Kicking The Cigarette Habit A Global Challenge

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Nora Volkow, M.D., director, National Institute on Drug Abuse
Yvette Chang, associate director, World Lung Foundation

One in five Americans smoke, and while millions of smokers try quitting each year, as many as three fourths of them end up smoking again within six months. Smoking is still rampant across the world as well; researchers predict cigarettes could eventually kill one third of young Chinese men.

NEAL CONAN, host:

This is TALK OF THE NATION. Im Neal Conan in Washington.

Twenty percent of adult Americans smoke. That's one in five, 46 million people. Those smoking rates dropped significantly after the surgeon general first reported health risks back in 1964. In recent years the numbers have held steady. As many as three-quarters of smokers who do quit end up smoking again within six months.

Michelle Obama said on "The Today Show" last week that the president has now been smoke-free for a year, but she left many to wonder how he finally managed to kick cigarettes.

So what worked for you or not? Tell us your story, 800-989-8255. Email us, talk@npr.org. You can also join the conversation at our website. That's at npr.org. Click on TALK OF THE NATION.

Later in the program, a social psychologist on the ideological bias of social psychologists. But first, what worked for you to quit smoking? And we'll start with a caller, and Mike(ph) is on the line, Mike calling us from Bradenton in Florida.

MIKE (Caller): Hi, how are you doing?

CONAN: I'm well, thanks.

MIKE: Well, in January of '91 I was up to two(ph) - about four packs a day, and I had already tried to quit once. I quit for four months. I smoked one, and then I was back to even worse.

So what I did is, the hardest thing was making it through the first day. I ended up quitting at 7:00 at night and I forced myself to lay in bed till the next day at 12:00, and then when I got up, I made it to about 3:00 in the afternoon, to where I was just going crazy. I just forced myself, just went right back to bed.

Once I made it through that first day, it then passed that psychological barrier, and last month was 20 years, the best thing I ever did.

CONAN: Congratulations on the 20 years. I don't think you get a chip for that, but you ought to. But why did you decide to go cold turkey, skipping the nicotine pouch or any of those things?

MIKE: I just - smoking for me, it was like eating. It's not like anything else. Like, if you quit drugs or pot or anything like that, you get sick. You have those kinds of withdrawals. But quitting cigarettes is like a hunger. I just couldn't do it and cut down, you know, even like smoking light cigarettes. I just had to do it cold turkey, was the only way I could do it.

And I also quit pot back then. So it's been 20 years of pot and cigarettes. Just something about me, I can take or leave booze or anything like that, but smoking, I will smoke everything under the roof.

CONAN: I wonder: Do you still dream about it?

MIKE: What now?

CONAN: Do you still dream about it?

MIKE: Oh man, I'm having a hard time hearing you.

CONAN: Oh, well, never mind. We'll ask another caller then. Mike, thanks very much for the phone call, appreciate it.

Joining us now is Dr. Nora Volkow, director of the National Institute on Drug Abuse, who is with us from their office in Bethesda, Maryland. Dr. Volkow, nice to have you with us today.

Dr. NORA VOLKOW (Director, National Institute on Drug Abuse): Good afternoon. Nice to be with you.

CONAN: And that description of cigarettes, tobacco like food, you need it like, well, I guess like a drug. I guess that's not a surprise.

Dr. VOLKOW: No, it's not, and that caller actually described it like a hunger, which is a very interesting concept because when you have food, right, you eat food because you like, or you eat food because you're hungry and you need it.

And in addiction, what happens in the brain is that it changes the way it's processing the information of drugs, as if you need them, literally need them - a hunger, a thirst.

CONAN: And that is what he is describing, and that is, you say, what any of us would face trying to quit smoking.

Dr. VOLKOW: If we were addicted, that's absolutely correct.

CONAN: And I wonder, as you look at the numbers that we've had, this holding steady over the past several years, you think we're on a plateau?

Dr. VOLKOW: We are on a plateau. If you look at the numbers overall in the United States, there haven't been any significant decreases over the past 10 years.

