Would-Be Quitters Get Help Winning Against Nicotine
The urge will pass. Lucy Hellenbrand silently repeats this mantra to herself each time she watches others smoke and battles the temptation to light up. Hellenbrand, 28, who works for a printer in Middleton, Wis., chucked her 10-year, pack-a-day addiction on February 1 and is determined to be done with cigarettes once and for all. "I have tried to quit several times in the past," Hellenbrand says. "But it only lasted a week or two." This time, with the aid of a medication called Zyban, nicotine-replacement skin patches, and a support group at the University of Wisconsin-Madison, she hopes to make it stick.
For hard-core smokers like Hellenbrand, it takes an arsenal to beat the habit. "Everyone knows how difficult it is," she says. Of the nation's 50 million smokers, at least 20 million try to quit each year, but fewer than 6 percent succeed in the long term. And these days, it's the toughest cases who are trying to abstain. "Work-site restrictions and social disapproval have gotten the easy-to-quit smokers to give it up," says John Hughes, a professor of psychiatry, psychology, and family practice at the University of Vermont who specializes in nicotine research. So have statistics showing, for instance, that smokers risk shortening their lives by an average of 13.4 years. "Now we are left with the ones for whom quitting may be much harder," says Hughes.
But smokers and their doctors are mounting a renewed campaign against nicotine, with effective new weapons and an approach that treats smoking not as a bad habit akin to nail-biting but as a chronic disorder that calls for serious medical treatment. Ex-smokers can blunt the withdrawal effects and cravings by taking Zyban, a prescription antidepressant approved three years ago for smoking cessation. They can attend counseling sessions to boost their resolve. They can use nicotine patches to ease the transition. Or, like Hellenbrand, they can do all three. In studies, these three approaches have increased the chance of success for quitters by 5 percent to 30 percent compared with going cold turkey. And potentially more powerful weapons are already in clinical trials: other antidepressants, and drugs that block nicotine receptors in the brain.
Renaissance drug. Doctors should be using these tools to help their patients give up cigarettes, a surgeon general's report due out this summer will advise. Treating nicotine addiction as a medical problem not only recognizes that many smokers need help to quit but also removes the sense that relapse reflects failure. "This is a significant, chronic condition not unlike high blood pressure [or] diabetes," says Michael Fiore, director of the Center for Tobacco Research and Intervention at the University of Wisconsin Medical School. "And, as with high blood pressure, if doctors and patients stick with it, effective treatments can be found."
Most smokers get hooked in their teens, when health concerns seem remote (box, Page 60). Besides offering a way to rebel, smoking introduces teens to what Hughes calls a "renaissance drug" because its effects range from mood stabilization to improved concentration and weight control. "People use nicotine as a tool," he says. "They become dependent on its ability to deliver the benefits every time they smoke." The drug works through the same pathways in the brain as other chemicals of addiction, increasing levels of dopamine, a brain chemical responsible for feelings of pleasure. It elevates mood and sharpens concentration, which may explain why people with a history of depression, attention deficit disorder, and schizophrenia are far more likely to smoke than other people--and have a much harder time quitting. Genes play a role, too, making some people more likely to become addicted.
The flip side of nicotine's pleasurable effects is the misery experienced by many smokers who try to quit. Long-term exposure to nicotine causes the number of nicotine receptors in the brain to increase. This boosts the body's demand for the drug, according to Jack Henningfield, former head of clinical pharmacology at the National Institute on Drug Abuse. These hungry receptors lead to irritability, depression, and anxiety when the brain is deprived of nicotine. "There is no debate about the fact that if you are smoking and you stop, you may have problems with concentration, mood control, and handling stress," says Henningfield.
Nicotine-replacement products, which provide much smaller doses of the drug in gum, skin patches, nasal sprays, or inhalers, help smokers wean themselves from cigarettes. Jane Cooper, a 66-year-old retired cook from Monona, Wis., smoked a pack a day for 45 years. She tried to stop three times before doctors told her she had emphysema, a lung disease common in smokers. Three years ago, she finally succeeded. "I don't think I would have been able to quit had it not been for the patches," says Cooper. "I wanted a cigarette every minute, but the patches made it much more tolerable." Treatment with patches typically lasts between six and eight weeks, but Cooper says that she still slaps one on when she will be with people who are smoking.
