Chat with Michael Fiore, M.D., MPH

Dr. Fiore answered personal questions about quitting tobacco and discuss the most effective quitting strategies and techniques. Following is a transcript of the chat:

Moderator: QuitNet extends a warm welcome to Dr. Fiore and all our guests! Yesterday the Surgeon General released a new clinical guideline about quitting tobacco for doctors and patients. The guideline was developed by a panel of experts chaired by Dr. Fiore. If you'd like to submit a question for Dr. Fiore, just type it in the bottom window of your chat display and press return. We'll post and answer as many questions as time allows!

imeanit: What work is being done to develop other drugs such as Wellbutrin to assist in smoking cessation, particularly in light of some individuals' inability to tolerate Wellbutrin?

Dr. Fiore: First, I'd like to summarize that the public health service guidelines released yesterday identified five first line medications, including Buproprion (Zyban and Wellbutrin), as well as four nicotine agents. The guideline also recommends two second-line prescription medication, Nortriptyline and Clonidine. Clearly, further research on the neurochemistry of tobacco addiction has the potential to provide new pharmacological approaches to this chronic disease. I'm not aware of any that the FDA is currently considering for approval.

Laura: When I quit smoking, I become extremely angry and stressed. How can I get past this?

Dr. Fiore: First, congratulations on your willingness to keep trying even in the face of such withdrawal symptoms. In fact, your symptoms are classic for nicotine withdrawal. The good news is that today there are specific medications approved by the FDA and recommended by the new PHS guidelines that in most individuals will blunt or decrease such withdrawal symptoms.

Pam: I've studied quit rates and they seem flat despite the new pharmaceuticals. Can you explain this?

Dr. Fiore: I believe it's critically important to compare the quit rates of the public health service guideline-recommended therapies to the very low (above 5 percent) long term quit rates achieved when quitting cold turkey. Unfortunately, there still is not a magic bullet. Nothing available today will automatically transform a smoker into a nonsmoker. I believe the highest quit rates that we've observed, around 40 percent in a New England Journal of Medicine study, that combined Bupriprion, the patch, and counseling, may be as high as we get in the near future. This does mean though, that 4 out of 10 smokers can successfully quit. If this 40 percent quit rate is applied for people who try repeatedly, there is a very high likelihood that any smoker committed to quitting can do so successfully.

Susan: How do tobacco substitutes (nicotine gum, patches) fit into the guidelines?

Dr. Fiore: The guidelines specifically recommends four nicotine replacement products. It does not recommend substituting other tobacco products such as chewing tobacco or snuff as a treatment for quitting smoking. Nicotine, apart from its addictive potential, is a relatively safe agent. It is the other components of tobacco that cause illness and death.

LauraBilly: Is the counseling individual or group work such as AA?

Dr. Fiore: The counseling strategies recommended in the new guideline take advantage of a series of effective counseling strategies. These include treatment provided social support, outside of treatment social support, motivational counseling, and practical advice which is referred to as problem-solving and skills training. Some of these strategies are also components of the AA philosophy.

StephanieM: What is the latest research into depression and quitting?

Dr. Fiore: Approx. 20 percent of smokers who quit develop clinical depression. This suggests that many smokers are using tobacco to treat an underlying depression. In fact, depression upon quitting is more common in women than in men.

There is a neurochemical basis for this observation. Upon quitting, brain levels of the neurotransmitter Dopamine fall. Brain levels of Dopamine also fall when a person becomes depressed. Dopamine is also the brain chemical most associated with the experience of pleasure. Thus, it's no surprise that agents such as Buproprion are effective both to help people quit smoking and to treat depression.

Hawaiian: How about Hypnosis to quit? Can Chi Kung Meditations help quit?

Dr. Fiore: The guideline panel that prepared the PHS report systematically examined the research data on hypnosis and concluded that there is not research data to recommend this treatment. With that said, however, some individuals may benefit from such an approach and for that reason I personally never tell a patient that wants to utilize hypnosis to help quit smoking to not do so. What I do say, however, is to combine such hypnosis with treatment that we know will increase the likelihood of successful quitting.

Regarding the second modality I'm not aware of any published information and thus cannot comment on it.

Jim: What are the major differences between the old guidelines and the new guidelines?

Dr. Fiore: In fact, the new guideline is a totally new document and I would urge individuals to examine it directly, for example, by going online to www.surgeongeneral.gov or by calling 1-800-358-9295. To summarize, though, I would say that the guideline includes 3 types of new information: First, significant new information on effective components of counseling, including telephone counseling.

Second, the recommendation now of 5 medications that are effective versus 2 in 1996. Finally, the recognition of tobacco dependence as a chronic disease that warrants medical treatment and the challenge to insurers to pay for that treatment just as they pay for the treatment of other chronic diseases.

globug: After quitting for a period of four months I started smoking again. I feel that I want to quit again very badly. Why do I feel so "afraid" to put that patch on (which is what I used the first time)?

