- The Washington Times - Sunday, October 8, 2000

It has been more than 35 years since the U.S. surgeon general declared smoking a health hazard. That means for more than three decades, millions of smokers have been looking for the least painful way to become ex-smokers.

Smokers have coped with the cravings and irritability. They have dealt with the temptations and the stress-related re-lapses. The bottom line: Nicotine is addictive, and breaking free of any addiction is no simple task.

"Nicotine is a drug," says Dr. Elizabeth Houtsmuller, an assistant professor of psychiatry at Johns Hopkins University who has conducted extensive research on smoking cessation.

"It produces effects in the brain that feel good," she says. "Nicotine increases the release of the neurotransmitter dopamine, so you get a pleasure effect. Since nicotine affects the neurotransmitters, you have to keep using it to get the pleasure effect. And when you have withdrawal, you are likely to have withdrawal symptoms such as weight gain, sleep disturbances and cravings."

For the 47 million Americans who smoke, there has never been an easier time than now to cope with quitting, Dr. Houtsmuller says.

A range of nicotine-replacement options are available by prescription or over the counter. These products available in patch, gum, nasal sprays and inhalers slowly release nicotine into the body, giving a smoker the positive effects on the brain without the harmful effects tobacco has on the heart and lungs.

"Nicotine doesn't kill, it is the delivery system that does," says Edwin Fisher, a professor of psychology at Washington University in St. Louis and a spokesman for the American Lung Association. "If you have to choose between gum or a pack of cigarettes a day, that's a slam dunk. Choose the gum."

Current U.S. Surgeon General David Satcher agrees. In June, Dr. Satcher released a report titled "Treating Tobacco Use and Dependence." In it, he and 30 officials from other federal health care organizations gave their endorsement for nicotine replacement, the use of Zyban (a prescription anti-depressant that alters brain chemistry to cope with nicotine withdrawal) and counseling as the most effective way to quit smoking.

The report recommends that a smoker serious about quitting get involved with a counseling and support program for about four to six months. It takes about that long to learn to understand social triggers that lead to smoking (such as being around other smokers) and stressors that might lead to a relapse, says Linda Schwartz, a former smoker who runs smoking-cessation clinics at Sibley Memorial Hospital in the District.

"About one in four people does relapse," Ms. Schwartz says. "Nicotine replacement and Zyban work on the physical stress of quitting. I recommend that heavy smokers do something else, like counseling, to deal with the psychological stress."

Replacing the nicotine

The nicotine patch has been available for almost a decade. It recently became available as an over-the-counter product, making it easily accessible and relatively inexpensive (about $200 for a seven-week supply).

The patch delivers a steady stream of nicotine through the skin and into the blood, where it is delivered slowly to the brain. Side effects are rare, although some patients are allergic to the adhesive that attaches the patch to the skin.

Depending on the strength of the patch, it is changed every 16 to 24 hours. Users gradually reduce the dose after a few weeks.

The reason the patch works well and doesn't lead to "patch addiction" is that the levels of nicotine stay constant and the substance must go through the blood to get to the brain, Dr. Houtsmuller says. In smoking, nicotine is delivered to the brain in about seven seconds, which is why smokers feel withdrawal symptoms after a short time without a cigarette and relief when they finally get to smoke another one.

People are advised not to smoke while using the patch. That could lead to nicotine intoxication dizziness, nausea and a case of the jitters Dr. Houtsmuller says.

Richard, a 39-year-old District man who asked that his last name not be printed, successfully used the patch while attending Sibley's Freedom From Smoking program. Though he was a two-pack-a-day smoker for two decades, he hasn't smoked in almost six years.

"I woke myself up coughing every day," he says. "My mind was totally made up to quit. I geared myself up for it for two years. The patch seemed to help. I wore it for 10 weeks. When I took the last patch off, I noticed [I was missing the nicotine], but at least I had broken the association."

Another popular form of nicotine replacement is in gum such as Nicorette. This product, available without a prescription, contains small amounts of nicotine. The gum delivers faster doses of nicotine than the patch. To maintain nicotine levels, a person needs to chew about nine pieces a day. Using the gum effectively differs somewhat from chewing gum the conventional way. Users place the product between the cheek and gum and leave it there, rather than constantly chewing it.

Because the gum's nicotine delivery system is so quick, Ms. Schwartz advises her clients to use the patch rather than gum if they are serious about quitting.

"I think the gum is lousy," she says. "You can get addicted to it. I have seen people struggle to get off gum."

Nancy Lovre, a spokeswoman for SmithKline Beecham, the manufacturer of Nicorette, says the company offers tips on how to wean themselves off the gum.

"It is nicotine, and nicotine is addictive," she says of the product, "but in our estimation, less than 5 percent of users have complained of this. There are ways to stop using the gum. And the bottom line is, they are not smoking."

The nicotine nasal spray and inhaler are both available by prescription. The spray is the fastest of all the delivery systems and can be used in direct response to cravings. The inhaler is a cylinder similar in appearance to the cigarette. When a smoker puffs on it. a slow dose of nicotine is delivered. The inhaler is used most often by people who need the hand-to-mouth association of smoking.

Of course, some smokers don't like the idea of putting more nicotine into their bodies. When Sherry McClellan of Waldorf, Md., decided to start 2000 as an ex-smoker, she faced the new millennium cold turkey.

"I had a problem with putting nicotine back into my body," says Ms. McClellan, who quit once before, for two years in the 1980s. "I was trying to get it out. I did buy the patch. I walked around with it in my pocketbook, but I never put it on. After so many days, the physical craving was gone. I think I have quit for good this time."

Altering the neurotransmitters

Zyban (generic name bupropion), the only drug approved by the U.S. Food and Drug Administration for smoking cessation, is most effective when used in conjunction with nicotine replacement, Mr. Fisher says. Although its drug classification is as an anti-depressant, smokers should not dismiss the drug "because they are not depressed," he says.

"Zyban gives the brain what it is missing," Mr. Fisher says. "After a while, you will be able to give Zyban up, too."

Zyban or a similar drug, Wellbutrin, should be taken for several months and cause few side effects, Mr. Fisher says. Neither is recommended for people with seizure disorders or eating disorders.

Zyban has not been specifically approved for use by teens, but is being prescribed by some doctors to help teen smokers.

"There are people in the field who are realizing that teens are addicted much earlier than we think," Mr. Fisher says. "We ought to treat even a few cigarettes a day aggressively. I would rather see us do that to get teens off cigarettes at 18 rather than [let them] smoke for 10 years."

After getting suspended from a private school for smoking, Danielle Stewardson, 14, of Alexandria, faced expulsion if she didn't kick her pack-a-day habit. The ninth-grader who had been smoking since age 10 attended a counseling program through Inova Health Source, took Zyban and wore a 20-milligram patch. She has not smoked since early August.

"I had tried to quit a couple of times before," Danielle says. "After a couple of days, I would start up again. Zyban and the patch worked for me. After a week, I was able to be around friends who were smoking. I think I have quit for good now. I've gone this long without a cigarette, so why smoke another one?"

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