Ms. Lesa Abney, RN and Tobacco Treatment Specialist for Vanderbilt, Tobacco, Addiction, and Lifestyle (ViTAL), discusses smoking cessation and resources for treatment.
Shaina Farfel: Welcome to this edition of the Vanderbilt Health and Wellness WellCast. I am Shaina Farfel with Occupational Health. Today, we are speaking with Mr. Lesa Abney, a registered nurse and tobacco treatment specialist for the Vanderbilt Center for Tobacco Addiction and Lifestyle, also known as ViTAL. Thanks for being with us today, Lesa.
Lesa Abney, R.N.: Oh, you are welcome.
Shaina Farfel: We all know that smoking is bad for our health, and I am sure a lot of our listeners who are also smokers have been advised to quit by friends, family members, healthcare providers, but we also all know that quitting smoking is an incredibly challenging endeavor and certainly not one to embark on lightly and without a plan. As an expert in the field, I wanted to pose a few questions for you today that I think will help our listeners to contemplate and prepare for quitting smoking in a realistic way. Can you start by telling us what are the health benefits of quitting smoking and if I have been a smoker for let's say lots of decades is the damage already done or can it be reversed in terms of my health?
Lesa Abney, R.N.: Well, a lot of it depends on the exposure, but the bottom line for everybody to remember is that anyone at any age can benefit by quitting smoking and here is just a few of the time points that you can think about. After you have had your last cigarette, in 20 minutes, your heart rate and blood pressure will begin to drop. In about 12 hours, the carbon monoxide level in your blood begins to drop back toward normal. In 48 hours, the damage nerve endings will begin to regenerate, and your sense of smell and taste will begin to return to normal. In about two weeks to three months, your risk of heart attack will begin to decrease. Your circulation improves and your lung function increases. Also, something you probably do not think about is that your HDL cholesterol will improve. In the timeframe of like one month to nine months, the coughing and shortness of breath will improve. The cilia, or those tiny hair-like structures that help us keep our lungs clean, will begin to regain their normal function and help us reduce the risk of infections. A year after quitting, the excess risk of coronary heart disease is half of that of a continued smoker. After five years, the risk of lung cancer is about 40% lower than those of continued smokers. In that five-year period, your risk of cancer of the mouth, throat, esophagus, and bladder are cut in half. Most people do not think about bladder cancer as being related to smoking, but it is. Cervical cancer and stroke risk start falling to that of a nonsmoker at about five years. Ten years after you quit, the risk of cancer of the voice box or your larynx and your pancreas will decrease. You have probably also heard that smoking impacts the wrinkles around your face. If you quit smoking, the collagen will get better. You will have fewer wrinkles, meaning a more youthful appearance. One thing that people don’t really think about when they think about quitting smoking is cost. When you quit smoking, you reduce your own financial burden, the burden on the healthcare system and on society as a whole. You also are ill more often. You miss more work which impacts your bottom line. You expose your children and other relatives to risks of illness which means you may have more sick days taking care of sick children. Your pets are even impacted by smoke, so that is something to think about. Even if you go outside to smoke, you come back in and you have third-hand smoke on you which then still impacts your family. I do not know if you have heard this very much, but I have had patients tell me that you know I only smoke organic cigarettes. They are much more healthy. There is not a problem with those. Well, then we do a little bit of education because the chemicals are released from the tobacco set on fire. So, organic cigarettes, as well as regular cigarettes, are going to have the same 7000 chemicals because they are set on fire when you smoke it. So, you are still getting the same damage whether you have organic tobacco or not. Studies that looked at people who quit smoking versus people who continued to smoke noticed that people who had quit had lower scores of depression, lower scores of anxiety, and higher scores of wellbeing. Remember, when you do quit, you do need to use the three months of medication as well as the counseling to help you manage that nicotine withdraw and the coping skills.
Shaina Farfel: So, just huge spectrum of benefits from physical health to mental health to financial health and I did not know a lot of those numbers. That’s really significant. One of the questions I get a lot from patients is, okay, so let's say I am smoking a pack a day and I am able to cut back significantly to a half-pack or less, but I am still smoking, is this better than smoking a pack a day or do I only get the health benefits by stopping completely? Any thoughts about that?
