By Doug Brunk, San Diego Bureau

The day Dr. Robert L. Kistner turned his back on cigarette smoking was Jan. 1, 1982, a behavior he began as a 14-year-old growing up in St. Louis.

“I smoked through high school, college, and through medical school and the Air Force,” said Dr. Kistner, now a vascular surgeon who practices in Honolulu. “As I got into practice in the 1960s, I was still smoking more and more.”

For him, taking drags from a cigarette “was a very enjoyable thing to do. It was relaxing. I smoked long and heavily. I really hungered for cigarettes.”

When the first Surgeon General's Report on Smoking and Health came out in 1964, “it became obvious that there was something bad about the stuff,” Dr. Kistner said. “But the horrible extent of it and its far-reaching effects that we now know really well were just becoming fact. Ultimately, I was faced with [the notion that], 'this is something I really enjoy but it's not pleasing to other people and it's not good for me.' It's something I had to get rid of because I began to preach to people that they shouldn't be smoking and then I'd be reaching for a cigarette. It was incompatible.”

His two young daughters also gave him flak about his habit. “Fortunately, they did not take up smoking,” he said. “They were turned off by the smell of it and the dirty ashtrays. My wife, on the other hand, enjoyed smoking, but never was addicted. She could take it or leave it.”

Dr. Kistner gradually weaned himself from cigarette use in the late 1970s. First, he chose to not smoke during his workday when he was around patients. Next, he decided he wouldn't smoke at work or at home. Then, he lit up only when he left Hawaii on business travel.

In the end, he appointed Jan. 1, 1982, as his cold turkey quit date. He has not smoked since.

“For some reason, my mind was made up enough that I didn't smoke and it didn't make any difference,” he said. “It was a conviction. From that point on, for 6 months or 6 years, I'd walk around where somebody was smoking and just smell it. But I had no desire to pick one up and take a puff.”

He went on to note that physicians who currently smoke are “not only hurting themselves, but they're hurting their environment—not just by smoking but by giving the example of smoking. It's very much against the [medical] profession. I'm not a student of the physiology of addiction, but as in many things [the urge to smoke] is controllable by a very strong intellectual conviction, [the notion that] 'this is something I want to do.'”

From Basketball to Cigarettes

Smoking was commonplace in Dr. Richard D. Hurt's home town of Murray, Ky., in the early 1960s. He picked up smoking after dropping his basketball scholarship at Murray State University.

“After my first year of college, it was obvious that I was going to have to do something else to make a living besides play basketball, because I had a good shot, but I was a little bit slow and couldn't jump very high,” recalled Dr. Hurt, an internist who directs the nicotine dependence center at the Mayo Clinic, Rochester, Minn. “That's not a good combination. So I dropped my scholarship, joined a fraternity, and started drinking and smoking like what I thought everyone else did at the time.”

He described himself as a heavy smoker from the get-go, puffing three packs a day of Marlboros and Belairs through the rest of college, medical school, an internship, 2 years in the Army, and his residency.

During his Army assignment, he discovered that if you inhale tobacco through a pipe, “you really get a hit to your brain,” said Dr. Hurt, who is also a professor of medicine at Mayo Clinic College of Medicine. “The pH of pipe tobacco is 8, which means that half of the nicotine is in a freebase form. I smoked a pipe for awhile until I read an article from a Scandinavian study [that] said that cigarette smokers who switch to pipes or cigars end up smoking them like they used to smoke their cigarettes. So they have worse outcomes. I went back to smoking cigarettes. I didn't want to have a worse outcome.”

Like many other smokers, Dr. Hurt spent years trying to quit; sometimes for as little as 30 minutes, other times for as long as a week.

One day his wife, who also smoked, phoned him at work to tell him she had signed them up to attend a smokers' clinic at Rochester Methodist Hospital. “Had it not been for her calling me that day, I don't think I would have ever stopped smoking,” he said. “More than that, I would probably not be here today. She was the motivation.”

The group support there, “made it so I was able to focus attention on me and what I was doing,” Dr. Hurt said. “There was no pharmacotherapy at that time. I was focusing my energy and attention in a way I had never done before.”

For him, the hardest part was dealing with the constant urges to smoke. “I took it in time increments that were manageable,” he said. “I knew I could stop smoking for an hour, but I wasn't sure about 2 hours.”

After a group session on Nov. 22, 1975, he drove home and quit smoking for good.

“There's an old adage in the alcoholism treatment world: Take it one day at a time,” he said. “Some people take it in smaller increments than that. I certainly did [in] the beginning. The urges to smoke can be very powerful and intense, but they don't last very long. Finally figuring that out was helpful.”

He returned to the smokers' clinic, this time as a counselor for the group sessions. This role helped to “focus attention on preventing relapse and maintaining my abstinence from smoking,” he said.

Today, when he counsels smokers at Mayo's nicotine dependence center, Dr. Hurt points out that smoking “brings an end-of-life experience that none of us want. The end-of-life experience all of us want is to live to be 85 or 90 and die in our sleep after having had a good meal, a couple of drinks, and sex,” he said.

“None of us want to die in a hospital, in an ICU, or in a nursing home with a protracted end of life. The message is that nonsmokers and ex-smokers have compressed morbidity. That means that nonsmokers live longer and die shorter. Smokers live shorter and die longer. All of us have had firsthand experience with that,” Dr. Hurt said.

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Dr. Hurt claims that if it wasn't for his wife Mary, he may never have quit (both are pictured above with their grandkids.) Courtesy Dr. Richard D. Hurt

For Many, Dependence Runs Deep

If Dr. Hurt could speak to the estimated 6%–7% of physicians in America who currently smoke, he'd start by asking: “What can we do to help you?”

Physicians who smoke “should be treated, because they obviously have a degree of tobacco dependence that a casual smoker does not have,” declared Dr. Hurt, who smoked heavily for 13 years before quitting. “If you could measure the degree of dependence in physicians, I bet it would be much higher than the run-of-the-mill smoker's.”

He also noted that most physician smokers will need help beyond that of traditional treatments such as a nicotine patch, nicotine lozenges, or bupropion. “I think they need to see someone who specializes in treating tobacco dependence,” said Dr. Hurt. “They may need to be in a place where they have very specialized treatment, even to the point where they come into a residential program and spend 8 days in intensive treatment. That sounds like a huge commitment in order to stop smoking, but that's what a lot of people need.”

Physicians who use smoking cessation medications properly “should be able to minimize the cravings, urges, and disruption to their practice,” he said. “But it takes some creativity. So if you have a smoker who's smoking a pack and a half or two packs a day, [you may need to] use more than one nicotine patch at a time or use more than just one medication at a time.”

Ultimately, efficacy depends on the intensity of the treatment. “If you have counseling by a physician or by a tobacco treatment specialist and use proven effective medications, you can expect 20%–25% 1-year stop rates,” Dr. Hurt said. “If you go into a residential treatment program, the outcome is closer to 50% at 1 year. We can maximize the chances of stopping smoking by bringing the forces to bear.”