In young people, on the other hand, in adolescence, we've seen significant decreases in the past decade, but not in the adults. And I think what that may mean is that the strategies that we've used for prevention, which have been very, very effective, have enabled us to attract those individuals that are responsive to them, and we're left with those that become (unintelligible) genetic vulnerability or other vulnerabilities have a much harder time to stop smoking or engaging on smoking behaviors.

CONAN: Yet you'd think if younger people are smoking less, as they get older the numbers would go down.

Dr. VOLKOW: One would expect that, but we have not seen that. So that probably means that we're starting to see initiation in the early 20s; that is maintaining the similar rates of smoking, despite the fact that we're seeing lower levels on adolescence.

CONAN: That's interesting because a lot - you used to think that people got introduced to smoking when they were, as you say, teenagers, and that's really what made it so difficult to quit. You're suggesting now that people are being introduced to smoking and starting in their 20s.

Dr. VOLKOW: Well, what we're seeing is - and we're tracking because it's important - at what age does a person start smoking, and the earlier you start, the more the likelihood that you will become addicted.

So an indicator that is very useful for us is: Can our prevention make people start smoking later? And indeed, there is some data to suggest that the age of initiation for smoking, it has been delayed, which is good news.

Now, I was - as I was trying to infer, what is there that - apparently this contradiction on the one side, seeing significant decreases in adolescent smoking behavior, but no changes in the adults. That's (unintelligible) I was making a possible explanation.

CONAN: I see, all right. We want callers to tell us what worked for them or not, 800-989-8255. Email talk@npr.org. Liz is on the line, calling from Wichita.

LIZ (Caller): Hi, Neal.

CONAN: Hi, Liz.

LIZ: My husband was diagnosed with lung cancer about a year and a half ago, and after I had tried to quit smoking for 40 years, different ways, and that's what did it for me.

CONAN: So you had tried the patch, the gum and various other things?

LIZ: I tried everything, yeah - hypnosis, cold turkey, pregnancy, everything, and couldn't quit smoking. But living with someone who's going through cancer treatments is a big eye-opener.

CONAN: How's he doing?

LIZ: He's doing great, thank you.

CONAN: And you've managed to stay off?

LIZ: Yes. I gained 20 pounds. That's a reason that I think a lot of people start smoking again. I know I did many times when I quit. I would gain weight and couldn't seem to get the weight off. But this time I'm pretty bound and determined not to pick up a cigarette again.

CONAN: And your husband, is he or was he a smoker?

LIZ: He was a smoker and he quit as well, which I think is a - we know people who were diagnosed with lung cancer and kept smoking, two of which are dead now. But I think it's really made a difference in his survival rate.

CONAN: Liz, thanks very much. We wish your husband the best of luck.

LIZ: Thank you very much.

CONAN: So long. And Dr. Volkow, interesting, a couple of things she said, one of which was the weight gain. Cigarette smoking raises your metabolism and burns off a few calories every single day, and well, when you stop smoking, your metabolism gets lower and you can put on a little bit more weight, and that may be one reason that some people, after six months or so, go back to smoking.

Dr. VOLKOW: That's unfortunately correct. And in fact it also - one of the reasons why we are seeing young women smoking more, because they use it as a way of controlling their weight.

And so one of the interventions that has been shown actually to be effective in promoting abstinence from smoking is physical activity. And so you're killing two birds with the same stone, because with physical activity evidently there's more - less of a desire to take the cigarettes, and at the same time the physical activity is keeping your weight down.

So one of the recommendations that I would make in someone that is trying to stop smoking, to increase their physical activity, which will help them to decrease the urges and also to maintain their weight.

CONAN: She also mentioned that she and her husband, obviously the cancer diagnosis will have an effect, but quitting smoking with someone else, does that help?

Dr. VOLKOW: Yes, definitely it helps. And it's one of the - there was something very interesting that the caller said, which is very unfortunate that her husband is sick.

But one of the things that we've come to realize is that when someone is faced with something that can be very devastating, as this is the case, that can be a very good teachable moment to motivate a person to change their behaviors into something healthier. And she evidently is doing this.

