Kicking butt: a look at smoking cessation through the decades

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Kicking butt: a look at smoking cessation through the decades

From ‘grandma groups’ to pharmacotherapy to online interventions, people will try just about anything to kick the habit

Nov. 19, 2014

Aversion therapy -- being put in a small room full of cigarette butts and being forced to chain smoke while getting shocked with each puff -- is just one way people have tried to kick the habit over the years.

Photo by Robert Hood / Fred Hutch News Service

When it comes to kicking the smoking habit, people will pretty much try anything. Some go cold turkey. Others try Wild Turkey – bourbon flavored e-cigarettes, that is. Still more turn to hypnosis, nicotine gum, pharmaceuticals or phone lines.

Shawn Burke, a 54-year-old Seattle meter reader who smoked for 23 years, was so desperate to dump his three-pack-a-day cigarette habit back in the mid-1980s he went to the Schick Shadel Hospital for their now-discontinued smoking-aversion therapy.

“They put me in a small room full of cigarette butts and forced me to smoke one cigarette after another for an hour while getting shocked with every puff,” he said. “You weren’t even allowed to put the old ones out. They continued to [smolder] and light the other cigarettes on fire. I thought I was cured but about 10 minutes into my drive home, I lit up.”

Dr. Jonathan Bricker

"As far as a public media campaign, it's probably the most successful one for quitting smoking," said Dr. Jonathan Bricker of the Great American Smokeout. "Each time you try, you continue to increase your odds of succeeding."

Photo by Robert Hood / Fred Hutch News Service

While Burke finally was able to quit for good using the nicotine patch, millions more struggle with the powerful addiction, which has plagued American men, women and even children since cigarettes became big business during World War II.

How effective are the various smoking-cessation programs that have been introduced over the years? And what’s coming down the pike in days to come? We turned to Dr. Jonathan Bricker, a behavioral psychologist who specializes in smoking-cessation research at Fred Hutchinson Cancer Research Center, for a look at kicking the habit, past, present and future.

The dawn of smoking cessation

The whole concept of smoking cessation is relatively new, sparked in large part by the landmark 1964 U.S. surgeon general’s report on smoking and health, the first federal government report to show the irrefutable link between smoking and cancer, heart disease and other health problems. After its publication, both individuals and public health groups began pushing for ways to definitively kick tobacco to the curb, including the creation of a national “Don’t Smoke Day.”

That push eventually became the American Cancer Society’s Great American Smokeout, which for nearly four decades has encouraged people to stop smoking for at least a day on the third Thursday of November.

It’s a simple approach and, according to Bricker, it’s a fairly effective one.

“As far as a public media campaign, it’s probably the most successful one for quitting smoking,” he said. “We know that if you quit smoking for 24 hours, there’s about a 5 percent success rate.  That’s doing nothing but saying, ‘I want to go for a whole day [without smoking].’ Five percent will stop, but if you keep doing it, it’s multiplicative. Each time you try, you continue to increase your odds of succeeding.”

The ACS doesn’t have statistics on how many people have quit as a result of participating in the Smokeout, but it does point to the raft of anti-smoking laws and public policy changes that have taken place since the Smokeout began in 1977.  Since 1965, cigarette smoking among adults in the U.S. has dropped from more than 42 percent to around 18 percent, according to the ACS.

Two very different types of anti-smoking behavioral therapies also got their start in the 1970s.  

On one end of the spectrum were therapy groups – or “grandma groups,” as Bricker affectionately calls them – which met in church basements, hospitals and private clinics to offer group support and homespun advice that primarily focused on distraction tactics. 

“They weren’t based on psychological theory but were things your grandma might have taught you,” he said. “‘Have a cup of water in the morning instead of coffee. Smoke with your left hand instead of your right hand. Chew on a carrot stick or gum or do a jigsaw puzzle.’ There was no science behind it. The concepts were very commonsensical.”

On the other end of the spectrum was aversive counter-conditioning, which turned smoking into an extremely unpleasant experience. Those who signed on for this type of therapy sat in a cramped, hazy room hooked to electrodes, chain smoking cigarettes. With each puff, they received an electrical shock.

Aversion therapy didn’t work for longtime smoker Shawn Burke, but an uncontrolled trial conducted by the Seattle-based Schick Shadel Hospital did point to a low relapse rate, Bricker said. 

“They did some science around it and I give them credit for that, but it wasn’t the gold standard because it wasn’t a randomized trial,” Bricker said, adding that the program eventually fell out of favor and was retired. “It was a very unpleasant thing to go through. People wanted other ways that were not so uncomfortable.”

