Nixing Nicotine

The latest updates in current solutions for smoking cessation.

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Quitting is the most important step a smoker can take to achieve a healthier lifestyle. Information and resources on smoking cessation seem to surround us in the form of billboards on highways, posters in doctors' offices and public service announcements on television. But all of this information can be overwhelming to someone attempting to quit, whether it's the first or the fourth try.

According to figures reported by the CDC in 2011, 43.8 million Americans, or 19% of the population, are smokers. Cigarette smoking, the leading cause of preventable death in the U.S., is responsible for one of every five deaths each year.

"At the American Lung Association, our stop-smoking programs address the three cornerstones of smoking addiction: the biological, psychological and social factors," said Bill Blatt, MPH, the ALA's director of tobacco programs. "It takes most tobacco users multiple attempts to quit, which is completely normal and expected."

The physical addiction to nicotine is the biological component of smoking; using cigarettes to relieve stress or during a break at work is the psychological element; and finally, the habit of lighting up a bar or while having a cup of coffee with friends represents the social aspect.

The Battle Against Tobacco

According to Scott McIntosh, PhD, many people think of smoking as simply a bad habit when in reality, it's both a habit and an addiction. "If smoking was only a habit, then public education and anti-tobacco messages alone would have been much more successful over the past 50 years," he explained.

As the associate director of the smoking research program at the University of Rochester Medical Center, and director of the Greater Rochester Area Tobacco Cessation Center, McIntosh conducts smoking cessation research with various populations, facilitates changes in healthcare systems to support smoking cessation for patients, and contributes to the training of physicians and other medical professionals in guideline-based nicotine dependence interventions.

Because smoking is one of the most powerful addictions, with a chemical dependency rate of about 20% of all adults in the U.S., clear messaging is important to convey the dangers of smoking, according to the experts.

The ALA focuses on disseminating health education content to prevent teens from smoking in the first place. "We try to make sure that services and education are available when individuals need them," Blatt said.

McIntosh believes that cutting back on the number of cigarettes smoked is a hard goal for tobacco-dependent people to maintain over the long term. Additionally, even light smoking causes cancer and harms others with second-hand smoke. Complete cessation, therefore, is the best solution.

To reduce the disease and death caused by tobacco addiction as well second-hand smoke, it's crucial that people have access to scientifically supported treatment strategies, McIntosh told ADVANCE.

Recommended Methods for Quitting

The technique employed to quit smoking is typically a combination of several methods and varies by individual. "We rely on the tried and true methods," Blatt explained. "For instance, we recommend behavioral smoking programs used in combination with medications such as nicotine replacement therapy."

Experts with the ALA recommend using one of the seven FDA approved smoking cessation products. These include five nicotine products - patches, gum, nasal spray, inhaler and lozenges - and the medications Chantix and Zyban. Nicotine patches, gum and lozenges are available without a prescription.

"We leave it up to the healthcare provider to decide what medication will work best for each individual," Blatt said. "There is no one universal approach for quitting smoking."

Nicotine replacement therapy (NRT) reduces withdrawal by giving the user some nicotine, but not any of the other dangerous chemicals found in cigarettes. "Nicotine replacement therapies help lessen withdrawal symptoms," said Blatt.

There are financial barriers that need to be considered, according to Blatt. "The upfront cost of nicotine patches, for example, could easily be $45 for a two-week supply," he said. "But in the long run, smokers will save money when their health improves and by not buying cigarettes."

Blatt also cautions that NRT does not work alone. "The smoker will need to learn how to deal with stress in a healthy way or with trigger scenarios such as smoking at a social event or when driving," he explained.

Face-to-face clinical interventions and behavioral counseling strategies are the most individually effective methods available, stated McIntosh. "From a public health perspective, these programs should be funded, promoted and available, but we know that face-to-face treatment is either not an option or is not pursued by most smokers," he said.

McIntosh believes that physicians should be trained and motivated to "Ask and Act" with all patients who smoke. "Physicians need to advise smokers to quit for their health, and provide prescriptions and/or behavioral strategies," McIntosh said. "If this was followed up with every visit, smoking would go down significantly in their patient populations."

In addition to suggesting one of the front-line medications available, physicians should make referrals to the nationwide free quit line and evidence-based websites.