There is also evidence that the behavior of a spouse, and particularly for smoking, significantly influences, if the both of them are smoking, if one stops smoking influences the other one in the likelihood that they will stop smoking.

So these social network interactions are very important, and one of the most important in influencing us with smoking is our spouse.

CONAN: Here's an interesting email we have from Cindy(ph) in Cleveland: When my husband had a heart attack, I took liberty of quitting to be a good example. I quit, but my husband stopped for six months and started again. I stopped completely.

That's a variant on what you were talking about and, well, obviously cigarettes and smoking play a big role in heart disease and heart attacks as well.

Let's see if we can go next to Carl(ph), Carl with us from Napa in California.

CARL (Caller): Oh, hi. Yeah, I work in medical imaging, a technologist (unintelligible) on patients. And I was a smoker for about three years, and it was when I observed, directly observed the effects of smoking on my patients that I realized that I was going to be eventually (technical difficulties) perhaps, but what kind of old was I going to be, looking at the deleterious effects from smoking and how it affects my patients.

CONAN: What is the difference between looking at a non-smoker's lung and a smoker's lung?

CARL: It was - well, usually, again(ph), we'll see the patients that have masses, which is, you know, one thing. But what was really frightening to me was the vascular disease, that the vessels would close up. They would die, especially in the legs. And you would lose use of their legs, often, and it was just, it was awful. It was awful to see.

CONAN: Carl, thank - the imagery is a little scary, but thank you very much for the phone call. We appreciate it.

CARL: Thank you, bye.

CONAN: President Obama quit smoking after 30 years. We want to hear from you. Smokers, what worked? What didn't? Give us a call, 800-989-8255. Email us, talk@npr.org. Our guest is Dr. Nora Volkow, director of the National Institute on Drug Abuse. And when we come back, we're also going to be talking about the prevalence of smoking in other parts of the world, in particular in China. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan in Washington.

It's one of the hardest habits to break, smoking, and the rates of relapse are very high. President Barack Obama kicked the habit, but that after 30 years lighting up.

This hour, we're looking at how people succeed at quitting with Dr. Nora Volkow, director of the National Institute on Drug Abuse, and we want to hear your stories. How did you quit? What worked? What didn't? Give us a call, 800-989-8255. You can always reach us by email, talk@npr.org.

Here's an email from smokeandalcoholfree in Marin. He writes - DW(ph) writes: Tried several times to quit before moving to the SF Bay Area, where smoking is really frowned upon, not accepted at all. What finally did it for me was a date who refused to kiss me because I smoked.

I vowed at the time that smoking would never get in the way of that again, and it hasn't for six-plus years. As a tool, Nicorette gum worked for me a few times to retrain my brain and my body.

Well, that speaks to the influence of a larger social milieu. Joining us now from our bureau in New York is Yvette Chang, associate director and head of the China Program at the World Lung Foundation. And nice to have you with us today on the program.

Ms. YVETTE CHANG (World Lung Foundation): Hi there, Neal, thanks for having me.

CONAN: And smoking, as the emailer suggested, very frowned upon in certain parts of the United States, less so in others. In China, is it -how is it viewed there?

Ms. CHANG: Well, in China smoking is still considered a social habit, a socially acceptable habit. The general public are generally not aware that smoking is bad for them. So you really don't have the - kind of these social norms that we do here, that it's rude or it's unhealthy to smoke on other people.

CONAN: So at restaurants, in coffee shops, that sort of thing, it's perfectly okay to light up?

Ms. CHANG: Yes. I mean, we are very lucky here in New York City and in other parts of the U.S. where we are protected by smoke-free laws from secondhand smoke exposure.

In places like China, recent studies have shown that seven out of 10 non-smokers are confronted with secondhand smoke in their workplaces every day.

CONAN: And we - is there any information on what percentage of adult Chinese smoke?

Ms. CHANG: Absolutely. We know that about half of all Chinese men are tobacco users, they smoke. And women, although right now we're looking at about three percent, that percentage is increasing rapidly due to, you know, urbanization and marketing specifically to women.

CONAN: Is it seen as a mark of social equality if an upwardly mobile woman lights up?

