Tobacco Cessation Part 1 | Great American Smokeout

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@AllCEUS.com Counselortoolbox. Hey there everybody, and welcome to today's presentation of management of tobacco use or nicotine dependence or whatever you want to call it. Part one. Today we're going to be talking about really practical tips and tools. This is a three part series. The second part of the series is really going to be focused on clinical interventions, techniques that counselors can use to enhance motivation, yada yada. And the third component is really going to focus on resources that are available as far as workbooks and psychological interventions and medication. So you know, the actual interventions are the third part. So just kind of. So you know how this is going to lay out over the next three sessions. This is based in part on the VA Department of Defense guidelines for treating tobacco use and dependence. In this presentation, you're going to gain information on the assessment of tobacco use a little bit. Identify clinical interventions that we can use for patients willing and unwilling to make a quit attempt at this time. Remember I talked about we're going to use some real practical tools today. We'll examine systems interventions for healthcare administrators, insurers and purchasers. We're going to look at that more next week or in the next session and then we'll explore information relevant to specific populations. So why do we care? Well, you know, hopefully you just care because that's the right thing to do. But clinicians, mental health clinicians, nurses, social workers, doctors, whatever can make a difference with even a minimal intervention less than three minutes. For some people, you know, if they're sitting there on the fence and they're thinking, you know what, I might want to do something, but I don't even know where to start. All we have to do is go here, here, here's where to start. And they're like, oh, okay, thank you. Now, they recognize that it's going to be a long process, but if you can help get people kind of navigated in the right direction and feel like they've got support, that's awesome. A relation exists between the intensity of intervention and the cessation outcome. So if you're using a really intense intervention where you've got somebody checking in or touching base once a day, that's obviously going to theoretically be more effective than somebody who is not using any nicotine replacement, not using any medications, and only doing once a week counseling. Even when patients are not willing to make a quit attempt at this time, clinician delivered brief interventions, enhanced motivation and increased the likelihood of future quit attempts. We're going to talk a lot about that. Those clinical clinician delivered brief interventions in the next presentation. And tobacco users are being primed to consider quitting by a wide range of societal and environmental factors. So if they're primed, if they're ready to go, if they're in that contemplation or even preparation stage of change, that is fabulous. Let's, you know, strike while the iron's hot and see if we can help them make that next step and be successful. There's growing evidence that smokers who receive clinician advice and assistance with their quitting report greater satisfaction with their health care than those who don't. And sometimes we think, you know, these people have probably heard over and over and over again that they shouldn't smoke, yada, yada, yada, so maybe I just won't bring it up because they know it's bad for them. Well, yes, they know it's bad for them, but if you indicate that you care, you know, that's one of the things that you're going to really be able to use in terms of enhancing motivation. Tobacco use interventions are cost effective. You know, using nicotine replacement therapy and medications and even counseling, even intensive counseling in the long run is far more cost effective than dealing with the side effects, if you will, of smoking. I mean, obviously buying cigarettes or dip or whatever it is is not cheap, but you also are preventing or reducing the risk greatly of things like emphysema and cancer. So those are all wonderful things that will reduce the overall health care costs in the long haul. Tobacco use has a high case fatality rate. Up to 50% of long term smokers will die of smoking caused disease. And you would be surprised, or maybe you wouldn't at all the different cancers and diseases that smoking or using nicotine products can cause. So just something that you can explore. Three truths about tobacco use. All tobacco products, not just cigarettes, exact devastating costs on the nation's health and welfare. The okay, we know that for most users, tobacco use results in true drug dependence. So this is not something somebody can wake up in the morning and easily say, you know what, I'm not going to use anymore and never have another craving. Now does it happen? Sometimes? Maybe the majority of people when they decide that they are going to quit, they are physiologically dependent on those substances, so there is going to be a withdrawal period. This dependence is comparable to the dependence caused by opiates, amphetamines, and cocaine, you know, just kind of let that set in for a second. Tobacco is not just some easy peasy drug to quit. It's one of the hardest drugs to quit. Actually, both chronic tobacco use and dependence warrant clinical intervention. And as with other chronic disorders, these interventions may need to be repeated. So basically that's saying, don't be surprised or disheartened. If the person relapses once or slips once, then we want to look back at it and go, okay, what did we miss? What triggers did we miss? Where was the strain? Too much and you just gave in to those old