Smoking cessation experts prescribe a double-barreled approach
By Stephen Smith
The Boston Globe (Boston.com)
September 28, 2009
So you've tried, and tried, and tried, AND TRIED to quit
Though roughly 70 percent of smokers want to stop, they’re likely to fail unless they combine counseling and medication
Even now, 11 months, three weeks, and four days since smoking her last, she hears the siren song of the cigarette beckoning “I still have the craving, it’s true,’’ said Monica Collins, the syndicated newspaper columnist who was so fully under the spell of cigarettes that, by her own reckoning, it took eight attempts before she finally stopped puffing. “There are times I know I’m going to be doing a lot of errands and in my car and going here and there, and I say, ‘Oh, God. I would love to have a cigarette.’ ’’
But she doesn’t. Somehow, this time - maybe it was the nicotine-replacement patch, maybe the counseling - Collins resisted the call of the cigarette. But there is no denying: The stranglehold nicotine places on smokers can sometimes prove insurmountable.
Ask Jerry Remy, the Red Sox TV analyst who acknowledged last month that, despite enduring lung cancer, he still falls prey to the occasional impulse to smoke.
Ask Barack Obama, who signed a landmark law regulating tobacco in June and, a day later, conceded in a presidential press conference that he has episodically “fallen off the wagon.’’
And then there was Patrick Swayze, stricken with pancreatic cancer and captured in haunting photos with a lit cigarette perched on his lips.
The failure to quit, research has shown, has nothing to do with weakness of will. Nicotine, the primary addictive agent in tobacco, steals into the brain, setting on fire circuitry that regulates our sense of pleasure. At the same time, cigarettes acquire a sort of social permanence in smokers’ lives - a way to start the day, to end a meal, to celebrate good times, to muddle through bad times.
So specialists who treat smokers now emphasize a double-barreled approach that combines counseling and medication, including patches, gum, and other nicotine substitutes along with drugs designed to thwart nicotine’s addictive effects. There’s even a nicotine vaccine being tested that would prevent the substance from reaching the brain.
Still, it’s estimated that while roughly 70 percent of smokers want to quit, fewer than 10 percent succeed each year. Remy, reached last week, said he preferred not to discuss the issue further. In a May blog posting, he exhorted youngsters not to smoke, “and if you do smoke, try to quit! I don’t say that lightly because I know how difficult it can be.’’
Studies have shown that few smokers are able to stop for longer than a few days on their first attempt, and that many must lapse serially before succeeding - if ever.
“When I started working with smokers, I did not understand the process. I was never a smoker myself,’’ said Taru Kinnunen, director for tobacco dependence treatment and research at the Harvard School of Dental Medicine. “When we gave them counseling and we gave them nicotine gum, I thought they would quit smoking. It was a humbling experience.
“They’re all motivated, they all want to quit smoking, but the majority will return to smoking. I didn’t understand what was so difficult about it.’’
Now, she does.
Smoking is a uniquely efficient manner of delivering an addictive substance to the brain. “That’s why crack cocaine is so much more addictive than regular cocaine,’’ said Dr. Nancy Rigotti, chief of Massachusetts General Hospital’s tobacco treatment center. “Cigarettes are kind of like the crack cocaine of nicotine.’’
Inhaled nicotine from a cigarette arrives in the brain in 10 seconds. There, it attaches to an especially pivotal region of neurons, those cobweb-like structures that govern our physical and mental actions.
Nicotine, said Dr. Jonathan Winickoff, a tobacco control researcher at Mass. General, “stimulates the same area that get stimulated when you have a wonderful gourmet meal or when you have sexual intercourse. It lights up that part of the brain, which is the rewards center. It drives human behavior. It’s powerful stuff.’’
And that makes starting smoking particularly dangerous for adolescents. Their brains are still maturing, and their ability to make good choices isn’t nearly so refined as it will be in just a few years. So if they start smoking, it can send them irreversibly down the path toward a lifetime of tobacco use.
That’s why specialists have identified adolescence as a key moment to intervene. Another, Winickoff and other doctors said, is when young parents are having children. Half of women who are smokers quit during pregnancy but, further demonstrating the potent pull of cigarettes, two-thirds who stopped resume after giving birth.
Mass. General Hospital for Children has conducted a pilot study of an intervention aimed at young parents, and, to the surprise of researchers, fathers were more likely than mothers to participate in a telephone smoking-cessation service. Winickoff hypothesized that the men, feeling left out from the swirl of activity accompanying a birth, may see their efforts to stop smoking as contributing to the baby’s well-being.