Ms. CHANG: Definitely. I think that the best way to illustrate this, Neal, is to think of countries like China and some of the other kind of leading countries in tobacco consumption around the world, that they're about, you know, maybe 50 years behind countries like the U.S. in all aspects of tobacco control, including that, you know, tobacco use is seen as a rite of passage, often for young men.

You know, women think of, you know, tobacco use as a sign of, you know, independence or, you know, liberalization.

CONAN: You would think the government, the Communist Party, would certainly know that smoking is bad for you.

Ms. CHANG: Well, it's just a very interesting point. We need to look at it this way: The Chinese government is actually the world's largest tobacco company. The tobacco industry in China is state-owned and state-run. It's a monopoly. And so therefore, you know, the China National Tobacco Corporation contributes up to, you know, six and a half, almost seven percent of all government revenues in taxes. So it's - they're very influential in government.

CONAN: Surely another part of the government is starting to calculate the health care costs though.

Ms. CHANG: Yes, those calculations are starting. There are some research studies that essentially show that the cost to China, the economic cost, healthcare costs, et cetera, you know, amount to approximately 25 percent more than the intake.

But you know, it's a very - it's a slow process. You know, we didn't get to where we are in the U.S. in terms of tobacco control and regulation overnight, and it will take, you know, China and other countries a little while. It is a - it's a long-term goal.

CONAN: Are steps underway to cut down and to increase public information?

Ms. CHANG: Yes. Similar to the U.S., we really see some leaders at the sub-national and city levels. We do see city mayors stepping up to try and create some smoke-free environments in the cities.

By and large, we still, you know, don't have the model that we have, you know, here in the U.S., where, you know, we look at 100 percent smoke-free indoor places. But, you know, you see the initiative to move to, you know, smoke-free hospitals, smoke-free schools, you know, some smoke-free workplaces and smoke-free transport.

CONAN: Smoke-free hospitals, they're moving toward it. So patients in hospitals can smoke cigarettes?

Ms. CHANG: Well, I would say this, that up until very recently, you know, doctors can smoke in hospitals. We do see some progress. As you had asked, the Chinese government has declared, has issued a decree that all health care facilities in China are to go 100 percent smoke-free by the end of this year.

So we're looking at implementation and enforcements at this time. So, you know, we're all watching.

CONAN: The - tobacco, as you suggest, is a government monopoly there. So you're not talking about American brands competing for market share in China. Is the tobacco, though, from the United States?

Ms. CHANG: We actually do see some joint ventures in China. For example, Philip Morris is - has a joint venture with the China National Tobacco Corporation. So there are international brands present in China.

The majority of the tobacco, however, is grown and produced in China.

CONAN: Thanks very much. Yvette Chang, we appreciate your time today.

Ms. CHANG: Thanks for having me.

CONAN: Yvette Chang, associate director and head of the China Program at the World Lung Foundation, joined us today from our bureau in New York City.

Our guest is Dr. Nora Volkow, director of the National Institute on Drug Abuse, an expert on addiction. We want to know what worked for you, or maybe didn't, to quit smoking, 800-989-8255. Email us, talk@npr.org.

Let's see if we can go next to - this is John(ph), John with us from Oakland.

JOHN (Caller): Hi, Neal, thanks for the great show.

CONAN: Thank you.

JOHN: What worked for me, in 1991 I had tried quitting many times over the 17 or so years that I smoked and nothing seemed to work for more than a day or a few days.

But at that time I was kind of strapped financially, and cigarettes were $2 a pack, and I thought about it, and I thought that's over $700 a year I'm spending on these. And I told myself I would put - every morning I would put $2 in my breast pocket of my shirt, where my cigarettes used to live, and I would roll them up like a cigarette, roll the $2 up together. And when I felt a craving, I would take it out and fiddle with it and put it between my fingers, as if I were smoking it like a cigarette.

And I never actually put it in my mouth, but I did everything short of that. At the end of the day, I put it in a can, and I told myself that after a month I'd have $60, and I'd take myself out to a nice dinner.

