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Becoming Smoke-Free

Our guest experts in April 2011 were the members of the interdisciplinary team from The Journey to Become Smoke-Free, a smoking cessation program based at Women’s College Hospital Family Practice Health Centre:

Mary Novak, Registered Nurse and Lecturer in the Department of Family and Community Medicine at the University of Toronto

Dr. Helen Batty, Professor, Director, Health Professions, Teacher Education MScCH and Enhanced Clinical Fellowship for Future Clinical Teachers Programs, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto

Behnaz Abedi, Registered Dietitian

Karen Burrell, Social Worker

The Family Practice Health Centre is one of Ontario’s largest designated family health teams serving people of all ages. The interprofessional Journey to Become Smoke-Free program won an award for Excellence in Creative Professional Activity from the department of family and community medicine at the University of Toronto, 2008-2009.

Here are the responses to your questions about Becoming Smoke-Free.

Q: Are there any residential treatment programs available or being developed for smokers who wish to quit? The concept would be similar to the residential facilities available for other kinds of addictions, such as alcohol, drugs, etc., where smokers who wish to quit could get appropriate help (including counselling if required) throughout the process. This would remove the person from their usual environment, lifestyle, triggers, etc. and give them the support to get past even just the first week or two. I will be 69 this year, and have been a heavy smoker since age 12 or 13, so a very long time. The potential side-effects of the smoking cessation drugs scare me more than death itself, but I have tried every other possible cessation help, including hypnosis, laser therapy, the many patches, etc., psychotherapy, the CAMH program, etc. – all to no avail. There are of course all the obvious reasons for wishing to quit, even at this point in my life, not the least of which is that I have had worsening COPD for years, and have also had cancer twice in the past 10 years or so. My own sense of this is that I think I could possibly do it (quit), but experience to date is that I would very much need some consistent ongoing help. Hence my question today. Thank you for your consideration.

A: I love your question. Yes, if only we could be transported to that safe place where magically it would all be changed...and if it was…and you went to sleep tonight and while you slept, a miracle did happen, and when you wake up, you find that the miracle is that you are smoke-free and have been for a very long time, what would that be like for you? What would you be doing differently in your day-to-day living? What would you do when you got up in the morning? How would you spend your morning? What would your afternoon be like? Who would you be spending time with? How would you handle stress? How would you relax and enjoy yourself?

Is any of that happening now? How can you do more of that now?

Any hospitalization forces a person to be smoke-free and helps people get over the drug withdrawal in the first two weeks. But drug withdrawal from nicotine is only one of the three factors in quitting. You think you have beaten it, but then you go home where everything triggers the craving because practice makes perfect: it is not at home that you have practiced being smoke-free. Everything in the home reminds you of the smoking you do in this chair and on that sofa and at this table while you read this paper and drink from that cup while you talk to this person on the phone. While in hospital, you learn to be smoke-free with that environment, but that environment was easy because you never smoked there.  Learn about the other factors involved in being smoke-free and consider them in your journey. What can you be changing? Could you go out for walks more and not smoke? Could you go to the library and read where you cannot smoke? Could you visit with people who don’t smoke in their homes where smoking isn’t allowed?

You have worked very hard and you have determination. You gained something from every one of those things you mentioned above. What did work? Most people who quit do so with the accumulated knowledge of every one of those attempts, and most people start to quit with the very first cigarette they smoke. Did you say, ‘I will never smoke that much’?

You said that “The potential side-effects of the smoking cessation drugs scare me more than death itself…” and I wonder where your intense fear comes from? Cigarettes have 4,700 chemicals (drugs) in them. What makes those 4,700 ‘drugs’ safer than the smoking cessation drugs you fear? Those smoking cessation drugs each have no more than two or three different components to them. None has 4,700 like cigarettes do. Prescription drugs are safer than the chemicals in cigarettes, especially when prescribed for your particular concern and supervised by your trusted doctor. The CAMH’s smoking cessation program is led by Dr. Selby, who is a leading authority on these medications, and the newest of CAMH’s smoking cessation support groups offer a very long group support followup.

These drugs have only been available since about 1986. Before any of these drugs were available, 75 per cent of people who became smoke-free did so with no drugs. Is that an option for you at this time?

Going to stay with someone who doesn’t smoke for a month might also help.

Vacations are a good time to become smoke-free, when you are out of your normal element. But when you come home, you will need to be prepared for the cravings and be ready with a plan for how to manage them.

 


Q: Are there any communication approaches you recommend for people with loved ones who smoke? Any words of encouragement I should focus on? All I want to say to my brother is ‘why the heck won’t you quit,’ but I acknowledge that is not the right approach.

