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VOLUME I, Number 1, 1981

DR . M . A . H . RUSSELL ON SMOKING CESSATION

As Director of the Addiction Research Unit, Maudsley Hospital (London), Dr . Michael A . H .

Russell is well acquainted with both the promising trends in, and persistent difficulties of,
smoking cessation . Dr . Russell has been involved in psychopharmacologic research on the
effects of nicotine, with particular interest in the methods by which smokers "self-regulate"
their nicotine intake to avoid withdrawal symptoms . In addition, he has investigated
numerous forms of psychological counseling techniques to help smokers quit, including
physician counseling, group therapy, and aversive techniques . With this breadth of
knowledge and experience, Dr . Russell is widely recognized as one of the world's foremost
experts on smoking cessation .

For the inaugural issue of The Smoking Cessation Newsletter, Dr . Russell spoke with the
editor, Bernard Ellis, about steps that physicians can take to assist their patients to break
the smoking habit .

ELLIS : Before discussing how physicians can assist their patients to quit
smoking, it may be worthwhile to review how the smoking habit is initiated and
maintained . You have had a strong research interest in the role of nicotine in
the smoking habit .

RUSSELL : There are undoubtedly many social and psychological factors

that determine smoking behavior - who takes up the habit, when smoking is
initiated, etc . However, once a person has played around with cigarettes for a
little time, has learned to inhale and started to ingest nicotine, I think that
nicotine then dominates the smoking behavior over and above psychological
factors . I don't think that many people, even those who work in smoking
cessation research, realize the extent to which smoking for most smokers is
really a very finely adjusted drug-taking activity . Literally, when a person
inhales a cigarette, the nicotine is absorbed rapidly through the lungs and hits the
brain within seven seconds . Smokers modify and adjust that nicotine self-dosage
by the size of puffs they take, the rate at which they puff, and how deeply they
inhale . They seem to regulate that intake of nicotine when smoking different
strengths of cigarettes . We have shown that people on cigarettes with a nicotine
yield of 0 .6, which is fairly low in England, can get blood nicotine levels that a~'"e
very similar to the levels of people who are smoking cigarettes with two and
three times that nicotine level . When you get people to switch to low tar and

Continued on page 2 .

The Smoking Cessation Newsletter is a professional service of Merrell Dow

Pharmaceuticals Inc ., a subsidiary of The Dow Chemical Company . Bernard H . Ellis,
Jr., EDITOR . Complimentary subscriptions can be obtained by writinb : The Smoking
Cessation Newsletter, 9550 North Zionsville Road, R O . Box 68511, Indianapolis,
Indiana 46268.
nicotine cigarettes, they do self-regulate that nicotine intake . In addition, there
seems to be a bottom end of the cigarette market . In Britain, once you get
below a certain nicotine yield, the cigarettes 'don't sell, and I am sure if
psychological aspects were the predominant motive for smoking, very low
nicotine cigarettes and nicotine-free cigarettes would have some sale .
ELLIS : That's interesting, particularly in light of recent trends in
cigarette sales in the United States, where the low tar and nicotine market has
skyrocketed in the last ten years . It's gone from less than 2% of the total market
to close to 30°b now .

RUSSELL : It depends on what you mean by low tar and nicotine . The low
tar category is actually a very broad category and the only cigarettes in the low
tar category that sell are the ones that are up at the top end of that category .
Once you get to nicotine yields below about 0 .4, you get very poor sales in
England . They are higher in the U .S . with the better flavoring, and that is a bit
of a mystery .

ELLIS : I raised the point because the trend among smokers to switch to
low tar and nicotine brands is, in my mind, a very positive health trend, but it is
by no means an end point . We should not be satisfied at all with that movement,
as I think some people have encouraged us to .

Within the past few years there has been a flurry of activity in the smoking
cessation area, with many individual health professionals and health
organizations becoming more active . How do you view this trend ?

RUSSELL : One of the things that strikes me is that, as all family

physicians know, the 1979 U .S . Surgeon General's Report stated that
approximately 350,000 Americans die every year as a result of smoking . This
includes 80,000 lung cancer deaths a year, primarily caused by smoking . Even in
women, lung cancer is now fast approaching breast cancer as the greatest cancer
killer, and yet, almost 55 million Americans still smoke . For something like 20
years, we've had educational programs, public information programs, school
programs - all kinds of smoking cessation programs - and yet we still have
these 55 million Americans smoking . It has been said that family physicians in
the past haven't taken an active enough role in smoking cessation activity, and I
wonder whether this is true . Bernard, you've had the most immediate experience
of this in your former position as Program Director for Smoking and
Occupational Activities with the National Cancer Institute . What's your opinion ?

