1. Smoking Cessation for Recovery 2015

2. Learning Objectives What are the effects of smoking?
Why is smoking dangerous?
What makes tobacco addictive?
Making the decision to quit
Strategies to quit
Supporting someone as they quit
Resources

3. Tobacco addiction is the most common addiction in the US
The Problem
Smoking is the #1 cause of death
Smoking rate is 2-3 times higher among those living with a mental illness
People who live with a mental illness die an average of 25 years earlier than their peers
Tobacco addiction is the most
common addiction in the US
It kills more people than obesity, substance abuse, infectious disease, firearms, and traffic accidents, according to the CDC
Among people living with mental illnesses, tobacco is responsible for more deaths than substance use, AIDS, suicide, car accidents, and falls, combined. While rates of smoking have declined among the general population, it hasn’t declined among those living with mental illnesses.
Tobacco companies advertised to people living with mental illnesses, gave free cigarettes or discounts to inpatient mental health facilities, and targeted veterans and the homeless, two groups with high proportion of people living with mental illness. Often, people were told smoking could help them with stress relief or to manage their symptoms, and not educated on the harms of tobacco use. The mental health community is finally catching up to the rest of the health community, and trying to fix this problem we’ve ignored.
While smoking rates have declined among the general population in the last several decades, it hasn’t declined among people living with mental illnesses. When broken down by “disparity groups” such as race/ethnic groups, income, education etc., people living with mental illnesses have the highest smoking rate.
Recognition that recovery and treatment must focus on the whole person, including physical health.

4. Source: National Vital Statistics Reports, 2011
Top four annual causes of death are all tobacco-related (heart disease, cancer, COPD and respiratory diseases, stroke).
Estimated that more than half of these deaths are people living with a mental illness.
Source: National Vital Statistics Reports, 2011

5. Source: National Vital Statistics Reports, 2011
This picture really shows how smoking affects all parts of your body, not just with cancer risk, but also with chronic diseases or other problems. For example, smoking not only can cause mouth and throat cancer, but causes rotting and falling out teeth. This is also just an overview list of the disease names, but there is a spectrum of symptoms that may not fit under a chronic disease status.
Smoking can damage the lining of the blood vessels and cause the build-up of fatty deposits in the arteries (atherosclerosis).
It raises the heart rate and blood pressure by causing narrowing of the blood vessels (vasoconstriction). It increases the likelihood of forming blood clots in the arteries leading to heart attacks. It reduces the flow of oxygen to the heart and damages the heart muscles.
Source: National Vital Statistics Reports, 2011

6. Why is Smoking Dangerous?
Components
Chemicals
Tar
Additives
Flavorings
CO2
Nicotine
*** Nicotine itself isn’t actually that harmful. It is naturally a poison and insecticide (the tobacco plant creates it to protect itself from bugs) but the amt inhaled in cigarette smoke isn’t the cause of all the negative health affects, it is just what makes it addictive.
There are over 7,000 chemicals found in tobacco smoke. These chemicals are naturally occurring from burning tobacco, but are responsible for the negative health effects of smoking. All smoke contains harmful chemicals, whether from burning tobacco, grilling meat, marijuana, or a bonfire.
The same chemicals in cigarette smoke are found and used in other products, such as lighter fluid, insecticides, toilet cleaner, and fuel.
Nicotine is created by the tobacco plant as an insecticide to protect it from bugs. In large doses it is a poison, and is used commercially as an insecticide. In tobacco smoke, it is what keeps you addicted, but it is not the major source of negative health effects.
Tar is the black/ yellow sticky residue or resin that results from burning tobacco. It contains most of the chemicals and nicotine, and is responsible for the toxic and cancer causing effects. Once inhaled into the lungs, tar coats the “cilia” or little hairs coating our lungs that help move out toxins or dust particles. The tar makes it so they can’t move and trap the toxins, so they start to build up in the lungs and gets in the way of oxygen trying to come into your body, which leads to the coughing and rough breathing.
In addition to those naturally occurring elements, tobacco companies add flavorings and other additives to make smoking more enjoyable and more addictive.
Williams JM, et. al. Learning about Healthy Living: Tobacco and You Manual. Revised 2012.

