Quitting Smoking While Living With a Smoker

Many of the patients we see for help to quit smoking also live with a smoker. They regularly comment that it is harder to quit when you live with a smoker. This sounds plausible, but does the evidence back it up?

Professor Martin Jarvis of University College, London, has conducted research showing that the family can have a strong influence on people’s success at stopping smoking. One study followed 18,000 British people from 1981 to 1991. He found that of those smoking in 1981, their chances of having quit by 1991 was 39% if they lived with a non-smoker, but only 14% if they lived with a smoker. The effect is even more marked for smokers who were married to a non-smoker, 52% of whom were non-smokers 10 years later. Within this study there was further evidence that social support is important in that the lowest quit rate (12%) was found in smokers who had lost some social support by being separated, divorced or widowed. This kind of data fits with the notion that family support, and particularly the presence of a non-smoking partner, seems to help people to quit smoking.

Unfortunately we cannot always require the people we live with to quit smoking just because we have decided to quit. If the people you live with have seen you try to quit many times before, it’s possible they don’t think it’s a serious attempt and therefore won’t feel inclined to make much effort to help. Some may be threatened by your quit attempt. They may believe that if you quit, there will be more pressure on them to quit and more restrictions on smoking in the home. They may just realize that they will miss having you as a smoking buddy. So what can you do?

People smoking in front of you, and leaving their cigarettes around in the home will make it harder for you to stay quit. At the very least, it is worth speaking to the people who smoke in your home and explaining to them how important it is to you to quit smoking. Tell them about your reasons, and that you are really serious about it. Tell them it's your personal choice and you are not going to try to get them to quit, but that you’d really appreciate their help while you are trying. It will be important that they don’t smoke in front of you and don’t leave any cigarettes around to tempt you. If they could completely refrain from smoking in the house at all, that would be best. But not having any tobacco in your sight is a perfectly reasonable and sensible request.

Having had the serious talk with the smokers in your home, it’s important, however, to be clear that the only person who decides whether or not you smoke is you. So if someone you live with leaves their cigarette pack on the kitchen table by accident, that was a thoughtless mistake, but it doesn’t mean you need to smoke one of them. Ask them to remove their cigarettes or put the pack in the sink under cold water for a couple of minutes. They’re not as tempting when soaking wet! If the people you live with don’t seem to be acting on your request, have another try at explaining, but this time emphasize your health reasons for quitting. Mention that if you fail to quit it will probably take 10 healthy years off your life, and may mean you won’t get to see your grand-children grow up. These are important things and the people you live with should be able to understand that. If you were a heroin addict trying to give up heroin would they think it was OK to leave a pack of heroin and a syringe on the kitchen table? If you were an alcoholic trying to get sober would they leave an open bottle of whiskey on the kitchen table? Asking these questions should help them to understand and be more helpful with regards to your quit attempt. The rest is up to you.

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"Lost" and FDA Regulation of Tobacco

Last night I watched an excellent episode of the TV series, “Lost.” In it, a man named Ben who is the (sociopathic?) leader of one group of people trapped on a lost island, managed to get one of the members of the island’s opposing group (a man named Locke) to blow up a submarine which was apparently the only link to the outside world. The clever thing about it was that Ben managed to get Locke to do what Ben wanted--despite the fact that Locke was holding him at gunpoint, Ben was in a wheelchair, and Locke felt that it was all his idea! For those of you not familiar with this TV show, the main point here was that devious people can sometimes get what they want and yet make it seem like they have lost out and that it was all someone else’s idea.

Why am I talking about this on a forum about tobacco? Well today I’ve been thinking about parallels between that storyline and the proposed legislation to allow the US Food and Drug Administration (FDA) to regulate tobacco products. Don’t get me wrong; I strongly support the need for much tighter regulation of the tobacco industry. In fact I continue to think this bill will likely do more good than harm. But there is one big thing that bothers me. The biggest tobacco company in the country – Philip Morris (PM) – also supports the current FDA bill. So what’s that all about?

