Quitting: Do It For Atticus

By Suzanne Danforth

September 27, 2007 6:00 AM

After a long summer off (a gift from the childhood gods) I am back to work and have had to find ever more creative ways to afford my dog, Atticus, his walkabouts. I groan when the alarm goes off before the sun makes its appearance, but what gets me up and going is the vision of his joy as we approach our destination, his body aquiver with the excitement of the running to come.

Atticus came to me as "Artemis," complete with a BB in his back and a broken spirit. Addy is a Hoosier, from Indiana, where kill shelters are the norm. When we met, it was clear he'd been through some stuff; he didn't know how to play, startled easily, and looked for all the world like a lost cause.

We spent some time together in the shelter. When he finally put his long nose in my lap and shyly thumped his tail during our second visit, I was his. Thankfully, he did not (and has not) gone back on any of the silent promises dogs make. Even though he has had to put up with me. Which is where smoking enters.

Atticus is a sneezer. He sneezes. A lot. He sneezes when he is excited. He sneezes when he knows he is going outside. He sneezes when he is playing. He sneezes when he is nervous or when he is trying to assert his dominance in a small space. He sneezes sometimes 12 or more times in quick succession. He sneezes, truly, on command.

And, of course, he sneezes when I smoke, after he is finished snorting in disgust.

The familiarity of the words "according to the Surgeon General's report" belies this fact: there have been just 29 reports issued by the Surgeons General since 1964, and most of those focus on tobacco. Its health consequences, its costs in billions of healthcare dollars, its use by young people, women and minorities.

Secondhand smoke, known as involuntary exposure in Surgeon General speak, came to the fore of the national consciousness in 1986, when the office published a report that called it a cause of disease in healthy non-smokers. No friend of big business, these doctors.

The updated version of this report was issued by the office of the Surgeon General last year and it has just a few more teeth than the 1986 report. It makes for some scary bedtime reading; look, here is the information on the toxicology of secondhand smoke. There are the measurable biomarkers by which we can tell how much of your neighbor's butts you are smoking. And don't forget to check out the mechanisms by which secondhand smoke can cause heart disease (via a prothrombotic effect, in case you were wondering).

The major conclusions are few, but stark. For your reading pleasure, they are re-printed here.

1. Secondhand smoke causes premature death and disease in children and in adults who do not smoke.

2. Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children.

3. Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer.

4. The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.

5. Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces despite substantial progress in tobacco control.

6. Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.

That last one is clearly responsible for the clogged sidewalks on Daniel Street these days.

The report makes no mention of dogs, but I wonder in dread what the year and a half of smoking exposure Atticus got from me has done to shorten his life span. I've already risked my heart for him to tear (nod to Rudyard Kipling), but has he risked his too, in service to a stupid terrible habit?

The sunrise on Peirce Island is a favorite activity of ours, as of late. I get coffee and he gets a Munchkin before we head over. He begins to sneeze round about Strawbery Banke, and smiles broadly in between. I open my door and tilt my hip to the right so he can make the leap from the back seat out my door.

I experience embarrassed joy when he comes across an early exerciser, laboring on the ground doing scissor kicks, and he attempts to engage her with delighted barking and a play stance in his mistaken belief that her efforts are purely for him. This little dog of mine, who now knows how to play, for you I will keep trying to quit.

Suzanne Danforth is well aware she brings the schmaltz to the party. E-mail your own schmaltz to her at suzanne.danforth@gmail.com.

Quitting: Inspiration from the Stages of Change

By Suzanne Danforth

September 20, 2007 6:00 AM

My current column is titled, a la Winnie the Pooh, "in which it comes to be known that inflatable cigarettes do exist."

They aren't filled with sand and so could not be punched, but at 3-feet long a couple of them would be just the thing for an inflatable cigarette fight with a friend.

Or, they would be perfect to carry around with an invitation pasted to them: "If you see me smoking, please hit me with this giant inflatable cigarette!"

We could go out to dinner, my inflatable cigarette and I. And, even though we are in non-smoking New Hampshire, it could accompany me to hear music at The Press Room.

At night, it could rest next to my little inflatable scream guy by Munch. In the morning ...; oh, never mind, you get it.

In all seriousness, inflatable cigarette novelties are actually learning tools for kids, so they can escape this blasted need to quit in the first place.

Some years ago, I came across a group of theorists who studied successful changers. These changers were of many stripes; people who were successful in quitting smoking, losing weight, stopping drinking or leaving the inflatables at home. Being an academic-head myself, this material was for a time like finding the Holy Grail, fountain of youth and secret of life all in one.

Until I realized this: knowing that is not the same as knowing how. Knowing that successful changers go through distinct and predictable stages, does not in itself make one a successful changer. To wit, here I am.

The Stages of Change model is very Western in that it analyzes and categorizes, each conclusion leading to and influencing the next. Eastern thought on changing has been around a little bit longer and is found in the classic Chinese text the I Ching or Book of Changes.