7. Why is Tobacco Addictive?
Physical addiction
Nicotine changes brain chemistry
Dopamine reward pathway
Behavioral addiction
Situations linked with tobacco use
Emotional addiction
Becomes primary coping mechanism
Tobacco addiction is a complex issue with several factors, but we will discuss 3 main factors to tobacco addiction: physical, behavioral, and emotional addiction.
First, tobacco is physically addictive due to the nicotine naturally occurring in tobacco plants. Nicotine can enter the brain within 10 seconds of inhaling tobacco smoke. Once it enters the brain, it sets off a cascade of 7 transmitters along something called the “dopamine reward pathway”. The dopamine reward pathway is just a system of changes in brain chemistry that makes you feel good in response to doing something. It is the same feeling as when you are really thirst and take a drink of water. It is the “aaahh” relief feeling. But in smoking, the activation of that dopamine pathway is so much faster and stronger than that. And over time your brain gets used to the nicotine, so you need more and more of it to get the same feel good effect. That is called tolerance, and it is a sign of changes in your brain that mean you are addicted.
In addition to the physical addiction, tobacco can be behaviorally addicting when it always occurs in a particular situation. For example, driving to work, having a beer or cup of coffee, finishing a meal. In these situations you can feel the desire to smoke even if you aren’t having a physical craving.
Finally, tobacco use can be emotionally addictive, especially since most people say they use it as a coping mechanism for stress. If it replaces other coping mechanisms, or is the only one, you can stay addicted for that reason.
Williams JM, et. al. Learning about Healthy Living: Tobacco and You Manual. Revised 2012.

8. Source: Quit Guide: You can quit smoking. QUITPLAN.com
It is important to know that the emotional and behavioral components of addiction become just as powerful as the physical addiction. Smoking becomes ingrained in the smoker’s daily life, unlike other substances, like cocaine or opiates, which are generally not so pervasive, impacting daily behavior as much as smoking.
This is just another way of representing those 3 factors related to tobacco dependence.
We can see that behavioral addiction includes how you respond to places and times when you usually want to smoke. Emotional addiction includes how you feel when you use tobacco. Etc.
Every move a smoker makes: the lighting of the cigarette, the inhaling, all the feelings and sensations of it, the whole package becomes highly addictive,
Dependence helps maintain smoking, because smoking becomes just as emotionally and behaviorally addictive as the biological addiction, so it’s important that treatment address all of these.
And this explains why it can be so hard to quit. Nicotine is eliminated by your body within a few days, but you may have strong urges to smoke months or years after quitting.
Source: Quit Guide: You can quit smoking. QUITPLAN.com

9. Smoking and Mental Illness
Higher rates of hospitalization
Associated with suicide and psychosis
Interferes with full recovery
Need higher doses of medication
More side effects
Some of that special targeting from the tobacco industry has contributed to a high smoking rate among those living with mental illnesses, which is 2-3 times higher than in the general population. The next slide shows the rates of smoking for different mental illness diagnoses.
This high rate of smoking is partially responsible for the fact that people living with mental illnesses die about 25 years earlier than the general popualtion, because the top causes of death are still the top causes of death in the general population (heart disease, cancer, chronic respiratory infections, accidents). For example, among those who have lived with lifelong alcohol substance use, over half will die from a smoking related disease. Even among those with substance use disorder of hard drugs, such as cocaine or heroin, are more likely to die from smoking.
For those living with mental illnesses who smoke, smoking can complicate their recovery, because smoking has been associated with higher rates of hospitalization (both for medical and mental health reasons). In addition, smoking increases the rate at which psychiatric medication is eliminated from your body, so you may need higher doses to control symptoms. This is because smoking activates your liver to try to remove the toxins, which increases your metabolism of medication, caffeine, Tylenol, etc. This may result in more side effects if a higher dose is needed.
Source: National Vital Statistics Reports, 2011

