Cleveland_Clinic_Host: Welcome to our Online Health Chat with Iyaad Hasan, MSN, CNP, CTTS. How many times have you told yourself: "Today is the day I quit smoking!" only to start up again when you get stressed? Today, he will host questions to help smokers and tobacco users to quit the habit.
Iyaad M Hasan is a board-certified family nurse practitioner and a certified tobacco treatment specialist with over 10 years of clinical experience and tobacco treatment. He is presently Director of the Cleveland Clinic Tobacco Treatment Center and chief clinician. During today’s chat, he will offer the most up-to-date clinical and behavioral options to stop nicotine dependence.
Iyaad, thank you for joining us today to answer questions. A lot of information is available about the health consequences of using tobacco as well as the benefits of quitting. Yet, smokers are hooked, and need to understand what it takes to quit, how to prepare to quit, and most of all what medications or methods are out there to help. Today, we look forward to discussing all these issues with you and providing information to help individuals free themselves from this unhealthy, expensive, messy habit and become tobacco free.
The Basics of Tobacco Addiction
newtonm: What is nicotine?
Speaker_-_Iyaad_Hasan: Nicotine is a highly addictive substance that occurs naturally in tobacco. It is a poisonous and oily substance that turns brown upon exposure to air. In concentrated form, nicotine is used as a potent insecticide. One drop of pure nicotine can cause respiratory failure, paralysis and death. Tobacco companies dilute the poisonous levels of nicotine with ingredients to become just addictive.
carlyb: What is nicotine dependence?
Speaker_-_Iyaad_Hasan: There are 3 parts to the nicotine dependence:
- Addiction (Physical Dependence)
- First, there is a physical addictive nature to nicotine. It is a rapid, intense, and short acting effects in the brain. The effects of nicotine reach the brain in 8 seconds. Half the potence of nicotine is gone in 2 hours. What happens however, there is a tolerance that develops from long term use and an increased area of nicotine binding sites (receptors)? When these areas are deprived or drop nicotine levels, withdrawal symptoms set in (cravings, irritability, and insomnia). There are medications that help with the physical addiction.
- Associations (Links/Triggers)
- There are 3 behavioral parts to nicotine dependence. 1) Many patients report that there are specific situations (e.g. drinking coffee, driving to work, or after a meal) that trigger them to smoke or chew. 2) Other report that there are emotional states (e.g. boredom, anger, or nervousness) that trigger them to use. 3) Finally, many patients report that there are certain people that when seen or are around trigger them to smoke (e.g. “smoking buddies”). Now, these associations to smoke are what many have to avoided or changed during the quitting process so that they live smoke-free
- Assumptions (Psychological Meanings)
- The last part of the dependence is psychological. Many patients report that the cigarette is like an “old friend” who is always there for them. The classic false assumptions are it is a special means of handling stress, a way of “muffling” (suppressing) anger and other unpleasant emotions, a way of “buying time, ” An expander of one’s abilities (e.g., writing, problem solving, handling tough or ambiguous situations), or a means of rewarding oneself after an accomplishment. The person must break and not believe these assumptions because they are all false, one that is done then the road to a nicotine free life is achievable.
Effe1: The causes of addiction are well known. The question is how to trick myself into quitting and how to hold out long enough?
Speaker_-_Iyaad_Hasan: It is not tricking your self as much as it is replacing the amount of time that cigarettes consume your daily routine. For example, the average cigarette takes 10 minutes to smoke. If you smoke 20 cigarettes a day that is 200 minutes you need to replace. That can be tough and that is why we tell all our patients to prepare to quit, not just jump right into it. Again, we know there is a physical addiction but the behaviors and the psychological parts must be identified, understood, and permanently changed before the person can achieve success.
The Psychological Aspect of Tobacco Addiction
candycane: What do you do when the addiction is more emotional/situational than physical?
Speaker_-_Iyaad_Hasan: That is a good question. The emotional part of nicotine dependence is tough, because people smoke when they are nervous, stressed, bored, etc. We focus on the fact that you need to change and separate the emotion from the dependence. Use a behavioral technique like drinking a cup of ice cold water or walking away from the situation. Further, remember when triggered to smoke you are dealing with the emotion/situation at the same time getting withdrawal symptoms. This is just the tip of the iceberg; we address this in great detail at the first clinical visit.
brandnameonly: How are stress and smoking or chewing related?
