Is Nicotine an Alternative Vice and Should We Prohibit it's Use?

A colleague of mine shared that she had met a man who had quit spit tobacco by switching to nicotine gum. He uses 3 or 4 pieces at a time. He was happy that he quit spit and had no desire to stop using the gum. She wondered what she could say to him about his addiction to nicotine gum. Other colleagues gave her suggestions as to how to get the NRT user to change his behavior but no one really answered WHY he should change his behavior. Here is my thoughts: 

When compared with continued smoking/chewing, there is no question that long term use of NRT is preferable but when you compare it to using nothing, I don't think we really know what the relative long term risk of using medicinal nicotine (see links below). We talk about nicotine being a poison yet---the poison is in the dose.  How harmful are low doses of nicotine over a long term? 

In the FDA webinar this week, a presenter made the statement that he thought that within 10 years, if we could get e-cigarettes properly regulated and manufactured to deliver sufficient nicotine, that we could put the tobacco companies out of business. Wouldn't that be a good thing? The very next day during a different webinar, someone posed the question --"How do we put the e-cig manufacturers out of business?" Is this in a smokers best interest or is tough regulation better? 

With e-cigarettes there are other components in the vapor that need to be studied. But I think the long term use of both in regards to nicotine is similar----NRT was not designed for enjoyment as e-cigarettes are, but people do use nicotine (NRT) for their enjoyment. Is nicotine really the demon we need to be fighting, even though it is addictive? It seems to me that there are some people in tobacco control who want to prevent the use of nicotine for enjoyment in any form regardless of it's relative risk strictly because it is addictive or is it our puritanical nature to deny people its pleasure? If addiction is the only criteria, is that enough to warrant its prohibition and the desire to put e-cigs out of business?

Humans use a variety of substances for enjoyment from alcohol, caffeine, marijuana, and now nicotine. With the invention of e-cigarettes, I see using nicotine as a new (or alternative) vice for some. Should it be our job to stop them? Or is this a futile attempt at prohibition again? Although I'm not really sure we can compare nicotine to any other substance. We want to stop the addiction to heroin, meth, cocaine because of the detrimental health effects but so far we don't see that with nicotine addiction. Years ago the policy at the Betty Ford Center (not sure if this is still in effect) was to deny patients all access to caffeine--but they could smoke. To me this is giving the message that ingesting caffeine is more dangerous than nicotine. We know that nicotine is more addictive than all these other substances but is that reason enough to want to prohibit its use? 

http://cancerpreventionresearch.aacrjournals.org/content/4/11/1719.full.pdf+html

http://circ.ahajournals.org/content/94/5/878.full

http://www.webmd.com/smoking-cessation/features/addicted-to-nicorette

https://quitsmokingcommunity.org/nicotine-gum-side-effects-stories/

Why can't I stop crying since I've quit smoking?

Intense, non-stop crying can be a sign of depression, which is also a nicotine withdrawal symptom. It can also be a sign that you need to learn how to deal with your emotional connection to smoking. Most likely it is a combination of both.

Not only is quitting smoking a physical journey but it is an emotional one too. Often quitters under estimate the strength of that emotional connection. Smoking offers the illusion of being able to go through life with the least amount of pain and the greatest amount of pleasure because it enhances positive emotions like pleasure and happiness and suppresses negative emotions such as stress, anger, sadness and loneliness.

My last challenge to ending my relationship with cigarettes was learning how to deal with anger without smoking.

I had been quit for about three months when I got into a fight with my father. I had never been so angry at him before. He was an alcoholic and a prolific drunk dialer. He had been a  real estate broker for most of his life and I was now selling real estate. I'm sure in his mind he thought he was being helpful when he decided to drunk dial the manager of the office I was working at and identify himself as "Santa Claus". Lucky for me his call was intercepted by a sympathetic secretary.

I blew up and headed straight for my local convenience store and bought a pack of my favorite cigarettes - Marlboro 100's. I wasn't kidding myself about only going to smoke "just one", I knew I was going to chain smoke the whole pack and I did.  As I smoked each cigarette what I was really doing was "smoking at" my father and suppressing my anger.

This relapse only lasted a few weeks. After having cancer I knew it was stupid of me to go back to smoking. I had been trying so hard for so many years to quit, that I made the decision that no matter what I was not going to smoke ever again. That meant I had to learn how to deal with not only my anger but all of my emotions.

Almost all smokers start as teenagers, so at an early age we learn to associate smoking with emotions. They help us celebrate the good times and commiserate during the bad. No wonder it feels like we are losing our best friend when we quit.

There are four ways of dealing with emotions: express, suppress, escape and release. With anger I needed to learn how to release it in a healthy manner without smoking, instead of using nicotine to suppress it. I did have help with this from a professional therapist who I had been seeing to deal with the stress of going through cancer treatment.

