Too
Much, Too Soon?
Ending Nicotine Dependence in Recovery
by Valerie White, Esq.
Valerie White, a longtime member of the SOS
International Advisory Board, has written a regular column appearing in every
issue of the SOS International Newsletter since 1990. Her passionate
presentation about nicotine addiction delivered at the SOS conference follows.
I quit drinking in October of 1987. But I was still
smoking cigarettes. One Friday the following March, I came down with a severe
cold or flu which kept me in bed and asleep pretty much all weekend long, and
which had such obnoxious respiratory symptoms that I didn't want to smoke. When
I woke up Monday morning finally feeling as if I were going to live after all, I
thought about having a cigarette. But then it dawned on me that I had not had
one since Friday night and the worse of the nicotine withdrawal must be over. .
. . I never smoked again. My mother lived with me; she smoked. My secretary
smoked in the office. My boyfriend smoked. But by some mercy I didn't. I never
begged a drag or bummed a cigarette. I was cured! I cannot really account for
the grace of this recovery. I was not heavily addicted to nicotine, I have
learned since. I did not smoke in the mornings as a rule, even though that was
when my blood nicotine levels were lowest. I discontinued the use of tobacco
during my two pregnancies without much difficulty. But there were times when I
would go through the pockets of all the clothes in my closet and check the
bottom of my handbag to put together enough change for a pack of cigarettes and
times when I would be reduced to smoking my mother's brand. There were times
when I rummaged through the ashtrays looking for a butt which was long enough to
relight.
Many people discouraged me from quitting in such early
sobriety, but I did it anyway. And I'm so glad. What a relief it was to get this
monkey off my back. Never again to scrounge. Never again to have to check before
going out . . . do I have a lighter or a book of matches? Do I have enough
cigarettes to get through the evening? No more burn holes in my clothing.
This idea that asking alcoholics and drug addicts to
quit smoking too is "too much, too soon" is being challenged. In fact,
treating the use of tobacco as nicotine dependence, as another kind of substance
abuse, is Department of Public Health policy in the Commonwealth of
Massachusetts.
Recent research has made it clear that people who quit
smoking in recovery are less likely to relapse to their drug of choice than
people who continue to smoke. Exactly why this should be true isn't clear.
Smoking can be a trigger for cravings for other drugs of addiction, including
alcohol. Nicotine certainly affects brain chemistry in many profound ways.
Perhaps quitting smoking is a part of a new philosophy of "in corpora sana,
mens sana."
After 12 years of sobriety and substantial involvement
with SOS (I write a regular column for the newsletter, serve on the advisory
council, and convened a meeting for several years), I finally got a real job in
the field of substance abuse in July of last year. I became the director of
program development at a licensed private non-profit outpatient substance abuse
facility in Boston. Court-referred DUI defendants are the largest part of our
client base. My mandate as the new hire to a new position was to try to find
other populations we could serve. So when the Commonwealth issued a request for
bids for the provision of tobacco treatment, I was happy to write the grant.
Massachusetts is one of the states which received a lot
of money from the tobacco company settlement. Unlike many of the recipient
states, which now sport new bridges, morgues and prisons, Massachusetts, in a
burst of unusual wisdom and common sense, dedicated these funds to public
health. Further, a citizen initiative called Proposition 1, which passed in
1992, established new taxes on tobacco products which served both to deter
consumption and to generate millions of dollars to fund the Massachusetts
tobacco control program. Massachusetts has accrued an enviable record in the
effort to combat tobacco.
At 19%, the decreasing statewide adult smoking rate in
Massachusetts is much better than the national stagnant average of 25%. In
contrast to the rest of the country, where youth smoking is increasing,
Massachusetts youth smoking rates are going down. Two thirds of the towns in
Massachusetts, including the People's Republic of Cambridge, have banned smoking
in public places. Contrary to doomsayers' expectations, restaurants have not
lost business in consequence. The rate of smoking by pregnant women has been cut
by half since 1990, giving Massachusetts the lowest rate (13%) in the country.
The Boston Globe does not take tobacco advertising. The Massachusetts Department
of Public Health Bureau of Substance Abuse Services, the licensing agency for
treatment agencies like mine and for residential programs and detoxes, mandates
that these facilities not allow smoking inside. Some of these facilities are
also going "tobacco free" . . . that is, they require participants to
quit smoking and flunk them out if they catch them smoking even off-premise.
A strong motivator for substance abuse treatment
professionals to urge their clients struggling towards recovery to quit smoking
too is that these clinicians are tired of watching their clients dying of
tobacco related diseases. According to a 1996 study, tobacco related diseases
are the leading cause of death in patients previously treated for alcoholism
and/or other non-nicotine drug dependence.
Smoking is the number one preventable cause of death in
the US. Nicotine is more addictive than cocaine and heroin. If you ask people
who have EVER used cocaine when they last used it, 10% will have used it during
the past week . . . this is a rough measure of the number of people who became
addicted. Contrast that rate to the statistic recently reported that forty three
percent of people who smoke three cigarettes become addicted. I well remember,
when I served on a volunteer rescue squad in Vermont, repeatedly going to the
home of two middle-aged persons, a married couple, both of whom had chronic
obstructive pulmonary disease, emphysema, and who used oxygen, but who STILL
SMOKED - of course, they would turn the oxygen off before they lit up. I
remember and mourn a wonderfully talented musician, who played the organ in a
Unitarian Universalist church I used to go to, who could not walk from the back
of the church to the organ bench without stopping to rest because of emphysema
caused by smoking. And SHE still smoked.
