Kicking the Nicotine Habit, It's a Brain Thing

Introduction:
Welcome to the MedEvidence! Podcast hosted by Dr. Michael Koren and Michelle McCormick. MedEvidence!, where we help you navigate the real truth behind medical research with both a clinical and research perspective. In this podcast, we will have discussions with physicians that have extensive experience in patient care and research. How do you know that something works? In medicine, we conduct clinical trials to see if things work. Now let's get the Truth Behind the Data. 

Michelle McCormick:
This is MedEvidence! Truth Behind the Data. In this episode, Dr. Michael Koren and Dr. Mitch Rothstein are Kicking the Nicotine Habit, it's a Brain Thing. Dr. Michael Koren is a practicing cardiologist and chief executive officer at ENCORE Research Group, conducting clinical trials across Florida. He has been the principal investigator of over 2000 trials and published in the most prestigious medical journals. Dr. Koren received his medical degree cum laude at Harvard Medical School. And today, we also have Dr. Mitch Rothstein. Dr. Rothstein has practiced Clinical Pulmonary and Sleep Medicine for over 30 years in Jacksonville. For the last six years, he has transitioned into clinical research as the Medical Director of the Phase One unit at Jacksonville Center for Clinical Research. Always be sure to subscribe to the podcast for weekly notifications. All right, gentlemen, let's continue the conversation about Kicking the Nicotine Habit. Dr. Rothstein, we'll start with you. How do you counsel people on quitting? In our last episode, we discussed how vital this could be for the longevity of the heart and life. How do we counsel that? 

Dr. Mitch Rothstein:
Well, it's a problematic area, and there are a lot of different answers. The key to counseling is that you have to have the right patient. So if you don't have a patient that wants to stop, you cannot counsel. All the work in the world is not going to do much. So let's look at different counseling environments. One-on-one counseling versus group counseling versus drop-in counseling and direct medical counseling. With drop-in counseling, people come and go as they start to stop smoking or end or quit their smoking and leave the group and come back and forth. And found, for the most part, they found was that group environments tended to do better than one-on-one environments. And then, when you look at the people that are trying to stop smoking, we know that women have a more difficult time stopping smoking than men. We know that people from lower socioeconomic environments have a more difficult time stopping smoking than people from more affluent communities. So there are a lot of complicating issues that are involved in it. Genetics is involved. We know that people who metabolize nicotine more quickly have a more difficult time stopping smoking than those who metabolize it more slowly.
Furthermore, how long you have smoked also has something to do with it. We know that in the United States, at least 80% of smokers start smoking before they are 18 years old. Moreover, that is a time period where you're learning all these associations. So when you approach someone, you need to have a complete picture of where they are in their smoking history. And what part of the smoking issue is the most important to them? Because it is not always the drug that's the most crucial issue. Some of it is social. We know that it can be relaxing and reduces anxiety, and people can use it socially to help them feel better. Moreover, for many people, an emotional relationship develops with a pack of cigarettes. 

Michelle McCormick:
Yeah. It is always there. Is it a weight loss tool? Because I've always heard that. And maybe this is why it's more difficult for women, is that smoking helps you maintain a weight or keep your weight down. 

Mitch Rothstein:
I think that is urban fiction. I think the studies that looked at successful smokers and weight, successful people who succeeded in stopping smoking and followed weight over the course of the year, found that in the first three months after you stopped smoking, the average person gained about 10 pounds. If you looked at that same person a year later and they still weren't smoking, that weight wasn't there anymore. So it's one of the kinds of people that kind of scare themselves into not trying to stop smoking, 

Dr. Michael Koren:
There probably are some relationships between weight and nicotine, specifically smoking. One is that when you smoke, your heart rate is higher. And so it's like speed. And so when your heart rate is higher, your cardiac output is higher and you burn more calories just because of that. So it's not uncommon to see heavy smokers that are skinny. But quite frankly, our average patient is both a smoker and overweight. Right. So certainly that smoking is not a guarantee that you'll be thin, but for some people, it does help them. And again, and some people, it increases the amount of calories that they burn. 

Dr. Mitch Rothstein:
Yeah. I think the other thing that's happened is we have compared most of the animal experiments. Right. They compare the animals urged to tap for nicotine or to tap for food. And in those kinds of settings, you have animals that would preferentially want nicotine over food, just like you were talking about. So there is an association, but people that stop smoking and gain weight are doing it not just because of the lack of nicotine, but also because they want something to do with their hands and their mouth. We know that for the fact. 

Michelle McCormick:
Right. And is that where the nicotine gum comes in, keeps their mouths busy, gives them something to do? 

Dr. Mitch Rothstein:
Yeah. I think that's clearly part of the thing. The nicotine is the essence of it, what's in the gum. But having something in your mouth and something that you handle is also seemingly going to help you succeed in stopping that whole behavioral thing. 

Dr. Michael Koren:
And as Dr. Rothstein mentioned in the previous segment, smoking is a difficult habit to kick because it's both a chemical addiction and a behavioral addiction. And from the reading I've done, the most successful methodologies are to address both. And what I do clinically is when a patient comes in and I do this quite a bit, they're a smoker. I'm, of course, going to tell them, hey, that's a risk factor for heart disease and stroke. I'd love to see you get off the cigarettes. Is that something you thought about? Are you willing to do that? And I'd say it's 50-50. Some people are happy smoking, and for whatever reason, it fulfills some need in them. And I'm not going to push too hard. But even if they say they're not interested in quitting, I'll at least address the possibility of nicotine replacement. It's hard to get people to think about behavior and modification if they want to smoke. I had a recent funny anecdote a patient came in, a guy in his 60s who had lots of cardiovascular factors, lifetime smoker. So you think about quitting? He said, yeah, I've done it before. And like Mark Twain, I said, okay, How'd you do it? I just stopped and mind over matter. And I did it for three months at a time. He said, but I hated myself and I just didn't like who I was when I wasn't smoking. I just like myself better when I smoke. All right. Well, that's going to be hard to argue with. But on the other hand, if we can talk about the fact that he get the nicotine, which is probably why he likes himself better, maybe that is an opening. So for everybody, you need to kind of figure out how you're going to get into their inner world, into their brain space and figure out a way to help them. And we'll talk about alternatives where you don't have to burn tobacco to get that nicotine satisfaction. 

