Kicking Butts in the Twenty-First Century · The first smoking cessation programs began in the 1950s, after research had shown that smoking was a serious health hazard. In 1955, public

AMERICAN COUNCIL ON SCIENCE AND HEALTH1995 Broadway, 2nd Floor, New York, NY 10023-5860

Tel. (212) 362-7044 • Fax (212) 362-4919URLs: http://www.acsh.org • http://www.HealthFactsAndFears.com

E-mail: [email protected]

Kicking Butts inthe Twenty-First Century:

What Modern Science Has Learnedabout Smoking Cessation

Prepared forTHE AMERICAN COUNCIL ON SCIENCE AND HEALTH

by Ashlee DunstonAssistant Director of Public Health, ACSH

Art Director:Yelena Ponirovskaya

August 2003

THE AMERICAN COUNCILON SCIENCE AND HEALTH (ACSH) A P P R E-C I ATES THE CONTRIBUTIONS OF THE REVIEWERS NAMED BELOW.

ACSH accepts unrestricted grants on the condition that it is solely responsible for theconduct of its research and the dissemination of its work to the public. The organizationdoes not perform proprietary research, nor does it accept support from individual corpo-rations for specific research projects. All contributions to ACSH—a publicly fundedorganization under Section 501(c)(3) of the Internal Revenue Code—are tax deductible.

Individual copies of this report are available at a cost of $5.00. Reduced prices for 10 ormore copies are available upon request.

Copyright © 2003 by American Council on Science and Health, Inc.This book may not be reproduced in whole or in part, by mimeograph or any othermeans, without permission.

Michael Bracken, M.D.Yale University School of Medicine

Sir Richard Doll, M.D., D.Sc., D.M.University of Oxford

Michael C. Fiore, M.D., M.P.H.University of Wisconsin

Richard Hoar, Ph.D.Williamstown, MA

George Lundberg, M.D.Medscape General Medicine

Mark Taylor, M.D.,Physicians for a Smoke-Free Canada

Dimitrios Trichopoulos, M.D.Harvard School of Public Health

Mark Willenbring, M.D.Veteran Affairs Medical Center,Minneapolis, MN

Thomas P. Houston, M.D.American Medical Association

Greg Connolly, D.M.D., M.P.H.Massachusetts Department of PublicHealth

Pagona Lagiou, M.D.University of Athens

ACSH also thanks Kathleen Meister, M.A, for her extensive role inrevising this booklet.

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TABLE OF CONTENTSExecutive Summary Introduction Background: The Magnitude of the Problem The Successful Quitter Motivators for Quitting Barriers to Quitting Smoking Cessation Methods

Going it Alone Drug Therapies

First-Line Medications Nicotine Replacement Therapy

Nicotine Gum Nicotine Inhaler Nicotine Lozenge Nicotine Nasal Spray Nicotine Patch

Medications Other than NicotineReplacement Therapy

Bupropion SR Second-Line Medications

Clonidine Nortriptyline HCI Combination Therapy

Medications Not Recommended Counseling and Support

Support Groups Individual Counseling Telephone Counseling Internet Programs Self-Help Aversive Smoking

Combining Medication with Counseling/Support “Alternative” Therapies

Acupuncture Hypnosis Herbal Remedies

New Approach Inpatient Treatment

Future Approaches Nicotine Vaccine Nicotine Vaporization

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TABLE OF CONTENTS ( c o n t i nu e d )

Harm Reduction Additional Issues in Smoking Cessation

Weight Gain Depression Alcohol Special Populations Smokeless Tobacco and Other Tobacco Products Insurance Coverage, Access to Treatment, andCost Effectiveness

Conclusion

References

TA B L E STable 1. Comparison of Drug T h e r a p i e s

For Use in Smoking Cessation

Table 2. Smoking Cessation Resources

Table 3. States Providing Counseling andInformation on Smoking Cessation

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EXECUTIVE SUMMARY

Cigarette smoking is a very widespread and serious health problem.More than 46 million American adults smoke, and smoking contributesto more than 430,000 deaths in the U.S. each year.

Nearly 70% of smokers want to quit, and nearly 41% say that they haveattempted to quit at least once in the past year.

Only about 4-5% of smokers who to try to quit each year succeed instopping smoking permanently. However, after repeated attempts, nearly40 to 50% of smokers eventually succeed in quitting.

Counseling, drug therapy (nicotine replacement therapy or other formsof medication), or both methods in combination can substantiallyincrease the likelihood of successful smoking cessation.

Five forms of nicotine replacement therapy — gum, inhaler, lozenge,nasal spray, and patch — have been approved by the U.S. Food andDrug Administration (FDA) for the treatment of nicotine dependence.The drug bupropion has also been approved for this purpose. Scientificevidence indicates that two other drugs — clonidine and nortriptyline— are also effective in helping some smokers quit. However, at present,these two drugs have not been approved by the FDA for this purpose,although they are approved for other uses. No other drugs have beenshown to be effective as smoking cessation treatments.

Support groups, individual counseling, and telephone counseling havebeen shown to improve quit rates. The effectiveness of Internet pro-

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grams to help smokers quit is currently being evaluated. Self-help mate-rials and programs have not been documented as effective when usedalone.

“Alternative” therapies for smoking cessation, including acupuncture,hypnosis, and herbal remedies, have not been proven effective. Somealternative therapies may be hazardous, and some herbal remedies mayinteract in detrimental ways with prescription or over the counter med-ications.

Smoking cessation treatment is not integrated into the general U.S.healthcare system at the present time and may not be covered by healthinsurance. Considering the substantial health costs of smoking, smokingcessation interventions should be strongly encouraged and fully inte-grated into the healthcare system.

Kicking Butts in the Twenty-First Century:

I N T R O D U C T I O N

“Quitting smoking is easy. I’ve done it a thousand times.”—Mark Twain

If Mark Twain were alive today, he could have been more successful inhis efforts to quit smoking — thanks to what modern science haslearned about smoking cessation.

In Twain’s time — and for several decades after his death in 1910 —many people thought of smoking tobacco as merely a habit, and theybelieved that quitting was simply a matter of individual choice andwillpower. Smoking was not then widely recognized as addictive, butwe know now that it can be a strong addiction and that for many smok-ers willpower alone is not enough to give up tobacco permanently.

In recent years, researchers have learned a great deal about the factorsthat help people quit smoking successfully, the barriers that may inter-fere with smoking cessation, and the special problems faced by specificgroups of prospective quitters — such as pregnant women, adolescents,and individuals with psychological and psychiatric problems. Scientistshave also developed new techniques for smoking cessation — includingboth drugs and counseling methods — that substantially increase thechances of success.

This report by the American Council on Science and Health (ACSH)summarizes what science has learned about smoking cessation — withan emphasis on methods that have been proven to work. The report alsodescribes some new smoking cessation techniques that are currentlyunder development and evaluates some alternative methods that havebeen advocated as aids to smoking cessation. This report is not intendedas a stop-smoking guide; instead, it is best used as a source of back-ground information to complement the stop-smoking advice availablefrom local and national health organizations, government agencies, andphysicians.

BAC K G R OUND: THE MA GNITUDE OF THE PR O B L E M

More than 46 million American adults currently smoke, and the numberof adolescent smokers is increasing annually.1 Cigarette smoking con-tributes to more than 430,000 deaths in the United States each year.

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What Modern Science Has Learned about Smoking Cessation

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Tobacco dependence is now recognized as a clinical addiction and evenas a chronic disease — one of the most widespread in the world.

Quitting smoking has major health benefits. In the long term, smokingcessation reduces the risk of lung cancer and other cancers, stroke, heartdisease, chronic obstructive pulmonary disease (chronic bronchitis andemphysema), and a host of other diseases. In the short term, quittinghas some immediate health benefits such as reducing fatigue and short-ness of breath and increasing arterial circulation and libido.2

Recent U.S. surveys show that among current smokers, nearly 41% hadattempted to quit at least once in the previous year, and nearly 70%want to quit.1 But only about 4–5% of smokers who try to quit eachyear succeed in stopping smoking permanently.1 The prospects for suc-cessful smoking cessation are not as dismal as these numbers seem toindicate, however. The chance of success increases with each quitattempt and with the use of effective smoking cessation methods. Afterrepeated attempts, nearly 40 to 50% of smokers eventually succeed inquitting. Presently, more than 45 million Americans have quit smoking,and the total number of smokers has slowly declined in recent years.1

The first smoking cessation programs began in the 1950s, after researchhad shown that smoking was a serious health hazard. In 1955, public“stop smoking clinics” were introduced in Sweden; they used medica-tions, pamphlets, lectures, and physician counseling to help people quit.These clinics spread to the rest of Europe and the United States in the1960s and have evolved into what are now comprehensive, multi-faceted, individualized programs.

Smoking cessation rates in the United States started to stabilize in the1990s, after having increased over the prior few decades.1 Evidencesuggests that this is because the number of quit attempts as well as thesuccess of each attempt stabilized.3 However, in 1990, only 10% ofquitters used some form of treatment,4 whereas as many as 35% do sotoday.5 There are several ways to approach smoking cessation, and indi-viduals must decide for themselves which program or method is rightfor them. However, the more programs and methods available — andthe more a smoker is educated about quitting — the greater the likeli-hood of success.


THE SUCCESSFUL QUITTER

All smoking cessation programs have at least one thing in common — aflexible notion of what it takes to become a successful quitter. The pre-requisites for success vary from individual to individual, but tend toinclude the following:

Motivation, Desire, Commitment: Smokers who choose to quit shouldhave strong personal reasons that motivate them to do so. People whoattempt to quit solely to please others are usually headed for failure.Successful quitters must make a firm commitment to stop.

Timing: The time at which a smoker chooses to quit is very important tothe outcome. A quit attempt can temporarily affect a person’s lifestyle,state of mind, and general wellbeing. Trying to quit in the midst of animportant business deal or a difficult family or personal situation canlower the chances of success.

Choice of Method: No particular smoking cessation method is right foreveryone. However, the U.S. Public Health Service (USPHS) suggeststhat all smokers trying to quit should use some form of drug therapy(such as nicotine replacement therapy or bupropion), if possible, incombination with some form of counseling, behavioral therapy, orsocial support. However, not all experts agree that pharmacologicalagents are needed by all smokers. Smokers should plan ahead andchoose the methods that most closely conform to their personal needs.Since some types of medication are only available by prescription, it isa good idea for smokers to discuss their smoking cessation plans with aphysician. Physicians can also provide counseling, and they can refersmokers to organized smoking cessation programs in the community.

Repetition: One of the main keys to successful quitting is repetition.Most smokers will try to quit several times before succeeding. Witheach attempt, the smoker learns more about what to expect from thequitting process, and the chance of success increases. Many smokers arenot aware of this fact and may become needlessly discouraged whenthey relapse after an initial unsuccessful attempt.

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M OT I V ATORS FOR QUITTING

Although smokers must make their own decisions to quit, several com-mon factors often serve as motivators for quitting.

Health Benefits: Improved health seems to be the primary motivator forquitting. Many of the adverse health effects of smoking can be greatlyreduced or even reversed through cessation.2 Immediate benefits ofquitting include a decrease in blood pressure, a lowered pulse rate, anincreased oxygen level in the blood, and a decreased blood carbon

MYTHS ABOUT SMOKING CESSA T I O N

Many people have misconceptions that may stand in the way ofsuccessful smoking cessation. Here are five of the most widespreadmyths:

Myth: Smoking is just a “bad habit” and people should be able toquit with ease.Fact: Tobacco dependence is a true addiction, not just a habit.

Myth: Quitting merely takes strong willpower.Fact: Even if a smoker is deeply committed to quitting, successfulsmoking cessation may require additional methods and efforts.

