A Quitter's Dilemma: Hooked on the Cure


New York Times

Published: May 2, 2004

FOR years it was the same routine: wake up, light a cigarette, inhale deeply and start the day. "I wouldn't even get out of bed without a cigarette," said John Palagonia, 53, of Massapequa, N.Y., who was a two-pack-a-day smoker for more than 20 years.

In 1989, Mr. Palagonia, who entertains at children's parties dressed as characters like Barney and Elmo, decided to quit. He turned to Nicorette gum to curb the cravings for a cigarette. The smoke savored between sips of his morning coffee was replaced with a peppery square. On breaks at work, driving his car, after dinner - all the times he had luxuriated in smoke - he would pop another piece. 

"I got to the point that I was having problems with my teeth, and my jaw was killing me," Mr. Palagonia said. He eventually returned to smoking for a short time "to get off the gum." What ended up working for him was counseling, not a hit of nicotine.

A third of the nation's nearly 50 million smokers attempt to quit each year, according to the American Cancer Society, and that has made smoking-cessation products an $800 million business in the United States alone. The products include gum and patches sold over the counter; pills, inhalers and nasal sprays sold by prescription; and even more exotic products like nicotine-infused lollipops sold on the Internet.

Still, addiction to nicotine remains. The medical field has accepted that fact since the mid-80's, when the Food and Drug Administration approved, by prescription, products like gum to give would-be quitters a substitute comparable to cigarettes in price and nicotine content, but without other cigarette toxins.

Now some scientists and former smokers are voicing misgivings. No one disputes that cigarettes, which are laced with toxic additives like ammonia, pose far graver health risks than nicotine alone, but nicotine is also classified as a poison, and in recent studies it has been shown to break down into a substance that causes abnormal cell growth. In 2001, researchers at Stanford University found that nicotine speeds the growth of malignant tumors by stimulating the formation of the blood vessels that feed them, a process called angiogenesis.

Dr. John Cooke, the lead author of the Stanford study, said, "As long as people are using nicotine replacements properly, it's a win for all of us, if we can get people to stop smoking. But, I would urge people not to use it long term."

For people addicted to nicotine, using the replacement products properly can be difficult. A study financed by GlaxoSmithKline, the pharmaceutical company that manufactures Nicorette and other stop-smoking products, found last November that more than a third of nicotine gum users continued chewing beyond the 12 weeks recommended under F.D.A. guidelines.

"We estimate 36.6 percent of current gum users are engaged in persistent use," said Dr. Saul Shiffman, a company consultant and the study's primary author. Though the company says on its Web site that nicotine "may promote lung cancer," it insists its products are safe "when used as directed."

Even the companies that make nicotine-replacement products acknowledge problems with treating this particular addiction. Dr. Kenneth Strahs, GlaxoSmithKline's vice president for research and development in smoking control, said, "I wish we could tell you that if you took one piece of our gum it would be enough, but that's not the case. Nicotine addiction is a chronic relapsing condition."

When the F.D.A. approved over-the-counter sales of Nicorette gum and the NicoDerm CQ patch in 1996, sales of the two products soared. GlaxoSmithKline reported $578 million in global sales of over-the-counter nicotine replacements during 2003, down from $606 million the year before as other companies jockeyed for market position.

How effective these products really are remains a debate. Some ex-smokers and smoking-cessation experts oppose using nicotine at all when trying to quit. "It's like the difference between snorting cocaine and freebasing it," said Mr. Palagonia. He has neither smoked nor chewed nicotine gum for a decade now after years of meetings at Nicotine Anonymous, a 12-step program.

"The trick with getting off cigarettes is to stop delivering the drug," said Joel Spitzer, a smoking-cessation counselor and director of education at WhyQuit.com, an online support and education site that advocates quitting nicotine cold turkey.

Mr. Spitzer, who estimates he has counseled 5,000 individuals in stop-smoking clinics he has run in Chicago, says nicotine replacements keep ex-smokers in a protracted state of withdrawal.

