Quitting

European observers noted as early as the sixteenth century that tobacco users found it difficult to quit their practice once they had adopted the habit. The Spanish archbishop Bartolomé de Las Casas Cuzco observed in 1527 that Spanish soldiers on Hispaniola seemed unable to stop using the plant. In 1604 King James I of England in his Counterblaste to Tobacco wrote that smokers became "bewitched" to tobacco and overcome by "lust" for the "vile custome." Sir Francis Bacon observed in 1622, "The use of tobacco . . . conquers men with a certain secret pleasure so that those who have once become accustomed thereto can hardly be refrained therefrom" (Slade 1998).

Nineteenth-century American authors frequently warned readers that tobacco enslaved smokers, snuff users, and tobacco chewers. In 1852 one author warned boys that tobacco users were bound "in chains not easily broken" and compared tobacco with opium (Trask 1852).

Industrialist Henry Ford pointed out the addictive quality of cigarette smoking in 1914 in his popular book The Case Against the Little White Slaver. By the 1930s many medical writers saw the tobacco habit as "a form of drug addiction" (Dorsey 1936).

Thus, from an early time doctors and laypersons generally understood that quitting tobacco use was very difficult. However, a scientific consensus did not emerge until 1988, with the publication of The Health Consequences of Smoking: Nicotine Addiction: A Report of the Surgeon General, which said that the smoking habit was a biologically based addiction like that associated with cocaine or heroin. How then might one quit, given the great difficulty in doing so?

Three Twentieth-Century Models

In advice typical for the nineteenth century, one author recommended that users focus their "stern, resistless will" on breaking their dependency (Trask). He added that prayers, staying busy, signing a pledge, drinking copious amounts of pure water, and hydrotherapy could aid the slave to tobacco.

In the first half of the twentieth century writers continued to recommend the nineteenth-century smoking cessation measures and added recommendations such as drinking copious amounts of fruit juices, deep breathing, and psychoanalysis. A few physicians advised patients to use amphetamines, tranquilizers, or lobeline sulphate as aids to cessation. Taking the alkaloid lobeline (C₂₂H₂₇NO₂) and tobacco simultaneously caused smokers to become nauseous because of a cross-tolerance between lobeline and nicotine. Some physicians believed it also helped reduce cravings for nicotine because of similar pharmacological effects on the nervous system. By the 1930s scientists understood that lobeline "caused a brief stimulation of the motor centers in the spinal cord and medulla. This stimulation is soon followed by depression, and later paralysis with large doses. The feature of the action of the drug is the stimulation of the motor nerve endings in the involuntary muscles" (Dorsey 1936).

As strong scientific evidence linking smoking with lung cancer emerged in the 1950s, health scientists began to design formal programs to assist those smokers who were unable to quit on their own. The clinical treatment programs were generally based on techniques and ideas about self-control or pharmacological interventions.

WAYNE MCFARLAND. Dr. Wayne McFarland was a pioneer in the field of clinical treatment. In the 1950s he developed the Five Day Plan to quit smoking, and began to conduct smoking withdrawal clinics on a large scale in 1962. Although McFarland was associated with the Seventh Day Adventist Church, his Five Day Plan was a nonreligious smoking cessation program often cosponsored by local hospitals and local voluntary health groups such as the National Tuberculosis and Respiratory Disease Association (now the American Lung Association, or ALA). The clinics were free or only a small nominal fee was charged. Between 1961 and 1964, 50,000 Americans completed the Five Day Plan. Often more than 100 people attended a single Five Day Program at one location for one week. In the greater Los Angeles area alone, 8,000 to 10,000 people had completed 300 clinics by 1970. Because of the difficulty of following ex-smokers over time and the lack of prospective studies on the attendees, researchers do not know how successful the program was. Evidence from the time suggests that significant numbers of people were able to quit for a short time, but many returned to smoking later.

BORJE E.V. EJRUP. Another early programmatic attempt to aid smokers in quitting their addiction was made by the Swedish physician Borje E.V. Ejrup. He began his work in Stockholm in 1955 and continued it at the New York Hospital/Cornell Medical Center in the 1960s. By 1967 he had treated 7,000 patients with his method.

The Five Day Plan

T he Five Day Plan, developed in the 1950s by Dr. Wayne McFarland, sought to strengthen smokers' willpower and to weaken the physical craving for nicotine experienced during withdrawal. Participants met for five evenings at various convenient places such as school auditoriums, hotels, civic halls, or hospitals for one and a half to two hours. To motivate the smokers, participants were given frightening lectures on the hazards of smoking and shown graphic films of smokers having cancerous lungs removed. Ex-smokers gave hopeful testimonials and participants were encouraged to select a buddy for mutual support.

