[THURSDAY NIGHT IS HEALTH CARE CHANGE NIGHT is a new series started by TheFatLadySings. In it we seek to find ways to effect change in the health care system. Tonight, we observe that change begins at home. This diary is an update of one a few of you old timers might remember.]
"Did you ever smoke?"
That's a common response when I ask my patients to quit smoking. No, I answer, but I've been trying to get people to quit for more than 20 years, so my experience with the topic isn't that much briefer than yours. In those decades, I've evolved an approach to the subject which is slightly different than the usual. I've been able to help quite a few smokers quit who haven't been able to any other way.
There are many ways of quitting smoking, but there are also a finite number of challenges smokers face and ways of dealing with them. It helps to look at these analytically, to find your strengths and use them to your advantage, and to take advantage of past experiences in trying to quit. Please share your experiences and stories to help your fellow smokers.
Quitting smoking actually presents smokers with a number of interconnected and mutually reinforcing challenges. If these challenges are not all simultaneously recognized and addressed, the odds of quitting drop. So what are these challenges?
1. Smokers are nicotine addicts. Nicotine is a highly addictive substance, perhaps the most addictive legally-available chemical. Quitters must therefore overcome strong cravings for nicotine. They must also suffer withdrawal symptoms, including irritability, food cravings, headaches, nausea, insomnia, fatigue, and all the rest. (Add your own symptoms here ___.) Withdrawal symptoms can continue for up to three months, with gradually decreasing but variable severity. They're a bitch.
2. Smoking is a collection of habits. Most smokers readily admit that smoking is a habit. Actually, it is a series of habits that occur regularly through the day, very stereotyped behaviors which are unconscious rather than conscious choices. A pack-a-day smoker probably has between 6 and 10 smoking habits.
The first couple of cigarettes with coffee in the morning are a habit. The cigarette in the car on the way to work is a habit. Cigarettes during the morning coffee break, lunch, and midafternoon are habits. The one on the way home is a habit. The cigarette at the table after dinner is a habit. The 3 or 4 blogging in the evening are a habit. Weekends have their own habits.
Every situation during the day in which a smoker ritually lights up is a separate habit. These habits are different than -- though reinforced by -- nicotine addiction. It is vital to distinguish between nicotine addiction and habitual behavior when trying to quit, because they have very different solutions. Most quitters of my acquaintance have had far more difficulty with their habits than their addiction, mainly because the habits tend to go unrecognized and unaddressed.
3. Smoking serves different functions at different times. The most common cause of "secondary" smoking is as a stress releaser. What smoker under stress doesn't go outside, take out a cigarette, gaze off into the sky as they light up and take a deep drag, then bloowwwwww the stress away with that first lungful of smoke. Almost everything about that behavior is good stress management: taking yourself out of a stressful situation, unfocusing the eyes, deep breathing -- it's really almost mini-meditation. The thing is, you don't need a cigarette to do it.
Coping with boredom is another common cause of secondary smoking. Every smoker can name others. What are yours?
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With these realities in mind, how can we use that knowledge to quit smoking? By examining them one at a time. In my long experience of helping smokers quit, one challenge trips up smokers more than any other. We'll tackle this one first, then move on to the rest.
The most important step in quitting smoking: Changing Habits
You want to quit smoking? You gotta break your habits. It might be easier than you think. You can't change behavior until you become conscious of what it is, and most smoking is unconscious behavior. It's not a choice, it's automatic -- governed by habit. So the most vital task is gain control of your habits.
To do this, sit down with three pieces of paper. You're going to make three lists:
1. Write down every cigarette you smoke in the day, from the first one you light up after the alarm clock to the last one you stub out before turning out the light. When during the day do you light up each one? What are you doing? This won't be hard: you probably smoke the same cigarettes every day. Write them down. Don't forget weekends, too; they may be a separate list because your habits may be totally different then.