Speaker_-_Iyaad_Hasan: Stress is our response to daily life. Every one has stress, but smokers have two things going on when they are really stressed. They have an event that is causing stress in addition to their nicotine withdrawal. No one knows for sure, but there are 2 theories; either there is a higher demand of nicotine or dopamine (the hormone release when nicotine binds to the receptor) when a smoker is stressed or there is no nicotine getting to the brain due to hormonal changes in the body. Nonetheless, many former smokers and chewers report less stress in their life. Why? They have been able to control the withdrawals the dependence and now are just dealing with the stress.
Remember, the right amount of stress is a positive force. Stress helps us to do our best work and keeps us alert, energetic, focused, and engaged in the world around us. Too much stress can leave us tense, anxious, and uncomfortable. The key is to maintain an optimum level of stress (enough to keep us motivated) but not too much that we become overwhelmed.
Effe1: Is it a matter of weak character, or are some people genetically more predisposed to addiction than others.
Speaker_-_Iyaad_Hasan: There has been extensive research on this topic. Early results are indicating there may be a link or predisposition.
The Products of Tobacco
afraidofme: What are the products that are in the tobacco products?
Speaker_-_Iyaad_Hasan: Cigarette smoke contains over 4,000 chemicals such as:
- Arsenic (rat poison)
- Ammonia (poisonous, in many household cleaners)
- Acetone (fingernail polish remover)
- Ammonium bromide (toilet cleaner)
- Benzene (industrial solvent)
- Carbon monoxide (exhaust pipe fumes)
- Cadmium (used in rechargeable batteries)
- Cyanide (poison used in gas chambers)
- DDT (insecticide)
- Formaldehyde (preservative for dead frogs, embalming fluid)
- Lead (a poison removed from nearly all paints)
- Mercury (highly poisonous and easily absorbed through respiration)
- Nickel (poisonous, a known cancer-causing agent)
- Hydrogen cyanide (deadly poison used in gas chambers)
- Hydrogen sulfide (sewer gas)
- Polonium-210 (radioactive substance)
- 50 + cancer causing agents (carcinogens)
Quick note, these chemicals are filtered through the body and sit in the bladder until they are removed. Can you see bladder cancer patients who are smokers or chewers?
How Can You Quit?
capandgown: What are the best ways to quit?
Speaker_-_Iyaad_Hasan: There is no best way to quit. However, research shows that if you incorporate clinical counseling and pharmacology you will increase your success rate. Further, quit rates are increased when you have a person quit with you.
newtonm: What are the keys to quitting?
Speaker_-_Iyaad_Hasan: If you prepare to quit, then you will be able to succeed. Here are some tips:
- Make a personal pact with yourself to quit and realize the reasons why you want to quit!
- Write down, on a card, the three most important reasons for quitting.
- Carry that card with you (or in your cigarette box) from now on. Look at it several times each day.
- Set a date for quitting completely! (My date is ___/___/___).
- Make sure to let your friends and family know that you are quitting smoking, especially if they smoke.
- Reduce consumption with the taper method given to you. If you are over a pack, try to get less than a pack.
- Identify barriers or triggers that may cause you to smoke. Use the Smoking Diary to identify these triggers.
- Prior to quitting, taper or eliminate smoking completely in two or three of your high risk situations. Use the Smoking Diary to see these times.
- Understand that withdrawals symptoms may come, what they are, and be prepared for their occurrence.
- Spend a little time each day picturing in your mind stressful events occurring in the future and you not smoking.
- Get rid of ALL cigarettes and put away all smoking related objects such ashtrays.
- Ask people you live with not to smoke in your presence for two weeks.
- Consider the following for extra support: a person to quit with you; joining a web-based program; Reading a book on quitting; Calling the Quit line (1-800-QUITNOW).
Optional but recommended:
- Change to a less desirable brand of cigarettes.
- Discard your lighter, use matches.
- Carry your cigarettes in a different place.
hattieb11: Everybody I know who quit had their “own little way” of doing it, and have been successful, even when more traditional ways (patches and gum) didn’t work. What can you attribute this to?
Speaker_-_Iyaad_Hasan: I really attribute being able to quit to 4 parts; 1) The person has a personal reason why they want to quit. 2) They gain awareness of the dependence and they have a better understanding of the importance of quitting. 3) They are motivated to quit and this helps with gaining the confidence to over come the chance of relapse. 4) They have the strategy to quit that works for them (either from the Tobacco Treatment Center clinician or from their own research)
pleasemister: What are alternative methods to help with quitting?
Speaker_-_Iyaad_Hasan: Acupuncture, Lasers, and Hypnosis. Many patients report that these methods have helped them quit smoking and chewing, however, there has not been strong research backing their effectiveness as of yet.
