There are many reasons why people start using products with tobacco in them. You may be someone who started smoking with your friends because it seemed like a cool thing to do, or you didn’t want to be the only one that wasn’t trying it. Maybe your first cigarette was sitting with your Dad while he was smoking and you asked him if you could try one. Perhaps you don’t think you have a problem because you only smoke 3 or 4 a day right now, or because you only smoke when out with friends. Or maybe you think that smoking pipes or cigars are much more distinguished and not as addictive as cigarettes. Or maybe you see yourself as a non-smoker because you only use dip or snuff. Of course, this must not be a problem. Or is it?
Nicotine, the active addictive ingredient found in all tobacco products, is harmful to the people who use it, causing weakness to develop in the brain systems necessary for concentration, self-control, tolerating stress, and memory. Toxic chemicals and additives in tobacco and tobacco smoke are the main causes of other physical health problems. Tobacco smoking is dangerous to those who smoke and to those around them.
Consequences of Tobacco
Smoking is responsible for 87% of lung cancer deaths and is linked to cancers of the mouth, throat, voice box, esophagus, pancreas, cervix, kidneys, colon and bladder. It also accounts for at least 30% of all cancer deaths and is linked to other chronic health problems such as colds, allergies, asthma, chronic bronchitis and emphysema. Many people don’t realize that smoking causes heart diseases, vascular diseases such as stroke and erectile dysfunction, in addition to lung diseases. For young people, the early manifestation of these problems is lower performance in sports. In the end, smoking causes you to be sick and die much earlier than you would if you didn’t smoke. Six out of the ten most common causes of mortality in the United States in 2009 were caused by tobacco. Tobacco accounts for more deaths worldwide than all other drugs combined. Also, smoking affects people’s appearance: it causes yellow teeth, tooth and gum diseases, early aging and wrinkling of your skin, and bad breath.
Even smoke from other people’s cigarettes cause health problems in people and animals. Second-hand smoke is a major cause of lung cancer and heart disease for non-smokers. In public places, everyone is vulnerable to second-hand smoke, and today there is a growing awareness of this vulnerability and smoking is prohibited in many restaurants and businesses. Young children are particularly vulnerable to second hand smoke and exposure to cigarette smoke results in between 7,500 and 15,000 hospitalizations for lung related problems a year.
National Health Risk Awareness
In recent years, the American Cancer Society and other public health organizations have run anti-smoking campaigns to raise the public’s awareness about the health hazards of smoking and the use of any tobacco products. This has slowly resulted in a decrease in the rates of tobacco use nationally. Unfortunately, where rates of tobacco use has not dropped significantly, is among people with psychiatric or other addictive disorders.
Smoking in people with psychiatric or addictive disorders
Substantial research has demonstrated that chronic nicotine use increases the likelihood a person will become addicted to other substances (see Figure 1). Chronic nicotine use alters the structure of the DNA’s housing in the brain cells. This allows the addiction-promoting effects of other drugs to enter the brain’s reward system and change how the brain reads its DNA instructions. This leads to clear changes in the shape and functions of the neurons in the reward system as they become more addicted and increasingly susceptible to other drugs or alcohol.
Nicotine affects almost all areas of the brain and acts as a modulator of the way the brain processes information. There are more than 40 different combinations of nicotine receptors found in the brain; however, there are four common subunit combinations that are responsible for much of the disruption to the brain’s ability to process information. Nicotine reliably activates the brain reward processing centers – helping people feel enjoyment. Nicotine receptors in the hippocampus affect memory processing – so nicotine seems to slightly help people concentrate and remember information. Some nicotine receptors can even affect neurogenesis, the ability of new neurons to form and build new neural networks. But your brain does NOT need nicotine to function – these receptors are activated naturally by your own neurotransmitter, called acetylcholine, which can return to function normally again after smokers complete a nicotine detoxification.
Because nicotine is legal, people often start this drug along with alcohol when they are teenagers. There are many things about smoking that people with co-occurring disorders say are enjoyable: it helps them feel like they fit in; it increases alertness (possibly offsetting the sedating side effects of medication); it helps them calm down and diminishes anxiety; it becomes an habitual part of their routine; and it helps deal with boredom by giving them something to do. People don’t realize that during the day, anxiety and mood problems may actually be due to nicotine withdrawal. They think they are smoking to help their mental illness, but they are really smoking to reduce nicotine withdrawal.