Myth: If a smoker is unable to quit on the first attempt, he or shewill not succeed in the future.Fact: Many people make repeated attempts to quit before they suc-ceed.2 Relatively few people quit smoking permanently on the firsttry, but after repeated attempts, almost half are successful.

Myth: The best way to quit is “cold turkey” — to just stop smokingimmediately, without any help.Fact: According to an extensive review by the U.S. Public HealthService, combination approaches that involve both medication andsome type of counseling or social support have the highest successrates.3

Myth: Quitting is expensive.Fact: Smoking costs at least as much as smoking cessation treat-ments do.

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monoxide level.7 Also, the ability to smell and taste is enhanced. Aftertwo weeks of abstinence, circulation to the extremities improves, bloodpressure remains lower, and lung function improves. After just a fewweeks to a month, cough, sinus congestion, fatigue, and shortness ofbreath all decrease, although cough may actually worsen right afterquitting. Further, ex-smokers are less likely than current smokers tohave colds, develop gum disease, experience fertility problems, orexperience erectile dysfunction.

Long-term benefits may also motivate smokers to quit. One year afterquitting, the risk of developing symptomatic coronary artery disease(e.g., angina) is reduced by nearly half compared to those who continueto smoke.7,8 And after as little as two to five years, that risk can bedecreased to levels approaching those who have never smoked.8,9 Afterfive years of abstinence, the risk of stroke is reduced, approaching thatof people who have never smoked. The risk of lung cancer decreaseswith the number of years of abstinence and can be reduced by as muchas 40% after ten years; however, it never returns to that of people whohave never smoked.10 The risk of other cancers such as those of themouth, throat, esophagus, bladder, kidney, and pancreas also decreasesafter several years of abstinence.2 After nearly fifteen years of absti-nence, the overall risk of mortality tends to approach a level similar tothat of lifelong nonsmokers.7 Unfortunately, quitting does not reversechronic obstructive lung disease (chronic bronchitis or emphysema), butit does slow its progression.2 For women who stop smoking beforepregnancy or during the first trimester, the risk of having a low-birth-weight baby is decreased.2 Because the reversibility of the risks ofsmoking is greatly influenced by the duration of smoking prior to quit-ting, smokers should be encouraged to quit as soon as possible.11

Social Pressure: The increasing social pressure from tobacco controlefforts may motivate smokers to quit. For example, workplace and pub-lic space restrictions — including recent bans or proposed bans onsmoking in restaurants and bars in many locations — can increase themotivation or stimulus to quit.

The institution of totally smoke-free workplaces can motivate somepeople to quit smoking. A recent combined analysis of 26 studiesshowed that smoke-free workplaces encourage smokers to either quit ordecrease their smoking, thus reducing total cigarette consumption peremployee by an average of 29%.12

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Anti-tobacco campaigns and anti-smoking messages in the media canalso provide some much-needed motivation and may cause smokers toworry about the effect of smoking on their family’s health and well-being.13 Parents who smoke may be motivated to try to quit when theylearn that exposure to tobacco smoke in the environment is harmful tothe health of their children or another loved one. In addition, it is wellknown that children of parents who smoke are more likely to becomesmokers themselves. Fortunately, if a parent quits while a child isyoung, that child has a lower chance of becoming a smoker than if theparent continues to smoke.14

Personal Requests: Many smokers receive personal requests to quitfrom family members, friends, and physicians who are concerned aboutthe smoker’s health and/or are bothered by their habit. Although onerequest may not be enough motivation, each subsequent request mayincrease a smoker’s probability of quitting.

Economic Aspects: Although health is usually the main motivator forquitting, the economic cost and burden of the habit may also influencesome smokers’ decisions. Depending on the individual, smoking can bequite expensive — costing as much as $70.00-80.00 per week.Recently, many states have increased cigarette taxes, raising the cost ofa pack of cigarettes by more than a dollar in some areas. (In New YorkCity, the combination of city and state taxes increases the cost of ciga-rettes by almost three dollars a pack.) Although the main public healthobjective of raising the price of cigarettes is to deter adolescents fromsmoking, increasing cigarette prices does seem to increase smoking ces-sation.15 The economic benefits of quitting may be especially importantfor the 30% of smokers who have incomes below the national povertylevel.1

The cost of cigarettes isn’t the only economic cost of smoking.Smokers’ health care expenses are as much as 21% higher than those ofnonsmokers.16 It is estimated that smoking costs the U.S. $158 billioneach year in productivity losses and excess medical expenditures.17


BARRIERS TO QUITTING

So, exactly how hard is it to quit smoking? The answer to this questiondiffers among individuals. Success in quitting is related to personalcharacteristics, the length of smoking history, the level of cigarette use,the intensity of addiction, and the smoking cessation methods utilized.Those smoking more cigarettes for a greater time period may find itmore difficult, but by no means impossible, to quit. Some studies showthat women find it harder to quit than men do, although the reasons forthis are unclear.

There are several common barriers to quitting. While these vary fromone individual to the next, major barriers that most smokers can expectto encounter include the following:

Withdrawal: Probably the greatest barrier to quitting — and the hardestfor smokers to overcome — is withdrawal. Withdrawal is the body’sresponse to the physical need for nicotine and the psychological need ordesire for a cigarette. Immediately after quitting, many smokers willexperience headache and dizziness, coughing and sore throat, andhunger.18 These symptoms usually last a few days to a week. As cessa-tion progresses, other symptoms can develop, including anger, frustra-tion, irritability, difficulty in concentrating, impatience, insomnia,fatigue, and even intense anxiety and depression.18 Also, because of thebody’s dependence on nicotine, the most common symptom is intensenicotine craving, or the overpowering desire to smoke. The physiologi-cal symptoms and psychological desire to smoke are the major factorsin relapse (resumption of smoking). The use of nicotine replacementtherapies in a smoking cessation program can help ease the symptomsof withdrawal. Physical withdrawal typically peaks at one to threeweeks after quitting; “psychological withdrawal” and the desire for acigarette can last anywhere from weeks to a few years, but for mostpeople not much more than six months.

Behavioral Addiction: Behavioral, or psychological, addiction to ordependence on the practice of smoking may make quitting difficult.Many people associate smoking with other actions or situations such aseating, drinking, and social or stressful events — associations that aresometimes hard to change. Also, many smokers enjoy the oral activityof smoking a cigarette and the physical comfort of holding it betweentheir fingers.

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Social Circumstances: Another barrier to cessation can be the presenceof smokers in the household, workplace, or social or recreational envi-ronments. This can deter smokers from trying to quit or provoke smok-ers to relapse by providing an unsupportive environment or easy accessto cigarettes. Many smokers are so-called social smokers; they find itdifficult to be in a social environment without smoking.

Existing Mental Problems: People with psychiatric disorders, such asanxiety or depression, have higher smoking rates than other people do.It is possible that some of these people smoke to abate the symptoms ofthese disorders.19 Successfully treating the anxiety or depression mightincrease the likelihood of successful smoking cessation; however, thisidea has not yet been evaluated directly.

Difficulties Gaining Access to Treatment: Some smokers do not haveeasy or affordable access to smoking cessation treatments. Some smok-ing cessation products require a prescription, and most are not coveredby insurance plans. Increasing the number of over-the-counter medica-tions, reducing the cost of some treatments, and extending insurancecoverage should improve cessation outcomes.

Relapse: The occurrence of relapse is another barrier to cessation.Many smokers who try to quit on their own will suffer a relapse atsome point. Those who use drugs or counseling to help them quit havean increased chance of success, but the majority experience some formof relapse. A relapse can set smokers back to the point where they aban-don the quest for cessation.

SMOKING CESSA TION METHODS

There are several treatments currently available for use in smoking ces-sation. The two approaches for which there is the most evidence of effi-cacy are drug therapy (nicotine replacement therapy or bupropion) andcounseling/support. Each of these types of treatment is effective on itsown; however, using both in combination leads to the highest successrates.6


GOING IT A L O N E

Although treatment is available, many people prefer to try to quit smok-ing on their own — either by the “cold turkey” method (giving up ciga-rettes suddenly and completely) or by gradually decreasing their smok-ing. Quitting on one’s own is convenient and inexpensive. However,this approach to smoking cessation does not address any of the physicalwithdrawal symptoms or psychological consequences associated withquitting and does not teach coping methods for remaining cigarette-free.Some studies indicate that people who quit cold turkey experience ashorter period of withdrawal than those who quit by gradual reduction,and that the body rids itself of nicotine within 48 hours. Nearly 70% ofsmokers who try to quit cold turkey resume smoking within two days,and 80% do so within a month.20

D RUG T H E R A P I E S

The use of approved medications can increase the chance of long-termabstinence from tobacco. All smokers trying to quit should consider theuse of medications discussed below and should discuss their optionswith a physician. Those smoking fewer than 10 cigarettes per day,women who are pregnant or breastfeeding, and adolescent smokers mayuse the approved therapies but may require alterations in treatment orclose monitoring by a physician.6 (See Table 1 on p. 16 for a compari-son of the drug therapies available for use in smoking cessation.)

First-Line Medications

There are currently six first-line medications considered safe and effec-tive and approved by the U.S. Food and Drug Administration (FDA) fortobacco dependence treatment. These include five forms of nicotinereplacement therapy — gum, inhaler, lozenge, nasal spray, and patch —as well as the non-nicotine medication bupropion. These first-line med-ications have an established scientific record of efficacy. Most smokerscan and should use them; however, special precautions may be neededfor smokers with certain medical problems or for pregnant women.These medications have few side effects (fewer than 5% of users stopusing the medications due to side effects), are considered equally effec-tive, and can nearly double the chances of quitting smoking successful-ly. There is no method to scientifically match a patient to a specific

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First-Line Therapies

Availability Dosage (Average) Duration Cost/Day

Nicotine Replacement Therapies

Nicotine Gum OTC 2 mg, 4 mg pieces 1-3 $6.00-7.0010 pieces/day months

Nicotine Inhaler Prescription 4 mg cartridge 3-6 $5.706-16 cartridges/day months

Nicotine OTC 2 mg, 4 mg lozenges 3 months $6.00-10.00Lozenge 1 lozenge/1-2 hours

Nicotine Nasal Prescription 0.5 ml spray to each 3-6 $5.00-15.00Spray nostril months

8-40 doses/day

Nicotine Patch OTC/ 21 mg, 14 mg, 7 mg 2 months $4.00Prescription 16 hour, 24 hour

Non-Nicotine Therapies

Bupropion Prescription 150 mg, twice daily 3 months $4.00

Second-Line Therapies

Clonidine Prescription 0.10 mg/day initially 3-10 $0.24increase 0.10 mg/day weeksper week if necessary

Nortriptyline Prescription 25 mg/day for first 3 months $0.7410-28 daysincrease to 75-100mg/day

Table 1. C o m p a r ison of Drug T h e r a pies For Use in SmokingC e s s at i o n

treatment. Therefore, choice of treatment depends on individual prefer-ence, what is appropriate for a particular lifestyle, and how helpful theindividual smoker finds the medication to be.

Nicotine Replacement Therapy (NRT)

The concept behind nicotine replacement therapy is to address nicotinedependence and minimize withdrawal symptoms by replacing the nico-tine from cigarettes with an alternative nicotine source. This helps thesmoker to adapt to not smoking and to develop behavioral techniques tobreak the cigarette habit while still receiving the nicotine “fix” in a con-trolled manner. As smokers progress with cessation, they can then slow-ly taper the nicotine dose until it is no longer needed.