Some critics of the bill refer to it as the “Marlboro Protection Bill” because they see it as simply building bigger barriers to competition for the current leading cigarette brand, Marlboro (a Philip Morris brand). There is a particular part of the bill that refers to the introduction of new reduced harm tobacco products or claims that one product is less harmful than another. The bill correctly requires reasonable evidence that an individual using the “less harmful” product will really have lower risk of tobacco-caused harm, when the products are used in the normal way. However, the bill also requires that the product will benefit the health of the population as a whole. Now this seems to be a rather difficult standard for any new product to comply with, in the absence of a crystal ball or a massive research study involving hundreds of thousands of people and lasting decades.

So why would public health experts agree to this? Most likely, to prevent a repeat of the ”Light cigarette fiasco” in which millions of smokers switched to Lights (instead of quitting), in the false belief that light cigarettes are less harmful. So why would Philip Morris agree to it? Because they are the dominant cigarette manufacturer with by far the largest market share. New products that are much less harmful (e.g. the smokeless “snus” products that are now more popular in Sweden than cigarettes and being test-marketed in the US by competitor RJ Reynolds) have the potential to take significant market share from Marlboro. But this is much less likely if such products cannot be launched or can be prevented from making any reduced risk claims. Maybe Philip Morris is acting like Ben on "Lost," by making public health experts think they’re getting what they want, by restricting new products’ ability to make claims to be less harmful. In fact, we may just be doing PM’s dirty work by preventing less harmful competitors from entering the market and thus preserving Marlboro’s dominant position--unchallengeable by products that won’t cause lung cancer or chest diseases.

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Cold Turkey- 2

In 1969, Philip Morris Tobacco Company commissioned a research study on the town of Greenfield, Iowa to record the effects of the anti-smoking campaign and the experiences of the smokers who tried to quit (in connection with the filming of the movie “Cold Turkey” in the town). The town decided to encourage all the smokers to quit abruptly on August 8th, 1969 and to remain quit for at least the next 30 days (to September 6th 1969), just like the fictional characters in the movie being filmed there. The film’s star, Dick Van Dyke, commented on national TV that,
“It was crazy…you couldn’t tell where the film left off and the town began.”
6-8 months later (March-April 1970) a research team hired by Philip Morris tobacco company tried to contact everyone in the town to find out about their experiences and particularly the experiences of the smokers who tried to quit. They hired girl-scouts to hand deliver 1592 questionnaires with stamped addressed envelopes to every person in town aged 14 or over. Around 90% were returned of which 1385 contained usable responses. The townspeople were promised $5 plus a “personality profile” based on their responses to the questionnaire.
It turned out that 444 (28%) of the people returning questionnaires had been smokers immediately prior to the quit smoking campaign in August 1969. Of these smokers, 40% signed a pledge to try to quit on “Cold Turkey Day”. In fact about a third of the smokers said they really tried to quit, about a third said they made a half-hearted attempt and about a third said they didn’t try. Thus 284 (64%) of the smokers made some attempt to quit, and of these almost 60% stopped at least briefly. By the following Easter, 63 (22.2%) of those who made an attempt to quit, remained abstinent.
It was noted that only 4% of the women cigarette smokers remained quit 6 months later, and these were generally light smokers, averaging around 7 cigarettes per day. The women who didn’t try to quit or who tried but relapsed, averaged about 17 cigarettes per day.
It was also noted that those who quit smoking started to eat more nuts, gum and candy (but did not drink more alcohol) and put on around 5 pounds in weight. Those who quit smoking also devloped more nervous mannerisms, and were more likely to report feeling restless, tense and ill-tempered.
Overall, the results of this study are fairly consistent with many subsequent scientific studies of people trying to quit smoking, in finding that most (almost 80%) of those who try to quit do not remain abstinent in the medium term. Like later studies, they also found that quitters experience significant withdrawal symptoms. Interstingly, the cover of the report tells the reader that it should be referred to by its “in-house code name: BIRD”, and that, “This report contains information that is confidential to the business of the company.The information must be carefully handled and not divulged to outside sources..”
Clearly Philip Morris did not want the general public to know that they were aware that smoking is addictive, that when smokers try to quit they experience unpleasant withdrawal symptoms, and that most fail in their attempts to go “cold turkey”.
Philip Morris’ report on the town of Greenfield going “Cold Turkey” can be found at: http://tobaccodocuments.org/bw/11836639.html .

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Cold Turkey - 1

The phrase, “cold turkey”, when applied to quitting smoking, usually refers to the method of quitting abruptly (e.g. on specific date), without any gradual cutting down and without the use of pharmacological aids to treat withdrawal symptoms or cravings.