2. Figure out what your smoking habits are. Not quite the same as the first list. For instance: with coffee in the morning; in the car; during breaks at work; after meals; while watching the tube; while blogging. Each of your cigarettes on the first list are probably explained by a habit.
Habits are what trigger smoking. They put the butt in your hand and drive you to light up. Until you have control of them you don't have control of your smoking. Recognizing them and writing them down begins the process of taking control
3. Generate change strategies for each habit. Your habits will each have to be tackled individually, so try to think of what you'll have to do to break each and every habit. There are two strategies that are generally effective: avoidance, or staying away from a smoking situation (e.g. Friday night at the pub); or substitution, putting a new habit in place of the old one. Substitution is much more widely applicable. Come up with a couple of ideas about how to change each habit you've listed on page 2. Ideally, they shouldn't all involve calories, so you don't gain weight. Write them down in the third list.
Finished? Congratulations. You've just done the hardest part. Next, putting it into action. Pick your approach:
One habit at a time. Look at your list of habits and pick the one that looks like it would be easiest to break. Grab the low hanging fruit. Take a deep breath and put your change strategies into action, for that one habit. Don't worry about the others.
Work on that one habit until you've got it licked. Don't worry about how long it takes. You're learning how to change habits: it takes time. Keep trying changes until you've got it licked. Now congratulate yourself and cross it off the list. Look at the list of habits again and pick another habit that looks pretty easy. Lather, rinse and repeat. Keep it up until you've got them all crossed off the list.
Quitting smoking one habit at a time breaks an awesome task down into bite-sized pieces. It teaches you how to change your habits, and gradually reduces your nicotine consumption. As you work through your list of habits, you get better at changing them, and you become gradually less addicted to nicotine. Withdrawal symptoms are generally not a problem, because you don't reduce your consumption too much at once.
All at once. Some people can't take a gradual approach. They are powerless, in the 12-step sense. That's OK. Make your lists. Consider chemical assistance (see below). Review your change strategies. Pick a date. Use all the ideas below that sound good to you. And have at it!
Better living through chemistry.
Chemical aids are generally aimed at helping smokers through nicotine withdrawal syndrome. For people whose previous quit attempts can be measured in hours or a few days, they're worth investigating. These people are usually the stone addicts. There are two general types of chemical aids:
Nicotine replacement systems. Nicotine can be delivered in any number of ways aside from cigarettes. Gum, patches and cigarette-like inhalers are all available and have their devotees. Lozenges (like Commit) are probably the most popular. For pack-a-day-plus smokers patches are a good option, but for lighter or more casual smokers one of the others might be more suitable. Side effects are occasional (mouth sores, skin reactions, etc.) but usually not severe.
Withdrawal symptom suppressors. Varenicline (Chantix) is the newest drug available, with up to a 50% quit rate with six months of use according to the most optimistic results. It blocks the brain's ability to perceive nicotine, causing smokers to lose interest in cigarettes. Side effects are moderate, from GI complaints to vivid dreams to new or revived psychiatric problems. Most people in my experience tolerate the drug well, but it's not for everybody.
Bupropion (Zyban, Wellbutrin) is an antidepressant drug which has been used for over a decade to help smokers quit. Anxiety, sleeplessness, and a tendency to bring out seizures are the most significant side effects, but on the brighter side people tend to lose a little weight using it.
Clonidine, a blood pressure drug, and nortriptyline, a sleeping pill and old-line antidepressant, are sometimes used to help smokers quit, but no longer widely. Both cause significant sedation in many patients, but the latter is useful for insomniacs. Neither is as effective as the drugs listed above. There are a wide variety of herbal, Chinese, ayurvedic and homeopathic smoking cessation aids as well, but I'm not qualified by training or experience to comment on them. All can be valuable if they help you. Consult with your doctor before considering chemical aids: they're not safe for everyone, and should be chosen carefully with professional advice.
