Quit Cigarette Smoking : Dr. David B. Abrams is executive director of the Steven A. Schroeder National Institute for Tobacco Research and Policy Studies at the American Legacy Foundation, a nonprofit group dedicated to reducing tobacco use. He was formerly director of the Office of Behavioral and Social Sciences Research at the National Institutes of Health. As a researcher and a clinical psychologist, he has studied and treated nicotine addiction for 25 years. He co-wrote an Institute of Medicine report, “Ending the Tobacco Problem: A Blueprint for the Nation,” published in 2007.
Q. Do you think it’s much easier to Quit Cigarette Smoking now than it was 5 or 10 years ago?
A. Yes. There are now a variety of good treatments available that can be tailored to individual smokers. There are good cognitive behavioral treatments for the part of addiction that has to do with needing to unlearn the habit. There have also been some breakthroughs in pharmacologic treatments, from the introduction of the first nicotine replacement therapies to the very recent new drug, Chantix, that’s tailored to nicotine receptors in the brain.
Q. The Food and Drug Administration recently warned about suicidal behavior with Chantix. Are people more wary of trying it now because of that?
A. As with other new drugs, there are a few people that have some untoward reactions. In some of them, frankly, it’s not clear that it’s directly related to the drug itself. They may have other predisposing factors that coincidentally happen around the same time. So I hope there isn’t an overreaction to that. I think it continues to be a very safe and effective drug.
Q. What about changes in social norms? Does less tolerance of smoking in public support the clinical side of treating the addiction?
A. It is probably one of the most important drivers of helping people to Quit Cigarette Smoking. It’s not just that it motivates people to Quit Cigarette Smoking because it’s more inconvenient to smoke, or because they don’t want to damage the health of people around them. It’s also that there’s less smoking around them at bars or in restaurants, and therefore, they’re not as tempted. The way I like to say it is that once your brain has tasted “chocolate cake” — the powerful benefits of nicotine — it’s very hard to forget it. So every time you’re reminded of it when you see someone smoking, or you smell smoke, you have an instant reaction to want to smoke.
Q. In addition to new medicines, have counseling methods improved?
A. Right. I think one of the biggest breakthroughs was taking the best components of behavioral treatments and boiling them down so they could be distributed widely through different channels, like telephone quit lines and primary care practices, where physicians or nurses can be trained to deliver a brief treatment.
Q. Might smoking bans and high taxes make some smokers feel persecuted, and as a result more recalcitrant about their smoking? Or doesn’t that matter much?
A. I think it does matter. Sometimes when they dig their heels in, it’s because they really don’t feel that they can get the help they need to change. I think you need to be very supportive. But certainly, there will be a small group of people who say, “I have the freedom to smoke, and leave me alone.”
Q. What major obstacles remain for smokers trying to Quit Cigarette Smoking ?
A. The general public is not as aware of the value of using evidence-based treatment as they should be. When we do surveys of current smokers, a fair number of them actually believe that nicotine replacement products could be as harmful to their health as smoking, which is absolutely not true. It’s the burnt carcinogens in tobacco, and not the nicotine, that’s the really harmful substance. Unfortunately, I think people are not using the best pharmacologic treatments and the best behavioral treatments. They still try to use willpower.
I think another barrier is that busy physicians, because of managed care and other things, have so much pressure to move patients through their offices that they aren’t able to take the time to do brief lifestyle counseling. I would love to see the reimbursement system change to allow physicians to bill for, say, 15 minutes of talk therapy, and allow them to do brief behavioral treatment, along with nicotine replacement or other drug therapies.
We need a system where you have comprehensive continuity of care until the smoker quits. You never give up on a diabetic if they go off their diet or stop taking their insulin. You still bring them back, and you remind them, and you have all sorts of support systems because it’s a lifetime commitment.
We’re talking about a stepped-care system. The idea is that you should give people a chance to use a low-level treatment on their own, but if it doesn’t work, then you need to step them up to a more specialized treatment. In fact, a third step may well be that if you’ve tried to Quit Cigarette Smoking with your primary care physician and failed, maybe you ought to be referred to a specialist in addiction treatment.
Q. Do you think today’s young children will take up smoking the way their parents’ generation did?
A. Of course, my hope would be absolutely not. I hope within 5 to 10 years that the F.D.A. would have approved the reduction of nicotine content in tobacco; therefore, it wouldn’t even be an interesting thing to try, because there would be so little reward value in the small amount of nicotine left. I also hope that because so many fewer parents smoke, that kids would grow up smoke-free. The third thing is, there may well be a more significant vaccine. The real hope is that we could give pre-adolescent kids a vaccine, just like we do for childhood diseases.
