Prepare to quit or plan to die prematurely
Harvard expert offers tips on stubbing out smoking once and for all.
During a 90-minute interview with Harvard Prof. Nancy Rigotti in a Jerusalem cafÃ©, not one customer lit a cigarette. This might be a matter of vague interest for a foreigner who hasn't visited Israel since she was a youngster 40 years ago - but not for Rigotti, a world expert on smoking prevention and cessation.
Born in Rockport, Illinois and living in a Boston suburb, Rigotti teaches and does research at Harvard Medical School and the Harvard School of Public Health; has 25 years' experience in developing, testing and implementing strategies to treat tobacco addiction; was a pioneer in authoring evidence-based tobacco treatment strategies now used by clinicians; founded and directs the Tobacco Research and Treatment Center at Massachusetts General Hospital; is director of the hospital's tobacco research and treatment unit; scientific editor for US Surgeon General's Reports on Smoking; and was deputy editor of the journal Nicotine and Tobacco Research. Although she is very busy, she also works once a week as an internal medicine specialist in a Boston primary-care clinic.
BUT EVEN though she was pleased to have a smokeless lunch with The Jerusalem Post, she was aware that illegal smoking is still common in many Israeli public places and that the laws - which preceded most of those in the US - are not well enforced. While Israel's adult smoking rate of 21-22% is somewhat above the national US rate of 19.8% - it has plunged to 16% to 17% in health-conscious Massachusetts and 14% in California, and virtually all Americans observe laws about smoking in public places. An estimated 438,000 Americans and 10,000 Israelis die of smoke-related causes each year. There is still much work to be done.
Rigotti recommends that all smokers who are hospitalized - whether due to tobacco-related diseases or not - be encouraged during their stay to kick the habit. This is an appropriate venue for encouraging cessation and can save much money in future health expenditures, she says, noting that Massachusetts General staffers ask every individual who arrives at the emergency room and all inpatients if they are smokers. "While some may say they quit and mean two hours before," she assumes that most are telling the truth, but the possibility that they are not is being studied. Just being in a hospital emergency room and realizing one's own mortality can be enough to persuade long-time smokers to give up, notes Rigotti.
If Massachusetts General patients admit to smoking, booklets in English (not yet in Spanish) are placed on their beds explaining the dangers and advising on how to quit, as well as describing the symptoms of tobacco withdrawal.
"Smoking cessation counsellors also come around to visit them, and before they are discharged, we inform them about quit lines they can call for support." They can also be prescribed medications that help them kick the habit, she adds. "Half of the hospitalized patients use nicotine replacement patches or gum in the hospital," says Rigotti, who came last month to attend conferences of the Medical Association for Smoking Prevention and Cessation and the Israel Cardiology Society.
THE ADVANTAGE of promoting cessation in the hospitals is that long-time smokers suddenly find themselves in medical institutions where they are forbidden to light up. They suffer from nicotine withdrawal in addition to their illness. They have high motivation to quit, says Rigotti.
In Israeli hospitals, whether a patient smokes or used to smoke is usually registered in his medical record, but nothing more is done. As all our medical institutions are owned either by the government, the health funds, voluntary organizations or profit-making companies and Health Ministry supervision is all-inclusive, such a smoking-cessation policy could easily reach tens of thousands of smokers each year.
Rigotti also urges that university and college dormitories be designated as no-smoking areas so that students don't learn to smoke. Aware of the fact that many Israelis start to smoke during military service, she suggests the Israel Defense Forces put a major effort into smoking cessation. There are also hotel chains in the US that have declared themselves smoke free. "We are at the tipping point. Smoke free is becoming the norm in many facilities," says the Harvard expert.
NO CIGARETTE has ever touched Rigotti's lips. Her father (who owned a machine tool company and came to Israel with his wife and daughter to make sales) learned to smoke in World War II, but quit "cold turkey" at 50 - after his nicotine-addicted best friend died of a heart attack on the golf course.