Each mode of thought proposes distinct stages in changing, markers that can guide us in our efforts to change. In both views, change in its incipient state is invisible. It is the energy in a seedling, a life spark, a quickening. The theorists call this stage Precontemplation, in which there is little to no desire or intention to change. Although the person in this stage can be under aware, something is nonetheless brewing.

Contemplation follows Precontemplation, implying an awareness of a problem and the thinking that goes along with knowing something has to give. What does not occur in this stage is a commitment to take action. That comes next, in the Preparation stage, where intention and intent merge to become an action plan.

This is the stage to write home about, but not too fast, for it is also the stage where the company includes backsliders from the Action stage. Whoops-ers who tried to make overt behavioral changes but were unsuccessful. If at first you don't succeed, get back to the Action stage, and recommit time, energy and behavioral strategies.

Eventually, you end up in the Maintenance stage, where the commitment is to preventing relapse. Maintenance can last, in the case of addictive behaviors, for a distressingly long "indeterminate time period past the initial action." Man, I may really be fighting this for a long time to come.

Being hooked on tobacco is undeniably an addiction. Medical research is getting ever more sophisticated in this area of study and the mechanisms of addiction are slowly being revealed.

In this country and time, lay people use the term "addictive personality." This misnomer has taken on breezy explanatory qualities, when in fact addiction is a change in the neural architecture and hormone soups of the brain. And if you don't think that is powerful, watch a child's development between the ages of zero and 10 months or so. That's what we're up against, only in grown up, smelly tobacco-brain form.

There are plenty of days when I am tired of myself and barely have the energy to change my outfit, never mind my brain. On those days I usually end up thinking less than positive thoughts, like "oh brother, just get over it, move on." That is when I conjure the research showing that positive changes to the brain, any brain, whether because of addiction, or traumatic events, take a long time.

There is good news, though. I speak for myself only and not to the model of change. Although I may backslide from Action to Preparation, it would be impossible for me to return to the halcyon days of Precontemplation.

There is no innocence here anymore.

Suzanne Danforth wants Bobbie Krewson's son to stay quit smoking. E-mail tips to suzanne.danforth@gmail.com.

Quitting: Memories of Mama

September 13, 2007 6:00 AM

My mother died 363 days ago, at dawn. It had been a lovely stretch of September weather, clear cool mornings, hot afternoons, crickets calling cadence in the evenings. My siblings and I left her body after our goodbyes in the early hours of Sept. 16 to find nature on display; moon and stars waning in the west and the sun nudging forward in the east. The over large silence of that morning ruptured when a roost of small black birds took to wing startling us in their seemingly choreographed flight.

I still find comfort in my belief that those night birds flying were more synchronicity than coincidence.

I would be writing revisionist history if I recalled the days of her death without a cigarette in my hand. Or if I chose not to acknowledge their role in our decision to let her die from the pneumonia that took hold of her over most of last summer. In those 12 awful days up to her death, smoking was a comfort and friend, a sure dopamine-releaser when none other existed.

I am weary of trying to quit. Oh, make no mistake; I am committed to becoming a non-smoker (remember, though, the clinical definition being six months of continuous abstention). My pattern seems to be that I stay away successfully (which means not a whole lotta brain space devoted to thinking about butts) for a while. I do healthy things like ride my amazing new bike, eat well, sleep good, read or write. I "thought stop" the occasional unbidden intrusion into my thinking.

These nicotine intrusions usually take one of two forms; a craving or a sweet recollection. The sweet recollections are infinitely more dangerous than the cravings. The cravings, at this point in my quit trajectory, have changed their nature. Instead of my friend the black hole, they have collapsed into a small ball of dense matter, much like that preceding the big bang. While it doesn't have a gravitational field, this matter is theoretically capable of imploding to give birth to a universe. Point is, it hasn't.

Sweet recollections, on the other hand, sashay in from the perimeter, and comment on your beauty or erudite nature. They invite you to try your luck at shimmying like your sister Kate, to hoist your glass and make the toast, to gamble on love. It never occurs to sweet recollections to mention risk, or if it does, they reason it away. They mess. You up.

I view the nasty weed, personified, as a deceptively benevolent Napoleon, a patron of "let's consider it my way" (consider being non-optional in the final analysis).

In most areas of my life I am black or white, full speed ahead. If trying to quit were a matter of, say, getting another graduate degree or mounting Everest, I would have few problems reaching the goal. But, like most of us, my strength is my weakness.

There must be a genetic basis to this either/or aspect of my personality. Because I am not a breeder, I must look further than myself for clues, specifically to memories of my mother and her own convictions. As a child, I recall visiting a homeless student and his family at a campground; I remember withstanding community pressure when she challenged the practices of a local orphanage; I well recollect how long it took her to realize that my father was best out of our lives.

And, of course, I remember when she quit tobacco. We were peppered with the statistics. Her description of reduced blood flow to the extremities after one cigarette continues vivid in my mind. My rebuffs of her repeated offers to pay for a program or medication make me sorry, now, that she is not aware of my current attempt. When it gets really hard, I don't focus on what I suspect would be her pride; rather I focus on what I know would be her relief.