The best place to start is to talk with your doctor about cessation medication to lessen the withdrawal symptoms. The use of bupropion, which is an anti-depressant, may be a suitable choice. It can also be used in combination with nicotine replacement products. Next, if professional therapy is not an option, join a support group such as nicotine anonymous, or on an online group such BecomeAnEx.org. It helps to share your emotional journey with others who can relate how they are dealing with the same issues.

Realize that smoking has been numbing you to the full range of the emotions of life and without smoking you are just beginning to experience the richness of life. Nicotine is not a best friend but a saboteur and an enemy who doesn't want the best for you but only wants your money.

I just quit smoking, when will I feel better?

Most smokers feel better in three to four weeks. By this time the nicotine withdrawals have subsided or are being effectively managed and "habit" cigarettes have gone away.

Nicotine withdrawal is the main reason why smokers relapse the first month they quit. Physical withdrawal symptoms are: Cravings, depression, anger, irritability, insomnia, hunger or weight gain, fatigue, restlessness and frustration. For some smokers these symptoms can last up to six months.

There is no reason why a smoker should feel uncomfortable during this first month because there are seven FDA approved cessation medications to help with physical withdrawals. Often a combination of medications works better than using one. A recent study showed that the combination of Chantix with the Nicotine Patch worked better and had higher quit rates than using either of them alone. A professional tobacco treatment specialist can help a smoker figure out what combination of medications may work best.

Habit cigarettes are often seen as the hardest to quit. The one with your morning coffee, in the car on the way to work, or the one at break time. The cigarettes are a conditioned response. Your brain has associated different activities with the jolt of nicotine. This is the same conditioning as Pavlov's dogs. The dogs were taught to associate the ringing of a bell with food. Every time they heard a bell, they started salivating because they knew food was coming. A smokers brain is exactly the same - you smell the coffee and your brain immediately thinks of a cigarette. You get into your car and your brain immediately thinks of a cigarette.

What most people are not aware of is that Pavlov also taught the dogs to stop anticipating food when they heard the bell. It's called "extinguishing the condition". It takes about three to four weeks or about 30 different times where you have a cup of coffee without a cigarette. After this amount of time, your brain no longer anticipates getting a cigarette.

When nicotine withdrawals and the habit cigarettes are no longer an issue, a smoker will feel "normal" again. This is when a smoker may think they have the problem beaten. They have mastered their addiction. But they have only mastered two parts and the tools used for withdrawals and habit cigarettes are not the same tools needed to overcome what is needed to overcome the reasons for long-term relapse: stress, weight gain, emotional triggers, alcohol and being around other smokers.

So just because you feel better soon, don't let your guard down but develop new tools and strategies tostay quit for forever.

Can personality traits tell which cessation medication will work best?

Every smoker is different and when trying to decide which medication is the best one to use, it is often a matter of trial and error. But over the years I have seen different patterns emerge. It's only my observation and not scientific but it may be better than trial and error.

I always ask smoker to complete the following sentence: "I want to quit BUT......" What I've noticed is what comes after the BUT can influence what medication may work best.

For someone who says "I want to quit BUT I enjoy smoking, it relaxes me, I like it..." Their focus is on the enjoyment and positive benefits received from smoking. Chantix seems to help these smokers since Chantix works by blocking the receptors in the brain which decreases the pleasure a smoker gets when smoking. It also releases a small amount of dopamine (the I feel good neurotransmitter in the brain).

For someone who says, "I want to quit BUT I can't handle the side effects, the depression, irritability, ..." Their focus is on the negative effects of quitting. In this case a combination of Zyban and nicotine replacement products (NRT) helps. It it unknown why Zyban helps smokers quit. It was originally developed as an anti-depressant and over the years, it was noticed that smokers would quit.

For smokers worried about weight gain after quitting, Zyban and NRT have been shown to stave off weight gain during the first 6 months after quitting. But NRT needs to be taken on a regular schedule to be effective. To be helpful oral NRT needs to be used on a regular basis to keep the level of nicotine in the blood steady.

 Often smokers will wait until a craving comes up before they pop a piece of gum or a lozenge but by that time, it's too late and then will say that NRT doesn't work. The reason it's not working is because they were under dosing themselves. When you smoke a cigarette, the level of nicotine in your blood peaks at about 20-25 mcg/L in 5 minutes. At the end of one hour, the level drops to about 8 mcg/L.

In contrast, it takes The Patch 2 to 6 hours to reach the maximum absorption. The absorption is similar for nicotine gum, lozenge and inhaler at about a peak of  8mcg/L at 30 minutes. Only the nicotine spray gives a kick within 5 minutes like a cigarette but at less than half the amount of nicotine as a cigarette.

