My earlier posts introduced continuous quality improvement concepts, which can hopefully be used to effect behavioral change for healthier living. The next few posts will delve into various disease states and various agents that can promote disease states. This post deals with smoking.
According to the Centers for Disease Control, smoking cigarettes is responsible for nearly 90% of all lung cancer deaths in men and 80% of all lung cancer deaths in women. According to the Department of Health and Human Services, over 20% of all coronary heart disease deaths are attributable to cigarette smoking. According to the National Cancer Institute, among current smokers, over 50% of all deaths (both men and women) are attributable to smoking cigarettes. Most smokers know many of the health consequences of smoking, but they continue to smoke. Why? I hope this post may elucidate some of the possible reasons.
“The cigarette is ... among the most awe-inspiring examples of the ingenuity of man....The cigarette should be conceived not as a product but as a package. The product is nicotine....Smoke is beyond question the most optimized vehicle of nicotine and the cigarette the most optimized dispenser of smoke.”
To me, those few simple sentences speak volumes. They were written in 1972 by a Philip Morris senior researcher named William Dunn. Those words express why cigarettes fascinate me. I am an internal medicine physician with a strong interest in smoking cessation, but I find myself continually amazed by a simple cigarette.
I view cigarettes as exquisite nicotine delivery systems.
The middle of a lit cigarette can reach over 1,000 degrees Fahrenheit. This heat generates a smoke that allows almost instantaneous absorption of nicotine as it passes through the mucous membranes of the mouth. Further, the nicotinic effect of smoking can be auto-regulated at the will of the smoker -- that is, he can take short, frequent puffs or long, "satisfying" draws. He can extinguish it when he desires. What other drug can be so instantly regulated by the user?
Then there are the cigarette additives: ammonia, for example. Ammonia is a "base" substance. That is, it makes its environment less acidic and more basic. As smoke is inhaled, ammonium compounds neutralize the natural acidity of the mouth from a pH of around 6.8 to a pH of between 7 and 8. This increase in the mouth pH allows for more nicotine, which is also a basic substance, to be absorbed through the mucous membranes. Thus, by adding ammonium compounds, it is possible to "free the base" of nicotine, giving the smoker a much stronger "hit" of nicotine. With ammonium compounds, nicotine can be “free-based,” much the way cocaine is free-based with baking soda.
And ammonia is only one of hundreds of chemicals in a cigarette. There's menthol, which anesthetizes the back of the throat, allowing greater ease of smoking; cocoa, which opens up the lung airways and allows for deeper inspirations; and various sugars and sweeteners, which can soften and improve the taste of a cigarette.
Further, nicotine is incredibly addictive. In fact, according to the National Institutes of Drug Abuse, nicotine is more addictive than heroin or cocaine. This can make "breaking the habit" much harder than it seems.
I think an understanding of some basic pharmacology can help the smoker who decides to quit. Nicotine lasts in the body for six weeks. That is why nicotine patches use step-down approaches over a six-week period of time. And that is one reason why six weeks is considered a critical time-period to be smoke free, because by that time all the nicotine is effectively out of one’s system.
And that’s just the power of nicotine.
But, although the physical addiction to cigarettes can be very strong, the psychological addiction can be even stronger. Most people don’t just "smoke" cigarettes. Rather, they are smokers. Smoking changes their identity. And, I feel, this is why many people who desire to quit can break the incredible physiological addiction and be smoke-free for six to 12 weeks, but find it much more difficult to be smoke-free for a year or a lifetime. Ultimately, the smoker has to see herself a non-smoker. This is really a change in self-identity.
The ex-smoker not only has to resist the urge of a cigarette for the rest of her life, she also has to resist the thought of seeing herself as ever smoking a cigarette again, not after a satisfying meal, not after a stressful experience, and not even after a loved one passes away. Stopping smoking is a life-changing event.
And that’s why I ask smokers not only to set a quit date, but also to set a freedom date. Freedom from the cigarettes that don’t really offer stress relief or pleasure or satisfaction, but really only offer heart attacks, lung cancer, throat cancer and emphysema. In my opinion, one does not quit smoking; rather one sets himself free from it.
The CDC has a five-step plan to become smoke-free:
1. Get ready.
2. Get support.
3. Learn new skills and behaviors.
4. Get medication and use it correctly.
5. Be prepared for relapse or difficult situations.
1. Get Ready
Set a Quit Date and KEEP IT. Make yourself a diploma. Plan for your quit date by getting rid of all cigarettes and ashtrays, and don’t let people smoke in your home. Then, once you quit, don’t smoke –- NOT EVEN A PUFF!
2. Get Support and Encouragement
Tell your friends and family members that you have quit. This creates a positive peer pressure force to remain smoke free. Further, contact local agencies such as the local Health Department. Find a “stop smoking buddy.”
3. Learn New Skills and Behaviors
Develop action strategies to stop smoking. You may need to distract yourself. Talk, walk, exercise, drink water, but DON’T OVEREAT! If you associate smoking with certain activities, then change your routine –- take a different route to work, eat breakfast in a different place, eat a mint instead of using cigarettes. If you smoke for stress relief, find different activities to supplant this role (a hot bath, exercise, reading, etc.) CELEBRATE your daily successes with at least one enjoyable activity every day.
4. Get Medication and Use It Correctly
Nicotine replacement products, Buproprion SR (Zyban®) or Chantix can double your chances of success. Ask a physician if one of these products is right for you.
5. Be Prepared for Relapse or Difficult Situations
Most people relapse before they quit. Most relapses occur within the first three months after quitting, so be especially vigilant during this time. Avoid alcohol and other smokers. Accept a few extra pounds (most gain less than 10). Finally, accept stressful situations as challenges to see if you can find other means of stress relief besides getting a cigarette.
I have posted an 8 minute youtube video on smoking which you may find informative.
Lastly, for a little personal plug -- I do have a trademarked anti-smoking cartoon character named Jack Jackass. Check the Smoking Mule Fool out at www.JackJackass.com
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