Michelle McCormick:
Yeah. So is cold turkey not the way to go, or do you modify or taper down? 

Dr. Micheal Koren:
It depends on the person. You probably would agree that you have to tell it to the people. Some people like the setting better. 

Dr. Mitch Rothstein:
Yeah. I think in terms of cold turkey, there has to be a point where you stop smoking if you're going to stop smoking. So there is that cold turkey point. Whether you get there through reducing the amount you smoke, I think, less important than it is on achieving a quit date and sticking to your quit date that you decide that after next Tuesday, I'm no longer going to be a smoker and have a plan as to what you're going to do to make that successful. And that has to be some you have to know your own triggers and when you like to smoke the most. So you don't sit there just going because that person's not going to succeed no matter what they do. But at some point, I always used to tell my patients that we all stop smoking.

Dr. Michael Koren:
Yeah. It's interesting. Just the concept of cold turkey has a negative consequence or connotation. So you can just say, just stop. No, cold turkey reminds me of that John Lennon song from the 70s, Cold Turkey, where he screams for about five minutes into the song. And so there are a lot of negative associations with that. But one of the things I like to do because of this concept of both nicotine addiction and the chemical parts of that addiction and the behavioral parts that Dr. Rothstein was talking about is to work on the behavioral stuff right away. So it's a little less intimidating for people, even though it's just as important in terms of the habit. And so I read years ago about this five-step method for helping people change their behavior. And the concept simply is that a lot of behaviors get the part of your brain where you don't even think about it anymore. They're just automatic behaviors. And if you can change those automatic behaviors to behaviors that are associated with thought, it's going to be easier to quit. So what I tell people is that if you want to get ready to quit, you're not ready for that cold Turkey day, but you're ready to start to change your brain. Maybe you can do these behavior modification things. So without further Ado, they're basically five things, and they're all really easy. Okay. They're actually all really easy. And I just laid out the patient. I'll say number one. Rule number one is only buy one pack of cigarettes at a time. So just the fact that people buy cartons and cartons and cartons, it makes it really easy for them to smoke and continue to smoke in high volumes. But if you buy one pack at a time, again, you're forcing yourself to think so you're making a little bit of a hassle, and you're forcing yourself to think, so that's number one, that's easy. And you can buy one pack at a time cost a little bit more, but you'll smoke less. So, okay, number two is you buy a different brand every time. So part of the habit and the culture that we're talking about is you kind of get associated with the brand and you like that, but make a conscious effort to buy a different brand every time and maybe buy a brand you would never think of buying before, 

Michelle McCormick:
like a menthol

Dr. Michael Koren:
as a non-smoker, I can't comment on that. I don't know. Maybe. 

Michelle McCormick:
Yeah. Well, some people, like 

Dr. Michael Koren:
actually, the FDA thinks that may be an additional draw, and then they're talking about taking menthol cigarettes off the market. But that's a side note. But the point is that the imagery changes, the brand association changes. Rule number two. So one pack at a time to a different brand each time. Number three, never keep cigarettes on your person. Always put them in a place where you have to make an effort. So, for example, don't put them, like, in the glove box of your car when you're driving. So if you like to smoke at home so you like to smoke in your back patio, keep your cigarettes in the garage. So when you decide to smoke, you have to make an effort. So always put them in a place where there has to be an effort made to smoke. That's rule number three, rule number four is that if you decide to smoke, you get up from your kitchen table, you go to the back patio, oh, you don't have any cigarettes there. And go back to the garage. You get your cigarettes, you go back to the back patio, you get all set, get your ashtray, get ready to go. Okay, I'm going to relax. But before you do anything, you take the cigarette out and you look at it for 30 seconds. That's easy to do, right? Just look at it for 30 seconds. So instead of just automatically putting your mouth and lighting it, just really look at it during the 30 seconds. Ask yourself, do I really want that? Do I really need it? Do I really want it? I'm actually feeling pretty good. You put it back in the pack, you put it back in the garage and you go play golf or do whatever you're going to do. Now, the fourth rule is that okay, you look at it for 30 seconds, saying, yeah, I need the cigarette. I really need it. So go ahead. I'm not taking it away from you. Just go ahead and light that cigarette, take a puff, put it out, and then wait a few seconds and say, do I still want it? You still want it? Light it up again and finish it. So none of those things actually take the cigarettes away from you. You still have access to them. It's not intimidating, but you are forcing yourself to rethink your behaviors. And extra data shows that these types of methods can work and prime people actually to get over the chemical addiction down the road. So those are my little tricks. 

Michelle McCormick:
What do you think? You're nodding. 

Dr. Mitch Rothstein:
Yeah. I think you can get people thinking differently about smoking Than the way they think while they're smoking. That's the key is that anything that can help kind of break those positive reinforcing behaviors that they previously had with cigarettes, that gives them a better chance of succeeding than if you don't. If you just leave people out on the road and tell them they can't smoke, they're going to go crazy.


Michelle McCormick:
I'm your host, Michelle McCormick, and we want to thank Dr. Michael Koren for his clinical and research perspective behind the science in this episode of MedEvidence! The Truth Behind the Data.