Experts in tobacco control are now even recommending that smokers start using NRT before they quit to help them cut down. The reason why this wasn't suggested in the past was because the fear of nicotine overdose. But every smoker can spot nicotine overdose symptoms--all you have to do is think  back to your very first cigarette ever--you probably got dizzy, light-headed, maybe had a headache or nausea, maybe even vomiting---these symptoms are nicotine overdose but as you continued smoking your body adjusted to the level of nicotine and developed a tolerance for these side effects.

One reason why the e-cigarette has gained popularity is that is delivers a higher and faster dose of nicotine than NRT's because it was designed to keep a smoker addicted to nicotine instead of helping them wean off of it. There also is probably a placebo effect by having something to hold in your hand that is similar to a cigarette. It tricks the brain into associating the sensory effects.

There are other factors besides personality when making a choice about cessation medication. It depends on your medical and mental health history, how much you smoke, how long, what other medications you take and what you've used before.

Avoid any "100 guarantee" product or service to stop smoking

Several services send me daily updates on news items, blogs and other postings on anything to do with tobacco issues. I'm always amazed at the amount of misinformation available and the products that guarantee a smoker will quit. That 100% guarantee should be the tip off that it's just a 100% guarantee that they want your money. Every method will work for some individuals but no method will work for everyone. Many products “work” because of a placebo effect or the belief or positive expectation that it will work. Trying some of these products or services can be harmless but others can have devastating effects. Here are some products and services that have not been shown to be effective:

  

• Acupuncture: No evidence to support efficacy as a cessation method in research studies.
• E-cigarettes: A battery operated devise, not regulated by the FDA that vaporizes nicotine and propylene glycol. No independent safety studies. Mainly produced in China with no safety standards for manufacturing. A small study by the FDA showed some harmful chemicals and inconsistent levels of nicotine. Cannot be advertised as a cessation devise.
• Hypnosis: Anecdotal stories as to efficacy but insufficient evidence to support hypnosis as a cessation method.
• Lobedia: Also known as Indian tobacco, a substance chemically similar to nicotine that used in tablets, gum and vitamins pills. Marketed as a substance to help with nicotine withdrawal. Controlled studies have not shown it to be effective. Banned by the FDA in 1993 as a cessation medication.
• Silver Acetate: A crystalline substance often an ingredient in chewing gum that is claimed to produce a repulsive taste when combined with cigarette smoke. No beneficial effects for cessation have been shown in randomized clinical studies.
• Smokeless tobacco or snus: Tobacco products that held in the mouth. Different products have varying levels of harmful components. Linked to cancers of the mouth, tongue, gums, lips, and cheeks. Causes cavities, tooth loss, stained teeth, gum disease. Swallowing spit can cause heartburn, ulcers and cancers of the voicebox, esophagus, and parts of the throat and stomach. Increases blood pressure and heart rate. May contain more nicotine than cigarettes.
• Welplex: An injection consisting of a combination of atropine, scopolamine and chlorpromazine (thorazine). This combination may cause a temporary mental break including hallucinations, heart palpitations, paranoia and possible coma. Not approved by the FDA for smoking cessation. Atropine is used to dilate the eyes. Scopolamine is used for motion sickness. Chlorpromazine is used for psychiatric disorders such as schizophrenia.

President Obama continues to struggle to quit for good

The White house released the results of President Obama's first physical which noted that occasional use of nicotine replacement therapy (NRT). Obama admitted to smoking an occasional cigarette but what does that mean -what is "an occasional" cigarette. Regardless of his apparent health--no one who smokes is healthy. One cigarette increases the heart rate, blood pressure, releases carbon monoxide into the blood system and damages the blood vessels. But the bigger threat of having "just one" is that many former smokers relapse by thinking they can have "just one" every now and then. The addictive nature of nicotine is vastly underestimated when it comes to relapse prevention. Smokers have an abundunce of nicotinic acetylcholine receptors in their brain. Nicotine fits into those receptors and the brain lights up and craves another cigarette. I've treated smokers that had quit for over 20 years and relapsed back to full time smoking very quickly after having "just one".

But to quit for good, President Obama should track when he has those occasional cigarettes--when is it, what is going on--there is probably a pattern that will show up. Often men relapse in positive social situations whereas women often relapse due to stress and negative emotions. It is assumed that because he has a stressful job that he is smoking out of stress but that may not be the case. An occasional cigarette is not due to the physical craving but it is a behavioral challenge and we don't know what his triggers are. Instead of stress, it could be that it's when he's out on the golf course, socializing with his buddies , we just don't know. Everyone is connected to their cigarettes in a unique way--there is NO one size fits all, or even one size fits most when it comes to quitting--it must be a personalized plan that fits the individual, not what worked for someone else. By tracking when he has those occasional cig's, his pattern will emerge and then he can formulate a plan to deal with his individual triggers.
My hope is that because the President understands the difficulty in quitting that he will pave the way to increase treatment options and coverage for other smokers struggling to quit.  Smoking is NOT just a bad habit or a lack of willpower but a physical addiction. Right now, it's not popular to pay for treatment. Non-smokers don't understand why the smoker just doesn't put them down and walk away, former smokers state that if they can quit anybody can quit and current smokers scream that it is their right to smoke. Yet I work everyday with those who struggle, who think that something is wrong with them  because they just can't put them down and walk away. Former Surgeon General Koop called nicotine more addictive than heroin or cocaine--yet if someone was a heroin addict, 30 days of in-patient treatment is paid for and then 90 meetings in 90 days is suggested--4 months of treatment, yet for a substance (nicotine) that is more addictive, we blame the smoker for lacking willpower, and for many years we promoted the product (both in our military and overseas) and we protected the pusher (the tobacco companies).

