Quitting Tobacco: Why is

it so hard? What works?

Harry A. Lando
University of Minnesota
March 16, 2015

I have no disclosures or conflicts of interest

with the material presented in this talk

Nicotine Addiction
https://www.youtube.com/watch?
v=yd46Hs7pTow

Those who have tried to give up smoking

usually know the meaning of being
hooked
Even those who initially succeed in quitting
suffer the same relapse rate as recovering
alcoholics and heroin addicts
1988 U.S. Surgeon General Report:
cigarettes and other forms of tobacco are
addicting

 Recommended warning labels about

addiction
Power of desire for cigarettes
Physiological need that is more than
mere urge
Like many drugs that stimulate the
nervous system, nicotine at the same
time stimulates and relaxes the body

 Because it is inhaled, it only takes

seven to ten seconds to reach the
braintwice as fast as heroin
Mimics some of the effects of
adrenaline, a hormone, and
acetylcholine, a powerful
neurotransmitter
After a few puffs, the level of nicotine
in the blood increases dramatically

 Heart beats faster and blood pressure

increases
Result: smokers become more alert
and may react faster
In addition, nicotine may produce a
calming effect by triggering the
release of natural opiates called betaendorphins

 Because nicotine cannot be stored in the

body, smokers maintain a relatively
constant level in the blood by continuing
to smoke
Because a smoker takes 200 to 400 puffs
per day, there is a lot of reinforcement
Nicotine is self administered, and it
affects mood and performance

 That makes it powerfully addicting

New research shows that addiction
can occur very quickly
Even limited exposure to nicotine can
change the brain, modifying neurons
in a way that stimulates the craving to
smoke

 Studies have indicated that some smokers

experience withdrawal symptoms after
smoking as few as one to four cigarettes
Functional magnetic resonance imaging
(fMRI) was used to measure levels of
metabolic activity in brains of rats given a
dose of nicotine on five consecutive days
Response to the first dose was relatively
limited

 Brain activity was much more intense

and widespread after the fifth dose
These findings indicate that the brain
quickly becomes sensitized to nicotine,
enabling addiction to occur after just a
few doses
Reference: DiFranza, J. Hooked from the first cigarette,
Scientific American May 2008, 82-87.

Tobacco Industry Secrets

The industry acknowledged
nicotines addictive properties
internally by 1963
Law firm advised that entire matter
of addiction is the most potent
weapon a prosecuting attorney can
have in a lung cancer cigarette case

 Cannot defend continued smoking as

free choice if the person was
addicted
Sir Charles Ellis, scientific advisor to
British American Tobacco: As a result
of these various researches, we now
possess a knowledge of the effects of
nicotine far more extensive than
exists in the published literature.

 Addictive potential of a drug is

enhanced by delivery systems that
cause it to reach the brain more quickly
This concept was fully appreciated by
tobacco industry scientists
Denial, rationalization, and
reinforcement are key elements in the
addictive process

 Clearly the smoker is concerned

about smoking and health
This factor can be used to advantage
in marketing Kent and True brands
Consumer faith in safer smoking or
denial of anti-smoking information

 For cigarettes as with all drug

delivery devices critical to ensure
that the drug is delivered within an
acceptable dose range
Proposal to reduce absolute level of
nicotine in cigarettes below addicting
levels

 For decades, industry scientists,

executives, and lawyers have known
that nicotine is addicting and that
they are in the business of selling a
drug delivery device
The cigarette is a sophisticated drug
delivery device
The smoker can control the nicotine
dose by altering smoking behavior

 This makes the cigarette one of the

most technologically sophisticated
drug delivery devices available
W.L. Dunn: Think of a cigarette as a
dispenser for a dose unit of
nicotinesmoke is the most
optimized vehicle of nicotine and the
cigarette is the most optimized
dispenser of smoke

The Scam: Low-Tar LowNicotine Cigarettes

Industry implied reduction in health
consequences
Smokers compensate to maintain
desired blood nicotine concentrations
Ventilation holes often blocked by
smoker

 Smoking with greater intensity,

deeper inhalation, larger puff volume
Industry recognized that those who
smoke low tar and nicotine cigarettes
generally believe that such cigarettes
pose less risk

Freebasing Nicotine
Ammonia and pH manipulation, the higher
the pH the more extractable nicotine
Perhaps most surprising finding in
document review was evidence of
industry-wide efforts spanning three
decades to increase freebase nicotine
delivered to smokers
Outside the industry little was known of
this

 A 1966 BAT report noted: It would

appear that the increased smoker
response is associated with nicotine
reaching the brain more quickly
From Hurt, R. Prying open the door to the tobacco
industrys secrets JAMA October 7, 1998

Quitting: What Works?