For unclear reasons, people with mental illness and addictions are more likely to smoke and therefore more likely to get sick and die young from a tobacco-related illness. People who recently quit other drugs and alcohol but maintained their tobacco smoking addiction may be more likely to relapse when compared to those who quit tobacco smoking at the same time as they stopped using drugs and alcohol.
Smoking Cessation
Quitting smoking or use of other nicotine products is not easy. Nicotine is a very powerful and addictive drug. When a person tries to stop smoking they go through withdrawal from nicotine – they can feel symptoms like anxiety, irritability, tension, nausea, sleep disturbances or mood changes for a week or two. After that, people may continue to feel urges to smoke, especially when they are in situations where they smoked in the past. While it may seem easier to quit one drug at a time, people who quit smoking and using other drugs or alcohol at the same time have more success at long-term abstinence.
Nowadays instead of having to quit cold turkey, there are other options that can boost people’s will power and control over smoking, making it easier to quit. Counseling to learn skills that help with quitting is important. Also, several kinds of medications reduce nicotine withdrawal and craving for nicotine.
Nicotine replacement therapy comes in the form of patches, lozenges, gum and inhalers. These are used for a month or more before quitting and up to a year after quitting. Slowly tapering the daily dose of nicotine using these replacement methods can make the withdrawal symptoms more tolerable and can allow the brain’s receptors time to readjust to becoming nicotine-free. Even though electronic (e-cigarettes) reduce exposure to toxic tobacco carcinogens, they are not recommended as they continue to strengthen the smoking habit. Nicotine replacement is safe. The side effects of nicotine replacement can include itching or irritation wherever the nicotine is applied, nausea and headache.
Chantix (Varenicline) is a medication that comes in pills taken twice a day that works by interfering with the nicotine receptors in the brain. It decreases the pleasure of smoking and also decreases withdrawal symptoms. People take Chantix for a month or more before quitting and up to a year after quitting. Research suggests it is the most effective quit smoking medication. Also, this medicine may help people’s thinking skills (memory and attention). But, many people have some side effects, such as increased headache, nausea, vomiting and trouble sleeping. Drinking a lot of water seems to help. Since depressed mood, agitated behavior, and suicides have been reported among some people who were trying to quit with Chantix, people shouldn’t use Chantix unless their mental illness is stable. WestBridge encourages participants to monitor their mood and sleep each day during smoking cessation with Varenicline until the acute withdrawal has passed. With this kind of close monitoring, any problems with mood can be addressed immediately. Side effects are reversible by stopping the medication.
Buproprion (Wellbutrin or Zyban) is another medication that reduces nicotine cravings. It is taken as a pill, once or twice a day for a month or more before quitting and up to a year after quitting. Buproprion is more effective if people use it in combination with nicotine replacement therapy. People who quit while taking Buproprion have half the cravings and less mood swings compared to people who are quitting cold turkey. The current standard of care for people with schizophrenia who are trying to quit smoking is to start Buproprion in combination with a nicotine patch and/or shorting-acting nicotine replacement such as lozenge or gum. These medications can be used for up to a year with psychosocial support. Buproprion is also an effective antidepressant. Bupropion may induce mania among people with bipolar disorder unless they are taking mood stabilizers.
Relapse Plan
For people who have decided to quit using tobacco, it is often helpful to have a plan and the support of others. It can be useful to write down the reasons you want to quit, for example: more money, better health, more energy, healing your brain, taking back control of your life, less risk of relapse to alcohol and drugs and being able to breathe easier. Keeping this list handy can be helpful when you begin to crave a cigarette, so you can pull out your list and read it. Identify what things trigger you to use tobacco – and make plans to avoid these triggers. Identify support people that will help you in your effort to quit and be sure they know you are quitting and are willing to help you with this. You might want to consider touching base with a friend who has already successfully quit smoking, or join a smoking cessation group or class, so you are doing it with others who share a common goal. Be sure you have a plan to fill up your time. Boredom and not knowing what to do with time on your hands are major reasons why people return to smoking. If you have tried to stop before, be sure you incorporate what worked and what didn’t work into this try. While you are planning your quit date you might want to start cutting down. Be sure to tell everyone what your quit date is so everyone can support you.
Mark Twain said, “Quitting smoking is easy, I’ve done it a thousand times.”
Quitting smoking and sustaining this change is often a challenge. Filling your life up with pleasurable and motivating healthy activities will help you sustain this change. Learning the tools to avoid relapse helps people with co-occurring illnesses to live independently in the community. At WestBridge, we offer participants tools like cognitive-behavioral therapy, relapse prevention and mindfulness training to help them achieve their own recovery, substance- free and managing any other mental health issues as they see fit.
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