Denialism

tobacco and mental illness

—

by

MarkH
in

ResearchBlogging.orgAnyone who works with the mentally ill knows that they smoke more than other people. In fact, people with mental illness (hereafter, MI, not to be confused with myocardial infarction) are about twice as likely to smoke as people without mental illness, with smoking rates of 60-90%. One of my favorite stats is that “44% of the cigarettes smoked in the United States are by individuals with a psychiatric or substance-abuse disorder.” People with MI are also heavier smokers, and may even be better at extracting nicotine from the cigs that they smoke.

Studies have shown that people with MI can in fact quit, but from a front line perspective, this is really, really tough. In fact, quit rates aren’t all that great for people without the added burden of mental illness, so any barriers to quitting are formidable ones.

The reasons for high smoking rates in schizophrenics and others with serious mental illness are both socio-psychological and physiologic, with nicotine acting on CNS nicotine receptors and dopamine pathways. Smoking is sometimes viewed as a form of “self-medication”, but it can be difficult to differentiate the symptoms of nicotine withdrawal from symptoms attributable to the pre-existing mental illness.


As an internist, I take a very aggressive approach with my patients to help them quit smoking. Tobacco abuse kills a large number of my patients, and studies have borne out that people with MI suffer tobacco-related disease and death at a much higher rate than people without MI.

But in patients with co-morbid MI, the challenge of quitting smoking is often poorly met. Since data show that it is possible for the mentally ill to quit smoking, how should we approach this problem?

The answers aren’t clear. When someone is in crisis, we tend to put off taking care of all but the most immediately life-threatening issues. Since depression has a high fatality rate, when someone comes to me acutely depressed, this has to be dealt with and other health concerns are often pushed aside, with the thought that if the patient survives the crisis, we can move on to other things. I’m not sure if this is the best approach. For example, many psychiatric units have no provision for smoking, which probably scares away a number of patients. And why shouldn’t a person’s psychiatric and physical health be treated equally?

Why can’t we have a more comprehensive approach to treating mental illness, recognizing that tobacco abuse is an important co-morbidity? Before we get to this step, we need an intact national mental health care system, something that seems a long way off.

References

Karen Lasser, MD; J. Wesley Boyd, MD, PhD; Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD; Danny McCormick, MD, MPH; David H. Bor, MD (2000). Smoking and Mental Illness: A Population-Based Prevalence Study The Journal of the American Medical Association, 284 (20), 2606-2610

Nady el-Guebaly, M.D., Janice Cathcart, B.S.N., M.Ed., Shawn Currie, Ph.D., Diane Brown, R.N. and Susan Gloster, R.N., B.N. (2002). Smoking Cessation Approaches for Persons With Mental Illness or Addictive Disorders Psychiatric Services, 53 (9), 1166-1170 DOI: 12221317

J WILLIAMS (2004). Addressing tobacco among individuals with a mental illness or an addiction Addictive Behaviors, 29 (6), 1067-1083 DOI: 10.1016/j.addbeh.2004.03.009

Comments

  1. D. C. Sessions

    Details matter.

    Nicotine is known to act as a CNS stimulant for people with ADHD, for instance [1]. ADHDers have high rates of depression, in part due to chronic “self-medication” on stress hormones. Untreated ADHDers also have a high incidence of substance abuse.

    Unraveling that hairball (or peeling that onion) is not easy, and it’s not something that most health plans are prepared to cover (“Write a scrip for an SSRI and we’re out of here!” is more like it.)

    And that’s just one likely scenario.

    [1] Head over to jonimitchell.com and read her account of her first cigarette [2]. Anyone with ADHD in the family will identify.
    [2] Yeah, anecdotal. I’ve tracked down the published literature, too, but I’m a Joni Mitchell fan. Sue me.

    Reply
  2. Denice Walter

    E. Fuller Torrey has a nice chapter on the issue of “coffee and cigarettes” in his book, “Surviving Schizophrenia”;suitable for the layperson, the book is often suggested by organizations such as NAMI.