Less pain, less gain. The antidepressant Zyban can also help, by minimizing effects such as bad mood, irritability, and difficulty concentrating. As a bonus, it can forestall the weight gain--typically 5 to 10 pounds--that makes some smokers reluctant to quit. "Zyban really helped me keep down the weight gain," says Lucy Hellenbrand. "And it helped control the mood swings I experienced in the past." Others need even more help. Gary Ferrell, 43, an inventory manager for the Durham County Alcoholic Beverage Control Board in North Carolina, smoked 21/2 packs of cigarettes a day for 26 years. "I felt it was impossible" to quit, after four years of unsuccessfully trying hypnosis, Zyban, patches, and self-help tapes. "One time I made it two months without smoking," he says. "But each time I quit, eventually I would tell myself that I was only going to smoke one cigarette, then I would buy a pack, and pretty soon it was all over." Finally, Ferrell enrolled in a clinical trial of an experimental drug that blocks nicotine receptors in the brain, and he stopped smoking over a year ago.
Mecamylamine, the drug under investigation, is meant to block the rewarding effects of nicotine while the person is still smoking. "The connection in the mind of the smoker between smoking and feeling good is very strong," says Jed Rose of Duke University, who is the study's lead investigator. That link, he says, " is a major contributor to relapse."
So is what Leslie Schuh, a professor of psychiatry and behavioral neurosciences at Wayne State University School of Medicine in Detroit, calls a sense of mourning in smokers who quit. "People become very attached to their cigarettes because they provide a sense of security, relief from boredom, and help people relax," she says. "Often people need help finding something to fill the void." Many take up hobbies such as knitting or gardening. Counseling can also help quitters through the rough patches. Willpower often breaks down at parties where people are drinking alcohol or after stressful encounters, says Saul Shiffman, professor of psychology at the University of Pittsburgh. Step out of the room for a 10-minute break if necessary, he suggests. Some doctors recommend avoiding alcohol for the first few weeks because it can weaken resolve and because many smokers reflexively light up whenever they drink. And if you relapse, don't give up, says Fiore. "Think about what helped and what hurt and use that information the next time you try."
Smokeless tobacco. Even with all the new tools, it may turn out that not everyone can break the addiction. "I don't think I will ever get past nicotine," says Faye Moody, a 48-year-old clinic coordinator for the dental-hygiene program at Ferris State University in Big Rapids, Mich. Moody says she tried to quit "about 15 times" from 1981 to 1994, using patches, hypnosis, motivational tapes, and classes. Finally, she gave up and turned to smokeless tobacco. "I went from smoking to chew, and I didn't feel deprived," she says.
"Nicotine maintenance," as proponent Brad Rodu calls it, may be a safer alternative to smoking for people like Moody. "Nicotine is addictive, but it isn't the agent that causes disease," says Rodu, professor of pathology at the University of Alabama-Birmingham School of Medicine. Hughes agrees, provided quitters use patches or gums and not smokeless tobacco, which has risks of its own, including cancer of the mouth. "People who chew nicotine gum for long periods of time have no more heart attacks or ulcers than those who don't," Hughes says.
Ultimately, quitting still takes determination. Hellenbrand recalls a recent night out. "I had a couple of drinks, and the friends I was with were smoking," she says. "I was really hankering for a cigarette." Instead, she chewed straws. Lots of them. "You should have seen the mess on the table," she says, laughing. After surviving that bout in the lion's den, Hellenbrand proudly says, she knows she is free.
WHERE TO FIND IT Support. www.quitsmokingsupport.com offers chat rooms, bulletin boards, and information on how to quit. Clinical trials. Go to www.centerwatch.com; click first on "Listing of Clinical Trials" and then on "Cardiology/Vascular Diseases." Trials of experimental drugs and strategies for smoking cessation are listed by state. Clinics. The American Cancer Society sponsors smoking-cessation clinics called FreshStart around the country. Call (800) 227-2345.
This story appears in the May 29, 2000 print edition of U.S. News & World Report.