10. Medications Affected by Smoking
Antipsychotics
Antidepressants
Mood stabilizers
Anxiolytics
Others
Tylenol
Caffeine
Insulin
Like I mentioned before, there are several psychiatric medications that are affected by smoking and you would need a higher dose of if you smoked.
This is important to know, and important to communicate any changes in your smoking to your doctor, because you may need to adjust your dose if you quit smoking.
Additionally, if you are having a lot of side effects, quitting smoking can help you reduce your medication, which may reduce your side effects.
Source: University of Colorado Denver

11. The Decision to Quit Should you consider quitting?
What are the benefits of quitting?
What are the cons?
If you’re not ready to quit, consider changes you are ready for.
So we’ve covered some important information on smoking, like how smoking hurts your body, why it is addictive, and how living with a mental illness can be effected by smoking.
At this point you may be starting to think about whether you should consider quitting, but you may be unsure.
It is important that each individual decide for themselves whether quitting smoking is right for them. What would be your benefits to quitting smoking? What are your cons?
Even if you decide that you aren’t ready to quit yet, you can start to think about changes you ARE ready to make, such as talking to others you may know who’ve quit to hear their experience, delaying smoking, or count and keep track of your smoking patterns.
Williams JM, et. al. Learning about Healthy Living: Tobacco and You Manual. Revised 2012.

12. Success is Possible!
Given the right support, people living with mental illnesses quit at the same rate as those without mental illnesses
Quit plan
New coping skills
Social support
Medications
Access to resources
CBT, individual, and phone counseling
Although many people who smoke and live with a mental illness are worried about how quitting will effect their recovery, there is no evidence that quitting smoking increases symptoms or relapses in treatment. And studies have shown that people living with mental illnesses can be successful at quitting, at the same rate as the general population.
Successful smoking cessation starts with creating a plan. As part of that plan you will learn new coping strategies to replace smoking, trying a variety of different strategies, and then practicing them over and over again. It is also important to ask for support, either from friends and family, coworkers, a support group, or quitline or text programs. Quitlines and text programs are two examples of lots of free resources that you have available to help you quit, and I will go over that in a little bit.
Williams JM, et. al. Learning about Healthy Living: Tobacco and You Manual. Revised 2012.

13. Source: Quit Guide: You can quit smoking. QUITPLAN.com
Creating a Quit Plan
Assess current smoking and impact
Set a quit date
Prepare for withdrawal
Choose method of quitting
Decide if and what kind of medication to use
Ask for support
Plan and use new coping strategies
*** Try to challenge beliefs that justify smoking. Beliefs such as "I smoke because I'm stressed," "I'll quit tomorrow," "I'll only smoke one," and "I'm not strong enough to quit" are common and tend to cement smoking as a behavior.
One of the most important steps to smoking cessation is planning for how and when to quit.
First, it is important to assess your current smoking and the impacts of that smoking. This will help you see how much money you are currently spending on smoking, situations or people you usually smoke around, any negative impacts from your current smoking. You are trying to identify When and what are you doing when you smoke? And Why you want to quit? It can be helpful to write it down and keep it somewhere you can see everyday.
Then, set a quit date. The quit date should be between 1 – 2 weeks away, to give yourself time to prepare, but not too far away that you might lose motivation.
Part of good preparation is knowing what to expect. We will go over what to expect when you quit smoking on the next slide.
As part of your quit plan you should learn about and decide if you’ll use medications, such as nicotine replacement therapy, to help you quit. You may want to meet with your doctor to discuss this, as they can help you choose the right medication, dosage, and arrange for followup after your quit date.
You also want to identify people you can ask for support, and also plan for how you will deal with social situations, especially around friends who you smoke with.
We will discuss strategies to cope with urges in a few slides, but it is important to learn new tools to replace smoking, since smoking is often used as a way to cope with stress, and quitting smoking can also be stressful itself.
Source: Quit Guide: You can quit smoking. QUITPLAN.com