    Reply
  3. DuWayne

    I love Jonie too D.C., it’s all good…

    As a person with very severe ADHD (untreated for most of my life) and also bipolar (also untreated), I have always managed to attract/congregate with people who are either mentally ill, fairly heavy drug users or both. Not to mistake all the heavy drug users as mentally ill or pathological substance abusers, a great many of them were just young and grew out of it eventually.

    I dropped out of high school because it just wasn’t working. When I was really young I was diagnosed with the ADD, but my dad was pretty well convinced that the whole notion of ADD was a crock of shit and eventually I believed it too. So I rebelled against the notion that I needed help and became convinced that I was just lazy – I mean I was tested and told that I am exceptionally bright – freakishly so, yet I was constantly failing classes. So fuck it, I figured, why keep trying?

    I left school, left home and before long was hitchhiking the U.S. and even into Mexico, where I sold weed to American tourists for a month or so. I decided that the very worse that could happen, I end up dead. And I really didn’t expect that I’d even make the ripe old age of thirty-two I hit last March, so fuck it – right? I was going to experience everything I possibly could – live life to it’s fullest, because that’s what I was here for.

    Along the way, I hung out with a lot of folks who were similar in at least some ways to me. My very favorite people, were those who have neurological issues (I hate labels like mental illness and neurological disorders, because they are remarkably shortsighted and/or misleading).

    Almost everyone I know with neurological issues smokes. Many of them smoke a lot, at least when they can. A lot of them are also really spotty about their meds too, if they take any at all. And lack of actual care is a huge part of the problem.

    I mean I understand it for me, since reproducing, I have worked very hard at at least providing the illusion that I am as sane as sane can be. I quit wearing wild clothes (I love those long, light, “hippie” skirts) and delved deep into my midwestern heritage to be teh super-normal guy that folks want to hire to work on their home. I also utilized my hyperactive mind to become exceptionally good at working on people’s homes. The downside being, I am an abysmal businessman and I am too easily distracted, when I’m not hyper-focused.

    But I have a great many friends who aren’t even close, who also can’t get the help they need. They can go into a mental health facility, get a bottle of pills and booted back onto the street. then they either take all the pills in a short time, give them all away or some combination of both, if they don’t just throw them in the trash. All it would take in some cases, is keeping them a month or so, to make sure they are well onto their therapy and release them to some level of managed care – not necessarily high maintenance managed care. But we can’t even fucking do that.

    Sorry for rambling, life is pretty much shit right now.

    Reply
  4. gmcfly

    This reminds me of the psych unit I rotated through this year. Since smoking was only allowed on the patio, patio passes were a major incentive for many patients to attend their group sessions, comply with medications, maintain self-control, etc.

    Of course, this also made patio passes worthless for nonsmokers, who would rather stay inside during breaks and avoid the smoke.

    Reply
  5. Gray Gaffer

    Anecdotal:

    I smoked from 14 to 57. I tried quitting many times over the last 20 years, with increasing frequency. I tried everything – Cold Turkey, Acupuncture, patch, gum, Wellbutrin (which just made me not care that I did not stop smoking), hypnosis, several programs, several times each. About the only thing these attempts established for me was that my problem was behavioral not chemical. I never had any withdrawal symptoms. But picking up the habit again each time seemed to happen without volition.

    So what made the difference?

    Two things: I read Dr. Geoffrey Schwarz’s books on his work treating OCD, and I attended Nicotine Anonymous. The former gave me an insight into a possible description of the mechanism of nicotine addiction such as I had, as a feedback signal reversal in the Amygdala, that could be attacked via extended clear attention to internal thought processes. The latter provided what none of the other programs did – ongoing follow-up support group with others dealing with the same issues. I just ignored the “12-step” religious nonsense. The weekly focus helped maintain the internal attention regime I had set out for myself. I should point out that I do mean precisely “Attention”. I mean it without interpretation or commentary. Just being aware of what happens in my mind as I enact the ritual of smoking a cigarette. As with so many things in life, bringing subterranean forces out into the light of day can be very effective at defusing them.