ELLIS : I share your frustration with the fact that 55 million Americans
still smoke . However, some progreF° has been made . We have dropped from
about 53% of American males smoking before the 1964 Surgeon General's Repor t

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to about 37% today, and to some extent that improvement can be credited to the
efforts of the health professional community . Physicians were one of the first
groups to respond to the Surgeon General's message and a large number of
physicians have quit smoking . In fact, in the U .S . we have more physicians today
who have quit smoking than who eontinue to smoke . By their nonsmoking
example, these physicians have had some impact . (Unfortunately, about one in
five physicians still smoke .)

There are a number of other activities that physicians can engage in to

encourage and assist their patients to quit smoking . Several years ago the
National Cancer Institute became interested in why more action had not been
taken . Perhaps one of the reasons why is that smoking is such a difficult habit to
break, and physicians who do no more than recommend that their patients quit
seldom have a big impact . As a result, many of us have been engaged to some
extent in trying to perfect and to improve the interaction between the physician
and the patient to improve the smoking cessation rate . Your recent large-scale
study of physicians' influence with smokers is a good example of the effect that
health professionals can have within their office practices . Could you share
some of this information with our readers?

RUSSELL : We studied some 2,000 patients of 28 family physicians,

randomly assigned to various levels of counseling intervention . The study showed
that simple straightforward advice given over one or two minutes during a
routine examination, plus handing the patient a leaflet with some tips and hints
on quitting had a worthwhile effect . Five percent of people who received
counseling stopped smoking and were still nonsmokers a year later, compared
with 0 .3% in the control group . Expanded on a large scale, that's a worthwhile
effect . It's an average, in fact, of 25 long-term ex-smokers for each physician
per year. Unfortunately, an individual physician performing this counseling
routinely would not notice that he had had a 5% success rate, or be encouraged
by this result . Physicians often don't realize that the 5% of smokers whom a
physician influences with a minimum of intervention can be more worthwhile
than special withdrawal clinics, with an 80% success rate, that require very, very
intensive therapy . In fact, we estimate that if every physician in England were
to achieve a 5% smoking cessation rate with their patients, the impact would be
equivalent to that of 10,000 smoking cessation clinics .

ELLIS : Perhaps it would be good for us to review why health professionals

do have an impact and why many health agencies would like to work with them
more closely .

Clearly, they are a very strong health exemplar for patients, and unTike
those efforts that reach smokers +hrough public information or education
eampaigns, health professionals have the opportunity for a face-to-face

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 discussion with a smoker to discuss that smoker's particular health condition and
how smoking may affect it . They see patients at what is called a "teachable
moment" -a time when patients are very sensitive to health advice . Seventy
percent of American smokers have indicated that if a physician would encourage
.them to quit, they'd attempt to do so . Yet, in other surveys, fewer than a third
of the smokers interviewed said that physicians had ever raised the issue of
smoking with them . Finally, American physicians have indicated a strong
interest in working more to help smokers break the habit .

You have mentioned the 5% smoking cessation rate in your study . I think
it's important to point out that this 5% was achieved with a population who did
not necessarily have a smoking-related disease . If a smoker came in with a
sprained ankle, he was advised to quit . Other studies of physician counseling
with patients who present smoking-related symptoms - chest pains or early
pulmonary disease or cardiovascular disease - have demonstrated greater
impact . In probably the most extreme example, approximately 60% of a group of
Post M .I . patients quit on advice from the physician . Granted, that's a very late
point at which to intervene .

Are there other things that health professionals can do to improve their
patients' success with quitting smoking?

RUSSELL : There are an expanding number of programs being offered in

U .S . communities to serve smokers . Your private health organizations, such as
the American Cancer Society and American Lung Association, offer withdrawal
clinics and, in some cities, individual counseling to smokers . In addition, many
government agencies are also increasing their efforts in this area .

ELLIS : Thank you, Dr . Russell .