If I were to wave a magic wand so that those three things happened, I think we may actually have very close to a smoke-free next generation, which would be my ideal.
Q. What do you think about people continuing to use nicotine replacement for a long time after Quit Cigarette Smoking ?
A. Certain people may well need some kind of pharmacologic treatment to correct their brain imbalance, just like some people need long-term medication for serious mental illness. I’d rather see them on long-term nicotine therapy than go back to smoking.
Q. Is there anything new on the horizon that could make it much easier for people to Quit Cigarette Smoking ?
A. There are two things that I’m quite excited about. One is the talk with the F.D.A. about systematically reducing nicotine in tobacco over a 5- or a 10-year period. If they did reduce it significantly, there’s a lot of research suggesting that we could, in effect, wean the whole population off their nicotine addiction and get to the point where, gradually, smokers would be less and less addicted and may find it easier to Quit Cigarette Smoking. I think as a public health solution, that’s a very good one. I’m hoping that kind of legislation will be taken seriously.
The second thing is that we may be developing a nicotine vaccine — the NicVAX. There is some preliminary evidence that it’s promising. It’s not quite there yet, but it’s particularly useful, perhaps, to prevent relapse.
We’ve got a lot of people trying to Quit Cigarette Smoking every year — millions, actually. What we have to do is figure out how to prevent them from relapsing after they Quit Cigarette Smoking. I think relapse prevention is the single biggest research challenge. The vaccine may help with that; getting nicotine out of cigarettes would certainly help with that.
Q. What do you say to your friends and family who still smoke?
A. I want to find a way to hold your hand and help you Quit Cigarette Smoking, not to be nasty to you and box you in a corner, but really be sympathetic and understand that this is something that you couldn’t help doing. When you were younger and you got hooked on nicotine, you had no idea that you would become a lifetime slave to this substance, because it changed the reward pathway in your brain. I want to help you get over that, and I know it’s extremely hard to do because nicotine is a very powerful addictive substance.
The biggest problem with nicotine is that, actually, your brain works better on nicotine. It improves reaction time, it improves memory, it improves concentration, it helps you get through a frustrating workday. There are reasons why people hang on to nicotine. It’s almost the perfect drug.
I’m an ex-smoker, and I still miss it. I think I might actually have been more productive as a researcher if I’d continued to smoke, because I know it made my brain work better. It’s very, very hard to give up, and I’m very sympathetic.
Quit Cigarette Smoking~Q & A With Dr. David B. Abrams About On Becoming an Ex-Smoker
Q. Do you think it’s much easier to Quit Cigarette Smoking now than it was 5 or 10 years ago?
A. Yes. There are now a variety of good treatments available that can be tailored to individual smokers. There are good cognitive behavioral treatments for the part of addiction that has to do with needing to unlearn the habit. There have also been some breakthroughs in pharmacologic treatments, from the introduction of the first nicotine replacement therapies to the very recent new drug, Chantix, that’s tailored to nicotine receptors in the brain.
Q. The Food and Drug Administration recently warned about suicidal behavior with Chantix. Are people more wary of trying it now because of that?
A. As with other new drugs, there are a few people that have some untoward reactions. In some of them, frankly, it’s not clear that it’s directly related to the drug itself. They may have other predisposing factors that coincidentally happen around the same time. So I hope there isn’t an overreaction to that. I think it continues to be a very safe and effective drug.
Q. What about changes in social norms? Does less tolerance of smoking in public support the clinical side of treating the addiction?
A. It is probably one of the most important drivers of helping people to Quit Cigarette Smoking. It’s not just that it motivates people to Quit Cigarette Smoking because it’s more inconvenient to smoke, or because they don’t want to damage the health of people around them. It’s also that there’s less smoking around them at bars or in restaurants, and therefore, they’re not as tempted. The way I like to say it is that once your brain has tasted “chocolate cake” — the powerful benefits of nicotine — it’s very hard to forget it. So every time you’re reminded of it when you see someone smoking, or you smell smoke, you have an instant reaction to want to smoke.
Q. In addition to new medicines, have counseling methods improved?
A. Right. I think one of the biggest breakthroughs was taking the best components of behavioral treatments and boiling them down so they could be distributed widely through different channels, like telephone quit lines and primary care practices, where physicians or nurses can be trained to deliver a brief treatment.
Q. Might smoking bans and high taxes make some smokers feel persecuted, and as a result more recalcitrant about their smoking? Or doesn’t that matter much?
