Treatment of nicotine addiction should be geared to how much patients smoke and why they smoke, according to nicotine addiction specialists.

For some, that means patches, gum, nasal spray or pills, alone or in combination. For many, it also means behavioral therapy as part of a group or by phone. "All smokers are not alike," says Richard Hurt, M.D., director of the Nicotine Dependence Center at the Mayo Clinic in Rochester, Minn. "And they may need different doses depending on how they handle the nicotine." He recommends lower than average doses of nicotine replacement for smokers of fewer than 10 cigarettes a day and higher doses for those smoking more than two packs a day. "They will be severely under-replaced if you just put them on a single-dose patch," Hurt says. "More complete nicotine replacement improves withdrawal symptom relief, and it may actually improve the efficacy." Tailoring the treatment to reduce or eliminate the nicotine withdrawal is particularly crucial during the first two weeks, when a quit attempt is most likely to succeed or fail. "Effective management of the first two weeks of abstinence is essential to long-term quitting," says David Malin, Ph.D., a scientist from the University of Houston. "In the few days or the week before nicotine withdrawal syndrome goes away, a very high percentage of ex-smokers have returned to smoking. The No. 1 reason given is trying to relieve the discomforts of the withdrawal syndrome." Barriers to treatment, however, are significant. Although nicotine addiction is widely recognized as a health problem, insurance coverage of cessation services remains uncommon, but crucial to ensuring greater physician attention, according to a report from the U.S. Surgeon General called Reducing Tobacco Use. When Seattle's Group Health Cooperative launched the Free & Clear smoking cessation program, about 150 people enrolled. When the HMO scrapped all out-of-pocket costs, enrollment jumped to 4,000. "It is cost-effective and has good cost-benefit," says Tim McAffee, M.D., the program's medical director. "People who go through our program cost us less than $500 per year of life saved. Other than infant immunization, there's nothing else in medicine that is such a bargain." Another factor is the seesaw nature of smoking cessation treatment. Smokers rarely quit on the first attempt, frequently not succeeding until the third or fourth time, frustrating themselves and their physicians. "It's part of a learning process," says David Anderson, M.D., a British doctor running a general practice in Hong Kong. "If there's an unsuccessful quit attempt, it's not to be viewed as a failure. The best quit results come from people who managed to quit before for three or four months or more. The prognosis when they become motivated again is very good."

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