Smoking cessation

[Lynn Cremona]

something I came across from Will Taylor regards smoking cessation and a practitioners effect on their patients/clients/partners in health:
I find it useful to break down the issue of smoking into 3 arenas:

(1)The physical addiction

(2)The habits that have grown up around the use of tobacco

(3)The meanings for the person - of smoking, of stopping, etc.

Of course any time we divide a complex phenomenon up into parts, these divisions are artificial, & exist for our understanding only. But these divisions are useful in designing a plan to assist folks in becoming non-smokers.

Allopathic intervention pays attention to the division between parts (1) & (2), in the use of nicotine supplementation (not something I advocate, tho it appears clever at first glance). Nicotine gum or patches ameliorate the physical addiction, while the person has an opportunity to disassociate from the behaviors that surround and support the smoking habit; then they get to go thru withdrawal later, hopefully after these habits are changed, & hopefully in a more gradual & controlled manner. Problem is, in practice, it is not typical for a doc to introduce an effective habit-change program during the period of patch or gum use, & the withdrawal from the nicotine supplement is not often orchestrated well. And issue (3) rarely gets addressed.

With these 3 issues in mind, I like to approach a person's request to assist in smoking cessation as follows:

An appropriate remedy is given, more often in repetitive dose in water, with that dosing method chosen if only to offer a daily reminder of support in their process. This is chosen on the presenting totality, & only in a couple of cases in my experience has it been a "smoking" remedy - what I mean by this, is that most of the folks who've presented to me with the request to stop smoking, present with a chronic miasmatic illness of which the smoking habit is only one of many aspects. After all, when we look at the populations in which we live, habitual tobacco use is *not* an aphorism 153 symptom! So the role of this remedy is not necessarily to act directly by "reducing cravings", etc.; tho it likely assists in all of what will be discussed below.

Habit change is an essential part of smoking cessation. I take a good history of smoking behaviors - when; where; associated with what other activities; with whom, who else smokes in their environments at home, work, etc. Adhering with my general theory that it makes sense to tackle the 5% of the problem that holds 95% of the solution, we work on a plan to alter the principle behaviors that surround smoking *for this person*. This might involve (variably, for different folks) something *else* to do while drinking coffee; drinking cocoa or tea instead of coffee; meeting their friends who smoke at times when smoking is not happening (e.g., instead of the cigarette outdoors outside the entrance door to the store where they work, having their morning chat in the non-smoking lounge inside); buying a good CD player for the car & some music (see below) & listening to Mark Knopfler on the way home instead of smoking; buying a different brand every week; keeping their cigarettes in a different location, or in a case; keeping their lighter & cigarettes in different locations; etc. Investigation & creative problems solving together with the patient is the key here, there is no one formula to apply to all.

I suggest that they find a clear glass quart jar, & each day that they don't smoke, put the money they *would* have spent on smoking, in the jar instead. That's ~$3-$6 a day for most folks, & it adds up fast. When you train a dog, you do not wait & at the end of a week say, "good work Fido, here's your bone & a chuck under the chin" - the reward needs to be contingent in time to the behavior to be effective. Similarly, the held-out hope for a longer & better life, less smelly, no COPD or cancer, does not really help folks stop smoking. And fear of things *never* seems to help us change (witness that we still have nuclear weapons). So anyway, they get to see their savings on a regular basis, and at the end of each week, they should spend this on something as a *treat* (NOT the phone bill, etc., even if it's late, or to pay me for their visit - it would not have gone toward that anyway!). So ~$21-$42 each week for a *treat* - a new Tom Petty CD for the drive home, or that anthology of Robert Johnson, or a silk scarf from the Asian Import shop or some of that really great cocoa, or treat a (non-smoking!) friend to a movie out. I do have some patients who have saved the money up - one guy, a 3-pack a day smoker, bought a bass boat with his years' savings; a woman paid for her life's dream, a trip to Ireland (but she got there & discovered that nearly everybody in Ireland smokes!). I don't encourage this, 'cause I think the regular reward at short intervals is more effective for *most* folks - but if they really want to do this, have them put a picture of their goal on the jar, so it's *tangible*. The more palpable the reward is, the closer it is to their daily reality & moment-to-moment choice about smoking or not. If they smoke that day, the money does not go in the pot - they *chose* to smoke it instead. Tomorrow they can choose again.