It is not clear where the phrase came from, but it is usually thought to have originally referred to the cold sweats and goose bumps (resembling the skin of a turkey) sometimes experienced during acute opiate withdrawal. The phrase received wide public attention in 1969 when John Lennon used it as the title of one of his songs, believed to have been written while he was withdrawing from heroin. Part of the lyrics of the song state,

“Cold turkey has got me on the run
My body is aching
Goose-pimple bone
Cant see no body
Leave me alone.”

Of course nicotine withdrawal doesn’t typically involve cold sweats and goose-bumps, (see my previous two posts) but the phrase is commonly applied to abrupt withdrawal from any addictive drug. The phrase’s application to nicotine withdrawal was solidified in 1971 with the release of a movie of the same name. The movie was a comedy starring Dick Van Dyke and Bob Newhart (among numerous other famous comedians) telling the story of what happened when an evil tobacco company offered $25,000,000 to an entire town to stop smoking for thirty days. In the movie, a few thousand heavy smokers from the small town of Eagle Rock, Iowa, took up the challenge. In fact, much of the film was filmed in the small town of Greenfield, Iowa, and many local people were used as extras. In a strange example of life immitating art, the local town council (in the real town of Greenfield) decided to try to encourage all the smokers in the town to actually quit smoking, using all the fuss surrounding the filming of the movie to generate publicity and momentum.
So many people actually tried to quit, that real life tobacco company, Philip Morris, commissioned a research study on the town of Greenfield to record the effects of the anti-smoking campaign and the experiences of the smokers. Many tobacco company documents are now required (as the result of law suits) to be publicly available on the internet, and the Philip Morris’ report on the town of Greenfield going “Cold Turkey” can be found at: http://tobaccodocuments.org/bw/11836639.html .
Tomorrow I’ll tell you what they found.

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Quit Smoking Group: Judgements Imposed Upon Smokers

Carrie here! In my last post, I wrote about attending a quit smoking group at the Tobacco Education Center at UCSF. I've attended two classes in the past two weeks and have lots of information to share. I will continue with a series of posts relaying my experience and what I've learned. This post is dedicated to the group experience and what smokers have in common: the judgment they endure from others, as well as themselves.

The attendees of the class consist of four smokers (including myself), two pharmacy students who have never smoked, and Suzanne, our smoking cessation counselor. The first class began with introductions, and Suzanne started. Suzanne is a former smoker who tried to quit a dozen times. She even quit for 5 years and then relapsed. She's no stranger to the seduction of cigarettes, and she can sympathize with those of us who are finding it very difficult to quit. Suzanne views smoking as an illness, just like diabetes. "Tobacco dependence is a powerful disease."

The four of us who smoke ranged in the number of cigarettes we smoke per day. I'm on the low end, smoking 7 to 10 a day, and the high is a pack "or so" a day. We each spoke of our experience with smoking: how long we've been smoking, the number of times we've tried to quit, and our reasons for quitting. What was surprising to me was that the other three had attended group smoking cessation classes more than once -- in a couple of cases, multiple times. It became very clear to me how difficult it is to quit this habit. You may say, "Well, duh -- nicotine's addictive, you moron." You may even say, "Carrie, you barely made it for 24 hours smoke free -- this shouldn't be a surprise." But, you see, I've realized that the only serious attempt I've made to quit smoking is now (and I'm probably not taking it seriously enough -- Suzanne pointed out that I have some denial issues). These people have tried to quit with dedication, made it through 3 to 4 months, and somehow found themselves back to puffin' on the butt.

I'll be honest, my initial thought was "How could someone make it through 3 months of no smoking and then blow it by picking up a cigarette?" I had more thoughts that contributed to my denial problem -- "Well, they're pretty heavy smokers -- I'm not. This won't be as hard for me." After attending the second class and recognizing that I had denial issues, I understood that these types of thoughts contribute to the shame a lot of smokers feel -- feelings of weakness, failure, and guilt. The same shame I feel when friends of mine say, "Just quit. Don't buy cigarettes, and you'll be done with it" and "You're still smoking? I thought you quit a couple of weeks ago." I can't imagine how many times each of them has heard this-- not to mention how they must have felt when they succumbed another time to tobacco. In California, the amount of disdain a smoker experiences is amazing. The health nuts out here show no passion for those suffering from nicotine addiction. A scowl appears on their faces as they walk by smokers outside of a bar. The guy on the other corner smoking a joint receives a clever grin and a wink.

