Chapter 5

"THERE MUST BE MORE TO SMOKING than nicotine," Joe insisted, shortly into their next session. "I've been watching how I smoke, and I don't always light up in a fit of nicotine withdrawal. There's the casual cigarette, the relaxing one, the cigarette lit to concentrate on a difficult task, the cigarette to cool down a frustration....

"That's right," Robert said. "Nicotine withdrawal symptoms only last for two or three weeks at the most. Yet many ex-smokers still experience occasional cravings for a cigarette, years after quitting. What do you make of it?"

"There must be psychological cravings which outlast the physical ones," Joe said. "I guess that means nicotine patches and gum don't work in the long run, then."

Joe knew a great deal about nicotine in tobacco smoke, but was evidently less familiar with nicotine replacement. Robert set him straight.

"Nicotine replacement definitely works when used properly. Of 100 people who stop smoking cold turkey, about 85 will be smoking regularly again within one year. But studies have shown that when the patch or gum is used, the success rate is almost doubled."

Joe thought for a few moments.

"But that still leaves 70 out of 100 quitters smoking again after one year, doesn't it?"

"You're absolutely right. Of course that also means that 30 people stay quit, instead of just 15. Nicotine replacement doesn't guarantee success, but it sure helps."

"So the patch or nicotine gum is the secret to quitting successfully?" Joe asked. "If there was an easy, sure-fire way, even I might consider it."

Robert laughed, gratified that his client was at least now joking about himself.

"Joe, you know there's no simple way out," he said "Nicotine replacement is just part of the picture. Those who've tried and found quitting too difficult should prepare carefully before trying again. They'd be wise to find some effective ways of coping with stress. It's important for them to get support from other people and to avoid temptation."

"That's easier said than done, Robert. Some days I'd say I feel tempted to smoke every ten minutes."

"Let's see, Joe. That'd be six every hour, about sixteen waking hours... I make that 100 temptations a day. Congratulations, you must be resisting most of them."

"Gee thanks, I think," said Joe.

"Seriously. I suggest that you start keeping track of your smoking, so you can figure out what really triggers you to light up. After you quit, you'll need to avoid or change those situations for awhile. Here, take this and have a look at it later." Robert handed Joe a plastic-laminated index card.

Joe eagerly accepted the card and read it immediately anyway. Unusual behavior for somebody who really wants to keep smoking, Robert thought.

"I get it," Joe said. "Thanks. But I see one big problem with this approach."

"What's that?"

"If I'm always anxious," Joe said, "then I'll record that I'm anxious every time I smoke. It might look as though anxiety were making me smoke, even if that wasn't true." He handed the card back to Robert.

"Much better," Joe said. "I'll try that."

"Excellent," said Robert. Joe was really showing signs of interest, and change. "Now, did you give some thought to the graph I gave you last week?"

"Of course I did, Robert. Here it is," said Joe, rummaging in his briefcase and producing the diagram. "I believe it shows the difference between smoking cigarettes and using nicotine patches, gum, and a newly-developed nasal spray. The systems deliver the drug at different rates."

"Exactly," said Robert, providing another copy of the diagram with the labels shown. "The nicotine levels also vary a bit more with cigarettes and nasal spray than with either patches or gum. Why do you think that's important?"

Joe claimed he wasn't sure, so Robert produced a small tape recorder from his desk and set it on the table.

"Listen to this assignment from one of my former clients, Joe. She makes an important point about how nicotine is delivered to the body."

With that Robert punched the "start" button and they settled back to hear the tale.

The Smoker's Cup

A man traveling alone through a desert had the misfortune to meet some bandits who stole all his belongings. In exchange the leader tossed him an elegantly-crafted cup. "Drink to the end of your thirst!" he cried out, before galloping away on his camel.

The poor man was astonished to discover that the cup was always full of water, no matter how much he drank from it. As he struggled on through the stressful heat he came to cherish the magical treasure. The first draught in the cool of morning was just as exquisite as one drawn in the blistering hell of mid-day.

One night he had a vivid and terrifying dream, in which an angel warned him that the cup was the devil's trap: each drink would cost him five minutes of his life!

The poor man was filled with fear, but couldn't resist satisfying his thirst. The cup seemed to be his only means of survival and he simply couldn't bring himself to throw it away.

After several days of this anguish the angel reappeared in his dreams to offer him relief, telling him that he'd never be thirsty if he simply wore a water-patch on his arm. "But," the angel warned "you will always have to carry the cup with you."

At first the traveler found that the patch provided him all the water he needed. Then thoughts of drinking from the cup again began to trouble him. He was never actually thirsty, but he missed the smooth satisfaction of a cool drink.

"Perhaps just one sip?" he kept wondering. The obsession became a torment worse than the heat that scorched his throat with every breath.

The temptation proved to be too strong for the unfortunate fellow. In the hottest hour of a very hot day, when the sun was high in the sky, he sipped from the seductive cup once again.

The next day he had a sip to wake up with, and one at each meal. He resumed drinking regularly from the cup, about 20 times a day. "It's not so bad," he told himself. "After all, I can stop anytime I want to."

The poor fellow died at 42 of heart and lung disease The cup was a problem, but he would have lived to 65 if only he had managed to find the satisfying solution inside himself.

 

The recording ended there.

"Do you get it?" Robert asked.

"Well, that makes sense," Joe concluded. "The quicker nicotine is delivered, and the more that delivery is under the user's control, the more habit-forming the system will be."

"Right, Joe. Of course the cigarette is the most addictive way to deliver nicotine, by far, because it can provide such a large dose of the drug on demand so quickly. So..."

