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Clearing the Smoke about Quitting
Alex Blau,  Health Watch

Why on earth would anybody still smoke? Not only do cigarette smokers have to wade through daily press updates on the dangers of their habit, but they also pay higher health insurance premiums, are driven out of their office building whenever they want to catch a smoke, and suffer nasty stares wherever they light up. Despite a@ of this, the number of smokers quitting each   year has actually decreased in the past decade. As it stands, one in four Americans-nearly fifty million people-still lights up every day, at a time when it would seem to be easier than ever to quit. The past few years have seen a rash of new prescription and over-the- counter cessation aids hit the market-nicotine patches, nicotine gum, Zyban, Welbutrin-all of which promise to make the process of quitting far less painful than ever before. Smokers are getting an earful at doctors' offices, too. "Some people get pretty theatrical," says Dr. Ned Schluger, M.D., chief of pulmonary medicine at Columbia-Presbyterian Medical Center. "I've heard stories of physicians taking patients' cigarettes and ripping them up in front of -them. Many surgeons will refuse to operate on a smoker." Dr. Alan Hecht, a cardiologist wit a private New York practice, uses a more point-blank forcefulness with his patients. ÒA personÕs decision to quit often begins with a doctor yelling at them or a family member yelling at them,"  he says. "I will often approach smokers by bluntly telling them they are going to die.' What else could anybody possibly need to hear?

For the nonsmoker, having a close friend or family member who smokes can be an emotionally trying experience. When urging smokers to quit seems to fall on deaf ears, genuine concern can sour into disappointment, frustration, and anger and can even lead to confrontation. And growing anxiety about the effects of secondhand smoke has only further alienated smokers, who come off in the face of all this as stubborn, insensitive, and self-destructive.

What nonsmokers may not realize, however, is that many smokers have gone through this with themselves and harbor similar feelings; many are equally disappointed and frustrated with their own inability to stop and have resigned themselves to the fact that they may never kick the habit. Surveys show that the vast majority of smokers want to stop, and most have tried several times, but quitting is often much more difficult than advertisements for cessation aids and antismoking campaigns let on. Most quit attempts are mismanaged, with little or no thought given to preparation and timing. Pharmaceutical aids are often misused, especially since nicotine replacement therapies have become available without a prescription. Perhaps most significantly, nicotine is such a powerfully addictive drug that some ex-smokers have cravings decades after quitting.

Doctors who have grappled with the issue of smoking have come to see smokers as not simply weak of will but firmly in the grip of a psychological and physical dependency. "Smoking is an acute illness," says Dr. Elliot Wineburg, M.D., director of the New York Stop Smoking Center and assistant clinical professor of psychiatry at Mount Sinai. "We now know without a doubt that nicotine is more addictive than heroin. The common thought is, 'It's my best friend and I'll never live without him.' People are terrified of stopping."

When smokers do try to give it up, many are quickly discouraged by initial failures. "Most people are not successful quitting smoking right away," says Dr. Warren Huberman, Ph.D., director of outpatient psychological services for the Joan and Joel Smilow Cardiac Rehabilitation and Prevention Center at NYU Medical Center. "There is usually a series of relapses and setbacks; some people attempt to quit fifteen times before they are finally successful." And most smokers try to quit "cold turkeyÓ-without any assistance-the least effective method, according to the Center for Disease Control Office of Smoking and Health, resulting in a dismal 96 percent relapse rate within a year.

Even those smokers who take advantage of the many medications on the market are rarely using them as intended. "Most of the products that are on the market are meant to be used as part of a comprehensive behavior change program,' says Dr. Huberman. "A lot of times, doctors familiar with these drugs will suggest that people take them, but typically physicians do not monitor their patients progress on a daily basis. In order to be successful quitting smoking, the vast majority of people really need the structure beyond simply using the patch, the gum, or these other drugs." Comprehensive smoking creation programs like Dr. Wineburg's and Dr. HubermanÕs combine the use of medications with various other techniques, like hypnotherapy or behavioral modification, all closely supervised over the course of repeat counseling sessions.

What these programs have proven quite effective, boasting success rates in the 70-to-80 percent range, even the experts lose their share of patients. But these smokers are not beyond help. "Very often, if someone fails it may have more to do with the timing of their quit attempt than the content of the program," says Dr. Huberman. "Some people are under severe stress from their job, or at home, and the smoking may be their primary, if not only, coping mechanism. And as much as they may want to quit, to take that away in the middle of a major stress is like taking the crutches away from someone with two broken legs-"

Whether a smoker has tried over' and over to quit or is simply paralyzed by a fear of failure, the key to success is finding a combination of timing, method, and support that works. Quitting is a highly individual process, and relapses are just a part of finding the path to a personal solution. "The most important thing is that you stop poisoning yourself with cigarettes," says Dr. Huberman. "However you choose to go about it, as long as you're Successful, who cares?"