Tobacco Treatment: An Overview
Tobacco Treatment: An Overview
Because quitting tobacco is so difficult, many smokers seek some form of treatment to help them succeed. Nicotine is the addictive substance in tobacco, and nicotine addiction can be treated in several ways. The most effective methods are behavioral counseling and nicotine replacement therapy, particularly when they are combined.
Cigarette smoking is the most common form of tobacco use, and smoking is one of the nation's most serious public health problems. Tobacco use causes more than 430,000 deaths each year in the United States and is the leading preventable cause of death. Most adults in the United States have either smoked cigarettes or used some other tobacco product. In addition, an estimated 13.4 percent of young people ages 12 to 17 were smokers in 2000.
Although the number of Americans who smoked decreased in the late 1900s, the current number of smokers is still high. In the late 1990s, about one-quarter of adult Americans, or about 48 million people, smoked. Most of these people wanted to quit but were unable to do so because they found it too difficult. According to some figures from the late 1990s, only an estimated 2.5 percent of all smokers successfully quit each year.
A Note on Smokeless Tobacco
Like cigarettes, chewing tobacco and snuff present a similar risk of nicotine addiction. These products may prove more difficult to treat than cigarette use because they are sometimes viewed as less risky alternatives to cigarettes. One study quoted in a surgeon general's report on smoking reported that 77 percent of youth thought that cigarette smoking was very harmful, but only 40 percent rated smokeless tobacco as very harmful. Yet smokeless tobacco can cause cancer, bleeding gums and mouth sores that never heal, bad breath, stained teeth, and other related health problems. Once the negative publicity on smokeless tobacco use reaches a level close to the bad press on smoking, there should be a growing demand for using therapies to help smokeless tobacco users quit. Although a growing number of people use smokeless tobacco, most tobacco use is from cigarettes and most of the research on tobacco treatment has focused on helping smokers. Still, most of the tools that help smokers quit can also aid any nicotine addict.
The Effects of Quitting
When a person stops smoking or quits chewing smokeless tobacco, the body responds in a number of ways, some immediate and some over time. About twenty minutes after the last cigarette, blood pressure and pulse rate return to normal, and body temperature increases to normal. About eight hours later, the carbon monoxide level in the blood drops to normal, and after one day, an individual's chance of a heart attack decreases. After two days, nerve endings start to regenerate, and the ability to smell and taste improves. After two weeks, an individual's circulation improves and lung function increases by a maximum of 30 percent. After a year of smoking abstinence , the risk of coronary heart disease is reduced to half that of a smoker, and after five years of abstinence, the risk of death by lung cancer is cut in half. After fifteen years, the risk of coronary heart disease is equal to that of a nonsmoker.
Early Ideas About Quitting
Until the 1980s many people doubted that tobacco use was based on an addiction to or dependence on nicotine. In the 1950s and 1960s, a common view among experts was that smoking was just a bad habit. Experts at that time failed to realize that tobacco use was a form of drug use. Instead, they saw smoking and chewing tobacco as the kind of habit that could be broken by taking certain steps to change the behavior of the smoker. Behavioral approaches to stopping smoking or quit chewing have been in use ever since.
In the early twentieth century, self-help movements to treat alcohol or drug problems were very popular. The focus of these movements was to help people change the behaviors that contributed to their smoking habit. Such efforts at behavioral changes have a long history in society. Perhaps because minor behavioral problems are so commonplace, people tend not to seek professional help for dealing with them. As a result, over the years much of the "treatment" for cigarette smoking has amounted to individuals trying to quit on their own. However, researchers find that self-help treatments have not generally been effective for most people. In one study of 5,000 smokers, only 4.3 percent of individuals who had quit on their own remained abstinent for one year after they attempted to quit. Self-help treatments, combined with more formal treatment such as behavioral counseling, nicotine replacement, or a combination of the two, is likely to be more effective.
Group Therapy and Individual Therapy
A nicotine addict may see a therapist in one-on-one sessions in order to quit smoking. In these sessions, the smoker gets instruction and support from the therapist. Smokers and smokeless tobacco users can also seek such support in group therapy. Group programs have been used to provide hypnotism (a trance state in which smokers may be more suggestible), education, behavioral therapy , and combinations of therapies. There is no clear scientific evidence indicating which form of therapy is best, but group programs can be less expensive than individual programs. Some clients have strong personal preferences for one or the other form of treatment: Some enjoy the group support and like to share their experiences in a group; others find such involvement with groups unpleasant or embarrassing. For either type of therapy, the longer a person stays in treatment, and the greater the number of treatment sessions, the better the chances of success at quitting.
The Role of Doctors in Treatment
Physicians take an interest in preventing health problems in their patients. Thus, they often make special efforts to encourage patients to stop smoking or to quit chewing. In 1964 only about 15 percent of current smokers reported that a physician had advised them to quit smoking. By 1987 about 50 percent of current smokers had received such advice. Sometimes simple things like the advice of a doctor to quit and setting a date for quitting can lead to success. Doctors who take just a few minutes to give advice and provide a patient with pamphlets about smoking can make a difference. Physicians can also be helpful by referring patients to smoking treatment programs. Specialists who deal with patients already suffering from tobacco-related disease are in a good position to help those with a strong wish to quit. Yet cardiac or lung patients often fail to stop smoking. Being diagnosed with a smoking-related disease is no guarantee that the patient will quit smoking.