What works and what doesn't work?

I'm approached all the time to sell products that claim to help a smoker quit. One company claimed that cravings would vanish by smelling a cinnamon scented wand. In a very unscientific experiment, I gave them out to all of the participants in one of my workshops. One third said that the wands did remove the craving, one third said the wands did nothing and one third said smelling the wand caused an increase in cravings. Another man swore that when he rubbed a Peruvian amulet, his cravings went away.
I firmly believe that regardless of how outlandish a quitting method seems, that every method will work for some, but no method works for everyone. Some products will work because of the placebo effect, which if the user believes strongly that a method will work for them, then with the power of their own mind, they will be successful. So when a client will ask about any alternative method used for quitting, I have to admit that I am biased. I've been facilitating cessation classes for 19 years and I often hear, "This class is my last resort--I've tried everything and nothing works." (which includes acupuncture, & hypnosis). The individuals that attend my classes are the ones that have tried all the other methods and products and found they didn't work.

So what does work? Smokers are like individual snowflakes, each connected to their cigarettes in various ways. So instead of endorsing any particular product or method, I encourage smokers examine how they relate to their cigarettes. When do they smoke? What habits are associated with smoking? What physical effects do they feel when quitting? By looking at how they are connected to their cigarettes, will tell them what aspect they need to work on to be successful and often it is not just one aspect but many.

Rather than spending money for products claiming to be a magic wand to quit but probably won't work, except to line the manufacturer's pocket with the smoker's money, practice changing one aspect of smoking. Break one habit, such as not smoking in the car anymore, only smoking outside. Practice going outside for a smoke break with your friends but don't smoke. Talk to your doctor about different medications, it may take trial and error to find a combination that works for the individual.

Staying Quit Forever and Preventing Relapse

I always ask the participants in my stop smoking workshops, "What is the longest time you have been off cigarettes?" Their answer tells me quite a bit about how to help them be successful with their latest quit attempt. Here is what some of their answers mean:

"I've never quit for more than a few days." This smoker is probably heavily addicted to nicotine and relapses because of the withdrawal symptoms. They might have used medications in the past but probably incorrectly or in inadequate amounts or they might need a combination of medications to be successful. Unfortunately, once the physical aspect is handled, these smokers still need to deal with the other aspects of their smoking and without addressing those issues, they will relapse and blame it on the medication not working.

"I can go 2 or 3 weeks before I give in and smoke." These smokers need help overcoming habitual smoking. Most smokers think that the habit cigarettes are the hardest one to overcome, yet actually it only seems that way for the first month, after that habit cigarettes fall away because smokers get to practice avoiding habits several times every day. For example, often when smokers get a new car, they will avoid smoking in it and very quickly, the urge to smoke in their car passes and this habit is extinguished. These smokers need help with different quitting tips for individual habits.

"I've quit for a year and then something happened and I went back to smoking." When I ask what it was that happened, it is usually stress, negative emotions, or a positive social situation. These smokers need additional coping techniques for these areas.

"This is my first time quitting." Virgin quitters often will have an easy time quitting, too easy and they think they can control their smoking, which they can't. They are too cocky and will almost always relapse.

"It wasn't that hard to quit and I thought I could have one when I wanted to smoke." Very similar to virgin quitters. These smokers underestimate the addictive nature of nicotine. they also may have a selective memory about how hard it was to quit and even if it was easy, it may be more difficult the second time around.

"This class is my last resort, I've tried everything and nothing works." I love getting these smokers in my class because I know that they have the basic foundation to be successful--motivation-otherwise they wouldn't keep trying to quit. They are willing to try almost anything but they lack the confidence that they can be successful and they need an personalized plan to overcome their individual roadblocks to successful. this is where my expertise can help them finally be successful.

Most of the participants in my stop smoking classes are able to quit. It's not magic but it is because I understand the psychology of smokers and I understand the relapse cycle and what it takes to become a successful quitter.