The Side Effects of Quitting
candytrail: Do all people who quit gain weight?
Speaker_-_Iyaad_Hasan: Stopping smoking or nicotine dependence may cause some weight gain but most people gain fewer than 10 pounds (with the average gain around 5 pounds), and some people don’t gain any weight at all. Having a better understanding why people gain weight after they quit will help you to avoid this concern that keeps people from quitting.
bringiton: How do I deal with the urges?
Speaker_-_Iyaad_Hasan: Your life has become accustomed to having nicotine in your body as a smoker. Cravings develop when the body wants more nicotine. Cravings can also come on with triggers and even “one little puff.” Cravings are NOT “just in your head.”
Here are some “craving crushers”:
- Delaying and distraction are key! (Wait or Walk is another way to look at it!)
- Stay busy and plan your days ahead (Fill the time tobacco took out of your life)
- Do things that require you to use your hands (puzzles, sewing, video games)
- Ask others not to smoke around you or go where there will be a lot of smoking
- Drink ice cold water and drink a lot of water
- Exercise (both cardio and resistance are the key for a healthier you!)
- Stretch as often as you can (relaxes your muscles)
- Take short rests or naps
- Brush your teeth after every meal (never want to mess-up a clean mouth)
- Snap a rubber band around your wrist (negative reinforcement)
- High peppermint, spearmint, or cinnamon sugar free candies (relaxes the body)
- Have some sunflower seeds (these seeds are said to stop cravings)
- Take a deep breath through your nose & blow out slowly through your mouth several times.
- Avoid situations and activities (like drinking alcohol) that you normally associate with smoking.
- Remember basic rule: Smoking is not an option in my life!
- Think about the reasons why you want to quit.
- Think of positive coping statements!
- Tell yourself that you quit smoking and sometimes this is hard.
- Think of the positive consequences from quitting (appearance, self-esteem, & energy).
- Think of the negative consequences from not quitting (money, cancer, & hassles).
- Never allow yourself to think that "one won't hurt" - it will.
dandorl: When quitting, is having an occasional cigarette here and there to help with the cravings really bad?
Speaker_-_Iyaad_Hasan: At the Tobacco Treatment Center, we design a taper plan for the individual. But once you quit, that is it. NO MORE! Would you ever tell an alcoholic who just quit drinking, “let's just have one more drink for old times sake.” NEVER! The same holds true for a person who has quit smoking. You should NEVER have just one puff. That one puff will increase your chance for relapse.
newtonm: On average, how long does it take to quit, before the cravings finally go away and a person is not "consciously" not smoking?
Speaker_-_Iyaad_Hasan: This is a tough question. Quitting is an individualized process. However, strong cravings usually become weaker and less often in about seven days. As time goes on, people forget about smoking and chewing, but occasionally there is something that will trigger a craving even years later. Yett as fast as these urges come, they disappear because the person is in control.
Effe1: Is the quit stress worse than smoking 10 cig. a day
Speaker_-_Iyaad_Hasan: No. Ten cigarettes equal 150 minutes of life lost. Where as the negative impact of stress of quitting is related to the withdrawals of nicotine. Once the symptoms of withdrawal have ceased, the stress of withdrawal goes with it. I must say, that people however have a lot of the behavioral influence since they can tell you when and where they had the cigarettes being that they are less in number. We really focus on the behavioral change with these patients.
kels1780: My husband is trying to quit smoking (he just quit 2 weeks ago) he's doing very well, only had one in that time, but I was wondering is there anywhere to get the gum for free?
Speaker_-_Iyaad_Hasan: Truly, no there is no free gum available. But I will recommend that you look in the newspaper for discounted gum. Or you can try Googling ‘Pharmaceutical Assistance Programs’ to see if there are any options there.
tootootoo: What medicines are available to help with cessation?
Speaker_-_Iyaad_Hasan: There are several options to help. Oral medications (Zyban & Chantix) and Nicotine replacement (patches, gun, lozenges, inhaler and nasal spray). Each has its own pros and cons. Please see www.clevelandclinic.org/tobacco for more information.
kcloonan: What options are there to help stop smoking besides the patch?
Speaker_-_Iyaad_Hasan: There are many options. There are prescription oral medications like Zyban and Chantix. But also there are other forms of nicotine replacement medications over the counter like gum and lozenges. There is also the nicotine inhaler and nasal spray. These last two need a prescription. Please see www.clevelandclinic.org/tobacco for more information.
kibbey: Do you have any concerns about the use of Chantix?