The idea of using a potentially harmful drug — nicotine — as a medicaltreatment may seem strange at first, but it makes sense because smokersare already being exposed to nicotine — in the very dangerous form ofcigarettes. In addition to nicotine, cigarettes contain numerous poisonssuch as carbon monoxide and cyanide, a large number of cancer-causingagents, and other harmful substances. Nicotine replacement therapy(NRT) products contain nicotine and only nicotine, so they expose theuser to just one potentially dangerous substance, unlike smoking.Although high doses of nicotine may have some harmful effects on thebody, it does not appear to be a cancer-causing agent, and it does notplay a major role in the development of heart disease.1,21 Thus, whenpeople stop smoking and start to use NRT, they are already reducingtheir health risks.

However, since nicotine is the addictive agent in cigarettes, some publichealth officials are concerned that NRT medications themselves willcause dependence.22 The nicotine levels in NRTs are much lower thanthose in cigarettes, though, and the nicotine in some NRTs is absorbedmore slowly than it is from cigarettes. Thus, the potential for depend-ence is rather small.

For all NRTs, caution should be taken for pregnant and lactatingwomen, individuals who have recently had a heart attack (within twoweeks), and those with serious cardiovascular disease including arrhyth-mias or angina.6 Pregnant and lactating women should be encouraged toquit first without NRT, as it is not completely clear to what extent nico-tine causes harmful effects on the fetus or nursing infant.23 However,NRTs produce lower levels of nicotine in the body than cigarettes do,and they do not expose the user to carbon monoxide (which is thoughtto be harmful to the fetus) the way that smoking does. Thus, someexperts suggest that pregnant women can use NRT if the likelihood of

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abstinence without it is minimal.6,24 For people with cardiovascular dis-ease, studies have shown that it is possible to use NRT with little risk;however, it is very important that patients are monitored closely andthat cigarettes are not used along with NRT.25

The FDA and manufacturers of NRT products strongly advise againstsmoking while using any form of NRT. Smoking while using NRT canlead to a harmful overload of nicotine in the body. In the case of thenicotine patch, users also should not smoke within a few hours afterremoving a patch because the nicotine from the patch remains in thebloodstream for several hours after the patch is removed.

NRT users should remember that NRT does not work equally well foreveryone and does not completely eliminate the withdrawal symptomsassociated with smoking cessation. Further, it will not magically allowor motivate the smoker to quit. What it does do, however, is add anoth-er weapon to the arsenal of techniques that can help people quit.

Nicotine Gum (Nicorette)

Nicotine polacrilex (nicotine gum) is designed to deliver nicotine orally.The gum was approved by the FDA in 1984 and made available exclu-sively over the counter in 1995. Generic brands are available. It comesin doses of 2 milligrams (mg) (recommended for those who smokefewer than 25 cigarettes per day) and 4 mg (for those who smoke 25 ormore cigarettes per day).6,26 Studies show that the gum can improvelong-term abstinence rates by 30 to 80% compared to placebo, and the4 mg dose is more effective than the 2 mg dose in highly dependentsmokers.6

The gum is not meant to be chewed in the way that ordinary gum ischewed. Instead, it is inserted in the mouth, chewed a few times until apeppery or minty flavor is sensed and nicotine released, and then placedbetween the gum and cheek. This action should be performed intermit-tently for 30 minutes or until the taste subsides. This is called “park andchew.” If a user fails to “park” the gum, the nicotine will be releasedinto the saliva and swallowed; this may cause nausea. Parking allowsnicotine to be absorbed through the lining of the mouth into the circula-tion. The nicotine takes several minutes to reach the brain and thusresults in a less intense “hit” than that produced by smoking. (Smokingdelivers nicotine via the lungs to blood that travels to the brain.)

Approximately 50% of the nicotine in the gum will be released andabsorbed. Food and beverages can interfere with the efficacy of thegum, so users should not eat or drink anything except water for 15 min-utes before, during, or after chewing. Users should chew an adequateamount of gum on a fixed schedule in order to achieve the maximumbenefit. Many users do not chew enough pieces per day or do not do sofor a sufficient number of weeks. The typical daily dose is 10 pieces fora maximum daily nicotine dose of 60 mg, and the recommended dura-tion is for 1 to 3 months, although this can vary.27

Nicotine gum has some advantages over other NRT products: it pro-vides faster nicotine delivery than some of the other NRT products,more effectively satisfies cravings induced by certain situations, is rela-tively discreet, and is readily available. Some disadvantages areunpleasant taste, the need to use multiple pieces per day, and potentialside effects such as jaw ache, mouth soreness, nausea, and stomachache.The average cost of the gum is $6.00-7.00 per day (depending on thedose), or approximately $40.00-50.00 for one week’s supply.6

Nicotine Inhaler (Nicotrol Inhaler)

The nicotine inhaler, or “puffer,” is a device consisting of a mouthpieceand a thin, plastic cartridge that contains a 4 mg nicotine plug. Theinhaler was introduced in 1998 and is available only by prescription.Each cartridge delivers as many as 400 puffs of nicotine vapor, thoughit takes nearly 80 puffs to obtain the amount of nicotine that one getsfrom smoking one cigarette. Studies show that the nicotine inhaler,compared with a placebo inhaler (an inhaler containing an inactive sub-stance instead of nicotine), more than doubles long-term quit rates.6

Although this product is labeled as an inhaler, it actually delivers nico-tine through the mouth — as the gum does — rather than though thelungs as cigarettes do. When the urge to smoke occurs, the user placesthe cartridge into the mouth and puffs in either shallow or deep breaths.This passes the vaporized nicotine into the back of the mouth andthroat, where it is absorbed through the lining of the mouth. Users gen-erally need to puff frequently for approximately 20 minutes (or one car-tridge) to get the 4 mg dose of nicotine, of which 2 mg will be absorbed— equivalent to the nicotine in two cigarettes. Users should note thatcold temperatures (below 400F) can decrease the amount of nicotine thatis extracted from the inhaler. To compensate, in cold weather the device

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should be kept in a warm place. Also, food and beverages can affect theabsorption of nicotine and should be avoided before, during, and afteruse to achieve maximum benefit. Users may need to use anywhere from6 to 16 cartridges per day during the first 6 to 12 weeks and then cantaper the number of cartridges over the subsequent 3 months. The man-ufacturer and public health officials recommend against using theinhaler for longer than 6 months.6,28

One advantage of the inhaler is that it can be used to address nicotinecravings and delivers nicotine as quickly as the gum does. Also, theproduct mimics the inhaling process and hand-to-mouth behavior ofsmoking, which may serve as a comfort to those trying to quit.However, some may see this as a disadvantage because for many smok-ers trying to quit, breaking the behavioral habit of smoking is an impor-tant part of the smoking cessation process. The most common sideeffect of the inhaler is irritation of the lining of the mouth (about 40%of users), but coughing, runny nose, and stomachache are also experi-enced by some users.6 However, these symptoms are often mild andusually diminish with regular use. The average cost of the inhaler is$5.70 per day, or $40.00 for a one-week supply, in addition to any doc-tor’s or prescribing fee required.29

Nicotine Lozenge (Commit)

This is a lozenge releasing small amounts of nicotine that is absorbedthrough the lining of the mouth and gums. The lozenge has been avail-able in Europe for many years but has just recently been approved bythe FDA for smoking cessation purposes.30 The lozenges are availableOTC (over the counter) in doses of 2 mg and 4 mg. Users should let thelozenge slowly dissolve in the mouth and may experience a warm ortingling sensation. Users should move the lozenge from one side of themouth to the other until it has completely dissolved (approximately 20-30 minutes) and should not chew or swallow the lozenge. Users alsoshould not eat or drink while using the lozenge, nor within 15 minutesbefore.

The recommended lozenge dose is determined by how soon a smokerhas a cigarette after waking up in the morning. For example, if a smok-er smokes within 30 minutes after waking, the 4 mg is recommended. Ifit is longer than 30 minutes, the 2mg is recommended. Users shouldtake 1 lozenge every 1-2 hours per day during the first 6 weeks, then


every 2-4 hours in weeks 7 through 9, and finally every 4-8 hours forweeks 10 through 12. Lozenges should not be used for more than 12weeks. The manufacturer recommends using only one lozenge at a timeand allowing some time between lozenges, as doing otherwise couldcause side effects such as hiccups, heartburn, or nausea. Also, usersshould not consume more than 20 lozenges daily. The cost is $39.95 for72 lozenges.

Nicotine Nasal Spray (Nicotrol NS)

The nicotine nasal spray is a spray pump containing aerosolized nico-tine that is delivered into the nostrils and absorbed through the nasalmembranes. This product was introduced in 1996 and is available byprescription in a quantity of 10 milliliters (ml). Each 0.05 ml spraydelivers 0.5 mg of nicotine, and one dose consists of one spray to eachnostril, for a total of 1 mg of nicotine. The nicotine nasal spray deliversnicotine more rapidly than other NRTs do, thus making it attractive tohighly dependent smokers. The spray can more than double long-termquit rates compared to placebo sprays.6

The nicotine nasal spray is similar to over the counter decongestantnasal sprays. The spray should be administered with the head tiltedslightly back, and users should not sniff, swallow, or inhale through thenose while the spray is administered. Initially, one spray should beadministered to each nostril once or twice per hour, or more frequentlyas needed, up to a maximum of 40 doses (40 mg) per day (or 5 dosesper hour), for 6 to 8 weeks. The minimum recommended dosage is 8doses per day for 3 to 6 months. Manufacturers suggest that for the opti-mum benefit from treatment, users should begin to taper doses after 3months in order to prevent withdrawal symptoms.

The major advantages of the nasal spray are that it can address suddennicotine cravings within minutes of use and it provides higher levels ofnicotine, allowing the user to “self-dose” as necessary. But there aresome side effects associated with use of this product, including irritationof the nasal passage, sinuses, and throat; coughing; and sneezing. Morethan 75% of users report such side effects.26 However, these side effectsusually subside and become more tolerable over time, usually after thefirst week as users learn how to use the nasal spray correctly. Peoplewith severe asthma, allergies, or other reactive airway diseases shouldnot use the nasal spray without discussing it with a physician.

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Users should be aware that there is a slightly greater dependency poten-tial for the nasal spray compared to the gum or patch — 15-20% ofpatients reported using the spray for longer than recommended (6-12months), and 5% used it at a dose that was higher than recommended.6

Those concerned with ongoing addiction may want to consider otherNRTs or other medications. The average cost of the spray is $5.00 perday (average of 13 doses) and as much as $15.00 per day for maximumusage (40 doses), in addition to any doctor’s or prescribing fee required.

Nicotine Patch (Habitrol, Nicoderm CQ, Nicotrol)

The nicotine patch, or transdermal nicotine, is a self-adhesive strip thatis applied to the skin and releases nicotine into the outer layer of theskin in various doses and intervals. The nicotine in the patch may takeas long as three hours to be absorbed through the skin and into thebloodstream. Thus, the patch must be worn for extended periods of timeso that the user maintains a constant blood level of nicotine. The patchwas introduced in 1992 and is available by prescription or over thecounter through three major brands. Generic patches are also available.Similar to other NRTs, patch use can double long-term quit rates com-pared to placebo.6

The 24-hour patch is available in 21 mg, 14 mg, and 7 mg doses,depending on the brand (generic brands have additional doses). A newpatch is applied to the skin each morning, usually on the abdomenbetween the neck and the waist or the upper arm or shoulder, and thelocation of the patch should be periodically rotated. According to manu-facturers, the patch should be used for 4 to 10 weeks; however, studiesshow that treatments of 8 weeks duration work as well as longer treat-ments.6 Highly dependent smokers — or those smoking more than 10-15 cigarettes per day — should begin with the highest possible doseand may opt initially for the 24-hour patch. Less dependent smokers —or those smoking fewer than 10 cigarettes per day — should start with alower dose. Manufacturers also recommend, in general, starting with ahigher dose and then tapering over 2-4 months. For example, the rec-ommended taper is 21 mg for 4 weeks, then 14 mg for 2 weeks, andfinally 7 mg for 2 weeks. The 16-hour patch comes in doses of 15 mg,10 mg and 5 mg. It should be applied in the morning and removedbefore bedtime. The recommended duration of treatment is 8 weeks.6

There are several advantages of the patch, including that it is very easy


to use, it comes in various doses, so the user can taper the dose asprogress is made, it need only be used once a day to provide a continualstream of nicotine, and it is inconspicuous. One disadvantage to thepatch is that it releases nicotine more slowly than other NRTs do andtherefore cannot be used to combat sudden nicotine cravings.

