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Episode 7 : Smoking Part 1: Its Harmful Effects and Getting Ready to Quit

Release Date: December 8, 2006

Dr. David Meyerson: Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for this edition of Vascular Disease Foundation's HealthCast. The Vascular Disease Foundation is made up of organizations widely known as premiere health education groups throughout the country and HealthCast is brought to you as a public service. In past episodes, we've chatted about peripheral arterial disease that causes claudication, disability and amputation, carotid artery disease which causes transient ischemic attacks and stroke, and coronary artery disease which, as you all know, causes angina, and heart attacks and leads to heart failure. We've talked about how to identify these processes before they cause serious damage and how to prevent and treat many of these problems before they cause you harm.

Common denominators to these diseases include high cholesterol, hypertension, diabetes and of course, smoking. Smoking is such a potent cause of the blood vessel disease all over the body that we thought it deserved its own healthcast with an expert on smoking cessation. If a seven-forty-seven jetliner full of passengers and three hundred and fifty people were killed, it would be on every news organization in the country. If two seven-forty-sevens crashed, the fleet would be grounded. A third would be grounds for a Senate investigation. Well, listen to this. The equivalent of four seven-forty-sevens full of people are dying every single day directly attributable to the ravages of tobacco smoking. About fourteen hundred people a day, about half a million people a year and this is preventable disease. What can you do today if you're a smoker? What can you do to help a loved one quit? How can you beat the addiction of cigarettes before they beat you?

With me today is a true expert in the field, Dr. Susan Bartlett. She's Associate Professor of Medicine, a Health Psychologist at Johns Hopkins and a smoking cessation expert. Dr. Bartlett welcome to the microphones of HealthCast. I'm so glad you're here.

Dr. Susan Bartlett: Thank you David, it's a pleasure to be here with you.

Dr. David Meyerson: Nicotine addiction is an addiction, but I'd like you to comment on this. Somebody once said it's approximately twenty percent physiological and eighty percent psychological and they said think about it. The chemical effect of the drug does not have to work very hard to keep you addicted because you reinforce your perceived satisfaction with just about every cigarette through your thoughts and words. Is this true? Is this over simplified? It's really an addiction though.

Dr. Susan Bartlett: It's truly an addiction and the way I think of it and I think the way the field thinks of it now is more of the reverse. In fact, we believe it's about eighty percent physiological and twenty percent psychological and the reason for that is, we've come to understand that nicotine is probably the most potent, addictive substance known to man.

Dr. David Meyerson: More than street drugs, for example.

Dr. Susan Bartlett: Think about it. We have nicotinic receptors in our brain. It's almost as if we were hard wired to want this stuff.

Dr. David Meyerson: And when you think about it, the number of people dying every single day from heart and blood vessel disease and directly attributable to cigarette smoking. We're not just talking about heart and blood vessel disease, we're talking about mouth and throat and lung cancers. We're talking about bladder cancers. We're talking about chronic obstructive pulmonary disease and people on ventilators. You tell everybody and I would echo that, that if you have smoked for forty years, it's still worth quitting immediately.

Dr. Susan Bartlett: It's never too late to quit. There are benefits to everyone who stops, even the eighty-year-old smoker. As you were saying, smoking is responsible for so many diseases or the exacerbation of so many of our diseases. We also know that it's responsible for about one third of all cancer deaths. There is some good news with smoking though, I will say. The public health efforts that have been made to try and help people to stop smoking have made a difference in the last twenty-five years. In fact, smoking cessation is considered one of the greatest achievement of the twentieth century because we have literally cut the rate of smoking in men in half.

Dr. David Meyerson: I think we've changed a lot of society's views. I have a small poster, it's a 1930 magazine back from -- in my office that's framed - and it has a picture of an elegant 1930's debutante with cigarette and the caption is "2679 physicians say Lucky's are less irritating" and I think that we've come a long way in that regard.