Always Nice to hear from Successful Quitters

My first workshop at Hi Desert Medical Center was a success!! All of the participants quit smoking. One individual, who had been a two pack a day smoker, was still struggling with smoking less than 10 cigarettes by the last class but called me yesterday to say that she had finally stopped a few days later by using a combination of bupropion and the nicotine inhaler that I had suggested. Here is a letter to the editor from one of the other participants. I love hearing success stories:

http://www.hidesertstar.com/articles/2009/02/19/editorial/doc499bb9a9a64d5513280172.txt

Should Stop Smoking be an Inpatient Program like for Alcohol?

There are a couple of inpatient programs in the United States. The Mayo Clinic has a inpatient program that is a combination of medications, cognitive-behavior therapy and relapse prevention. Many people successfully quit in this environment. Yet the people that come to my workshops that have been through other inpatient programs, tell me that it is easier to quit in a protected environment because you are away from your normal triggers but once back in your "real" life, every smoker still has the small issues to deal with and it is easy to relapse. Like I have said before--every method will work for some, no method will work for everyone.
I am often told by smokers in my workshops that I am their "last resort" that they have tried everything else and nothing has worked for them. I think that individuals that may benefit the most from an inpatient program are ones that are highly addictive, have other substance abuse problems or a mental illness and need a physician to monitor their medications. Often individuals such as these will need a combination mediation therapy that lasts at least 6 months to a year while they are dealing with the other aspects of quitting such as habits, stress, and social situations.
So if you have the money to spend on an inpatient program that might be the way to go but only if you are serious about working on the other issues to prevent relapse.

Different Skills Needed to Stop Smoking and then to Stay Quit

There are two different periods when a smoker quits. The initial quitting lasts 2 to 4 weeks. This is when the quitter is learning how to deal with the physical aspects of quitting and the habit cigarettes. There are now 7 FDA approved medications to handle the physical aspect of quitting and most individuals are able to get through this period by using one or a combination of these medications or for some, they are able to handle going cold turkey. Habit cigarettes fade away within 3 to 4 weeks because they are habits, you get to practice new habits on a daily basis, so that in a short period of time, most quitters have mastered the physical aspect and their habits. But many are not prepared for the second phase which can last up to a year or more. Without medicinal or counseling support, up to 95% of smokers will relapse within the first year and another 15% the second year. This drops to 60% to 90% if medications and counseling are used.
So the reality is that we are successfully able to get smokers to quit for a period of time but not forever. Preventing a relapse takes different skills than were needed in the first couple of weeks. After 6 months, when the telephone rings, the quitter is not still looking for their cigarettes, the car starts without lighting one up, the withdrawals have long since past but new situations pop up and without preparation, the quitter can very easily relapse.
The problem areas usually center around positive social situations, negative emotions and stress situations, being around other smokers, alcohol and weight gain. For long term success, a quitter will need to face this situations without turning to their long lost friend-a cigarette.

Top 8 Reasons Why Medications Don't Work When Quitting Smoking

I've heard it over and over again--"I tried The Patch (or the gum or any other medication) and it didn't work". there are several reasons why the 7 FDA-approved medications don't work.
1. Under dosed. The guidelines with the use of nicotine replacement products may not deliver sufficient nicotine. If a smoker is smoking two packs a day that is the equivalent to two-21mg patches. If they were only using one, they were not getting anywhere close to the level of nicotine that they are used to and they will suffer from withdrawal symptoms. 2. Used incorrectly. The gum is not to be chewed like gum but just soften enough and then parked so the nicotine is absorbed through the mucosa of the mouth instead of being swallowed into the stomach, which can cause indigestion.
3. Expecting too much. Medications are not a magic wand. Often a smoker will "try" medications with a "show me" attitude. Medications are used to help with the physical symptoms while the smoker learns to deal with the behavioral, social and psychological aspects. If nothing is done to address this issues, after discontinuing the use of the medication, the smoker will relapse.
4. Not used long enough. In a short period of time, most smokers have released their "habit" cigarettes and feel like a non-smoker but they are still at high risk for relapse but they will discontinue their medication because they think they've got smoking beat. Or the individual may experience side effects and simply stop the medication instead of changing the regiment to lower the risk of side effects.
5. Not having strong motivation to quit. Quitting can be one of the hardest things a smoker ever accomplished and it takes the right kind of motivation for the smoker to stick it out when the going gets tough instead of caving in and reaching for a smoke.
6. Assuming that because one kind of medication didn't work, the others won't either. Often it takes someone that is familiar with the medications to make adjustments to fit a particular individuals situation. for some smokers, a combination of several medications is suggested to increase the effectiveness.
7. Not even giving them a chance. Some individuals are concerned about the long term effects of medications or that they may become addicted. Discuss these concerns with your physician.
8. Doesn't make sense to take a little bit of your drug to overcome the withdrawals of your drug. Inhaling nicotine is the faster way to get the highest dosage of nicotine to the brain. None of the over the counter nicotine replacement products can match the speed and dosage level of smoking which is why there is little risk of becoming addicted to OTC nicotine replacement products. Nicotine spray which is by prescription only is an exception and should be monitored by a physician because it is closest to inhalation, in delivering the rapid dose of nicotine
I believe that the physical addiction to nicotine is over estimated when individuals are trying to quit and there are effective medications to help with these withdrawal symptoms BUT I believe that the physical addiction is UNDER rated when it comes to relapse prevention. Inhaling nicotine causes structural brain changes that are still there even after a smoker quits and having even one cigarette is risking a full relapse. Remember, you're a puff away from a pack a day.