A. I think it does matter. Sometimes when they dig their heels in, it’s because they really don’t feel that they can get the help they need to change. I think you need to be very supportive. But certainly, there will be a small group of people who say, “I have the freedom to smoke, and leave me alone.”
Q. What major obstacles remain for smokers trying to Quit Cigarette Smoking ?
A. The general public is not as aware of the value of using evidence-based treatment as they should be. When we do surveys of current smokers, a fair number of them actually believe that nicotine replacement products could be as harmful to their health as smoking, which is absolutely not true. It’s the burnt carcinogens in tobacco, and not the nicotine, that’s the really harmful substance. Unfortunately, I think people are not using the best pharmacologic treatments and the best behavioral treatments. They still try to use willpower.
I think another barrier is that busy physicians, because of managed care and other things, have so much pressure to move patients through their offices that they aren’t able to take the time to do brief lifestyle counseling. I would love to see the reimbursement system change to allow physicians to bill for, say, 15 minutes of talk therapy, and allow them to do brief behavioral treatment, along with nicotine replacement or other drug therapies.
We need a system where you have comprehensive continuity of care until the smoker quits. You never give up on a diabetic if they go off their diet or stop taking their insulin. You still bring them back, and you remind them, and you have all sorts of support systems because it’s a lifetime commitment.
We’re talking about a stepped-care system. The idea is that you should give people a chance to use a low-level treatment on their own, but if it doesn’t work, then you need to step them up to a more specialized treatment. In fact, a third step may well be that if you’ve tried to Quit Cigarette Smoking with your primary care physician and failed, maybe you ought to be referred to a specialist in addiction treatment.
Q. Do you think today’s young children will take up smoking the way their parents’ generation did?
A. Of course, my hope would be absolutely not. I hope within 5 to 10 years that the F.D.A. would have approved the reduction of nicotine content in tobacco; therefore, it wouldn’t even be an interesting thing to try, because there would be so little reward value in the small amount of nicotine left. I also hope that because so many fewer parents smoke, that kids would grow up smoke-free. The third thing is, there may well be a more significant vaccine. The real hope is that we could give pre-adolescent kids a vaccine, just like we do for childhood diseases.
If I were to wave a magic wand so that those three things happened, I think we may actually have very close to a smoke-free next generation, which would be my ideal.
Q. What do you think about people continuing to use nicotine replacement for a long time after Quit Cigarette Smoking ?
A. Certain people may well need some kind of pharmacologic treatment to correct their brain imbalance, just like some people need long-term medication for serious mental illness. I’d rather see them on long-term nicotine therapy than go back to smoking.
Q. Is there anything new on the horizon that could make it much easier for people to Quit Cigarette Smoking ?
A. There are two things that I’m quite excited about. One is the talk with the F.D.A. about systematically reducing nicotine in tobacco over a 5- or a 10-year period. If they did reduce it significantly, there’s a lot of research suggesting that we could, in effect, wean the whole population off their nicotine addiction and get to the point where, gradually, smokers would be less and less addicted and may find it easier to Quit Cigarette Smoking. I think as a public health solution, that’s a very good one. I’m hoping that kind of legislation will be taken seriously.
The second thing is that we may be developing a nicotine vaccine — the NicVAX. There is some preliminary evidence that it’s promising. It’s not quite there yet, but it’s particularly useful, perhaps, to prevent relapse.
We’ve got a lot of people trying to Quit Cigarette Smoking every year — millions, actually. What we have to do is figure out how to prevent them from relapsing after they Quit Cigarette Smoking. I think relapse prevention is the single biggest research challenge. The vaccine may help with that; getting nicotine out of cigarettes would certainly help with that.
Q. What do you say to your friends and family who still smoke?
A. I want to find a way to hold your hand and help you Quit Cigarette Smoking, not to be nasty to you and box you in a corner, but really be sympathetic and understand that this is something that you couldn’t help doing. When you were younger and you got hooked on nicotine, you had no idea that you would become a lifetime slave to this substance, because it changed the reward pathway in your brain. I want to help you get over that, and I know it’s extremely hard to do because nicotine is a very powerful addictive substance.
The biggest problem with nicotine is that, actually, your brain works better on nicotine. It improves reaction time, it improves memory, it improves concentration, it helps you get through a frustrating workday. There are reasons why people hang on to nicotine. It’s almost the perfect drug.
I’m an ex-smoker, and I still miss it. I think I might actually have been more productive as a researcher if I’d continued to smoke, because I know it made my brain work better. It’s very, very hard to give up, and I’m very sympathetic.
Quit Cigarette Smoking~Q & A With Dr. David B. Abrams About On Becoming an Ex-Smoker
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