Dr. Susan Bartlett: Well, we certainly recognize now that avoiding smoking or stopping smoking is the single most important thing that you can do to improve your health.

Dr. David Meyerson: Now when I, as a cardiologist, talk to patients with heart disease, I tell them that smoking diminishes the amount of oxygen in the blood, it increases the carbon monoxide level, it causes spasm of the arteries that nourishes the heart muscle, it makes the blood cells called platelets in blood more sticky and more likely to cause a blood clot when they should not ordinarily. It can literally trigger the next heart attack or stroke, can't it?

Dr. Susan Bartlett: Absolutely. When you smoke, you affect every single system in the body. There is no part of the body that is left unscathed by the smoke that you are taking into your lungs.

Dr. David Meyerson: And although we see some occasional people who say I've smoked for many, many, many years and look at me doc, I'm fine. That is really just the tip of the iceberg. Everybody below the water is long gone.

Dr. Susan Bartlett: You know David, what patients used to say to me a lot was, "Well you got to die of something, right doc? So, might as well die of this."

Dr. David Meyerson: But you know it's funny, as Ubee Blake said on his hundredth birthday, when every other organ system is still working, he said, if I knew I was going to live this long, I'd a taken better care of myself. And that's what you can do with cigarette smoking. So, one last thing. It is so interesting to me and I'd like your comment on this. This is the one product that I am aware of that is sold in the United States of America when even when used as directed, it is still guaranteed to cause harm to a body.

Dr. Susan Bartlett: Well, this puts it in perspective for me. Nicotine is so dangerous and so powerfully addictive that it is not allowed to be produced in the United States. We consider it too dangerous to produce it here, so when we need nicotine for nicotine patches for instance, we have to go over to India and other countries to get the nicotine where it can still be made.

Dr. David Meyerson: That is incredible, but we -- part of it I guess is so financially driven, economically driven. And then when we talk about not selling as many cigarettes here in the United States, I think we're a little bit hypocritical when we think that we can just ship them to other countries. That's not a great idea either.

Dr. Susan Bartlett: Absolutely. The rates of smoking are going down in the United States fortunately, however they are escalating dramatically, especially in third world countries.

Dr. David Meyerson: So now let's give our listeners some real, real palpable advice that they can take home with them now and they can begin their smoking cessation. Again if you have a loved one that's smoking that you want to help them stop, you want to stop yourself, how do we go about that? I understand there are age differences in how you would council somebody to stop smoking. For example, a young man was said to have said, "I stopped smoking for five reasons. To save money, I didn't like the smell of smoke on my clothing, for health reasons," he said that smoking can be a big turn-off to women, "I found it hard enough to meet and attract women to give them another reason not to like me or think that I was just stupid and I wanted to be classified as a nonsmoker as I felt that I was being treated like some sort of loser when I was a smoker." Is this, do you tailor your counseling based upon age and other issues?

Dr. Susan Bartlett: Well, when I'm working with healthcare providers and teaching them how to work with their patients on methods, effective methods to stop smoking, that's one of the things that I definitely encourage them to do is to talk with the individual and we know that different people and different ages certainly, different things are more salient.

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Susan Bartlett: Let me give you an example. If I'm working with a young mother or a young father, one of the things that I will talk about is the fact that there's a direct relationship between the presence of smoke in the home and the number of ear infections a young child will experience.

Dr. David Meyerson: And asthma for the child.

Dr. Susan Bartlett: And asthma. However, think about those two things. What do parents want more than anything else?

Dr. David Meyerson: The well-being of their child.

Dr. Susan Bartlett: And the ability to sleep.

Dr. David Meyerson: Right.

Dr. Susan Bartlett: And what is one of the prime thieves of sleep when it comes to those young children? Ear infections and asthma, as you're saying. And so, one of the ways in for me is often to talk about how many ear infections the child may have had and then say if you were able to stop smoking, there's a pretty good likelihood that those ear infections would certainly diminish if not disappear.