    Now, this was not a quick process – none of this 6 week wonders of say Smoke-enders. Long ago I worked out for myself that any significant habit changes take a minimum of 6 months to establish, and this took a good year to actually quit and a second year to establish the new habits.

    Another meme that I am sure helped was happening across the idea that the subconscious does not understand negatives. Insisting to ones’ self “do not smoke” simply raises the “smoke” entrainments and presto the next you know you have a lit cigarette going. I also knew from bitter experience that quitting was not amenable to reason – I am not dumb, I knew all the medical arguments against it, and I worked really hard using conventional tools for many years, but fruitlessly.

    It is now 4 years. I am still a smoker. I just happened to forget to smoke today.

    Reply
  6. Pieter B

    I was diagnosed with ADD at the age of 48. I smoked off and on most of my life, but like the Gaffer I’ve forgotten to for a couple of years. Nicotine is a nice drug — it’s the delivery system that sucks.

    Add me to the list of Joni fans, and I’ve been kissed by her.

    Reply
  7. longsmith

    My late brother-in-law was schizophrenic and also smoked off and on for years. Truthfully, it was the least of his problems. He never seemed to be affected by quitting and was most often led back to it by his environment because, as you point out, a lot of the mentally ill smoke. Until there are effective treatments, I say, let them smoke if it gives them pleasure. From what I saw the mentally ill get very little of that in life.

    I quit this year at age 50. Thank goodness for gum!

    Reply
  8. divalent

    The vast majority of the morbidity and mortality linked to tobacco is specifically tied to smoking. Nicotine, although a powerfully addicting drug, is relatively harmless; it is not a potent carcinogen. It is the inhalation of carcinogens created in the process of burning tobacco that are responsible most of the health effects of tobacco use.

    A sensible (but for some a politically incorrect) solution is to encourage smokers to switch to alternative nicotine delivery methods such as nicotine patches and gum, or even “smokeless” tobacco products. Particularly for those with MI, where the CNS effects of nicotine are likely a non-trivial (but difficult to assess) component of the pharmacological manipulation of their mental state, a solution that targets the harmful physical health effects of smoking without collaterally interfering with their mental state would seem like a good compromise.

    Physicians would be free to treat both problems (the physical harm due to smoking and MI) without concern that treatment for one would interfere with their ability to diagnose and treat the other.

    Reply
  9. PalMD

    even “smokeless” tobacco products

    Oh, really bad idea.

    Reply
  10. The Perky Skeptic

    Ewwwww @ the photo!

    I am very grateful for my draw in the genetic lottery. I have never ever been tempted to smoke, and the one time I tried to abuse alcohol (the night after a bad breakup) I failed epically at it (gave up after 2-and-a-half glasses of wine). I am hypomanic bipolar– didn’t get diagnosed until I was thirty-five, for goodness sake– and quite Aspergery, though it doesn’t show much. The former has been well-controlled by medication since diagnosis.

    My neurological wiring could so easily have brought about serious drug or alcohol problems, and I’m just extremely grateful that it hasn’t. It’s humbling to contemplate just how much chance there is in the paths our lives take, when one considers the genetics involved.

    DuWayne, and all others who have smoking issues, you have my heartfelt empathy.

    Reply
  11. DuWayne

    divalent –

    The problem with smokeless tobacco, beyond the extreme that Pal posted, is that it is very carcinogenic.

    The problem with other nicotine supplements is more multi-facited.

    First, smoking anything gets the drug into your system very rapidly and in relatively high concentrations. It is immediate relief. And if you’re smoking something like pot or meth, it get’s you higher faster. Even though the “high” from tobacco is almost non-existent, the principle is the same. Nicotine supplements just don’t provide the same immediate gratification.

