2021539714 9721 smoking cessaton newsletter 1981

8/14/2019 2021539714 9721 Smoking Cessaton Newsletter 1981

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VOLUME I, Number 1, 1981

DR. M . A . H . RUSSELL ON SMOKING CESSATIONAs Director of the Addiction Research Unit, Maudsley Hospital (London), Dr . Michael A . H .

Russell is well acquainted with both the promising trends in, and persistent difficulties of,

smoking cessation . D r . Russell has been involved in psychopharmacologic research on the

effects of nicotine, with particular interest in the methods by which smokers "self-regulate"

their nicotine intake to avoid withdraw al symptoms . In addition, he has investigated

numerous forms of psychological counseling techniques to help smokers quit, including

physician counseling, group therapy, and aversive techniques . W i t h t h i s b r e a d t h o f

knowledge and experience, Dr . Russell is widely recognized as one of the world's foremost

experts on smoking cessation .

For the inaugural issue of The Smoking Cessation Newsletter, Dr . Russell spoke with the

editor, Bernard Ellis, about steps that physicians can take to assist their patients to break

the smoking habit .

E L L I S : Before discussing how physicians can assist their patients to q uit

smoking, it may be worthwhile to review how the smoking habit is initiated and

maintained . You have had a strong research interest in the role of nicotine in

the smoking habit .

RUSSELL: There are undoubtedly many social and psychological factorsthat determine smoking behavior - wh o takes up the habit, when smoking is

i n i t i a t e d , e t c . However, once a person has played around with cigarettes for a

little time, has learned to inhale and started to ingest nicotine, I think that

nicotine then dominates the smoking behavior over and a bove psychological

factors. I don't think that many people, even those who work in smoking

cessation research, realize the extent to which smoking f or most smokers is

really a very finely adjusted drug-taking activity . Literally, when a person

inhales a cigarette, the nicotine is absorbed rapidly through the lungs and hits the

brain within seven seconds . Smokers modify and adjust that nicotine self-dosage

by the size of puffs they take, the rate at which they puff, and how deeply they

inhale . They seem to reg ulate that intake of nicotine when smoking different

strengths of cigarettes . We have shown that people on cigarettes with a nicotine

yield of 0 . 6 , w h i c h i s f a i r l y l o w i n E n g l a n d , c a n g e t b l o o d n i c o t i n e l e v e l s t h a t a ~ ' " e

very similar to the levels of people who are smoking cigarettes with two and

three times that nicotine level . When you get people to switch to low tar and

Continued on page 2 .

The Smoking Cessation Newsletter is a professional service of Merrell Dow

Pharmaceuticals Inc ., a subsidiary of The Dow Chemical Company . Bernard H . E l l i s ,

Jr. , E D I T O R . Complimentary subscriptions can be obtained by writinb : The Smoking

Cessation Newsletter, 9550 North Zionsville Road, R O . Box 68511, Indianapolis,

Indiana 46268 .


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nicotine cigarettes, they do self-regulate that nicotine intake . In addition, thereseems to be a bottom end of the cigarette market. In Britain, once you getbelow a certain nicotine yield, the cigarettes 'don't sell, and I am sure ifpsychological aspects were the predominant motive for smoking, very lownicotine cigarettes and nicotine-free cigarettes would have some sale .

ELLIS: That's interesting, particularly in light of recent trends incigarette sales in the United States, where the low tar and nicotine market hasskyrocketed in the last ten years. It's gone from less than 2% of the total marketto close to 30b now .

RUSSELL: It depends on what you mean by low tar and nicotine . The lowtar category is actually a very broad category and the only cigarettes in the lowtar category that sell are the ones that are up at the top end of that category.Once you get to nicotine yields below about 0 .4, you get very poor sales inEngland. They are higher in the U .S . with the better flavoring, and that is a bitof a mystery.

ELLIS: I raised the point because the trend among smokers to switch tolow tar and nicotine brands is, in my mind, a very positive health trend, but it isby no means an end point . We should not be satisfied at all with that movement,as I think some people have encouraged us to.

Within the past few years there has been a flurry of activity in the smokingcessation area, with many individual health professionals and healthorganizations becoming more active. How do you view this trend ?

RUSSELL: One of the things that strikes me is that, as all familyphysicians know, the 1979 U .S . Surgeon General's Report stated thatapproximately 350,000 Americans die every year as a result of smoking. Thisincludes 80,000 lung cancer deaths a year, primarily caused by smoking . Even inwomen, lung cancer is now fast approaching breast cancer as the greatest cancerkiller, and yet, almost 55 million Americans still smoke . For something like 20years, we've had educational programs, public information programs, schoolprograms - all kinds of smoking cessation programs - and yet we still havethese 55 million Americans smoking. It has been said that family physicians inthe past haven't taken an active enough role in smoking cessation activity, and Iwonder whether this is true. Bernard, you've had the most immediate experienceof this in your former position as Program Director for Smoking andOccupational Activities with the National Cancer Institute. What's your opinion?