14. What to Expect When Quitting
Nicotine Withdrawal
Irritability, sleepiness, anxiety, anger, sadness, restlessness, insomnia, increased appetite, sweating
Triggers
Situations or people that trigger the urge to smoke
Social situations
Who will ask you to smoke? How will you say “no”?
Relapse
Weight management
TRIGGERS: strong feelings, especially if smoking was used as a way to avoid feelings
So, one of the first things to prepare yourself for when quitting smoking is the physical nicotine withdrawal. Nioctine withdrawal can bring on irritability, sleepiness, anxiety, strong emotions like anger or sadness, restlessness, insomia, increased appetite, and sweating.
These symptoms are your body’s reaction to adjusting to not having that nicotine everyday, and part of the symptoms is trying to get you to use nicotine/smoke again. Using nicotine replacement medications can reduce these symptoms, and they also can be cared for in the usual way (naps, relaxation, etc.)
It is also important to anticipate that you will experience these withdrawal symptoms because they are similar to many mental illness symptoms. So for some, it can be scary as they may interpret the withdrawal symptoms as a relapse. Some people may then start using tobacco again. It is important to let your doctor know if you are quitting tobacco, and you may want to schedule followup visits to ensure monitoring, but no study has shown that quitting smoking causes an increase in depressive symptoms, a relapse in substance use, or a worsening of mental illness symptoms.
You also want to plan ahead and identify what may be your triggers- situations or people that you usually smoke around, so that you can plan what to do before those situations arise.
This is similar to identifying the social situations or people who may ask you to smoke, and to plan to avoid those situations/people or how you will respond.
You should know that relapse is also very common, and people usually have to make an average of 7 serious quit attempts before they are able to stay quit.
Finally, metabolic changes after you quit smoking may make you more likely to gain weight. As we discussed before, smoking activates your liver as it tries to filter out all of the toxins from the smoke. When you quit smoking, your liver doesn’t have to work as hard, and therefore you are naturally burning less calories. Appetite can also increase, since nicotine is an appetite suppressant. Eating regular meals, eating healthy snacks, finding substitutes to occupy your hands and mouth, and exercising can all help you keep from gaining weight when you quit. It is true that most people do gain weight, an average about 9 pounds, but the health impact of gaining that weight is far less than the benefit from quitting smoking.
Source: Quit Guide: You can quit smoking. QUITPLAN.com

15. Source: Quit Guide: You can quit smoking. QUITPLAN.com
Coping Strategies
Substitutes and Distractions
The 5 Ds
Delay, Distract, Drink water, Deep breaths, Discuss
Manage overall stress
Physical activity, Sleep, Journaling, Music, Taking time to relax, Healthy eating, etc.
Control the environment
Specifically, smokers already recognize the benefit to mental health of taking a few minutes’ “time out,” several times throughout the day. At times, the cigarette itself may be primarily an excuse to step away for five minutes, stand outside and contemplate a different view, practice some deep inhaling and exhalation exercises, and regroup one’s mind for whatever is next on the day’s agenda.
In addition to the self-care strategies we just discussed for the first week or so, you will likely need to use other coping strategies to reduce and manage your stress.
Substitutes and distractions are behaviors to do in the moment either as a substitute to smoking or to distract from the desire to smoke.
Substitutes: are things that can be used to keep your mouth and hands busy when you get an urge to smoke. Substitutes can include things like toothpicks, short straws, cinnamon sticks, gum, and hard candies for your mouth. For your hands, you can try pencils, paperclips, worry stones, or worry beads.
Distractions
can include things or activities that take your mind off smoking when an urge hits. These
can include taking a walk or getting some exercise, doing a puzzle of some kind, doodling, or starting a new hobby—anything to get your mind off smoking for 5 minutes. You can think of this as “urge surfing”- you are distracting yourself long enough for the urge to smoke to pass- which usually is only 5-10 minutes.
For example, if one of the triggers for smoking is waking up, subsitutions or distractions could be: changing routine by showering instead of drinking coffee first, drinking tea instead of coffee, take the dog for a walk, eat breakfast. Etc.
The 5 Ds can be an easy to remember coping strategies that include both distracting and substituting:
Delay: The average craving lasts ~5-10 minutes
Distract: Do things like go for a walk, talk with a friend, munch on crunchy vegetables
Drink water: Helps flush out toxins, keeps hands and mouths busy
Deep breathing: Provides a calming effect. Deep breathing also mimics a person’s breathing when smoking a cigarette
Discuss: call a friend, quit coach, or anyone who can offer support and encouragement
Managing overall stress: Other wellness activities can help you overall lower stress and cope.
Control the environment: tobacco-proof your home and car (get rid of all tobacco, lighters, ashtrays, etc.). Talk to family, friends, and coworkers: ask them to support you by smoking outside, not offering you a cigarette, not smoking around you, etc.
Find another coping mechanism for strong feelings: intense exercise, going for a walk, calling a friend, journaling, etc.
Source: Quit Guide: You can quit smoking. QUITPLAN.com