    Secondly, there is more to most people’s smoking than just a nicotine addiction. I am probably a little more extreme than a lot of people, but for me the nicotine addiction is the least of my problems. I also have a multi-faceted psychological dependence (DrugMonkey would probably like me to point out that the psychological is also physiological and I think that’s important to, so there you have it).

    When I was wandering the world, I had very little continuity in my life. I didn’t own one thing that I originally left with, when I stopped traveling. As often as not, folks would give me clothes in exchange for the filthy ones I was wearing and had in my pack (if I had more than I was wearing). I went through myriad bedrolls and even packs. The only consistency I had, was coffee, cigarettes and that I almost always had a copy of Huxley’s Brave New World. Now I am on again/off again with the coffee (ulcers) and don’t even currently own a copy of Brave New World. But I still have the thread of cigarettes in my life.

    The other problem, is that I really love smoking. I roll my own (have almost since I started) and for me, it’s like a hobby. I enjoy rare and special tobaccos, the way that wine lovers enjoy a fine wine. When my finances have been better, I would buy particular tobaccos to go with this coffee or that small batch bourbon, some special beers are well accented by the right type of cigarette. When I could really get some good tobaccos, I actually got to the point where I was only smoking a few a day – but even that only worked for so long. Ultimately, I cannot smoke just a few a day. It may work for a week, even a few months, but inevitably I am back to heavy smoking (not as bad as many, especially given that my tobaccos are always additive free, but even ten to fifteen is bad).

    Perky Skeptic –

    I would guess the aspergery bits help a lot with the not so addictive qualities. I have a great many friends who are aspies or autistic and most of them are pretty addiction averse. Although a really good friend is just the opposite – she is an extreme marijuana compulsive and if it’s put in front of her, she can’t say no to cocaine either, though she avoids seeking that out. But with hypomanic bipolar, you are rather lucky, because that can get ugly. Makes me wonder at the interplay of the bipolar and aspergers.

    I wonder at chance too, though from the opposite direction. Nothing that I deal with is really environmental. But my paternal genetics came from someone other than my dad and after meeting the donor and many of his children, I realized where a lot of who I am did come from. Not just the negatives either – both him and his youngest son whom I became friendly with, tend to write music in a very similar pattern to my own composition. And not a one of his kids has avoided some form of substance abuse – mostly the worse sorts.

    At the same time, had I never gotten in with the folks who got me smoking, who knows what would have happened. I doubt it would have made much of a difference though. I had a very skewed perspective on consequences that made a lot of my experimenting a virtual certainty.

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  12. divalent

    Pretty poor response, pal. One anecdote does not address the fact that there is a *huge* difference in the relative health risks between smoking and non-smoking nicotine-delivery methods (including smokeless tobacco), but if you want to go toe-to-toe with the gross pictures, for each smokeless-tobacco linked oral cancer I can match you one in a smoker, and can also add 20 or so lung cancers and 3-4 neck/throat cancers. It’s not my point that smokeless tobacco and other smokeless nicotine sources are riskless, only that it is a much (MUCH) lower risk. If you don’t recognize that, then you risk failing to effectively treat those patients who subbornly cling to their nicotine habits despite your efforts break it.

    Duwayne: smokeless tobacco is not “very carcinogenic” when compared with smoking, although if you search the popular literature that fact is often obscured. There are huge epidemiological studies on the issue (many of them in Sweden, where smokeless tobacco use is much more common than in the US, and the type of tobacco product they use is very similar to type used in the US), and the plain fact is that, relatived to smoking tobacco, it is not very carcinogenic.

    No one would recommend taking up any nicotine habit, and the safest alternative is to quit all forms of it, but the plain fact is that if a person smokes to get their nicotine, the vast majority of their nicotine-linked health risk will be eliminated by switching to an alternative delivery method.