NCITs "Quit Kits" for Health Professionals Well Received

The National Cancer Institute (NCI) recently announced that orders for the "Helping
Smokers Quit" Kit, a package designed for use by physicians and other health
professionals to help their smoking patients quit, have exceeded 100,000 kits . The kit,
provided free of charge to interested physicians, contains enough "quit smoking"
materials for 50 patients . •

Nancy McCormick-Pickett, Program Director for Smoking Activities with NCI's Office
of Cancer Communication, told the Newsletter : "We are very pleased with the
medical community's enthusiastic reaction to the 'Help Smokers Quit' Kit . To date, as
many as 5 million smokers have received counseling and supportive materials from
their physicians as a result of the kit ."

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The kit was developed by NCI in 1978, with pretesting assistance from M . D . Anderson
Hospital and Tumor Institute and the Harris County (Houston, Texas) Medical Society .
Since its release in late 1978, the kit has received editorial endorsements from
numerous state and national medical societies, and has prompted requests from at
least ten other countries for assistance in producing and distributing similar kits
abroad .

The kit is designed to provide physicians with a simple four-step procedure to counsel
smokers, which can be administrated in a single office visit . The kit contains
instructions for the physician and office staff ; attractive office posters with the
slogan, "The Question for Smokers Is Not Whether To Quit . . .but How . Ask Us ."; and
several handouts for patients . Each kit also contains a reorder form through which
physicians may request additional materials, free of charge .

One additional positive spin-off of the success of the kit has been the development of a
similar kit for use by dentists . The "Let's Help Smokers Quit" Kit,. coproduced with the
American Dental Association (ADA), has already reached 35,000 dentists . "Dentists,
dental hygienists, and dental assistants can stress the cosmetic as well as health
benefits of smoking cessation with their patients . Given the dental profession's long-
standing commitment to preventive health education, the development of a'quit
smoking' kit by the NCI and ADA was a natural . Now," concluded Ms . McCormick-
Pickett, "smokers can receive direct assistance from two important health
professionals -their physician and their dentist ."

For our readers :

The abovementioned kits can be ordered, free of charge, by writing to :
Department DC
National Cancer Institute
Bethesda, Maryland 20205

Please be sure to indicate by name whether you wish the physician's kit - "Helping
Smokers Quit" - or the dental kit -'TLet's Help Smokers Quit ."

Resources to Help Smokers Found in Most Communities

Health professionals who wish to do more to help their patients quit smoking have an
increasing variety of supportive services at their disposal, both at the local and
national level .

Several voluntary health organizationG devote considerable resources to reducing the

smoking problem, and stand ready to provide assistance to interested health
professionals . The American Cancer Society, American Heart Association and

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T

American Lung Association all have materials designed to help smokers quit . In many
communities these organizations also provide individual and group counseling to
smokers who feel they need extra assistance in kicking the habit . Local affiliates of
these organizations should be contacted to determine the "quit smoking" services
provided in each local area .

Numerous commercial smoking cessation programs also exist to help smokers quit, at a
fee . Perhaps the best known programs are the Schick Centers for the Control of
Smoking, and Smokenders, Inc . Each of these organizations offers services in
numerous cities around the country . For information on the nearest available program
offered by these companies, contact the national office, or consult the local telephone
directory under "Smokers Information and Treatment Centers ."

For your information

American Cancer Society (National Office) - 777 Third Avenue, New York, N .Y . 10017
American Health Foundation - 320 East 42 Street, New York, N .Y . 10017
American Lung Association - 1740 Broadway, New York, N .Y. 10019
SmokEnders (National Office) - 37 North Third Street, Easton, Pa . 18047

The Office on Smoking and Health - How It Can Help You Help Your Patients

The Office on Smoking and Health is one of the smallest agencies in the Department of
Health and Human Services, with an overall budget of $2 .5 million and a staff of only.
19 full-time employees . It does, however, have an extremely active information
program that is dedicated to carrying out the smoking and health agenda described in
its recent Report on Smoking and Health in this way : "The decision to smoke is a
personal decision, but once this is said it remains unquestionably the responsibility of
health officials to ensure that smokers and potential smokers are adequately informed
of the hazards . This is especially true in a society where hundreds of millions of
dollars are spent each year promoting cigarettes . . :'

The Office has contracted with several advertising agencies to devise a radio,
television and print campaign addressing three specific objectives :

* to encourage children and young people, particularly girls,

not to take up smoking
* to encourage women to quit smoking, particularly during
pregnancy
* to encourage less hazardouF .;moking; i .e ., use of low tar,
low nicotine cigarettes