16. Smoking Cessation Medications
7 approved medications
5 nicotine replacement therapies
2 prescription medication
Treats nicotine withdrawal
Doubles chance of successful quit
Can start using before quit date
Can use more than one
Covered by insurance, medical assistance
A common myth that nicotine is harmful, so many people don’t take the maximum dose, or doctor’s don’t prescribe it as long or as high of a dose as needed. Actually, FDA reviewed NRT last year and removed some of its warnings. You can start using NRT before you stop smoking, you can use more than one at a time, and you can use them long-term, which has been shown to help people stay smoke-free after relapse. The danger of smoking is in the smoke, not the nicotine.
Clinical practice guidelines recommend that all smokers attempting to quit use medication to assist them in quitting. There are 7 FDA approved medications, including 5 nicotine replacement therapies (patch, gum, lozenge (available without a prescription) and nasal spray, and inhaler- available with prescription) and 2 prescription pill medications.
Nicotine replacement therapy contains nicotine to treat the physical withdrawal symptoms. Since you are still getting niotine, users report less urges to smoke, less weight gain, and less depressive symptoms. The prescription pills work by tricking your brain into thinking it has nicotine and making smoking less pleasurable.
Using medication doubles your chance of successfully quitting. For some medications, it is best to start using before your quit date, and it is OK to use NRT if you still smoke. It can be one way to reduce the number of cigarettes you are smoking before your quit date. It is also OK to use more than one medication, and actually improves success rates, such as using the patch for consistent delivery of nicotine and a lozenge when a strong craving hits. Although the amount of nicotine in NRT is similar to that in cigarettes, it is released much slower, so there isn’t a risk of getting addicted. Actually, doctors have found that most people are not using a high enough dose of their NRT, which will not be as effective.
And with the implementation of the Affordable Care Act, smoking cessation is listed as an essential health service, so all health plans should be covering NRT and medication, along with counseling, for free, though what they actually are covering varies based on the plan, so you will want to check with your insurance company. Those on MA can receive NRT and medications with just $1-3 copay, and counseling, and we will go over some more resources for medications at the end.
Important to know: not addictive, and most people don’t use high enough doses or use it for ling enough.
Williams JM, et. al. Learning about Healthy Living: Tobacco and You Manual. Revised 2012.

17. Why E-Cigarettes Are Not A Smoking Cessation Tool
Unregulated
Unknown levels of chemicals
Several of the same chemicals as tobacco smoke
Unknown levels of nicotine
Still an addiction
Risk of getting addicted to both
I’ll just mention briefly that e-cigarettes are not recommended as a smoking cessation strategy, because the chemicals are unknown and unregualted. In fact, recent reports have come out that the smoke from these may be more dangerous from cigarette smoke because of formaldehyde.