US Clinical Practice Guideline 2008
10 Key recommendations:
1.Tobacco dependence is a chronic
disease that often requires repeated
intervention

2. It is essential that clinicians and health

care delivery systems consistently
identify and document tobacco use status
and treat every tobacco user
3. Tobacco dependence treatments are
effective across a broad range of
populations
4. Brief tobacco dependence treatment is
effective

5. Individual, group, and telephone

counseling are effective and their
effectiveness increases with
treatment intensity. Two
components of counseling that are
especially effective are practical
counseling (problem solving/skills
training) and social support
delivered as part of treatment

6. Numerous medications are available for

nicotine dependence: Bupropion SR,
Varenicline, nicotine gum, nicotine inhaler,
nicotine lozenge, nicotine nasal spray,
nicotine patch (Also more recent evidence
for cytisine)
7. Counseling and medication are effective
when used by themselves, but combination
of counseling and medication is more
effective than either alone
8.

8. Telephone quitline counseling is effective

with diverse populations and has broad
reach
9. If a tobacco user currently is unwilling to
make a quit attempt, clinicians should
use motivational treatments

10. Tobacco dependence treatments are

both clinically effective and highly costeffective

 Even after long periods of abstinence,

cues in the environment may promote
cravings
If long time abstinent smoker surrenders
to an urge to smoke, addiction can be
quickly reestablished
The US Clinical Practice Guidelines
describe nicotine dependence as a chronic
relapsing condition

FCTC Article 14
Each party shall develop and
disseminate appropriate, comprehensive
and integrated guidelines based on
scientific evidence and best practices,
taking into account national
circumstances and priorities, and shall
take effective measures to promote
cessation of tobacco use and adequate
treatments for tobacco dependence

 Challenges to implementing Article 14 in

low-resource settings
Importance of primary care
Tobacco dependence is a chronic disease
that often requires repeated intervention
It is essential that clinicians and
healthcare delivery systems identify and
treat tobacco users

 Brief tobacco dependence treatment

is effective
Numerous medications have been
demonstrated to be effective for
tobacco dependence
However, cost is a barrier

 Clinicians often do not treat smokers

Too busy
Lack of expertise
No financial incentive
Believe smokers cannot or will not quit
Do not wish to scare patients away

Opportunity: Most smokers want

to quit
Without assistance only 5 percent of
quit attempts are successful
Most try to quit on their own95%
relapse
Using evidenced-based methods can
greatly increase success
Repeated advice and support for
quitting are important

Brief advice can significantly increase

quitting
As your doctor, I believe the most
important thing you can do for your
health is to quit smoking
All tobacco users should be offered at
least minimal intervention

 Even when patients are not ready to quit,

brief motivational messages can increase
likelihood of future quit attempts
Brief treatment is effective
Telephone counseling is effective
Lay people can be trained to provide
support

 Individual and group counseling

Problem solving/skills training
Social support as part of intervention

Lay Interventionists
May be readily available and low-cost
Can provide practical counseling and
social support
Can also support appropriate use of
medications

 We successfully trained lay

facilitators to lead multi-session
group programs
Cost kept low through use of lay
facilitators and donated sites
Lay facilitators often are highly
motivated

 Studies have supported effectiveness

of using trained lay health
influencers and peer interveners
Teaching lay people knowledge and
skills for tobacco intervention is both
feasible and practical
Project Reach in Arizona

 Nurse-managed, lay-led tobacco

cessation intervention for poor Ohio
women

World Health Organization recommends

three types of treatment:
Tobacco cessation advice incorporated
into primary healthcare services
Easily accessible and free quitlines
Access to low-cost pharmacological
therapy

Quitlines (where available)

Can refer patient to tobacco cessation
quitlines
Quitlines often staffed by trained
cessation experts
Calling a quitline can significantly
increase a smokers chance of
successfully quitting

Ask: Do you, or does anyone in your

household, ever smoke or use any type of
tobacco?
Advise: I realize quitting is difficult, but it is
the most important thing you can do to
protect your health now and in the future.
Refer: To other clinicians for additional
counseling, local group program, or quitline

Tips from former smokers

US Centers for Disease Control
and Prevention
http://www.cdc.gov/tobacco/campaign/
tips/resources/videos/beatricevideos.html#cessation
treatobacco.net (efficacy, policy,
health effects, resources)

If we do not act decisively, a hundred

years from now our grandchildren and
their children will look back and seriously
question how people claiming to be
committed to public health and social
justice allowed the tobacco epidemic to
unfold unchecked.
Dr. Gro Harlem Bruntland
Former Director-General of the World Health Organization