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"Quitting tobacco is easy. I've done it thousands of times." (Mark Twain)

[NOTE:  I have not had an opportunity to update this for quite a while. It was written prior to the advent of nicotine patches and Zyban.  Most of it remains relevant, however, and I hope to get around to updating it soon!]

So! You've finally decided that you want to "kick" the smoking habit. "ARE YOU CRAZY??? DON'T YOU KNOW HOW HARD IT IS TO QUIT TOBACCO???" These are probably the most common responses that you'll hear from the people in whom you confide.

Unfortunately, we've been conditioned all of our lives to believe that quitting tobacco is a feat akin to climbing Mount Everest ("It's sooooo hard!!!!"). Thousands of Americans respond to this myth by simply choosing the "easy way out" and don't even bother trying to give up their addiction. Tobacco companies, of course, love this quality of human nature because it keeps them in business.

Who Smokes?

Overall, approximately one third of U.S. adults (53 million) currently smoke cigarettes, accounting for more than 1.3 billion packs per year. Of this population, 90% acknowledge the risks associated with tobacco use and 80% want to quit. Sixty per cent have made the effort to try and quit at least once, thirty per cent within the past year. On a more positive note, one third of U.S. adults have managed to quit for good.

The numbers of smokers in the United States is finally falling, and this is due to the fact that more people are tossing away their cigarettes than ever before. However, the number of new smokers has fallen relatively little, unfortunately. Smoking usually begins during adolescence. Studies have shown that 75% of teens have tried cigarettes and that approximately 20% of school seniors are regular smokers.

Virginia Slims advertisements bring out the fact that men make up the vast majority of smokers and this is reflected in statistics documenting that men were historically much more likely to die from heart attacks, cancer, and other

smoking-related diseases, than women. "You've come a long way, baby!" is all to true in our present society; because more women are smoking, particularly on the high school level, their death rates have been climbing steadily. For example, lung cancer has finally surpassed breast as the major cause of cancer deaths in American women.

With regards to race, nonwhites smoke more than whites. The higher the level of education achieved, the less likely one is to smoke; high school graduates smoke more than college graduates, who smoke more than professional school graduates.

A break down by level of income tends to be biased by sex; male lower income and blue collar workers smoke more than their higher income white collar counterparts. Women, on the other hand, tend to smoke more if they earn a higher income and work outside of the home, in comparison to housewives. (These gender differences may be partially explained by a perceived need by women in the workplace to smoke while "networking" with their male counterparts.) Finally, divorced or separated individuals tend to smoke more than those who are married or never married.

Why do people smoke?

Social forces are usually to blame in the adolescent population, with teens whose parents or friends smoke being more likely to start. Only a minority of those who begin smoking ever develop a regular habit, which requires several years.

There are two factors as to why people continue to smoke as a habit; first is the chemical dependence upon nicotine which can be quite powerful, particularly in susceptible individuals. A very definite withdrawal syndrome exists, although the degree to which it is significant depends upon the size of the past habits. (Incidentally, there are many more chemicals in cigarette smoke, including radioactive polonium, that can cause harm to individuals.)

Second is the psychological dependence upon smoking as a learned response to certain environmental/social cues (such as finishing a meal or smoking by others), as a means of handling stress or other unpleasant emotions.

Helping people to quit tobacco must therefore address both of these factors in order to be successful.

How does tobacco affect you?

Cigarettes do all sorts of "nice" things for you. They make your throat sore, eyes burn, hair and clothes smell bad, and your teeth, tongue and fingertips brown (remember Topol Tooth Polish?) - not particularly "sexy" features to most of us.

One generally simple rule in medicine is that "the family that smokes together, croaks together." Smokers carry more than twice the risk of dying from heart attacks than nonsmokers, and dying from them suddenly (under 2 hours) as well. Tobacco has been implicated as the major contributor to many different types of cancer, notably of the lung and oral cavity. (Lung cancer is the number one cause of cancer deaths in American men and

women.) Screening for this disease in asymptomatic individuals has proven to be impractical for a variety of reasons. Therefore, the only means that we have to stop this major killer is prevention through education.