The rise of pharmacotherapy

Smokers looking for other options found them in nicotine patches and gum, innovations that were introduced in the early 1990s, the beginning of the pharmacotherapy era.  Priced comparably to cigarettes, nicotine products offered an easy, over-the-counter medication that helped about 8 percent of smokers quit.

There was just one problem: people simply became addicted to another form of nicotine.

“The devices are useful in reducing the harm from smoke tobacco,” Bricker said. “But they don’t teach you how to deal directly with your cravings to smoke. I know many people who are addicted to nicotine gum. It’s much safer than smoking a cigarette. However, it’s expensive.”

Equally expensive – and addictive --are the new nicotine-based e-cigarettes, which some claim to use as a smoking-cession device. Bricker worries that instead of helping smokers quit, the devices actually may encourage them to smoke more.

“There are different levels of nicotine in each of these products,” he said. “And you don’t know if you’re getting more or less.  And people may become dual users. They’ll smoke cigarettes and then smoke e-cigarettes where smoking is publicly prohibited.”

Also potentially problematic, Bricker said, is the smoking cessation drug Chantix, known generically as varenicline, which became available in 2008. Designed to block off the brain’s pleasure response to smoking, Chantix offers a 25 percent quit rate, but at a high cost, at least for some.

“It was a very smart drug, based on basic science,” Bricker said. “The problem is there have been a number of suicides and cases of major depressive episodes linked to the drug.”

Chantix now carries a black box warning, per the U.S. Food and Drug Administration, as does another anti-smoking drug, Zyban (also known by the brand name Wellbutrin). A prescription antidepressant that reduces symptoms of nicotine withdrawal, Zyban has about a 15 to 20 percent quit rate, Bricker said.

Kicking the habit in the digital age

As pharmaceutical approaches to smoking cessation have become more sophisticated, so have behavioral therapies designed to overcome addiction.

The “grandma groups” evolved into telephone and text support lines like the National Cancer Institute’s 1-800-QUIT-NOW and 1-877-44U-QUIT, where instead of hit-and-miss advice or do-it-yourself aversion therapy (“Eat dog biscuits when you want a cigarette!”), smokers receive scientifically proven cognitive therapy. Such interventions include relapse prevention, which focuses on triggers and how to avoid them, and motivational interviewing, which gently guides the person to make the decision to quit smoking and help them deal with their cravings. 

“That’s now the mainstay,” Bricker said. “If you go to get help or call a quit line or use a group, their main method will use some combination of motivational interviewing and cognitive behavioral therapy.”

Bricker is also an internationally recognized leader in another new form of behavior modification known as acceptance and commitment therapy, or ACT, which encourages people to notice and accept their urges to smoke with the understanding that the urges will eventually disappear on their own.

Another important development in recent years: the use of websites and apps to deliver smoking- cessation help.  Bricker said there are currently about 400 anti-smoking apps on the market; their efficacy is just starting to be studied. 

Bricker is currently recruiting 2,500 adult smokers nationwide for his WebQuit study, which will use two separate online quit-smoking programs to help people overcome their nicotine addiction.

“You get randomly assigned to one of two websites to quit smoking,” he said. “Both show great promise and we’re going to learn which one is more effective.”

Bricker said one big benefit of Web-based smoking-cessation programs is that they’re less of a financial – and psychological – burden.

“Websites are low cost, they’re accessible to many demographics and they’re private,” said Bricker, who will present some of his research in a TEDxRainier talk this Saturday in Seattle. “They don’t require you to show up in a group. You can do it privately. And there’s a lot of stigma around smoking.”

The future is bright for those who want to quit

How should people encourage a loved one who wants to quit? Listen but don’t judge or proffer advice, Bricker suggested.

“Let them know you’re available to do things together, to engage in nonsmoking activities like going for a walk or going to dinner or talking on the phone,” he said. “Show them you care and that you’re not going to judge them if they fail. Focus on the relationship as opposed to being an expert on how to quit smoking.”

As for the future of smoking cessation and other efforts to improve public health, Bricker said the future is bright. Not only does he have a study revolving around an effective new anti-smoking app waiting in the wings, he may also soon be developing a weight-loss app based on the principles of ACT.

“If you want to be in the service of the public and in the service of preventing cancer, you have to be able to reach millions of people at low cost with effective treatment,” he said. “If people are using apps, that’s where we’re going.”

Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she also writes the breast cancer blog doublewhammied.com. Reach her at dmapes@fredhutch.org.

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