Dr. David Meyerson: There's nothing like getting pregnant to get a young woman to stop smoking immediately, isn't there?

Dr. Susan Bartlett: You know, some of the research --

Dr. David Meyerson: Maybe we should recommend that to everyone.

Dr. Susan Bartlett: Some of the research that's been done here, right here in Baltimore, suggests that, in fact, one of the easier times to stop smoking is when a woman becomes pregnant, probably because she's not feeling that well in the first three months anyway. Unfortunately, what we see is the resumption of smoking is so high, anywhere between seventy and ninety percent of women, will return to smoking within three weeks after having the baby.

Dr. David Meyerson: When patients come to you and say, "Doc, I'm cutting down." I tell them that's a little bit like saying I only drive a hundred and thirty-five miles an hour two days a week, so something's still going to happen. You don't like the idea. Cutting down is of value or is not of value? Or is bad behavioral a value?

Dr. Susan Bartlett: Well, what I say to patients is, it's absolutely necessary that you stop and that you stop today because everyday that you continue to smoke, your health is being damaged. But I also balance that with the fact that I understand that they may not be ready at this time. And being ready to smoke is a really important piece of ultimately being successful.

Dr. David Meyerson: Now I understand that if you're an adult and have smoked for many years, once you stop smoking, your risk of developing lung cancer drops dramatically within a certain period of time, a year or two out or something like that. There really is dramatic benefit to stopping, even if you are a twenty or thirty smoker.

Dr. Susan Bartlett: Well, I think the newer, the newer research would suggest that your risk of lung cancer may not be that influenced by stopping smoking. Unfortunately it seems that the changes that take place in the first few years that you smoke, actually set the state for twenty years later for the lung cancer to develop.

Dr. David Meyerson: I'm glad to correct that. What about the progression of obstructive pulmonary disease?

Dr. Susan Bartlett: Well, certainly the area in which we know it makes the most dramatic difference is your risk of sudden death, so you are much less likely even one year later to drop dead, for instance, of a heart attack.

Dr. David Meyerson: All right, today, I want to make a serious attempt to stop smoking. What do I have to do right now ?

Dr. Susan Bartlett: The first thing I want you to do is really understand what you're up against, because this will be one of the most difficult things that you try to accomplish in your life. For many people, stopping smoking represents more effort and more struggle than almost anything else they've tried to do and again we think that's because the nicotine is so powerfully addicting and just so potent. Quitting is very hard. You want to make sure that when you make a quit attempt, that you're thinking about the timing. Is this the right time for me to do this? You want to get as much support as you possibly can. And you want to make sure that you do everything possible to help yourself because you've got a tough road ahead of you.

Dr. David Meyerson: So if you're in a situation where you know you're going to have severe emotional stress for the next several weeks, you would say set a quit date just after that?

Dr. Susan Bartlett: Well, for example, I would never suggest that a tax accountant consider stopping smoking in the early spring.

Dr. David Meyerson: Okay.

Dr. Susan Bartlett: It's just going to be too hectic and similarly for most of us, before the holidays, it's just too busy and stressful so you definitely want to find a time in your life -- there's never going to be the perfect time.

Dr. David Meyerson: You need help from your family. You have to tell them you're going to be ornery for a little while, right?

Dr. Susan Bartlett: Well, and the truth is you are.

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Susan Bartlett: What we understand is that you're probably going to feel more uncomfortable for the first couple of days than you've felt in a long, long time.

Dr. David Meyerson: Isn't it true that the dramatic urge for a cigarette that people get lasts about twelve or thirteen minutes or something in that - - and if you can get by that initial urge, then you have a little bit of a window of time until you can come to the next one?

Dr. Susan Bartlett: It's absolutely true that we have cravings and the intensity of the craving actually seems to peak within about ten minutes or so. So if you can wait out those ten minutes, then you have a pretty good chance of making it through the next couple of hours.