18. Quit Programs Nicotine Anonymous SMOKEFREETXT
QuitSTART Mobile phone app
Health Insurance Plan
QUITPLAN
Quitlines are a free resource that is very popular among smokers and can double the chance of quitting.
1-800-QUIT-NOW is a national quit line that transfers callers to their state quitline.
Nicotine anonymous is a support group format based on the Alcoholics anonymous model. There are 7 local metro meetings.
SMOKEFREETXT and QuitSTART are both free phone services created by the National Cancer Institute. SMOKEFREETXT is a 24 hour text service that send tips, strategies, and support. QuitSTART is an app where you can track your urges, play games to distract you, and offer support and resources.
QuitPlan is our state quitline and smoking cesation service.
Source: QUITPLAN.com

19. QUITPLAN Provides free services for residents of MN:
Launched by ClearWay Minnesota in 2001
In 2012
9000 total calls
Provides free services for residents of MN:
Telephone coaching
2 week supply of free patches, gum, or lozenges
support
Comprehensive quit plan guide
QUITNOW Mobile phone app
Funded by 3% of the settlement MN received from tobacco companies in 1998.
Receive about 9000 calls a year, and also have online services.
For all MN residents: 2 weeks worth of free patches, gum, and lozenges; 2 phone coaching sessions
For uninsured or on MA: 4 weeks of free patches, gum, and lozenges; 5 sessions of phone coaching
Phone app: gives tips, games to take mind off cravings, reminders, tools to track tobacco use/urges, and information on money saved.
program: that gives similar information on tips, support, ways to manage stress, benefits of quitting, etc.
Source: QUITPLAN.com

20. Bouncing Back From Relapse
Learn from it
What can I do next time?
Review triggers
Stay positive
Positive self-talk
Celebrate any gains
Assess current strategy
May need to adjust medications, add strategy, or counseling
Relapse is very common among people who are trying to quit smoking, with most ex smokers taking an average of 5-7 serious attempts before quitting.
If a slip happens, view it as a setback, not a failure. You can use it to learn from, such as how you can use your new coping skills the next time.
It is important to stay positive, and realize that a slip doesn’t have to mean giving up completely, Review and celebrate any reductions in tobacco use or any health gains made.
You should also review your current strategy whenever a relapse occurs. You may need to adjust medications, make sure you are using them properly, or add another strategy.
Source: QUITPLAN.com

21. What if You’re Not Ready to Quit?
It’s common to have mixed feelings
You can still benefit from assessing your smoking
What would be your benefits to quitting?
Are there any negatives to your smoking now?
What is stopping you from quitting?
What keeps you smoking?
What can you do with this information?
What small changes could you make?
So, what if you’re not ready to quit?
It is common to have mixed feelings about quitting.
Even if you don’t feel like you are ready to quit now, it can still be helpful to assess your current smoking. You can start to ask yourself some of these questions, and decide what to do with that information.
You can also start making small changes in your tobacco use even if you aren’t ready. Some of the things we’ve talked about, like delaying or limiting the location of smoking, are some examples. You may also feel ready to just learn more information or talk to your doctor.
Williams JM, et. al. Learning about Healthy Living: Tobacco and You Manual. Revised 2012.

22. Supporting Someone Who’s Quitting
Understand
Praise
Be there
Check In
Help them to relax
Be positive
Be in it for the long haul

23. Resources QUITPLAN Quitplan.com Extensive resources and free NRT
Smokefree.gov
QuitSTART Mobile phone app
NAMI
CHOICES (Consumers Helping Others Improve their Condition by Ending Smoking)
Nicotine Anonymous – 7 metro meeting locations

24. NAMI Minnesota 800 Transfer Road, Suite 31 St. Paul, MN 55114
or NAMI-HELPS
Jessica DeWolfe, MPH
Wellness Coordinator
ext. 124