The Therapist's Role in Smoking Cessation

We all know that smoking has an insidious and cumulative effect on our physical health throughout years of smoking. What it doesn’t affect directly, it will most definitely complicate and while smoking may be blamed for causing problems that it may not actually cause, the medical problems it does cause will complicate the other problems we get.

When the 1st Surgeon General’s warning was put on all of the cigarette packs (1966) with updated warnings in 1970 & 1984 (the latter being more impressive of a warning that in previous years) and the information about the dangers of smoking (inclusive of multiple additives that we had not been aware of before) were released in 2000, it became “uncool” to smoke. Public places no longer allowed smoking indoors and/or had “smoking sections” depending in the State you were in (1973-1980s) and even outdoor places (such as amusement parks) sectioned off smoking sections due to the dangers of smoke being released into the air around us. Children’s candy cigarettes were taken off the market in some States but the word cigarettes was taken off the labels and replaced with the word sticks and smoking commercials were banned in 1970, taking effect in 1971; all in an effort to deter people from smoking.

So why do we smoke and why don’t we “just stop”? Most likely because we are addicted.

According to the articles reviewed, smoking provides temporary good feelings and those good feelings, over time, train your brain to want it even more. Despite the fact that many articles say that smoking does not make people feel better, some articles finally admit the truth. For a smoker, smoking does improve mood and helps with relaxation. If we are going to explore smoking cessation, let’s begin with the truth.

We can’t tell someone who smokes that it doesn’t make them feel the way that they feel. Smoking causes our bodies to release Dopamine. Remember our old friend Chocolate? Chocolate stimulates our neurotransmitters to release dopamine (as does sex). Studies have suggested two interesting things. People who gained benefit from smoking may have had lower dopamine in their systems. However, it is possible that their smoking lowered their dopamine production levels. What came first, the chicken or the egg? But it is an interesting concept.

The point is that while we are being told that it doesn’t “really” help with anxiety, depression, stress reduction and so on, it “really” does. The reality is that it doesn’t “fix” those feelings, it replaces them temporarily so that we want to smoke more. Sounds like addiction. It is an addiction. And this is indisputable. No matter how many articles are reviewed, smoking is an addiction. Knowing how addictions work, receiving information about the dangers of smoking can only serve to stop others from starting. People who were and are addicted already don’t just stop.

We can explain the changes in the brain, the temporary good feelings, the stress reduction and how the pattern is repetitive. Herein lies the problem. On a Pamphlet from one of those State issued free smoking cessation nicotine patches, it challenged it’s reader to take a test to determine how high they are physiologically addicted, emotionally addicted and psychologically (behaviorally) addicted. The truth is that the longer we have been smoking, the more addicted we are, as with any other drug.

NAMI (The National Alliance of Mental Illness) points out that smoking actually worsens a person’s mental health and interferes with the effects of Psychotropic medication. This may not be worded in the most convincing manner but yes, if you are feeling good and smoke 15 to 40 cigarettes a day, and your medication isn’t really working that well anyway, we can see how your mental health issues may worsen. While Web MD states that smoking actually creates anxiety and stress. That has yet to be proven with full certainty. However, it is not something that a smoker is going to buy into because it is not what the smoker experiences and they are likely not to identify this as a reason to stop smoking. People who want to stop smoking typically identify health reasons and increasing life expectancy. Others may identify the cost as a motivator and still others may discuss the smell on their person and clothes as reasons to stop smoking.

One of the reasons we, as mental health practitioners (and medical practitioners) fall short with our smoking clients is because many of us fail to recognize that “Even though nicotine’s high isn’t as dramatic as cocaine or heroin’s, it’s equally as addictive as those illegal drugs” (Felson, MD).

Herein lies another problem. The addiction is not given the same credence or potence as any other addiction and so is not addressed as comprehensively as other drug addictions. The physiological, emotional and psychological/behavioral addictions are not validated. Smokers are often told by their doctors to stop smoking and suck on a lozenge or chew on carrots instead.

Most smokers are not going to do that. Most smokers are going to substitute with a dopamine producing activity. For instance, tootsie pops. Tootsie pops stay in your mouth a relatively long time, release dopamine, are crunchy; most smokers experience “angst” and taste good. Much more so than carrots. My mother quit smoking by using radishes. But she was an atypical person (more on Nanny’s ways in another article). Most of us would rather tootsie pops. We all have encountered people who were addicted to smoking, managed to stop smoking and gained 30-50 pounds. That can’t be healthy physiologically (being overweight will be discussed in another article). That will ultimately affect their selfimage and add more social stigma into their lives; so it certainly isn’t emotionally healthy and most smokers will immediately tell you they don’t want to give up smoking and gain weight.

This is a well-known factor in smoking cessation. So, let’s look at some of the other symptoms we might have during cessation that are not typically acknowledged by our providers. In the literature, it is acknowledged that there is a fishbowl of physical, mental and emotional symptoms that will last for weeks:

Profuse sweating,, Anxiety Insomnia, Depression, Nightmares, Irritability, Strong cravings, Increased appetite, Stomach pains, Dizziness, Headaches, Coughing, Fatigue, Constipation/nausea, Mental Fog, Feelings of hopelessness, Tremors, & Mood swings.

Note that these are known withdrawal symptoms for nicotine; and do not include any withdrawal symptoms for the other products that are put into cigarettes that are also addictive. When we are working with clients who are trying to quit smoking, are we expecting them to carry on their usual daily activities while they are going through these symptoms? Are their doctors preparing them and working toward lessening the withdrawal that they will go through?