Along with the three local Federally Qualified Health Centers, McIntosh's organization is working on a statewide initiative in New York to address the prevailing disparities in smoking prevalence where individuals with lower incomes have higher smoking rates. By establishing systemwide tobacco control policies, including procedures to address smoking with every patient at every visit and default referral to evidence-based treatment, this initiative directly targets underserved populations.

"With the advent of the Affordable Care Act, healthcare systems can expect to see dramatically improved access to care for underserved populations," McIntosh said.

Education First

You'd have to be living under a rock to be unaware of some of the harmful effects of smoking. But the extent of how bad smoking is may not have been properly conveyed. That is where education comes in, McIntosh said.

According to McIntosh, many people may be unaware of important details that could affect their motivation to treat their dependence, such as: all the different kinds of cancer caused by smoking; the number of years added to life expectancy even if quitting smoking after years of dependency; the dangers of e-Cigarettes despite false claims of safety by the tobacco industry; or where to go for free evidence-based cessation treatment.

"The scary TV commercials with people dying from smoking are effective," McIntosh said. "From an educational point of view, they demonstrate ways smoking can harm you that are backed by decades of research and statistics."

Every time one of those commercials airs, McIntosh relayed, there is a statistically significant and substantial spike in calls to the national quit line, 1-800-Quit-Now. "Although the commercials may be extremely negative for people who are not ready to quit smoking and for non-smokers, they are immensely effective in educating the public and in referring smokers who are ready to quit to an evidence-based treatment," he said.

No Shame in Quitting

The ALA stop-smoking campaigns, including its most recent the "Quitter in You," are designed to support the smoker's attempt to quit. The experts at ALA are angling to take the shame out of quitting.

"Our newest campaign says, 'we support the quitter in you,'" Blatt explained. "Most people try several times to quit before it works and they get frustrated. We want people to know that it's OK to try several times, the ALA is here to support you and we don't judge you."

Blatt believes that attempts to quit smoking will prove futile if the individual is not ready. But it's not all for naught. In fact, Blatt believes that each time a smoker quits and is unsuccessful, it brings him closer to quitting successfully.

"We sometimes call the first few attempts 'practice quits,'" Blatt said. "If the person has tried to quit before, we ask how many times? How long did you quit for? What helped you during that time? What tripped you up at the end? What would you do differently next time? There are so many lessons to be learned."

What's Next in Smoking Cessation

Web-Assisted Tobacco Interventions (WATI) is an ongoing series of international workshops funded by the National Cancer Institute, Health Canada and the American Legacy Foundation to bring together researchers, interventionists and decision-makers to discuss and disseminate the best practices of using technology to help people quit smoking for good.

WATI is an expanding area for cessation opportunities, given the rapid advances in Internet and phone-based apps and programs, observed McIntosh, a founding co-chair of the initiative. "In a related way, more and more people are involved with social media, including the sharing of health information and resources," he explained. "These new capabilities and trends mean that cessation resources can become more accessible and impactful."

Emerging technologies can help smoking quit lines stay current, improve services, increase reach and address budget concerns. WATI is focused on the use of web- and phone-based technologies such as texting, chatting, video, interactive voice response (IVR), Click-to-Call and other technologies as they become available.

With continued funding for research, such as by the NHI, new solutions and resources will continue to advance in technology-based strategies and medications, reported McIntosh.

"Other advances in the way medicine and public health interventions are delivered are on the verge of becoming more common, such as easy and automatic referrals to cessation resources using electronic medical records, and patient visits via telemedicine," McIntosh said.

Increased understanding of our genetic code will lead to new discoveries about the physiological and psychological underpinnings of chemical addictions, including new medicines and new behavioral strategies, stated McIntosh.

According to Blatt, every smoker can quit. "We try to build their confidence and provide the tools they need," Blatt said. "Once they figure out the right combination of things for them, they will be able to quit for good."

Research studies on smoking cessation are being conducted all the time. For information on how to join a study in your area, or in general how to quit smoking for good, call or visit these free resources: 1-800-QUIT-NOW, smokefree.gov, cdc.gov, lung.org, cancer.org or webmd.com.

Rebecca Mayer Knutsen is on staff at ADVANCE. Contact: RKnutsen@advanceweb.com


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