    It’s not nicotine that is the major risk, it’s smoking tobacco.

    Reply
  13. DuWayne

    divalent –

    It’s not that smokeless tobacco isn’t better for one than smoking, it’s that it’s not a whole lot better and if the nicotine is the goal, non-tobacco sources are the best. Nicotine gum provides the exact same nicotine benefit that smokeless tobacco, without the added danger that any tobacco poses. And there is no benefit to using smokeless tobacco instead of the gum, excepting that the tobacco might taste a bit better. There isn’t anything else that smokeless tobacco provides, that can’t be provided with the gum.

    And ultimately, the best delivery method for the smoker trying to quit, is the inhaler, because of the similarity of delivery methods. Too (though this is based on the anecdotal experience of others – I’ve never had the opportunity to use the inhaler) it apparently provides a quicker relief than other delivery methods, including smokeless tobacco.

    My point is, that smokeless tobacco is about the worse thing that anyone can use to quit smoking. It just doesn’t put anyone in much better a position they are in smoking. There are much better ways to get the exact same thing that smokeless tobacco provides, with much less risk. Nicotine alone is really bad for humans, but it is a minor portion of all the other poisons in tobacco.

    And none of this addresses the other problems that I detailed, none of which are trivial. Smoking gets the drug into my system far more efficiently and rapidly than any other delivery method. And there is far more to smoking and smoke cessation than dealing with nicotine withdrawal. And believe me, I am far from alone in having other problems than the nicotine withdrawal. If that was all it took for most people, most people who want to quit wouldn’t have much of a problem quitting. But the fact of the matter is, there are a whole lot of smokers who have medicine cabinets rife with patches, gum and inhalers.

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  14. Danimal

    There are very good reasons people with MI might smoke. Have you ever tried a cigarette? Makes you a little dizzy. Regular smokers can not tell anymore. Helps concentrate, boy did they work in college. Helps calm.

    My personal doctor knew he could not get me to quit smoking, but thought that losing weight was more important. He wanted me to one or the other. I choose losing weight. I can quit anytime, I have done so three times. Twice for a year and once for three years. I started again after I could not deal with the weight gain. Without exception, I have never known anyone who quit smoking that did not become obese. In my family where everyone smokes, those that managed to quit became obese, got diabetes, and died from the complication caused by diabetes. My family members who did not quit lived to normal life expectancy (Mid to high 70s). My point is do not smoke, but if you start stopping can kill you.

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  15. divalent

    DuWayne: “It’s not that smokeless tobacco isn’t better for one than smoking, it’s that it’s not a whole lot better”

    DuWanye, you are wrong. Smoking is far far far far worse than any other nicotine delivery system, including smokeless tobacco. That is just a FACT! It’s supported by countless epidemiological studies, as well as numerous in vitro and in vivo tox studies on the numerous carcinogins that chemical studies show are produced in significant amounts when tobacco is burned. You can deny the evidence that exists, but that doesn’t make it go away. You are repeating the propaganda of the rabid anti-tobacco groups whose (justifiable) hatred of the tobacco companies and their products has blinded them to reality that all tobacco products are not equally harmful.

    This misconception that they perpetuate prevents some hard core nicotine addicts from at least getting away from the part of their habit that is the most lethal. Danimal may be one, and probably you, too.

    Smoking is associated with habitual rituals that are reinforced by Pavlovian conditioning to delivery of nicotine, and the absence of these features of the gum or inhaler make then initially seem less satisfying. Stick at it for a while and you will find that those elements of your craving will likely subside (and will be replaced with gum or inhaler-associated rituals).

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  16. DuWayne

    divalent –

    Lets see, how many users have gotten cancer from using the patch? Inhalers? How about that gum?

    How many users get cancer from smokeless tobacco?

    Now do you see my point? In relative terms, smokeless tobacco ranks much closer to cigarettes, than it does non-tobacco delivery methods for nicotine. And for no advantage over the latter.

