Pall on the Patch : Without Help From Their Doctors and Programs on Behavior Modification, Smokers Say the Nicotine Patch Is No Panacea

Like millions of other smokers, Dan Aaronson saw the television commercials touting a new product to help people give up cigarettes.

‘Ask your doctor,” the advertisement urged.

Aaronson did.

“Try it,” said the doctor, scribbling a prescription for a nicotine patch.

That was last April, when sales of the patch were soaring to the highest levels ever seen in a new pharmaceutical product--$270 million for one quarter alone.

Aaronson, who had been smoking for 36 years and was up to about three packs a day, had tried to quit before. This time, he slapped on the patch, which releases a small amount of nicotine into the bloodstream to curb the withdrawal symptoms of addiction. He tossed his cigarettes out.

“With the nicotine patch, this was the first time I was able to make inroads into stopping smoking,” Aaronson, 50, says. “I was down to four cigarettes a day. But. . . .

But he resumed smoking after four months of using the patch.

“I guess,” he concedes, “I really wasn’t ready to quit.”

He wasn’t alone. His experience, it turns out, reflects that of smokers across the country.

By the time Aaronson gave up on the patch last fall, sales of the product were plummeting, success rates were dismal and smoking-cessation experts were coming to some somber conclusions. Such as:

* The nicotine patch is not a panacea to cure tobacco addiction.

* The patch appears to work best when used in conjunction with a stop-smoking program that emphasizes behavior modification.

* Even the patch and a stop-smoking class may not be enough to help the most deeply addicted smokers kick the habit.

The wild history of the nicotine patch has painfully reminded drug makers, doctors and smokers that the process of quitting is extraordinarily complex.

“People are disillusioned, but this has been very healthy,” says Michael Samuelson, president of the National Center for Health Promotion, which operates the popular Smoke Stoppers cessation program. “People now recognize that indeed this is very complex, pharmacologically, socially and psychologically.”

Laboratory testing of the patch before it was released showed that about 20% of people remained smoke-free after one year’s use. But the actual success rate is thought to be lower, with estimates ranging down to 9%. Stop-smoking experts blame heavy, misleading advertising to consumers and a lack of involvement by the doctors dispensing the patch.

“The response to the product has been unprecedented,” says Dr. Calvin Fuhrmann, chief of the respiratory division at Baltimore’s Harbor Hospital Center. “It was brilliant consumer advertising--a breakthrough. And the public responded by demanding this miracle treatment.

“The doctors responded,” he adds, “by writing prescriptions but by not instructing patients (in behavior-modification options) and not giving them adequate support. And in my estimation, the patch has been a significant failure because doctors didn’t instruct people.”

The first of the four nicotine patches marketed in the United States was launched by Marion Merrell Dow--called Nicoderm--and was heavily advertised during the Super Bowl last year.

First-quarter sales were so high that supplies of the patch ran out and other manufacturers jumped into the fray. Now, nicotine patches are marketed by Ciba-Geigy (Habitrol), Lederle Laboratories (ProStep) and Warner-Lambert (Nicotrol).

But after a frenzied demand for patches early in 1992, sales plummeted at least 50% by year’s end. Reports of people who had tried the patch and still couldn’t stop smoking were everywhere.

“Many people hoped this was a magic pill, that it would be totally passive,” says Samuelson. “This is ludicrous and dangerous. Patches can only be effective if they are used with a medical component, a strong behavior component and, most important, a sincere desire to stop smoking.”

Of the estimated 5 million smokers who tried a patch last year, at least 4 million are thought to have been unable to quit, Fuhrmann says.

No one, however, is actually calling the patch a bad idea or a poor product. And market analysts say they expect sales to rebound to about $125 million per quarter this year.

“There are a huge number of people who want to quit but can’t. There is a lot of demand,” says David Steinberg, an analyst specializing in pharmaceuticals with Volpe, Welty & Co., a San Francisco investment bank.

The use of behavior modification may increase success rates and, at the Food and Drug Administration’s insistence, manufacturers now must emphasize the importance of that component to those using the patch. One manufacturer even has reportedly considered offering its own stop-smoking seminars to be attended in conjunction with using the patch.

Some researchers say nicotine gum, introduced in 1984, and the patch represent only the first nicotine-replacement products under development.

“People do want to quit smoking,” Samuelson says. “And one of the biggest concerns about recidivism is the physiology of withdrawal symptoms.”

The curbing of the urgent craving for nicotine is what smokers and ex-smokers praise about the gum and the patch.

One smoker, 35-year-old Suzanne Little of Los Angeles, had tried to quit smoking twice by participating in classes. This time, the two-pack-a-day smoker is enrolled in an American Lung Assn. class and is using the patch. The combination, she says, has given her a better chance at success.

“I still find it hard to quit,” Little says. “But the patch does make it easier. The last two times, if you would have looked at me cross-eyed, I would have started crying. Now I’m working on the psychological habit, and I’ll work on the physical habit later. But the patch takes care of that for now.”

Smokers start with a high-nicotine patch, although the amount of nicotine is much less than in a cigarette. Over several months, they wear patches with a smaller nicotine content to wean themselves off the drug. The patches, which can be worn for up to a day, cost $3 to $4 each and are not usually covered by insurance.

One shortcoming of the patch is that it takes four to six hours for the nicotine to get into the bloodstream, says Nina Schneider, an associate research psychologist at UCLA.

“Every puff of a cigarette allows a chemical hit to the brain in seven to 10 seconds, and blood changes in two to three minutes,” Schneider explains. “Smokers are deciding how much (of the chemical) they are going to get. That’s why this is such an insidious drug.”

Nicotine gum, while delivering a dose of nicotine into the blood in only 30 minutes, has sometimes failed to help heavy smokers because the dose (2 milligrams) is too low, Schneider says. Now, she says, she advocates the patch along with occasional use of the gum “in emergencies.”

The technique might prove especially useful because a higher-dose gum (4 milligrams) is expected on the market later this year. But the FDA is reluctant to allow the use of the gum and patch together because of fears of a nicotine overdose, Schneider concedes.

In the meantime, a Swedish company this year is expected to apply to market a nicotine nasal spray in the United States. And Schneider is seeking smokers for a UCLA study on a nicotine inhaler.

Smokers need the option of several tactics to help them stop, Schneider says: “We have to match the smoker to the treatment. And, of course, there will always be people who need the behavioral component.”