No magic in kicking the habit
The addiction gripped Allison Blakebrough in ways that surprised her. A smoker since she was 13, the Durham 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 multitherapy 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. Just this past week, Duke University researchers 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 -- smoking cessation requires a wholesale change that the smoker must embrace.
Still, a smoker cannot simply pop a pill and quit -- and therein lies the trouble for people like Blakebrough.
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 nonsmokers," says Eleanor Blackwell, area director with the American Lung Association in Raleigh. "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, 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 the researchers learned this lesson from tests of the nicotine patch that Duke scientist Jed Rose developed. 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.
The Duke researchers are working on several fronts. They have developed a nicotine patch that includes a drug to block nicotine's effects on the brain. It's in a final phase of testing, and results show it helps people quit in up to 45 percent of cases.
And in a lab housed in a First Union office tower, they are studying smokers such as Faith Hinkley, a Duke law student, who has agreed to test a de-nicotinized cigarette. Technicians hook Hinkley's cigarette -- either one of her Winston Ultra Lights or the test brand, she doesn't know which -- to a special mouthpiece. It's connected to a computer that gauges how deeply and often she puffs.
The data will help researchers know if the de-nicotinized cigarette is something smokers would find appealing as an alternative.
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, however, are afoot. Over the past two years, N.C. 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. Where an alcoholic can get to a 12-step program at all hours of the day, anywhere around town, smoking cessation classes are few and far between.
"I was surprised that there weren't more resources out there for people to quit," said Blakebrough, the Durham woman who recently quit. "It took a long time for me to find the American Lung Association class."
At the American Lung Association in Raleigh, Blakebrough has been attending small group sessions led by Blackwell, and has recently weaned herself off the patch. But even at the lung association, such classes are offered only periodically, when enough people have expressed interest. Blackwell said the program is heavy on group activities, so it works best with about eight participants.
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.
"We are down to the people who have tried before and have gone back, or people who have never been able to have a successful attempt," Blackwell said.
Such 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 nonsmoker 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. He teaches second-year medical students how to make initial assessments of a patient's smoking status, but learning how to counsel a patient through an attempt to quit takes special expertise.
Simply writing a prescription for Zyban or a nicotine replacement therapy is not enough, and too often, that's all that is done.
"No drug stands alone, no program stands alone," says Jeanie Mascarella, a pulmonary nurse clinician at UNC Hospitals whose smoking cessation classes boast a 65 percent success rate. "Most people say they had a quit attempt, but all they did was start on some therapy, and it didn't work, so they don't want to go on that therapy again. I think a lot of improper pharmacotherapy is prescribed without assessing need, or willingness to use it, or ability to afford it, and without support."
Unless or until the Duke researchers develop a magic bullet, such pharmacological aides 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.
"People smoke for different reasons, so people have to quit in different ways," said Dr. Elizabeth Campbell, a Raleigh oncologist who has a special interest in counseling patients to quit smoking. Her patients are fighting cancer, and they tend to want to quit for health reasons.
Lori Henderson wasn't sick, but she was feeling bad. She had started smoking, like millions of others, as a teenager. She thought it was cool. But by the time she was married and had children, it was decidedly uncool. So she smoked in secret, slipping outside to light up and then dashing the evidence in a soda can she kept hidden off her deck.
"It began to bother me more and more," Henderson says, "and I would devise ways to get out of the house and run errands so I could smoke. It started affecting my moods. I was edgy if I couldn't run outside and sneak a cigarette."
Finally, for Henderson, the sneaking and lying became oppressive: "I felt like I was cheating on my husband with cigarettes."
She attended a class, followed all the tips and gimmicks, and quit. That was 15 months ago.
"This is it," she said. "I really have no desire to smoke again. It's not an option."
Having that resolve has made all the difference for Henderson, who had failed earlier attempts. She had tried cold turkey without any outside help, done the patch, signed on to have pressure points on her ears activated, and paid for an aversion therapy session where she was made to smoke a bunch of cigarettes until she became nauseated.
Such treatments and self-help approaches keep success rates down, so even though 1 million Americans quit smoking each year, about 75 percent to 80 percent of them start back up after six months. In the end, only 6 percent of smokers manage to stay smoke-free for a year.
Certain tactics are simply not effective. Acupuncture and hypnosis offer little more than short-term resolve, studies have shown. Having people cut back instead of quit often backfires, because they tend to inhale deeper and longer on the few they allow themselves and actually end up increasing their nicotine hit.
And scaring people about health risks also doesn't work. If it did, the 15 percent of women who continue to smoke during their pregnancies would be scared into quitting, because smoking causes premature births, low birth weights and has other harmful affects on developing babies.
Lashonda Montague, eight months pregnant with her third baby, wishes every day she could quit, but the addiction is so powerful it trumps even her best intentions.
"Every week I try to quit," she says. "I wake up Sunday and say, 'I'm not going to smoke today.' And then I'll have one, and promise myself that will be it all day. And then I'll have another. I get mad at myself, but it's hard."
She has been able to cut back to eight to 10 cigarettes a day, but is tempted by her husband and her grandmother, who both smoke.
"Everyone around me smokes," she says, "so it makes it hard."
For Montague, the ultimate solution to end her smoking addiction may be developed in a scientific lab, or it may result from the counseling she has been receiving through the county health department, or it may come from her own resolve.
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 with the Sheps Center at UNC-CH and one of the authors of last year's smoking cessation guidelines. "People in the field know what works. There's been a ton of research on this, and there are effective ways of helping people quit. We don't have to throw our hands up and say nothing works."