Stress management and smoking
Why do people go back to smoking after quitting? There seem to be two main reasons: unresolved habits and major stresses. Quitting by changing habits, as outlined above, helps to prevent old habits from coming back to bite you on the ass. Stress is another matter.
Almost all smokers use cigarettes as stress releasers. When the going gets tough, the tough go outside and light up. If you give up cigarettes you need a new stress releaser, otherwise a situation will someday arise you don't know how to handle. Next thing you know you'll be at the corner 7/11 buying a pack and smoking it greedily.
Think about how you deal with stress in your life now, aside from lighting up. Going for a walk, yelling at the cat, going into the bathroom at work and banging your head against the wall ... all these are even more valuable when you're trying to quit smoking. Learning two-minute meditation can be invaluable, if you have a friend or a local class to teach you. However you do it, you need a readily-available stress releaser to take the place of smoking.
If you don't have another reliable stress releaser, practice this: go outside and "smoke," but don't bring your cigarettes. Look off at the mountain in the distance, pantomime lighting up, take a drag off that imaginary cigarette, and watch the invisible smoke blow your stress away. I promise you, you'll get the same release. You don't need the cigarette. Keep doing it, and drop the silly smoking pantomime. It's a great technique; you just don't need to smoke to do it.
Other Ideas for Quitters:
If you want to quit, give yourself every advantage you can. Play every angle that works. Following are some techniques that are very helpful for some people. There are a million of them: share your favorites in the comments and invent your own.
1. Keep your motivation fresh. Make a list of all the reasons you want to quit. Attach pictures of the kids or grandkids. Make copies, and post them where you'll see them: the refrigerator, the bathroom mirror, the cubicle wall, the passenger seat in your car, wherever you might need reminding.
2. The piggy bank. Just for fun, add up the amount of money you spend in a month on cigarettes. Prepare to be scandalized. If your budget is a little tight, try this one: every day, drop the amount of money you'd spend on cigarettes into a piggy bank. You won't miss it--you're already spending it. Tell yourself that when you've been a non-smoker for 6 months, you get to buy yourself a present. Don't blow it on the light bill, make it something you really want, but maybe can't afford. This can be a wonderful reward for quitting--as if your health and your sense of smell weren't enough--and can be a fantastic motivator for some.
3. Vanity. Think back to last Thanksgiving, when you last saw your aunt Tillie. You know, the one who's smoked two packs a day for 40 years. Remember how her face looked like a piece of unironed washed linen? Cigarette smoke dramatically ages the skin of the face, creating those fine lines that multiply and deepen and make people look much older. If you care about your appearance, ponder this deeply.
4. Accountability is your friend. Tell all your friends, family, and coworkers you're quitting smoking, in your cockiest voice. When they scoff, be self-assured. Offer to bet them, even. That way, if you're ever tempted to backslide, the thought of all the "I told you so's" that go unsaid but not unthought will deter all but the hardiest recidivist.
5. Be responsible for yourself. "I'd like to quit smoking, but my husband [wife, partner, son, mother, cat...] smokes. I can't do it alone." Bullshit. Sure you can. It's great if you can get other smokers in your house to quit with you, but you can't hold your success hostage to theirs. If you smoke together, that's a habit. Deal with it. If you get no cooperation, that makes it harder. You just have to try that much harder. Once you're a pain-in-the-ass ex-smoker, maybe you'll nag your loved one into joining you.
6. Use the Internets. The list of stop-smoking websites is endless and to a certain extent repetitive. Every smoker has his/her favorite, so please share yours in the comments. Here are a few well-recognized sites:
Official Government Information.
American Cancer Society.
American Lung Association.
About.com (surprisingly informative, if you poke around.)
You've made it this far?
Wow, you must really want to quit! Well, good. That's the one necessary requirement. Quitting is hard; it's not impossible. You've really got to want to do it to succeed. If you're reading this sentence, you obviously do. You can quit. Believe, and make it so.