There are minimal side effects associated with the patch. The main sideeffect is a localized rash and skin irritation many users develop from theactual patch — approximately 50% of users experience such a reaction,but less than 5% actually have to stop using the product.6 Users cantreat these reactions with hydrocortisone or triamcinolone cream androtate the location of the patch as recommended. Further, people withexisting skin conditions, such as eczema, or allergies to adhesivesshould be cautious about using the patch and consider alternative NRTs.

Another potential side effect from the nicotine patch is sleep distur-bance. This usually occurs in those using the 24-hour patch, becauseusers are unaccustomed to having nicotine in the system while asleep.This can produce insomnia. Sleep disturbance can be prevented byusing the 16-hour patch or by removing the 24-hour patch during sleep-ing hours. However, taking the patch off at night can leave the user withan intense cigarette craving first thing in the morning. The average costof the patch is $4.00 per day, or about $30.00 for a one-week supply.

In development: Attempts were recently made to market several othernicotine-containing products in the U.S., including nicotine-containingwater,31 lollipops, and lip balm.32 However, these products were takenoff the market because they did not have FDA approval for use in smok-ing cessation.

Medications Other than Nicotine ReplacementTherapy

Bupropion SR (Zyban/Wellbutrin)

Bupropion SR (sustained-release) was the first non-nicotine medicationapproved to treat tobacco dependence. This drug, which is also used asan antidepressant, was made available by prescription for smoking ces-sation purposes in 1997,33 under the brand name “Zyban.” Researcherspresume that blocking reuptake of the neurotransmitters dopamineand/or norepinephrine is what makes this drug effective; however, this

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has not been definitively established.6 Bupropion is considered a first-line therapy because it has been proven effective in helping smokersquit; research shows that using bupropion can nearly double quit ratescompared to placebo.6 This is equivalent to the benefit achieved withNRT.

Users are advised to begin taking bupropion approximately 1-2 weeksbefore they plan to quit, as this is the amount of time required toachieve a steady blood level of the medication. The recommended doseis 150 mg daily for 3 days, then 150 mg twice daily (for a daily total of300 mg) for up to 12 weeks.6,33 For maintenance therapy, bupropion canbe used for up to 6 months, which is the FDA-approved duration.However, new research shows that using the medication for up to 12months is both safe and effective at preventing relapse.34 Treatmentduration should be discussed with a doctor and geared towards the indi-vidual’s progress. However, those not making significant progress inquitting by the seventh week should consider discontinuing the attemptand stop taking bupropion.35

Bupropion offers many benefits to those trying to quit. Because bupro-pion treatment must be initiated before the quit attempt, it prepares asmoker’s body for the actual stress of quitting. Many people like bupro-pion because it is an alternative to traditional nicotine replacement, orbecause they have previously tried NRT without success. Further, thistherapy is in the form of a twice-daily pill, which is an easy regimen tofollow. Another benefit of bupropion is that the side effects are mini-mal. The most common side effects are insomnia (in 35-40% of users)and dry mouth (10%).6 Users can minimize the risk of insomnia byabstaining from a dose near bedtime or by taking it much earlier in theafternoon or evening (though doses should be taken in intervals of atleast 8 hours). Less common side effects include shakiness, skin irrita-tions, headaches, and dizziness.

The major drawback of bupropion is that people with a history ofseizures or eating disorders and those taking a monoamine oxidase(MAO) inhibitor or another medication containing bupropion (such asWellbutrin to treat depression) should not use bupropion for smokingcessation purposes.6 In addition, similar to recommendations for NRTs,pregnant and lactating women should be encouraged to quit first andconsider bupropion only when the prospect of quitting without it isminimal. Although there is no evidence of danger to a fetus or nursing


infant, women who are pregnant or lactating should check with a physi-cian prior to starting this or any other medication. The average cost ofbupropion is approximately $4.00 per day, plus any necessary doctor’sor prescribing fee.

Second-Line Medications

There are also two second-line medications that may be helpful tosmokers — clonidine and nortryptyline — in addition to or instead ofnicotine replacement therapy. Second-line medications have evidence ofbeing effective in helping smokers to quit; however they are not FDA-approved specifically for tobacco dependence treatment and have anincreased potential for side effects compared to first-line therapies.These treatments should be explored on a case-by-case basis and onlyafter first-line medications have been utilized and determined ineffec-tive. As with first-line therapies, pregnant and lactating women shouldfirst be encouraged to quit without pharmacologic treatment and to usethese medications only if the chances of quitting without them are minimal.

Clonidine (Catapres)

Clonidine is a prescription medication used primarily for treating highblood pressure. However, studies show that clonidine can be effective intreating tobacco dependence and nearly doubles quit rates compared toplacebo.6 Clonidine can be administered orally or via a skin patch, andalthough an official dosing regimen for smoking cessation has not beenestablished, the preliminary recommendation is 0.10 mg daily, increas-ing by 0.10 mg/day per week if needed, for 3-10 weeks. Users shouldbegin the medication 3 days prior to quitting. Users should not stoptaking clonidine abruptly because side effects such as dry mouth,drowsiness, dizziness, headaches, and sedation may occur. Reboundhypertension (rapid increase in blood pressure) may occur if the med-ication is stopped abruptly. Instead, users should taper the dose over aperiod of a few days before discontinuing treatment. The average costof clonidine is $0.24 per day.

Nortriptyline HCI (Aventyl, Pamelor)

This prescription medication is FDA-approved as an antidepressant.Like bupropion, which is also an antidepressant, it has been shown to beeffective in helping smokers quit. Treatment is initiated 10 to 28 days

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prior to quitting, at a recommended dosage of 25 mg per day initially,increasing to 75-100 mg per day, for a duration of 12 weeks. Commonside effects include sedation, dry mouth, blurred vision, urinary reten-tion, lightheadedness, and shaky hands. Because of the sedative effectof nortriptyline, users should take extra caution while driving and oper-ating machinery. Also, because this medication increases the risk ofarrhythmias, patients with cardiovascular disease should discuss the useof nortriptyline thoroughly with their doctors. The risk of overdose ishigh and the drug may produce cardiotoxic effects. The average cost is$0.74 per day.

Combination Therapy

Combining drug therapies has been suggested as a way to improve quitrates, compared to using one treatment alone. However, the FDA hasnot approved any specific combinations, and thus any combination isconsidered a second-line treatment. Based on various research studies,the USPHS recommends using one therapy that provides a steady dos-ing of nicotine or other smoking cessation medication in the blood-stream and adding a therapy that can readily address nicotine cravings.6

For example, using the patch in combination with a self-administeredNRT such as the gum, inhaler, or nasal spray is more effective thanusing one NRT alone.6,26 Also, using bupropion with the patch has beenshown to increase quit rates significantly compared to using either thepatch alone or placebo.35-37 Because combination therapy usually resultsin higher blood levels of nicotine than the use of a single NRT andcould possibly cause nicotine overdose, and because combination thera-py is relatively new, users should only consider combination therapy ifthey are highly addicted smokers, if one-drug therapy has failed, andthey are following a doctor’s recommendation.

Medications Not Recommended

The USPHS does not recommend any drug therapies for use in smokingcessation other than those already mentioned.6 Medications that are notrecommended include antidepressants other than bupropion and nor-triptyline; anti-anxiety drugs, benzodiazepines (a class of anti-anxietydrugs), and beta-blockers; silver acetate; and mecamylamine.6 Researchhas not demonstrated that these medications are effective as aids tosmoking cessation.


COUNSELING AND SUPPORT

There are several forms of counseling and support available that canhelp smokers cope with the physical, mental, and behavioral aspects ofquitting. Counseling and support are an integral part of the quittingprocess and can be used either alone or in combination with drug thera-py (see Table 2 for additional smoking cessation resources).

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Table 2. Smoking Cessation Resour c e s

• American Cancer Society • National Cancer Institute1599 Clifton Road, NE 9000 Rockville PikeAtlanta, GA 30329-4251 Building 31 10A16American Psychiatric Assoc. Bethesda, MD 20892(800) ACS-2345 (800) 4-CANCERwww.cancer.org www.nci.nih.gov

• American Lung Association • Nicotine Anonymous1740 Broadway NAWSONew York, NY 10019 PO Box 591777(800) LUNG-USA San Francisco, CA 94159-1777www.lungusa.org (415) 750-0328

(415) 750-0328www.nicotine-anonymous.org

• American Heart Association • Society for Research on NicotineNational Center & Tobacco7272 Greenville Avenue 7611 Elmwood AvenueDallas, TX 75231 Middleton, WI 53562(800) AHA-USA-1 (608) 836-3787www.americanheart.org www.srnt.org

• Campaign for Tobacco-Free Kids • American Legacy Foundation1400 Eye Street, Suite 1200 1001 G Street, NW, Suite 800Washington DC 20005 Washington, DC 20001(202) 296.5469 (202) 454-5555www.tobaccofreekids.org www.americanlegacy.org

N ATIONAL ORGANIZA T I O N S

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All smokers trying to quit should consider counseling in order toaddress some of the behavioral hardships associated with cessation.Counseling can help a smoker learn practical tactics that are effective intreating tobacco dependence. The smoker needs to recognize situationsthat may trigger relapse. These may include being in the presence ofother smokers, whether at home, work, or in a social situation; drinkingalcohol, which is a common initiator of smoking in many individuals;and experiencing stressful situations. These situations will vary fromone smoker to the next. Counseling can help smokers identify thesesmoking “cues” and develop behavioral coping skills to learn how tobreak the link to what urges them to smoke. For example, askingfriends and family to avoid smoking in one’s presence is a coping skill


Table 2. Smoking Cessation Resources ( c o n t i nu e s )

• Your physician • Local hospital or worksite wellness/employee assistance program• Your local or state department of health• Your state alcohol and drug abuse office• Local chapters of national health organizations, such as the American

Cancer Society or American Lung Association

• Smart Move! A Stop Smoking • You Can Quit SmokingGuide U.S. Department of Health American Cancer Society Services(800) ACS-2345 (800) 354-9295www.cancer.org www.surgeongeneral.gov/tobacco

• Quit Smoking Action PlanAmerican Lung Association(212) 315-8700www.lungusa.org

• QuitNet.com• Smokeclinic.com• LungUSA.org• Trytostop.org

L O C AL RESOURCES

B R OCHURES FOR SMOKERS

INTERNET PR O G R A M S

that can help the smoker avoid temptation. Also, committing to lifestylechanges that increase pleasure and reduce stress, such as increased exer-cise and taking up a hobby, can help in a difficult situation.

Many different types of counseling are available, ranging from individ-ual sessions to support groups and telephone counseling. Any communi-cation directed towards encouraging the smoker to quit seems to be ofsome benefit, and the USPHS recommends using at least one type.6

Using multiple forms of counseling or support may be even more eff e c t i v e .