ELLIS: I share your frustration with the fact that 55 million Americansstill smoke. However, some progreF has been made . We have dropped fromabout 53% of American males smoking before the 1964 Surgeon General's Repor tContinued on page 3.

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to about 37% today, and to some extent that improvement can be credited to the

efforts of the health professional community . Physicians were one of the first

groups to respond to the Surgeon General's messa ge and a large number of

physicians have quit smoking . In fa ct, in the U . S . we have more physicians today

who have quit smoking than who eontinue to smoke . By their nonsm oking

example, these phy sicians have had some impact . (Unfortunately, about one in

five physicians still smoke . )

There are a number of other activities that physicians can engage in to

encourage and assist their patients to quit smoking . Several years ago the

National Cancer Institute became interested in w hy more a ction had not been

taken . Perhaps one of the reasons why is that smoking is such a difficult habit to

break, and ph ysician s who do no more than recomme nd that their patients quit

seldom have a big impact . As a result, many of us have been engaged to some

extent in trying to perfect and to improve the interaction between the physician

and the patient to improve the smoking cessation rate . Your recent large-scale

study of physicians' influence with smokers is a good example of the effect that

health professionals can have within their office practices . Could you share

some of this information with our readers?

RUSSELL: We studied some 2,000 patients of 28 family phys icians,randomly assigned to various levels of counseling intervention . The study showed

that simple straightforward advice given over one or two minutes during a

routine examination, plus handing the patient a leaflet with some tips and hints

on quitting had a worthwhile effect . Five percent of p eople who receive d

counseling stopped smoking and were still nonsmokers a year later, compared

with 0 .3% in the control group . Expanded on a large scale, that's a worthwhile

effect. I t's an average, in fact, of 25 long-term ex-smokers for each physician

per year. Unfortunately, an individual physician perfor ming this counseling

routinely would not notice that he had had a 5% success rate, or be encouraged

by this result . Physicians of ten don't realize that the 5% of smokers whom a

physician inf luences with a minimum of intervention can be more worthwhile

than special withdrawal clinics, with an 80% success rate, that require very, very

intensive therapy. In fact, we estimate that if every physician in England were

to achieve a 5% smoking cessation rate with their patients, the impact would be

equivalent to that of 10,000 smoking cessation clinics .

ELLIS : Perhaps it would be good for us to review why health professionals

do have an i mpact and why many health agencies would like to work with them

more closely .

Clearly, they are a very strong health exemplar for patients, and unTike

those efforts that reach smokers +hrough public in formation or education

eampaigns, health professionals have the opportunity for a face-to-face

Continued on Page 4 .

A P r o f e s s i o n a l S e r v i c e o f M e r r e l l D o w P h a r m a c e u t i c a l s I n c .


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discussion with a smoker to discuss that smoker's particular health condition and

how smoking may affect it . They see patients at what is calle d a "teachable

moment" -a time when patients are very sensitive to health advice . Seventy

percent of American smokers ha ve indicated that if a physician would encoura ge

.them to quit, they'd attempt to do so . Yet, in other surveys, fewer than a third

of the smokers interviewed said that physicians had ever raised the issue of

smok ing w ith them . Finally, American physicians have indicated a strong

interest in working more to help smokers break the habit .

You have mentioned the 5% smoking cessation rate in your study . I think

it's important to point out that this 5% was achieved with a population who did

not necessarily have a smoking-related disease . If a smoker came in with a

sprained ankle, he was advised to quit . Other studies of physician counseling

with patients who present smoking-related symptoms - chest pains or early

pulmonary disease or cardiovascular disease - have demonstrated greater

impact . In probably the most extreme example, approximately 60% of a group of

Post M . I . patients quit on advice from the physician . Granted, that's a very late

point at which to intervene .

Are there other things that health professionals can do to improve their

patients' success with quitting smoking?

RUSSELL: There are an expanding number of programs being offered inU . S . communities to serve smokers . Your private health organizations, such as

the American Cancer Society and American Lung Association, offer withdrawal

clinics and, in some cities, individual counseling to smokers . I n addit ion, many

government agencies are als o increasing their efforts in this area .

ELLIS : Thank you, Dr . R u s s e l l .