Speaker_-_Iyaad_Hasan: Chantix is the newest medication on the market used to help people quit smoking. There have been concerns about psychological changes in individuals from the medication. Some of the symptoms are depression, suicidal thoughts, and mood disorders. Besides these severe concerns, the majority of my patients report some nausea and vivid dreams. However, we do screen for these tendencies at the Tobacco Treatment Center.
trying: What happens if you use the patch, gum or other such products, but still smoke?
Speaker_-_Iyaad_Hasan: It is not recommended to use nicotine replacement products and continue to smoke or chew. This is due to the possible cardiac complications that may arise.
Effe1: Are nicotine pads or nicotine gum a way out?
Speaker_-_Iyaad_Hasan: Both products are great options for individuals who want to quit. The patch provides longer coverage of cravings. Here at the Tobacco Treatment Center we tailor the medication to the individual need.
kcloonan: How about free patches?
Speaker_-_Iyaad_Hasan: In Ohio, you can contact the Ohio Quit Line at 1.800.QUITNOW. They may be able to provide up to two weeks of free patches.
The Difference in Tobacco Products
kcloonan: Is there a difference between lights, ultra lights, and regular cigarettes?
Speaker_-_Iyaad_Hasan: Actually, there is no difference between any of these cigarettes other than the filter design. Research shows that ultra light smokers and light smokers get less nicotine when they smoke these cigarettes. However, the same research also shows that these same smokers take harder puffs with the lights and ultra lights, thus taking in the same amount of nicotine as smoking a regular cigarette. DO NOT BE FOOLED by the name.
concerned: Smoking Black and Milds is very big with today’s youth. How bad are these things really?
Speaker_-_Iyaad_Hasan: One Black and Mild is equivalent to 10 cigarettes. So if you smoke a pack of Milds you are smoking about 50 cigarettes. Just an aside one big cigar is equivalent to 20 cigarettes. That is how bad those things are.
dandorl: Are menthol, or other “flavored” cigarettes worse than regular cigarettes?
Speaker_-_Iyaad_Hasan: Menthol may help to cover the actual strength of cigarette smoke making it more pleasurable and more difficult to quit. Menthol has a cooling and anesthetic (or pain killing) effect. This also decreases the cough reflex and can soothe the dry throat feeling that many smokers have. As a result, menthol smokers may inhale more deeply, hold the smoke in the lungs longer, and get more exposure to the dangerous chemicals in cigarette smoke.
concerned: My son doesn’t understand why marijuana is still illegal. He and his friends share the belief that it is no more harmful than cigarettes. Can you give me some info that I can take back to him and explain why it is?
Speaker_-_Iyaad_Hasan: There has not been any comparative studies regarding Cigarette smoking and Marijuana use. That being said, they are both harmful in their own way.
kels1780: How can support systems, i.e. spouse, family, friend help with coping?
Speaker_-_Iyaad_Hasan: Research shows that if a smoker or tobacco user has a strong support system in place, there is a better chance of that person quitting and remaining quit. However, here are tips I recommend to family members when a person quits.
- Don't take the quitter's grumpiness personally during his or her nicotine withdrawal.
- The symptoms will pass in about two weeks.
- Do spend time doing things with the quitter to keep his or her mind off smoking or chewing – go to the movies or take a walk to get past a craving (what many call a "nicotine fit").
- Do ask to see how the person is doing.
- Let the person know that it's okay to call you whenever he or she needs to hear encouraging words.
- Do respect that the quitter is in charge.
- This is their lifestyle change and their challenge, not yours.
- Don't offer advice.
- Just ask how you can help with the plan or program they are using.
- Do help the quitter get what she or he needs, such as hard candy to suck on, straws to chew on, fresh veggies cut up and kept cold in the refrigerator, etc.
- Do help the quitter with a few chores, some child care, cooking – whatever will help lighten the stress of quitting.
- Do celebrate along the way.
- Quitting smoking is a BIG DEAL!
Cleveland_Clinic_Host: Iyaad, thank you for joining us today to answer questions. A lot of information is available about the health consequences of using tobacco as well as the benefits of quitting. Yet, smokers are hooked, and need to understand what it takes to quit, how prepare to quit, and most of all what medications or methods are out there to help. Today, we enjoyed discussing all these issues with you and providing information to help individuals free themselves from this unhealthy, expensive, messy habit and become tobacco free.
Speaker_-_Iyaad_Hasan: Thank you. Remember at one point or another a smoker will be told they have to quit. Make it your decision, not someone else's decision. We are here to help.
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