Efforts by Organizations
Several charitable organizations are devoted to reducing the rates of smoking and smoking-related diseases such as cancer, heart disease, and lung disease. The American Cancer Society, the Lung Association, and the Heart Foundation promote research and distribute public health information about smoking. Each has developed materials and programs to help people quit smoking. These materials, such as booklets and pamphlets, can reach many smokers at very low cost. U.S. government agencies concerned with smoking and smoking-related disease have also developed and promoted materials and procedures to encourage smokers to quit.
Charitable organizations also support efforts to ban or reduce smoking in the workplace. They provide smoking-treatment services to employees, such as employee assistance programs (EAPs). In addition to workplaces, restaurants and many other businesses now prohibit smoking on their premises. Just as social pressures encouraged many smokers to start the habit, social pressures might encourage them to stop. Once it was fashionable to be a cigarette smoker; now it is becoming fashionable to stop smoking.
Nicotine-replacement therapy is considered an effective treatment for stopping smoking or ceasing to use smokeless tobacco. The most commonly used nicotine-replacement therapies are a gum that releases nicotine as it is chewed and a patch that slowly releases nicotine into the body through the skin. These therapies are available over the counter. Nicotine-replacement therapies can help reduce the nicotine withdrawal symptoms after a person stops smoking. As a result, the individual can focus on dealing with the behavioral challenges of stopping. For example, a smoker may be accustomed to having a cigarette while drinking a cup of coffee or while driving. He or she needs to learn how to separate those behaviors from the urge to smoke. People appear to prefer the nicotine skin patches over nicotine gum. They seem to have the fewest side effects and produce the greatest long-term abstinence rates.
Nicotine nasal sprays and nicotine vapor inhalers that deliver nicotine through the respiratory system are less common forms of nicotine-replacement therapy. They became available in the United States in the late 1990s. There have been reports of eye, nose, and throat irritation with the nasal sprays, but for some individuals these irritations decrease over time.
Other Drug Therapies
For someone who has tried repeatedly and yet failed to stop smoking for good, a medicine that could take away the desire to smoke would be welcome. A number of non-nicotine medications have been developed that reduce nicotine withdrawal symptoms, including irritability and anxiety. These medications mimic the effects achieved by smoking. As a result, they may help decrease an individual's desire for a cigarette. These medications include antidepressants (such as nortriptyline and bupropion or Wellbutrin), anxiolytics (medications usually prescribed to treat anxiety, such as buspirone, marketed as Zyban for use by people quitting smoking), and the blood pressure medication clonidine.
Hypnosis is worth special mention because of its popularity as a smoking therapy. Hypnosis therapists make suggestions to the smoker when he or she is in a trance and possibly more open to suggestions, such as "You will not want a cigarette" or "The thought of a cigarette will make you feel sick." Careful evaluations of hypnosis therapies show small or no treatment effects. These therapies are difficult to study, since there are no standard procedures. The methods and suggestions used vary from one therapist to the next. For those seeking hypnosis therapy, it is important to deal with therapists who have good reputations and who charge reasonable fees for their services.
A wide range of behavioral therapies have been tested, and no single method stands out as particularly effective. Combination approaches are now widely used, in hopes that trying everything will lead to success at something. Currently, there is no reliable way to judge beforehand which smoker will be most helped by a particular technique. (The exception is that heavier, more dependent smokers are consistently more likely to benefit from nicotine replacement.) However, the something-for-everyone approach is reasonable.
One of the behavioral therapies involves the preparation of detailed contracts that spell out punishments if the smoker returns to smoking. For example, if the patient has a relapse, that is, returns to smoking, he or she must give $100 to someone he or she dislikes. Other procedures emphasize the extremely unpleasant effects of very heavy smoking, such as dizziness or nausea. In this type of therapy, the smoker eventually finds these effects so unpleasant that he or she will have a stronger desire to quit. Other behavioral techniques aim to prevent relapse, a common problem among smokers who have tried to quit.
Smokers have sometimes organized Smokers Anonymous programs. The program allows smokers to support each other and teach each other techniques that will help them to stop smoking and to keep from returning to smoking. However, unlike the great popularity of Alcoholics Anonymous (AA) groups, these programs have not generally become popular.
See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.
Tobacco addicts must understand that if one method does not help them, they should try another, and another, until they have stopped smoking. Any one attempt to stop smoking can be a failure, but this does not mean that all attempts will fail. Repeated attempts give the individual experience with assorted treatment techniques, so that the individual begins to learn what helps and what does not help.
Tobacco addiction often goes hand in hand with the abuse of alcohol or other drugs. Smokers who fail to stop smoking may have serious drug problems that require treatment before the smoking problem can be resolved.
see also Addiction: Concepts and Definitions; Nicotine; Tobacco Treatment: Behavioral Approaches; Tobacco Treatment: Medications.
IN THEIR OWN WORDS
Nicotine is as addicting as heroin or cocaine.
C. Everett Koop, former Surgeon General, 1988.
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