Denise Henrie, a mother of four from Owasso, Okla., is familiar with that. Ms. Henrie, 43, tried and failed twice to quit smoking, using nicotine gum for more than a year. "You feel a little hopeless," said Ms. Henrie, adding, "I just don't want to be addicted to anything at all." She has slipped back to her pack-and-a-half-a-day habit, but she remains optimistic. A package of Nicorette sits in her kitchen pantry for a third try.

According to the American Cancer Society, fewer than 5 percent of smokers who attempt to quit each year succeed. Of those who do, the society reported last year, 91 percent quit cold turkey.

Some people succeed only after a long struggle. Jeanne Hutchinson, 59, began chewing nicotine gum in 1984, the first year it was available by prescription. "One of the happiest days of my life was when nicotine gum was allowed to be sold over the counter," said Ms. Hutchinson, a social worker in Chicago.

But, years later, she was still hooked on the gum. "I felt almost like a drug addict," said Ms. Hutchinson, who estimates the 12 pieces she chewed each day cost her more than $15,000 over the years, without curing her habit. Suffering from a receding gum line and worn molars, she joined WhyQuit last January and managed to stop using nicotine.


STILL, when she reached into her coat pocket a few months ago and found a long-forgotten piece of gum, it took all her willpower not to pop it into her mouth.

That may be why analysts say that demand for nicotine-replacement therapies is unlikely to wither anytime soon. "We see it as a market with tremendous potential, but efficacy-starved," said Devesh Gandhi, a research associate at Sanford C. Bernstein, adding that the market - for "a product that really works, that manages both the addiction and the side effects of the withdrawal" - is there for the taking.


Copyrigtht 2004 The New York Times Company

So what's the harm of just using nicotine for the rest of your life. After all, it is not totally clear if nicotine itself is a carcinogen, and so many medical professionals think that it is relatively harmless when compared to the well established dangers of smoking.

The real danger is an issue that most people asking this question are not taking into consideration. The products are keeping the users in a mild to moderate form of chronic withdrawal. These people are never getting free of nicotine and thus free of the demands that their bodies are going to put on them.

When I first met Jeanne who was talked about in this story it was at a Chamber of Commerce meeting in the city where I live. Jeanne, knowing that I was the person who ran the clinics for the city, came up to introduce herself to me and to tell me that she had been off smoking for 12 years. Jeanne was proud of that fact. She was not looking for help or advice at the time. My guess was that she didn't feel she needed it considering she was off smoking for 12 years.

Her next comment to me though is what triggered our longer term association. She told me that she has still struggles every day and still constantly thinks of smoking. This raised a flag to me. You see, whenever I meet a person who has been off anywhere close to Jeanne's time off, they will generally say that they hardly think of smoking anymore. Or sometimes, they will say that the still think about smoking, and when I pursue the conversation it turns out that they think about it once a month or once every six months, and that it is nothing major or difficult to contend with.

Jeanne's story was different though, she was clearly saying that she was still struggling daily and has been for the past 12 years.

This is when I asked Jeanne how she quit and when she told me that she had used nicotine gum. When I asked her how long she used the gum she said that she was still using it. I think I let out a little laugh and proceeded to ask her if she ever tried to get off the gum. To that she responded that she had at one time tried to get off the gum by using the patch. That one elicited a bigger laugh from me.

Actually, when Jeanne first quit she used the gum as prescribed and pulled off the quit and got off the gum. I talk about this kind of person in the post Is cold turkey the only way to quit? She was off for a number of months, but one day under stress felt that she needed something and took a piece of her left over gum to help her through the moment. That piece of gum is what resulted in a 12 year, $15,000 addiction that kept her in a constant state of relative discomfort.

So is long-term use of NRT going to have the potential of killing a specific individual? No one knows the answer to this for sure at this point in time. But long-term use of NRT is going to have the full potential of making a person suffer years or decades longer and spend a small fortune compared to any person who simply makes and stick to the commitment to never take another puff!