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Most smokers try to stop multiple times before finally kicking the habit, and fewer than 10% will succeed in permanently abstaining without medicine or counseling.
Nearly 1 in 5 Americans are at least occasional smokers, risking cancer, heart disease and a shortened life span -- and costing the nation more than $193 billion annually, including healthcare costs and decreased workplace productivity among smokers, the CDC says. They continue to light up even as employers increasingly charge higher health insurance premiums for smokers.
Nicotine's hold on the brain is not easily broken, as the struggles of President Obama -- a very self-disciplined man by all accounts -- illustrate. Many would-be quitters, like the president, relapse when the appeal of nicotine is simply too strong.
For the vast majority who can't go it alone, researchers and pharmaceutical companies are developing new treatments that can help smokers stub out that final butt. And they are finding newer, more effective ways to use nicotine-replacement therapies such as gum and patches.
In short, says Dr. Michael Fiore, director of the Center for Tobacco Research and Intervention at the University of Wisconsin, though there is no magic bullet, "It's a great time to quit."
Nicotine replacement therapies, which have been around since the 1980s, work by fulfilling the desire for nicotine in a noncigarette form. Nicotine replacements come in patches, gum, lozenges, inhalers and nasal sprays.
The Food and Drug Administration has approved each medication for use on its own, and only for quitting cold turkey. Many smokers would prefer to quit gradually.
"There's a kind of mythology that if you smoke while using one of these nicotine-replacement products, that's toxic," says Saul Shiffman, a psychologist at the University of Pittsburgh. During the 1990s, there were rumors that smoking while using a nicotine patch could lead to heart attacks. Studies have found no safety risk in using cigarettes and nicotine replacements simultaneously, Shiffman says.
In a recent analysis, published in 2008 in the journal Addiction, Shiffman concluded from four separate studies that starting the nicotine patch two weeks before quitting cigarettes doubles a smoker's chance of success. Some subjects used the patch before quitting, while others did not, and Shiffman's analysis examined whether people were smoke-free six weeks, and then six months, after a target quit date. In three of the studies, patch users were smoking fewer cigarettes even before their planned quit day, though they had not been told to do so.
The therapy might work by breaking the association between lighting up and getting the pleasure of nicotine, says Jed Rose, director of the Duke Center for Nicotine and Smoking Cessation Research in Durham, N.C. "Cigarettes become less enjoyable when smoking on the patch, just as eating when you're not hungry is not as rewarding as when you are," Rose says.
In another study, published this month in the American Journal of Preventive Medicine, Shiffman and colleagues showed that use of nicotine gum before quitting also helps people stop smoking. The researchers instructed more than 3,000 smokers to taper off cigarette use while chewing gum that contained zero, 2 or 4 milligrams of nicotine. Those on nicotine-containing gum were three times more likely to quit and still be abstinent at six months (6% of people on nicotine gum, compared with 2% on placebo gum); those on 4 milligrams had the best results overall, with odds of quitting six times greater than people on a placebo.
In 2008, the U.S. Department of Health and Human Services released revised guidelines for tobacco-addiction treatment that discuss gradually trading cigarettes for nicotine replacements. However, the authors chose not to recommend pre-quitting nicotine replacement use yet, citing the limited number of studies.
The guidelines do recommend mixing replacement aids, based on five studies that found using the patch plus gum (versus patch alone) nearly doubles the likelihood of quitting. Smokers might use the patch to control baseline cravings but pop a piece of gum or lozenge when the urge for a drag intensifies.
"I think no one should use one nicotine replacement anymore," says Dr. John Hughes, a psychiatrist at the University of Vermont in Burlington.