Smoking, like baseball, lends itself well to numbers and statistics. From the 20 cigarettes in a pack to the 45.3 million adults the Centers for Disease Control and Prevention say smoke in America to the 443,000 annual preventable deaths all that puffing causes, it's an addiction that warrants numeration.

One of the most important numbers associated with cigarette smoking is also one of the smallest: seven.

"It takes approximately seven times for a smoker to quit smoking," says Beena Thomas, vice president of health and wellness for Optum Health and a tobacco-cessation expert.

It's a daunting statistic, and one echoed by tobacco experts of all varieties. With a relapse rate that high, they say, smokers need all the help they can get trying to quit.

Smoking's addictive nature makes the habit notoriously hard to kick completely - according to CDC research, nicotine "may be as addictive as heroin, cocaine or alcohol." It's a psychological addiction as well as a physical one - a collection of habits, fears and mental obstacles - and quitting for good can be a long road in need of a guide, Thomas says.

If, she says, an employee's true desire to quit is "coupled with programs that they can get engaged in, it increases that smoker's chance of really quitting. I always talk about how smoking is a learned behavior; individuals learn how to smoke, so quitting smoking has to be a learned behavior. The more preparation time you put into it, the more likely you'll be successful."

A smoker's need for a support network in quitting is exactly why workplace smoking-cessation programs have such a good chance to be successful, as people spend most of their waking life in the office.

"The ability to form communities and partnerships within the organization to say, 'I'm dealing with this; how did you deal with this?' has been very successful," Thomas says. "So, especially when you have former smokers, and there's almost this buddy system in a work environment, smokers then feel like there's someone who understands them in that effort."


Solving one problem, creating another?

"It's not that a smoker can't quit. Every smoker can quit; it certainly is possible," Thomas says, but adds that smokers trying to kick the habit and the employers who support them "must be aware of ... withdrawal symptoms like disturbed sleep, intense cravings, or perhaps anger and hostility."

One of the most common withdrawal symptoms is weight gain. The increased appetite associated with quitting tobacco steps on the toes of fighting obesity, the biggest wellness initiative in the country right now.

But that doesn't mean smoking is taking a backseat. Amy McAllister, director of product management at Provant Health Solutions and another tobacco-cessation expert, says business is booming as employers demand smoke-free outdoor spaces, and, sometimes, workforces. Employer efforts to combat obesity, she says, have not eclipsed the fight against America's deadly smoking habit.

"In the past two years, there has been an increase in clients that we're working with [on combatting tobacco use]," McAllister says.

America's weight issues might be the primary driver of medical costs, she acknowledges, but health is a total-body issue, and plenty of employers are forcing the issue.

"So many companies are becoming 100% smoke-free," McAllister says, "so they're trying to provide their employees with an option to be smoke-free."


Carrots and sticks

McAllister says more companies are testing for tobacco and using both carrots and sticks, "incenting the tobacco program." One of her clients implemented a $350 surcharge for employees who use tobacco, for example.

"Participation rates are higher with an incentive program, there's no question about that," she says. "Everyone knows that they have to stop, but they are much more apt to participate when there is an incentive."

Provant itself is not so stringent as to demand employees be smoke-free. Tobacco reduction might be more accurate than tobacco cessation, at least as a stop-gap, and any decrease is, of course, good news.

"Success is not only when people quit - obviously that's our ultimate goal - but we also focus on tapering down," McAllister says. "So if someone starts a program at 20 cigarettes day, and they go down to 10 cigarettes a day, then that is successful because the more they taper, the more they get close to quitting."

Getting someone to exercise, McAllister says, is a good way to combine the goals of weight-loss and smoking cessation; someone who runs every day isn't likely to polish off a couple of packs of Marlboros as well. It's also a good way to replace an unhealthy hobby with a healthy one.

One of the most effective ways to quit smoking is to tether it to some other major shift.

"If it works with a life change such as having a baby, getting married, changing your job, moving to a new house, [that's] very significant, but you can make those changes on a much smaller level," McAllister says. "So, for example, if you get up every morning and the first thing you do is have a cup of coffee and a cigarette, our recommendation is, don't have that cup of coffee. Try to break the habit you have associated with tobacco.

"Another recommendation for people who buy a new car is never to smoke in the new car. If you have a cigarette when you drive to work, change the way you drive to work."


Emotional needs

McAllister and Thomas both think employers who want to reduce their smoking rates need to address the emotional and mental needs of their smokers. With the ominous seven-times-to-really-quit average looming over anti-smoking efforts, health plan providers should use every tool at their disposal to try to bring that number down.

"Quitting involves really reducing that physical dependence on nicotine, as well as the opportunity to change behavior so one is able to sort of break that psychological reinforcement that results from being addicted to the use of tobacco," Thomas says. "People say, 'I just can't quit smoking because I know I'll gain weight' or 'I know my appetite will increase.' It is so important that the individual realize how to combat those issues.

"How do you deal with intense cravings? How do you deal with being irritable? What are those coping mechanisms that one can learn to deal with the actual withdrawal of nicotine? Those are the individuals that will actually stand a good chance of quitting."

McAllister agrees, saying, "We recommend that participants try every approach possible," be it prescription medication, group sessions or work-sponsored smoke-outs.

"Studies indicate that people have the most success when people use multiple methods to stop smoking," she says.


Rise in use of other tobacco formsSharp increases in total adult consumption of pipe tobacco (used for roll-your-own cigarettes) and cigarette-like cigars since 2008 have offset declines in total cigarette consumption, according to a recent report from the Centers for Disease Control and Prevention. Although total cigarette consumption continued an 11-year downward trend with a 2.5% decline from 2010 to 2011, dramatic increases in use of non-cigarette smoked tobacco products have slowed the long decline in overall consumption of smoked tobacco products.

From 2000 to 2011, the largest increases were in consumption of pipe tobacco (482%) and large cigars (233%). According to the CDC, the increase in cigars was due largely to tobacco manufacturers adding weight to many small cigars so they can be classified as large cigars and avoid higher taxes and regulation, while at the same time retaining a size and shape very similar to cigarettes.

According to the report, total consumption of all smoked tobacco products (including cigarettes, roll-your-own tobacco, pipe tobacco and cigars) declined by 27.5% between 2000 and 2011. However, decline was minimal (0.8%) between 2010 and 2011. Despite the overall decline, the consumption of non-cigarette smoked tobacco products increased by 123%.

"The rise in cigar smoking, which other studies show is a growing problem among youth and young adults, is cause for alarm," said Tim McAfee, director of CDC's Office on Smoking and Health. "The Surgeon General's Report released this past March shows that getting young people to either quit smoking or never start smoking is the key to ending the tobacco epidemic, because 99% of all smokers start before they're 26-years-old."

The study, Consumption of Cigarettes and Combustible Tobacco-United States, 2000-2011, uses Treasury Department data to calculate consumption for all forms of smoked tobacco products.

The report explains there is a disparity between consumption of cigarettes and other forms of smoked tobacco because the federal excise tax on pipe tobacco and roll-your-own tobacco is lower than cigarettes. The difference led to a dramatic increase in the sale of pipe tobacco used to make roll-your-own cigarettes, a lower-priced alternative to manufactured cigarettes.

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