Lesa Abney, R.N.: Actually, there was an article written and published in the British Medical Journal in 2018 that really helps answer this question. They report there is no safe number of smoked cigarettes. Smoking one cigarette a day, carries 40% to 50% of the risk of cardiovascular disease and stroke as smoking 20 cigarettes per day. So, think about it like this, it is just like asbestos. There is no safe level.
Shaina Farfel: Just sticking with it to get down to zero is the goal.
Lesa Abney, R.N.: As you said, if they are in the process of cutting down to quit, I have cut down to a half-pack and I am on my way to quitting, that is something that we encourage because you are cutting down to quit but have that quit as the end goal.
Shaina Farfel: Yes. Absolutely. This is a loaded question and I know you could probably answer this for days. If someone has tried and failed to quit in the past, how can they remain motivated to quit in the future and what might they consider doing differently next time that may be more successful?
Lesa Abney, R.N.: One thing to remember is this statistic, only 5% of the people who are trying to quit use medication and counseling. We need to remember to use the tools that are proven to be successful. Those are the FDA approved medications as well as getting into a structured counseling program. This counseling program can be used through the State QuitLine which is free. You can go to smokefree.gov and sign up and get text messages or they can contact you guys at the Occupational Health Clinic because you guys have got a really good program. So, using these helps improves your odds of quitting, but the most important thing is do not get discouraged. If you think back to a time where maybe you were trying to learn a new skill, that new skill could be something to do with work, maybe learning how to type, maybe learning a new exercise or trying to learn a craft, something that might even be fun, when you learned this new skill how did your first attempts go with this? How did that attempt go? Did you do perfect the first time you did it? Did you get frustrated or discouraged because I just cannot get this typing down? I know it took me quite a while to get the skills down to where I can type and do so with very few errors and that is the way it is with smoking. Always think back to a time in your past. What did I do to be successful then? Maybe I practiced. Maybe I got help from friends. So, always remember, we learn from the challenges. As you are going through this process, you are going to have some ups and downs, but you learn from them and just keep on going.
Shaina Farfel: Absolutely. I think that is a really good way to think about that. I like the analogy of learning a new skill because it is something you have to relearn and retrain your body.
Lesa Abney, R.N.: Exactly. Because you learned how to smoke. You have got to learn how to quit.
Shaina Farfel: Right. Right. Exactly. Unfortunately, that part is harder.
Lesa Abney, R.N.: Yes, it is.
Shaina Farfel: Again, this is another thing that I hear a lot from patients who are ready to quit smoking, but one of the biggest hindrances that I think they face is when they have family and friends around them or even in their household who are still smoking. If someone is ready to quit, how might they be able to overcome a hurdle like that?
Lesa Abney, R.N.: And that is a really, really big challenge for a lot of the people that I speak with as well. One thing we usually start with is you will call a family meeting. Say okay guys, I am quitting smoking. I have this reason, this reason, and this reason. I am quitting smoking. I would like your help and support. Make your home a no smoking area. Say I understand we all smoke, we are all going to start smoking outside. We are not going to smoke inside the house anymore. Because if you have to get up and go outside, it usually makes you look at it a different way. I don't want to go outside. I will just wait. It is too hot. It is too cold. If you are an outside smoker, most everybody has a little smoking area setup outside, chair, table, ashtrays, you want that to look different inside and out. Clean away all your smoking paraphernalia. Put something different on the table. Make it look different. You want to have a different visual for that trigger when you see it. It is also really important that you have props in your hands. Something as silly as a pen or pencil that you can mess around with, you can hold. The spice cinnamon we use in cooking comes in a form of cinnamon sticks. Those cinnamon sticks are rolled up bark. They feel like a cigarette. Hold that in your hand and breath in and out through it. A straw, breathe in and out through it. Hold it in your hand. Works great in a car. Flavored toothpicks are another good prop. You can get those on Amazon and find recipes to make them yourself, especially if you are a menthol smoker. Menthol is another layer in quitting because people are addicted to the nicotine and the hit of the methanol going down their throats. Using things like that and oral nicotine replacement when you are around other smokers can also be very beneficial.
Shaina Farfel: Those are great ideas. We do not have to get into this kind of exhaustively, but you know you mentioned that there are medications available for treatment. What’s sort of the overview of what those medications are just so people have an idea?
