Quitting Smoking Is Still Hard to Do

Back when Elaine Marmer decided to douse a 25-year love affair with nicotine, it was still an era of smoke-filled back rooms - and front rooms, dining rooms, even hospital rooms.

You would go to bed every Sunday night and say, `Tomorrow morning when I get up, I'm not smoking anymore,' '' said Marmer, recalling a battle that framed much of her life through the 1960s and '70s.But it was everywhere, just everywhere - smoke was all over the place. I smoked terribly. Everyone did. There was no way out.''

Now, more than two decades later, smoking has been banished from all workplaces in nearly 100 Massachusetts cities and towns. It is a prohibition that includes, notably, the last public redoubts for smokers - nightclubs, taverns, and restaurants - which are destined to become smoke-free statewide starting July 5.

While the crusade to remove smoking from the workplace has often been cast as an effort to eliminate exposure to secondhand smoke, advocates concede there is a subtler - but, from a health perspective, even more vital - objective at hand.

It makes smoking more difficult, and making it more difficult makes more people quit smoking,'' said David Mulligan, who championed a smoking ban last year as chairman of the Boston Public Health Commission. If a worker on the 45th floor of an office tower has to venture all the way to the sidewalk to grab a smoke in the cold, Mulligan said,that's a pretty strong incentive to quit.''

And it's not just the incentives that have grown stronger since Marmer quit in 1979.

The tools for quitting are far better, too, though still imperfect. Studies have shown that while 46 percent of smokers try to stop each year, few succeed. Of the 17 million American smokers who vowed to stub out their cigarettes in 1991, only 7 percent - or nearly 1.2 million - remained smoke-free a year later.

I had to do it on my own,'' said Marmer, who lives in Framingham.There were no pills, there were no patches, there were very few support groups. But I did have three kids who wanted this more than anything else and a husband who quit along with me.''

Today, Marmer, who has volunteered for 20 years as part of the American Cancer Society's drive to help people extinguish their cigarette habit, can share with smokers a potpourri of methods to end their addiction.

Some are available over the counter, such as nicotine patches, nicotine gum, and nicotine lozenges; a prescription is needed for inhalers and nasal sprays that also deliver nicotine.

Regardless of the delivery system, the goal is the same: seeding nicotine in the bloodstream to stave off the withdrawal symptoms and cravings that bedevil so many people who have tried to quit.

Scientists now know that while nicotine is what hooks smokers, it's the hundreds of chemical reactions that ignite when a cigarette is lit that result in the cancer, heart disease, and other conditions that make smoking the nation's leading cause of preventable death.

``The goal of this is not to reproduce the pleasure of smoking, the hit you get from smoking nicotine,'' said Dr. Nancy Rigotti, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital. Instead of spikes of pleasure that leave smokers craving more, the nicotine replacements aim to provide a slow, steady dose that sates the need for nicotine while weaning smokers both physically and emotionally from the habit.

A review of medical studies performed by the US Department of Health and Human Services found that the various nicotine treatments did, in fact, help with smoking cessation. Smokers who used the patch were twice as likely to have long-term success in becoming nonsmokers as those placed on a placebo, the federal researchers found when analyzing 27 studies conducted over several years.

Still, the nicotine treatments proved to be far from universally effective. Only 18 percent of smokers on the patch managed to give up cigarettes for more than a year, according to the federal report.

There's a huge controversy regarding the effectiveness of stop-smoking medications,'' said Lori Pbert, director of the Center for Tobacco Prevention and Control at the University of Massachusetts Medical School.What we typically say is that the medications double quit rates, recognizing that quit rates are low to begin with. Still, I would say there are medications out there that many smokers have found to be helpful, and they're worth considering.''

That's because while a series of studies - including research from the Harvard School of Public Health - have shown that workplace bans inspire some smokers to completely forsake the habit, other surveys discovered that workers cut down during work hours, but kept puffing in doorways and off-hours.

In an attempt to boost those rates, Harvard researchers are in the midst of a medical trial that could lead to a wider range of nicotine doses, instead of the three strengths now available over the counter.

We're trying to individualize the dose of nicotine we give people,'' said Randall Hoskinson, project coordinator for the smoking cessation research program at the Harvard School of Dental Medicine.If we give them 100 percent of what they got from cigarettes, are they more likely to quit? We're trying to find out what works best because none of what's out there has a really high success rate. There's no right answer yet, basically.

``But it's better than quitting cold turkey,'' he said.

Recognizing the limited potential for nicotine replacement, researchers are hunting for different medicines to help smokers quit. Already, there's a prescription drug called Zyban, a compound originally designed as an antidepressant. Scientists believe it works on certain brain chemicals to reduce the urge to light up.

At Mass General, Rigotti is involved in a study of a drug that traces its creation to a natural remedy favored by scientists in the 1960s-era Soviet Union. Known now as Varenicline and made by Pfizer, the pill works by flipping on nicotine receptors in the brain and fooling it into believing nicotine has arrived. But the drug does that in a way that is considerably less pleasurable than nicotine, thus reducing prospects that patients will develop a craving for cigarettes.

Preliminary reviews of the drug have been encouraging, with one small-scale study showing that nearly half the smokers threw their cigarettes away. But even if the drug does ultimately come on the market, nobody is portraying it as a panacea for a habit that has cast a lifelong spell over millions of smokers.

In part, that's because specialists who have devoted themselves to stopping smoking recognize that a constellation of social forces determine who will succeed - and who won't. Pbert, for instance, recalls a patient who would make great strides until she slid into a booth at a favorite diner with her pal, an inveterate smoker, and was left defenseless.

The next time she tried to quit,'' Pbert said,she skipped three weeks of lunch with Dorothy at the diner, or talked to Dorothy on the phone or went someplace they couldn't smoke.

`She had to learn:How do I make this major change in my life without losing the other pleasures in my life,'' Pbert said.

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