Support Groups

Counseling and behavioral therapies were initially developed for use ina group format, in order to provide a supportive environment for thosetrying to quit. Social support in general increases the chances of quit-ting,6 and support groups can teach behavioral coping skills and intro-duce members to partners or buddies who are trying to quit. Groupmembers can also offer each other personal tips on how to stay ciga-rette-free. Group counseling programs should be at least 20-30 minuteslong, offered a few times per week, and last for more than two weeks.38

Although group programs can increase long-term abstinence rates by asmuch as 25-40%,38 few smokers actually attend them.49

Individual Counseling

Individual counseling sessions are also an option. This form of behav-ioral therapy increases the chances of quitting — perhaps more so thanother types of counseling. Brief advice from a physician to an individ-ual, lasting as little as 3 to 5 minutes, has been shown to produce highercessation rates than no advice.6,40 And the more time spent with the indi-vidual, the better the outcome. A smoker should look for a trained coun-selor or a physician with whom he/she feels comfortable and easily ableto discuss the difficulties of cessation. Individually tailored sessions thataddress the specific problems of a smoker are most desired; however,this format can be expensive.

Telephone Counseling

Telephone counseling also seems to improve quit rates.41,42 Many statehealth departments, NRT manufacturers, and nonprofit organizationsoffer free telephone counseling or “quitlines.” Thirty-three states cur-

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rently have some form of quitline, and other states are planning to fol-low suit (see Table 3 for information on those states offering smokingcessation resources). In an effective telephone program, the counselorwill usually contact the smoker several times after the initial call tomonitor progress and provide continued support and encouragement.Because of the confidentiality associated with telephone counseling, itmay prove more acceptable and hence more effective than other formsof counseling for some people. It also can be used as an adjuvant to aprescription or OTC tobacco dependence medication.


Table 3. S t a tes Providing Counseling and Inf o rm at i o non Smoking Cessa t i o n *

Alaska 1-888-842-QUIT (7848)

Alaska 1-888-842-QUIT (7848)

Arizona 1-800-556-6222

California 1-800-NO-BUTTS (662-8887)1-800-45-NO-FUME (456-6386) (Spanish)1-800-778-8440 (Vietnamese)1-800-838-8917 (Mandarin and Cantonese)1-800-556-5564 (Korean)TDD: 1-800-933-48331-800-844-CHEW (2439) (Smokeless Tobacco)

Colorado 1-800-639-QUIT (7848)TTY: 1-866-228-4327

Connecticut 1-866-END-HABIT (363-4224)

Delaware 1-866-409-1858

Florida 1-877-U-CAN-NOW (822-6669)TTY: 1-866-228-4327

Georgia 1-877-270-STOP (7867)1-877-2NO-FUME (266-3863) (Spanish)TTY: 1-877-777-6534

Illinois 1-866-QUIT-YES (784-8937)

Iowa 1-866-U-CAN-TRY (822-6879)

Louisiana 1-800-LUNG-USA (586-4872)

If information regarding your states is not listed, please call 1-800-425-3422 for addi-tional resources. * This information was provided by the New York Times, November 19, 2002.

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Maine 1-800-207-1230

Massachusetts 1-800-TRY-TO-STOP (879-8678)1-800-8DEJALO (833-5256) (Spanish and Portuguese)TDD: 1-800-833-1477

Michigan 1-800-834-4781 (Medicaid)1-800-537-5666 (Printed Materials)

Minnesota 1-877-270-STOP (7867)1-877-2NO-FUME (266-3863) (Spanish)TTY: 1-877-777-6534

Mississippi 1-800-244-9100

Nebraska 1-866-NEB-QUIT (632-7848)

Nevada 1-888-86-NONIC (866-6642)1-702-877-0684 (Las Vegas)

New Hampshire 1-800-TRY-TO-STOP (879-8678)1-800-8DEJALO (833-5256 (Spanish and Portuguese)TDD: 1-800-833-1477

New Jersey 1-866-NJ-STOPS (657-8677)TTY: 1-866-257-2971

New York 1-866-609-6292TTY: 1-800-280-1213

Oklahoma 1-866-PITCH-EM (748-2436) (Tulsa County)TTY: 1-866-228-4327

Oregon 1-877-270-STOP (7867)1-877-2NO-FUME (266-3863) (Spanish)TTY: 1-877-777-6534

Pennsylvania 1-877-724-1090TTY: 1-866-228-4327

Rhode Island 1-800-TRY-TO-Stop (879-8678)1-800-8DEJALO (833-5256) (Spanish and Portuguese)TDD: 1-800-833-1477

South Dakota 1-866-SD-QUITS (737-8487)TYY: 1-866-228-4327

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Internet Programs

Recently, several Internet sites have been developed to help smokersquit. These sites create a virtual support group and offer online counsel-ing services similar to telephone counseling. Here smokers can alsoplan a quit attempt, track progress, chat with others trying to quit, andhave access to smoking cessation resources and information. Internetprograms are very flexible and can provide round-the-clock support.Research is underway to see if this type of counseling is effective, butpreliminary results show that these virtual programs may help smokersquit at rates similar to those of in-person programs.

Self-Help

Many self-help materials and programs are available, including pam-phlets, books, videotapes, audiotapes, and others. However, the effec-tiveness of self-help when used alone is inconsistent, and success ratesare similar to those experienced by smokers who do not use any coun-seling.6,43


Table 3. S t a tes Providing Counseling and Inf o rm at i o non Smoking Cessa t i o n ( c o n t i nu e d )

Texas 1-877-YES-QUIT (937-7848)TYY: 1-866-228-4327

Utah 1-888-567-TRUTH (8788)1-877-2NO-FUME (266-3863) (Spanish)TDD: 1-877-777-4327

Vermont 1-877-YES-QUIT (937-7848)TTY: 1-866-228-4327

Virginia 1-877-856-5177 (Printed Materials)

Washington 1-877-270-STOP (7867)1-877-2NO-FUME (266-3863) (Spanish)TTY: 1-877-777-6534

West Virginia 1-800-Y-NOT-QUIT (966-8784)

Wisconsin 1-877-270-STOP (7867)1-877-2NO-FUME (266-3863) (Spanish)TYY: 1-877-777-6534

Aversive Smoking

The use of aversive smoking interventions, in which a smoker repeated-ly smokes intensively and rapidly until the point of discomfort to asso-ciate smoking with negative feelings, can be effective in some smokersand may increase the likelihood of quitting.6 However, this approach tosmoking cessation may pose a health risk to some individuals andshould be monitored closely. This type of therapy is not commonlypracticed today.

COMBINING MEDICATION WITH COUNSELING/S U P P O R T

Using some form of drug therapy, such as NRT or non-nicotine medica-tions as discussed above, in combination with some form of counselingor group support seems to produce the highest long-term success rates.The medications help treat the physical addiction to smoking, whilecounseling helps with the behavioral addiction. Thus a smoker can easethe nicotine addiction and develop coping methods for quitting, learnstrategies for staying smoke-free, and receive general social support atthe same time. Adding drug therapy to counseling can nearly doublequit rates.26

“A LT E R N AT I V E ” T H E R A P I E S

Although therapies such as acupuncture and hypnosis have become pop-ular “alternative” ways to try to quit smoking, there is no clinicalresearch to support the effectiveness of these therapies. The USPHSdoes not recommend these treatments and suggests that any effect ismost likely due to a positive expectation that the therapy will help(placebo effect).

Acupuncture

This ancient technique of using needles to stimulate nerve endingsthought to be associated with particular functions of the body has beenproposed as an alternative treatment to help smokers quit. For example,acupuncturists think that certain spots in the ears, nose, and wrists maybe correlated with the urge to smoke. However, no studies have support-ed this claim and thus smokers should be skeptical about whether this isa plausible therapy.

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Hypnosis

For years, hypnosis has been used in an effort to diminish the subcon-scious desire to smoke. Although hypnosis may be helpful for someindividuals, research does not support its efficacy, and it is not general-ly accepted as a standard form of therapy.6

Herbal Remedies

Some people have touted herbal medications such as St. John’s Wort(used as an antidepressant) and kava kava (used to relieve anxiety) assubstitutes for approved smoking cessation medications. These herbalremedies have no proven benefit in helping smokers quit and may haveharmful side effects.38 Since herbal remedies interact with some pre-scription and over-the-counter drugs, anyone who is taking any kind ofmedication — including medications used in smoking cessation —should not take herbal remedies without consulting a physician.

NEW A P P R OAC H

Inpatient Treatment

Despite the treatments currently available, many smokers still do notachieve the ultimate goal of quitting permanently. Some researcherssuggest that those who fail to quit after several tries with the availabletreatments may be more addicted than most to nicotine and thus in needof more intensive therapy.44 There are many inpatient facilities, or so-called “rehab” centers, for people who are addicted to other drugs, andresearchers are exploring the possible use of this setting for combatingnicotine dependence as well. The Nicotine Dependence Center at theMayo Clinic in Rochester, Minnesota, provides a week-long residentialinpatient treatment program for highly dependent smokers that com-bines intensive behavioral counseling with drug therapy. This programencompasses many facets of smoking cessation treatment and includesindividualized nicotine replacement therapy, daily group and individualcounseling sessions, seminars for stress reduction, diet and nutritioninformation, and exercise programs. Preliminary results suggest thatthis form of treatment is more effective than traditional outpatient treat-ment and could be an option for highly dependent smokers.45 After oneyear, as many as 45% of the inpatients remained abstinent, compared to23% of a control group of people treated on an outpatient basis.


Inpatient treatment is substantially more expensive (the current cost isapproximately $3,300 per week) than outpatient therapy; however, itmay prove to be more cost-effective for some highly addicted smokersin the long term.

FUTURE A P P R OAC H E S

Nicotine Vaccine

A new development in the treatment of nicotine addiction is theprospect of an “anti-smoking” or nicotine vaccine. The nicotine vaccineworks by producing antibodies that bind to nicotine and prevent thedrug from reaching the brain, thus eliminating the reward effects thatare usually produced upon smoking. The vaccine would most likely beused to end an existing addiction, protect former smokers from relapse,and prevent the onset of addiction.46 Animal studies have shown that theconcept works,47,48 and a British biotechnology company recentlyannounced that preliminary results from human trials indicate that thevaccine is safe and effective.49 The vaccine could offer many advan-tages over other smoking cessation treatments. The early versions areeffective for 4-6 weeks, which could increase cessation rates. The vac-cine will most likely be relatively inexpensive to manufacture and canbe distributed widely. If the vaccine proves effective in preventing theonset of addiction, it could be used as a prevention method. The vaccinewould not help smokers with the behavioral aspects of smoking, but itcould be used in conjunction with the forms of counseling discussedearlier. U.S. companies are in the process of developing similar products— including an anti-smoking pill — and although this concept showspromise, it will be several years before a product is available.

Nicotine Vaporization

This is a new technology in development that is intended to delivernicotine with a significantly smaller amount of carcinogens than ciga-rette smoking produces.50 A nicotine vaporization device heats tobacco,as opposed to burning it, causing the release of nicotine vapors. Themanufacturer has also developed a smoking cessation plan based on thisconcept. Like other NRTs, the discs used in this method will come invarious doses and then can be tapered as the desire for nicotine sub-sides. And like the nicotine inhaler, the device can be held like a ciga-rette, thus giving the smoker something to do with the mouth and hands.

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This product is not currently approved by the FDA for smoking cessa-tion purposes.

Harm Reduction

Harm reduction means encouraging smokers to alter tobacco use habitsif they cannot be eliminated altogether in order to reduce the adversehealth effects that result from smoking. Common, though often ineffec-tive, methods for doing this include cutting back on the number of ciga-rettes smoked or switching to so-called “lite” or low-tar cigarettes.While these methods may sound good in theory, they are not alwayspractical and do not eliminate the hazards of smoking. Smokers whoattempt to smoke less sometimes compensate by inhaling more deeplyand usually revert to prior smoking habits. “Lite” cigarettes are not lessharmful, especially since smokers may inhale these more deeply, coverthe filters with their fingers to take in as much “tar” and nicotine aswith regular brands, or simply smoke more cigarettes.