Dr. Fiore: First, the fact that you successfully quit for four months is a powerful predictor that you will successfully quit again. While I can't say why you feel the way you do, I would imagine that you recognize that quitting again will again require hard work and the unpleasant experience of withdrawing from tobacco use. The encouraging note is that for most smokers, the withdrawal syndrome is transient, lasting a few weeks to a few months, and your previous successful experience combined with this knowledge should, I hope, give you the strength to try again.

vinnytherat: How does internet support impact/rate in support of smoking cessation?

Dr. Fiore: I'm not aware of data that has evaluated the impact of the Internet. The fact, though, that 5000 people visit www.quitnet.org daily tells me that is is having a positive impact.

StephanieM: Dr. Fiore, did you ever smoke?

Dr. Fiore: No. I have however treated more than 5000 smokers who want to quit and as a result I'm acutely aware of both the powerfully addictive nature of tobacco and the enormous differences among people who smoke and want to quit.

Viviane: Should smoking cessation be approached differently for adolescents than adults?

Dr. Fiore: Unfortunately, there is little research on effective smoking strategies for adolescents. As a result, the guideline urged adolescents who smoke and want to quit to use the same strategies shown to be effective in adults. The guidelines also urges more research in this important area. Finally, adolescents report that they are as addicted as adults, arguing against the misconception that adolescents are not addicted to tobacco.

purplkoala: Has the rate of teenage smoking increased or decreased in the last few year?

Dr. Fiore: From 1990 the rate of teenage smoking increased by more than 1/3. Today, 6000 adolescents will take their first puff of tobacco smoke and 3000 adolescents will become addicted to tobacco.

hopefully: Is there new research regarding tobacco use/cessation and other addictions? (i.e., drugs & alcohol)

Dr. Fiore: We know that many addictions coexist. For example, the rate of tobacco use among current alcoholics is among the highest rates of tobacco use observed. In this group, up to 70 percent of alcoholics also smoke. This is probably associated with the common neurochemicals that are associated with addiction in general.

Moderator: Hi Dr.Fiore! Why after 9 months of being smokefree, am I suddenly having tremendous cravings?

Dr. Fiore: First, 9 months is a important amount off cigarettes. Congratulations! A couple things to consider are is whether you are in environments that prompt you to think about smoking. That is, with friends, co-workers or family members that smoke. Are you under increased stress or dealing with a particularly difficult challenge in your life? Finally, be confident that this period will pass and refrain from the temptation to have just one cigarette. It rarely ends with one cigarette. I would add one last point, if this becomes particularly difficult, you may want to consider using an immediate release form of nicotine like nicotine gum, temporarily.

vinnytherat: Should we now expect that our primary care physician will use the guidelines to support patients in quitting? How might a patient use this information to gain the support they need to successfully quit?

Dr. Fiore: Ideally, your primary care clinician will be knowledgeable enough to provide that expected support. In the absence of that, I would urge smokers who want to quit to both review the clinical practice guidelines as well as request the consumer guide entitled You Can Quit Smoking. That also is available online at www.surgeongeneral.gov or by calling 1-800-358-9295.

vinnytherat:Would it be advisable to agree to a DSM-IV diagnosis in order to qualify for medical care?

Dr. Fiore: There is already a DSM-IV specific diagnostic code for tobacco dependence. Additionally, there is an addendum in the guideline that provides guidance to clinicians in using appropriate diagnostic codes for billing.

Teri: Was there any particular treatment plan that has been most successful in your practice, such as a combination of therapies, counseling, use NRTs, etc.? I realize every smoker is different, but has there been some combination of treatments that has worked more often than others?

Dr. Fiore: Every smoker is different. It would particularly depend on the degree of nicotine dependence. For heavy smokers, we are increasingly using combination pharmacotherapy with counseling.

In terms of combination pharmacotherapy, clinically we have found it particularly helpful to combine Zyban with an immediate release form of nicotine, such as the nicotine inhaler of gum. I want to emphasize, however, that these combination therapies are what we have developed clinically and have not yet been systematically examined and are not part of the guideline released yesterday.

Richard: Do you recommend that tobacco use be addressed in drug rehabs?

Dr. Fiore: The guideline recommends that tobacco use be addressed every time a patient visits a health care setting. When a person enters treatment for another drug dependency, there are two approaches. One is to attack both dependencies simultaneously and the second is to first address the illicit drug or alcohol dependency and then tobacco. What has been shown to NOT be effective is to attempt tobacco cessation first while still abusing alcohol or an illicit drug.

StephanieM: Dr. Fiore, because smoking is now a chronic disease will insurance companies be required to pay for therapy?

Dr. Fiore: No. Private insurers are not mandated in most instances to cover one treatment or another. As consumers, however, we can influence insurance coverage by recommending it to insurers and our legislators.

ElainevH: I gained 30+ lbs and am having a terrible time trying to lose it—am going vegan.

Dr. Fiore: Unfortunately, most people gain some weight upon quitting, on avg. 5-10 lbs. However, 20 percent of people who quit gain more than 20 lbs. The current recommendations are to get smoking fully under control, which it sounds as though you have done, then attack the weight gain with a vengeance. Increasing exercise in particular can help to offset the changes in our biological set points that occur when a person quits smoking.

