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Excerpts from Quitting cigarettes especially difficult for hard-core smokers

By ALAN BAVLEY, Kansas City Star [05/01/99]

Every morning after Ken Waring finishes his eggs or oatmeal, he settles into his living room recliner with the newspaper and a cup of coffee. That's when the irresistible urge strikes.

"There's the sense that something is missing," he says.

Waring is irked by his lack of willpower, but he still bargains it away. "All right, I'll do it this time," he says to himself. "But we're going to have to stop this Mickey Mouse."

So he pads back to the kitchen, finds his pack of Raleighs and lights up his first cigarette of the day.

Meet the toughest challenge to the anti-smoking movement: the hard-core smoker.

After decades of health warnings and social pressure, millions of smokers have kicked the habit, experts say.

Among the nearly 50 million people who still are puffing, many are more deeply addicted, harder to convince about smoking's hazards, or haven't been adequately influenced by the no-smoking message.

"We've increasingly reached the people who can be easily reached," said Jasjit Ahluwalia, a University of Kansas Medical Center smoking researcher. "What we're stuck with are the so-called recalcitrant smokers."

Reaching smokers like Waring will take more than health warnings on cigarette packs or smoking cessation class pep talks, experts say. But there is hope.

Researchers are building an array of more effective anti-smoking tools for the stubborn smoker.

In recent years, chewing gum, skin patches, inhalers and nasal sprays laced with nicotine have turned into a $300 million-a-year business. These products help quell cravings for tobacco's addictive ingredient.

Studies show that nicotine replacement therapies as much as double the chances of quitting smoking.

Bupropion, an antidepressant drug, also is proving a champion at helping smokers quit. Still other drugs are being studied.

Most insurance plans, however, won't cover smoking cessation products.

Researchers also are looking closely at the coping strategies people use to quit smoking, such as giving themselves pep talks, avoiding smoky bars or occupying their mouth and hands with snacks.

The hope is that eventually, doctors will be able to tailor motivational messages, drugs and coping strategies to best suit each patient.

"It would be great for someone to go into a clinic, answer a few questions and be assigned to the best treatment," said Douglas Jorenby of the University of Wisconsin Medical School's Center for Tobacco Research and Intervention. "Now it's a very seat-of-the-pants sort of thing."

Reaching the hard core

Despite a recent increase in teen smoking, federal health survey statistics show that cigarettes have lost their widespread appeal among adults.

In 1965, a year after the first surgeon general's report on the dangers of smoking, 52 percent of men and 34 percent of women smoked. Twenty-five years later, in 1990, the numbers were down to 28 percent of men and 23 percent of women.

Since then, however, the percentages haven't budged.

One reason, some researchers say, may be that the health messages hammered home for the past three decades don't work on a lot of smokers.

Most smokers, even those who smoke two or more packs a day, don't think they run a higher-than-average risk of heart attack or cancer, a recent national survey of 3,031 adults by Harvard Medical School researchers found. Even smokers with high blood pressure, angina or a family history of heart attacks were unlikely to say they were at greater risk.

Anti-smoking messages emphasizing the immediate benefit of quitting -- such as fresher-smelling clothes and breath, and saving money -- might work better than health lectures for these smokers, Ayanian said.

The most effective new motivator, though, has been the drugs that treat tobacco addiction.

Nicotine replacement products have become a standard part of smoking cessation treatment. And rising rapidly in popularity is bupropion. Smokers are buying more than $50 million of this prescription drug annually under the brand name Zyban.

Zyban's usefulness as a smoking cessation aid was discovered accidentally by a doctor who noticed that depressed patients on bupropion gave up smoking.

A recent study by Jorenby and other researchers in the New England Journal of Medicine found that 30 percent of smokers who took Zyban were able to quit cigarettes and stay tobacco-free. That was double the percentage who quit with a placebo.

How Zyban works is unclear. But people who are depressed often smoke. And depressed smokers are less likely to stop smoking. So the drug might be removing a psychological barrier to quitting.

Researchers are studying whether other antidepressant drugs have the same effect. And a skin patch that combines nicotine with the drug mecamylamine, which may reduce smoking satisfaction, is being developed.

Extra help needed

Smoking is a habit as well as an addiction. Smokers closely associate it with finishing a meal, driving a car or having a drink.

Most smokers need coping skills to overcome that urge for a cigarette.

While many smokers try to quit on their own, experts recommend smoking cessation classes. These offer a variety of techniques: positive thinking, deep breathing, low-calorie snacks to take the place of cigarettes.

Breathing away the urge

At the Midwest Research Institute in Kansas City, psychologists are focusing on how best to use breathing exercises, which many smoking cessation programs recommend.

MRI researchers have found that smokers trying to quit are particularly likely to relapse when they're excitable and playful, such as when they're out drinking, or when they are upset.

"That's particularly true if they feel they're not getting what they need in life," said MRI psychologist Mary Cook.

Cook and collaborator Mary Gerkovich trained 130 smokers to recognize when they were in these states and to use different breathing techniques as alternatives to smoking.

The study subjects took short, quick stimulating breaths when they felt excited and wanted a cigarette to enhance their mood. When they were upset and craved a calming cigarette, they breathed deeply and held their breath to build up carbon dioxide in the blood.

A second group of smokers did deep-breathing exercises whenever they had a smoking urge.

So far, the two groups of ex-smokers are doing about equally well. Three months after quitting, 30 percent were tobacco-free or still trying to abstain.

Cook and Gerkovich anticipate that as the effects of nicotine withdrawal subside and the psychological urge to smoke intensifies, the group with special training will do better.

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