Julie Billian has heard it all before. Smoking is bad for her. It stinks up her clothes, her hair. It's expensive.
"I've been smoking since I was 13 years old," said Billian, a 59-year-old nurse from Baltimore. "I understand. It's not a question of intelligence."
Billian understands she's addicted and like other longtime smokers, she has had a hard time quitting despite multiple attempts.
New efforts are underway that doctors and policymakers hope will help more smokers end their dependence on nicotine, the highly addictive stimulant additive found in cigarettes and other tobacco products. The U.S. Food and Drug Administration has proposed cutting the amount of nicotine in cigarettes to non-addictive levels, which could reduce the number of people who smoke and prevent people from ever becoming hooked.
The Maryland Department of Health is handing out more nicotine gum and patches via its Quitline service for smokers who want to stop. It's also allowing doctors to immediately tap a wider range of medical cessation tools for Medicaid beneficiaries, who smoke in disproportionate numbers.
The measures are being applauded by physicians who regularly counsel their patients to quit.
"We talk a lot about smoking, which is the single most preventable cause of death," said Dr. Richard Bruno, a family physician for a health clinic in Belair-Edison operated by Baltimore Medical System, a community-based health center that serves nearly 45,000 mostly low-income patients in underserved areas in the Baltimore region.
"Patients try [to] quit by themselves and it's often futile," he said.
Bruno said studies show two-thirds of smokers want to quit but only about 3 percent of those who try to kick the habit cold turkey are successful. That makes outside measures more important.
The U.S. Centers for Disease Control and Prevention reports about 15 percent of American adults smoke, down from about 50 percent in the 1960s, but smoking still accounts for one in five deaths and costs the economy more than $300 billion a year.
Doctors say perhaps the biggest move in years to reduce smoking is the FDA proposal announced in July to regulate nicotine.
"The overwhelming amount of death and disease attributable to tobacco is caused by addiction to cigarettes — the only legal consumer product that, when used as intended, will kill half of all long-term users," said Dr. Scott Gottlieb, the FDA commissioner, when the initiative was announced.
The FDA's approach is a departure from past efforts to reduce the prime cancer-causing chemicals in cigarettes, rather than the nicotine. But eliminating one chemical at a time could give users a false sense about the safety of cigarettes, said Dr. Joshua Sharfstein, a former principal deputy commissioner at the FDA and now associate dean for public health practice and training at the Johns Hopkins Bloomberg School of Public Health.
He said targeting nicotine instead was a promising approach. Many people begin smoking as teens, he said, so the move would likely reduce smoking among young people and prevent them from developing a habit. He also said studies show that people who do smoke eventually stop when the nicotine is reduced.
Sharfstein said the FDA regulation may nudge smokers to use e-cigarettes because it allows them to contain higher levels of nicotine. The battery-operated devices vaporize a liquid containing nicotine when users puff on them and produce smaller amounts of dangerous chemicals than burning tobacco.
The flavored liquids, however, have made the e-cigarettes popular with teens, and the FDA plans a public education campaign to discourage youth from using them as part of the overall smoking reduction effort.
Sharfstein said he didn't want anyone, especially teens, to get the impression that e-cigarettes are safe. But he said they could help adults ween themselves from cigarettes.
"Nicotine is an extremely addictive chemical and operates in the same part of the brain as other addictive drugs and in some respects is harder to quit than opioids, so it's not surprising so many smokers wish they could quit and can't," he said. "We do have to be careful not to make nicotine attractive."
Policymakers also have to take into account who is still smoking.
Action on Smoking and Health, an anti-tobacco group, says the declines in smoking have not been even, with racial minorities, less educated and poor people smoking more than others.
In Maryland, the Department of Health has taken several steps in recent years to make cessation products more readily available, specifically to Medicaid beneficiaries, but also state residents generally.
In 2015, about 15.1 percent of Maryland adults smoked, according to department figures. But the rate was 29.7 percent among those on Medicaid, the federal-state health insurance program for low-income people. The rate was also higher for those with less education: 28.5 percent for those with less than a high school diploma versus 6 percent for those with 4 or more years of college.
About 40 percent of those who call the state Quitline — 1-800-QUIT-NOW — are Medicaid participants. The line offers both counseling and nicotine replacement therapy products including gum, patches and lozenges.
Recently, the department began allowing callers to get up to 12 weeks of the products for free. The department also just lifted a requirement that smokers try the replacement products before being eligible for other medications.
Health officials are working with health systems to encourage doctors to talk to patients about smoking, employing a program called screening, brief intervention and referral to treatment, or SBIRT. It's better known for its use in identifying and aiding patients who use illicit drugs.
Bruno said he asks his patients about smoking and has pledged to help Billian, who is a clinic co-worker. On a recent day he reviewed nicotine replacement options for her. She already uses nicotine gum to get through her work day, and she used e-cigarettes to quit for a six-year stretch and said she'd consider trying them again.
The cost alone is an incentive. In Maryland, the average cost for a pack of cigarettes is $6.64, according to the Campaign for Tobacco Free Kids. That ranks the state as the 16th most expensive.
Billian's mother died of lung cancer, another strong motivator. She'd also like to be a better example to her 19-year-old daughter, who became a smoker not long ago. And as a nurse, she's seen up-close the devastating health effects.
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According to the CDC, cigarette smoking harms nearly every organ in the body, causes fatal diseases including lung cancer and chronic obstructive pulmonary disease, and increases risks for heart disease, stroke and other conditions.
About 480,000 people die from smoking annually in the United States, which is more than HIV, illegal drug and alcohol use, car crashes and shootings combined.
The CDC says the risks begin to diminish just a year after the smoker stops.
Still, Billian said it would be tough to give up the "little reward" that cigarettes give her at the end of a long day.
"We all know better," Billian said. "It's just hard."