And I got to the end of the month, and I never smoked again. I still have this can with a fresh, unopened pack of cigarettes in it and about $60. I didn't actually need to take myself out to the dinner. I felt it was more important to keep the can with the money and the cigarettes in there as a symbol of my power over the tobacco.

CONAN: These days that can would be - that would be quite an asset at that...

JOHN: It's a 20-year-old pack of cigarettes, unopened.

CONAN: John, thanks very much for the call, and good luck to you.

JOHN: Thank you.

CONAN: And it's interesting, Dr. Volkow. Everybody who's called in or sent us an email about quitting, the day they did it as successfully is an event they remember for the rest of their lives.

Dr. VOLKOW: And most people will because stopping smoking when you're addicted is not an easy task to do. And when this caller was speaking, I was smiling because he actually was able to do one of the interventions, policy-wise, that has been most effective in decreasing smoking, which is increasing the cost of cigarettes, increasing the taxes. And so he did it to himself without the social system imposing an increase on taxes.

The other thing that I find remarkable is all the callers have described a different reason that led them to stop smoking, again highlighting the diversity, vis-�-vis how we as individuals respond to drugs and also how we're able to more or less successfully stop taking them once we've become addicted.

CONAN: Here's an email from Stephanie(ph): My husband quit by reporting his progress on Facebook. Every day he'd post how many days he'd gone without smoking. His friends would congratulate and encourage him. He's been smoke-free since New Year's Day. It's looking like this time it's for good.

So that kind of social reinforcement, again, that's proved beneficial in any number of circumstances, not just smoking.

Dr. VOLKOW: That's absolutely correct. I mean, for example, the 12-step programs that are used for alcohol or for even people that have compulsive eating patterns, take advantage of the strong social reinforcement, how powerful networks can be modulating one's behavior, which is also we were discussing with a spouse. If your spouse stops smoking, you are much more likely to stop smoking yourself. So, yes, social networks are very powerful.

CONAN: Eric's calling us from Santa Fe.

ERIC (Caller): Thank you for the opportunity. I just wanted to give a shout out to my doctor for encouraging me to use an anti-depressant, and that's how I wound up kicking my habit after 17 years.

CONAN: And was the anti-depressant prescribed to combat depression or to combat smoking?

ERIC: A funny question, Neal - thank you - is that I was in therapy for marital problems. And quitting smoking was a by-product of the anti-depressant.

CONAN: Does this work, Dr. Volkow?

Dr. VOLKOW: Well, one of the things we know is that if you are depressed, the likelihood of smoking is much, much greater. So the co-morbidity between smoking and depression is very well recognized. It's also recognized that when a person is depressed and is doing okay and they stop smoking, they may relapse in their depression. So it's a very close association, and this has led some to believe that people may be smoking to auto-medicate the depression. And in that case, of course, if you treat - properly treat the depression, that will help the person stop smoking because the need to actually feel better is no longer there.

CONAN: And does that describe your situation, Eric?

ERIC: That is correct. It was very miraculous. I was not quite prepared for it. So best wishes to my brothers and sisters.

CONAN: Okay. Eric, thanks very much for the phone call. Appreciate it.

Here's an email. This is from Erin(ph) in St. Louis. I quit smoking by using electronic cigarettes. I'm 28. I've been smoking two to five cigarettes a day since I was 18. Electronic cigarettes use a food-grade glycerin product, which is vaporized into water vapor and nicotine. These have all the pleasure of smoking, better taste, and no second-hand smoke. And that's a device, a technology, Dr. Volkow, that some people are beginning to adopt.

Dr. VOLKOW: Yes, correct. And it is, of course, to - I mean, a lot of the harmful effects of cigarettes come from all of the chemicals that are in it and not just from nicotine. But we have to be aware, though, that just nicotine is addictive and nicotine by itself. Like one of the callers that have earlier reported one that was the - working on imaging that showed a lot of vascular pathology, and this is because there are nicotine acetylcholine receptors affected by nicotine in blood vessels.

So it is a means that can help minimize the harmful effects of cigarettes. But ideally, of course, you would like to have it as a transition that will - ultimately will allow the person to stop altogether nicotine taking.

