Pleasure-reward pathway
Smoking facts
• Average number of attempts required for successful smoking cessation: 7.
• Chances of staying smoke-free after quitting for one year: 85 percent. After five years: 97 percent. • Chance of relapse after 2-6 years: 2 percent to 4 percent each year.
• After 10 years: less than 1 percent each year.
Quit lines
• Washington state's Department of Health has a new toll-free quit line: 877-270-STOP (877-270-7867). Hours: 8 a.m.-9 p.m. Mondays through Thursdays, 8 a.m.-5 p.m. Fridays, 9 a.m.-1 p.m. Saturdays. At other times, leave a message and they'll get back to you. The line provides: private counseling and support; a customized quit plan; skills to help quit; information on other resources, such as insurance benefits and additional programs available in your area; and a Tobacco Quit Kit. More info: quitline.com.
• National quit lines include those run by the American Cancer Society (800-ACS-2345), the American Lung Association (800-LUNG-USA) and the Cancer Information Service of the National Cancer Institute (800-4-CANCER).
• The Web site www.quitnet.com, funded in part by the institute and run in conjunction with Boston University School of Public Health, offers 24/7 help. The institute also provides live online assistance 6 a.m.-4:30 p.m. Pacific time Mondays through Fridays at cis.nci.nih.gov/news/new.html#news.
|
|
|
No one suggests that quitting is easy, even with medications.
"It takes just a few heartbeats to get nicotine from the tip of your finger to the brain," says Richard Hurt, director of the Nicotine Dependence Center at the Mayo Clinic in Rochester, Minn. Once there, nicotine produces significant changes in brain cells. Chemically similar to naturally occurring neurotransmitters or chemical messengers, nicotine displaces some brain chemicals. Just 10 days of smoking triples the number of entry points — receptors — that allow nicotine to get inside brain cells.
There, nicotine acts on the pleasure-reward pathway by raising levels of four key neurochemicals that affect alertness, energy and mood — dopamine, norepinephrine, beta endorphins and serotonin. (Newer antidepressant medications target levels of these same brain chemicals.)
Research published last month shows that nicotine also disables a regulatory mechanism that limits the pleasure system. Result: The reward system is turned on right away and keeps sending reward signals for 60 minutes, even though the nicotine levels drop off 15 minutes after smoking.
That's why the development of effective nicotine-replacement drugs has finally given an edge to would-be quitters. Using one or more of these medications boosts success rates to about 25 percent.
Close monitoring of withdrawal symptoms and tailoring nicotine-replacement therapy to the individual have produced success rates of up to 50 percent at some of the best smoking-cessation programs.
In the community at large, however, research suggests that both smokers and some physicians are confused about what approach to use.
"The challenge is finding the right combination for each individual," says Neil Grunberg, professor of psychology and neuroscience at the Uniformed Services University of the Health Sciences in Bethesda, Md.
(See chart on E 3 for pros and cons of methods, and what research suggests about who might benefit most from each method.)
'Tough it out'
Despite the expanded choices, smokers often think the habit is a character weakness, so they should "tough it out" and go cold turkey. They don't take advantage of the medications proven to help assuage the strong physiological symptoms of withdrawal, or they use too little.
"That is why there is such a high relapse rate," explains David Sachs, clinical associate professor of pulmonary and critical-care medicine at Stanford University School of Medicine. "It's like killing all four engines on a Boeing 747 when you're 2,000 feet above the runway."
Underdosing can sabotage the most dedicated attempts to quit. At Stanford, Sachs and his colleagues monitored the blood levels of nicotine as smokers quit and compared them with the eventual rates of success. When nicotine levels dropped too precipitously, to 50 percent or less of what they had been while participants were smoking, success rates were no better than the 5 to 8 percent seen with a placebo, about equivalent to going cold turkey.
Another mistake smokers make is ignoring the importance of behavior therapy or social support.
The federal treatment guidelines found that only a combination approach — proper doses of medication along with professional and/or social support — can consistently push the success rates to about 30 percent.
More than willpower
There is, fortunately, a growing recognition that smoking is not a weakness but an addiction, and a serious chronic disease that warrants treatment.
"We wouldn't tell someone with a blood sugar of 500 to (just) work on their willpower," says Michael Fiore, chairman of a federal panel that issued treatment guidelines two years ago calling for nearly every smoker who wanted to quit to use medications.
"We don't tell someone who has a systolic blood pressure of 250 that if they really had character they could control it on their own."
And yet Medicare doesn't pay for smoking-cessation medications, and only about half of private insurers do (health-maintenance organizations often do).
But the bottom line that tobacco experts are delivering is this: Smokers should keep trying to quit no matter what the cost. Giving up cigarettes at age 50 cuts in half the risk of dying from smoking-related illnesses during the next 15 years, Fiore says.
Even so-called "failures" — people who quit for days or weeks but go back to smoking — stand a good chance of succeeding ultimately. Studies show that being able to stay off cigarettes for a week is strongly linked — eventually — to long-term quitting.
"Keep trying; a lot of people give up too soon," says Hughes, the Vermont psychiatrist.
"The No. 1 message is that there is a lot of help out there now." |