    To put it in simple terms, why are you trying to convince anyone to use a product that is dangerous, when alternatives that are pretty much safe and provide the exact same benefit are available?

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  17. divalent

    DuWayne said: “why are you trying to convince anyone to use a product that is dangerous,”

    Here’s what I said: “A sensible (but for some a politically incorrect) solution is to encourage smokers to switch to alternative nicotine delivery methods such as nicotine patches and gum, or even “smokeless” tobacco products.”

    Anyone who is not now addicted to nicotine (in any form) would be stupid to start. But any *smoker* who is unable or unwilling to give up their nicotine would be far (FAR) better off switching to *any* non-smoking delivery method. The health risks of long term use of the gum, patch, inhaler, etc are not known. But on a relative scale, if smoking is a 100 on the health risk scale, smokeless *tobacco* products available in the US are under a 5 (and I would expect that gum and other non-tobacco products would be lower).

    Some people (like Danimal?) continue to smoke for the “benefits” of nicotine (weight control, mood effects, etc) and their fear of the consequences if they stop. To suggest (as you continually do) that the health risks of all alternative nicotine delivery methods (even smokeless tobacco) is even close to that of smoking is 1) factually untrue and 2) denies these hard core nicotine addicts information that might allow them to make a compromise choice that would have substantial health benefits.

    From a public health standpoint, smoking is a huge and costly problem. But 95% or more of this problem is not a direct result of nicotine intake: it’s the simultaneous intake of potent carcinogens that mostly are created when the tobacco is burned.

    Taking the position that treatment of smokers in all cases *must* be all-or-nothing in terms of nicotine intake is medically and ethically irresponsible. Sometimes 95% of a loaf is all you can get, but if so, then you should take it and be grateful that you acheived so much.

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  18. DuWayne

    divelant –

    Are you even fucking reading what I am writing? I am not arguing against the use of all alternative sources fo nicotine. I am arguing against one and only one, smokeless tobacco.

    And calling it a five, if smoking is a hundred is going to require a lot more than your word to convince me. Tobacco contains a great many carcinogens before it is ever smoked. And most smokeless tobacco products utilize abrasive fiberglass to get more of them into the bloodstream faster. Oral cancer is not a negligible risk of using smokeless tobacco products.

    My point is (and please feel free to show where I am wrong) that encouraging people to use smokeless tobacco provides no benefit and many dangers, when compared to non-tobacco nicotine delivery methods.

    Please argue against what I am actually saying, rather than against what you think I am saying after reading virtually nothing I actually wrote.

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  19. DuWayne

    Indeed, divelant, did you even read the entire sentence you quoted?

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  20. divalent

    DuWayne,

    The information is out there. Here’s a review, and from that you should be able to track down the original research if you would like. (and if for some reason you think these authors are biased, your can track forward from the original research to see what others are saying)

    http://www.harmreductionjournal.com/content/3/1/37

    Reply
  21. DuWayne

    divalent –

    Actually, I love the Harm Reduction Journal.

    So having read the article, I will happily concede that ST is substantially safer than smoking – with the caveat that the level of relative danger is dependent on the type of ST used. That said, I will concede that all ST’s are substantively safer than smoking.

    I would even go as far as to say that based on the studies discussed in that paper, recommending a smoker use ST would be a reasonable direction to go.

    But the most important thing I got out of that paper, is that we need to produce non-tobacco delivery systems for nicotine that are considerably more potent. Because even considering relative risk factors, ST is (very, very likely) substantially more dangerous than non-tobacco nicotine delivery methods.

    I also tend to be very reticent about the notion expressing the safety of ST over smoking, because unfortunately most people tend to misunderstand the concept of relative risk. Given the status quo, it is entirely reasonable to clarify the relative risk of ST v smoking. But ultimately it would be considerably preferable to follow the reccommendation put forth in that paper, that the dosage of non-tobacco nicotine delivery methods be substantively increased and the price brought down.

