Cigarette smoking is widely recognized by the medical community as a major public health problem but with an effective smoking cessation program, this addiction can be dramatically controlled.

Even given the sharp decline seen since the early 1990s in smoking rates among adults, statistics concerning cigarette smoking remain frightening. More than 400,000 Americans die from the effects of smoking each year–a total higher than that attributable to AIDS, alcohol, illegal drugs, fires, murder, and suicide combined. Although 16 million US residents try to stop smoking each year, less than 10 percent succeed.1

Cigarette smoking is widely recognized by the medical community as a major public health problem. According to the American College of Chest Physicians2, and several other medical organizations, smoking accounts for 87 percent of deaths from lung cancer, for 82 percent of deaths from chronic obstructive pulmonary disease (COPD), for 21 percent of deaths from coronary disease, and for 18 percent of deaths from cerebrovascular accident (CVA). Even when they are without overt pulmonary symptoms, smokers have chronic inflammatory disease of the lower airways with an accelerated decline in lung function.

Given these statistics, it is not surprising that smoking cessation programs have become so prevalent. David Eubanks, EdD, RRT, is vice president of education of the American College of Chest Physicians. He says, “Smoking cessation has immediate and substantial health benefits and dramatically reduces the risk of most smoking-related diseases.” Eubanks adds that the risk of coronary disease decreases by 50 percent after a smoker has stopped for a year; 15 years after cessation, the risk of death from coronary disease approaches that of a lifelong nonsmoker. The risks of developing lung cancer, COPD, and CVA also decrease. In addition, smoking cessation has been shown to improve pulmonary function, particularly in young people.

For the past decade, a variety of hospital-based and community smoking cessation programs have been introduced nationwide. These classes provide smokers with the greatest chance of success in stopping smoking because they address the various facets of nicotine addiction. Many of the programs offered through organizations such as the American Lung Association (ALA) and the American Cancer Society use behavior-modification techniques and group counseling. Some programs are patterned after Alcoholics Anonymous meetings, while others offer pharmacological treatment using bupropion hydrochloride, a drug that has been proven effective in helping smokers stop.3 Available by prescription since 1997, it was originally marketed as a depression-fighting drug.

A Hospital-Based Approach
In response to physicians’ and patients’ requests, many hospitals have offered smoking-cessation programs. The Quit Smoking Service of Massachusetts General Hospital (MGH), Boston, is one of the oldest, most prominent programs in the United States. Led by Nancy Rigotti, MD, an expert in the field of tobacco control, MGH’s Quit Smoking Service uses a comprehensive approach combining cognitive, behavioral, and pharmacological treatment. Specifically, the program features information on nicotine transdermal patches, nicotine gum, inhalers, and bupropion; relaxation and self-hypnosis techniques; weight-gain prevention; and telephone support.

MGH offers three different smoking cessation programs: an 8-week evening class, an 8-week afternoon program, and one-on-one counseling. Thelma Tisdale, RN, MPH, director of the Quit Smoking Service, says, “The participants in our classes vary from session to session. At times, we’ll have all women; other times, we’ll have predominantly men.” Tisdale also points out that the age of participants varies because cigarette smoking is a problem that affects people of all ages (and ethnic backgrounds). Among smoking educators like Tisdale, a great concern is the rising number of teen smokers. A recent ALA study of high-school seniors reveals a disturbing trend: the prevalence of daily smoking among high school seniors was 31.6 percent higher in 1997 than in 1987.4

Despite the effort put forth by hospitals like MGH, most smoking cessation programs have shown only average success rates. Tisdale and her staff contact participants 6 months and 1 year after they take the class to learn whether they have stopped smoking. MGH’s current database shows that the program’s quit rate is 60 percent at the end of the program, 42 percent after 6 months, and 35 percent after 1 year. “These rates may appear low, but they are a reflection of how difficult it is to quit smoking,” Tisdale says. In fact, according to Tisdale, Surgeon General C. Everett Koop, has stated in speeches that nicotine is 10 times as addictive as heroin, since cigarette smoke reaches the brain faster than drugs that are taken intravenously. Smokers not only become physically addicted to nicotine, but also link smoking with many social activities, making smoking an extraordinarily difficult habit to break.