Persons who have diabetes, particularly, should not smoke as this will hasten the formation of blockages in their blood vessels. In fact, after diabetes, smoking-induced circulation damage is the next most common reason for limb amputations.

The chemicals in tobacco smoke affect other parts of our bodies too. Patients receiving treatment for ulcers and related illnesses can plan on taking their expensive medicines ($40-60 per month) for years because the ability of their stomachs to neutralize acid becomes impaired as long as they continue to smoke. People who are concerned about their appearance discover that their facial features seem to age faster because they wrinkle prematurely for various reasons. Tobacco also accelerates osteoporosis (weakening of the bones) leading frequently to broken hips and compressed vertebrae (look at how older smokers seem more "hunchbacked" than their nonsmoking counterparts).

What about second hand smoke?

Secondhand smoke remains an important issue in our everyday lives. It's bad enough that our outside air is being polluted daily by thousands of factories that we have to consciously seek other means to further pollute our lungs. Physicians are acutely aware that children in smoking households are affected by upper and lower respiratory illnesses much more so than children of nonsmoking parents. Of even greater concern are the recent studies demonstrating that nonsmoking spouses of smokers have a higher risk of dying from lung cancer than wives of nonsmokers.

The costs associated with tobacco-related diseases such as chronic bronchitis, emphysema, coronary artery disease(angina, heart attacks), etc. are staggering, in the billions of dollars annually. These include costs associated with medicines, x-ray studies (every smoker with a worsening or change in his/her cough fears the "big C" (cancer), hospital and home nursing care, physician visits, surgeries, hospice and so on.

What happens to my lungs?

Comparing human beings to vacuum cleaners makes it easy to visualize how smoking causes damage. Both have filter mechanisms that perform similar tasks. If you were to vacuum clean a small room, for example, the filter would not be particularly dirty after only one day. After a while of daily use, however, you can be sure that the vacuum filter would be clogged up from dirt - at first making funny sounds as the motor tries to force air through a saturated bag, finally ceasing to function.

Your lungs behave basically the same way in response to tobacco smoke. Even if an individual only smokes one half of a pack a day, after 20 years or so the results will be the same as in the vacuum cleaner. As the lung filters out the tars and other residues in the tobacco smoke, it begins to get saturated (they don't make Topol Lung Polish yet!). When this happens, it takes more effort to be able to force air through the clogged filter.

Chronic smokers have to expend a good deal of energy simply to maintain normal air exchange. This, and the fact that nicotine is a stimulant, explains why chronic smokers tend to be under weight. (Incidentally, the lungs tend to become damaged even quicker in marijuana smokers because of the tendency to inhale much deeper and hold in the smoke longer, in comparison to tobacco, and the fact that most joints are unfiltered.

Are my lungs permanently damaged?

The good news about quitting is that for many smokers, the lung damage that they have sustained is reversible to a certain extent. For example, the person who has smoked one pack of cigarettes daily for about twenty years and quits now can generally expect his or her risk of cancer and heart disease to drop down almost to normal in approximately ten years. Remember, however, that if a smoker does not quit their lungs will continue to only get worse.

KICKING THE HABIT:   As noted earlier, the two factors of nicotine and psychological dependence must both be addresses in a successful program.

"I'm afraid of withdrawal!"

The nicotine component is easier to remedy, from a physician's standpoint. You see, if a smoker were to quit "cold turkey", all of the nicotine will be eliminated from the body by way of the urine in only three days time. Contrary to popular belief, the vast majority of smokers do not go through horrendous withdrawal symptoms. For those who choose not to believe this or trust their bodies, there exists a common blood pressure medicine called clonidine (trade name: Catapres) which can be used to block any "hyperactive" symptoms. Clonidine is available in two easy-to-take forms; a pill that must be taken daily, or a patch which lasts a week. The pill form's most common side-effects are a dry mouth ( which in itself may help to reduce the pleasure of smoking) and mild sedation, which can easily be circumvented by taking the pills at night. Although used to lower blood pressure in hypertensive individuals, it will not significantly affect the pressure in someone who is considered normotensive. Generally, only one to three weeks of medication are required, depending upon the individual.