Dr. David Meyerson: I have a friend who is a business person. I've been in his office where he picks up the telephone with his right hand and without looking, I'm sure without thinking, he's talking about something complicated, he's reaching into the left-hand drawer of his desk, he's pulling out a cigarette, he's lighting it, he's beginning to smoke, without even engaging his brain I'm sure. Almost as a reflex. What do you tell people in that situation? Get the cigarettes away, get rid of everything? What can they\ substitute for cigarettes?

Dr. Susan Bartlett: Well, let me go back and sort of lay out the scenario of what seems to work best for people to quit smoking. The first thing is to get ready. And getting ready means, becoming aware of all of these patterns that you're talking about that you do automatically. So many people automatically get in the car and light up a cigarette or they go for their morning coffee and they light up a cigarette. Now each time you pair two things together in time, what actually happens is a little groove in your brain is made. We call that a neural groove. The more you pair those two things together, the stronger the association, so it is exactly as you say. Your friend picks up the phone and another part of his brain says, get a cigarette because if the phone's in one hand, it feels like a cigarette should be in the other hand.

Dr. David Meyerson: Is it the same type of neural groove that when we hear a song from when we were in high school and college and it immediately brings us back to where we were, same type of --

Dr. Susan Bartlett: Exactly. We're talking about the strength of the association. So, one of the first things we want people to do is to understand all the different things that tend to trigger their smoking or that they pair up with smoking because these are going to be very important risk points. So if, as I said before, if you know in the car, if you know with coffee, if you have predictable times during the day when you have a cigarette, you want to become aware of that and see if it's possible to break some of those habits to begin with. So for instance, I've worked with many patients who have done things like, before their actual day that they're going to quit, for a couple of weeks before, they slow down their smoking and they stop smoking in the car. They stop smoking with coffee. They may not diminish the total number of cigarettes that much, but they're trying to break some of the associations and that's going to be helpful.

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Susan Bartlett: As you said, it's very helpful for most, but not everybody to let your family and friends know because you are going to be more irritable. You're going to have trouble sleeping. You're going to feel uncomfortable. There are many patients that I have worked with over time where their spouse has come to them after two weeks or so and said

Dr. David Meyerson: Please start smoking.

Dr. Susan Bartlett: Right. Brought them the cigarettes. I can't live with you like this and we'll talk --

Dr. David Meyerson: And that's the time that they have to dig deep and be as supportive as they can.

Dr. Susan Bartlett: That's right and also you know, most family members --

Dr. David Meyerson: Honey, you're crazy, I love you, but you're not going to smoke.

Dr. Susan Bartlett: Most family members I have found are actually very supportive, if you ask.

Our family members don't know what we need. The only way they can understand is if we specify to them and you might need to be as specific as saying, once I try and stop smoking, I think it would be really important that you smoke in a different area of the house. Or that you smoke outside because, you know, if we're sitting here at the breakfast table, reading the newspaper and you're smoking and I'm trying to stop, it's going to be very hard for me to do that.

Dr. David Meyerson: If you can get both to buy in at the same time, that's even better, right?

Dr. Susan Bartlett: If you can get both, that's wonderful.

Dr. David Meyerson: If there's not a war in the house.

Dr. Susan Bartlett: But absolutely. But the person who's stopping, has to be prepared to make these kinds of changes.

Dr. David Meyerson: Somebody once said, you get a dish of sugar free candy and you put it in every place that the cigarettes used to be so that you can have something that you can do both with your hands and orally. Is there value to that?

Dr. Susan Bartlett: For some people, I think there is. Some people really don't know what to do with their hands, for instance, at a cocktail party. And what they end up doing is having a cigarette because it keeps them busy. It keeps their mouth busy and it keeps hands busy. So if they're sort of at loose ends, they've got something to do. For those kinds of individuals, it probably is helpful to have some kind of replacement.

