BY SHARI COHEN

It's not a ranking to inspire pride, but Michigan is fourth in the nation for its number of smokers -- 27.4 percent of the state's population. This compares to a national rate of 22.9 percent, according to the Centers for Disease Control.

"Smoking is the largest cause of death and disease that is preventable. Between one-third and one-half of all smokers die of a smoking-related cause," says Leslie Schuh, PhD, assistant professor of psychiatry and behavioral neurosciences and director of the nicotine dependence programs at the Wayne State University School of Medicine.

Dr. Schuh says that the national rate of smoking has stayed about the same since the mid-1990s. "Forty percent was the peak, and male smoking was greater than 50 percent in the mid-60s, before the first Surgeon General's report came out and people became aware of the health risks of smoking," according to Dr. Schuh.

Dr. Schuh demonstrates some of the tools people typically use to help them quit smoking.

Reducing Michigan's high smoking rate will require aggressive prevention and cessation measures. The WSU School of Medicine, in conjunction with the Barbara Ann Karmanos Cancer Institute, is involved in research for both kinds of programs. Even though health education programs have been effective in communicating the consequences of smoking, and smoke-free work places make it more difficult to smoke, quitting the habit is difficult for most smokers.

"The average is seven quit attempts and only five percent of smokers are able to quit during a 'cold turkey' attempt the first time they try," Dr. Schuh said. Even serious health problems do not necessarily mean the end of smoking. She notes that only 50 percent of patients are able to quit without special assistance after a heart attack or loss of a lung. "Given the strong motivation this must be to quit smoking, it illustrates how difficult a task it is since 50 percent continue to smoke," she said. Nicotine is a mild stimulant and individuals differ in their ability to metabolize it.

The use of nicotine replacement therapy, such as a nicotine patch, gum, nasal spray or inhaler greatly increases the chances of successfully quitting. Research demonstrates that smokers who wear a nicotine patch while trying to quit experience less intense withdrawal symptoms than those with a placebo patch, according to Dr. Schuh.

She is currently conducting clinical trials to test fluoxetine, an anti-depressive medicine, in conjunction with a nicotine patch and group therapy as coordinated tools for smoking cessation. Fluoxetine, (trade name: Prozac), is "very safe and could help with weight gain and the depressed mood that occurs with smoking cessation," Dr. Schuh explained.

The four-year fluoxetine study will have 225 participants in a 14-week smoking cessation program with follow-up at three, six and 12-month intervals. Participants, who must be 18 or over, undergo a medical and psychological screening. They are questioned about their smoking history and attempts to quit. In addition, carbon monoxide levels in their breath are measured to determine how much smoke they are inhaling.

Once accepted into the program, they receive either fluoxetine at one of two dosage levels, or a placebo for four weeks before the official smoking "quit" date. The medication, which takes three to four weeks to become effective, is being given in advance to find out whether pre-treatment facilitates the smoke cessation process.

Participants begin weekly cognitive behavioral group therapy two weeks before they quit smoking and receive a nicotine patch on the day they quit smoking. The nicotine replacement therapy continues for 10 weeks and the therapy groups meet weekly for six weeks.

The groups are led by facilitators who have been trained by Dr. Karen Downey, director of clinical research for substance abuse in the department of psychiatry and behavioral neurosciences. The sessions provide group support for those trying to quit smoking and help them develop alternative behaviors for some of the situations when they would typically have a cigarette. The groups also discuss how to cope with likely relapse situations.

Dr. Schuh believes that the counseling component "definitely increases" the likelihood of successfully quitting. As a multi-factoral program, "I don't think there is anything better in the state," she says. According to Dr. Schuh, for those in the program one week after the official "quit date," 50 percent will be successful in giving up cigarettes. However, not all participants successfully complete the program the first time and they are permitted to participate in one of the other studies or clinics to try again.

This smoking cessation project is based at UPC's Jefferson Avenue Research Clinic in Detroit. With a combined medical-group therapy approach, Dr. Schuh says, "We're going to be able to help more folks. We're hoping to expand to other locations." The National Institute on Drug Abuse funds the current fluoxetine program. 
Dr. Schuh soon expects to be involved in laboratory studies of nicotine craving with the goal of learning more about how to help smokers quit the habit permanently. Wayne State researchers will test verbal scripts with a range of positive, neutral and negative situations which induce cigarette craving. They will measure regional brain activity using either functional MRI or PET scans. "We're interested in looking at craving systematically and developing models, which will allow us to test new medications and behavioral therapies," said Dr. Schuh.

Prior to joining the WSU School of Medicine faculty, Dr. Schuh was a post-doctoral fellow at the Addiction Research Center of the National Institute on Drug Abuse. "My post-doc was with Jack Henningfield, who is one of the world's foremost experts on nicotine dependence. I've always been interested in the effects of drugs on behavior, but my interest in nicotine grew as I was able to work with Jack," said Dr. Schuh. Her husband, Kory Schuh, PhD, is also an assistant professor in WSU's department of psychiatry and behavioral neurosciences.

In addition to the fluoxetine research, a number of studies will investigate some of the potential benefits of smoking cessation, such as a reduction in oxidative DNA damage, possibly a factor in cancer development. Another research project will analyze various aspects of the voices of individuals before and after completion of smoking cessation programs. The idea behind this is to develop information about positive voice changes that may motivate smokers to quit without relapse. 

Finally, Dr. Schuh has opened a smoking clinic where she applies state-of-the-art techniques to help smokers who have tried unsuccessfully to quit in the past.

The Karmanos Cancer Institute has a stated goal of reducing smoking by five percent in southeast Michigan by 2000. According to Gloria Heppner, PhD, deputy director of Karmanos, "Smoking is going down in some groups, but it's hard to document." Karmanos staff are reviewing state tax revenues by county to track tobacco tax receipts as one way of evaluating smoking trends. Dr. Heppner notes one group in which smoking is on the increase--teenage girls who believe that smoking keeps their weight down, which is very important to them.

The Karmanos Cancer Institute conducts a state-funded smoking prevention program, Hazards of Tobacco (HOT), which is targeted to sixth graders and junior high school students. Evaluations indicate that the program has been quite effective in discouraging the young people who stated initially that they expected to smoke from taking up the habit.

Dr. Schuh expects to be involved in an effort to recruit adult participants for smoking cessation programs through communication with students participating in the HOT program. Students will receive materials for their parents with the goal of identifying smokers and encouraging them to join smoking cessation programs. Dr. John Hopper, assistant professor of psychiatry and behavioral neurosciences, leads this project.

According to Dr. Heppner, such collaborative efforts are likely to become more frequent as a result of WSU's Smoking and Illness Interdisciplinary Research Initiative. This three-year program, funded through a grant from WSU, will help consolidate all of the smoking-related research being conducted at Wayne State and Karmanos.

Ada Jacox, PhD, is director of the initiative and associate dean for research at the WSU College of Nursing. "The goal is to facilitate information sharing among all of the researchers involved in smoking-related studies at Wayne State, so we can further our knowledge of smoking behavior and ultimately reduce the number of people who smoke," said Dr. Jacox.