The use of smokeless (also known as “chewing” or “spit”) tobacco inplace of cigarettes to obtain nicotine is an alternative to smoking. Someindividuals have found it a good way to help them stop smoking — noteliminating but at least reducing some health risks. Research into theusefulness of smokeless tobacco as an alternative to smoking is ongoingand controversial. It is well known, after all, that the use of smokelesstobacco poses health risks of its own,6 though they are small comparedto smoking. Until and unless future research identifies harm reductiontechniques that are safe and effective, smokers should try first to quitusing the methods currently available.

ADDITIONAL ISSUES IN SMOKING CESSA T I O N

WEIGHT GAIN

Fear of weight gain makes many people hesitant to quit smoking. Thetruth is that most smokers do gain weight after quitting. The averageweight gain is 5 to 10 pounds,2 but as many as 10% of people trying toquit will gain more than 30 pounds.6 This usually occurs because smok-ers snack or eat more to compensate for the lack of cigarettes and with-drawal symptoms. Also, many quitters experience an enhanced sense oftaste and smell, which may increase the desire to eat. Others need toreplace the behavioral aspect of smoking with eating.


Women, especially, are concerned with weight gain, and because nico-tine suppresses appetite and increases metabolism, many women beginsmoking or continue to smoke at least in part as a weight control meas-ure. And the tobacco industry even uses weight as an advertising strate-gy. Women who quit smoking do tend to gain slightly more weight thanmen do.6,51 The use of nicotine gum and bupropion seems to delay theonset of weight gain after cessation, but once their use is discontinuedthe potential for weight gain usually returns.6,52 Smokers must remem-ber that a slight weight gain is not as nearly harmful to health as thehazards from continued smoking. They should not let the fear of weightgain deter them from trying to quit.

In order to avoid or minimize weight gain, quitters should concentrateon eating a healthful diet and exercising regularly. They should notattempt to diet in the first few days or weeks after quitting because itwould be difficult to concentrate on smoking cessation and dieting atthe same time. In fact, dieting while attempting to quit may causerelapse.53 Exercise, however, has been shown to be effective in prolong-ing abstinence for women and delays weight gain when incorporatedinto a smoking cessation program.54

D E P R E S S I O N

There is a link between smoking and depression that can factor into anattempt to quit smoking: people who suffer from depression are morelikely to be addicted to cigarettes than those who are not depressed, andsmokers who experience more intense depression have a harder timequitting.55,56 Because bupropion is actually an antidepressant, it helpsease many of the symptoms of depression associated with trying to quitin addition to decreasing the urge to smoke. It is also possible that quit-ting smoking may precipitate a relapse of depression in smokers with ahistory of depression.57 Thus, prospective quitters with a history ofdepression might be well advised to seek medical and psychologicalmonitoring when attempting to quit smoking.

A L C O H O L

There is also a strong link between smoking and alcohol consumption.Many smokers are “social smokers” who smoke mainly in social situa-tions when they also drink alcoholic beverages. Those who drink heavi-ly are also more likely to smoke heavily. Thus, reducing alcohol con-

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sumption may actually help in smoking cessation, in addition to remov-ing the smoker from tempting environments. In fact, in those peoplewho suffer from alcohol dependency problems, a relapse to drinkingmay also cause a relapse to smoking.58 Conversely, continued smokingcan cause a relapse to drinking. Choosing smoking cessation methodsand programs that can address both of these issues is crucial to a suc-cessful quit attempt.

SPECIAL POPULA T I O N S

The USPHS has identified the following special populations for whoman adaptation in treatment for smoking cessation may be warranted.Taking these differences into consideration may help increase the num-ber of individuals who successfully quit smoking.

Women: All smoking cessation treatments have been shown to benefitboth men and women. However, smoking patterns can differ betweenmen and women: women tend to smoke fewer cigarettes per day, smokelower nicotine cigarettes, and do not inhale as deeply.59 Women mayalso experience more intense withdrawal symptoms.60 Women also faceslightly different barriers to cessation than men do, including a moreintense fear of weight gain, a greater likelihood of depression, and hor-monal fluctuations. Some suggest that women smoke more for the sen-sory aspect of smoking than for the nicotine.51 Thus, it may be that menand women should receive different treatments.

Pregnant women: Because smoking can seriously harm a developingembryo or fetus, pregnant women are encouraged to quit as soon aspregnancy is determined. Pregnant smokers should first try to quit usingcounseling, behavioral interventions, and social support. If this isunsuccessful, drug therapy should be considered. As mentioned previ-ously, nicotine replacement therapy and bupropion are potential treat-ment options under medical supervision. Further, other members of thefamily who smoke should be encouraged to do so outside the householdenvironment, as secondhand tobacco smoke can interfere with fetallung development.

Members of racial and ethnic minority groups: Although smoking andcessation patterns may vary among populations, smoking cessationtreatments are effective across all racial and ethnic groups. Someresearch has suggested that some populations may respond differently


than others to certain drug therapies. However there are no conclusivedata to support prescribing different medications for people of differentethnic backgrounds. Nevertheless, smoking cessation programs andcomponents such as educational materials and counseling should be tai-lored to an individual’s language and culture.

Hospitalized smokers: Hospitalized smokers, whether in long-term orshort-term facilities, should be encouraged to stop smoking and provid-ed with the necessary means to do so.6 Smoking can interfere withrecovery and further compromise preexisting conditions. Because hospi-tals are now generally smoke-free, patients are already in an appropriateenvironment and should use this as a catalyst in attempting to quit.

Patients with preexisting psychiatric conditions and/or chemicaldependency: Smoking cessation treatments can be effective in smokerswith preexisting psychiatric conditions, such as depression, and thosewith chemical dependency problems such as alcohol abuse. Becausebupropion and nortriptyline are antidepressants and are useful in treat-ing smoking cessation, these drugs specifically are options for smokerswho have a history of depression. Research shows that smokers withother chemical dependency problems can benefit from smoking cessa-tion treatments.6 Treatment for smoking cessation does not seem tocompromise treatment of other forms of chemical dependency.

Children and adolescents: The number of adolescent smokers hasincreased dramatically in the past decade, and the age at which youngpeople try their first cigarette is decreasing.1 Adolescents often becomeaddicted rapidly, and like adults, they may find it difficult to quit.1

There are currently no standard guidelines for treating tobacco depend-ence in children and adolescents.61 The same methods that are used foradults can also be used in adolescents, though some alterations may benecessary. Counseling and support are encouraged and should addressmany of the social and psychological issues involved with teen smok-ing. NRTs and bupropion can be used in adolescents under the supervi-sion of a physician. Young prospective quitters should be aware thatover the counter NRT products cannot be purchased legally by anyoneunder the age of 18, and that NRT products are subject to the sameschool rules that apply to other types of medication.

Older smokers: Smoking cessation interventions, including counseling,support groups, and NRT, have been shown to be effective in smokers

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over the age of 50 and also in those over the age of 65.6 In older adults,just as in younger people, quitting can reduce the risk of heart attacks,coronary artery disease, and lung cancer and can help individualsrecover more rapidly from illnesses that are exacerbated by smoking.

SMOKELESS T O BACCO AND OTHER T O BAC C OP RO D U C T S

Although tobacco dependence encompasses products other than ciga-rettes, the focus of this report is cigarette smoking cessation. There hasbeen only limited research on the treatment of dependence on othertobacco products such as smokeless tobacco, cigars, and pipes.However, experts suggest that some of the same methods used for ciga-rette smoking cessation, specifically counseling, may be effective inhelping users of these products quit.6

INSURANCE CO V E R AG E , ACCESS TO T R E AT M E N T ,AND COST EFFECTIVENESS

Smoking cessation treatment is not integrated into the general U.S.healthcare system at the present time. Few insurance companies andonly some Medicaid and state health agencies reimburse for smokingcessation treatments.16,62 When coverage is provided, there may bequalifications and limitations — such as lifetime caps or time con-straints — that may make it difficult to utilize services effectively.Some plans that do cover smoking cessation cover 50% of behavioralservices and 100% of nicotine replacement therapy.63 Currently, 34states provide some form of Medicaid coverage for tobacco dependencetreatments for low-income smokers, while the remaining states do not.64

Many smokers live below the poverty line and have no healthcare cov-erage whatsoever, making it very difficult to gain access to treatment.

The United Kingdom recently announced that it would reimburse fornicotine replacement products under the National Health Service pre-scription and will also provide additional benefits for bupropion.65

Some think that offering more drug therapies over the counter willresult in a higher utilization of these treatments and thus a higher suc-cess rate.66 Studies show that providing the nicotine patch over thecounter doubles quit rates compared to placebo,6 and NRTs such as thepatch and gum available over the counter have success rates compara-ble to when they are delivered via prescription.67 Most importantly,


over the counter status increases the number of smokers who haveaccess to the treatments and the likelihood that they will use the prod-ucts.

According to healthcare professionals, smoking cessation treatment isthe “gold standard” of preventive healthcare services.68 Given the sub-stantial costs of smoking and its effects on health and healthcare costs,smoking cessation treatment should be encouraged and integrated intothe healthcare system.

C O N C L U S I O N

Stopping smoking is one of the most important and most challenginglifestyle changes an individual can make. Although the efficacy ofsmoking cessation methods and programs may appear limited, drugtherapies and counseling/support do help many smokers quit. The moreintense, the more persistent, and the more integrated the treatment, thegreater the success rate. Smokers who participate in intensive therapieshave higher quit rates, and the most important factor in achieving suc-cess is utilizing treatment and maintaining the motivation to make mul-tiple quit attempts. Using some form of drug therapy can increase thechance of success by nearly 30%, and combining this treatment withcounseling can nearly double that rate. Choosing a smoking cessationtechnique is a matter of individual needs, expectations, and resources,and no single method has been proven to work for everyone.

Considering the many health, social, and economic benefits of quitting— and the many treatments available — it is in a smoker’s best interestto attempt to quit. More than 45 million Americans have liberated them-selves from smoking, so it is possible to quit — and quit for good.

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Elizabeth M. Whelan, Sc.D., M.P.H.President

A C S H B O A R D O F D I R E C T O R S

John H. Moore, PH.D., M.B.A.Chairman of the Board, ACSH

Elissa P. Benedek, M.D. University of Michigan

Norman E. Borlaug, PH. D .Texas A&M University

Michael B. Bracken, PH.D., M.P.H. Yale University School of Medicine

Christine M. Bruhn, Ph.D.University of California

Taiwo K. Danmola, C.P.A.Ernst & Young

Thomas R. DEGregori, PH. D .University of Houston

Henry I. Miller, m.d.Hoover Institution

A. Alan Moghissi, PH.D. Institute for Regulatory Science

Albert G. Nickel Lyons Lavey Nickel Swift, Inc.