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Of particular interest to physicians may be the Office's public affairs program, which,
as part of its agenda, includes the publication and distribution of some 21 pamphlets,
posters, and flyers . Any publication on this list may be obtained by writing to :

The Office on Smoking and Health

Public Health Service
Rockville, Maryland 28057

Selected materials/publications available from the Office include :

Teenage Self-test Teenage Self-test Discussion Guide

Smoking, Tobacco & Health : A Fact Book Smokers Self-test
Two Things Women Should Know Unless You Quit
Slim & Smokeless If You Must Smoke
Tar and Nicotine Card Smokers Health Book
We Americans Have Seen the Light

Also available from the National Cancer Institute, Bethesda, Maryland 20205 :

Smoking Programs for Youth Clearing the Air

A School Bibliography

Smoking as an Addiction

Clinical studies continue to indicate that cigarette smoking is an addictive behavior .

A recent article by Drs . R . C . Bone, J . R . Phillips and Parimal Chowdhury in the
Journal of Respiratory Diseases (May 1981) states that smoking results in a dependence
disorder, and that cigarette smoking is a physical dependence on nicotine . Craving a
cigarette during withdrawal periods is not merely psychological, but a physiological
reaction, according to the authors . The article from the University of Arkansas
concludes that since social factors important in acquiring the smoking habit have their
greatest impact before age 20, smoking cessation efforts should focus on adolescents
and preadolescents, and should emphasize the dependence aspects .

The Journal of the Addiction Research Foundation (Vol . 10, No . 4, April 1981) has dealt
extensively with nicotine dependence . They warn of the related danger of health
injuries brought about by so-called "secret additives" used by tobacco companies to
reduce nicotine content - additives thought to include : shellac, caramel, eugenol, and
other chemicals . The Journal also quotes the U .S . Surgeon General's fin•"dings that
pregnant women who smoke low tar and nicotine cigarettes cannot expect to reduce
significantly the hazards to the fetus .

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The Office on Smoking and Health publishes a yearly index to ongoing research in
smoking and health, as well as a bibliography to published materials . The most recent
volume (1979) of the bibliography lists over 1,500 papers on scores of related topics . In
the area of nicotine addiction, readers may wish to read the following :
Jaffe, J .H ., and Kantzler, M . : "Smoking as an Addictive Disorder" in
Krasnegor, N .A . (Editor) Cigarette Smoking as a Dependence Process .
National Institute on Drug Abuse Research Monograph Series, No . 23,
DHEW Publication No . (ADM) 79-800, January 1979, pp . 4-23 .
This paper points out similarities and differences between tobacco usage and drug
usage behavior commonly viewed as addiction in our society .

Also, the proceedings of the International Conference on Smoking Cessation, held by

the American Cancer Society in New York (June 21-23, 1978) produced two interesting
papers on this topic :
Harrup, T . : Addictive Processes in Tobacco Use-a discussion of the nature of
the smoking addiction and an examination of steps to treatment
Russell, M .A .H . : Smoking Addition : Some Implications for Cessation . In :
Schwartz, J .L . (Editor) Progress in Smoking Cessation- a report on 1,574 adult
smokers in Britain that showed 70% had tried unsuccessfully to stop smoking and
50% had tried more than once .

New Evidence on Survival Rate of Former Smokers

Front-page news was made recently by a report in the June 4, 1981, issue of The New
England Journal of Medicine stating that people who quit smoking raise their chances
of living longer by more than half . The Oakland, California Kaiser-Permanente
Medical Care Program did a"multivariable analysis" of ?5,917 patients over a 13-,year-
period and found that no matter how old they were, or how long they had smoked,
patients who quit will live longer than people who continue to smoke .

Drs . Gary Friedman, Diana Petitti and Richard Bawol, with A . B. Siegelaub, found that
the main risk of cigarette smoking is the increased chance to the smoker of developing
coronary heart disease, and that the average risk of dying over the period surveyed
(1964-1977) from that ailment was more than twice as great for persistent smokers .
Further, persistent smokers were found to have high death rates for all cancers,
circulatory disease, and just about all causes of death .

These findings go a long way toward answering the criticism of similar studies - that
low death rates for quitters can be tied to other, nontestable variables . The authors
set about to test just those factors, t ;; ruling out physical and habitual influences (such
as alcohol consumption) and by studying a large test group .

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