Dr. David Meyerson: What -- when you talk about replacement, we're talking about the nicotine patch, for example or gum or something of that nature, right?

Dr. Susan Bartlett: Well, that's another --

Dr. David Meyerson: Or replacement of the habit.

Dr. Susan Bartlett: Replacement of just something in your hands.

Dr. David Meyerson: Of something to do, okay.

Dr. Susan Bartlett: Another thing that works very well, for instance, for women is to take up some kind of activity like knitting or crocheting --

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Susan Bartlett: -- that's going to keep their hands busy in the evening.

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Susan Bartlett: Because those hands being at loose ends.

Dr. David Meyerson: Can you give that advice to a twenty-three-year-old young professional woman who, I mean is she really going to want to start with that kind of -- or maybe she should go work out.

Dr. Susan Bartlett: You know what's most important is that she change some of the patterns.

Dr. David Meyerson: Do something.

Dr. Susan Bartlett: Right.

Dr. David Meyerson: Okay.

Dr. Susan Bartlett: So if she really enjoyed that cigarette after dinner, sitting at the table, then we want her to not sit at the table. Get up and go for a walk, go to the gym and exercise, sit down and knit, do anything -- go have a shower. Do anything you can do that changes the pattern so that you reduce the strength of the craving that you're going to have for the cigarette.

Dr. David Meyerson: What about people who -the difference between cold turkey and using an aid like a nicotine patch?

Dr. Susan Bartlett: Well, I think those are really two different things. Let me talk first about the cold turkey. We know that most successful quitters, in fact, go cold turkey. Smoking cessation -

Dr. David Meyerson: And they can often tell you the date and time that they stopped smoking.

Dr. Susan Bartlett: Absolutely. Absolutely. And smoking is one of the more interesting areas, I think, of behavior change. For instance, if a patient comes to me and wants to lose weight, I'm probably going to suggest to them that they find some sort of support group, weight watchers or something like that. Because we know that people generally do much better changing lifestyle behaviors in a group format. Not with smoking. Most people are more successful just stopping on their own and the way they stop is cold turkey.

Dr. David Meyerson: There's nothing like a heart attack to get somebody to stop smoking.

Dr. Susan Bartlett: That, unfortunately, can often be the sentinel event. We hope that we can encourage more people --

Dr. David Meyerson: But so often, they go back. What do you tell people who say, "I stopped a million times and I'm starting again. How do I stop this?"

Dr. Susan Bartlett: Well, one of the things that I help them to understand is that very, very few if any people ever stop the first time successfully. Relapse is very common. The average successful smoker has tried more than four times, made four serious quit attempts. I've worked with many people who have stopped for fifteen years or more and then a very stressful event came up in their life and they went back to smoking. So once you've smoked, you always are at of relapsing and that's important to know, but once you start to smoke again, the fast you can address that and nip it in the bud, the easier it's going to be.

Dr. David Meyerson: These are some, the beginnings of some fascinating and wonderful, wonderful pieces of advice. Dr. Bartlett, this is -- we've only begun to scratch the surface. We should just call this volume one of our smoking cessation and would you come back very shortly and give us another moment of your time so we can talk about nicotine patch, other pharmacologic advice and how to integrate this and how to really get this going in your life. I really would like -- it's so important. I would love to give that to our audience next time. Would you be willing to do that?

Dr. Susan Bartlett: Absolutely because you know, that's one of the biggest improvements and the biggest changes we've made in the last twenty years is having these kinds of tools that really do double or triple the successful rates of quitting.

Dr. David Meyerson: My special guest today has been Dr. Susan Bartlett, Associate Profession of Medicine, a Health Psychologist at Johns Hopkins, a smoking cessation expert and as they say, incidentally, she's a hell of a person and we're very grateful that she's with us today. This is only the first episode of our smoking cessation series with Dr. Bartlett. For Dr. David Meyerson and for the Vascular Disease Foundation, have a great day.

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