habits. So variables to consider when we're really talking to people about whether they're ready to quit. And these are variables for people to consider too, about whether they're ready to start making this change. Because it is hard. And it's very, very hard. Every person in my family smoked. My mom, my dad, my grandparents, and you know, I watched most of them try to quit. And it was, you know, really, really difficult. So, you know, I've seen it, I get it. So the person has to have high motivation. And motivation is weird because it wanes. It waxes and wanes. Some days you'll be like gung, and other days you'll be just like, no, I'm not feeling it today. And that's okay. That's expected. The key in change planning is to prepare for those low motivation days and figure out how to ramp up your motivation again so you can do it. If you're more ready to change, you recognize it's a problem, you recognize it's not, you know, working to help you achieve your long term goals, those are things that are going to help you feel ready to change. If you recognize that there are interventions that can be helpful and that can be, you know, I don't want to say not painful, but they can make the withdrawal process easier. You know, that's going to increase readiness for change. So we're going to talk a lot about that in a few minutes. The person needs to have moderate to high self efficacy. If they have a can do attitude, or at least a I think I can attitude, that's wonderful. You know, let's work from there. If the person says, I think I can, that's awesome. And then we can start asking what things make you wonder? You know, keep you from going from I think to I know I can do this. And let's address those. And people who have a supportive social network are also at higher likelihood of success if they're not living in a Household with other people who smoke, if their friends who may still smoke are willing to not smoke around them, if they have people who are willing to try quitting. At the same time, you know, there are all kinds of ways that you can enhance social motivation. Relapse rates are higher for people with high nicotine dependence. People who are more like three pack a day smokers as opposed to, you know, an occasional cigarette. People who have psychiatric comorbidity and or substance use if they are currently experiencing neurotransmitter disruptions, for lack of a better word. You know, some people smoke when they're stressed, some people smoke when they're depressed, some people smoke when they're anxious. You know, so we're going to talk about the reasons people smoke, but if they're not addressing this underlying reason for use, they're going to be at much higher risk of relapse. You can't just stop smoking if that's your coping skill, not put something else in there. You've got to have a behavior to replace it. People with high stress levels, even if they don't meet the criteria for a mental health disorder or whatever, if they are high strung and tend to have high stress levels, they are at greater risk of relapse. Because a lot of times people smoke to reduce stress and exposure to other smokers. You know, if you work in a bar and people smoke either in the bar or, you know, right outside the doors, you know, there are a lot of people, environmental factors that can make somebody at higher risk for relapse. Now, that doesn't mean, you know, well, I've got all of these, I might as well not even try. No, it just means we got a plan for these. So if somebody has high nicotine dependence, we want to make sure that they talk with their doctor about ways to handle that withdrawal to minimize the unpleasantness of the withdrawal period. Psychiatric comorbidity. If they've got depression or anxiety, we need to make sure they've got resources to deal with that and they're learning new skills to deal with that as opposed to smoking so they've got something to put in its place. A good stress management plan should be in place before the person starts trying to quit smoking. Ideally, we want to make sure people have all of their resources kind of shored up before they start to try quitting. So we want to make sure they've got this stress management plan in place and we want to make sure that they have figured out where their social support is and how to handle other smokers. And exposure to smoke. You know, this all goes in pre change planning. I want to make sure that they're trying to consider the changes. So motivational enhancement. And again, some of the things we're going to talk about in the next section really focus on educating people about the impact of smoking. Most smokers and people who use nicotine products are well aware of the impact of these things on their health. So, you know, really hammering them with it isn't going to do any good and it may actually be kind of off putting. So we want to ask the person who comes in and indicates that they might be thinking about quitting, why do you want to quit? What do you think the benefits are? And encourage them to look at the rewards. Like they'll get their sense of smell back and maybe their taste, sense of taste will improve. They won't have the yellow fingers, you know, whatever it is that works for them, risk reduction, encourage them to look at, if you quit, are there health benefits, physical health benefits that you see as positive? Other rewards can also include financial rewards because you're not having to pay a higher premium for health insurance and you're also not buying cigarettes. So think about how much extra money you're going to have. So just encourage them to brainstorm all the different rewards that might come from quitting that are rewarding to them. You know, I can just roll off a litany of things, but they may be like, yeah, I don't really care about that. So I want to know what's