others. Also deeply intertwined with the issues of cessation and relapse is the smoker's milieu. As University of Michigan researcher Ovide F. Pomerleau noted in 1992, "Smoking is becoming the habit of the disadvantaged and the less affluent and less educated." This change in the worldwide demographics of smoking has ominous implications for success in eventually quitting. Those with limited knowledge of the health risks of smoking are also those with reduced access to programs, medications, and personnel who could help them quit. A middle-class working woman in the United States who smokes can, if she chooses, go to virtually any drug store, discount department store, or grocery and spend a relatively small portion of her take-home salary for nicotine replacement medication. She can see her physician and obtain a prescription for a stop-smoking pharmaceutical product not yet available over-the-counter, usually with her physician's encouragement and blessing, and sometimes at the expense of her health insurance company. She can sign up for a stop-smoking class through a hospital or a local organization that sponsors stop-smoking groups. She has many options, all of which increase her chances of quitting and staying quit.

A herdsman on the Bolivian altiplano does not have these options. A Fiji islander generally does not. A smoker in any developing country, or in less urban parts of a developed country, does not. Those with poverty-level incomes do not. Even affluent U.S. teenagers who hide their smoking from their parents do not. Science has already found many tools for helping smokers stop smoking, but science cannot circumvent the social, economic, and political barricades that keep these treatments from being widely available. Science can address the issues within its domain, but science has yet to find ways to prevent tobacco use from being widespread among those who have the least access to helpful interventions or to adequate health care.

A Case of Optimism

The British Royal College of Physicians and the U.S. Department of Health and Human Services have both made it clear: Cigarette smoking is their countries' primary self-imposed health risk. In light of this fact, many researchers have pondered why many smokers do not choose to quit. A common response to this question has been that, to some degree, smokers are irrational and have lost control over their behavior. It has even been suggested that smokers have "cognitive deficits," a polite term for a malfunctioning brain.

A more benign response to continued smoking has been to assume that smokers simply aren't aware of the risks. This has led to widespread public health campaigns in some developed countries, with smokers being bombarded with warnings about the dangers of their smoking. Public information blitzes have helped lower smoking rates in the United States since the 1960s, but they have not provided a complete solution to the problem of continued smoking. Millions of smokers who know that tobacco is dangerous continue to smoke.

F. P. McKenna and colleagues of the University of Reading in England put a fresher face on this question with their 1993 report about smokers and optimism. After extensively questioning 120 smokers about health risks and expectations, they determined that smokers have what they termed an optimism bias. In other words, smokers rated their chances of developing tobacco-related health problems lower than did nonsmokers. Strikingly, however, both smokers and nonsmokers were equal in rating the health risks of the average smoker and nonsmoker. Apparently, a smokers' optimism bias applies only to himself or herself.

"There was no evidence of defensive denial in smokers about the likelihood of ill-health occurring to the average smoker," the authors wrote. "However, clear evidence of an optimism bias is present in that smokers clearly consider they personally are less likely to develop smoking-related diseases, compared with the average smoker." The illusion has its limits, however. Smokers did perceive that their health risk was greater than that of the average nonsmoker.

The authors concluded: "[A]lthough for smokers the illusion is present and powerful it is constrained suggesting that illusory optimism operates within specific boundaries." Those boundaries apparently extend to the smokers' friends and family as well. A 1998 study by John Pennington and James Tate of Middle Tennessee State University found that smokers' optimism bias extends to those close to them. Although the unrealistic optimism was substantial, it was confined to smoking-related disease.

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