In fourteen years of practicing criminal law, I found
that the most common item taken by shoplifters was cigarettes. These thieves
were stealing not on impulse or for kicks but because they were addicted and
poor.
Smoking is expensive. A pack-a-day habit in
Massachusetts costs over $1400 a year. You undoubtedly know that smoking causes
cancer and contributes to heart disease and stroke and is associated with low
birth weight babies. It also causes WRINKLES! And it is clearly associated with
increased rates of asthma and ear problems in children exposed to secondhand
smoke.
According to substance abuse researcher George Vaillant,
". . . alcoholism is a major reason that people don't stop smoking. Those
who keep on smoking after age 50 tend to be alcoholics." Certainly, when we
surveyed the clients in Boston ASAP groups, almost all of whom have had at least
one DUI conviction, we found that 46% smoke, compared to the state adult rate of
19%. About 70% of current smokers wish they could quit.
So let's get down to brass tacks here: if you are in
recovery from drugs or alcohol, and you are a smoker, should you try to quit
smoking now? YES. You will increase your chances of long-term sobriety. You will
eliminate a large percentage of your risk of lung cancer, even if you quit late
in life.
HOW could you do this most effectively?
Well, first off, the least successful method of
quitting smoking, in terms of long-term quit rates is "cold turkey"
alone. Incidentally, did you know that the expression "cold turkey,"
describing a sudden end to use of an addictive substance, comes from the
goose-bumps experienced by cocaine users in withdrawal, when their bodies'
temperature control system is out of whack?
Sit down with a piece of paper and write down the
advantages and disadvantages to continuing to smoke. Be searchingly honest and
comprehensive. Set yourself a realistic quit date no more than two weeks into
the future. Tell those close to you that you are quitting, and ask for their
support. Then apply the technique amusingly known as "warm chicken":
that is, cut down on the number of cigarettes you smoke in the days approaching
your quit date, so that you have already begun the process of weaning yourself
off nicotine.
Engage yourself in a tobacco treatment program if you
can; check out Nicotine Anonymous if you can stand it; use your SOS group to
help with your recovery from nicotine dependence. Use the web sites which can
help.
Unless you are medically contraindicated, get yourself
some nicotine replacement therapy. The two kinds presently available in this
country are the gum and the transdermal patch. Both are available without a
prescription in drug stores and supermarkets. Adding NRT DOUBLES quit rates.
Some folks may benefit from using both the patch and the gum, especially those
with high levels of nicotine addiction - the patch will slowly bring up your
blood nicotine levels, and the gum can be used to give you a jolt when you need
one, like first thing in the morning or during incidents of craving. Be sure to
use a high enough dose - if you smoked enough that your daily nicotine intake
was 60 mgs per day, you are not going to be comfortable on a 15mg patch! So use
two and the gum.
Consider asking your doctor for a prescription for
Zyban (generic name buproprion), also marketed as Wellbutrin when used as an
antidepressant. Start taking the drug before your quit date. Adding buprioprion
doubles quit rates again.
Let me say a few words to those of you who started to
tune out when I mentioned taking a mind-altering drug. Buproprion, like most
antidepressants, is not a drug of abuse. You don't feel high when you take it.
Aside from a few side effects, like insomnia and constipation, you probably
wouldn't notice you were taking it at all. You may actually lose some weight on
it . . . I did, when I took it for depression, and gained it back when I
discontinued it. I don't think you should consider that taking buproprion
violates some principle of your sobriety priority. In fact, there has been a
substantial paradigm shift amongst treatment professionals about some classes of
psychoactive drugs. It used to be that treatment programs would not take anyone
who was on a prescribed psychoactive drug. That has changed. Now people with
co-occurring disorders who need antipsychotic or antidepressant or antianxiety
medications are accepted while taking meds.
One of the reasons why buproprion works may be that
many people smoke as a way of self-medicating for any one of a number of
underlying disorders . . . nicotine improves concentration and short-term memory
and is an antidepressant. It is thought that, particularly in women, people who
have extraordinary difficulty in quitting smoking may have undiagnosed
depression. In fact, women who smoke are three times more likely to be depressed
than women who don't. Persons with mental illness are much more likely to smoke
than the rest of the population, and this is a concern because nicotine may
interfere with the effectiveness of needed meds.
Okay, so now you've quit smoking, and you're miserable. Here are some tips to
help you resist that urge to smoke:
- Drink lots of water.
- Get your teeth cleaned.
- Understand that an episode of intense craving will
only last five minutes or so . . . if you can hold out that long, it will
pass.
- Anecdotally, cinnamon is said to help. Remember the
toothpicks dipped in cinnamon oil kids used to pass out in grade school?
- Use props like gum and hard candy to keep your mouth
occupied.
- Stay in places where you can't smoke.
- Use your hands. . . .
- Get dirty!
- Avoid triggers.
- Review your reasons to quit smoking. Think of new
ones.
- Exercise.
When my secretary quit smoking (one of several failed
attempts) she was horrified when she got her winter coat out of storage and
realized how bad it smelled. Think how much better you smell now. Remember that
kissing a smoker is like licking an ashtray.
Hiking in the Cascades of Washington State years ago, I
came to an idyllic rest spot on a rather steep trail. There was a comfortable
"sittin' log" and a beautiful mountain stream. On the bare ground in
front of the log, spelled out in new, unsmoked cigarettes, were the words,
"I quit." I went down the mountain by a different trail and so I will
never know whether that desperate, breathless smoker scrabbled in the dirt to
pick up those cigarettes on his or her way back down. With luck, maybe it rained
before that happened! I don't know whether that new non-smoker stayed a
non-smoker. But I would like to think so
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