Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, April 25, 1995 TAG: 9504250120
SECTION: EXTRA PAGE: 1 EDITION: METRO
SOURCE: JANE BRODY
DATELINE: LENGTH: Long
Smoking has been banned in most public buildings, at work sites and on public transportation, and is becoming increasingly unacceptable in restaurants, private homes and cars.
Smokers, no longer welcome to light up with cocktails or coffee, while reading the paper or doing their work, are being forced to go outside when they can no longer resist the urge.
Forty-six million American adults continue to pursue this ever more unsociable behavior mainly because nicotine, like heroin and crack cocaine, is an addictive drug.
For smokers who have become dependent on nicotine, each dose (that is, each cigarette) sets up a craving for the next one. If that craving is not satisfied, the smoker begins to experience withdrawal symptoms: anxiety, irritability, restlessness, difficulty concentrating, drowsiness, disturbed sleep, hunger and a strong urge for nicotine.
Yet half of all living Americans who have ever smoked have managed to break free of the tyranny of cigarettes.
To be sure, many were light smokers who were not highly dependent on the stimulating and relaxing effects of nicotine and were able to quit rather easily without outside assistance. But many other former smokers were true nicotine addicts, and most quit cold turkey and endured the extreme discomforts of withdrawal for weeks, months or even a year.
The remaining millions of nicotine addicts may now sail an easier course to becoming former smokers, thanks to a variety of new products to ease the nicotine craving while smokers break the habit.
Like the nicotine gum and patches that have been around for some time, the products supply low doses of nicotine in a way that allows smokers to taper off gradually, and without the usual agony, over a period of months.
Currently, all forms of nicotine replacement therapy, as it is called, are available only by prescription - the gum now comes in two doses and there are four brands of slow-release skin patches available. (A nicotine nasal spray and an inhaler are still being tested and awaiting marketing approval.) One or more of these products may soon be sold over-the-counter, eliminating what for many is a costly, forbidding or inaccessible obstacle - a visit to the doctor.
It may seem odd to give doses of the very drug a person is trying to stop using, but scientifically designed studies have shown that, at least in a research setting, nicotine replacement therapy does help smokers quit for good.
In fact, it is the only treatment for nicotine addiction that has been proved beneficial. Although methods like hypnosis and acupuncture have helped some smokers quit, these techniques have not been shown to be more effective than dummy therapy.
When measured against a look-alike placebo, nicotine replacement therapy in the form of the gum or patch has typically doubled the initial quitting rate and doubled the number of smokers who remain abstinent six months or one year later.
Still, even with a nicotine substitute, only about one smoker in four manages to stop smoking and only about half that number remains abstinent over the long term.
An analysis last year of 28 scientifically designed studies of the nicotine gum or patch showed that, over all, nicotine replacement therapy ``could enable about 15 percent of smokers who seek help in stopping smoking to give up the habit.''
Furthermore, the studies have shown, this approach to ending the habit is not suitable for everyone. Those most likely to benefit from nicotine replacement are smokers with a strong dependence on nicotine; for example, those who crave a cigarette as soon as they awake.
Smokers with a low dependence on nicotine - those whose smoking is not mainly driven by an addictive urge - do no better with nicotine replacement therapy than without it. For them, the secret to becoming a former smoker may simply be deciding that they will no longer smoke.
Nicotine replacement works by curbing the discomforts of withdrawal without providing the rapid, higher doses of nicotine that produce the stimulation and euphoria associated with smoking a cigarette.
Cigarettes deliver repeated, brief, high blood levels of nicotine that directly affect the brain, whereas the gum or patch present nicotine in lesser amounts and more slowly, with only gradual rises and drops in blood concentrations.
Chewing nicotine gum or using the patch does not provide the satisfaction of smoking a cigarette, nor does nicotine replacement therapy necessarily reduce the craving for cigarettes (as opposed to a craving for nicotine).
Chewing nicotine gum or using a patch is much safer than smoking because these products are free of the cancer-causing and lung-damaging substances in tobacco smoke.
Also, because replacement products deliver nicotine more slowly, they produce a less intense effect on the heart and blood vessels than does the jolt of nicotine that results from smoking a cigarette. After reviewing various studies, the Food and Drug Administration concluded that nicotine replacement therapy is safe and effective.
In an analysis of 17 studies using the nicotine patch published last June in The Journal of the American Medical Association, Dr. Michael C. Fiore, director of the Center for Tobacco Research and Intervention at the University of Wisconsin, raised many unanswered questions about nicotine replacement therapy. Among them is the most effective duration of treatment.
Most studies involved using the patch for eight weeks, and longer treatment periods did not seem to result in any further benefit. The nicotine gum is generally used for three or four months, although 10 percent to 20 percent of former smokers continue to use it for more than a year, more or less as maintenance therapy when they feel they might relapse to smoking.
Another crucial question is the value of behavioral counseling as an adjunct to nicotine replacement. Dr. Fiore noted that studies had shown nicotine gum to be twice as successful when combined with intensive counseling. Counseling can teach smokers how to break their associations with cigarettes and how to find effective substitutes for the benefits they derived from smoking, including relaxation, mental stimulation and weight control.
Also unknown is how well nicotine replacement works outside of a research setting, which tends to attract those most committed to quitting. Most cigarette smokers shy away from organized programs to halt smoking, and more than 90 percent of patch users receive no counseling or advice from a doctor.
At a recent conference on stopping smoking, experts emphasized that nicotine replacement therapy was helpful but not a panacea. They also advised smokers who are trying to quit not to be discouraged by relapse. The average smoker relapses three or four times before ultimately quitting. As Karen Monaco of the American Lung Association put it, ``Those who relapse have not failed - they are simply practicing quitting.''
by CNB