Kicking Butts

Nicotine is more powerfully addictive than most people realize. It will probably take several tries before you learn enough tricks to stay cigarette-free for good.

It may not be a "sin" anymore, but few would dispute that smoking is the devil to give up. Of the 46 million Americans who smoke—26 percent of the adult population—an estimated 80 percent would like to stop and one-third try each year. Two to three percent of them succeed. "There's an extraordinarily high rate of relapse among people who want to quit," says Michael Fiore, M.D., M.P.H., director of the Center for Tobacco Research and Intervention at the University of Wisconsin.

The tenacity of its grip can be matched by few other behaviors, most of which, like snorting cocaine and shooting up heroin, are illegal. Since 1988, nicotine dependence and withdrawal have been recognized as disorders by the American Psychiatric Association, legitimizing the experience of the millions who have tried, successfully and otherwise, to put smoking behind them while kibitzers told them to use more willpower.

It's not just a habit, the medical and scientific communities now fully agree, but an addiction, comparable in strength to hard drugs and alcohol.

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In fact, the odds of "graduating" from experimentation to true dependence are far worse for cigarettes than for illicit drugs, which testifies to tobacco's one-two punch of addictiveness and availability: Crack and heroin aren't sold in vending machines and hawked from billboards. Alcohol is as legal and available as cigarettes are, and as big a business, but apparently easier to take or leave alone. The majority of people who drink are not dependent on alcohol, while as many as 90 percent of smokers are addicted.

If nothing else, the persistence of smoking in the face of a devastating rogue's gallery of bodily damage, little of which has been kept secret, attests to the fact that this is no rational life-style decision. "Take all the deaths in America caused by alcohol, illicit drugs, fires, car accidents, homicide, and suicide. Throw in AIDS. It's still only half the deaths every year from cigarettes," says Fiore.

The news, however, isn't all bad. For the last 20 years, the proportion of Americans who smoke has dropped continuously, for the first time in our history. In America today, there are nearly 45 million ex-smokers, about as many as are still puffing away.

These quitters, perhaps surprisingly, are for the most part the same folk who tried and failed before. The average person who successfully gives up smoking does so after five or six futile attempts, says Fiore. "It appears that many smokers need to go through a process of quitting and relapsing a number of times before he or she can learn enough skills or maintain enough control to overcome this addiction."

Never underestimate the power of your enemy. Although nicotine may not give the taste of Nirvana that more notorious drugs do, its effects on the nervous system are profound and hard to resist. It increases levels of acetylcholine and norepinephrine, brain chemicals that regulate mood, attention, and memory. It also appears to stimulate the release of dopamine in the reward center of the brain, as opiates, cocaine, and alcohol do.

Addiction research has clearly established that drugs with a rapid onset—that hit the brain quickly—have the most potent psychological impact and are the most addictive. "With cigarettes, the smoker gets virtually immediate onset," says Jack Henningfield, Ph.D., chief of clinical pharmacology research for the National Institute on Drug Abuse. "The cigarette is the crack cocaine of nicotine delivery."

Physiologically, smoking a drug, be it cocaine or nicotine, is the next best thing to injecting it. In fact, it's pretty much the same thing, says Henningfield. "Whether you inhale a drug in 15 seconds, which is pretty slow for an average smoker, or inject it in 15 seconds, the effects are identical in key respects," he says. The blood extracts nicotine from inhaled air just as efficiently as oxygen, and delivers it, within seconds, to the brain.

The cigarette also gives the smoker "something remarkable: the ability to get precise, fingertip dose control," says Henningfield. Achieving just the right blood level is a key to virtually all drug-induced gratification, and the seasoned smoker does this adeptly, by adjusting how rapidly and deeply he or she puffs. "If you get the dose just right after going without cigarettes for an hour or two, there's nothing like it," he says.

The impetus to smoke is indeed, as the tobacco companies put it, for pleasure. "But there's no evidence that smoke in the mouth provides much pleasure," says Henningfield. "We do know that nicotine in the brain does."

For many, nicotine not only gives pleasure, it eases pain. Evidence has mounted that a substantial number of smokers use cigarettes to regulate emotional states, particularly to reduce negative affect like anxiety, sadness, or boredom.

"People expect that having a cigarette will reduce bad feelings," says Thomas Brandon, Ph.D., assistant professor of psychology at the State University of New York at Binghamton. His research found this, in fact, to be one of the principal motivations for daily smokers.

Negative affect runs the gamut from the transitory down times we all have several times a day, to clinical depression. Smokers are about twice as likely to be depressed as nonsmokers, and people with a history of major depression are nearly 50 percent more likely than others to also have a history of smoking, according to Brandon.

Sadly, but not surprisingly, depression appears to cut your chance of quitting by as much as one-half, and the same apparently applies, to a lesser extent, to people who just have symptoms of depression.