As Clinicians, we can be aware of the missteps in order to create a more wholistic treatment plan for smoking cessation. First, we would need to understand that a client should be informed of the truth regarding not only the effects of smoking but the effects of quitting. Yes, the benefits of quitting far outweigh the benefits of continuing to smoke but nonetheless, the client needs to be prepared.

The CDC informs us that there are medicines available to assist in the withdrawal process and in fact, do not recommend “Cold Turkey” for everyone as it increases the chances of relapse. It sites the following Nicotine Replacement Therapies (NRT) to help ease some of the withdrawal symptoms: Nicotine patches, Nicotine gum, Nicotine lozenges, Nicotine oral inhaler, Nicotine nasal spray, combining medicines ie: the Patch plus an additional NRT and the two other medications found to be helpful are Varenicline (Chantex) and Bupropion (Wellbutrin). A doctor should be involved with the planning, and it would be preferable if the clinician and the doctor consult with each other during the smoking cessation.

E Cigarettes are recommended by some. E cigarettes are not FDA approved however, are felt to be less dangerous to health than smoking and therefore are thought of as beneficial in the cessation stage. Counseling and coaching are highly recommended activities as well. This Clinician feels a “Sponsor” who is available for emergencies the same as they do in AA is a good idea for smoking cessation.

Some of the other techniques that are recommended by the Mayo Clinic and The Medical News today are the following: ·Assist the client in writing down what they do like about smoking so that other substitutes can be developed. ·Assist the client in writing down what they do not like about smoking (opposed to what we are told are the negatives, we have developed out own dislike; what are our reasons?) ·Assisting the client to mentally prepare for the withdrawal symptoms. ·Having the client make a list of the benefits of quitting and reviewing this list in times of struggle (Clinicians can broaden their own knowledge to bring more information to light that may not be known to clients) ·Suggest the client provide opportunity for more physical activities (exercise, walking, swimming, hiking) ·Most recommend the client should tell everyone in order to assert social pressure on their decision to quit but this needs to be explored because this can backfire for clients who are either defiant, have issues with shame and doubt and client’s who have friends who will goat them into giving up. ·Discuss triggers and what actions the client might take to avoid them. Have client list triggers and habits to understand their addiction. ·Discuss working on a new hobby or something that will keep client’s busy (again, this needs to be discussed fully as it shouldn’t be something that will frustrate the client) This is not the time to learn how to knit. ·Stock up on whatever is decided as a substitute for smoking ·Always discuss issues truthfully; don’t push client into doing what they are not ready to do; use relapse as a learning mechanism rather than a failure. ·Help client to identify online tools and apps and support groups; most recommend choosing a “quit date”. Look at the National Cancer Institute for implementing a quit plan www.smokefree.gov/build-yourquit-plan and Truth initiative at www.becomeanex.org/ which provides chat services, text messaging and apps for mobile devices for support. ·Suggest client schedule a dental cleaning during the cessation.

Most importantly, work with client on choosing whether client will use vacation time to stop smoking or work through it because while work may keep them busy, the withdrawal symptoms may interfere with their work. The same applies to clients with young children and home responsibilities. The decompensating effects may be worse for some than it is for others. Walk through the symptoms and discuss how client may cope with them. You can encourage your client that although some of what they experience may be extremely difficult to cope with, these symptoms will be temporary. All of the physiological symptoms should take anywhere from 1-3 weeks to rid themselves of the cigarette components from their system. Help the client to prepare for the psychological symptoms and cravings.

Help clients to be mindful of some of the behaviors they incorporate into smoking ie: blowing the smoke out, flicking their cigarette and other details they may not pay attention to as they will want to prepare for the urges to do these behaviors. Suggest clients drink water to wash nicotine from their system expediently. Recommend journaling so that clients can vent their feelings on paper rather than using smoking as a way of placating those feelings. This author recommends helping client to create a determent chart that they can put on their refrigerator reminding them of activities you have discussed to keep them occupied for the stormy times.

Symptom Type Action Plan Comments

Headaches Physical Drink water; take Tylenol Lie down when possible

Mental Fog Psychological Keep daily log Mindfulness

Strong Cravings Physical & Emotional Exercise/New Hobby Need to put another activity into place

Coughing Physical Take cough drop or honey This is your lungs clearing to ease soreness themselves

Bibliography:

_________, Brennan, Dan (Medical Reviewer) “What to know about Tobacco and Your Mental Health”WebMD (Online) March 2020

_________, “Which Quit Smoking Medication Is Right For You?”CDC; Control and Prevention, (Online) June 2021

_________, Felson, Sabrina, MD (Medical Reviewer) “What Is Nicotine Withdrawal?” WebMD (Online) March 2021 Chandler, Adam“Cigarettes Have Officially Been Bad For You For 50 Years” The Atlantic (Online) January 2014 Kandola, Aaron,Westphalen, Dena (Medical Reviewer) “Nicotine Withdrawal Symptoms And How to Cope” Medical News Today, (Online) January 2020

_________, “Smoking” National Alliance On Mental Health (NAMI) (Online) Mayo Clinic Staff“Healthy Lifestyle: Quit Smoking Create A Plan to Cope With The Hurdles You May Face As You Quit Smoking”

Written By: Dawn M. E. Picone, BCTMH, Psy.D, LCSW

Dr Dawn Picone is Board Certified in Telemental Health, holds a Psy.D and is licensed as a Clinical Social Worker in six States. She works exclusively online as a Clinical Consultant for Major Medical Venues and provided Clinical Supervision for MHC and CSW in the State of Florida, New York and New Jersey.