"As an internal medicine specialist in the late 1970s, I knew that smoking was bad for people. When patients asked me how to quit, I really didn't know, so I went to the medical library and became an 'instant expert" and lectured on the subject to doctors, who then did know about dangers but not about cessation techniques. The public viewed smoking as a 'bad habit,' while the tobacco industry sees it as a 'choice'."
Informed that Israel's health minister, Ya'acov Ben-Yizri, has been smoking for about 65 years, Rigotti said that if people really want to kick the habit, they can do it. "You can stop at any age. Relatively few older people smoke, as many of them die off before they reach old age."
US President Barack Obama - who admits to smoking (and chewing nicotine gum during the campaign so as not to be caught by a camera) - is now unable to smoke inside the White House, but can do it outdoors. "He would be a very good example to the nation if he quit."
The US has increasingly adopted anti-smoking laws - with half of the states outlawing smoking in workplaces, bars and restaurants - something Israel adopted nationwide 25 years ago. But America has still not ratified the World Health Organization's Framework Convention on Tobacco Control because, Rigotti says, of the power of the tobacco lobby; Israel, however, was the 77th country out of 192 members of the WHO to formally ratify it in August 2005 after initially approving it a month after it was passed in Geneva in May 2003.
SHE DECRIES the fact that actors are still seen smoking on TV and cinema screens. Some claim the tobacco companies are behind it, as it encourages smoking. There is a movement to try to give an R (age restricted) rating to any film with smoking in it. Graphic images of smoking dangers - such as lungs turned filthy by tar - are pretty effective, she says, as not all literacy levels are high, and even literate people often don't read the warnings on cigarette packs. These images are hard to ignore. While they are required by law in Canada, Thailand and Brazil, for example, they are not in the US."
A number of US cities, especially in California, bar smoking outdoors, as on beaches and at train and bus stops. California also bars smoking in cars in which a child is a passenger, she says. "It would be much easier if there were federal laws, but the tobacco industry has such a powerful influence at the federal and state level - although not yet at the local level. That's why legislation has been a grassroots effort," she says.
Due to restrictions in the US, most smokers cut down and learn to space out cigarettes to tolerate withdrawal, she explains. Some people cope by using nicotine patches or chewing nicotine gum. "There is no evidence that hypnotism or acupuncture are effective over the long term; with the placebo effect, some people believe it helps them. But the popularity of these cessation techniques "just show people are looking for magic. There is no magical way out. You have to want to and work at it. For some it is harder than others; there is probably a genetic component."
Tobacco taxes are high in the US, at about $2 a pack. Israel could do a lot to raise the price of cigarettes, Rigotti advises, denying the claim often heard by the Finance Ministry that doing so would inevitably increase the incidence of tobacco smuggling from neighboring countries. When cigarettes cost more, she notes, "children are less likely to start." Smoking cessation courses should be free and easily accessible," she adds.
A few prescription drugs for quitting smoking are available, such as GlaxoSmithKline's bupropion (commercially known as Zyban) and Pfizer's varenicline (known as Chantix in most of the world and Champix in Israel and Europe). Both have side effects. Zyban apparently works on the brain's neurotransmitters to reduce craving and the effects of nicotine withdrawal, while Chantix, which also contains no nicotine, targets nicotine receptors in the brain, attaches to them and blocks nicotine from reaching them.
Another possibility is an anti-smoking vaccine. "Three or four companies are working on these, which produce an antibody too big to get through the brain-blood barrier and prevents the smoker from getting any 'enjoyment' from the nicotine in tobacco smoke. "But vaccines have to be tested carefully, especially for young people. It isn't known how long the antibodies last. In Europe, vaccines are being tested to prevent relapse in smokers who have already quit. Actual approval and sales are several years away."
But she doubts tobacco use will plunge to zero in the foreseeable future. "I'm not afraid of losing my job doing research on cessation. And if it does go to zero," she says with a smile, "I will always have my primary care practice."