There was a pause in their conversation. Robert's unspoken conclusion was that since cigarettes are addictive, they should be better controlled in order to limit the damage done.

Robert was quick to reassure him.

"Smoking while using the patch can give the body a bigger jolt of nicotine than it has ever experienced, and that's not a very good idea at all," he said. "But nicotine replacement is extremely safe when used as directed. And of course you have to dispose of used patches properly, where kids or pets won't get at them."

"Okay," said Joe. "But it seems to me that nicotine replacement itself could be addictive. I certainly wouldn't want to get hooked," he added with an ironic smile.

"Don't worry about that, Joe. The bottom line is that nicotine replacement definitely helps a smoker to quit. The nasal spray and gum may be slightly habit-forming for some people, but that's nothing compared to smoking. You, my friend, might benefit from using a patch or gum someday."

"Nicotine doesn't cause the death and sickness from smoking," Robert emphasized. "The real culprits are the by-products of burning tobacco. Over 4,000 chemicals besides nicotine have been identified in cigarette smoke, at least 43 of which cause cancer. Tobacco smoke also contains potent poisons such as arsenic, cadmium, and carbon monoxide."

Joe seemed to stiffen a bit at the specifics, before Robert continued with his explanation.

"Although it can be addictive when smoked, nicotine alone isn't particularly harmful if used in moderation. It raises the heart rate and blood pressure and that might create problems for somebody with heart disease, but for healthy people it's essentially harmless when used sensibly in reasonable doses."

"Problems?" Joe asked. "You mean heart attacks?"

"No, but it's wise to check with a physician before using any kind of nicotine replacement if you have any doubts about your health. Don't forget, cigarettes usually provide far more nicotine than any form of replacement does, and a bunch of poisons and carcinogens besides."

Joe abruptly changed the topic. "How's a person supposed to use nicotine replacement, anyway?"

"It's easy, Joe. The spray would simply go up your nose. Not too often, mind you. The patch is applied daily to some clean non-hairy skin. Nicotine 'gum' may need some explanation, because it's useless to treat it like regular gum and swallow the juice."

"Really?" Joe asked. "Why is that?"

"Because of the way blood flows through the body, nicotine absorbed from the stomach goes directly to the liver where it is metabolized, or broken down. So the brain does not get very much nicotine, in that case. On the other hand most of the nicotine entering the body any other way will reach those empty receptors in the nicotine-starved brain."

"That makes sense. So a fellow just needs to chew on the gum and not swallow?"

"Not exactly. Here, take this and read it over," Robert said, handing Joe a wallet-sized instruction card.

Joe read the card carefully.

"But why shouldn't a person drink or eat anything while using the gum?" he asked. Robert explained that nicotine only crosses the skin inside the mouth when in a slightly alkaline state, and that any acidity such as a trace of orange juice can prevent the proper absorption.

"Right, I get it," Joe said. "Much the same thing applies to cigar and pipe smoke."

Now it was Robert's turn to ask for an explanation. "Tell me about that, Joe. You're the smoke expert. So it's not a good idea to smoke a cigar or pipe while using the gum?"

Joe laughed. "Of course not, Robert. That would defeat the whole purpose. Cigars and pipes cause oral cancer and other diseases. What I'm saying is that they produce an alkaline smoke and so the nicotine from them can be absorbed through the skin inside the mouth."

"Isn't that true of cigarettes, too?" Robert asked, testing the unfamiliar waters they were sailing into, blown along by the winds of change. Joe looked quizzically at Robert, hesitating somewhat before responding.

"Cigarettes used to be harsh and alkaline, too, but modern manufacturers use certain types of tobacco, curing processes, and additives to produce a neutral smoke. It goes down more easily, and the nicotine can then be absorbed from the lungs. We're making huge sales in countries where the competition doesn't have our, um, technology."

Joe frowned, and asked "Robert, what should I do?"

"That depends on your preference, Joe. Some people prefer the patch for its convenience and predictability. Others like the gum because it gets something in their mouth instead of a cigarette. Of course, one could always chew on a toothpick or something. There's been some research about using both patch and gum together, but that's not official."

"No, that's not what I meant," Joe said. Robert then very deliberately interrupted before he could say anything more. Above all, he didn't want to be put in the position of giving advice; the decisions were all Joe's. They both knew it.

"What should you do? My friend, nicotine replacement is only part of the overall solution to smoking. It's not a 'magic bullet' that miraculously ends a person's habit for them. I think one also has to change perspective a bit, and perhaps alter one's environment. Recent ex-smokers might want to try thinking something like 'that poor fool' rather than 'I wish I could have one' when they see somebody smoking."

"Right," said Joe, nodding his head and grinning slightly. "I think I get what you're saying. It isn't easy thing to change perspective, though. Old habits die hard."

"But like us, Joe, once they die, they're gone forever."

"Right again, Robert. Right again. About the old habits, that is. But I've been wondering about death. Do you believe in heaven or hell or an afterlife of some kind?"

"I'm not certain what comes next," Robert said, evading the question, "but I believe there's a bit of both heaven and hell right here and now on this planet. Everything we do or don't do contributes to the situation."

Joe stopped asking questions. He got up and wandered over to the window. Some children were playing in the freshly fallen snow, making imprints of "angels" by lying on their backs and sweeping their arms up and down. He muttered something that could have been "Lord help us all."

"I've really got to go now," Joe said, returning from his reverie. "I have things to do."

After arranging to meet again in one week, Joe abruptly took his leave.