First, the good news: The 46 million people (20.6 percent of all adults) who smoke in the U.S. are now outnumbered by former smokers. Between 1965 and 2004, smoking rates dropped by more than half, from 42.4 percent to 20.9 percent. About a month ago, New York City announced that just 14 out of 100 New Yorkers are still smoking. That's a 35 percent decline, or approximately 450,000 fewer adult smokers since 2002. So obviously people want to and can quit smoking.
Yet while most people quit relatively easily and without smoking cessation therapies like nicotine replacement therapy or counseling, other smokers struggle for years, further compromising their health. Some former smokers say quitting is the hardest thing they have ever done. Clearly, when it comes to quitting, all smokers are not alike.
For those who struggle mightily with quitting smoking, the belief that "some people just can't quit" resonates with their broken confidence in their ability to quit. Emotional beliefs and cognitions crop up around the physical realities of addiction such as: "I can learn to keep this under control," or "I need this to cope with stress" or "I just can't quit." The biology of addiction and withdrawal and the psychological dynamics of smoking addiction conspire to undermine the smokers' self-confidence, which is a central component of long-term quitting success (1). The addiction itself destroys smokers' confidence that they can quit, good therapy rebuilds it so they can restore themselves to a smoke-free life.
Recently, the destructive notion that "some people just can't quit" has opened up a way to market controversial products such as electronic cigarettes and smokeless tobacco to smokers desperate for a lifeline out of smoking. E-cigarettes are unregulated products (outside the scope of the FDA), with poor quality control and little unbiased research to guide consumers. E-cigarettes are essentially a new form of nicotine replacement therapy (NRT). They are now competing with the available forms of NRT by presenting themselves as a new kind of cigarette, and without going through all the usual product safety and effectiveness testing required by the FDA. This means they do not have to adhere to any quality control standards, except those imposed by the rough and tumble of the marketplace. So buyer beware.
A recent small pilot study (2), widely praised by the e-cigarette community, found that: "Sustained smoking abstinence at week 24 was observed in 9/40 (22.5 percent) participants, with 6/9 still using the e-cigarette by the end of the study." The study excluded participants with "a history of alcohol and illicit drug use, major depression and other psychiatric conditions" as well as smokers with a wide variety of smoking-caused medical problems. In other words, it excluded many of the people still smoking (and struggling to quit) today! While these findings may be encouraging to the e-cigarette industry, they probably indicate that e-cigarettes are unlikely to do any better helping smokers quit than FDA-approved NRT products. To put this small e-cigarette study in context, an analysis by the U.S. Department of Health and Human Services (3) of multiple rigorous scientific studies at six months postquit found that combining the nicotine patch and the nicotine gum produced, on average, a 36.5 abstinence rate compared to placebo.
Smokers may, however, take to e-cigarettes more readily than they take to established stop smoking therapies. Inhaling nicotine vapors directly into the lungs from e-cigarettes may be more rewarding, for example, and may make them harder to stop down the line. This bodes well for the bottom line of industries built on the premise that it's impossible to stop. In contrast, most people are happy to stop their nicotine patch (and other FDA-approved therapies) when they are confident in their newly smoke-free life. Smoking cessation medications are designed to boost the confidence of smokers who want to quit, not to profit from smokers' broken confidence.
The purveyors of e-cigarettes and smokeless tobacco usually exaggerate poor outcomes with traditional quit-smoking methods, such as nicotine replacement therapies, which are also meant to be combined, but seldom are, with proven counseling approaches. Quitting smokers can greatly benefit from the National Cancer Institutes' field-tested brief intervention program or motivational interviewing from health professionals, or cognitive-behavioral therapy (CBT) for smoking cessation. Recent treatment reports for extended CBT show it has the potential to help over half of smokers quit in a given treatment cycle (4).
When marketers capitalize on the unhelpful belief that it's impossible to quit, it reinforces addicted smokers' own broken confidence. Let's redouble our efforts instead to make available proven and safe methods which can inspire confidence in all of us.
Dr. Daniel Seidman is director of smoking cessation services at Columbia University Medical Center, and author of "Smoke-Free in 30 Days: The Pain-Free, Permanent Way to Quit," with a foreward by Dr. Mehmet Oz (Simon & Schuster 2010). For more details about the book, go to www.danielfseidman.com.
(1) Hendricks, P.S., Delucchi, K.L., & Hall, S.M. (2010). Mechanisms of change in extended cognitive behavioral treatment for tobacco dependence. Drug and Alcohol Dependence, 109, 114-119.
(2) Polosa, R. et al. Effect of an Electronic Nicotine Delivery Device (e-Cigarette) on Smoking Reduction and Cessation: A Prospective 6-Month Pilot Study. BMC Public Health 2011, 11:786 doi:10.1186/1471-2458-11-786.
(3) Treating Tobacco Use and Dependence: 2008 Update. Tobacco Use and Dependence Guideline Panel. Rockville (MD): US Department of Health and Human Services; 2008 May
(4) Hall, S.M., Humfleet, G.L., Munoz, R.F., Reus, V.I., Robbins, J.A., et al (2009). Extended treatment of older cigarette smokers. Adiction, 104, 1043-1052.
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