For many folks who smoke, this habit has subsumed the role of relaxation breaks and daily unnamed rituals. So they haven't been doing *non*smoking relaxation breaks or daily rituals for a long, long time - so long that they've forgotten them. So if they just plain stop smoking, there are no relaxation breaks, no rituals - & we really need those things. They miss them, & they *think* they are just missing smoking. So we have to work with folks to help them create these things, maybe even to learn how to do them. A simple 20-minute relaxation training session (either you can do that, or send them to a friendly yoga instructor or wellness-oriented counselor) with a tape to take home. Discuss the need for daily rituals, & help them set some up - maybe reading aloud with their partner; or sitting in the morning with a cup of tea & some music; or a walk; there are many options, explore with them what might fit in with their values & interests. Regarding relaxation, it has been objectively observed that folks who have recently stopped smoking have far fewer spontaneous deep breaths than the general population. It appears that their deep breathing has become associated with inhaling when smoking - and when this is stopped, they just don't revert to it spontaneously. So some diaphragmatic breathing exercises might be really valuable - again, a yoga instructor can be really helpful here if you lack the experience in doing this. (BTW, some simple relaxation training, incorporating breathing work, is a *great* adjunct to homoeopathic practice, relatively easy to learn & implement, & great self-care for yourself as well).

This topic - the habit-change issue - is a big one, & I could go on, but I'll leave it here to your explorations with your patients & your creativity to come up with more possibilities. Oh - except for one thing. They're probably going to get really bitchy during esp. the first 10 days of withdrawal. So PRESCRIBE this for them - ask them to speak to the folks around them, and show them your written prescription for them to be outrageously bitchy & irritable, & get permission from their family & friends to be OUTRAGEOUSLY bitchy for 2 weeks. Being bitchy is hard enough to begin with - but being bitchy and feeling bad about it is awful. This is called "prescribing the symptom" by cognitive-behavioral psychologists, & is a great tool.
Regarding the Meanings of smoking -
There are several dimensions to this.

One is, just how many things to we decide to do *forever after*? Like "I'm never going to smoke ever again?" Marriage, kind of, & having kids, certainly. & Alcohol, if that's been a path. That's about it. Nearly everything else we do has to do with continuing choice in time. Most folks who smoke feel like shit because they've tried to stop several times in the past, & "couldn't" do it, & carry stories about their "will power" being weak. Bullshit. So they stop, & then find themselves smoking with a friend in a bar, & go, "shit, I failed again." Help them re-write these stories, so they have the choice of putting that cigarette out, & continuing with their choice to not smoke.

Another point about "will power", is that the stuff they are addicted to is honestly truly physically addicting - one of the most addictive substances known to man - & is manufactured by an industry that knows that & relies on it for sales. Help them re-write the story of their "weak will power" into one about the assholes who *know* how to secure sales thru marketing an addictive substance.

What are the patient's stories around smoking? Many folks were recruited with romantic imagery of smoking celebrities or mythic images of Marlboro men or anorectic women in ads. For many there's an adolescent rebellion element tied up in their self-definition as a "smoker". For others, smoking is wrapped up in a Sycotic story of feelings of inadequacy & struggle for peer acceptance. Can we help them to re-write some of these stories? Are there other ways to honor the their adolescent rebellion or images of romanticism, or address their inner feelings of inadequacy?

A lot of folks will tell you, & likely believe, that they are "an irritable and anxious person" and need to smoke to relax. Usually, they've been smoking for 10-15-20 years, since they were 15, & the truth is, THEY DON"T KNOW FOR SHIT WHAT KIND OF A PERSON THEY ARE. What is really true, is, that when they go into withdrawal, (which is 15-30 minutes after they've finished a cigarette, including the morning when they wake up), they are irritable & anxious, & smoking takes them out of withdrawal temporarily so they feel better. & When they stop smoking, they're going to be in physical withdrawal for 10 days or so, and then likely will be missing their accustomed relaxation (not tobacco, but the deep breathing and the break from activities associated with smoking) even after that. Understanding this can help them tremendously.

Suggestion is really important here as well. In a study of the effectiveness of family physicians in assisting folks in stopping smoking, it was found that the *major* determinate of effectiveness was the physician's confidence in their ability to help. When I studied clinical hypnosis, the *first* thing that my instructor - Karen Olness - told us, was that the most powerful hypnotic induction she knew was a white coat & a diploma on the wall. This of course is figurative, & applies as well to my Birkenstocks & reading glasses & the shelf of Allen & Hering in my office; but the point is, that we inadvertently practice *negative* suggestion every day, and need to be conscious of making our suggestion to patients as positive and productive as possible; even when it is not *intended* to be hypnotic or transformative. Because it is, whether we intend it or not.

Will Taylor, MD