NCITs "Quit Kits" for Health Professionals Well Rece ived

The National Cancer Institute (NCI) recently announced that orders for the "Helping

Smokers Quit" Kit, a package designed for use by physicians and other h ealth

professionals to help their smoking patients quit, have exceeded 100,000 kits . The kit,

provided free of charge to interested physicians, contains enough "quit smoking"

materials for 50 patients.ancy McCormick-Pickett, Program Director for Smoking Activities with NCI's Office

of Cancer Communication, told the Newsletter : " W e a r e ve r y p l e a s e d w i t h t h e

medical community's enthusiastic reaction to the 'Help Smokers Quit' Kit . To date, as

many as 5 million smokers have received counseling and supportive materials from

t h e i r p h y s i c i a n s a s a r e s u l t o f t h e k i t . "

Co n t i n u e d o n Pa ge 5 .



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The kit was developed by NCI in 1978, with pretestin g assistance from M . D . Anderson

Hospital and Tumor Institute and the Harris County (Houston, Texas) Medical Society .

Since its release in late 1978, the kit has received editorial endorsements from

numerous state and national medical societies, and has prompted requests fro m at

least ten other countries for assistance in producing and distributing similar kits

abroad .

The kit is designed to provide physicians with a simple four-step procedure to counsel

smokers, which can be administrated in a single office visit . The k it con tain s

instructions for the physician and office staff ; attractive office posters with the

slogan, "The Question for Smokers Is Not Whether To Quit . . .but How . Ask Us . " ; and

several handouts for patients . Each kit also co ntains a reo rder form thr ough which

physicians may request additional materials, free of charge .

One additional positive spin-off of the success of the kit has been the development of a

s i m i l a r k i t f o r u s e b y d e n t i s t s . The "Let's Help Smokers Quit" Kit, . coproduced with the

American Dental Associati on (ADA), has already reached 35,000 dentists . "Dentists,

dental hygienists, and dental assistants can stress the cosmeti c as well as health

benefits of smoking cessation with their patients . Given the dental profession's long-

standing commitment to preventive health education, the development of a'quit

smoking' kit by the NCI and ADA wa s a natural . Now," concluded Ms . McCormick-

Pi c k e t t , " s m o k e rs c a n r e c e i v e d i r e c t a s s i s t a n c e f r o m t w o i m p o r t a n t h e a l t h

professionals -their physician and their dentist . "

For our readers :

The abovementioned kits can be ordered, free of charge, by writing to :

D e p a r t m e n t D C

National Cancer Institute

Bethesda, Marylan d 20205

Please be sure to indicate by name whether you wish the physician's kit - "Helping

Smokers Quit" - or the dental kit -'TLet's Help Smokers Quit . "

Resources to Help Smokers Found in Most Communities

Health professionals who wish to do more to help their patients quit smoking have an

increasing variety of supportive services at their disposal, both at the local and

national level .

Several voluntary health organizationG devote considerable resources to reducing the

smoking problem, and stand ready to provide assistance to interested health

professionals . T h e A m e r i c a n C a n c e r S o c i e t y , A m e r i c a n H e a r t A s s o c i a t i o n a n d


A Professional Service of Merrell Dow Pharmaceuticals In c .


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American Lung Association all have materials designed to help smokers quit . In m any

communities these organizations also provide individual and group counseling to

smokers who feel they need extra assistance in kickin g the habit . Local affiliates of

these organizations should be contacted to determine the "quit smoking" services

provided in each local area .

Numerous commercial smokin g cessation programs also exist to help smokers quit, at a

fee . Perhaps the best known programs are the Schick Centers for the Control of

Smoking, and Smo kenders , Inc . Each of these organizations offers services in

numerous cities around the country . For information on the nearest available program

offered by these companies, contact the national office, or consult the local telephone

directory under "Smokers Information and Treatment Centers . "

For your information

American Cancer Society (National Office) - 777 Third Avenue, New York, N .Y. 10017

American Health Foundation - 320 East 42 Street, New York, N .Y. 10017

American Lung Association - 1740 Broadway, New York, N .Y. 10019

SmokEnders (National Office) - 37 North Third Street, Easton, Pa . 1 8047

The Office on Smoking and Health - How It Can Help You Help Your Patients

The Office on Smoking and Health is one of the smallest agencies in the Department of

Health and Human Services, with an overall budge t of $2 .5 million and a staff of only .

19 full-time employees . It does, however, have an extremely active information

program that is dedicated to carrying out the smoki ng and health agenda described in

its recent Report on Smoking and Health in this way : "The decision to smoke is a

personal decision, but once this is said it remains unquestionably the responsibility of

health officials to ensure that smokers and potential smokers are adequately informed

of the hazards . This is especially true in a society where hundreds of millions of

dollars are spent each year promoting cigarettes . . : '

The Office has contracted with several advertising agencies to devise a radio,

t e l e v i s i o n a n d p r i n t c a m p a i g n a d d r e s s i n g t h r e e s p e c i f i c o b j e c t i v e s :

