Fred Contino has been smoking since he was 13. He is, at 53, trying to quit.
He has replaced his Marlboro Reds with a small, white plastic tube - his new prescription nicotine inhaler. "It's going to take time," he says. "When I want a cigarette, I try and take puffs on it. That takes away the craving for a little bit, but the cravings are still there."
Contino is one of about 44 million cigarette smokers in the United States, 19 percent of all adults, according to the Centers for Disease Control and Prevention. Many will make attempts to quit in 2014 (as they did in 2013, and 2012), the 50th anniversary of the surgeon general's first report linking heart disease and lung cancer with smoking.
It has been a decades-long struggle for Contino, a Pennsylvania state constable. "I tried the patch, Chantix, gum, tried going cold turkey, tried using the e-cigarette," he says. He has even tried thinking of his 2-year-old grandchild when the urge to smoke hits.
Chantix, the brand name for varenicline, is a medication in pill form that binds to the nicotine receptor in the brain. The Food and Drug Administration has approved one other pill, bupropion, which has antidepressant effects, to help smokers quit, as well as several "nicotine-replacement therapies" such as the patch, lozenges, gum, and inhalers. Nicotine is what makes cigarettes addictive, but it does not cause heart disease or cancer.
"You want to get all your nicotine from something other than a cigarette," says Anna Tobia, a clinical psychologist at the Jefferson Center for Integrative Medicine and director of JeffQuit, a four-week smoking-cessation program. One of the most common mistakes people make when trying to quit, Tobia says, is underestimating how much nicotine they will need. It is not unusual for smokers to use the highest-dose patch with a lozenge or gum every hour under a physician's supervision. Trying simply to reduce the number of cigarettes each day often does not work, because that produces greater swings in nicotine blood levels, and because smokers compensate by drawing deeper on the cigarettes they do smoke.
Though e-cigarettes are increasingly popular, they are not regulated by the FDA - a decision is expected soon - and they have not been proved to increase one's chance of quitting. "In the U.S., there are over 400 products that are generally referred to as e-cigarettes. There's no consistency in terms of what they are, what they do, what they contain or deliver," says Frank Leone, director of the Comprehensive Smoking Treatment Program at the University of Pennsylvania. Despite all the anecdotes of smokers quitting with e-cigarettes, researchers don't know yet whether they keep more people from quitting than they help.
Evidence shows smokers' best chance of quitting is by combining FDA-approved treatments with behavioral counseling.
"Many smokers see cigarettes as a friend. They use their cigarette when they've had a bad day, as a reward when they've had a good day," says Melissa Maier, a tobacco treatment specialist for the Crozer-Keystone Health System.
For more than 25 years, Darlene Richardson, 52, would smoke a Salem Light Menthol 100 first thing in the morning, while talking on the phone, after eating, and before bed. "As much as I hated the cigarette - the whole smell - I was still smoking," she says.
The first step in any behavioral counseling is identifying a smoker's triggers and finding healthy alternatives. Community cessation programs often teach other ways of coping in the moment, such as distraction, breathing, or positive self-talk.
JeffQuit offers acupuncture and hypnotherapy, which involves visualizing trigger activities without a cigarette. It also uses a "brand-switching" strategy, which asks smokers to switch their brand of cigarette for two weeks before quitting completely. "[Smokers] really love their brand, so it feels perfect," says Tobia, citing the specific mix of flavors and chemicals. "If you mess with it, they enjoy it less," though she cautions that just switching brands or to a light cigarette without a specific timeline for quitting does not have any health benefits.
For Richardson, brand-switching with JeffQuit worked after years of trying other methods and enduring side effects from medications. "The cigarette I picked was so nasty that the first week I went from nine to two cigarettes a day," she says. She stepped down again the second week to eventually no cigarettes, and has stayed off them for nearly three years.
Leone takes a different approach at Penn, encouraging patients to take their time with steps to quit while accepting there may always be a part of them that wants to smoke. "Just drop the timeline and let you be you," he says. "It's OK to do this even if you don't know what challenges are ahead, even though you'll have to give up things that you don't want to give up."
What all the experts emphasize is that some kind of help can make the difference between relapsing and staying smoke-free, whether that's in the form of a doctor, a class, or a free telephone counselor from the hotline 800-784-8669, which serves as a clearinghouse for smoking-cessation resources.
Blaming smokers for continuing - or for illnesses like lung cancer - can also be detrimental. "Smokers are made to feel culpable, and, as a consequence, actually avoid looking for help," says Leone.
Contino and Richardson both had major health scares, after which they quit smoking for a time. Contino managed to stop for six months five years ago after a heart attack, but on a vacation without Chantix, he thought he would have just one cigarette, and he fell back into smoking.
Richardson quit for a period when she had chest pain, and again after a spot was discovered on her mammogram: "As soon as I found out everything was OK, I went back to smoking."
"On average, people try seven times to quit before they're successful," Maier says. "But if this is your first time, it doesn't mean that you won't do it, and if it's your 15th time, it doesn't mean it's too late."
National quitline: 800-784-8669. http://smokefree.gov/talk-to-an-expert/
Pennsylvania quitline: 877-724-1090., www.determinedtoquit.com. Links to free telephone counseling and nicotine-replacement therapy.
New Jersey quitline: 866-657-8677, www.njquitline.org. Free phone counseling and nicotine replacement therapy.
JeffQuit: groups start each month: 800-533-3669, www.jeffersonhospital.org/departments-and-services/jeffquit
Penn Comprehensive Smoking Treatment Program: 888-736-6786, www.pennmedicine.org/heart/patient/resources/patient-information/comprehensive-smoking-treatment-program.html/
Clear the Air with Crozer-Keystone: 610-447-6009, www.crozerkeystone.org/healthcare-professionals/medical-staff/patients/smoking-cessation New class starts at 6 p.m. Jan. 8 at the Upper Chichester Recreation Center.