rewarding to you? Why are you deciding to change and why now? You know, why not six months from now, why not six months ago, why now? What's changed that is prompted you to go, I'm ready to do this. The other thing we can ask them about is what I abbreviate as rml, a rich and meaningful life. In what ways does stopping smoking help you, the person, get closer to your vision of a rich and meaningful life? Maybe it means, you know, if you stop smoking, you'll be able to start running marathons again or you know, do cross country hiking or whatever it is you do, because that sounds like a lot of fun, but right now you just can't do it because you know, your lungs are in too bad a shape or whatever it is. Maybe you envision living to a ripe old age to see your great grandkids in your rich and meaningful life. Well, stopping smoking increases the chance that you will be protected from a lot of the health problems. So there are a lot of ways to elicit the Reasons you want to quit. And, you know, the person who's getting ready to quit ideally would share this with a support person, you know, whether it's their spouse or their best friend or their counselor. So we can talk about why they want to quit, and we can both get excited about it, the next step. And a lot of people kind of miss this is, why do I use. Why do I use these products? Some people will say for mental reasons, it helps with concentration, obsessive thoughts or cravings. You know, I think about, I need to have a cigarette or whatever, and they can't get that out of their head. And some people use it mentally. I put rationalizing here because they have reasons why they have to use. So we want to address all those. You know, if it helps you concentrate, in what way does it help you concentrate? What else have you done besides smoking to help you concentrate? We'll talk about techniques for handling obsessive thoughts. And then, you know, a lot of times I'll have people write down all their rationalizations for continuing to smoke, and then they will go through for themselves and debunk each one of those rationalizations emotionally. Some people use out of boredom, you know, might as well have a cigarette. I'm just sitting around doing nothing. Some people use, and we talked about this earlier because of what I call dysphoria, anger, anxiety, stress, depression, any of those unpleasant emotions. Okay, again, what do you do other than smoke in order to deal with these things? Or what have you done in the past, or could you do, do you think, to deal with these things? So encourage people to start brainstorming. What can I do when I start feeling bad? Besides using nicotine products environmentally, you know, you want to remove as much access as possible. Because some people use just because it's there, you know, you know, your friend's smoking, you might as well smoke, too. And environmental triggers, and these can be seeing people on TV smoking. These can be seeing other people in your office smoking, walking past the smoking patio, sitting around the dinner table after dinner. There's a lot of environmental triggers. Smells. If you smell smoke, that can be a trigger. It can be a trigger if you usually smoke when you're drinking alcohol, a lot of different things. So you want to be aware or encourage people to be aware of their triggers that make them start wanting to smoke. And then we need to ask them, you know, to use mindfulness at this point to go, okay, you know, I'm having this thought that I want to smoke right now. What can I do instead? Or what am I really needing. You know, if you're bored, then what else could you do? Some people use for physical reasons because they are nicotine dependent and the withdrawals are really pretty miserable. Okay, well, that's addressable. Some people use because they think it helps with their pain conditions. And some people use for weight management, they think it works more as a appetite suppressant. And some people continue to smoke because they're afraid of weight gain. And then social reasons people use can include things like peers that smoke. You know, they want to hang out with their friend during break time at work, and their friend always smokes, so they're going to smoke. One of the keys here is to remember that you can add stop gaps, you know, like if your friend smokes. All right, let's not go hang out with that friend during break time, because that's too triggering. But eventually you need to address the reasons that you used. So figuring out other ways to deal with your boredom, your unpleasant moods, help you concentrate, those sorts of things. So the next step is to develop a plan. Remember, we haven't started doing anything yet. You want to make sure, in order to set yourself up for success, you want to make sure that you have tools in your toolbox and you're ready to go. You know, an electrician wouldn't show up, drive in his personal car, and show up without any tools to do a job, hopefully. So we want to make sure that this person, or you, if you're the person, has a plan in mind. So what are some of your obstacles to quitting? And we've already talked about some of them. If your obstacles are mental, like your thoughts, you get stuck with those thoughts of, I've got to have a cigarette right now. You can unhook, which instead of saying, I must have a cigarette, you can say, I'm having the thought that I need a cigarette right now. Thoughts come and go. You know, I forget things by the time I walk into the kitchen half the time. So we know that thoughts come and go. If you're saying, I need it, it's semantic, but it makes a difference, and it's a powerful difference if you really repeat it to yourself and believe it. I'm having the thought that I need a cigarette. Okay, well, what's another thought you could have? Urge surfing is