A Journey to Recovery: What Does
the Cigarette Represent
Myths & Facts
The Impact of Cessation on Health and
Wellness
Eric Arauz MLER
International Behavioral Health
Lecturer/Trainer/Advocate/Author
Adjunct Instructor: Rutgers- Robert Wood Johnson Medical
School
www.ericarauz.com
2
Treatment: Full Recovery or Stabilization?
Maturation of Recovery:
•
•
•
•
•
Psychological
Physical
Physiological
Social
Spiritual
Live or Survive
3
The Role of Cigarettes
Personal Experience: My relationship to
Cigarettes
Hospital Culture: “Cigarettes are used in a variety
of ways in the hospital. They are currency, crutch,
escape, lover and friend.” (An American’s Resurrection
p. 116)
4
5
Recovery: The Process and Pain of Change
Recovery Trajectory:
Early Recovery: Day programs, Addiction program
5 years out of Hospital: First Cessation Attempts
10 years out of Hospital: Olympic Triathlon
Today: Martial Arts, Yoga, Mt. Biking, Sober 17 years
Olivia
6
References
Guernica painted by Pablo Picasso. Completed 1937. Housed
at the Museo reina Sofia Madrid Spain.
Man of Fire painted by Jose Clemente Orozco. Completed
1939. Housed at the Hospicio Cabanas, Guadalajara, Mexico
Arauz, E., An American’s Resurrection. St. Louis:
Treehouse, 2012.
Herman, J., Trauma and Recovery. New York: Basic Books,
1997.
7
Tobacco Use and Behavioral Health 101
Chad Morris, PhD
Director, Behavioral Health & Wellness Program
University of Colorado
On average, persons diagnosed with
mental illnesses and addictions have
higher rates of disease and disability, and
die up to 25 years earlier than the general
population
Tobacco Use by Diagnosis
Schizophrenia
62-90%
Bipolar disorder
51-70%
Major depression
36-80%
Anxiety disorders
32-60%
Post-traumatic stress disorder
45-60%
Attention deficit/ hyperactivity disorder
38-42%
Alcohol abuse
34-80%
Other drug abuse
49-98%
Tobacco Use Affects Behavioral Health Care
and Treatment
Persons with behavioral health conditions
who use tobacco:
 Have more psychiatric symptoms
 Have increased hospitalizations
 Increased suicidality among youth
 Require higher dosages of medications
Tobacco-Free –
Common Concerns
“Smoke breaks are a
time when I build
relationships with
clients.”
“This is one of
their last
personal
freedoms.”
“How are we going
to fund this?”
“The issues
we face are
unique.”
“I don’t have
the training
necessary.”
“If we go tobaccofree, behavioral
problems will
increase.”
“Why spend time on this when
there are more important
psychiatric, substance abuse,
and medical issues?”
Tobacco-Free –
Common Concerns
“They will lose their
sobriety if they also try
to quit smoking or lose
weight.”
“They don’t
want to.”
“It isn’t my job to
police smoking.”
“They can’t”
“It isn’t
relevant”
“I don’t have time
to do this on top of
everything else”
“I’ve always heard smoking
helps symptoms. I don’t want to
make their symptoms worse.”
Bio-Psycho-Social Model
Psychological
Factors
Biological
Factors
Social
Factors
Tobacco
Use
Neurochemical Effects of Nicotine
 Dopamine
Nicotine
Pleasure, reward
 Norepinephrine Arousal, appetite suppression
 Acetylcholine
Arousal, cognitive enhancement
 Glutamate
Learning, memory enhancement
 β-Endorphin
Reduction of anxiety and tension
 GABA
Reduction of anxiety and tension
 Serotonin
Mood modulation, appetite sup.
Benowitz. Nicotine & Tobacco Research 1999;1(suppl):S159–S163.
Nicotine Withdrawal Effects
 Irritability/ Frustration/ Anger
 Anxiety
Most symptoms:
 Difficulty Concentrating
 Appear within the
first 1–2 days
 Restlessness/ Impatience
 Depressed Mood
 Insomnia
 Increased Appetite
 Peak within the
first week
 Decrease within
2–4 weeks
Schizophrenia
• Decreased α-7 nicotinic
receptors
• Nicotine activates nAChR
• Partially normalizes sensory
processing deficits
• Smoking may improve
negative symptoms &
cognitive functioning
• attention
• orientation
Cessation Interventions Work
Quitting tobacco is difficult but absolutely
feasible if assistance is provided
Quit rates with willpower alone – 4%
Pharmacotherapy (NRT) alone – 22%
Counseling plus NRT – 36%
Chantix – 44%
Quitting: It Can Be Done
Persons with behavioral
health conditions:
 Are able to quit using
 75% want to quit
using
 65% tried to quit in
the last 12-months
Tobacco Use Affects Treatment & Recovery
from Addiction
Addressing tobacco dependence during
treatment for other substances is associated
with a 25% increase in long-term abstinence
rates from alcohol and other substances
Prochaska et al., 2004
Psychiatric Symptoms Are Not Exacerbated by
Smoking Cessation
• Smoking cessation is associated with:
• reduced depression, anxiety, and stress
• improved positive mood and quality of life
compared with continuing to smoke.
• The effect size seems as large for those with
psychiatric disorders as those without.
• The effect sizes are equal or larger than those of
antidepressant treatment for mood and anxiety
disorders.
Taylor et al, 2014
Why Behavioral Treatment Settings?