Kenneth M. Prager, M.D.Columbia College of Physicians and Surgeons

Stephen S. Sternberg, M.D.Memorial Sloan-Kettering Cancer Center

Mark C. Taylor, M.D.Physicians for a Smoke-Free Canada

Lorraine Thelian Ketchum Public Relations

Kimberly M. Thompson, SC.D. Harvard School of Public Health

Elizabeth M. Whelan, SC.D., M.P.H. American Council on Science and Health

R o b e rt J. White, M.D., PH. D .Metrohealth Medical Center, OH

A C S H B O A R D O F S C I E N T I F I C A N D P O L I C Y A D V I S O R S

Ernest L. Abel, Ph.D.C.S. Mott CenterGary R. Acuff, Ph.D.Texas A&M UniversityJulie A. Albrecht, Ph.D.University of Nebraska, LincolnJames E. Alcock, Ph.D.Glendon College, York UniversityThomas S. Allems, M.D., M.P.H.San Francisco, CARichard G. Allison, Ph.D.American Society for Nutritional Sciences (FASEB)John B. Allred, Ph.D.Ohio State UniversityPhilip R. Alper, M.D.University of California, San FranciscoKarl E. Anderson, M.D.University of Texas, Medical BranchDennis T. AveryHudson InstituteRonald Bachman, M.D.Kaiser Permanente Medical CenterRobert S. Baratz, D.D.S., Ph.D., M.D.International Medical Consultation ServicesNigel M. Bark, M.D.Albert Einstein College of MedicineStephen Barrett, M.D.Allentown, PAThomas G. Baumgartner, Pharm.D., M.Ed.University of FloridaW. Lawrence Beeson, Dr.P.H.Loma Linda University School of Public HealthSir Colin Berry, D.Sc., Ph.D., M.D.Institute of Pathology, Royal London HospitalBarry L. Beyerstein, Ph.D.Simon Fraser UniversitySteven Black, M.D.Kaiser Permanente Vaccine Study CenterBlaine L. Blad, Ph.D.Kanosh, UTHinrich L. Bohn, Ph.D.University of ArizonaBen Bolch, Ph.D.Rhodes CollegeJoseph F. Borzelleca, Ph.D.Medical College of VirginiaMichael K. Botts, Esq.Ames, IAGeorge A. Bray, M.D.Pennington Biomedical Research CenterRonald W. Brecher, Ph.D., C.Chem., DABTGlobalTox International Consultants, Inc.Robert L. Brent, M.D., Ph.D.Alfred I. duPont Hospital for ChildrenAllan Brett, M.D.University of South CarolinaKenneth G. Brown, Ph.D.KBincGale A. Buchanan, Ph.D.University of GeorgiaGeorge M. Burditt, J.D.Bell, Boyd & Lloyd LLCEdward E. Burns, Ph.D.Texas A&M UniversityFrancis F. Busta, Ph.D.University of MinnesotaElwood F. Caldwell, Ph.D., M.B.A.University of MinnesotaZerle L. Carpenter, Ph.D.Texas A&M University SystemC. Jelleff Carr, Ph.D.Columbia, MDRobert G. Cassens, Ph.D.University of Wisconsin, MadisonErcole L. Cavalieri, D.Sc.University of Nebraska Medical CenterRussell N. A. Cecil, M.D., Ph.D.Albany Medical College

Rino Cerio, M.D.Barts and Institute of Pathology, Royal London HospitalMorris E. Chafetz, M.D.Health Education FoundationBruce M. Chassy, Ph.D.University of Illinois, Urbana-ChampaignDale J. Chodos, M.D.Kalamazoo, MIMartha A. Churchill, Esq.Milan, MIEmil William Chynn, M.D.Manhattan Eye, Ear & Throat Hospital/New York Eye and Ear InfirmaryDean O. Cliver, Ph.D.University of California, DavisF. M. Clydesdale, Ph.D.University of MassachusettsDonald G. Cochran, Ph.D.Virginia Polytechnic Institute and State UniversityW. Ronnie Coffman, Ph.D.Cornell UniversityBernard L. Cohen, D.Sc.University of PittsburghJohn J. Cohrssen, Esq.Public Health Policy Advisory BoardNeville Colman, M.D., Ph.D.St. Luke’s Roosevelt Hospital CenterGerald F. Combs, Jr., Ph.D.Grand Forks Human Nutrition Research CenterMichael D. Corbett, Ph.D.Omaha, NEMorton Corn, Ph.D.Johns Hopkins UniversityNancy Cotugna, Dr.Ph., R.D., C.D.N.University of DelawareH. Russell Cross, Ph.D.Future Beef Operations, L.L.C.James W. Curran, M.D., M.P.H.Rollins School of Public Health, Emory UniversityCharles R. Curtis, Ph.D.Ohio State UniversityIlene R. Danse, M.D.Novato, CAErnst M. Davis, Ph.D.University of Texas, HoustonHarry G. Day, Sc.D.Indiana UniversityRobert M. Devlin, Ph.D.University of MassachusettsSeymour Diamond, M.D.Diamond Headache ClinicDonald C. Dickson, M.S.E.E.Gilbert, AZJohn DieboldThe Diebold Institute for Public Policy StudiesRalph Dittman, M.D., M.P.H.Houston, TXJohn E. Dodes, D.D.S.National Council Against Health FraudSir Richard Doll, M.D., D.Sc., D.M.University of OxfordTheron W. Downes, Ph.D.Michigan State UniversityMichael Patrick Doyle, Ph.D.University of GeorgiaAdam Drewnowski, Ph.D.University of WashingtonMichael A. Dubick, Ph.D.U.S. Army Institute of Surgical ResearchGreg Dubord, M.D., M.P.H.RAM InstituteEdward R. Duffie, Jr., M.D.Savannah, GAEdward R. Duffie, Jr., M.D.Savannah, GALeonard J. Duhl, M.D.University of California, Berkeley

James R. Dunn, Ph.D.Averill Park, NYRobert L. DuPont, M.D.Institute for Behavior and Health, Inc.Henry A. Dymsza, Ph.D.University of Rhode IslandMichael W. Easley, D.D.S., M.P.H.International Health Management & Research Associates/National Center for Fluoridation Policy & ResearchJ. Gordon Edwards, Ph.D.San José State University

George E. Ehrlich, M.D., F. A . C . P., M.A.C.R., FRCP (Edin)Philadelphia, PAMichael P. Elston, M.D., M.S.Rapid City Regional HospitalWilliam N. Elwood, Ph.D.Center for Public Health & Evaluation ResearchJames E. Enstrom, Ph.D., M.P.H.University of California, Los AngelesStephen K. Epstein, M.D., M.P.P., FACEPBeth Israel Deaconess Medical CenterMyron E. Essex, D.V.M., Ph.D.Harvard School of Public HealthTerry D. Etherton, Ph.D.Pennsylvania State UniversityR. Gregory Evans, Ph.D., M.P.H.St. Louis University Center for the Study ofBioterrorism and Emerging InfectionsWilliam Evans, Ph.D.University of AlabamaDaniel F. Farkas, Ph.D., M.S., P.E.Oregon State UniversityRichard S. Fawcett, Ph.D.Huxley, IAJohn B. Fenger, M.D.Phoenix, AZOwen R. Fennema, Ph.D.University of Wisconsin, MadisonFrederick L. Ferris I II, M.D.National Eye InstituteDavid N. Ferro, Ph.D.University of MassachusettsMadelon L. Finkel, Ph.D.Cornell University Medical CollegeJack C. Fisher, M.D.University of California, San DiegoKenneth D. Fisher, Ph.D.Washington, DCLeonard T. Flynn, Ph.D., M.B.A.Morganville, NJWilliam H. Foege, M.D., M.P.H.Emory UniversityRalph W. Fogleman, D.V.M.Doylestown, PAChristopher H. Foreman, Jr., Ph.D.University of MarylandE. M. Foster, Ph.D.University of Wisconsin, MadisonF. J. Francis, Ph.D.University of MassachusettsGlenn W. Froning, Ph.D.University of Nebraska, LincolnVincent A. Fulginiti, M.D.University of Colorado/University of ArizonaArthur Furst, Ph.D., Sc.D.University of San FranciscoRobert S. Gable, Ed.D., Ph.D., J.D.Claremont Graduate UniversityShayne C. Gad, Ph.D., D.A.B.T., A.T.S.Gad Consulting ServicesWilliam G. Gaines, Jr., M.D., M.P.H.Scott & White ClinicCharles O. Gallina, Ph.D.Professional Nuclear AssociatesRaymond Gambino, M.D. Quest Diagnostics Incorporated

Randy R. Gaugler, Ph.D.Rutgers UniversityJ. Bernard L. Gee, M.D.Yale University School of MedicineK. H. Ginzel, M.D.University of Arkansas for Medical SciencesWilliam Paul Glezen, M.D.Baylor College of MedicineJay A. Gold, M.D., J.D., M.P.H.Medical College of WisconsinRoger E. Gold, Ph.D.Texas A&M UniversityReneé M. Goodrich, Ph.D.University of FloridaFrederick K. Goodwin, M.D.The George Washington University Medical CenterTimothy N. Gorski, M.D., F.A.C.O.G.Arlington, TXRonald E. Gots, M.D., Ph.D.International Center for Toxicology and MedicineHenry G. Grabowski, Ph.D.Duke UniversityJames Ian Gray, Ph.D.Michigan State UniversityWilliam W. Greaves, M.D., M.S.P.H.Medical College of WisconsinKenneth Green, D.Env.Fraser InstituteLaura C. Green, Ph.D., D.A.B.T.Cambridge Environmental, Inc.Saul Green, Ph.D.Zol ConsultantsRichard A. Greenberg, Ph.D.Hinsdale, ILSander Greenland, Dr.P.H., M.A.UCLA School of Public HealthGordon W. Gribble, Ph.D.Dartmouth CollegeWilliam Grierson, Ph.D.University of FloridaLester Grinspoon, M.D.Harvard Medical SchoolF. Peter Guengerich, Ph.D.Vanderbilt University School of MedicineCaryl J. Guth, M.D.Hillsborough, CAPhilip S. Guzelian, M.D.University of ColoradoAlfred E. Harper, Ph.D.University of Wisconsin, MadisonTerryl J. Hartman, Ph.D., M.P.H., R.D.The Pennsylvania State UniversityClare M. Hasler, Ph.D.University of Illinois at Urbana-ChampaignRobert D. Havener, M.P.A.Sacramento, CAVirgil W. Hays, Ph.D.University of KentuckyCheryl G. Healton, Dr.PH.Columbia UniversityClark W. Heath, Jr., M.D.American Cancer SocietyDwight B. Heath, Ph.D.Brown UniversityRobert Heimer, Ph.D.Yale School of Public HealthRobert B. Helms, Ph.D.American Enterprise InstituteZane R. Helsel, Ph.D.Rutgers University, Cook CollegeDonald A. Henderson, M.D., M.P.H.Johns Hopkins Bloomberg Shool of Public HealthJames D. Herbert, Ph.D.MCP Hahnemann UniversityGene M. Heyman, Ph.D.McLean Hospital/Harvard Medical SchoolRichard M. Hoar, Ph.D.Williamstown, MA

