When quitting smoking feels like losing a best friend, this Penn Medicine program can help

When Frank Leone first became a pulmonologist, he’d diagnose patients with a severe or deadly lung disease. Many reacted with stoic calm. Then came news his patients took much harder: They’d have to quit smoking cigarettes.

Too often, Leone recalled, his patients would start to cry, imploring, “How do I do that?”

“I imagined it as almost a silly question — ‘Well, you just stop,’” Leone said. “But when people kept responding with this deeply emotional kind of response to that advice, I realized that I was the one who didn’t understand the problem.”

Fast forward to today. Leone, 62, is now director of Penn Medicine’s Comprehensive Smoking Treatment Program, where he gives patients the pharmacological and cognitive tools to curb and ideally control the compulsion to smoke in a way that feels manageable, supportive, and free of guilt and pressure.

Cigarette smoking is the leading cause of preventable disease and death in the United States. It kills more than 480,000 Americans each year, according to the U.S. Centers for Disease Control and Prevention.

Of an estimated 50 million U.S. adults who routinely use tobacco, many will put quitting on their New Year’s resolution list. Likely not for the first time — or the last.

Then there are those, like Joseph Pultrone, who won’t even entertain the idea. The 63-year-old lifelong Philadelphian and former pizzeria owner introduces himself to new doctors as “Smoking Joe.”

“The reason I’m not quitting is because I don’t know any other way,” Pultrone said. “It’s part of me. It’s part of who I am.”

Pultrone said a doctor had first told him to quit when he suffered a massive heart attack at age 35. Both his parents had smoked until their deaths — his mom from an autoimmune disease and his father from a heart attack.

Pultrone has coronary heart disease and a lung disease called bullous emphysema. He smokes up to a pack a day and started at age 11.

Pultrone said he successfully weened himself off Percocet, a potent prescription painkiller, after taking it for nine years for leg pain while in his 50s. But that took “1,000% mental focus” and a “long-term commitment” that he’s not willing to apply to his tobacco use.

Pultrone’s story sounds like those of the majority of patients who come through Penn’s treatment program, which saw about 800 new patients at four clinics in Philadelphia and South Jersey in the fiscal year ending in June 2024.

Almost all started smoking between ages 10 and 14, according to its associate director, Sarah Evers-Casey, who coauthored with Leone the book Why People Smoke.

“In the 20 years of doing this, I can count on one hand the number of people who have started smoking after age 25,” Evers-Casey said, adding that tobacco companies historically have targeted adolescents while their brains are still developing.

“They really develop this powerful relationship with the cigarettes,” she said. “We’ll constantly hear things like, ‘It’s my best friend. I can’t imagine my life without it.’ So the idea of taking that away feels like a major loss to a person.”

Understanding why it’s so hard for people to stop smoking and how to help has been Leone’s focus for 27 years. He started a smoking treatment program at Jefferson Health in 1997. He brought the program, which treats smoking as a medical condition like asthma and diabetes, to Penn in 2007.

While Leone has never smoked, he’s had his own struggles with impulse control. On a recent chilly day, the burly 6′1″ doctor, wearing Levi’s jeans and black size 11 Dr. Martens, patted his stomach. “I want to lose weight and people say, ‘Just eat less,’ but as soon as I walk by the pizza, I’m like, ‘Oh, maybe I’ll just have two slices.’”

Leone said one of the first things he tells patients is “it’s not your fault.” He blames chemical engineers who designed an efficient nicotine-delivery product and savvy marketing aimed at adolescents. A person’s struggle to quit smoking is neither a character flaw nor a lack of motivation. Rather, smoking becomes ingrained in the brain as a survival instinct, Leone said.

“Their brain has been changed — functionally, biologically,” Leone said. “A lot of new connections have formed and old connections have diminished to the point where the brain, following exposure to nicotine, knows how to be a smoker and does it very, very well. The idea of becoming a nonsmoker is akin to learning a new set of skills.”

It’s like learning to play the guitar. It takes practice. There are ups and downs. Some days you’re motivated to work on it; other days you’d rather not. It doesn’t have to be painful, but it’s work, he said.

Most of the patients who make it to his program ultimately succeed in changing their habits: Roughly 67% of the program’s patients achieve control over their smoking within a year, he said.

Penn’s program uses a combination of pharmacological and behavioral strategies to help people begin to wrap their minds around the idea of giving up smoking. People struggling with tobacco dependence deserve to find a solution “that allows them to have a little bit of grace,” Leone noted.

Leone said patients first need to understand what internal forces or instinctive drive gets in the way of their goal to stop.

Patients will say they’ll go on a cruise with their family and not smoke the entire trip, but as soon as they get home, they start again. He calls that “conditioned place preference.” If you always smoke in the same EZ-chair, with the television remote in your hand, you don’t feel safe and secure until you complete the process and smoke. So patients need to think about changing patterns and rituals, which is difficult.

“You have to recognize there is a reflex involved and then deconstruct it so that you recognize the signal. The alarm. The pain in your brain that said it’s time to have a cigarette,” Leone said. “Just the idea that you recognize the call and response — you are now in a position to slow that down.”

In addition to behavioral interventions, Leone uses medication to help patients not necessarily quit but “activate their readiness” to do so. He recommends a combination of varenicline, a medication that tricks the brain into thinking there’s plenty of nicotine in their body, and some form of nicotine replacement in the form of a patch or gum.

“The medications actually work. They work really well,” Leone said. “But the expectation has to change. What they don’t do is shut off smoking miraculously. What they do is make the brain more willing and able to learn how to not smoke.”