Are you Physically Addicted to Nicotine?

This will indicate whether you are dependent upon nicotine and may indicate whether you will need medicinal support for withdrawals when you quit.
Answer each question in the list below, giving yourself the appropriate points.

1. How soon after you wake up do you have your first cigarette?
a. within 5 minutes
b. 6-30 minutes
c. 31-60 minutes
d. After 60 minutes
2. Do you find it difficult to refrain from smoking in places where it is forbidden, such as the library, theater, or a doctor’s office?
a. yes
b. no
3. Which cigarette would you most hate to give up?
a. the first one in the morning
b. any other
4. How many cigarettes a day do you smoke?
a. 10 or less
b. 11-20
c. 21-30
d. 31 or more
5. Do you smoke more frequently during the first hours after waking than during the rest of the day?
a. yes
b. no
6. Do you smoke if you are so ill that you are in bed most of the day?
a. yes
b. no

Scoring:
1. a: 3 b: 2 c: 1 d: 0
2. a: 1 b: 0
3. a: 1 b: 0
4. a: 1 b: 2 c: 3 d: 4
5. a: 1 b: 0
6. a: 1 b:0

A total score of 7 or greater indicates that you are very dependent on nicotine and are likely to experience withdrawal symptoms when you stop smoking. A score of 6 or less indicates low to moderate dependence.
For a highly addicted smoker, there are 7 firstline and 2 second line medications approved for nicotine dependence, so there are lots of choices to finding the right combination for you. If you choose not to use medications, then it is important to take care of yourself physically while you go through withdrawals. The tings that you can do to help is to drink more water, do deep breathing exercise, avoid alcohol, and exercise.

(The Fagerstrom Test for Nicotine Dependence)

Should you Quit Smoking at the Same Time as you Diet?

Both smoking and weight can cause health problems, so which do you tackle first? Many individuals will gain weight when they stop smoking (see previous post about 7 reasons for weight gain) but few will start smoking when they go on a weight loss program (unless they are a former smoker who has relapsed). We do know now that smoking changes insulin levels and increases the risk of metabolic syndrome and diabetes. I read an interesting article about arsenic in drinking water increasing the same risks and I wonder since arsenic is in cigarettes, if this isn't the causation mechanism in smoking?
There are two schools of thought about making multiple changes at once and I believe that either approach would work depending on the individual. The first approach is to make only one change at a time. Stop smoking and after you stabilize, set up a weight loss program. The idea is instead of making huge sweeping changes all at once, change in small incremental steps because small steps are easier to maintain.
The second approach is that it is hard enough to maintain any change that it is better to do it all at once because each change will reinforce the other. Since stopping smoking can cause weight gain, wouldn't it make sense to work on that issue at the same time, to avoid any weight gain?
To avoid weight gain after quitting, those that are aware of the reasons of weight gain and that have a plan to avoid the traps, are more likely to be successful at minimizing weight gain and be successful at quitting than those with no plan. The combination use of bupropion (zyban) and nicotine replacement products for the first 6 months after quitting can also minimize weight gain. Those who gain the most weight are at a high risk of relapse because the common thought is that-"I'll go back to smoking, lose the weight and then quit again." Unfortunately, as we all know, once the weight is on, it's very difficult to take it off and the individual who relapsed never gets around to quitting again.

