Despite decades of Surgeon General's warnings and a cornucopia of quit-smoking patches, pills and gums, surprisingly tough hurdles still face smokers trying to quit, researchers report.

"Unfortunately, there are still no magic bullets out there," says David P.L. Sachs of the Stanford University School of Medicine. But there is hope. Last year, the Public Health Service released guidelines that supported a newer view of nicotine addiction as a chronic disease, like asthma or high blood pressure, which varies from individual to individual. Hoping to quit cold turkey through willpower alone isn't a realistic option for most smokers, whose brain chemistry has been altered by years of nicotine use. The federal guidelines endorse four nicotine products and an antidepressant sold as Zyban to help smokers control cravings while they ease off nicotine. Most experts also stress the need for counseling, supportive friends and a stop-smoking plan as necessities for quitting. Some say recent studies suggest that hard-core smokers may need nicotine medications for years to control their craving. "It's only in the last few years that we've been looking in the right direction," says Sachs, a longtime nicotine addiction researcher. He argues that current smoking-cessation treatments — the patch, gum and others — provide nicotine in too low a dose for too short a time to help people trying to overcome an addiction. "My view is that most people need to be treated for a long time" to overcome changes in brain chemistry triggered by a lifetime of tobacco use, he says. Sachs says some of his clinic patients have needed to use nicotine gum and nicotine patches for years in order to remain free of deadly tobacco smoke. Because nicotine is not cancer-causing and is medically safe in small doses, there is no reason not to use it for as long as a patient needs it, Sachs says. He points out that current scientific studies, including his own, have failed to address tobacco dependence as a chronic medical disease. Rather, they have looked at only the first few months of treatment. Smokers were then cut off too soon, he argues. Michael Fiore of the University of Wisconsin, who headed the guideline effort, partly disagrees. He estimates that only 10% of would-be quitters need nicotine medications indefinitely. Still, for those individuals, he calls long-term use of nicotine "a no-brainer" when weighed against the risks of smoking. "Few diseases kill 50% of the people who have it," he says of smoking. "This one does." Prevention, of course, is still a key concern for experts, who continue to look for the best ways to keep young people from ever starting to smoke. "Families matter, and communities do as well" in keeping kids from smoking, says Jennifer Unger of the University of Southern California School of Medicine in Los Angeles. In a study published in a recent issue of the journal Nicotine & Tobacco Research, Unger and colleagues report that kids with minority backgrounds seem less influenced by peer pressure — the focus of many anti-smoking campaigns — than white kids when deciding to smoke. Parental examples and community norms play a bigger role in such decisions among black, multi ethnic and Hispanic teens, Unger says. "That's important, because we can't assume the average American is a white Midwesterner anymore" when designing anti-smoking campaigns, she says. Her study surveyed 5,143 eighth-graders in 68 California schools.

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