A: Twenty-five years ago, society didn’t know how to help anyone to become smoke-free, and in fact we prescribed and supported smoking for weight reduction and stress relief before the negative side-effects of smoking came to be recognized. Then health care turned its focus to helping people to become smoke-free. In 25 years we have moved from 27 per cent of the population smoking to 20 per cent. It is still legal to smoke, but the places where people can smoke legally have been reduced. That has been very valuable in helping people to realize that they in fact can be smoke-free in some places – and that is a beginning. 

The first challenge for us all was to learn how to dialogue with those who smoke (for the same reasons you state) and still maintain a good relationship. All smokers are working on quitting after their very first three cigarettes, when they vow to quit before they reach a certain number or age or health state. It is one thing to know you have to do something and another thing to actually act on it. Motivation interviewing is an art.

The key to any relationship is compassion. Expressing your genuine concern and wish to have your brother in your life could be a start, using words that you and he are comfortable with. Allowing him to dialogue safely about that and his plan to become smoke-free (all smokers have one) is the best start. The second thing is to support the person’s plan with compassionate understanding and an offer to be there for him when he wants you to be.  If you are a comedian and your brother and you have such a method of communicating, then “why the heck won’t you quit” may in fact be where you want to start if you think it will engage him and not turn him off.

 



Q: If I use a nicotine patch or gum to help me quit, won’t I just be addicted to the patch or gum instead?

A: There are 4,700 chemicals in the smoke of tobacco, including arsenic, cyanide, mercury, DDT, formaldehyde, urethane, lead and carbon monoxide, to mention a few. Nicotine is also one of those chemicals. Nicotine is a drug that affects mood. It makes people ‘feel better,’ ‘calm down,’ ‘decrease stress,’ and ‘think more clearly,’ ‘feel like they have a friend,’ ‘escape.’ It is not thought to be ‘bad’ by itself, but it is the one that keeps you taking in the other 4,699 just to get the nicotine.

The addiction to nicotine is only one of the reasons people struggle when they are in the active process of withdrawing from smoking cigarettes, but it is the discomfort of nicotine withdrawal that people recognize the most. There are effective replacements to help with that withdrawal and that is the patch, and the gum.

In order to get nicotine from smoking, a person has to take the 4,699 other chemicals in smoke. The amount of all these chemicals absorbed into the body is regulated by how deeply, how long and how frequently one inhales. To take in more nicotine, more of everything else has to be inhaled. The other 4,699 chemicals are thought not to be addictive. Your body doesn’t miss them.

If the patch or gum prevents a person from having even one more puff of smoke, then being addicted to the patch or gum is a risk a person might prefer and may even prefer it for life if that makes them stay smoke-free. For life, though, may not mean every day. Once you become comfortable with your everyday routine as a smoke-free person, you could choose to keep the patch or gum for new and difficult times that you have not practised as a smoke-free person. People relapse when they go into situations where they have only ever been as a smoker. Knowing this in advance, and ‘patching up’ in advance of a difficult situation, could keep you from relapsing.

If you quit ‘cold turkey,’ which means no more smoke, it takes two to three weeks for the chemical of nicotine to be out of your body. In other words, the nicotine will no longer be what is keeping you uncomfortable. During these weeks, you are also changing habits and social patterns, so many people find it easier to use a replacement for nicotine to get over the hurdle until they have practiced being smoke-free long enough in their day-to-day activity, and to wean off the replacements slowly and at a pace you are comfortable with. Each time you lower your dose of nicotine replacement, you will need to prepare for a much smaller but still present physical withdrawal. There is no need to rush withdrawal of replacements if it keeps you smoke-free.

Your journey to becoming smoke-free is a journey you will design, and you will know which one is the best for you.

 


Q: What are the differences between the prescription drugs used to help people stop smoking? Do Zyban and Champix work differently? Can they be used together? Are there any other medications that are helpful?

A: Zyban and Champix fit into the class of mood-modifying drugs. Sometimes people use nicotine ‘to feel good.’ That means they use nicotine as an antidepressant or as an anti-anxiety medication, and that is why some people may choose to consider antidepressants to help them stop smoking. Many people dislike the idea of a prescription drug but if it treats your problem more accurately and more safely than smoking does with 4,699 other chemicals, then it is an option some people should consider. Again, 4,700 chemicals that are non-prescription, are not a better option to continue with.

Sometimes people choose antidepressants and nicotine replacements. They work differently and can be taken together.

When nicotine replacements first came on the market, they were by prescription only but they soon became available over-the-counter as their risk is far less than that of smoking. A denial of a prescription for a nicotine replacement was a prescription to continue smoking.

 

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