Quitting Tobacco: What Works and What Doesn't with Michael Fiore

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Quitting Tobacco: What Works and What Doesn't with Michael Fiore

WebMD Live Events Transcript

Dr. Michael C. Fiore, director of the Center for Tobacco Research and Intervention and a professor of medicine at the University of Wisconsin Medical School, will talk about the most -- and least -- effective means to quit smoking.

Event Date: 06/27/2000.

The opinions given by Dr. Fiore are his and his alone. If you have specific questions or are concerned about your health, please consult your personal physician. This event is for informational purposes only.

Moderator: Welcome to WebMD Live's World Watch and Health News Auditorium. Today we are discussing Quitting Tobacco: What Works and What Doesn't, with Michael C. Fiore, MD, MPH.

Fiore is the director of the Center for Tobacco Research and Intervention, and a professor of medicine at the University of Wisconsin Medical School. He is also the principal investigator on an NIH-funded Transdisciplinary Tobacco-Use Research Center (TTURC) grant, "Relapse: Linking Science and Practice." He formerly worked as a medical epidemiologist at the United States Office on Smoking and Health, where he contributed to a wide range of national research, educational and policy projects. He has also received training as an Epidemic Intelligence Service (EIS) Officer for the United States Centers for Disease Control (CDC). Dr. Fiore completed his undergraduate studies at Bowdoin College and received his medical degree from Northwestern University in Chicago.

Dr. Fiore, welcome to WebMD Live.

Dr. Fiore: Thanks for inviting me.

Moderator: Why should you quit smoking?

Dr. Fiore: Well, there's not a single health risk that poses the same concern as tobacco use in America today. If we take three smokers and line them up side by side, unfortunately one of those three are going to die prematurely from a disease directly related to their tobacco use, losing, on average, about 10 years of life. The reason to recommend smoking cessation is that virtually all of these health risks are reversible upon quitting. We know, for example, that tobacco use is one of the leading causes of heart attacks. Upon quitting smoking, within one year, your risk of a heart attack is decreased by 50%. Within five years, it returns to that of a person who's never smoked. In terms of cancer risk, it takes a bit longer,  Approximately 10-15 years to approach that of a "never smoker." We can now say with confidence that starting on the day you quit, you'll begin to feel better and the benefits of quitting will continue for the rest of your life. There's probably not a single more powerful health gift a person can give to themselves as successfully quitting smoking.

Moderator: Why do the negative effects of smoking "wear off" when you quit?

Dr. Fiore: Well, in fact, ALL of the negative effects don't wear off. Unfortunately, the actual lung damage that occurs in a person who develops emphysema, or what we now refer to as COPD (chronic obstructive pulmonary disease), is not reversible. But many of the effects result in changes that the body is able to recover from, and the changes in the cardiovascular system are one example of that.

Moderator: What is the first thing people need to do once they've decided to quit?

Dr. Fiore: Well, you've already emphasized the first thing, and that is to make a commitment to remove cigarettes from their lives. One struggle that many people who smoke experience is the misconception on the part of people who don't smoke that tobacco use is just some bad habit, and that if the person had enough willpower, they should be able to quit on their own. Once a person has made that commitment, based on the Public Health Service (PHS) guideline that was released today, the recommendation is to talk with your clinician. For most people, quitting is a difficult process. But, with the right counseling that a clinician can provide, as well as one of the right medicines that will blunt the painful withdrawal symptoms that smokers experience, you can markedly enhance your likelihood of successfully quitting.

Moderator: What are the symptoms of nicotine withdrawal?

Dr. Fiore: Nicotine withdrawal has a characteristic syndrome that most smokers can describe. It consists of a series of experiences such as irritability, difficulty concentrating, disturbed sleep, increased appetite, and a physical craving for cigarettes. These symptoms usually begin within a few hours to one to two days after quitting, and are greatest in the first week after quitting. For most people, they then begin to decline, but in some, they can continue for months. That actually is not clear -- why certain people have a more prolonged withdrawal syndrome than others. But, it may be related to the biochemistry that occurs in the brain of a person who smokes vs. a person who's trying to quit. We know, for example, that the brains of smokers are objectively different than those of non-smokers, particular in terms of a series of neurotransmitters (brain chemicals) that change in the brains of smokers. This can be related to why it's more difficult for some people to quit than others.

Moderator: Why is nicotine so addictive?

