Misconceptions can hamper smoking treatment efforts

Viewing nicotine addiction as a chronic disease and treating it as such could yield good results.

By Susan J. Landers — Posted July 17, 2006

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Smokers, and even their physicians, harbor many misperceptions about effective treatments that could help them kick their habits if only they would use them. But rather than turning to nicotine replacement therapies, telephone quit lines or counseling, most smokers try to go it alone -- and fail.

Some erroneously believe that the nicotine contained in a patch, lozenge or gum causes cancer, so why trade one cancer-causing agent for another? Others think -- incorrectly -- that the nicotine replacement products themselves are addictive and balk at switching to a new habit. Then there are those who think the function of a quit line is to harangue them into stopping. Not true.

"Smokers tend to start out thinking that the treatment is worse than the disease," said Jack Henningfield, PhD, professor of behavioral biology at Johns Hopkins Medical School in Baltimore. Thus, the treatments sit on the shelf and the phone lines are idle, several experts said.

A panel of physicians and behavioral scientists recently convened at a National Institutes of Health state-of-the-science meeting on smoking prevention and cessation. Their June 14 report concluded that successful cessation rates could double or triple if effective treatments were utilized.

Tobacco use remains the nation's leading preventable cause of premature death. Each year more than 440,000 Americans die from disease caused by tobacco use, according to the Centers for Disease Control and Prevention. Of the estimated 44.5 million adult smokers and 3.75 million high school student smokers in the United States, 70% say they would like to quit, and 40% try each year, but the quit rate remains very low.

Arming smokers for the battle to quit

"Quitting is a struggle, but researchers have learned a lot about what works to help people," said panel chair David F. Ransohoff, MD, professor of medicine at the University of North Carolina at Chapel Hill. "We need to make sure that effective interventions reach the people who need them."

The idea that nicotine replacement products are dangerous is one obstacle that blocks the path to success. John Hughes, MD, professor of psychiatry at the University of Vermont College of Medicine in Burlington, can see where that comes from. "If you open up the package of medications, you see all these warnings. But you open up a package of cigarettes and there is only one little warning."

Plus, smokers who do quit often say it was the hardest thing they've ever done but also the most rewarding. Many wanna-be ex-smokers believe quitting is a test of character and decide to go cold turkey. "What physicians have to do is convince them that living longer is more important than their pride," Dr. Hughes said.

Still, the average smoker thinks that quitting takes a single burst of energy and then it's over, said Nancy Rigotti, MD, associate professor of medicine at Harvard Medical School and director of the Tobacco Research and Treatment Center at Massachusetts General Hospital.

But it takes much more. The nicotine in tobacco products causes long-lasting addiction that produces changes in the structure and function of the brain, Dr. Rigotti said. "So a person has to break the addiction."

The longstanding habits of smoking also must be changed so that a behavioral component comes into play, she added.

By delivering a slow, constant supply of nicotine, the replacement products are designed to break the cycle of addiction. Instead of getting hits of nicotine when inhaling smoke from a cigarette, a gradual and more continuous level allows smokers to avoid some of the pain of withdrawal while gradually weaning their brains from nicotine, she said.

More and more people are coming to the realization that nicotine addiction is a chronic disease similar to asthma, diabetes or hypertension and should be treated as such, said Dr. Henningfield. "Physicians understand that you spend a few minutes with a patient who has a chronic disease, you do your best to try to figure it all out, and if one treatment doesn't work, then you try another."

The same should be true of nicotine addiction. If one treatment does not work, try another and another and another. "Stick with your patient and follow them up," he said.

Physicians also should be aware that they don't have to undertake long-term counseling. "Tell a patient to call the 800 number that comes with the treatment. It increases the odds of success in the same way that teaching someone to properly use an asthma inhaler improves their control of their disease."

Addiction also can begin early in a smoker's life, said Alexander Prokhorov, MD, PhD, professor of behavioral science at MD Anderson Cancer Center at the University of Texas in Houston. In a recent survey, he and his colleagues were surprised to find that 20% of high-school students had nicotine dependence levels similar to middle-age smokers. "It's not a trivial thing."

Younger people, who have no signs of smoking-related diseases, might feel somewhat invincible, noted Dr. Prokhorov. They can be disabused of that notion by a process of determining the chronological age of their lungs using spirometry. "Sometimes we see a fairly high lung age, and that makes people very uncomfortable to think that their lungs may be five or 10 years older than they are," he said. "It makes them listen more carefully to what we have to say."

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New guidelines

What: Experts on smoking cessation are being given an opportunity to provide input for an update of the Public Health Services' Clinical Practice Guidelines: Treating Tobacco Use and Dependence.

When: E-mailed suggestions will be considered from now until mid-August.

Why: The latest version of the guidelines was published in 2000. More recent research has uncovered new strategies and treatments. As many as 10 topics will be chosen for updating.

How: Suggestions with accompanying research citations should be e-mailed to the Center for Tobacco Research and Intervention (link).

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AMA seeking a smoke-free America

In an effort to promote broad smoking cessation efforts, the AMA passed new policy actively supporting national, state and local smoking bans in all public places as well as the workplace. The policy, which was adopted at the June House of Delegates meeting, also promotes smoking cessation programs to accompany the bans.

"The dangers of secondhand smoke are evident," said AMA Trustee J. James Rohack, MD. "The AMA is very excited to eliminate Americans' exposure to secondhand smoke, as well as assist smokers in quitting."

Restrictions on smoking do work, said Jack Henningfield, PhD, professor of behavioral biology at Johns Hopkins Medical School in Baltimore. They provide motivation and they give smokers more places where they are free of the stimuli that could trigger their desire to smoke.

Meanwhile, a recent surgeon general's report, "The Health Consequences of Involuntary Exposure to Tobacco Smoke," found that even brief exposure to secondhand smoke can cause harm.

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External links

National Institutes of Health State-of-the-Science statement on Tobacco Use: Prevention, Cessation and Control, June 14 (link)

Public Health Service guidelines on treating tobacco use and dependence (link)

University of Wisconsin's Center for Tobacco Research and Intervention (link)

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