By Lloyd I Sederer, MD, written with Gregory A. Miller, MD and Teresa C. Armon, RN MS
Visit Dr. Sederer's website at www.askdrlloyd.com -- for questions you want answered, reviews and stories.
Tobacco use is the greatest preventable cause of death and medical disability in the United States. Tobacco kills and contributes significantly to the development of killers like heart disease and cancer. Yet its deadly impact is preventable. When people stop smoking, their risk of death and disability drops steadily and progressively.
The CDC estimates that approximately 450,000 people die prematurely in the USA, and more than 8 million Americans are medically disabled by use of tobacco (the consequences of smoking to the lungs, heart, blood vessels, and organs that develop cancer). If you think that is just someone else's problem (and don't calculate the economic costs to society) then consider that inhaling other people's smoke (second-hand smoke) has recently been shown to increase the risk of adult onset diabetes and of impaired mental functioning. It is the tars and byproducts of inhaled tobacco smoke that cause lung damage and serious health consequences. In fact, when nicotine is absorbed but not inhaled (like with patches, gum and nicotine "inhalers" which deliver nicotine through the skin and membranes of the mouth and throat) it is not a dangerous drug, even when used for long periods. (1,2)
Women smoke a little less than men and Asians smoke significantly less than Caucasian, African-Americans and Hispanics (in the US). Native Americans greatly exceed all these groups. But there is one group that blows away the others (hard to resist that pun): people with a mental illness or heavy users of alcohol or drugs. These individuals consume near to half the cigarettes smoked in this country! Among individuals with mental illness or with alcohol and drug problems over 70 percent smoke (compared to about one in five of the general population - whose smoking rates have dropped from 50 percent 50 years ago). About one in two people with depression and anxiety conditions smoke - twice the rate of the general population. Three out of four people with alcohol and drug problems smoke - a rate comparable to people with bipolar disorder or schizophrenia. Notably, these individuals report a desire to quit at the same rate as do others (70 percent).
There are a number of good reasons to explain the huge disparity in smoking between people with mental and substance use problems and the rest of those who light up. The nicotine in tobacco has been shown to improve mental concentration and can improve mood, especially in depressed individuals. Smoking is well known as a way of coping with stress, and the greater the stress the greater our need to combat it. The pleasure of smoking is no small factor (Freud did get it right when he wrote that the pleasure principle warrants respect), particularly in people whose mental states find it hard to engage in and feel the pleasures of relationships, work and play. What's more, quitting takes support from friends and families and quit rates are increased by medications prescribed by doctors - both resources that are often limited in people with these conditions. Finally, doctors have not done such a good job of asking about smoking, and offering to help.
The "5 A's", from the Public Health Service, Clinical Practice Guideline, are one way doctors and other health care providers are being trained to inquire about smoking and to help their patients:
1. Ask about tobacco use during regular visits
2. Advise the person to quit in a clear and personal manner (like, smoking is the most important thing you can do for your health and for your family)
3. Assess for a willingness to quit. On a scale of 1-10, ask "where are you?" Ask "are you willing to make a commitment to quit in the next 30 days?"
4. Assist in helping someone quit. Set a date for quitting. Offer medication and/or counseling
5. Arrange for the person to return for a visit - soon - in a week, if possible, to support the effort and address relapse, which is common. Congratulate success!
Since some of us have trouble remembering 5 things, a simpler approach is:
- Have you had a puff of a cigarette in the past month?
- If so, do you want to do something about your smoking?
There are various treatments now available to help people quit smoking. Medications include NRT, or nicotine replacement therapy, which comes as a patch, gum, lozenges, inhaler, or nasal spray; some are available over the counter and some require a doctor's prescription. Buproprion, customarily used as an antidepressant, is effective for people with or without a history of depression and can reduce craving and thus improve quit rates. Varenicline, which seems to work like nicotine does in the brain; it enters the nicotine receptors on neurons, reducing craving and improving quit rates. It is not a good idea to combine Varenicline with NRT agents. All medications have risks and side effects as well as benefits, so be sure to understand both before you start. Counseling may be through individual, group, or telephone format, and focuses on providing encouragement and support from all who can provide it (the doctor, smoking cessation counselor, friends and family) as well as problem solving - or helping people develop skills for those moments they used to rely on a cigarette to master.
Combining medication and counseling adds to the effectiveness of each one, and increases your chances of successfully quitting. For your sake, keep in mind that smoking is one of the hardest addictions to control. What is common is that most people try many times before they finally quit. But don't lose faith - when the time comes the results are priceless.
1. Murray RP, Bailey WC, Daniels K, et al: Safety of nicotine polacrilex gum used by 3,094 participants in the Lung Health Study. Lung Health Study Research Group. Chest. 1996 Feb;109(2):438-45.
2. David Moore, D, Aveyard, P, Connock, et al: Effectiveness and safety of nicotine replacement therapy
assisted reduction to stop smoking: systematic review and meta-analysis, British Medical Journal, 2009;338:b1024.
The opinions expressed herein are solely our own as psychiatrists, a nurse and public health advocates.
Lloyd I Sederer, MD
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