Dr. Fiore: Well, we know that when a person begins to smoke and then continues to smoke, as mentioned a few moments ago, demonstrable changes occur within that individual's brain. Specifically, brain levels of a chemical or neurotransmitter called "dopamine" increase. This is the neurotransmitter associated with the sensation of pleasure. Upon quitting, after having been exposed to these bursts of nicotine or dopamine in the brain that occur every time a person takes a puff of cigarette smoke -- once that's removed, there's a sensation that we describe as "withdrawal." There are probably many other reasons. Smoking, for many, is a key coping strategy, often associated with pleasurable activities in a person's day -- in essence, for many smokers, upon quitting, there is a sensation that they have given up one of their closest friends, and this, of course, can be very unpleasant.

Quick Guide25 Effects of Smoking on Your Looks and Life

25 Effects of Smoking on Your Looks and Life

Moderator: What actually harms you when you smoke, the nicotine itself or the chemicals in the smoke that you're inhaling?

Dr. Fiore: Excellent question! In fact, nicotine, apart from being highly addictive, is not harmful in general. In doses beyond that which a person would get from a pack of cigarettes or a nicotine patch, nicotine can be toxic, but the harmful effects of nicotine are solely for smokers in that it is addictive. It is the other components of tobacco smoke that destroy our health -- the carbon monoxide, as well as the 4,000 other chemicals in the tobacco smoke which we collectively refer to as "tar."

Moderator: What are some of the new pharmacological therapies used to help people quit?

Dr. Fiore: Well, with the guideline that we released today, available at www.surgeongeneral.gov, there will be a menu that will allow you to click a link for "smoking cessation." The Public Health Service Guideline there describes five first line medications that each, individually, markedly enhance successful quit rates among people motivated to quit. And, I want to emphasize that none of them are "magic bullets." Each of them require a commitment on the part of the smoker. Those five agents are: First, bupropion (Zyban, Wellbutrin), which is more commonly known as Zyban . That is the only non-nicotine medication. It is a pill, and its mechanism of action is to directly counteract the changes that occur in the brain when a person quits. Specifically, it raises brain levels of dopamine. The other four medications are all nicotine replacement products that include the nicotine gum, the nicotine patch, the nicotine nasal spray, and the nicotine inhalant. Each of these five medicines, when combined with the commitment of a person who wants to break free of tobacco dependence, can increase the likelihood that that individual will do so successfully.

Moderator: How many people try to quit, and how many are successful? Why is the success rate so high/low?

Dr. Fiore: Let me give you some statistics on tobacco use in America today. One in four adults, 25% of all adults in America currently smoke, representing about 50 million Americans. Almost eight out of ten of them now tell us that they want to quit and have already made one unsuccessful quit attempt. Each year, about 40% of smokers (about 20 million of them) try to quit. Unfortunately, only about one million, or 5%, are able to quit and stay quit. This very low success rate is in large part a result of the fact that most people who try to quit try to do so on their own, "cold turkey." The treatments underlined in the Public Health Service Guideline released today hold promise to double, triple, or quadruple that success rate. The implications of that for our nation would be enormous. We would increase our current rate of quitting, which is at about one million smokers per year, to somewhere between two to four million smokers per year. Almost immediately, these "quits" will translate into positive changes in the health of literally millions of Americans.

Moderator: How do you keep from getting frustrated if you try to quit but fail?

Dr. Fiore: Well, I think the short answer is that it's totally understandable that a person would become frustrated. But, an important finding in the guideline released today is the recognition of tobacco dependence as a chronic disease, not unlike high blood pressure, diabetes, or high cholesterol. With those, we are comfortable with the idea that we see our doctor, he/she may recommend an initial treatment that will either control the disease or not, if not, we return and another intervention is tried. Using this model for tobacco independence, we can then recognize that for many, it's going to take a number of tries before successfully quitting. On average, it takes between three to five serious quit attempts before breaking free of tobacco dependence. Some may be successful on the first try, others may take three or more tries. I like to tell people to visit our clinic, that every time you make an effort, you're smarter and stronger, and you can use that information to increase the likelihood that your subsequent quit attempt is successful.

Moderator: What are some alternative therapies for quitting, and how effective are they?

Dr. Fiore: Well, the two that are probably the most common, both of which were examined in the guideline released today, are acupuncture and hypnosis. In a review of the research about these techniques, neither was found to be effective. With that said, we all know individuals who were able to successfully quit using one of these therapies. Just as we all know people who were able to quit "cold turkey." But, when we think about smokers, in general, hypnosis and acupuncture were not more effective than the placebo, in comparison with a treatment that didn't have these interventions.

Moderator: What role does self-image play in addiction to cigarettes, and how can you go about changing your self-image?