Experts in behavioral change
Duration of treatment
Therapeutic alliances
Co-occurring treatment
Integrated and health home models
Access to high risk populations
Community-based and patient-directed
Complements other prevention and
wellness activity
 Performance measurement








Effective Health Behavior Change
Cognitive-Behavioral Therapy
Motivational enhancement
Individual counseling >4 sessions
Psycho-educational groups
Individualized treatments based
on diagnoses
 Referral to quitlines





Tobacco Cessation Interventions:
The 5 A’s Model
ASK
about tobacco USE
ADVISE
tobacco users to QUIT
ASSESS
READINESS to quit
ASSIST
with the QUIT ATTEMPT
ARRANGE
FOLLOW-UP care
A Peer-to-Peer Model
Peer Advocate/ Mentor – An individual with “lived
experience” who has received specialized training
and supervision to work with others who have a
similar history
Potential Peer Roles
 In-services, lunch & learns, and trainings
 Motivational interventions
 Tobacco free groups
 Community linkage
 Positive social options
Integration is the New Norm
 Mental health and
addictions
 Across healthcare sectors
 Integrated care & health
homes
 Public health
 Quitlines
 Community integration
 EHRs & Performance
measurement
50th Anniversary Surgeon General’s Report on
Smoking and Health:
Where are we now?
Steven A. Schroeder, MD
Director
Smoking Cessation Leadership Center
http://smokingcessationleadership.ucsf.edu
The Health Consequences of Smoking:
50 Years of Progress
A Report of the Surgeon General
1964
2014
It’s a New Era
Remember When
Ashtrays out in every home?
Smoking in airplanes?
Tobacco companies sponsored news hours and ads barraged
the airways?
Nurses took frequent smoke breaks?
Patients smoked in the bathrooms?
I do. We came a long way baby, but there is still much more to
be done
Tobacco’s Deadly Toll
480,000 deaths in the U.S. each year
4.8 million deaths world wide each year
> Current trends show >8 million deaths annually by 2030
42,000 deaths in the U.S. due to second-hand smoke
exposure
>16 million in U.S. with smoking related diseases
45.3 million smokers in U.S. (78.4% daily smokers, averaging
14.6 cigarettes/day, 2012)
Percent/Number of Cigarettes Smoked Daily
Smoking Prevalence and Average Number of Cigarettes Smoked
per Day per Current Smoker 1965-2010*
* Schroeder, JAMA 2012; 308:1586
TRENDS in ADULT CIGARETTE
CONSUMPTION—U.S., 1900–2010
Annual adult per capita cigarette consumption and major smoking and health events
First Surgeon
General’s Report
Number of cigarettes
5,000
Master
Settlement
Agreement;
California
first state to
enact ban on
smoking in
bars
Broadcast
ad ban
End of WW II
4,000
3,000
Nonsmokers’
rights movement
begins
2,000
Cigarette
price drop
1,000
Federal cigarette
tax doubles
Great Depression
20 states
have > $1
pack tax
0
1900
1910
1920
1930
1940
1950
1960
1970
1980
Year
Centers for Disease Control and Prevention. MMWR 1999: 48:986–993.
Per-capita updates from U.S. Department of Agriculture, provided by the American Cancer Society.
CDC. Consumption of Cigarettes and Combustible Tobacco – United States, 2000-2011. MMWR 2012: 61(30);565-9.
1990
2000
2010
PREVALENCE of ADULT SMOKING,
by EDUCATION—U.S., 2011
25.1% No high school diploma
45.3% GED diploma
23.8% High school graduate
22.3% Some college
9.3% Undergraduate degree
5.0% Graduate degree
Centers for Disease Control and Prevention. (2012). MMWR 61(44);889-894.
Self-Reported Mental Health Conditions Among Helpline
Callers (N=102,103)
60
50.3
37.2
31.2
(Zhu et al. 2014. Unpublished data)
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40
Smoking and Behavioral Health:
The Heavy Burden
200,000 annual deaths from smoking occur among patients
with CMI and/or substance abuse
This population consumes 40% of all cigarettes sold in the
United States
> higher prevalence
> smoke more
> more likely to smoke down to the butt
People with CMI die earlier than others, and smoking is a
large contributor to that early mortality
Social isolation from smoking compounds the social stigma
Lung Cancer Deaths 2003-2005
Source: National Vital Statistics System—Mortality, CDC, NCHS
40
Benefits of Tobacco Control in the United States,
1964-2012*
17.7 smoking-related deaths occurred
8 million such deaths prevented
Preventing smoking-related deaths accounted for 30% of life
expectancy gains during that period!
People with mental illness did not benefit as much from these
declines in smoking rates **
* Holford ; **Cook : JAMA, 2014
Surgeon General’s Goals for the Future
10% prevalence by 2020
Focus on populations hardest hit, e.g., behavioral health
Work in regions to spur local tobacco control efforts
Tobacco Tipping Point?
California 11.9% adult smoking prevalence in 2010
2012 national prevalence at modern low—18%!
Smokers smoke fewer cigarettes
Physician smoking prevalence at 1%
CVS/Caremark stops selling tobacco products (2014)
Cigarette butt pollution as emerging concern
Tobacco Tipping Point (2)
Higher insurance premiums for smokers
Lung cancer deaths in women start to fall
Increasing stigmatization of smoking
National 2014 mass media campaigns—FDA, Legacy, and CDC
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