We Need More Help For Those Trying to Quit Smoking

Many insurance policies do not cover programs or medications to quit smoking, yet quitting smoking is the best thing a smoker can do to improve their health. The long term cost savings alone would more than cover the initial cost. 50% of smokers will die from a direct cause of their smoking, which are very expensive diseases-heart disease, cancer, emphysema, stroke, just to name a few. But does that mean the 50% of smokers can smoke without consequences??--No, it just means that they die from something that is not smoke related but that doesn't mean that their health wasn't affected by smoking. A man with emphysema was in one of my workshops and told of the time he was driving from Texas to California and someplace in Arizona, his oxygen tank ran out of oxygen and he passed out and wrecked his car. Luckily he wasn't hurt. Mr. O'Kelly was a patient I took care of, who came in for daily treatments for his emphysema. He died from complications from his medications for his emphysema. In neither of these two cases would "smoking" have been the "cause" of death and would fall outside of the 50% statistic.
Statistics don't apply on an individual basis. The average American family has 2.4 children--have you ever seen a .4 child? But we kid ourselves that not all smokers are affected because they don't die but what we should really be talking about is--disability. How many smokers become disabled because of smoking? I haven't seen any statistics on that but from the individuals that have been through my workshops since 1990, I would estimate that close to 90% have some kind of health problem related to smoking.
So why don't the insurance companies do more? Politics--individuals who have never smoked, will say--I don't understand why the smoker just doesn't put down their cigarette and walk away? Smokers will agree that it is their right to smoke and that is isn't an addiction. Then we have the smokers that really do want to quit but need help but can't afford medications (even though cigarettes are expensive, the cost is spread out over days, instead of one big upfront cost, like with medications). Some will get information from the internet or from the very few books that are out there. but many don't want to spend anymore needless money on another 100% guaranteed program or gimmick that just doesn't work.
Helping others quit is my passion because I know that misery that being treated for cancer can be--and I'm a survivor but will have effects from the treatment for the rest of my life. That's the reason for this blog--to share with you free information that will hopefully help you to live smoke free. Let me know what you need help with and I will post suggestions for all questions.

Myths About Nicotine Replacement Products

Many smokers believe that medicinal nicotine is just as harmful as getting nicotine from smoking but that is not true. Inhalation is the faster way for nicotine to enter into the brain because the smoke goes from the lungs to the heart and is pumped directly to the brain. It only takes about 7 to 10 seconds for nicotine to reach the brain. Inhalation of smoke give a higher concentration of nicotine with the fastest delivery possible. Medicinal nicotine takes much longer to get to the brain and give no way near the amount of nicotine that you get from smoking.
Another myth is that medicinal nicotine doesn't work. the truth is that most individuals who use nicotine replacement products don't use enough, they under dose themselves so that the withdrawals never do get under control or the quit using it before they should. The Mayo Clinic in their Tobacco Treatment Specialist Program suggest dosing to the level of addition. They will use a combination of the patch and oral nicotine on an as needed basis. The dose of the patch should match the amount of cigarettes smoked. 20 cigarettes = 21 mg patch. 40 cigarettes = 2 21 mg patches. Then they advocate the use of oral nicotine, the lowest dose gum or lozenge on an as needed basis, when a particularly difficult craving arises. Medicinal nicotine can be used with Zyban (bupropion is the genetic label) for those that are extremely addicted and where one product has not been enough to control withdrawal symptoms. Medicinal nicotine should not be used with Chantix (varenicline is the genetic label) because the two products work on the same receptor sites in the brain and would work against each other instead of together.
Another myth is that if you smoke when you have the patch on, you will have a heart attack. This is not true. Smokers are at a higher risk for heart disease and the best thing they can do for their heart is quit smoking but using medicinal nicotine and smoking together may give the smoker a stomachache or a headache because they are getting too much nicotine.
Medicinal nicotine can help a quitter deal with the withdrawal symptoms of quitting while they are learning to deal with all the other connections to their cigarettes such as breaking habit cigarettes, learning new coping strategies for stress and strong emotions. Tapering off medicinal nicotine is not the same as coming off of nicotine that has been inhaled, the amount of medicinal nicotine is not even close to the dosage from smoking and doesn't reach the level for addiction. Besides, nicotine is addictive but it's not the most dangerous drug in smoke.
Using medicinal nicotine can also help with post cessation weight gain.

Why Smokers Gain Weight When They Quit Smoking and Tips to Quit

there are 7 different reasons why smokers gain weight when they quit, most of it is because of eating more food:

1. Change in metabolism accounts for 3-6 pounds. 70% of weight gain is due to increase calorie consumption.
- Exercise, 20 minutes per day more than you normally do
- Discuss using Zyban™ and Nicotine Replacement Products with your doctor, these medications can help reduce the amount of weight gained.

2. Withdrawal from nicotine causes low blood sugar
- Substitute raw fruit or vegetables for pastries, candy bars and junk food
- Eat on a regular basis, do not skip meals

3. Ingesting more food as a habit of hand to mouth motion
- Stock up on low fat crunchy foods, such as unshelled unsalted sunflower seeds, or unbuttered popcorn, eat one at a time.
- Increase intake of vegetables such as carrot sticks, celery, green peppers, jicama,
- Get a fake cigarette, a coffee stirrer or toothpick to chew on
- Get a water bottle and take frequent sips of water


4. Using food as a reward for not smoking
- Find other rewards than food, treat yourself with the money you are saving by not smoking
- Stay conscious about the amount of food that you are eating
- Keep a food diary, writing down before you eat what you are going to eat, where you are, what
you are doing and how you are feeling.