Reaching out to the Community
Smoking cessation programs are also offered by many national health organizations and local community groups. Most of these organizations recruit health care practitioners to become trained smoking cessation facilitators within their own hospitals or other health care facilities. One of the more successful programs is the ALA’s Freedom from Smoking class, which is administered throughout the country by local ALA affiliates. Linda Schwartz, a volunteer facilitator of the Washington, DC Freedom from Smoking program, stresses the value of a group smoking cessation program, combined with nicotine replacement products and bupropion.

Designed as a 7-session, 6-week course, the Washington program teaches participants, during their first 3 weeks, how to prepare and plan to give up smoking. Schwartz encourages them to start using nicotine patches and other products to help them give up smoking entirely, which is required by the third week of the program. Some Freedom from Smoking participants even form support groups after the program ends to ensure that they continue to lead smoke-free lives.

Schwartz points out that she sees many people repeat the class, which indicates not only how difficult it is to stop smoking, but how committed some individuals are to breaking the habit. Most smokers need to practice stopping several times before they completely conquer their addiction.

Because of the rising incidence of smoking among teens, the ALA has created programs specifically targeting this population. The ALA’s Smoke-Free Class of 2000 is a 12-year awareness project created in response to Koop’s 1988 call as US Surgeon General for a smoke-free society by the year 2000. This year’s students in the class of 2000, who are currently in the 11th grade, have been involved in Teens Against Tobacco Use, or TATU, a peer-education program that involves adult volunteers, teen trainers, and elementary school students. According to Ruth Newlin, ALA’s manager of the Smoke-Free Class of 2000, more than 30,000 teens throughout the country have been trained to instruct students in the fourth through sixth grades about the dangers of cigarette smoking. “It’s been exciting to see these teenagers become strong role models for their peers, as well as for younger children,” Newlin says .

The ALA is also conducting a pilot teen smoking cessation program. Developed in conjunction with researchers from the West Virginia University, Morgantown, the program is running at 20 sites and will be expanded to other locations by the end of 1999.

An RCP’s Approach
Constantly treating patients who were heavy smokers was one of the reasons that Eric Strauss, RRT, decided to start a smoking cessation program at Havasu Samaritan Regional Hospital in Lake Havasu City, Ariz. “When you continue to see patients whose health deteriorates because of smoking, you want to do something to help them,” Strauss says. He is a former smoker and is currently working as a staff therapist at Providence St Vincent Hospital, Portland. His smoking cessation program was first offered to employees at Havasu Samaritan and was then opened to the public.

The major difference between his class and most other smoking cessation programs is that he offers a one-session, behavior motivation class that de-emphasizes the word quitting. According to Strauss, smoking cessation is the result of an action. “Smoking cessation is about courage and conviction and being determined to win, not quit,” Strauss says. By de-emphasizing the quitting, Strauss believes that he gives smokers a greater incentive to take the first step toward living a smoke-free life.

Although Strauss does not deny the value of pharmaceutical intervention and nicotine replacement products, he stresses the importance of using the proper semantics in getting people motivated to stop smoking. The program that Strauss designed was well received in Arizona, and he hopes to establish a similar program in the Portland area. “With 1 in 5 smokers dying early, I feel it’s a major accomplishment if I can help people in my local community conquer their addictions.”

Carol Daus is a contributing writer for RT.

1. American Lung Association Fact Sheet on Smoking, September, 1998.

2. Smoking and Health: A Physician Responsibility Statement of the Joint Committee on Smoking and Health. American College of Chest Physicians, American Thoracic Society, Asia Pacific Society of Respirology, Canadian Thoracic Society, European Respiratory Society, International Union Against Tuberculosis and Lung Disease.

3. Huges JR, Goldstein, MG, et al. Recent advances in the pharmacotherapy of smoking. JAMA, 1999; 281(1): 72-6.

4. Trends in Cigarette Smoking: Epidemiology and Statistics Unit, American Lung Association, February, 1998.