Dr. Fiore: Well, that's a complicated question, and one that might be better answered by a clinical psychologist than me, as a physician. But, I'll say this: Frequently self-image is wrapped up in peer group (by that I mean, some of our closest friends who also smoke), and it is very difficult for a person to quit when his/her spouse or significant other or closest friends continue to smoke. I guess what I would offer as advice is to say that one needs to want enough to be free of the health risks that result from smoking, but, maybe even more importantly, desire enough the health benefits that they'll experience upon quitting. Particularly for young people, talking about health risks like heart attacks and strokes that may not take place for 20-30 years, sometimes is less relevant than saying, "When you quit, you'll feel better, smell better, have more energy, be less winded and protect your health, both today and tomorrow."

Moderator: How can you change your daily routine if it incorporates smoking (e.g. smoking a cigarette with breakfast)?

Dr. Fiore: Well, I think that's an important question, because one of the things we frequently do in counseling is to ask "What cigarette would be the most difficult to give up?" Or, "What do you envision would be some of the barriers to successfully quitting?" And, changing your routine is a great strategy. For many, it could be something as simple as changing the order in which they prepare for school or work each day; substitute tea for coffee, have breakfast in a different room in the house, drive to work or school using a different route. Any way you can change the routine, you will make having a cigarette less automatic. Many smokers will say, "I frequently light a cigarette, smoke it, and put it out without ever consciously realizing I've done it." If you consciously change the routine that you live by, particularly in the first couple days after quitting, you can help take the automatic part of your smoking out of your life. There's another key part of that effort, and that's to ensure that you don't bump into any cigarettes. The night before your quit date, physically destroy any cigarettes and ensure that there aren't any cigarettes in your home, office, clothing or car.

Moderator: Why do people tend to smoke while drinking?

Dr. Fiore: Well, I frequently -- I'm struck by the questions and the fact that some of the "whys" I really don't have answers for. But, for many, smoking becomes part of the ritual of their daily lives. And, going into a bar provides for many people an enormous cue to have a cigarette. Very few bars are smoke-free; many people in them are smoking as well as drinking. One of the things that drinking alcohol does is lower our inhibitions, and for someone who's trying to quit, going to a bar or having an alcoholic drink is frequently a high-risk behavior. And, finally, both alcohol and nicotine share one component and that is that they both cause the brain to release the neurotransmitter dopamine, that, as we said earlier, is associated with pleasure.

Quick Guide25 Effects of Smoking on Your Looks and Life

25 Effects of Smoking on Your Looks and Life

Moderator: How can you keep from gaining weight when you're quitting?

Dr. Fiore: Well, first we need to face the reality that for most smokers, there will be some weight gain associated with quitting. On average, people who successfully quit gain between 5 to 10 pounds. Strategies that have been associated with reducing that weight gain have been to incorporate exercise as part of the quitting process and two medications, Zyban and nicotine gum, have also been shown to blunt or decrease the weight gain.

Moderator: How do nicotine gum and the nicotine patch help people quit?

Dr. Fiore: The mechanism of action is presumed to be this: People continue to smoke for a lot of reasons, but one important one is dependence upon nicotine. Some of the other reasons that people continue to smoke, however, involve the habitual aspects and rituals of smoking, as well as the emotional links that we establish with smoking, something we turn to when under stress, anger, or frequently, when happy. What nicotine replacement therapy allows one to do (the patch, the gum, or inhalant) is to "decouple" or "unlink" the physical dependence upon nicotine from the habitual and emotional links to cigarette smoking. In essence, we help the smoker to break the habit of smoking, and once that's under control it's much easier to break the addiction to nicotine specifically.

Moderator: Can you tell us about some of the new telephone strategies for counseling smokers?

Dr. Fiore: In many states now, across the U.S., Massachusetts, California, Arizona, Florida, and Oregon, they now have statewide help-line hotlines. These telephone-based counseling services allow smokers, free of charge, to call an 800-number and to get matched up with a trained smoking cessation counselor, who will then work with the smoker to provide a quit plan for them, and to follow with that patient as they move through the quitting process from the quit date forward. They might recommend medications to try, to see your doctors, or frequently mail self-help info to try or read. These lines have been shown to successfully increase the likelihood that people quit and are also very appealing because they are a cost-effective investment of limited resources.

Moderator: What should you do when you're trying to quit, but you're with friends or family members who smoke?

Dr. Fiore: Well, my experience has been, and the guideline recommends, that you enlist the support, the social support of people around you when trying to quit. When I talk with smokers, most of them tell me that their family members and close friends who smoke are supportive of their efforts to quit. So, I'd say an important strategy to say to your friends and family members who smoke is that you're about to make a quit attempt,  you'd appreciate their support, and one way to "help me through that effort would be for you to not smoke when I'm around and not leave your cigarettes out and about, which would be an awful temptation to me." My experience is that most friends/family members will support these efforts.