5. Eating more at meals to delay having a craving that comes at the end of a meal
- Get up from the table as soon as you are full
- Go brush your teeth, have a breathe mint, chew gum
- Use a smaller plate
- Go for a walk after eating

6. Food tastes and smells better once you have quit smoking
- Eat slower, putting your fork down in between bites
- Decide and write it down, how much food that you are going to eat before the meal
- Be conscious of what you are putting into your mouth

7. Emotional eating. Not dealing with feelings and emotions but using food as a substitute for
emotional needs. To escape from boredom, tension, depression. Hungry, Angry, Lonely, Tired
- Continue the food diary, paying particular attention to how you are feeling when you are eating. Decide how to handle emotions in a health, non-judgment manner without resorting to food, alcohol, cigarettes or other substances.

Genes may Influence Quitting

Here is an interesting article in the Washington Post that states in a recent research project, different genes were identified that may make it easier to decide to use Nicotine Replacement Products or Zyban or Chantix. It seems different gene pattern respond differently. The take away message is that if you tried one product and you weren't able to quit, Blame it on your genes and try, try again. There is no failure to quit until you stop trying. If one method doesn't work, try something else until you find the right combination of medication, behavioral modification and support for you to be successful.

http://www.washingtonpost.com/wp-dyn/content/article/2008/06/03/AR2008060302759.html

Alternatives to Medications to Stop Smoking

There are a number of reasons why some smokers resist using medications to help ease them through the withdrawal stage when they stop smoking. There are a number of things you can do to help:

Nicotine is water soluble so drink plenty of fluids. Cold water supplemented with fruit juices with Vitamin C is best. Drink enough until the color of your urine is clear. Avoid coffee if it is a trigger to smoke.

An increase in the oxygen you breathe can have the same calming effect as smoking a cigarette. Start the habit of deep breathing. Most smokers are shallow breathers yet our lungs are quite large. Practice breathing in through your nose and out through your mouth, expanding your abdomen.

Smoking generates an acidic condition and an alkaline diets consisting of fruits and vegetables helps in detoxification and withdrawals. So start eating more fresh fruits and vegetables, preferably raw. Stock up on crunchy low fat foods such as carrots, celery, radishes, broccoli, bell peppers, apples, pears, cinnamon sticks, sugarless candy, unbuttered popcorn, rice cakes, cereal. This will also help with weight gain since since withdrawing from nicotine can lower the blood sugar, it's better to reach for fruit for natural sugar instead of a candy bar or pastry.

Take a multi-vitamin with extra vitamin C and vitamin B’s. Smoking robs the body of vitamin C and this lowers the immune system making the smoker more likely to catch a cold or get the flu when they quit. Vitamin B's will help calm the nervous system.

Get plenty of rest. Do not take on extra responsibilities at this time. When quitting the smokers body is going through tremendous stress, this is not the time to burn the candle at both ends but to treat yourself gently and focus on what is important.

Exercise helps with unwanted weight gain and uncontrolled stress. Walk briskly for 20 minutes each day.

Avoid alcohol for several weeks. Alcohol impairs your judgment. If you will not stop drinking alcohol, you may want to look at your reasons why. 85% of hard core alcoholics smoke yet smoking is more likely to kill an alcoholic than their liquor.

Change the way you think about withdrawals--they are actually recovery symptoms, telling you that your body is healing itself.

If you have any health problems, speak with your physician before making any changes in your routine or starting an exercise program. If you are taking medications, the dosages may need adjusting after you stop smoking. If after 3 to 4 weeks, you are still having physical problems, go see your doctor. Smoking mask physical problems that quitting exposes. A middle age man in one of my workshops complained that every time he quit smoking, his stomach hurt, so he would go back to smoking. It turned out that he had an ulcer but the smoking was masking the pain. Quitting didn't cause the ulcer, but helped him get a diagnosis and get it treated.

To Use or Not to Use Medications to Stop Smoking

" I tried (...fill in the blank... the patch, the gum, Zyban, Chantix...) and it didn't work."

"How long were you off cigarettes?"

"6 months."

"Then what happened?"

"I got a divorce (or lost my job or.....some other stressful event)."

This is a typical conversation I have had with many people trying to quit smoking. The medications DID work, but the smoker needed more tools in his tool box to be successful. When the only tool you have is a hammer, then every problem looks like a nail. Medications are used to help lessen the withdrawals from nicotine or to block the receptors in the brain, so that nicotine is not as reinforcing. They do NOT relieve stress, a different tool is needed for that trigger.

If you were an early relapser, meaning quitting for less than one month, you may have been using the medication incorrectly. It is not uncommon for those using nicotine replacement products (NRP) to under dose themselves or not use enough of the medication. Or to quit using it too early.

If you were a late relapser, it was probably not because of using the medication but from stress, thinking that smoking "just one" won't hurt, being around other smokers, drinking or using other substances, or gaining weight.

So if you have quit before but relapsed, don't blame the medication, look to see what additional tools you need to learn to be successful.

Tell me what your experience has been with medications to quit. Maybe you just need to try again, this time with a little more knowledge and you will be successful.