According to Alexander Glassman, M.D., professor of psychiatry at the Columbia University College of Physicians and Surgeons, the act of quitting can trigger severe depression in some people. In one study, nine smokers in a group of 300 in a cessation program became so depressed—two were frankly suicidal—that the researchers advised them to give up the effort and try again later. All but one had a history of major depression.

"These weren't average smokers," Glassman points out. All were heavily dependent on nicotine, they smoked at least a pack and a half daily, had their first cigarette within a half hour of awakening, and had tried to quit, on average, five times before. It is possible, he suggests, that nicotine has an antidepressant effect on some.

More generally, suggests Brandon, the very effectiveness of cigarettes in improving affect is one thing that makes it so hard to quit. Not only does a dose of nicotine quell the symptoms of withdrawal (much more on this later), the neurotransmitters it releases in the brain are exactly those most likely to elevate mood.

For a person who often feels sad, anxious, or bored, smoking can easily become a dependable coping mechanism to be given up only with great difficulty. "Once people learn to use nicotine to regulate moods," says Brandon, "if you take it away without providing alternatives, they'll be much more vulnerable to negative affect states. To alleviate them, they'll be tempted to go back to what worked in the past."

In fact, negative affect is what precipitates relapse among would-be quitters 70 percent of the time, according to Saul Shiftman, Ph.D., professor of psychology at the University of Pittsburgh. "We invited people to call a relapse-prevention hot line, to find out what moments of crises were like; what was striking was how often they were in the grip of negative emotions just before relapses, strong temptations, and close calls." A more precise study using palm-top computers to track the state of mind of participants is getting similar results, Shiftman says.

Most relapses occur soon after quitting, some 50 percent within the first two weeks, and the vast majority by six months. But everyone knows of people who had a slip a year, two, or five after quitting, and were soon back to full-time puffing. And for each of them, there are countless others who have had to fight the occasional urge, desire, or outright craving months, even years after the habit has been, for all intents and purposes, left behind.

Acute withdrawal is over within four to six weeks for virtually all smokers. But the addiction is by no means all over. Like those who have been addicted to other drugs, ex-smokers apparently remain susceptible to "cues," suggests Brandon: Just as seeing a pile of sugar can arouse craving in the former cocaine user, being at a party or a club, particularly around smokers, can rekindle the lure of nicotine intensely.

The same process may include "internal cues," says Brandon. "If you smoked in the past when under stress or depressed, the act of being depressed can serve as a cue to trigger the urge to smoke."

Like users of other drugs, Henningfield points out, addicted smokers don't just consume the offending substance to feel good (or not bad), but to feel "right." "The cigarette smoker's daily function becomes dependent on continued nicotine dosing: Not just mood, but the ability to maintain attention and concentration deteriorates very quickly in nicotine withdrawal."

Henningfield's studies have shown that in an addicted smoker, attention, memory, and reasoning ability start to decline measurably just four hours after the last cigarette. This reflects a real physiological impairment: a change in the electrical activity of the brain. Nine days after quitting, when some withdrawal symptoms, at least, have begun to ease, there has been no recovery in brain function.

How long does the impairment persist? No long-term studies have been done, but cravings and difficulties in cognitive function have been documented for as long as nine years in some ex-smokers. "There are clinical reports of people who have said that they still aren't functioning right, and eventually make the 'rational decision' to go back to smoking," Henningfield says.

The conclusion is inescapable that smoking causes changes in the nervous system that endure long after the physical addiction is history, and in some smokers, may never normalize.

The wealth of knowledge about smoking clarifies why it's hard to quit. But can it make it easier? If nothing else, it should help people take it seriously enough to gear up for the effort. "People think of quitting as something short term, but they should expect to struggle for a couple of months," says Shiftman.

What works? About 90 percent of people who give up smoking do so on their own, says Fiore. But the odds for success can be improved: Programs that involve counseling typically get better rates, and nicotine replacement can be a potent ally in whatever method you use.

In a meta-analysis of 17 placebo-controlled trials involving more than 5,000 people, Fiore found that the patch consistently doubled the success of quit attempts, whether or not antismoking counseling was used. After six months, 22 percent of the people who used the patch remained off cigarettes, compared to 9 percent who had a placebo. Of those who had the patch and a relatively intense counseling or support program, 27 percent were smoke-free.

More than 4 million Americans have tried the patch, which replaces the nicotine on which the smoker has become dependent, to ease such withdrawal symptoms as irritability, insomnia, inability to concentrate, and physical cravings that drive many back to tobacco.

You're likely to profit from the patch if you have a real physical dependence on nicotine: that is, if you have your first cigarette within 30 minutes of waking up; smoke 20 or more a day; or experienced severe withdrawal symptoms during previous quit attempts.

