why it's hard to quit. But can it make it easier? If nothing else, it should help people take it seriously enough to gear up for the effort. "People think of quitting as something short term, but they should expect to struggle for a couple of months," says Shiftman.
What works? About 90 percent of people who give up smoking do so on their own, says Fiore. But the odds for success can be improved: Programs that involve counseling typically get better rates, and nicotine replacement can be a potent ally in whatever method you use.
In a meta-analysis of 17 placebo-controlled trials involving more than 5,000 people, Fiore found that the patch consistently doubled the success of quit attempts, whether or not antismoking counseling was used. After six months, 22 percent of the people who used the patch remained off cigarettes, compared to 9 percent who had a placebo. Of those who had the patch and a relatively intense counseling or support program, 27 percent were smoke-free.
More than 4 million Americans have tried the patch, which replaces the nicotine on which the smoker has become dependent, to ease such withdrawal symptoms as irritability, insomnia, inability to concentrate, and physical cravings that drive many back to tobacco.
You're likely to profit from the patch if you have a real physical dependence on nicotine: that is, if you have your first cigarette within 30 minutes of waking up; smoke 20 or more a day; or experienced severe withdrawal symptoms during previous quit attempts.
Standard directions call for using the patches in decreasing doses for two to three months. Some researchers, however, suggest that for certain smokers, the patch may be necessary for years, or indefinitely.
"It's already happening," says Henningfield. "Some doctors have come to the conclusion that some patients are best able to get on with their life with nicotine maintenance." One such physician is David Peter Sachs, M.D., director of the Palo Alto Center for Pulmonary Disease Prevention. "I realized that with some of my patients, no matter how slowly I tried to taper them off nicotine replacement, they couldn't do it," says Sachs. "They were literally using it for years. Before you start tapering the dose, you should be cigarette-free for at least 30 days."
His clinical experience leads him to believe that 10 to 20 percent of smokers are so dependent that they may always need to get nicotine from somewhere. One study of people using the gum found that two years later, 20 percent of those who had successfully remained cigarette-free were still chewing. The idea of indefinite, even lifetime, nicotine maintenance sounds offensive to some. "Clearly, the goal to aim for is to be nicotine-free," says Sachs. "But if that can't be reached, being tobacco-free still represents a substantial gain for the patient, and for society." And getting nicotine via a patch or gum source means a far lower dose than you'd get from a cigarette. Plus, you're getting just nicotine, and not the 42 carcinogens in tobacco smoke.
Although the once-a-day patch has largely supplanted the gum first used in nicotine replacement, Sachs thinks that for some, the most effective treatment could involve one or both. The patch may be easier to use, but the gum is the only product that allows you control over blood nicotine level. Some people know they'll do better if they stay in control. And would-be quitters who do fine on the patch until they run into a stressful business meeting may stifle that urge to bum a cigarette if they boost their nicotine level in advance with a piece of gum, Sachs says.
However nicotine replacement "is not a magic bullet," says Fiore. "It will take the edge off the tobacco-withdrawal syndrome, but it won't automatically transform any smoker into a nonsmoker." Other requisite needs vary from person to person. A standard approach teaches behavioral "coping skills," simple things like eating, chewing gum, or knitting to keep mouth or hands occupied, or leaving tempting situations. Ways people cope cognitively are as important as what they do, says Sh