Nicotine chewing gum

There are also various products on the market for use in tapering down the daily nicotine dose, should one fear to stop "cold turkey." Just a few years ago, nicotine substitutes became available in chewing gum form (trade name: Nicorette). This product is helpful to some smokers, but there are several drawbacks to it's use; in addition to being a fairly expensive product to use (average cost is $31 for a box of 90 pieces; average person consumes 8-12 daily), it must be chewed slowly in a very specific manner in order to provide a more even release of nicotine from the gum. Chewing it too fast results in a greater nicotine release and a higher incidence of side effects which can include dizziness, nausea and headache. It is also not greatest tasting gum in the world (but since smokers have a decreased sense of taste anyway this may not matter.)

What about the "miracle" patch?

In the past year, we have seen the release of the long-awaited nicotine patch, four of them actually. Although some minor differences exist between them, we'll consider them here as a group. They were designed to replace the nicotine gum whereby eliminating those pesky problems like erratic release of the nicotine chemical and the poor taste. They did manage to preserve the not insignificant cost however with the average patient cost to be in the $55-65 range per two week prescription ( although they are still a bargain in comparison to the bundle of dough spent on a tobacco habit). By utilizing a "controlled release membrane" the pharmaceutical companies make use of the patch almost idiot proof with regards to nicotine delivery as no longer does one have to worry if they chew too fast or too many pieces.

The patch is even rapidly becoming a status symbol in society of late - "Simply everybody has got to have one." It is perceived as the miracle event of the century for smokers, and although they are very good at what they do, they are not the total answer to a tobacco addiction and can still be dangerous if not used appropriately.

For example, once a decision has been made to use a nicotine patch, the patient must totally abstain from cigarettes altogether. Some patch wearers unfortunately learned a nasty lesson when the additional nicotine load from their cigarettes caused them to die from heart attacks. This is generally considered a negative patient outcome and must be avoided!!!

Reconditioning your brain

It really doesn't matter by what method you choose to get the nicotine out of your system (quickly by cold turkey, or slowly through patches), because unless you also address the psychological aspects of your addiction any one of them can fail.

It's generally accepted today that smoking is not a particularly "intelligent" thing to do. So why then do people continue to smoke in the face of the obvious dangers associated? Because it's a learned habit, and a powerful one. The psychological dependence upon nicotine requires the consideration of several factors.

First, it's important to recognize any emotional reasons for why one someone smokes. How often do we hear that someone smokes because they are stressed out - whether it be from work, family, or whatever? The smart thing to do is to learn how to effectively deal with and relieve stressful tensions in a healthy manner, rather than to automatically light up another cigarette and let those tensions continue to mount. (Many a patient has bee reminded that the slow suicide through tobacco is not an appropriate escape mechanism from stress.)

Often it's difficult to quit because a spouse also smokes. Like dieting, it's awfully hard to restrain one's self when everybody around you appears to be overindulging. The very smell of a spouse's cigarette can interfere with your hard efforts and it's for this reason that physicians encourage husbands and wives (and kids) to try and buck this habit together. Avoiding cigarettes during social excursions is getting easier all of the time, especially since more and more restaurants and theaters offer nonsmoking sections. Adjustments can also be made at the workplace such as changing the locations of one's desk, or improving the ventilation system.

Remember: Smoking sucks!

Freud used to speak of oral fixations and there is no argument that some people always have to keep something in their mouth. However, there are a host of alternative things to chew or suck on that are infinitely safer than tobacco products. [cinnamon flavored toothpicks or chewing gum may to be particularly helpful as this flavor seems to stimulate your taste and smell receptors in much the same way as nicotine.] Try substituting your favorite vegetable, gum, fake cigarette, etc. for when you feel a need to smoke.

"If I quit, I'll become a blimp!"

The question of weight gain invariably arises at some point, partly due to the fact that binges on donuts and other "junk foods" tend to be amongst the cigarette substitutes-of-choice. Nicotine is a stimulant and removing it from your body can allow your body's metabolism to return to it's normal rate. This relative slowing of metabolism can contribute to a mild weight gain.