something else that you can do, recognizing that most urges crest within, you know, 10 or 15 minutes and then start to diminish. So if you're having this urge to use nicotine products, that's okay. Recognize it, acknowledge it, and then ride the wave out. Now, a lot of people find it's very helpful when urge surfing to do something else, because if they sit there and they think about where they're at on the wave, you know, it seems like it's going to delay the process and they keep thinking about what they want to do. So urge surfing. The way I teach my clients is to recognize the intensity of their urge. When they're having it, are they at the beginning, are they cresting? You know, it's just, I really need it right now, or is it starting to diminish? And a lot of times it'll be somewhere between growing and, you know, I really need it right now. The good news is that means it's almost completely crested and you just have to get through the washout. So if you can find something else to do for 15 minutes, you're probably going to forget about that urge. Radical acceptance of thoughts is another thing. If you're thinking to yourself, I'm having this thought that I have to have a cigarette right now. Accept it is what it is. Don't get angry at yourself. Don't get frustrated. Just be like, okay, well, I'm having this thought, whatever, and it is what it is. What can you do to improve the next moment? You don't want to dwell on this thought. You don't want to give it energy. You want to move forward. Other thoughts that you may have to radically accept. A lot of people when they quit, are giving up something that they truly enjoy. So, you know, there are days, maybe more often than not, especially at the beginning, where you may get frustrated and grouchy because you're giving up something that you truly like. You're giving up something that you truly enjoy so you can be frustrated, and that's okay. Radical acceptance means accepting the good and the bad, recognizing that, yes, I can't do this one thing anymore that I or I'm choosing not to do this one thing anymore that I really like. However, by choosing not to do it, I'm having these benefits. So you can recognize that, yeah, there's some drawbacks to it, but there are some benefits and hopefully meet in the middle where it's still worthwhile. Decisional balance exercises. You really want to look at the reasons for quitting and the reasons for continuing to smoke. Because the reasons for continuing to smoke are those reasons that are going to set you up for relapse. You need to find alternate things to do besides smoking to address those issues and mentally, what I call efficacious self talk. That means repeating to yourself, you know, I can do this. You know, when you're starting to have that urge just repeating to yourself, I've come this far, I can make it, or I can deal with it for 15 minutes and then it'll go away. Efficacious or self efficacy means having that belief that you can do it, that can do attitude, emotional triggers to quitting. You know, we all have bad days, and some people, especially people who are nicotine dependent, often cope with their unpleasant moods by using, okay, that's fine. So we recognize that that's what you've done until now. You do the best you can with the tools you have at any point in time. What else can you start learning to do now? So, again, I encourage people to look back over past times when they have had unpleasant moods and what they have done to deal with it and what's worked, even if it's only worked a little bit, we can build on that, and then we start talking about new skills that are out there. Distress tolerance exercises are great ones. Dbt, Dialectical behavior therapy. They have two acronyms, accepts and improves. And they stand for different activities you can do in order to help you tolerate distress. Because sometimes life just sucks and there's nothing you can do about it. Sometimes quitting smoking just sucks and there's nothing you can do about it. So dwelling in that, just going to feed it and keep you stuck there, like in quicksand. Distress tolerance encourages you to do something else. And I use this analogy a lot, and I'm going to use it again. Distress tolerance is like if you've got a bee and we're assuming you're not, like, deathly allergic to bees. Bee lands on your arm, well, your initial urge is probably to wipe it off, you know, get off, because it tickles or you don't want to get stung or whatever. But if you do that, you're likely going to get stung, which I think also kills the bee, which is really sad. So distress tolerance means tolerating that bee being on your arm until it's ready to fly away and then letting it fly away on its own. The same thing is true for our emotions. You know, you don't pay a lot of attention to it and sit there and go, all right, Mr. B, when are you going to leave? You just kind of do whatever, because if you're moving around too much, Mr. B is probably going to fly off. So distress tolerance exercises help us deal with something that may be unpleasant. Instead of acting on our initial urge, we do something else in order to get through that period. Stress management. A stress management plan is crucial. Well, for everybody, but especially for people who are in recovery or trying to recover from depression, anxiety, use of nicotine products, drug addiction, whatever. So don't have enough time to go into how to develop a stress management plan, but know that you have to have one in early recovery. It is hard enough to deal with the neurochemical changes that are going on in your brain. You don't need to add to it. Burning the candle at Both ends, working 16, 17 hours a day, you know, having all these other obligations and feeling like you've got way too much to do and not enough time to do it. So you need