New Year's Resolution 1 = Stop Smoking

Smoking Cessation Smoking cigarettes is the most important preventable cause of death and disability in this country. It is estimated to be responsible for one fifth, or 480,000 deaths a year. The life expectancy of a smoker is 10 years less than a non-smoker. It affects nearly every organ system. Lungs, heart, GI tract, nerves, skin, etc. We know that smoking causes cancer: lung, bladder, blood, cervix, colon, esophagus, kidney, voice box, liver, mouth, pancreas, stomach. It is also terrible for the circulation, causing heart attacks, stroke, peripheral vascular disease, and wrinkles. And every smoker develops chronic lung disease (emphysema or chronic bronchitis) if they live long enough. Babies of smokers are born weighing too little. Children of smokers develop asthma more frequently than children of non-smokers. But it’s not just that smoking causes premature death. It causes premature aging. Smokers look and in effect are older than their numerical age. I come from a family of smokers. Both of my parents smoked. All of my siblings smoked. I smoked. Nothing gives me more pleasure than to help someone stop smoking. This is a good time of year to stop. I think 10 of my patients have told me they stopped smoking this week. I wanted to write about it. I like to tell my own story. I started smoking at 17. To put that in context, cigarettes were 25 cents a pack and $2.25 a carton and available to anyone at a cigarette machine. They were advertised on television by people wearing white jackets and looking like doctors. You were allowed to smoke almost anywhere: in theaters, in bars, in restaurants, in planes. I believe you were not allowed to buy cigarettes if you were under 18, but no one checked. Though most people knew cigarettes were dangerous, the cigarette companies insisted there was no proof. My father, who was a PCP and clear about the dangers of smoking, though he himself smoked a couple of packs of unfiltered Chesterfields every day, warned me not to start smoking, but I did, and I was soon addicted. At about 19, it was a bitter cold, windy, and snowy night. I was comfortably in my bed under the blankets in my pajamas. I ran out of cigarettes, put on my boots and coat and went to the closest store to buy more. When I got back to my dorm, I told myself “I am not going to let these things put their fingers around my neck any more.” At that moment, I became a non-smoker, though it took me 15 years to stop. So I was a non-smoker who was still smoking.

At that time as I recall, the only aid available for stopping smoking was nicotine gum, but somehow it never occurred to me to use it. So I quit cold turkey. About 100 times. I tried changing to a pipe. To cigars. No help. The last few times I quit I told myself: “There may be someone out there who can take a puff here and there or a cigarette here and there and won’t go back, and it's possible that I could, but one thing I know for sure – if I don’t, I won’t. And do we remember how much fun it was to quit the last time? How much more of THAT kind of fun are we looking for?” For the first few days, I thought about smoking every minute. For the first few weeks, every hour. For the first few months, every day. But after about twenty years, I stopped craving it.

Cigarettes are among the world’s most addictive substances. I once read that of people who smoke two cigarettes in their life, 72% become addicted. Every puff produces powerful positive reinforcement, and at 20 puffs per cigarette and 20 cigarettes per pack, people experience 400 surges of dopamine per pack.

When evaluating someone for smoking cessation treatment, it is important to check for other addictions. An active alcoholic or substance abuser is unlikely to be able to stop smoking. Cannabis is a possible exception, perhaps because an experienced cannabis user does not experience a significant loss of inhibition. Sometimes patients choose to stop smoking cigarettes and cannabis at the same time and because for most people stopping cannabis does not produce a withdrawal syndrome, stopping both can enable the user to get rid of ashtrays, lighters, etc., together.

It is also useful to screen for mood and psychotic disorders. A report from a smoking cessation clinic in, as I recall, Maine, showed that of the 3000+ participants, a typical fraction, about 20%, achieved objectively confirmed cessation of cigarette consumption after several months. Of the 300+ participants who had a major depression, however, none stopped. To my way of thinking, smoking cessation requires substantial mental control and depression (along with mania, psychosis, sleep deprivation, and intoxication) robs a person of self-control, making them what is sometimes referred to as “frontal”, meaning lacking the function of the frontal lobe.

For people who either have not decided to quit yet or who have another reason which makes the likelihood of their quitting low, I tend to say the following: “Do not stop. Do not cut down. Hate them.” What people mostly mention when I ask what they hate about them are the expense, the smell, having to smoke outside, the risk to their children and the risk of not living to see their children and grandchildren grow up, the cough, the difficulty breathing, and the other health risks. I ask them to think about those things when they smoke. I suggest that when a child says to them that they smell or that they shouldn’t smoke, they thank the child and say that hearing that will help them stop.

When it’s time to stop smoking, I usually recommend Chantix plus nicotine replacement, such as the patch, gum, lozenge, or inhaler, or an electronic cigarette. Chantix stimulates the nicotine receptors in the brain. It usually helps people cut down to about 4-5 cigarettes a day. Combining it with nicotine seems to be even more effective in helping people stop completely.

People are understandably concerned about both. About Chantix, I remind people that the FDA no longer has a special warning about its risk of depression and suicidality. I mention that I treat only psychiatric patients and that I have given hundreds of them Chantix. I ask people “do you suppose I ever see depression and suicidal thinking in the patients I give Chantix to?” I answer my own question: “Of course I do. Psychiatric patients at times develop depression and suicidal thinking.” “But is it worse in patients on Chantix?” “It can be more intense, but stopping the drug stops the reaction, and I have not had a patient have a suicide attempt on it.” More of an issue is loss of appetite and insomnia, but those can be handled with a dose reduction. My patients have done well on as little as a fourth as much medication as the usual dose.

What about nicotine replacement? Isn’t that dangerous, too? It may be slightly dangerous, but it is so much safer than regular cigarettes that if it helps you stop smoking, the choice is clear. What about the expense? Electronic cigarettes are much less than conventional cigarettes. I recommend that people go to a shop that cells a lot of electronic cigarettes and get their advice. Some people think that an electronic cigarette is to give them something to do with their hands and mouth. No. It is to deliver nicotine and make people less likely to smoke. Nicotine is addictive but in itself does not appear to be harmful. Smoking is.

Nicotine replacement products are produced as a patch in three strengths, as a chewing gum or a lozenge in two strengths, and as an inhaler which is available only by prescription. Bupropion (Wellbutrin or Zyban) is a prescription antidepressant also found to be helpful for some people (I would estimate one out of three people is helped dramatically with it).

However you do it, and no matter how often you slip, stopping smoking is worthwhile. I never met anyone who regretted it.