Standard directions call for using the patches in decreasing doses for two to three months. Some researchers, however, suggest that for certain smokers, the patch may be necessary for years, or indefinitely.

"It's already happening," says Henningfield. "Some doctors have come to the conclusion that some patients are best able to get on with their life with nicotine maintenance." One such physician is David Peter Sachs, M.D., director of the Palo Alto Center for Pulmonary Disease Prevention. "I realized that with some of my patients, no matter how slowly I tried to taper them off nicotine replacement, they couldn't do it," says Sachs. "They were literally using it for years. Before you start tapering the dose, you should be cigarette-free for at least 30 days."

His clinical experience leads him to believe that 10 to 20 percent of smokers are so dependent that they may always need to get nicotine from somewhere. One study of people using the gum found that two years later, 20 percent of those who had successfully remained cigarette-free were still chewing. The idea of indefinite, even lifetime, nicotine maintenance sounds offensive to some. "Clearly, the goal to aim for is to be nicotine-free," says Sachs. "But if that can't be reached, being tobacco-free still represents a substantial gain for the patient, and for society." And getting nicotine via a patch or gum source means a far lower dose than you'd get from a cigarette. Plus, you're getting just nicotine, and not the 42 carcinogens in tobacco smoke.

Although the once-a-day patch has largely supplanted the gum first used in nicotine replacement, Sachs thinks that for some, the most effective treatment could involve one or both. The patch may be easier to use, but the gum is the only product that allows you control over blood nicotine level. Some people know they'll do better if they stay in control. And would-be quitters who do fine on the patch until they run into a stressful business meeting may stifle that urge to bum a cigarette if they boost their nicotine level in advance with a piece of gum, Sachs says.

However nicotine replacement "is not a magic bullet," says Fiore. "It will take the edge off the tobacco-withdrawal syndrome, but it won't automatically transform any smoker into a nonsmoker." Other requisite needs vary from person to person. A standard approach teaches behavioral "coping skills," simple things like eating, chewing gum, or knitting to keep mouth or hands occupied, or leaving tempting situations. Ways people cope cognitively are as important as what they do, says Shiftman.

He advises would-be quitters at times of temptation to remind themselves just why they're quitting: "My children will be so proud of me," or "I want to live to see my grandchildren," for example. Think of a relaxing scene. Imagine how you'll feel tomorrow if you pass this crisis without smoking. Or simply tell yourself, "NO" or "Smoking is not an option."

Coping skills, however, are conspicuously unsuccessful for people who are high in negative affect. Supportive counseling works better. Depression or anxiety may interfere with the ability to use cognitive skills.

One exercise that Brandon teaches patients asks them to inventory—and treat themselves to—things that make them feel good, a substitute for the mood-elevating effect of a cigarette. These might include exercising, being with friends, going to concerts, reading, or taking a nap. "Positive life-style changes that improve mood level" are particularly useful if you use cigarettes to deal with negative emotional states, he says.

Depression treatment is particularly important for those trying to quit smoking. One study found that cognitive therapy significantly improved quit rates for people with a history of depression. Various antidepressants have been effective in small studies, and a large double-blind trial using the drug Zoloft is underway.

Fiore has found that having just one cigarette in the first two weeks of a cessation program predicted about 80 percent of relapses at six months. Even when the withdrawal symptoms are gone, a single lapse can rekindle the urge as much as ever.

In the critical first weeks without cigarettes, a key to relapse prevention is avoiding, or severely limiting, alcohol, which not only blunts inhibitions, but is often powerfully bound to smoking as a habit. Up to one-half of people who try to quit have their first lapse with alcohol on board.

Watch your coffee intake, too. It can trigger the urge to smoke. And nicotine stimulates a liver enzyme that breaks down caffeine, so when you quit, you'll get more bang for each cup, leading to irritability, anxiety, and insomnia—the withdrawal symptoms that undermine quit efforts.

Try to change your routine to break patterns that strengthen addiction: drive to work a different way; don't linger at the table after a meal. And don't try to quit when you're under stress: vacation time might be a good occasion.

And if you do have a lapse? Don't trivialize it, because then you're more likely to have another, says Shiffman. But, "if you make it a catastrophe, you'll reconfirm fears that you'll never be able to quit," a low self-esteem position that could become a self-fulfilling prophecy. "Think of it as a warning, a mistake you'll have to overcome."

Try to learn from the lapse: examine the situation that led up to it, and plan to deal with it better in the future. "And take it as a sign you need to double your efforts," Shiffman says. "Looking back at a lapse, many people find they'd already begun to slack off; early on, they were avoiding situations where they were tempted to smoke, but later got careless."