There are plenty of tools to help smokers stub out their habit - but many go unused, even by people desperate to quit. Two 2005 studies concluded, for example, that only one in five smokers who try to stop smoking use nicotine substitutes or other medicines.
“The data are very clear that you can double your chances if you use a medication if it’s appropriate for you, and you can triple your chances if you use a medication and counseling,’’ said Thomas Glynn, director of cancer science and trends at the American Cancer Society.
The medicine cabinet now includes seven first-line treatments, anchored by five forms of nicotine replacement. Regardless of the delivery system, the goal is to stave off the withdrawal symptoms and cravings that bedevil so many people who want to quit.
A drug called bupropion, marketed as Wellbutrin and Zyban, was originally developed to quiet depression. Its ability to dampen the need for nicotine was discovered accidentally, when researchers observed that hospitalized psychiatric patients - a group known for high tobacco use - smoked less when taking the drug.
Doctors don’t know precisely why the medication works but suspect it has something to do with its stimulation of dopamine, a brain chemical involved in the reward pathway.
Another drug, varenicline, works by both tricking nicotine receptors into thinking a shot of nicotine has arrived and also capping those receptors so that the real thing can’t get there. In a study released earlier this year, smokers with heart disease were given the medication, marketed as Chantix, and received counseling. After a year, 19 percent who got the drug had ceased smoking, compared with 7 percent in the study who received a dummy pill.
Still, that means most patients had failed to quit. The drugs, which are covered under many private and governmental health plans, are meant to be taken for a few months at a time.
“It takes smokers seven to 11 quit attempts to quit for good,’’ said Lois Keithly, director of the Massachusetts Tobacco Control Program. “We need to get the message out that if you make a quit attempt and you relapse, you don’t give up.’’
Monica Collins didn’t. She started smoking at 16, while at summer camp in the Catskills. The habit persisted through her tours of various newsrooms, including the Boston Herald.
Her first major attempt to quit was in 2000, when she went to group counseling at Mass. General. “I’d go there and I’d talk. And I’d leave immediately and have a cigarette.’’ She tried again and again to stop smoking for good. Finally, last year, she decided, “This is ridiculous.’’ She again sought counseling and wore the most potent nicotine patch available.
Her last drag on a cigarette, she said, was last October.
“No one can tell you to quit smoking. No one can make you feel like a social miscreant to make you quit smoking,’’ said Collins, who lives in Belmont. “You have to summon it up from inside. You really, really do.’’
By Stephen Smith
The Boston Globe (Boston.com)
September 28, 2009
So you've tried, and tried, and tried, AND TRIED to quit
Though roughly 70 percent of smokers want to stop, they’re likely to fail unless they combine counseling and medication
Even now, 11 months, three weeks, and four days since smoking her last, she hears the siren song of the cigarette beckoning “I still have the craving, it’s true,’’ said Monica Collins, the syndicated newspaper columnist who was so fully under the spell of cigarettes that, by her own reckoning, it took eight attempts before she finally stopped puffing. “There are times I know I’m going to be doing a lot of errands and in my car and going here and there, and I say, ‘Oh, God. I would love to have a cigarette.’ ’’
But she doesn’t. Somehow, this time - maybe it was the nicotine-replacement patch, maybe the counseling - Collins resisted the call of the cigarette. But there is no denying: The stranglehold nicotine places on smokers can sometimes prove insurmountable.
Ask Jerry Remy, the Red Sox TV analyst who acknowledged last month that, despite enduring lung cancer, he still falls prey to the occasional impulse to smoke.
Ask Barack Obama, who signed a landmark law regulating tobacco in June and, a day later, conceded in a presidential press conference that he has episodically “fallen off the wagon.’’
And then there was Patrick Swayze, stricken with pancreatic cancer and captured in haunting photos with a lit cigarette perched on his lips.
The failure to quit, research has shown, has nothing to do with weakness of will. Nicotine, the primary addictive agent in tobacco, steals into the brain, setting on fire circuitry that regulates our sense of pleasure. At the same time, cigarettes acquire a sort of social permanence in smokers’ lives - a way to start the day, to end a meal, to celebrate good times, to muddle through bad times.
So specialists who treat smokers now emphasize a double-barreled approach that combines counseling and medication, including patches, gum, and other nicotine substitutes along with drugs designed to thwart nicotine’s addictive effects. There’s even a nicotine vaccine being tested that would prevent the substance from reaching the brain.
Still, it’s estimated that while roughly 70 percent of smokers want to quit, fewer than 10 percent succeed each year. Remy, reached last week, said he preferred not to discuss the issue further. In a May blog posting, he exhorted youngsters not to smoke, “and if you do smoke, try to quit! I don’t say that lightly because I know how difficult it can be.’’