to figure out how to set boundaries, how to set limits, and how to manage your anxiety about everything that may be going on. Deep breathing. All right, well, we had a little crash there, so let's see if we can pick up where we left off. So we were talking about obstacles to quitting, and we want to encourage people to use deep breathing practices because deep breathing is going to slow your heart rate when you're anxious, when you're angry, it's going to cause the fight or flight reaction, which is going to cause the release of norepinephrine and glutamate and all those excitatory neurochemicals, which is great when you need to fight or flee. But if you're just stressed out, not so much. So by deep breathing, you slow down your heart rate, which causes the release of gaba and sometimes serotonin, your more calming chemicals work toward acceptance of the loss. Remember I said a lot of times people are upset about the fact that they've got to give up something they kind of enjoyed and it's, it's unpleasant. So encouraging people to go through the grieving process, accepting the good with the bad, and keep active. A lot of times when we're bored, those thoughts creep into our head a lot louder than when we're not bored. So try to focus on not, you know, keeping yourself active, but also, like I said, with distress tolerance activities. If you're feeling unpleasant emotions, I use the phrase distract. Don't react when you're feeling angry. Instead of, you know, lighting up, go on a walk, do something to distract yourself for 10 minutes or so while that urge passes. And you can get into what we call your wise mind. You can let the adrenaline go and you can get into this place where you're not thinking with emotions, you're thinking with your head. Make a better decision. Other triggers include environmental triggers such as times of day and activities. My mother, for example, when she would roll out of bed in the morning, she would light up. You know, then she'd get come out and she'd make her breakfast and whatever she'd eat, and she'd go back into the bathroom and start getting ready for work, and she'd light up, and then she'd get into the car and drive to work, and she would be smoking the entire way there. So there were a lot of time of day triggers and environmental triggers for her when she started trying to quit. So for a lot of people, the morning routine can be really stressful because, you know, they're getting ready to approach their day, which some people approach with a sense of dread, apprehension, anxiety. Well, you got to deal with that. In order to be successful at quitting, we need to try to have some paradigm shift. So you're not going, oh, I need something to help me get through this. You want to approach your day with some level of optimism, but you also want to change some of those activities that you do that you normally would smoke during. So, for example, when you're driving in the car, obviously if you're changing, you know, stopping smoking, you won't have nicotine products there. Well, that changes that behavior pretty easily. First thing in the morning when you roll out of bed, what can you do instead besides smoking? How can you distract yourself? You know, maybe get up and go to the gym and you're like, yeah, right. It's bad enough stopping smoking. I really don't want to be at the gym at 4am okay. But find things that you can do that differ. And, you know, some people do really well with nicotine replacement therapy during those times of day that there's not a lot of wiggle room to change stuff in the morning. They got to get up and get ready for work. So if their first instinct is to smoke, then a nicotine replacement gum or something could be helpful. Some people, you know, smoke like when they're sitting there watching a football game. So if that is something that triggers you to want to use when you're, you know, doing particular activities, find something else to do with your hands during that period of time that can be helpful. You know, I hate to say avoid those activities because a lot of times they're activities we really like. So, for example, when I watch television, I have a bad habit of snacking when I eat, but if I am crocheting, then I'm doing something else with my hands and I'm not quite as antsy and bored so if you can find something else to do with your hands, play on, you know, checkers or something on your mobile device or pet your dog or whatever. Avoid things linked to smoking when you can, when it's not something that's gonna be really devastating. If you typically smoke when you drink, you may want to consider not drinking for a while. That's a personal choice. You just got to figure out how you're going to handle it. If you are going to drink and, you know, you usually smoke when you drink, make sure you don't have nicotine products available, because then you're going to break that association. Your brain will stop thinking, well, when I do this, I have to do this. Because it's. Once you've drank a few enough times without smoking, that pairing is broken. Remove sensory triggers, like sounds. You know, if you sit in your chair and listen to Willie Nelson and smoke, you know, maybe Willie Nelson is not what you need to be listening to right now, or Pink Floyd or whatever it is that does it for you. So consider what things that you might hear that might trigger you to, you know, think about using smells. Obviously, the smell of nicotine can be a trigger. The smell of smoke can be a trigger, but there may be other smells that trigger it for you. And I remember when I was little, my Uncle Jack used to smoke a pipe, and I loved the smell of pipe tobacco. Not crazy about the smell of cigarette smoke, but I loved the smell of pipe tobacco. So that was a smell. And, you know, when I would walk past the