Moderator: What kinds of activities can you do when you feel the urge to smoke?

Dr. Fiore: It's important to remember that urges to smoke don't increase in an exponential manner, leaving a person, in essence, out of control. More typically, urges come in waves. And, if you can come up with a strategy to delay through that wave, you'll be able to overcome it. Some strategies people use are first, just to get up and move, secondly to drink water, thirdly, to engage in deep breathing exercises, and one strategy I use at our clinic is to tell the individual trying to quit to look at their watch when a powerful urge comes upon them and say, "I'm not going to do anything about this urge for one hour, I'm going to delay for one hour." For most individuals, by the time the hour has passed, the severity of the urge has decreased markedly. It's better to say, "I'm not going to give in to this urge for an hour," rather than to say, "I'm having this terrible urge and can't smoke for the rest of my life." More information on all the strategies to help you quit are available in the guidelines released today, "Treating Tobacco Use and Dependence: A Clinical Practice Guideline," available at www.surgeongeneral.gov.

Moderator: Why do so few physicians offer assistance for quitting?

Dr. Fiore: First, it's important to recognize that over the last five years, physicians have actually significantly improved their rates of intervening with their patients that smoke. But, you are right, physicians have a long way to go. I think one key reason for their reluctance to intervene with their smokers is that they have not, until now, known what to say beyond, "you need to quit smoking." The Public Health Service Guideline released today provides clinicians with a step-by-step approach to help their patients who use tobacco. It's my feeling that with the availability of these evidence-based recommendations, treating every patient who presents to a clinic, who smokes, by first, asking them if they use tobacco, and then asking them to quit, and then providing them with specific advice on how to quit successfully, that brief intervention should be the new standard of care in providing healthcare for all Americans, in my opinion.

Moderator: What should you do if you need more help?

Dr. Fiore: I think there's a variety of options and activities a person can do or engage in if they need assistance in quitting. See your doctor, tell him/her that you want to quit, and want some of the key advice as well as an appropriate medicine to help you do that successfully. Second, I would go online to www.surgeongeneral.gov and click on "smoking cessation", then review the material that's available for people trying to quit. In most communities today, there are also community resources. If you look in the yellow pages, many hospitals, clinics, and non-profit organizations like the Cancer Society and Lung Association, offer assistance to people trying to quit. And, finally, there are now many state-based programs that will help people who are motivated to quit, to do that successfully.

Moderator: What are some other resources people who are trying to quit can use?

Dr. Fiore: Well, I've given the list of resources I'd urge people to turn to. In terms of other net-based resources, I'm not familiar with them.

ccartt_webmd: I noticed that your report doesn't mention web-based "quit smoking" communities. How come?

Dr. Fiore: Well, maybe it would be helpful to share with you how we came up with the recommendations in the Public Health Service Report released today. We scanned, in an exhaustive way, the scientific literature, everything published and recorded from 1975 to 1999, medical research that addressed ways to quit smoking. All told, we identified more than 6,000 studies. They served as the basis for the analysis contained in the report, and the recommendation that followed those analyses. I suspect one reason there was little in the way of web-based research is that that modality is a very recent one and doesn't yet have a scientific basis to support it. That's not to say that it's not effective, only that we did not have evidence to endorse it. And every one of the recommendations in the guideline is based on that evidence of 6,000 research articles. The guideline was produced by a panel of 18 experts, none of whom are in the government, but the recommendations where then presented to the Surgeon General who adopted them as a Public Service Report. That does constitute our best estimate of those treatments that work and those that do not. I think the most important message from the guideline released by the Public Health Service today is a message of hope. Eight out of ten smokers in America now tell us that they want to quit, have tried at least once, and have failed. For these individuals, continued tobacco use is associated with frustration, a sense of failure and dependence on a drug that can't be overcome. The guideline offers such tobacco users and their physicians specific recommendations that will markedly increase the likelihood that a person motivated to quit will do so, successfully. I'm convinced that with these recommendations, virtually every smoker in America who wants to quit can do so, successfully. And, I urge all such smokers to take advantage of this new information. Thank you.

Moderator: Dr. Fiore, thank you for joining us today. WebMD members, please be sure to check the events calendar for other upcoming live events.

The opinions given by Dr. Fiore are his and his alone. If you have specific questions or are concerned about your health, please consult your personal physician. This event is for informational purposes only.

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Reviewed on 10/23/2003 1:20:58 AM

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