bit has been, for all intents and purposes, left behind.
Acute withdrawal is over within four to six weeks for virtually all smokers. But the addiction is by no means all over. Like those who have been addicted to other drugs, ex-smokers apparently remain susceptible to "cues," suggests Brandon: Just as seeing a pile of sugar can arouse craving in the former cocaine user, being at a party or a club, particularly around smokers, can rekindle the lure of nicotine intensely.
The same process may include "internal cues," says Brandon. "If you smoked in the past when under stress or depressed, the act of being depressed can serve as a cue to trigger the urge to smoke."
Like users of other drugs, Henningfield points out, addicted smokers don't just consume the offending substance to feel good (or not bad), but to feel "right." "The cigarette smoker's daily function becomes dependent on continued nicotine dosing: Not just mood, but the ability to maintain attention and concentration deteriorates very quickly in nicotine withdrawal."
Henningfield's studies have shown that in an addicted smoker, attention, memory, and reasoning ability start to decline measurably just four hours after the last cigarette. This reflects a real physiological impairment: a change in the electrical activity of the brain. Nine days after quitting, when some withdrawal symptoms, at least, have begun to ease, there has been no recovery in brain function.
How long does the impairment persist? No long-term studies have been done, but cravings and difficulties in cognitive function have been documented for as long as nine years in some ex-smokers. "There are clinical reports of people who have said that they still aren't functioning right, and eventually make the 'rational decision' to go back to smoking," Henningfield says.
The conclusion is inescapable that smoking causes changes in the nervous system that endure long after the physical addiction is history, and in some smokers, may never normalize.
The wealth of knowledge about smoking clarifies 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,