Don't be discouraged by ups and downs. "It's normal to have it easy for a while, then all of a sudden you're under stress and for 10 minutes you have an intense craving," says Shiftman. "Consider the gain in frequency and duration: the urge to smoke is now coming back for 10 minutes, every two weeks, rather than all the time."

If lapse turns into relapse and you end up smoking regularly, the best antidote to despair is getting ready to try again. "Smoking is a chronic disease, and quitting is a process. Relapse and remission are part of the process," says Fiore. "As long as you're continuing to make progress toward the ultimate goal of being smoke-free, you should feel good about your achievement."

Tips for Quitters

  • Nicotine addiction is powerful. Expect to struggle for a couple of months. It's an up-and-down course.
  • Don't despair. It may take six tries to learn enough skills to beat this addiction.
  • Aim for absolute abstinence—even a single puff leads to relapse.
  • Inventory those things that make you feel good and treat yourself to them—exercising, kissing, reading, taking a nap—instead of a smoke.
  • Watch your coffee intake. Not only is it a trigger to smoke, your sensitivity to caffeine increases, mimicking nicotine-withdrawal symptoms.
  • Change routines associated with smoking. Take a walk before your morning coffee. Drive to work a different way.
  • Although most quitters succeed (eventually) on their own, programs that involve counseling improve the odds, especially for the depressed or anxious.
  • Don't dismiss nicotine replacement with the patch or gum. Gum allows you control over your blood nicotine level.
  • Keep your guard up. Most lapses occur three or four weeks out, when you're feeling better.
  • In the first week, avoid, or severely limit, alcohol.

Born to Smoke

Although the difference between smokers and nonsmokers appears to reflect complex environmental and social factors, genetics apparently plays a role comparable to that observed in alcoholism, responsible for about 30 percent of the propensity. In particular, shared genetics appears to account for the link between smoking and depression, according to data collected on nearly 1,500 pairs of female twins. "The twin data show that whatever gene puts you at risk for depression, the same gene puts you at risk for smoking," says Alexander Glassman.

Further evidence for this conclusion comes from a prospective epidemiological study, in which 1,200 people in their twenties were surveyed twice; 18 months to two years apart. Nonsmokers who were depressed at the first interview were more likely to be smoking at the time of the second, while nondepressed smokers were more likely to have become depressed by then.

Genetics may even play a role in how you smoke. Shiftman studied a group of people who had smoked regularly but lightly, five cigarettes or less, four days or more a week, for several years at least. Says Saul Shiftman: "They had ample opportunity to become addicted—on average, they'd smoked 46,000 cigarettes, but we found not the slightest evidence of dependence: they showed no signs of withdrawal when abstinent. They really could casually take smoking or leave it."

Such nonaddicted users—chippers," in drug culture parlance—are also seen among consumers of hard drugs. "We didn't delve deeply into what made these smokers different," says Shiftman. "But we did find evidence that they also had relatives who smoked with little dependence, who followed the same pattern. This makes it plausible, although it doesn't prove that these folks are biologically different." With rare exceptions, chippers have always smoked that way, he points out. For a once-addicted smoker to try to become a chipper is "a risky business" that's probably doomed to failure.

Nicotine in the Nineties

Smoking just doesn't have the cachet it once did. Instead of a mark of worldliness and joie de vivre, it's become something of a social disease. Except on billboards and in magazine ads, the smoker him- or herself is less likely to be the object of admiration than of pity and contempt.

The change in smoking's status is no doubt in part responsible for the 40 percent decline in its prevalence since 1964. And it would seem logical that those people who are still smoking in the face of such adversity are an increasingly hard-core, heavily addicted bunch, unable to quit.

Alexander Glassman conjectures that as the social environment grows more hostile to smoking, the genetic component of the behavior will become more evident. And as the number of smokers drops, an increasing percentage will have psychiatric problems, particularly depression.

But the change hasn't yet been documented. "Actually, I don't think the data support the idea that today's smokers are very different from years back," says Fiore. "The average number of cigarettes they smoke today isn't dramatically different from 20 years ago—about 22 per day."

One thing that has happened is a change in the sociodemographics of smoking. "More and more, it's a behavior predominantly exercised by disadvantaged members of society: 40 percent of high-school dropouts smoke, compared to 14 percent of college grads. Poor people are more likely to smoke than wealthy. It's getting marginalized," he says.

If nothing else, today's antismoking climate has eliminated much denial about the true nature of the cigarette habit. "Smokers are much more aware of being hooked," says Saul Shiftman. "You can't tell how dependent you are if access is easy. If you can smoke at your desk and at a restaurant, you can delude yourself, as people have for decades: 'I like to smoke but I can take it or leave it.' It's hard to say that when the only place you can smoke is outside when it's hailing and 20 degrees."

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