Now appearing at a mall near you is "Blue," the latest electronic cigarette, a smokeless nicotine delivery device. Blue consists of a rechargeable battery, nicotine gel vaporizing atomizer, a cartridge, and a crystal that shines bright blue when the user inhales.

Blue "can mimic the act of smoking while eliminating the use of tobacco, tar and an open flame," touts its manufacturer.

Blue is a potent reminder of an inconvenient truth: While it may be loathsome, the cigarette is a marvel of chemical engineering, a far more effective and appealing nicotine delivery device than patches, gums, lozenges or nasal sprays.

"A cigarette delivers nicotine to the brain's receptors in seven seconds," explained Virginia Reichert, NP, a veteran smoking cessation counselor. "Nicotine patches require 20 minutes or more."   

Nicotine stimulates receptors in the hippocampus and thalamus to chemically induce pleasure and a sense of well-being, especially through the release of dopamine. "I tell smokers: Your brain chemistry has been altered, and we need to get it back," said Reichert, former director of the Center for Tobacco Control at North Shore-Long Island Jewish Health system, Great Neck, N.Y.

Compare that to dizziness, constipation, weight gain, and other negatives associated with quitting. "Who would quit on their own?" Reichert asked. Few can. But an estimated one-third of smokers try to quit at least once a year with professional help now that Medicare reimburses for two quit attempts per year. That number is expected to grow since a $.62 per pack increase in the tax on cigarettes went effect April 1. Calls to quit smoking hotlines have surged across the country.

Addiction severity increasing

Even with the added financial motivation to quit, unhooking smokers may get even tougher in the years ahead, says one expert with 25 years in the field.

David Sachs, MD, conducted a survey last year that suggests nicotine dependence severity increased 12 percent between 1989 and 2006, while the proportion of people classified as highly nicotine dependent increased 32 percent.

Why? Simple demographics. By now, many if not most people with less severe nicotine dependence have quit, leaving smoking cessation classes dominated by hardcore, harder-to-treat smokers, explained Dr. Sachs, a pulmonologist at the Palo Alto Center for Pulmonary Disease Prevention, Palo Alto, Calif.

Severely addicted nicotine users may not respond to therapies that have become standard in the world of smoking cessation for 15 years or more, Dr. Sachs stressed. The watchword today is individualized treatment. Counselors may need to try various combinations of cessation aids at various doses.

Reichert emphasizes to smokers that nicotine is not carcinogenic; it's merely the stimulant that hooks the smoker. "You must stress this to patients and dispel that myth to get them into nicotine replacement therapy," she said. 

Reichert is also not above trying to scare smokers straight. She enlightens her clients that smoking increases their risk of infertility and that among the 4,000 chemicals they ingest from cigarettes are rat poison, arsenic, ammonia, and formaldehyde. In fact, many cessation programs use carbon monoxide breath tests or pulse co-oximetry to measure the extent of carbon monoxide poisoning from smoking and show the results to would-be quitters to motivate them.

 "When the carboxyhemoglobin is 10 percent, it's easy to tell a patient that 10 percent of his or her blood is poisoned and unable to carry oxygen," said Sridhar P. Reddy, MD, MPH, FCCP, St. Clair Pulmonary and Critical Care, St. Clair, Mich. "By doing this, we catch the patient's attention right away and can begin smoking cessation counseling."

CO monitoring works even better as positive reinforcement when smokers do taper off cigarettes and see their CO counts dropping. And there's a juicy carrot you can dangle in front of smokers, Reichert added: Quitting is associated with a 10-year increase in life expectancy.

 Michael Gibbons can be reached at mgibbons@advanceweb.com.