She became unable to make those offers, or any others, because of the ravages of dementia. Although I risk the foolishly sentimental here, I remember one of the last times she spoke to me, as herself. We were in the hospital after a fall. I leaned into her and asked her, "Do I make you feel better?" She repeated everything at that point, so as was her wont, she mumbled, "Do I make you feel better?" Then, without missing another beat, clear, quick and emphatic, she said, "You do."

It is good to remember these things; not only do these memories re-stock my emotional larder, concentrating on a vision of my mother, relieved I don't smoke, is what keeps me trying to quit.

Suzanne Danforth thinks it is time to purchase a life-size blow up of a cigarette that wobbles when punched. If you know where to get one, e-mail her at suzanne.danforth@gmail.com.

Quitting: Studying the (potential) Outcome

By Suzanne Danforth

September 06, 2007 6:00 AM

Outcomes are big news right now, across a variety of fields; medicine, education, science and policy. Consumers, foundations and government agencies that grant money demand results and results are demonstrated, we are told, in the guise of data.

It is no longer enough to say, it sure does seem like that speech, occupational or physical therapy is helping. We have to prove it.

What is an outcome?

Basically, it's how the story ends. It asks the question: what is the change or benefit in an individual or group as a result of the offered service?

The thorny problem with measuring outcomes is that while information is countable, experience is not. Outcome literature so much as admits this.

"Outcomes are not how many birds the worm feeds its young, but how well the fledgling flies" (United Way 2002). Hmmm, pardon me for asking, but just how can the first flight of a fledgling be enumerated in such a way that it can be given to a desk jockey in a state capital for an end-of-year statistical report?

Welcome to the thoughts in my head after wading through piles of full-text literature on outcome studies related to giving up tobacco, including the veddy dry reading of studies about the dreaded but effective medication I ingest daily to help me stay quit.

That's right, stay quit. I am still quit, despite the smoking spasm chronicled last week in these pages. This fledgling is still aiming to fly.

I am back on a tiny amount of the wretched little pill and am walking the line between not smoking and holding my food down.

The absolute best thing I have read thus far is this, straight from the British Journal of Medicine. But first, please take a moment to visualize John Cleese as speaker.

"These large trials show once again that most people find it difficult to stop smoking, even in the best possible conditions and even when they want to quit badly enough to volunteer for a randomised trial of a new treatment."

Yeah.

I have learned several exciting new facts in my research. Non-smokers metabolize caffeine twice as efficiently as smokers do, for example. This means that as a recent quitter, if I haven't simultaneously decreased my coffee habit, there is a good chance I am hopping around out of my mind on caffeine. Or this one: recent quitters have warped time perception. Really. Recent quitters stink at estimating time, suggesting that cravings really do feel like they last three hours.

Let's focus this week on the facts, the data, the information, the stuff you can put in a report, Harper's style, but compiled by me.

• 6: months of complete abstinence defined as smoking cessation.
• 2: IQ points lost by young children exposed to even small amounts of secondhand smoke.
• 440,000: premature U.S. deaths every year attributable to smoking.
• 132: dollars not spent by me on cigarettes since trying to quit.
• 500: dollars given to losing state Senate candidate Tom Eaton (R) by Philip Morris in 2006.
• 50: percent of increased caffeine levels in non-smokers, after ingesting the same amount of caffeine as smoking subjects.
• 450,000,000: worldwide tobacco related deaths expected in the coming 50 years.
• 8: number of seconds someone dies from a tobacco-related disease.
• 1.08: N.H. state cigarette tax per pack
• 1: place in town where I just can't seem to resist the allure.
• 10: number of days left for me to attempt to resist the allure. (N.H. statewide smoking ban goes into effect Sept. 17.)
• 0.39: Federal cigarette tax per pack.
• 273,857: children worldwide who became regular smokers in 2007.
• 100: percent of organs in human body harmed by smoking.
• 3: percent of quitters who are successful for one year.
• 22: average percent of Chantix-taking quitters who are successful for one year.
• 7: number of free downloadable quit meters on whyquit.com.
• 5: subscales on the Modified Cigarette Evaluation Questionnaire, including smoking satisfaction, psychological reward, enjoyment of respiratory tract sensations, craving relief and aversion.
• 90: seconds estimated by recently quit smokers when asked to estimate time (which was in fact 45 seconds).
• 45: seconds estimated by non-smokers when asked to estimate time (which was in fact 45 seconds).
• 38: percentage increase in ear infections in children exposed to any tobacco smoke in first three years of life.
• 60: in billions, dollars spent annually in United States on smoking-related illnesses.
• 1: U.S. biopharmaceutical company prepared to market a nicotine vaccine, currently in clinical trials
• 1: ongoing spending spasm by author as compensation for not smoking.
• 90: percent of smoking adults who took their first puff before age 18.
• 1: outcome unknown — will she really quit for good?

Suzanne Danforth, clinician-researcher that she is, can provide references for each of these claims. E-mail her at the risk of being swamped with data at suzanne.danforth@gmail.com.