Combining nicotine replacements with behavior modification raises quit rates

Experts differ on best approach

For company benefits managers anxious to help their smoking employees kick the habit, the new over-the-counter availability of nicotine patches and other smoking cessation products may seem like a dream come true. But wellness coordinators should take note: Stop-smoking tools are only as effective as the behavior modification training that should accompany them, some experts say.

"You need to have a two-pronged approach," insists Don R. Powell, PhD, president of the American Institute for Preventive Medicine in Farmington Hills, MI. "The behavioral modification program is necessary to deal with the ‘habit’ component of smoking."

Observers agree that two weapons are better than one. "In any setting, the nicotine patch pretty much doubles your success rate," asserts Robert Shipley, PhD, director of the Duke Medical Center Stop Smoking program in Durham, NC, and president of QuitSmart Stop Smoking Resources.

(Editor’s note: Nicotine patch manufacturers also recognize that the reverse is true: The effectiveness of nicotine replacement therapy is enhanced by behavior modification. Each company makes available an education program to be used in conjunction with its patch.)

Weighing the options

While there is general agreement that nicotine replacement therapy can improve quit rates, there are several options available to health promotion professionals. Among the most popular are the nicotine patches: Nicotrol, from McNeil Consumer Products, a Fort Washington, PA-based Johnson & Johnson Company and NicoDerm CQ, from SmithKline Beecham Consumer Healthcare in Pittsburgh. SmithKline Beecham also produces Nicorette, a nicotine gum, and Nicotrol also is available in a nasal spray. Recently, Glaxo Wellcome of Research Triangle Park, NC, received approval from the U.S. Food and Drug Administration to market Zyban, an anti-depressant for smoking cessation.

"The patches will slowly release nicotine into the body," explains Powell. "You don’t get the same high, but it’s not as low as if you were not smoking at all. With the gum, you can regulate the ‘high’ by how quickly you chew it." All of them, he notes, help satisfy the craving caused by nicotine addiction, while behavior modification addresses the psychological habit of smoking.

But not all nicotine replacements are created equal, asserts Shipley. "The gum is a lot harder for a person to use correctly," he explains. "With a patch, all you have to do is remember to put it on. The advantage of a spray is you can get a ‘hit’ pretty quickly, while the patch takes hours to get into the bloodstream. The disadvantage people worry about is that the spray itself may be addictive. I’ve watched people use the stuff. They spray it, it burns their nostrils, they sneeze, they hack and they cough, and then they say, ‘Can I have some more?’"

Shipley explains that patches are the most logical nicotine replacement therapy for his program because they meet important requirements. "Every treatment component in QuitSmart has to meet three criteria: They have to help people quit; they must be cost-effective and not take up too much of an employee’s time or a health professional’s time; and they have to be ‘sexy’ enough to draw people in. The patch meets all those criteria. It’s sexy, it doesn’t take a lot of time, and it works." (See the American Cancer Society fact sheet on nicotine patch risks, inserted in this issue.)

Shipley says it’s important for employees to have different dosage options. "We have found the most effective dosage is determined by the number of cigarettes an individual used to smoke," he explains. "For example, if an employee smoked 25 cigarettes or more a day, they’d need the strongest dose. Under managed care, this approach can help save money."

Smoking cessation experts differ on whether to simply give employees a choice when it comes to nicotine replacement or to give them a strong incentive to use the replacements in conjunction with behavior modification.

"We recommend it, but we don’t require it," says Powell. "We’ve not seen where using patches or gum has raised [quit rates] that much. Physiological therapy needs behavior modification more than the other way around."

Neal Sofian, MPH, vice president of program and business development with Lexant (a new business unit of the St. Louis-based Monsanto Company and an affiliate of Monsanto Health Solutions), has concerns as well. His fear is that since the nicotine replacement products have been made available over the counter, employees will choose the "easy way" and simply use the products and avoid the education programs.

Consumers don’t always read the inserts

"The problem is that the pharmaceutical companies have flipped [programming] on its head," he complains. "They say, ‘Here’s our product, and by the way, here’s a pamphlet to read. They’ll say to the managed care provider that they don’t really need to worry about providing a behavioral change program; if they just purchase the pharmaceutical, the manufacturer will take care of the problem."

(The widespread availability of these aids over the counter also can hurt smoking cessation participation rates. See story, p. 86.)

In other words, says Sofian, you should let employees know that if they want the nicotine replacement products, they can get them for free if they sign up for the smoking cessation program. "You need to remove as many barriers [to quitting] as possible," he explains. "If an employee is assessed as appropriate [for nicotine replacement], intervention should be free, too. Tell them that it’s essentially pre-authorized."

Wellness professionals can be instrumental in helping to build participation levels, says Sofian. "They should let employees know that the company is providing a comprehensive smoking cessation course, which will include nicotine replacement therapy. They should also tell employees that if they sign up, and if it is deemed appropriate for them, the company will pay for it," he advises.

Not one-size-fits-all

Sofian is quick to point out that nicotine replacement therapy may not be right for every employee and that programming should be customized according to individual needs.

"There are multiple levels of behavior change we can address," he says. "These include tailored print materials, telephonic support, face to face or group counseling, perhaps along with pharmaceutical intervention."

An employee’s history can help determine the most appropriate intervention, Sofian suggests. "A lot can be learned by previous attempts to quit, an employee’s sense of self-efficacy (the belief they can quit without nicotine replacement therapy), and the level of addiction," he says. "If we can get them to change without the added cost [of pharmaceuticals], so much the better."

Whatever approach you take, experts agree, none will work if the participant is not ready to make a change. "We have developed a number of aids, but it comes down to commitment and resolve," adds Ron Todd, MS, ED, director of tobacco control for the American Cancer Society national office in Atlanta. (See the insert, in this issue, on alternative quit smoking methods.)