Along with the evening meetings, participants were given behavioral and psychological tools to use while on their own. The plan advocated complete and immediate cessation. To sustain abstinence, a three-pronged assault, with mental, physical, and spiritual components, was made on the addiction.

The plan's author advised taking large quantities of fruit juices and copious amounts of water with the hope that this would reduce craving sensations. Rhythmic breathing was also recommended to increase the oxygen supply to the brain and to fortify willpower.

Various behavioral interventions were suggested. One might take walks after meals or help his or her spouse with the dishes. Long hot showers in the morning and evenings, as a form of hydrotherapy, were recommended for their calming effect. The participants were taught to avoid spicy foods, sugar, coffee, and alcohol. The belief was that these stimulating foods would induce craving.

To fortify the will, the plan recommended repeating the mantra: "I choose not to smoke." Though the plan was nonreligious, it did incorporate a generic spirituality into its cessation armamentarium. Participants were instructed to ask for divine help at moments of crisis in accord with their own beliefs. In substance, the plan's recommendations echoed early-twentieth- and late-nineteenth-century recommendations. The main difference was its formal organization and system of social support.

Ejrup was especially interested in the "hard core" smokers with a strong physiological dependence on nicotine. He gave patients lobeline hydrochloride in injections and in oral form in order to support them in breaking their physiological dependence. In addition, Ejrup prescribed the tranquilizer meprobamate to allay anxiety. Because many patients were concerned about weight gain, he also gave them an amphetamine to reduce hunger.

Patients came to Ejrup's Tobacco Withdrawal Clinic every weekday for the first two weeks for injections and tablets. They also received individual counseling from a physician. Ejrup advised physicians to be dramatic in their counseling sessions as they attempted to warn, persuade, and cajole would-be ex-smokers.

DONALD T. FREDRICKSON. Donald T. Fredrickson, M.D., director of the Smoking Control Program at the New York City Department of Health, planned and directed the first smoking control program of the New York City Department of Health from 1964 to 1967. Nearly 100 volunteer ex-smokers, drawn mainly from the upper middle class, comprised most of the staff of the program. Fredrickson's program had three phases, beginning with motivational lectures, and progressing through group sessions involving discussion, question and answer, and mutual encouragement.

The core of Fredrickson's program was based on a lay self-help model derived from Alcoholics Anonymous, Gamblers Anonymous, and Weight Watchers. In addition, he derived elements of his model from conversations with ex-smokers, reports of other clinics, and studies of a handful of behavioral scientists.

Fredrickson believed that habituation to smoking was, in part, learned behavior, and the smoker needed to learn to manage emotional and psychological states without cigarettes. He instructed smokers that they needed to be highly motivated and to faithfully exercise the virtues of patience and persistence in order to alter their behavior through psychological retraining. Hopefully the smoker would experience the program as a positive exercise in self-mastery while achieving a new dimension of self-control.

ADAPTATIONS. The three early programs described above became the models on which many later smoking withdrawal clinics in North America and Europe were based. McFarland's Five Day Plan was transplanted to the United Kingdom and Canada and was often cosponsored by various health agencies and hospitals in the United States. Adaptations of Ejrup's pharmacological and intensive counseling treatment regimen were deployed by clinics in the United States, the United Kingdom, Denmark, and Germany. Fredrickson's self-help, self-control program became a model for other stop smoking clinics by 1970 including those of the American Cancer Society (ACS), the American Lung Association (ALA), and the Los Angeles County Department of Health.

Programs in the 1960s to 1970s

The ACS, ALA, local health departments, local hospitals, and local voluntary health associations began offering free or low-cost smoking cessation clinics in small numbers in 1964. By 1974, 13,000 smokers in California alone had participated in ACS stop smoking clinics. In the 1970s other voluntary agencies like the Young Men's Christian Association (YMCA) and the American Heart Association (AHA) began to offer smoking cessation clinics. During the period from 1977 to 1981, the ACS held 18,000 stop smoking clinics across the United States. All of these agencies continued to offer stop smoking clinics in the 1980s, notable among these were the American Lung Association's Freedom from Smoking Program and the ACS's Fresh Start smoking cessation program.

These clinics, generally based on a self-control rationale, usually included lectures, question-and-answer sessions, self-evaluation tests, the buddy system, some form of individual therapy or group therapy or group support in which participants shared experiences and stories, and handbooks that gave advice about changing behaviors. The non-commercial clinics usually had from four sessions to twelve or more sessions lasting from one to eight weeks and sometimes as long as six months.

