Despite nearly 40 years of warnings about the harmful effects of tobacco use and numerous public health campaigns, one in four Americans still smokes. That's a testament to the power of tobacco addiction and to the need for new ways to help people quit tobacco.

Figures from the U.S. Public Health Service help round out the picture:

• Tobacco use kills about 430,000 Americans each year, making it the country's leading cause of death and disease.
• Smoking prevalence among adolescents has risen dramatically since 1990, with more than 3,000 children and adolescents becoming regular users of tobacco each day.
• Thirty-nine percent of tobacco-related death takes place in women -- a percentage that has more than doubled since 1965. Lung cancer is the number one killer of American women, surpassing breast cancer.
• Medical care costs attributable to smoking have been estimated by the Centers for Disease Control and Prevention to be more than $50 billion annually, and tobacco use leads to a loss of earnings and productivity of about $47 billion yearly.

Such figures qualify tobacco dependence as a public health epidemic, creating an acute need for intervention to save lives.

Ironically, the people most qualified to intervene -- physicians and other health care clinicians -- usually have not done so. One study reported that only 15 percent of smokers who saw a physician were offered help with quitting tobacco. Only 21 percent of practicing physicians say that they have received adequate training to help their patients stop smoking, according to a survey of U.S. medical schools.

Today the opportunities to intervene are much improved. "Current treatments for tobacco dependence offer clinicians their greatest single opportunity to halt the loss of life, health, and happiness caused by this chronic condition," note the authors of Treating Tobacco Use and Dependence, a clinical practice guideline released in 2000 by the U.S. Public Health Service. The guidelines were established to help patients quit tobacco and are based on a comprehensive review of the medical literature published from 1975 to 1999.

Most prominent in the updated guidelines is the fact that there are more medical treatments than ever before to help people quit.

To begin, the guidelines list four kinds of nicotine replacement therapy: nicotine gum, the nicotine inhaler, nicotine nasal spray, and the nicotine patch. Technically known as nicotine replacement therapies, these treatments aim to diminish the symptoms of withdrawal for people attempting to quit smoking. They work by allowing people to consume nicotine in steadily decreasing doses. All of them provide nicotine without the toxins found in cigarette smoke.

The guidelines also recommend three medications to reduce nicotine withdrawal symptoms: the antidepressant bupropion (Zyban), the most commonly prescribed non-nicotine medication to deal with tobacco dependence, and clonidine and nortriptyline, two second-line medications that require more medical supervision.

In addition, the guidelines highly endorse counseling and behavioral therapies for everyone who tries to quit tobacco. Counseling can help people solve problems such as weight gain and mood changes after quitting tobacco. Through counseling, people can also learn how to gain support from relatives, friends, and coworkers.

The guidelines offer strong evidence that tobacco cessation treatments are both effective and cost-effective relative to other medical and disease prevention interventions. It recommends that insurance plans reimburse for the cost of tobacco treatments.

Dr. Michael Fiore, director of the Center for Tobacco Research and Intervention at the University of Wisconsin Medical School in Madison, headed the expert panel that developed Treating Tobacco Use and Dependence. He is upbeat about the odds for those who want to become tobacco-free, citing research that four out of 10 smokers can successfully quit. "If this 40 percent quit rate is applied for people who try repeatedly, there is a very high likelihood that any smoker committed to quitting can do so successfully," said Fiore.

--Published November 5, 2001