    Too, I would personally like to see the use of inhalers to increase. Purely anecdotal, but of all the people I know of who have successfully quit smoking using non-tobacco nicotine delivery, most of them used inhalers.

    I should also clarify that the reason I have such distaste for pushing ST so much, is the fear that it will lead to more use of non-tobacco users. Especially given the advent of products such as Camel Snus, which is made for marketing to kids. (though they do seem to be pushing it on smokers too – mostly through promotions that provide a free tin with a pack or two of cigarettes)

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  22. DuWayne

    Grr – that should have read;

    More use by non-tobacco users. Which really doesn’t make sense, now that I read it.

    Basically, I have the fear that people who don’t currently use tobacco will be attracted to ST.

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  23. PalMD

    I feel this is a bit like comparing driving while drunk vs. driving while stoned.

    Reply
  24. divalent

    DuWayne, I don’t think smokeless tobacco is a very attractive habit. In fact, it is pretty gross. It is not legal to advertise it, so I don’t worry that non nicotine addicts will take it up in significant numbers. The growth in use seems to be mostly from smokers moving over to it.

    If you are interested, this paper explores the prevalence, and the ethics, of the disinformation about the risks of smokeless tobacco by government and other health associations and advocates. It is pretty damning:
    http://www.biomedcentral.com/1471-2458/5/31

    Based on the way the risks are portrayed, it is not surprising that most people think smokeless tobacco is just as evil as smoking in terms of health risks. In fact, I gather, based on his response, that PalMD is one of those who are ignorant of the facts. Which is a pity, because, unlike you or me, he has a responsibility to use the best available information when recommending treatment to his patients.

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  25. PalMD

    divalent, that’s rather disingenuous. Recommending smokeless tobacco to stop smoking is insane. They are both very dangerous, one being more dangerous than the other. There are many ways of treating tobacco addiction, but smokeless tobacco is a horrid suggestion.

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  26. divalent

    No, PalMD, it is emphatically *not* like driving drunk vs driving stoned. (A better analogy might be that its like riding your bike down the middle of the interstate while drunk vs driving your Ford Pinto while sober.)

    But if you want to *deny* the evidence, I’m sure there is nothing I can do to change your mind. Have fun watching your MI smokers succumb to lung cancer.

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  27. PalMD

    Lung cancer is not what concerns me most about tobacco. It comes well after coronary artery disease, stroke, peripheral artery disease,and COPD.

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  28. DuWayne

    Pal –

    You’re actually dealing with someone who has done a fair amount of driving while stoned (a great many years ago, to be sure – I wouldn’t even consider doing so today because I’ve matured). And to be honest, if the choice is one or the other, instead of neither – I much prefer the stoned driver to the drunk. Both are quite obviously a very bad thing, but the drunk is worse by a long shot.

    divalent –

    They aren’t allowed to advertise on tee vee, that doesn’t mean there aren’t plenty of venues in which they can reach folks. And kids are stupid. I’m 32 now, yet I remember just how stupid I was – especially in regards to tobacco. I knew people who died of smoking, before I started – yet here I am today, a victim of the stupidity of youth.

    Camel snus is like fucking candy. It comes in a candy tin and all sorts of candy flavors. And it’s a no spit kind of deal, so much of the ick factor disappears. Yeah, they’re marketing it to smokers, but they are also marketing it to folks who don’t currently use tobacco.

    Don’t get me wrong, I am a huge fan of harm reduction. And this definitely qualifies. But there are always trade-offs and I believe the superior solution, both from a healthcare standpoint and a harm reduction standpoint, is to market cheaper, stronger non-tobacco nicotine delivery.

    I would also note that my biggest concern with smoking (because the first person I knew who died from smoking went that way) is emphysema. Beyond that, I am most concerned with stroke and heart disease (I have poor circulation, though coffee contributes).

