Nina Ball regularly walks by a row of smokers outside the charter school in North Philadelphia where she helps youths find jobs and get into college. A year ago, she might have bummed a cigarette there.
But today, after a series of group counseling and fitness sessions at a local health clinic, she hopes she has replaced her addiction to nicotine with another obsession: a drive to write and perform poetry.
"When I'm keeping busy with things I love, I feel less of a need to smoke," said Ball, who ditched her Marlboro Menthol 100s 10 months ago.
As Ball learned, the methods to stop smoking are growing. A few programs offer group counseling and fitness together -- to counter fears of weight gain and encourage overall health -- along with nicotine replacement products and drugs. Most sessions are free, courtesy of the money that tobacco firms pay yearly to states to cover smokers' health-related costs.
Insurers also may cover some prescription drugs for those enrolled in a state-sponsored cessation program.
Hospitals, in addition, are pushing smoking cessation to their patients. Studies suggest that they are likelier to quit when the health risks are high.
Each year about 443,000 people die from smoking nationwide.
The habit, the nation's leading cause of preventable death and disability, remains surprisingly persistent.
Twenty-seven percent of adult Philadelphians smoke "every day or some days," according to a survey by the Public Health Management Corp.
About 18 percent of Pennsylvania teens smoke, and 18,400 children under age 18 start smoking every year.
In New Jersey, the rate for adult smokers -- 14.8 percent _ is lower than in Pennsylvania, experts say, in part because the Garden State has the nation's third-highest excise tax on cigarettes -- $2.70 per pack -- compared with Pennsylvania's $1.35 a pack. New Jersey's tax helps fund smoking cessation classes.
Many programs in the city are based on the state Health Department's cessation curriculum, "Quit Smoking Comfortably," devised by Frank T. Leone, director of the University of Pennsylvania's Comprehensive Smoking Treatment Program, and his colleagues.
"Cessation preps the patient on what to expect and how to deal" with withdrawal symptoms and changes in daily routine, Leone said. For some, that might mean just counseling. For others, it could also mean medication.
The goal now, he said, is to "shift health care providers away from an antismoking attitude and towards ... managing and minimizing obstacles."
The most accessible medication, often offered free by cessation programs, is NRT, or nicotine replacement therapy. These include over-the-counter patches, gums and lozenges. Small doses of nicotine also come in prescription inhalers and nasal sprays.
Drugs that may help include bupropion, an antidepressant marketed as Zyban; and varenicline, or Chantix, a nearly four-year-old prescription drug.
"Varenicline seems to be the most effective," said Robert Schnoll, a Penn researcher who studies cessation medications. "In studies, those with a prescription have a lower reaction than we would see in the regular population. It's not for everybody but ... it's promising."
Last month the Food and Drug Administration put a black box warning -- its strongest -- on both Zyban and Chantix, cautioning patients to talk to their doctors if they get depressed or hostile, or have suicidal thoughts. Such reactions can also occur from stopping smoking, the FDA noted.
Chantix held a 91.2 percent market share in 2008, according to IMS Health, which tracks drug sales. Nicotine was the second most prescribed drug, followed by buproprion, the former market leader.
At least some of Chantix's rise can be attributed to the tendency for any new drug to appeal to people's hopes that "this is the one," said Leone. He noted that buproprion also saw "tremendous uptake," but died down after a year or two.
For Ball, 26, smoking was a misguided way to declare her youthful independence. She learned how to smoke in hopes of snagging the role of a "bad ass" character in a high school play in Baltimore. The role went to a nonsmoking classmate, but from then on, Ball was hooked.
"I liked the feeling. It relaxed me," she said. "I don't drive, so I was always waiting for buses, smoking. And when I used to substitute-teach, the stress ... I would find spots that sell loose cigarettes near every school."
In 2007, she discovered "Stay Quit, Get Fit," a free smoking cessation program at Eleventh Street Family Health Services of Drexel University in North Philadelphia. Over seven weeks, she exercised in the clinic's fitness center, received group counseling led by a certified counselor and was supported by participants. By the end, her cigarette count fell from 10 a day to zero. She still retains lifetime access to the gym.
The program at Eleventh Street was created by the National Nursing Centers Consortium, which promotes primary care to underserved communities.
The effort is innovative because it integrates fitness, health and counseling in a primary-care clinic. It has seen 50 percent of participants stay off cigarettes after one month.
"For me, it was great because I thought, 'I can quit and get the body I want!' " said Ball, who had gained 50 pounds since high school but has yet to lose the extra weight. "It was also great that it wasn't about quitting on day one. Cigarettes have been demonized so much.
"Instead, we were really honest and we talked about why smoking feels so good. Until you tackle why you're doing something, you can't stop doing it."
Program manager Elizabeth Byrne said the group tracks participants' weight, lung function and blood pressure so they can see their health improve. "That's a huge reinforcer," motivating them to eat better and exercise even more, she said.
Byrne also uses the sessions to introduce healthier foods such as hummus. "I got one group hooked on tofu meatballs," she said with a laugh.
There is currently no single best treatment for all smokers who want to quit. But new ideas are being tried.
Michael Baime, an internist at Penn's Program for Stress Management, will be leading a pilot program to see if mindful meditation can help prevent relapse.
"From our other research, we know anxiety and depression goes way down" because of meditation, said Baime. These "and also anger, which decreases sharply, are all associated with relapse. That was the primary reason why tobacco researchers thought this might work."
Everyone agrees that to quit successfully, the person has to really want to do so. Nina Ball has quit five times in the last three years, only to start again. It's unclear if she'll make it this time.
Her reason now is to set an example for the younger generation.
"I didn't want my niece to associate the smell of cigarettes with Aunt Nina," she said. "That, and I just knew I could do better."
"I'm thinking about training for a marathon. I went to Guatemala for 10 days, volunteering (with the students), and I hiked 15 miles on the Appalachian Trail," she said. "The quality would have been depreciated if I were still smoking."
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