"Do not judge lest you be judged yourselves. For in the way you judge, you will be judged; and by your standard of measure it shall be measured to you." (Matt 7:1&2 from the Bible -- not exactly sure which version)

A smoker's frustration compounded with declining self esteem, caused by the judgment of others, started to resonate within me after the first class. Recognizing that my denial and how I too was guilty of judgment settled in after the second class. I'm no different than the other group members -- I also suffer from this disease. I need to take tobacco dependence seriously and shed my denial. The shedding will be an enlightening experience, and I just may even find other areas of my life where I'm in denial. I hope that by the third class I'll have recognized most of them...


Other posts by Carrie:

24 Hours Smoke Free

"Cold Turkey" is for the Birds

Read the Fine Print

As the Smoke Clears

The Enchantments of Smoking

Good Bye to Mr. Cigarette

Photo courtesy of activefree

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Ten Tips On Coping With Tobacco Withdrawal Symptoms

Weight Gain:
1. Keep lots of healthy, low calorie food handy to munch on.
2. Plan a structured increase in exercise as part of a healthier lifestyle.
3. Don’t buy any larger sized clothes!

Bad Moods
4. Warn friends, family and work colleagues that you are quitting and that you might be a bit short tempered.
5. Arrange to keep yourself busy doing relatively fun things during the first few weeks in order to cheer you up and have something to look forward to instead of the next smoke.
6. Remember, you are not going to feel irritable and miserable forever. After a month your mood and stress levels will be back to normal and may in fact continue improving so that you feel less stressed than you did as a smoker.

Restlessness
7. The first couple of weeks after quitting are a good time to plan to do odd jobs around the house, gardening, spring cleaning etc. This kind of activity helps keep both your mind and hands busy when they need to be.

Craving
8. Remember, each period of craving typically lasts less than a minute. Get your mind occupied with other things as quickly as possible.
9. Change your routines as much as possible so that the points in the routine when you would have usually had a cigarette are not so obvious.
10. Wherever possible avoid “high risk” situations where tobacco is freely available. Seeing others smoke often triggers craving.

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What Is Nicotine Withdrawal Syndrome?

“I was like a bear with a sore head - even the dog stayed out of my way - but after a couple of weeks the dog was back at my side and I knew I was over the worst”

There are a number of symptoms which are commonly reported by people giving up smoking with such consistency that they are referred to as the “Nicotine Withdrawal Syndrome”. We know that they are caused by the absence of the drug, nicotine, because they are relieved by giving the person nicotine in another form (e.g. via nicotine replacement therapy). When a person stops taking nicotine, the amount of the drug in the body drops by half roughly every two hours. This means that it takes about 24 hours for all the nicotine to be gone from the body, and for withdrawal symptoms to reach their peak.

“It was like a bereavement, I’d lost my constant companion for the past 20 years. After about 6 weeks I realised I’d beaten my worst enemy rather than lost a best friend”

The main withdrawal symptoms are irritability, restlessness, depression, anxiety, difficulty concentrating, poor sleep, hunger and craving for tobacco. Professor John Hughes of the University of Vermont has studied this phenomenon extensively. One of his studies examined over 600 people giving up smoking without any help. He found that about half of them reported a significant increase in at least four of these symptoms within two days of quitting, but after 30 days most were finding it much easier and less than one in five were still suffering from an increase in four symptoms.

Clearly every smoker does not experience an increase in all these symptoms when they quit. It is also clear that most withdrawal symptoms return to normal within a month. A couple of months after quitting, most ex-smokers actually feel that their mood is better than while they were smoking (i.e. fewer unpleasant symptoms).

If you are feeling really irritable during the first couple of weeks after quitting and are starting to wonder if it is worth all the hassle (or your family and work colleagues are!), it is important to remember that you are not going to feel like that forever, and that within a few weeks your mood and concentration should be back to normal.
After a few more weeks your mood will probably be better than when you were smoking. It isn't clear why mood should improve to be better than while smoking. Perhaps it is so stressful to be a nicotine addict nowadays that it feels relatively stress-free in the long run to not have to be chasing that next nicotine "fix".

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