Lesa Abney, R.N.: Well, there are seven FDA approved medications. Five of them are nicotine replacement and two of them are oral medications. The big picture is patches are long acting and they can be purchased over the counter or as a prescription depending on your insurance. Short acting is the gum and the lozenges that also be purchased over the counter or prescription. They are dosed according to how much you smoke. It is important to have strong enough patches. So, if you smoke 10 cigarettes a day, you really need to start with a 21 mg patch to be sure you are covered. The important thing that a lot of people do not know about the short-acting nicotine replacement lozenges and gum is they have got to be used the right way. They absorb through the lining of your cheek, not your stomach. Read the directions very carefully. You want to make sure you are using these the right way so that you are getting the best benefits. Using patches which are long acting with the oral, which is short-acting, using those together covers breakthrough cravings and is much more affective. The two-prescription nicotine replacements are a nicotine inhaler and nasal spray. I do not see nasal spray used very often. A lot of people do not like to use nasal sprays. The inhaler is almost cost prohibitive because a lot of insurances do not cover it. It is not an inhaler like you think about using for asthma. It is a plastic piece shaped as a cigarette with a vial of FDA approved clean nicotine in it that you can do this with.
Shaina Farfel: That is a new one for me.
Lesa Abney, R.N.: Yes, and our insurance does not cover it. We have the oral medication which is called Wellbutrin or Zyban. Be aware that this is not used as often as it was in the past because there is multiple medication to mediation interactions. Chantix or varenicline is used quite frequently. There are now two genetics, one of them is called apo-varenicline and the other one is varenicline. They are very effective. The EAGLES trial published in 2016 showed the efficacy of varenicline as well as its safety profile. It did show also that you have a 50% chance of quitting over patches alone. Also, studies are showing using nicotine replacement short and long acting together are kind of on the same level as varenicline. Both of those are very, very good ways to quit. Always remember that whatever medication you choose you need to use it for three months. The general timeframe is 6 to 12 weeks that it takes the nicotine receptors in your brain to return to normal of presmoking levels. Let your brain heal. Once it heals, you are less likely to have issues with the nicotine withdraw, the irritability, the anxiousness, and those strong cravings and such. That is why they are always recommended for three months.
Shaina Farfel: Wonderful. Thank you for going through that. That was very helpful. Lastly, what smoking cessation resources are available here at Vanderbilt for folks if they are contemplating quitting?
Lesa Abney, R.N.: Well, you guys actually have an amazing program for all of our employees which is so amazing, and I wish more people knew about it. Also, there are free services such as the Tobacco QuitLine which is 1-800-quit-now. Each state has their own QuitLine funded by the state, giving some free medications depending on the state. You can also go to smokefree.gov which is a testing service that can kind of help give you assistance and that is sponsored through the National Cancer Institute. Tell me a little bit more about your program.
Shaina Farfel: Yeah, thank you. We at Occupational Health have a program that is called Quit Rx and it is a program that would allow any employee, both university and medical center, to come see one of our occupational health providers and the consultation with us is free and we talk about motivation to quit. We discuss whether or not some of these medications that you talked about may be appropriate, and we can prescribe them and follow you throughout your care and that could be up to three months and in some cases, there is indications for longer or help kind of get you in with your PCP to continue to follow you. We do, as you said, if you are in this program with us, we do also get you connected to a health coach through Health Plus who is also following you for counseling around smoking cessation so that you have got both of those pieces going. We like to remind folks that this is a service that can be done in person. It can be a telemedicine appointment. We like to make it convenient and accessible for all employees. So, I will link some resources to that when we post the podcast. If you are interested, you can call our main Occupational Health line too at 615-936-0955 and setup an appointment.
Lesa Abney, R.N.: It is a great program. From different staff members that I have worked with, I have heard a lot of really good things about your program.
Shaina Farfel: Yes. Just trying to get the word out because we are all here and ready to help you guys. Well, Lesa, thank you so, so much for your time today. I think folks will find this information incredibly helpful and we really appreciate your expertise and sharing with us. Thank you again.
Lesa Abney, R.N.: I appreciate the opportunity. Thank you.
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