There are several solutions to this possible problem: first, try cutting down on your total daily caloric intake by approximately 200 calories (learn how to read food labels - always a good idea!). When if indeed you do choose to snack instead of smoke, choose a healthy low-fat/high carbohydrate food such as pretzels instead of potato chips (although, there is a brand of fat-free potato chips on the market now).

Secondly, add a fun exercise program to your lifestyle. Just by adding 90 minutes a week (30 minutes 3x/week or 20 min daily) of any aerobic activity that your enjoy (walking, running, swimming, cycling, tennis/racquetball, etc..) will help you to maintain your proper body weight, not to mention the additional benefits of exercise such as stress reduction and improving self image.

Learn to hate smoking

Old habits are hard to break. Try to eliminate cigarettes from some of the activities that they are often associated with. Some of the more commonly identified opportunities for a cigarette include arising in the morning, morning coffee, breaks at work, meals, after sex, and while driving in the car.

Making it difficult to smoke at these times may help. For example, never carry cigarettes on you or near you; place them where they are difficult to get at such as on the top shelf of a kitchen cabinet. Find a part of your home or office that you hate to be in and make it a point to smoke only there. Always carry a substitute with you that you can fondle or chew on (see above) because if you get stuck without one the tendency is to try and bum a cigarette off of the nearest smoker that you can find.

Doing it "cold turkey"

Select a quit date that is realistic, usually about a week away and preferably during a relatively stress-free period at work or school. Until that time, "warn" all of your family, friends, and co-workers that you might be a little on edge for a short time. Explain that you're trying to give up a bad habit and that you'd appreciate their support.

When the day arrives, throw away all of your cigarettes and ashtrays. Wash your clothes and get rid of the smoky odors in your home. If your spouse or kids smoke, encourage them to quit with you in order to minimize their bad influences on you. (It's also easier when you have a support group) Try not to use any medications as "a crutch" unless you feel that you really need it (refer to sections on clonidine, nicotine substitutes). Use cigarette substitutes and modify your lifestyle activities as described. Also, try wearing clothes with lots of pockets so that you can keep your hands occupied (this sounds silly, but it works!).

Keep in mind al of the reasons why you are "torturing" yourself: remember the positive health benefits such as breathing easier, fewer coughing spells, less sore throats, whiter teeth, fingers without nicotine stains, etc. (Actually, expect to cough a little bit more frequently for about a month or two as the tiny little hairs lining your airways come back to life and start to clean out the tars that have been deposited over time.) Remind yourself that you're significantly reducing the risk of dying from cancer and heart disease.

Vanity can help you quit too; if you're a woman, remember that the scent of that nice perfume cannot be detected when you smell like a house that's on fire.

A penny saved is a penny earned

Finally, remind yourself of all of the money that you will be saving. At an average cost of $2.50 a pack, a one pack per day smoker blows over $900 a year. Double this if spouses smoke as well. You can also factor in the costs of visits to the doctor at least 2-3 times a year for bronchitis ($35-50/ visit average), breathing medications for persons with chronic smoking lung diseases (theophylline tablets, spray inhalers - about $50/ month), ulcer medications (about $40-60/ month), not to mention the chest x-rays to rule out cancer every time a smoker coughs ($65/ study). [Pity...all of this money literally up in smoke.]

This stuff really adds up surprisingly fast. You can take all of this new found money and spend it on a party, vacation cruise, or such "trivial" items such as rent, food and clothes. If you are a parent, think of all the toys that you can buy your children, instead of giving them frequent respiratory infections from second-hand smoke irritation. (Not to mention the fact that it will be nice to be able to play with your kids as they grow older, without getting too winded.)

Parting words

Good luck on your attempt to quit smoking, or chewing tobacco. Don't be frustrated if you fail the first time. Simply pick a new quit date and try again until your succeed - IT WILL HAPPEN!

You can obtain additional materials on tobacco cessation from your doctor, or groups such as the American Cancer Society and the American Heart Association.

Go ahead and perform a death-defying act - Quit smoking!

Jeffrey Pearson, D.O.

November 1990/Revised January 1993

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