CONAN: We're talking with Dr. Nora Volkow, director of the national institute on drug abuse.

You're listening to TALK OF THE NATION from NPR News.

And there was another issue raised in that email. Two to five cigarettes a day, people who sometimes call themselves chippers. I'm not really a smoker. I just have one or two.

Dr. VOLKOW: Yes, they exist. Contrary to what a lot of people believe, that the smokers were compulsive. And there are individuals that can smoke two or five cigarettes all their life without ever escalating. The concept, though, of course, is if it's harmful. That's what people want to know. And certainly it's better not to smoke because you are inhaling a wide variety of very - very irritants that are going to harm your lungs.

And the notion too is, why not stop? If you are taking something that is potentially harmful, why not stop? I mean, so that has always been the recommendation I give to individuals, even if they smoke two or five cigarettes on a given day.

There's also the other issue that we have to realize, is that there's a cumulative effect. So after many years this will start to have an impact into your body. And as we grow older, our ability to recover, our resiliency decreases. So something you may have been able to do with no problem when you were younger is going to start to have an effect, affecting your health.

CONAN: Let's go to Pare(ph), Pare with us in Portland.

PARE (Caller): Yeah. Well, I took advantage of a real bad cold.

(Soundbite of laughter)

PARE: I had a cold and cigarettes tasted so lousy I kind of stopped for a couple of days and I thought, well, maybe I just keep this going, and I did. And that was about 35 years ago.

CONAN: And you've managed to stay off since?

PARE: Yes, I have.

CONAN: And how long had you been smoking when you finally managed to quit?

PARE: Oh, I don't know, about 15 years or so.

CONAN: And I wonder - it was a question I asked somebody before. They couldn't hear very well. But do you still dream about it?

PARE: I did for a while. Yeah. I did for a while, but not anymore.

CONAN: So you're smoke free even in your dreams?

PARE: Oh, yes. Yes. You know, the hardest thing was to break the connection between having a drink and having a cigarette.

CONAN: Ah, the trigger. Ah, that's interesting.

PARE: What I did - I really worked on that. Now I can drink a lot and still not smoke, so...

CONAN: Well, congratulations, Pare. Appreciate it.

PARE: You bet.

CONAN: Bye-bye. The trigger that he talks about, sometimes it's a drink, sometimes writers looking at a blank piece of paper or a blank computer screen, whatever it is that sets off that habit of lighting up.

Dr. VOLKOW: Well, yeah. This is actually, he's commenting on one I think of the most fundamental aspects of addiction, which is what we call conditioning. Your brain learns. It memorizes to associate a particular stimuli with a drug. And as a result of that, your brain automatically starts to desire the drug - in this case, nicotine - when you are exposed to these stimuli, in his case alcohol, but in someone else's case it may be the coffee or it may be passing by a certain friend with whom they always smoke.

And those conditioned responses - actually, one of the reasons why we now believe it is so extremely difficult to stop smoking. Because when people smoke, they do it throughout the day and they associate a wide variety of stimuli then with nicotine, which would result in them starting to smoke when they are exposed to those environments. And that's what actually - and a lot of people actually, that's what drags them to relapse, that by being exposed to the environment, then they actually have this intense craving that is very difficult to control.

CONAN: We're going to end with two emails. This one from Melinda in Kansas City. I quit smoking 26 years ago when I found out I was pregnant. I realize this will only work for your female listeners. I never started again. However, if they announce the world is ending in seven days, the first thing I'd do would be to buy a carton of cigarettes and have at it. I still dream about it. I still miss it, particularly at a party or after a good meal with friends. Talk about conditioning.

And this is from Michael: Today is my first day. I set the date weeks ago after a failed attempt. This time I'm using the patch because I went nuts last time. Thanks so much for talking about this today. It is very affirming.

And we wish Michael the best of luck. And we hope the world is not going to be announced that it's ending seven days away so that the caller will not start smoking again.

Dr. Volkow, thanks so much for your time today.

Dr. VOLKOW: Thanks very much.

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