* to encourage children and young people, particularly girls,

not to take up smoking

* to encourage women to quit smoking, particularly during

pregnancy

* to encourage less hazardouF .;moking ; i . e . , u s e o f l o w t a r ,

low nicotine cigarettes




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Of particular interest to physicians may be the Office's public affairs program, which,

as part of its agenda, includes the publication and distribution of some 21 pamphlets,

posters, and flyers . Any publication on this list may be obtained by writing to :

The Office on Smoking and Health

Public Health Service

Rockville, Maryland 28057

Selected materials/publications available from the Office include :

Teenage Self-test Teenage Self-test Discussion GuideSmoking, Tobacco & Health : A Fact Book Smokers Self-test

Two Things Women Should Know Unless You QuitSlim & Smokeless If You Must SmokeTar and Nicotine Card Smokers Health BookWe Americans Have Seen the Light

A l s o a v a i l a b l e f r o m t h e N a t i o n a l C a n c e r I n s t i t u t e , B e t h e s d a , M a r y l a n d 2 0 2 0 5 :

Smoking Programs for Youth Clearing the AirA School Bibliography

Smoking as an Addiction

Clinical studies continue to indicate that cigarette smoking is an addictive behavior .

A recent article by Drs . R . C . Bone, J . R . Phillips and Parimal Chowdhury in the

Journal of Respiratory Disease s (May 1981) states that smoking result s in a dependence

disorder, and that cigarette smoking is a physical dependence on nicotine . Crav ing a

cigarette during withdrawa l periods is not merely psychological, but a physiological

reaction, according to the authors . The article from th e University of Ar kansas

concludes that since social factors impo rtant in acquiring the smoking habit have their

greatest impact before age 20, smoking cessation efforts should focus on adolescents

and preadolescents, and should emphasize the dependence aspects .

The Journal of the Addiction Research Foundation (Vol . 1 0 , N o . 4, A pril 1981) has dealt

extensively with nicotine dependence . They warn of the related danger of health

injuries brought about by so-called "secret additives" used by tobacco companies to

reduce nicotine content - additives thought to include : shellac, caramel, eugenol, and

other chemicals . The Journal also quotes the U .S . Surgeon General's fin"dings that

pregnant women who smoke low tar and nicotine cigarettes cannot expect to reduce

significantly the hazards to the fetus .


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The Office on Smoking and Health publishes a yearly index to ongoing research in

smoking and health, as well as a bibliography to published materials . The most recent

volume (19 79) of the bibliography lists over 1, 500 papers on scores of related topics . I n

the area of nicotine addiction, readers may wish to read the following :

J a f f e , J .H ., and Kantzler, M . : "Smoking as an Addictive Disorder" in

Krasnegor, N .A . (Editor) Cigarette Smoking as a Dependence Process .

National Institute on Drug Abuse Research Monograph Series, No . 2 3 ,

DHEW Publication No . (ADM) 79-80 0, January 1979 , pp . 4 - 2 3 .

This paper points out similarities and differences between tobacco usage and drug

usage behavior commonly viewed as addiction in our society .

Also, the proceedings of the International Conference on Smoking Cessation, held by

the American Cancer Society in New York (June 21-23 , 19 78) produced two interesting

papers on this topic :

Harrup, T . : Addictiv e Processes in Tobacco Use-a discussion of the nature of

the smoking addiction and an examination of steps to treatment

Russell, M .A.H . : Smoking Addition : Some Implications for Cessation . In :Schwartz, J . L . (Editor) Progress in Smoking Cessation- a report on 1,57 4 adult

smokers in Britain that showed 70% had tried unsuccessfully to stop smoking and

50% had tried more than once .

New Evidence on Survival Rate of Former Smokers

Front-page news was made recently by a report in the June 4, 19 81, issue of The New

England Journal of Medicine stating that people who quit smoking raise their chances

of living longer by more than half . The Oakland, C alifornia Kaiser-Permanente

Medical Care Program did a"multivariable analysis" of ?5,917 patients over a 13-, year-

period and found that no matter how old they w ere, or how long they had smoked,

patients who quit will liv e longer than people who continue to smoke .

Drs . Gary Friedman, Diana Petitti and Richard Bawol, w ith A . B. Siegelaub, found that

the main risk of cigarette smoking is the increased chance to the smoker of developing

coronary heart disease, and that the average risk of dying over the period surveyed

(19 64-19 77) from that ailment was more than twice as great for persistent smokers .

Further, per sistent smokers were found to have high death rates for all cancers,

circulatory disease, and just about all causes of death .

These findings go a long way toward answering the criticism of similar studies - that

low death rates for quitters can be tied to other, nontestable variables . The authors

set about to test just those factors, t ; ; ruling out physical and habitual influences (such

as alcohol consumption) and by studying a large test group .

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2021539714 9721 smoking cessaton newsletter 1981

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