Shel: Could the money from the state tobacco settlements be put toward insurance coverage for cessation treatments?

Dr. Fiore: Certainly. The problem is, however, that these treatments are expensive and in my view, the costs of such treatments, given that it is for a chronic disease, should most appropriately be covered by insurers. This, then allows funds from the tobacco settlement to be used for more public health and population-based approaches to preventing kids from starting to smoke and helping adults to consider quitting.

Dlily: Should smokers and ex-smokers insist on a CAT scan for early detection? (Multiple people have asked this question)

Dr. Fiore: I know that these questions results from some recent preliminary data on a new imaging technique to identify very small lung cancers. I would urge people to first focus on removing the carcinogen from their lives because even with the new techniques, all tumors cannot be identified and lung cancer in particular, a cancer caused almost exclusively by tobacco use, usually kills.

jean_oliver: Have you found that some smokers need to use higher dosages of the patch such as 42 to 53? why? success stats and risks?

Dr. Fiore: There have been about 3 studies that have examined higher dose nicotine approaches. The largest of these studies published in the Journal of the American Medical Association found that there was no benefit. With that said, however, in the clinical setting, we sometimes use higher doses when a smoker report continued significant withdrawal symptoms on a standard dose (21mg) The only risk that I am aware of is the potential for nicotine toxicity which usually manifests itself as acute toxicity, specifically nausea and vomiting. If a smoker is smoking 2 packs or more per day, they have indicated that they can tolerate higher doses of nicotine. However, if an individual has significant coronary artery disease, I might be more reluctant to use higher doses of nicotine replacement.

Tom: I'm a heart patient, and since I've quit I've noticed my symptoms have reduced dramatically. Any research results in this area on survival, quality of life, etc?

Dr. Fiore: First, congratulations on successfully quitting and removing the leading risk to your health from your life. There is powerful research that shows that your cardiovascular risk declines dramatically upon quitting. For example, your risk of a heart attack declines 50 percent within one year of quitting.

Jacob Plummer: Dr. Fiore, I stopped smoking 5 days ago, and this is the longest I have gone in the past several years (before, the most I would stop is for a full day) My question is, if I decide to have an occasional cigarette, what is my risk for entire relapse?

Dr. Fiore: Virtually 100 percent. I would urge you in the strongest way to maintain total abstinence as there are very rare smokers who are able to go from drug dependency to occasional or casual smoking.

candlefly: You suggested that fitnquit chew the nicotine gum in order to suppress her cravings if they got to be really bad. She's been quit for 9 months. Wouldn't that be "adding" nicotine to her system? I'm confused.

Dr. Fiore: I apologize if my answer was not clear. In fact I suggested that only as a last resort, with the alternative being returning to smoking. You're correct—it's always best to stay free of medication including nicotine. However, if the alternative to smoking is continuing to use nicotine indefinitely, I believe that this is a smart health choice.

Susan: Does one's cardiovascular risk still decline as dramatically with the use of nicotine replacement therapies?

Dr. Fiore: Yes.

vinnytherat: Do you think that the Human Genome project breakthrough will eventually be of benefit in aiding people in smoking cessation/ genetic indicators of tendencies towards addiction, etc?

Dr. Fiore: Possibly. However, I think that it will be years, to decades, before such helpful information is available. Thus, I urge those who currently smoke to seize the new information from the Public Health Service Guideline in successfully quitting now.

Janet: Is nicotine replacement an option that doctors will be recommending to their patients who are pregnant?

Dr. Fiore: The guideline addresses this issue specifically. The recommendation is for pregnant women to first try to quit without medication. But, if this fails, the woman should discuss the potential risks of medications, versus the known risks of continued smoking, and come to an informed decision with her doctor.

Moderator: This will be our last question folks, thanks for all the excellent questions.

winstarr: OK, I'm not on the patch, but what you're saying indicates that some of my problems, depression, weight gain, foggy mental ability might be better if I used some form of nicotine and that this might increase my chances of continued quit?

Dr. Fiore: Yes. I would definitely consider that as an option. What you didn't indicate is how long it's been since your quit date. If you've been off nicotine for a week or more, you may want to use a lower dose of nicotine if you try this method in order to prevent the nausea and vomiting that sometimes occurs with higher doses of nicotine.

winstarr: Four months.

Dr. Fiore: If it's four months, I would not use a patch but consider an immediate release form of nicotine such as the inhaler or gum. Probably my leading recommendation after 4 months would be Zyban.

Moderator: I'd like to thank Dr. Fiore for joining us this morning to discuss quitting smoking and the latest recommendations from the US Government. Good bye all!

Internet Citation:

Live Chat with Michael Fiore, M.D., MPH Adapted from Quitnet (http://www.quitnet.org). June 2000. U.S. Public Health Service. http://www.surgeongeneral.gov/tobacco/fiore.htm

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