tobacco counter at the. At the store and I actually worked at one for a while, that was a smell that brought back happy memories. So thinking about smells that remind you to use sights, obviously things that you see, if you're seeing nicotine, right there could be a trigger. If you are, you know, maybe you associate nicotine with trying to stay up all night to study or, you know, if you were a soldier when you were deployed, anything that reminds you of those things you want to figure out, okay, how do I deal with those. When I see those sites when I get triggered? You can't plan for every possible trigger. It's just. It's not possible. So what you need to do is know again, mindfulness. Be aware of when you're triggered and feeling like, ugh, I really want to use and have a plan for dealing with the cravings as opposed to trying to plan for every single trigger. Anything that might trigger you that you can eliminate in the first three months, you know, to make it easier on yourself. Well, that's certainly going to make life easier. But again, focus more on how to handle the cravings that are triggered instead of preventing all triggers and have an emergency exit plan. Other triggers can be physical, like withdrawal. So if you experience withdrawal from nicotine, which you probably will, talk with your doctor about medications that can help you handle those cravings so you can step down gradually instead of going cold turkey or mood issues. And the research is kind of ambiguous about whether people tend to feel better when they smoke or experience higher depression and anxiety when they quit. Quit. When I talk to people, most people I talk to say, yeah, my depression and my irritability and my anxiety went through the roof when I tried to quit smoking. Well, okay, you know, if, you know, if you have a pre existing mood issue and you know that a lot of times you smoke to deal with unpleasant feelings, talk to your doctor about ways to deal with it. Maybe you need to be on a combination therapy like bupropion and nicotine replacement therapy. So talk with your doctor. Also look at ways to develop other coping skills to deal with your mood issues. Being aware that during the first three to six months of recovery, if you want to say that you are probably going to have more mood lability, just be aware of that and practice good sleep hygiene. Some people, when they quit smoking, feel like they've got all the energy in the world and other people can't sleep. You know, they wake up in the middle of the night, they have cravings, yada, yada, whatever. You want to make sure that you're keeping your circadian rhythms stable. So you're getting about eight hours of sleep a night. And it's good quality sleep. If you smoke because of pain, you know, when you've got migraines or whatever it is, pay attention to and learn about other pain management techniques. Obviously you could go pharmacological. My recommendation would be to talk with your doctor about alternatives such as ice, heat massage, stretching, physical therapy, tens units. There's a lot of stuff out there that can be used besides drugs. Oral fixation. I couldn't figure out another nice way to put this. Some people when they are trying to quit, they've been smoking so long, they're used to having something in their mouth. And that's just the way it is. And when they don't have something in their mouth, they feel, you know, antsy. I mean, think about a child that is just totally attached to either sucking their thumb or their pacifier. My son, bless his little heart, he always had a pacifier attached to his Shirt. He had a pacifier in each hand and then he had three pacifiers above his head when he slept at night until he was like three. His orthodontist loves me. Let me tell you what. But some people need some. They have some need or some way of comforting themselves or calming themselves orally. Okay, well, if this is one of your things, we call it harm reduction. So instead of having a cigarette in your mouth, maybe you look at having something else in your mouth, like a toothpick or gum or even just a straw. You know, I know when I study and stuff, oftentimes I will chew on a pencil if I've got a pencil. I know it's nasty, but I do it. And I bite my fingernails too, which is not healthy. But those are all other things that you may pick up. So if you don't want to start biting your nails when you quit smoking, if you don't want to be eating all the time when you quit smoking, you need to think, think, what else am I going to do to satisfy that oral need that I've got right now? And it can be just calling a friend and talking because you can't have something in your mouth and talk at the same time. Alrighty, social triggers. Avoid being around people when they're smoking or vaping or dipping. You know, any of those things can trigger your desire to use. Try not to sit next to people who smell like smoke. So if you ride the bus or when you go to a restaurant, you know, you may want to try not to sit next to people who smell like tobacco. Find alternative activities to smoke breaks like going on a walk and have something else to do with your hands. I have actually, I think I gave it to my daughter. Nope, it's right here. I have this worry stone, and it's just a little quartz worry stone that's in the shape of a heart. But sometimes I'll hold it and you know, and that's. They have the fidget spinners and everything else now too, that you can get things to do with your hands. And I got this because I used to always fidget with my hands. I had a USB drive on my, on my keychain and I broke it because I would push it out and click it back in. Push it out and click it back in. Yeah, that's not real helpful. But if you're one of those people like me who has a lot of nervous energy, that can be helpful. So you're