Studies have shown that few smokers are able to stop for longer than a few days on their first attempt, and that many must lapse serially before succeeding - if ever.
“When I started working with smokers, I did not understand the process. I was never a smoker myself,’’ said Taru Kinnunen, director for tobacco dependence treatment and research at the Harvard School of Dental Medicine. “When we gave them counseling and we gave them nicotine gum, I thought they would quit smoking. It was a humbling experience.
“They’re all motivated, they all want to quit smoking, but the majority will return to smoking. I didn’t understand what was so difficult about it.’’
Now, she does.
Smoking is a uniquely efficient manner of delivering an addictive substance to the brain. “That’s why crack cocaine is so much more addictive than regular cocaine,’’ said Dr. Nancy Rigotti, chief of Massachusetts General Hospital’s tobacco treatment center. “Cigarettes are kind of like the crack cocaine of nicotine.’’
Inhaled nicotine from a cigarette arrives in the brain in 10 seconds. There, it attaches to an especially pivotal region of neurons, those cobweb-like structures that govern our physical and mental actions.
Nicotine, said Dr. Jonathan Winickoff, a tobacco control researcher at Mass. General, “stimulates the same area that get stimulated when you have a wonderful gourmet meal or when you have sexual intercourse. It lights up that part of the brain, which is the rewards center. It drives human behavior. It’s powerful stuff.’’
And that makes starting smoking particularly dangerous for adolescents. Their brains are still maturing, and their ability to make good choices isn’t nearly so refined as it will be in just a few years. So if they start smoking, it can send them irreversibly down the path toward a lifetime of tobacco use.
That’s why specialists have identified adolescence as a key moment to intervene. Another, Winickoff and other doctors said, is when young parents are having children. Half of women who are smokers quit during pregnancy but, further demonstrating the potent pull of cigarettes, two-thirds who stopped resume after giving birth.
Mass. General Hospital for Children has conducted a pilot study of an intervention aimed at young parents, and, to the surprise of researchers, fathers were more likely than mothers to participate in a telephone smoking-cessation service. Winickoff hypothesized that the men, feeling left out from the swirl of activity accompanying a birth, may see their efforts to stop smoking as contributing to the baby’s well-being.
There are plenty of tools to help smokers stub out their habit - but many go unused, even by people desperate to quit. Two 2005 studies concluded, for example, that only one in five smokers who try to stop smoking use nicotine substitutes or other medicines.
“The data are very clear that you can double your chances if you use a medication if it’s appropriate for you, and you can triple your chances if you use a medication and counseling,’’ said Thomas Glynn, director of cancer science and trends at the American Cancer Society.
The medicine cabinet now includes seven first-line treatments, anchored by five forms of nicotine replacement. Regardless of the delivery system, the goal is to stave off the withdrawal symptoms and cravings that bedevil so many people who want to quit.
A drug called bupropion, marketed as Wellbutrin and Zyban, was originally developed to quiet depression. Its ability to dampen the need for nicotine was discovered accidentally, when researchers observed that hospitalized psychiatric patients - a group known for high tobacco use - smoked less when taking the drug.
Doctors don’t know precisely why the medication works but suspect it has something to do with its stimulation of dopamine, a brain chemical involved in the reward pathway.
Another drug, varenicline, works by both tricking nicotine receptors into thinking a shot of nicotine has arrived and also capping those receptors so that the real thing can’t get there. In a study released earlier this year, smokers with heart disease were given the medication, marketed as Chantix, and received counseling. After a year, 19 percent who got the drug had ceased smoking, compared with 7 percent in the study who received a dummy pill.
Still, that means most patients had failed to quit. The drugs, which are covered under many private and governmental health plans, are meant to be taken for a few months at a time.
“It takes smokers seven to 11 quit attempts to quit for good,’’ said Lois Keithly, director of the Massachusetts Tobacco Control Program. “We need to get the message out that if you make a quit attempt and you relapse, you don’t give up.’’
Monica Collins didn’t. She started smoking at 16, while at summer camp in the Catskills. The habit persisted through her tours of various newsrooms, including the Boston Herald.
Her first major attempt to quit was in 2000, when she went to group counseling at Mass. General. “I’d go there and I’d talk. And I’d leave immediately and have a cigarette.’’ She tried again and again to stop smoking for good. Finally, last year, she decided, “This is ridiculous.’’ She again sought counseling and wore the most potent nicotine patch available.
Her last drag on a cigarette, she said, was last October.
“No one can tell you to quit smoking. No one can make you feel like a social miscreant to make you quit smoking,’’ said Collins, who lives in Belmont. “You have to summon it up from inside. You really, really do.’’
