Meg Dougherty and Darlene Richardson are pleasant, well-mannered women, but in the world of smoking-cessation counseling, they rank among the hard cases.

Dougherty started smoking cigarettes sometime in her 20s. She's not sure how many attempts she has made to stop, but nothing worked for more than six months.

Richardson remembers exactly how and where she started: at a party shortly after her marriage at 21. And she stayed hooked for decades, even when "it made me feel like I was taking my tongue and licking an ashtray."

Then, at age 50, both women enrolled in the JeffQuit smoking-cessation program at Thomas Jefferson University Hospital. The program, which instructors offer at sites around the country under the name QuitSmart, is for anyone 18 or older, but especially for those who have tried to stop and failed.

"It's almost been too easy," said Dougherty, a nurse who reports being smoke-free since March 2. "It's the first time I can see myself quitting for years and years."

Cessation researchers and counselors say that with the growing public awareness of smoking's health risks, social rejection through smoke-free areas, and the rising price of cigarettes, it's mostly folks such as Dougherty and Richardson who are left.

"Individuals who have continued to smoke despite pressure to quit tend to be more 'hard-core' than were smokers of several years ago," says Robert Shipley, who developed the QuitSmart program (the parent of JeffQuit) and has led the Duke Medical Center Stop Smoking Clinic since its inception in 1977.

To reach this group, physicians, therapists, and researchers are enlarging their bag of tricks, repackaging old techniques, trying newer ones like acupuncture, and looking for genetic clues to what makes it harder for some people to quit.

They are prescribing antismoking drugs more aggressively while taking a gentler approach in counseling. One might call it "talk softly and carry a big prescription pad."

"In every smoker, there's a non-smoker trying to come out," says Frank Leone, who directs the Comprehensive Smoking Treatment Programs at the Hospital of the University of Pennsylvania. "We want to make that as easy and effective as possible. The field has shifted toward being more supportive. 'You deserve not to smoke and here's how we're going to do it.' "

Leone drew up the "Quit Smoking Comfortably" curriculum used in the free smoking-cessation classes and workshops offered by the Philadelphia Department of Public Health. The mix of prescribing and counseling is similar to that of QuitSmart.

Lorraine Dean, manager of the department's Tobacco Policy and Control Program, said that about 800 people have taken the program in the last year.

Statistics bear out the need to reshuffle the smoking-cessation deck. As the percentage of adults who smoke has slowly fallen, so has the effectiveness of cessation programs.

At the time of the first Surgeon General's Report in 1964, about 42 percent of adults over the age of 18 smoked cigarettes. By 2009, the figure was just under half that, although the decline has slowed in recent years.

But at the same time, Shipley says, smoking-cessation programs have proved less successful. He cites one study showing that the success rate (6-12 months of abstinence) grew from about 20 percent in 1965-69 to about 30 percent in 1970-74, but has been declining in recent years, slipping back to around 20 percent.

Prospective quitters may be getting some help on the DNA front.

A new study by researchers at the University of Pennsylvania indicated that the number of so-called mu opioid receptors in the brain may show why many people find it so tough to quit.

"For the first time, we've identified a mechanism that explains why people with a particular genetic background may be more prone to relapse when they try to quit smoking," said study director Caryn Lerman, a psychiatry professor at the Penn medical school. Nicotine, she said, releases brain chemicals such as beta-endorphins, and those with more of these receptors found nicotine more pleasurable.

Medications that block the activity of these receptors have had mixed results, but further research may show how they can become more effective, Lerman said.

The researchers used positron emission topography (PET), a nuclear imaging technique, to measure the amount of mu opioid receptors in smokers' brains. The machines are too expensive for use in treating individual smokers, Lerman said. But "eventually, we hope to be able to predict who will have the easiest time quitting" and design programs more tailored to the individual.

Meg Dougherty was sitting in a small circle of chairs in an exercise room in Jefferson's Center City complex. "I feel like I should be wearing a 'smoke-free' tiara," said Dougherty, who lives in Overbrook.

Sitting beside her, smoking-cessation counselor Anna Tobia was a verbal streaming billboard of encouraging messages for Dougherty and two others. "You have to try new ways of coping, that's what this comes down to. . . . You've given up so much. . . . I feel like without a doubt you're going to stay."

The four-week program costs $249, though many insurance plans will cover $200. It is based on moving slowly into abstinence. Tobia calls it a "warm chicken" approach compared with the "cold turkey" methods used years ago. Participants attend an opening class and then ease down into quitting by smoking progressively weaker brands of cigarettes. They may even have started wearing a nicotine patch before the program begins, flooding their bodies with nicotine the way one might have a large meal to kill the appetite. Nicotine gum and lozenges also are used.

Other weapons in the program's arsenal are a tobacco-free fake cigarette with an adjustable draw to help them disassociate the hand-to-mouth movement of smoking from the pleasure sensations that follow - and discounted acupuncture and stress-reduction programs. There is also a self-hypnosis CD that another QuitSmart practitioner, Lafayette Hill and Jefferson University Hospital psychiatrist Francisco Merizalde, finds particularly helpful. "It's the combination that makes it work," he says.

The most commonly prescribed drugs are Chantix and Zyban, which contains the same medicine as the antidepressant Welbutrin. (It's used to help break the addiction; there's no assumption that smokers are depressed.)

Chantix was prescribed sparingly in past years due to possible side effects including depression and suicide attempts. But Shipley and other cessation experts say it is generally safe if used under supervision and that if nothing else works, it's still a lot safer than continuing to smoke. He believes that a combination of drugs and mental reinforcement is most effective with most longtime smokers.

Whatever is prescribed for QuitSmart clients, however, it is buttressed by supportive group sessions and a self-hypnosis CD. Tobia makes herself available as much as possible by cellphone and frequently calls or e-mails clients while they are in the program or after completion.

Smoking Cessation Programs

1-800-JEFF Now (533-3669)

New Jersey: http://bit.ly/l4AItZ

For Phone Counseling:

1-800-QUIT-NOW (784-8669)

For information on QuitSmart programs, including one in Lafayette Hill, or to become a counselor: www.QuitSmart.com

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Contact Paul Jablow at pjablow@comcast.net