not thinking about, you know, smoking or doing something with your hands. That's not Helpful. Okay. I've been talking about medications. The use of approved cessation medications can be really helpful. Not everybody's down with that. And I get that, you know, not a problem. But it can help you taper. And one of the things that wasn't mentioned in the guideline that I'll mention here before, medications actually is there are tobacco products that have lower levels of nicotine. So if you go down to like a light cigarette, you can choose products that have lower levels of nicotine to start helping you on your way before you make the leap to going smoke free. Some people find that that tapering is a little bit easier. Other people prefer to just cut it and go, you know what? No more nicotine products. And then taper with a nicotine replacement therapy. Whatever it is that you're comfortable trying is a good thing to try. So if you decide to go with the medications to help you taper, first line medications include bupropion sr, which is extended release, and that helps a lot with cravings. Nicotine replacement therapy, or NRS, come in the forms of gums, lozenges, patches, or nasal sprays. One thing to remember when you are used, especially when you're using nicotine replacement therapy, is that nicotine is not well absorbed in the mouth when you are drinking things that are acidic, like sodas and coffee and citrus juices. So you want to avoid those while you're chewing your nicotine gum if you want to get the full benefit from it. Second line medications include clonidine and nortriptyline. And, you know, those are all things that can be added if the first line medications aren't working. And people who have concurrent depression especially have done really well with nortriptyline and nicotine replacement therapy. So it's a matter of what works for you and communicating with your doctor about what most effectively works. If the first thing you try doesn't do it or it's just it's still too difficult, that's okay, you didn't fail. It just means the medication they chose or you guys chose wasn't the exact right level for you, either dosage or the type of medication, because all of these medications act on different neurotransmitters and have slightly different mechanisms of action. So if bupropion doesn't work, try something else. You also want to consider medications for any underlying mood disorders, especially in the short term. So if you've got clinical depression, it's definitely worth considering addressing the clinical depression with medication in the short term. The higher dose preparations of Nicotine gum. The patches and lozenges have been shown to be effective in highly dependent smokers. So again, like I said, it may not be the type of medication, it may be the dose. So talk with your doctor, advocate for yourself. Combination nicotine replacement therapy may be particularly effective in suppressing tobacco withdrawal symptoms and increasing long term abstinence rates. The nicotine patch over 14 weeks can be paired with either nicotine gum or nasal spray. The nicotine patch can also be paired with a nicotine inhaler, bupropion. So there are, and there are other options out there, but these are the your first line combinations that might be considered. Bupropion and nicotine replacement therapies. In particular, 4 milligram nicotine gum and 4 milligram nicotine lozenges delay but do not prevent weight gain. Okay, I want, I want you to have that sink in. Weight gain is caused by eating too much. So we need to figure out why. Are you eating too much? Are you eating to self soothe? Are you eating because you have to have something to do with your hands? Are you eating because. So in order to manage weight gain, you need to figure out, you know, why are you eating? And also maybe look at what are you eating? Because a lot of times when people are trying to stop smoking, the things they choose to eat tend to be higher in fat and sugar. Why? Because fat and sugar cause the brain to release serotonin and dopamine, which make you feel better. So you're basically substituting addictions, if you will. In patients with depression, bupropion and nortriptyline appear to be effective, especially in combination with nicotine replacement therapy. So getting ready to quit. Set a quit date, usually within two weeks. You know, you've got everything shored up, you're ready to go, then you got to make that quit date within two weeks. Tell family, friends and co workers about your getting ready to quit and request understanding and support. You know, give them a heads up so you know, you don't drop it on them on Monday morning. Anticipate challenges to the upcoming quit attempt, particularly during the first few weeks. And I say 12 weeks, you know, the first 12 weeks is really critical. Remove tobacco from your environment, tobacco products as well as tobacco smell. You know, give your house a good scrub down so you're not walking in and smelling it and getting triggered. Prior to quitting, avoid smoking in places where you spend a lot of time, such as work, home or even the car. So prior to quitting completely, you may start cutting back and saying, okay, I am not going to smoke when I'm in the car, I am not going to smoke in the house. I'm not going to smoke, yada yada. It doesn't mean you're stopping smoking completely, but you're again, unpairing, if you will. Those places and those activities with smoking make your home smoke free. Make sure nobody else in the house is smoking. If they are, it's going to make it a lot harder for you to quit. Individual, group and telephone counseling are also effective treatment formats. Particular types of counseling strategies are particularly effective. You want to look at practical counseling so you know, when you're talking to