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  29. divalent

    PalMD: “Lung cancer is not what concerns me most about tobacco. It comes well after coronary artery disease, stroke, peripheral artery disease,and COPD.”

    You can continue to be willfully ignorant of the data, but that doesn’t change it. With respect to the cardiovascular risk of smokeless tobacco, the data is quite equivocal. Most studies say no significant risk, but even if you cherry pick the worse-case estimate, it is about 1/2 or less the risk for smoking. For the sake of further consideration, take that as the risk if you want. Add that to an equal risk for oral cancer, and no risk for lung or other cancers tied to smoking, no risk for emphysema, etc. You’d be hard pressed to get close to an overall 50% of the risk of smoking.

    So I am baffled by your summary dismissal of alternative nicotine delivery methods for your MI patients. I don’t know this patient group well, but from your original post on the subject you paint a picture of a group that appears to be *particularly resistant* to interventions designed to stop their nicotine addiction. They are substantially more likely to smoke, and much more likely to be heavy consumers. You characterize the success of cessation-interventions as “poor”, and it is not difficult to see why. You concede that they are more likely to be sensitive to, aware of, and desirous of, the CNS effects of nicotine. The nicotine effects are likely an important background factor that has been accounted for in the tailoring of other medications they are on, and so cessation of nicotine is likely to cause a disruption to that part of their treatment. And they are more likely to live lives dominated by crisis and the stresses that confound smoking-cessation efforts even in the “normal” population.

    What other patient population and illness would you refused to give a treatment that would alleviate [insert your level of lower risk; I’d say *at least* 90%; but use 60% if you want] of the harm, while you continue to attempt to cure by repeated application of an ineffective one? Would you refused to give less-than-perfect anti-arrhythmia drugs to help a patient because you feel the perfect cure would be ablation surgery? And would you still refuse to treat with those less-than-perfect drugs when the surgery fails, with the intention of sending them back to surgery for as many times as it take for the surgery to work? And still refuse to treat with the drugs after the patient tells you he won’t do any more surgery?

    Reply
  30. Comrade PhysioProf

    Excellent post, PAL. One thing that I think we have to consider is the possibility that for severely mentally ill people, a shorter life that ends in stroke or heart attack but with the undeniable comfort of tobacco may be preferable to them than a longer healthier life without.

    Reply
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  32. Iro Cyr

    Revealing the Swine Flu Conspiracy

    For immediate publication (for the love of God, help us get the word out)

    Here is the latest thing from the Antis. Distort statistics of people dying from a made-up disease, get everyone in a panic so we’re all walking around with our faces covered. And for what? The answer should be obvious: to make it harder for us to smoke.

    Unfortunately, protecting people is not what face masks are for – it’s actually about harassing us for unhealthy lifestyle choices. A little common sense and research on the issue would convince even the most skeptical individual of the fallacies behind the swine flu propaganda. Swine flu warnings are not in place to protect people from the fictional harms of swine flu, but to coerce smokers to comply to the government’s view of an ideal citizen through immoral, fear-inducing propaganda.

    Wake up people, and smell the odor of dangerous precedents being set in your own so-called democratic country.

    Reply
  33. Carol

    Just found this post. It’s very timely for me, as my husband, who is bipolar, also smokes. Prior to the bipolar issues, I knew he was a smoker, and married him anyway. What I didn’t foresee was all the financial problems his then-latent (but not latent any longer) bipolar would bring, and the fact that, once he was no longer able to work, I had to pay the cigarette bill (as well as the pop bill) on top of the other bills, and it has just been KILLING me financially to keep our heads above water and still shell out all of this money for what seems to me to be a “useless” expenditure.

    I NEED him to quit. He’s tried a couple of times “for me”, but we all know that won’t really help. Not sure how to solve the problem, but I did find your post enlightening. It’s possible that it is as hopeless for me to want him to quit smoking as it is for me to want him to quit being bipolar. Hmmm.

    Reply

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