In addition to these noncommercial stop-smoking clinics, by 1970 there was a $50 million per year industry of for-profit smoking cessation programs. Some of these programs included Smokewatchers, Quit Now, Smokenders, and Schick Centers. By 1977 Smokenders alone reported that it had 150,000 graduates of its eight-week program. The commercial clinics sometimes used adaptations of the Fredrickson model, hypnosis, and aversive conditioning.

Due to high drop-out rates and the difficulties of following patients over time, researchers are not certain of how effective these programs were. Impressions from the time and current data indicate that clinics had some initial success but over time many smokers returned to tobacco use.

Besides these clinical interventions, health agencies, among whom the ACS was the largest and most active, also attempted to induce cessation through educational campaigns directed at the population level. The ACS waged their "Who Me? . . . Quit Smoking!" and "The Time to Stop Is Now" campaigns beginning in 1965. In 1968 the ACS began its "I Quit" or "IQ" smoking cessation campaign. Other notable population level interventions included the ACS's "Target Five" campaign from 1977 to 1981, in which 20 million adults were reached with antismoking messages and, during which, the ACS sponsored 18,000 Quit Smoking! clinics through local affiliates. The Great American Smokeout, held annually since 1977, has been another prominent attempt at intervening at the population level. For example, in 1983, 19 million Americans participated in the Great American Smokeout. During this event the ACS, through a national publicity campaign, attempts to persuade smokers to try to quit for one day hoping that a fraction of them will quit permanently.

EXPERIMENTAL STUDIES. Clinical delivery of smoking cessation treatment preceded the large increase in formal, experimental studies of smoking cessation that began in the mid-1960s, a field that one study described as still in its infancy in 1968. During the 1970s there was a great deal of wide-ranging research into smoking cessation methods. Most of the research was based on behavioral strategies of aversion or self-control. In aversion strategies the idea was to associate unpleasant stimuli with smoking so that smoking would no longer be experienced as pleasurable. Among the aversion methods studied were giving electric shocks to people while they smoked, having people rapidly smoke cigarette after cigarette or smoke so much that they became ill, blowing smoke in the face of a cigarette user as he or she smoked creating irritation and discomfort, and having smokers concentrate on negative, disgusting, or unpleasant images in their minds while they smoked. It was hoped these negative associations would deter smoking.

In other studies researchers hoped to help participants resist the idea or craving to smoke; in essence, to help them increase their ability to control their smoking behavior. Researchers did this by making contingency contracts wherein smokers would receive some reward, such as money, if they avoided smoking, and wherein they would have to pay money if they smoked. They tried social contracts, like the buddy system, wherein smokers attempted to quit with a partner. It was hoped that through increased social support smokers could resist the temptation to smoke. In the 1980s experimental research began to focus on physician advice models, work site interventions, and community wide approaches. In these approaches it was hoped that less intensive interventions directed at a much larger population would end up, on balance, creating more ex-smokers than intensive interventions directed at individuals and small groups. In addition, researchers increasingly studied nicotine replacement strategies such as the nicotine patch with and without behavioral components. These interventions continued to demonstrate modest effects with relatively low quit rates because of the strength of "multiple societal, psychosocial, biobehavioral, and biological processes that maintain smoking behavior" (Lichtenstein and Glasgow 1992).

The 1990s to the Present

Based on research from the 1990s into the new millennium, scholars and medical professionals understand that nicotine is the addicting drug that has the poorest success rate for cessation when compared to alcohol, cocaine, and opioids. Withdrawal symptoms might include craving sensations, irritability, anger, anxiety, difficulty concentrating, restlessness, decreased heart rate, or weight gain.

Approximately 87 percent of those who successfully quit smoking do so on their own, while only 13 percent quit with the help of a formal program or drug therapy. Smokers usually have to make several attempts at quitting before achieving success.

Since the 1990s some progress had been made with medical interventions to help with smoking cessation. Specifically, nicotine replacement therapies in the form of gum, patch, and nasal spray, and the use of bupropion, a non-nicotine-based quitting medication, have shown promise. Researchers have shown that the concomitant use of drug therapy (including nicotine replacement) and receiving counseling of some kind give the addicted smoker the best chance at quitting.

See Also Addiction; Nicotine; Quitting Medications.

▌ COLIN TALLEY

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snuff a form of powdered tobacco, usually flavored, either sniffed into the nose or "dipped," packed between cheek and gum. Snuff was popular in the eighteenth century but had faded to obscurity by the twentieth century.

opium an addictive narcotic drug produced from poppies. Derivatives include heroin, morphine, and codeine.

physiology the study of the functions and processes of the body.