a therapist, if you are somebody trying to quit, talk with them about what types of things will we talk about. You know, humanistic therapy is great and it's got a place. But a lot of people when they're trying to quit smoking need practical interventions and problem solving to say, all right, I feel like I have stronger urges and triggers first thing in the morning or you know, I try, I'm trying to quit and my irritability is through the roof. I need to develop some skills to, you know, tamp down those emotions a little bit and look for social support, social support from people who've never smoked or people who are starting to try to quit themselves or people who've stopped smoking. Those are really helpful because they've been there and they can tell you what works for them. They can tell you it gets better. They can tell you the good, the bad and the ugly. Because quitting smoking is not just good, there is some bad and ugly in there too. And you know, forewarned is forearmed institutionally, you know, looking at where you work, but also in clinics where you know you may be receiving treatment policies that can facilitate stopping smoking. You want to have a tobacco free workplace, have a tobacco user identification program as part of any assessments in medical clinics. Ensure that everybody at your workplace or at your medical clinic are adequately trained in assessing for and making referrals for smoking cessation activities. If you have a workplace wellness program or you know, again in clinics, have a dedicated staff person who, who is assigned to doing nothing but nicotine dependence interventions. And maybe they don't do all the counseling right there, but they can facilitate the connection, ensure that covered and or cost effective treatments are available. It's important. Special populations. When someone smokes, when they're pregnant, it increases their heart rate, reduces their circulation, which can cause the baby to have a low birth weight. And the baby might also have some withdrawal symptoms. Substance dependent Individuals. Remember I talked about alcohol earlier. A lot of times people who are substance dependent dependent smoke. So nicotine products are associated with use. So that's a trigger for their use as well as, you know, nicotine use. But it's also a, if you want to call it a substitute addiction. If they can't get to their crack or their methamphetamine or whatever, you know, they may just be jonesing for a cigarette. They need something to help them feel better because their neurotransmitters are out of whack from the detox or whatever it is. So, you know, I worked in substance abuse treatment in a residential facility for many, many years. And a lot of the people that I worked with smoked. And you know, they found that quitting their substance of choice was really hard, but quitting their substance of choice and quitting nicotine was, you know, even harder. So we want to make sure to provide adequate support to those people, the elderly. Now this isn't, this is written in a slightly different way. The improvements the elderly see. If they stop smoking, their circulation improves immediately. Well, that's true for everybody. Their lungs begin to repair any damage. That's also true of just about anybody. In one year, the added risk of heart disease is cut in almost half and their risk of stroke, lung disease and cancer also diminish among smokers who quit at age 65. So it's never too late to quit. Men gained an average of 1.4 to 2 years of life and women gained on average 2.7 to 3.4 years. I have no idea how they determined that, but that's what the statistics say. So if you want to live a few more years, you know, think about cutting, cutting back on the nicotine products. People of low socioeconomic status also have issues when it comes to smoking cessation because they may have some environmental immobility. They're stuck in an environment that is pro smoking. They may not have access to nicotine replacement therapy. That's much less problematic now that the Affordable Care act policies are in place. And there's really, most insurances cover at least some level of nicotine replacement therapy and access to medical care. Identification and intervention of tobacco use should be a priority in all settings. Even, you know, whether you're identifying yourself or, you know, a workplace. You know, you want to identify workers who are smoking because they're probably going to have more absentee days. They may have more health related problems which can increase insurance rates for the whole group, yada yada. So we want to have somebody in hr. We want to have somebody at the doctor's office, we want to have somebody at the mental health clinic who all can screen and make referrals for tobacco cessation activities. Effective interventions are dose dependent, so the more intense the intervention, the more effective it often is, especially in the first 12 weeks. A combination of nicotine replacement therapy options is often helpful for heavy smokers and long term abstinence is most strongly related to a combination of practical counseling because remember I said you have to address the reasons you were using in the first place and medication assisted therapies in motivated patients. So that's three things you have to have practical tools that you can replace the smoking with medication assisted therapy to help with the withdrawal and motivation to actually follow it through even when the going gets tough. All right everybody, thanks for being with me today and I will see you on Wednesday. Counselor Toolbox Podcast is sponsored by BetterHelp, the world's largest E counseling platform providing accessible and affordable counseling services via messaging, live chat, phone or video. 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