A C S H E X E C U T I V E S T A F F

Theodore R. Holford, Ph.D.Yale University School of MedicineRobert M. Hollingworth, Ph.D.Michigan State UniversityEdward S. Horton, M.D.Joslin Diabetes CenterJoseph H. Hotchkiss, Ph.D.Cornell UniversitySteve E. Hrudey, Ph.D.University of AlbertaSusanne L. Huttner, Ph.D.University of California, BerkeleyRobert H. Imrie, D.V.M.Seattle, WALucien R. Jacobs, M.D.University of California, Los AngelesAlejandro R. Jadad, M.D., D.Phil., F.R.C.P.C.University of TorontoRudolph J. Jaeger, Ph.D.Environmental Medicine, Inc.William T. Jarvis, Ph.D.Loma Linda UniversityMichael Kamrin, Ph.D.Michigan State UniversityJohn B. Kaneene, Ph.D., M.P.H., D.V.M.Michigan State UniversityP. Andrew Karam, Ph.D., CHPUniversity of RochesterPhilip G. Keeney, Ph.D.Pennsylvania State UniversityJohn G. Keller, Ph.D. Olney, MDKathryn E. Kelly, Dr.P.H.Delta ToxicologyGeorge R. Kerr, M.D.University of Texas, Houston George A. Keyworth II, Ph.D.Progress and Freedom FoundationMichael Kirsch, M.D.Highland Heights, OHJohn C. Kirschman, Ph.D.Emmaus, PARonald E. Kleinman, M.D.Massachusetts General HospitalLeslie M. Klevay, M.D., S.D. in Hyg.University of North Dakota School of Medicine/Grand Forks Human Nutrition Research CenterDavid M. Klurfeld, Ph.D.Wayne State UniversityKathryn M. Kolasa, Ph.D., R.D.East Carolina UniversityJames S. Koopman, M.D, M.P.H.School of Public Health University of Michigan Alan R. Kristal, Dr.P.H.Fred Hutchinson Cancer Research CenterDavid Kritchevsky, Ph.D.The Wistar Institute Stephen B. Kritchevsky, Ph.D.Wake Forest University Health SciencesMitzi R. Krockover, M.D.Scottsdale, AZManfred Kroger, Ph.D.Pennsylvania State UniversityLaurence J. Kulp, Ph.D.University of WashingtonSanford F. Kuvin, M.D.University of MiamiCarolyn J. Lackey, Ph.D., R.D.North Carolina State UniversityJ. Clayburn LaForce, Ph.D.University of California, Los AngelesPagona Lagiou, M.D., DrMedSciUniversity of Athens Medical SchoolJames C. Lamb, I V, Ph.D., J.D.Blasland, Bouck & LeeLawrence E. Lamb, M.D.San Antonio, TXWilliam E. M. Lands, Ph.D.College Park, MDLillian Langseth, Dr.P.H.Lyda Associates, Inc.Brian A. Larkins, Ph.D.University of ArizonaLarry Laudan, Ph.D.National Autonomous University of MexicoTom B. Leamon, Ph.D.Liberty Mutual Insurance CompanyJay H. Lehr, Ph.D.Environmental Education Enterprises, Inc.Brian C. Lentle, M.D., FRCPC, DMRDUniversity of British ColumbiaFloy Lilley, J.D.Amelia Island, FLPaul J. Lioy, Ph.D.UMDNJ-Robert Wood Johnson Medical School

William M. London, Ed.D., M.P.H.Walden UniversityFrank C. Lu, M.D., B CFEMiami, FLWilliam M. Lunch, Ph.D.Oregon State UniversityDaryl Lund, Ph.D.University of WisconsinGeorge D. Lundberg, M.D.MedscapeHoward D. Maccabee, Ph.D., M.D.Radiation Oncology CenterJanet E. Macheledt, M.D., M.S., M.P.H.Houston, TXRoger P. Maickel, Ph.D. Purdue UniversityHenry G. Manne, J.S.D.George Mason University Law SchoolKarl Maramorosch, Ph.D.Rutgers University, Cook CollegeJudith A. Marlett, Ph.D., R.D.University of Wisconsin, MadisonJames R. Marshall, Ph.D.Roswell Park Cancer InstituteMargaret N. Maxey, Ph.D.University of Texas at AustinMary H. McGrath, M.D., M.P.H.Loyola University Medical CenterAlan G. McHughen, D.Phil.University of California, RiversideJames D. McKean, D.V.M., J.D.Iowa State UniversityJohn J. McKetta, Ph.D.University of Texas at AustinDonald J. McNamara, Ph.D.Egg Nutrition CenterMichael H. Merson, M.D.Yale University School of MedicinePatrick J. Michaels, Ph.D.University of VirginiaThomas H. Milby, M.D., M.P.H.Walnut Creek, CAJoseph M. Miller, M.D., M.P.H.University of New HampshireWilliam J. Miller, Ph.D.University of GeorgiaDade W. Moeller, Ph.D.Harvard UniversityGrace P. Monaco, J.D.Medical Care Management Corp.Brian E. Mondell, M.D.Baltimore Headache InstituteEric W. Mood, LL.D., M.P.H.Yale University School of MedicineJohn W. Morgan, Dr.P.H.California Cancer RegistryW. K. C. Morgan, M.D.University of Western OntarioStephen J. Moss, D.D.S., M.S.Health Education Enterprises, Inc.Brooke T. Mossman, Ph.D.University of Vermont College of MedicineAllison A. Muller, Pharm.D.The Children’s Hospital of Philadelphia Ian C. Munro, F.A.T.S., Ph.D., FRCPathCantox Health Sciences InternationalKevin B. MurphyMerrill Lynch, Pierce, Fenner & SmithHarris M. Nagler, M.D.Beth Israel Medical CenterDaniel J. Ncayiyana, M.D.University of Cape TownPhilip E. Nelson, Ph.D.Purdue UniversityMalden C. Nesheim, Ph.D.Cornell UniversityJoyce A. Nettleton, D.Sc., R.D.Denver, COJohn S. Neuberger, Dr.P.H.University of Kansas School of MedicineGordon W. Newell, Ph.D., M.S., F.-A.T.S.Palo Alto, CAThomas J. Nicholson, Ph.D., M.P.H.Western Kentucky UniversitySteven P. Novella, M.D.Yale University School of MedicineJames L. Oblinger, Ph.D.North Carolina State UniversityDeborah L. O’Connor, Ph.D.University of Toronto/The Hospital for Sick ChildrenJohn Patrick O’Grady, M.D.Tufts University School of MedicineJames E. Oldfield, Ph.D.Oregon State UniversityS tanley T. Omaye, Ph.D., F. - A . T.S., F. ACN, C.N.S.University of Nevada, Reno

Michael T. Osterholm, Ph.D., M.P.H.University of MinnesotaM. Alice Ottoboni, Ph.D.Sparks, NVMichael W. Pariza, Ph.D.University of Wisconsin, MadisonStuart Patton, Ph.D.Pennsylvania State UniversityJames Marc Perrin, M.D.Mass General Hospital for ChildrenTimothy Dukes Phillips, Ph.D.Texas A&M UniversityMary Frances Picciano, Ph.D.National Institutes of HealthDavid R. Pike, Ph.D.University of Illinois, Urbana-ChampaignThomas T. Poleman, Ph.D.Cornell UniversityGary P. Posner, M.D.Tampa, FLJohn J. Powers, Ph.D.University of GeorgiaWilliam D. Powrie, Ph.D.University of British ColumbiaC.S. Prakash, Ph.D.Tuskegee UniversityKary D. PrestenU.S. Trust Co.Marvin P. Pritts, Ph.D.Cornell UniversityDaniel J. Raiten, Ph.D.National Institutes of HealthDavid W. Ramey, D.V.M.Ramey Equine GroupR.T. Ravenholt, M.D., M.P.H.Population Health ImperativesRussel J. Reiter, Ph.D.University of Texas, San Antonio William O. Robertson, M.D.University of Washington School of MedicineJ. D. Robinson, M.D.Georgetown University School of MedicineBill D. Roebuck, Ph.D., D.A.B.T.Dartmouth Medical SchoolDavid B. Roll, Ph.D.The United States PharmacopeiaDale R. Romsos, Ph.D.Michigan State UniversityJoseph D. Rosen, Ph.D.Cook College, Rutgers University Steven T. Rosen, M.D.Northwestern University Medical SchoolKenneth J. Rothman, Dr.P.H.Boston UniversityStanley Rothman, Ph.D.Smith CollegeEdward C. A. Runge, Ph.D.Texas A&M UniversityStephen H. Safe, D.Phil.Texas A&M UniversityWallace I. Sampson, M.D.Stanford University School of MedicineHarold H. Sandstead, M.D.University of Texas Medical BranchCharles R. Santerre, Ph.D.Purdue UniversityHerbert P. Sarett, Ph.D.Sarasota, FLSally L. Satel, M.D.American Enterprise InstituteLowell D. Satterlee, Ph.D.Vergas, MNJeffrey Wyatt SavellTexas A&M UniversityMarvin J. Schissel, D.D.S.Roslyn Heights, NYLawrence J. Schneiderman, M.D.University of California, San DiegoEdgar J. Schoen, M.D.Kaiser Permanente Medical CenterDavid Schottenfeld, M.D., M.Sc.University of MichiganJoel M. Schwartz, M.S.Reason Public Policy InstituteDavid E. Seidemann, Ph.D. Brooklyn College/Yale UniversityPatrick J. Shea, Ph.D.University of Nebraska, LincolnMichael B. Shermer, Ph.D.Skeptic MagazineSidney Shindell, M.D., LL.B.Medical College of WisconsinSarah Short, Ph.D., Ed.D., R.D.Syracuse UniversityA. J. Siedler, Ph.D.University of Illinois, Urbana-Champaign

Marc K. Siegel, M.D.New York University School of MedicineLee M. Silver, Ph.D.Princeton UniversityMichael S. Simon, M.D., M.P.H.Wayne State UniversityS. Fred Singer, Ph.D.Science & Environmental Policy ProjectRobert B. Sklaroff, M.D.Elkins Park, PAAnne M. Smith, Ph.D., R.D., L.D.The Ohio State UniversityGary C. Smith, Ph.D.Colorado State UniversityJohn N. Sofos, Ph.D.Colorado State UniversityRoy F. Spalding, Ph.D.University of Nebraska, LincolnLeonard T. Sperry, M.D., Ph.D.Barry UniversityRobert A. Squire, D.V.M., Ph.D.Johns Hopkins UniversityRonald T. Stanko, M.D.University of Pittsburgh Medical CenterJames H. Steele, D.V.M., M.P.H.University of Texas, HoustonRobert D. Steele, Ph.D.Pennsylvania State UniversityJudith S. Stern, Sc.D., R.D.University of California, DavisRonald D. Stewart, O.C., M.D., F RCPCDalhousie UniversityMartha Barnes Stone, Ph.D.Colorado State UniversityJon A. Story, Ph.D.Purdue University Michael M. Sveda, Ph.D.Gaithersburg, MDGlenn Swogger, Jr., M.D.Topeka, KSSita R. Tatini, Ph.D. University of MinnesotaSteve L. Taylor, Ph.D.University of Nebraska, LincolnJames E. Tillotson, Ph.D., M.B.A.Tufts UniversityDimitrios Trichopoulos, M.D.Harvard School of Public HealthMurray M. Tuckerman, Ph.D.Winchendon, MARobert P. Upchurch, Ph.D.University of ArizonaMark J. Utell, M.D.University of Rochester Medical CenterShashi B. Verma, Ph.D.University of Nebraska, LincolnWillard J. Visek, M.D., Ph.D.University of Illinois College of MedicineDonald M. Watkin, M.D., M.P.H., F.A.C.P.George Washington UniversityLynn Waishwell, Ph.D., CHESThe UMDNJ–School of Public HealthMiles Weinberger, M.D.University of Iowa Hospitals and ClinicsJanet S. Weiss, M.D.University of California at San FranciscoSimon Wessely, M.D., FRCPKing’s College London and Institute of PsychiatrySteven D. Wexner, M.D.Cleveland Clinic FloridaJoel Elliot White, M.D., F.A.C.R.John Muir Comprehensive Cancer CenterCarol Whitlock, Ph.D., R.D.Rochester Institute of TechnologyChristopher F. Wilkinson, Ph.D.Burke, VAMark L. Willenbring, M.D.Veterans Affairs Medical CenterCarl K. Winter, Ph.D.University of California, DavisLloyd D. Witter, Ph.D.University of Illinois, Urbana-ChampaignJames J. Worman, Ph.D.Rochester Institute of TechnologyRussell S. Worrall, O.D.University of California, BerkeleyPanayiotis M. Zavos, Ph.D., Ed.S.University of Kentucky Steven H. Zeisel, M.D., Ph.D.The University of North CarolinaMichael B. Zemel, Ph.D.Nutrition Institute, University of TennesseeEkhard E. Ziegler, M.D.University of Iowa

A C S H B O A R D O F S C I E N T I F I C A N D P O L I C Y A D V I S O R S

The opinions expressed in ACSH publications do not necessarily represent the views of all ACSH Directors and Advisors.ACSH Directors and Advisors serve without compensation.

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Kicking Butts in the Twenty-First Century · The first smoking cessation programs began in the 1950s, after research had shown that smoking was a serious health hazard. In 1955, public