It’s that hectic morning hour when everyone in the family is racing against time to get out of the house. Casey cannot get her two daughters to stop fighting, and her son is crying because Casey won’t let him have lollipops for breakfast.
As the school bus honks outside, she makes only a short run up the stairs to get her son’s backpack, but she succumbs to the seemingly relentless cough. The tightness in her chest reminds her that she has an appointment with the radiologist today.
She suddenly starts to panic - “what if I test positive for something terrible?” Her thoughts are interrupted as a glass of juice shatters on the kitchen floor. Somehow, her tension reaches a new peak. And then, suddenly, it dissipates. For some reason, looking at the scene through the haze of her cigarette smoke, she feels an incredible sense of calm and emotional resilience.
That is, before the guilt and shame of having smoked sets in.
On the third Thursday of November, declared the Great American Smokeout by the American Cancer Society, it makes sense to take a closer look at how to help smokers who persist in smoking despite all the health consequences and social stigma that they suffer.
Over the last 15 years that I’ve practiced dentistry in New York City, I have noticed that the smoking population is a heterogeneous group, just like any other cross-section of society. In fact, based on the numbers from the CDC, the population of smokers in our country is the same size as the entire population of Canada. Smoking affects people below the poverty line or with disabilities asymmetrically.
One can immerse oneself in volumes of literature addressing why and how smoking affects different strata of our society differently, but to many, smokers really seem to fall into two groups: the ones who quit “cold turkey” and the ones who struggle with quitting for many years, or just don’t quit.
Is smoking a disease?
The number of people who die each year in the United States from smoking-related illnesses is equal to the entire population of Sacramento, California. If I were to believe the statistics of the Department of Health and Human Services, an average smoker patient of mine lives about 13 to 14 years less than an average non-smoking patient of mine. The savagery of this data is mind-boggling. What is wrong with these people? Why don’t they stop smoking?
There is no question that for many people, smoking is a disease. I reached out to Dr. Mary O'Sullivan, a pulmonologist and expert in smoking cessation treatment at Mt. Sinai Hospital in Manhattan, to learn more about smoking. Not only is there a chemical component to the disease, but there are behavioral and genetic components as well.
Dr. O'Sullivan notes that research has shown that whether someone begins smoking is 50 percent determined by genetic makeup. Whether someone continues smoking is then 60 to 70 percent genetically determined.
“When I’m talking to somebody with lung cancer and they can’t figure out why they can’t quit, and I tell them that it’s their biology - it’s not that you’re a weak, lazy person with no strong moral fiber - they feel relieved,” she says.
Something else that she emphasizes is that nicotine addiction is a permanent addiction whose sufferers are always going to be vulnerable to relapse. Further complicating the plight of smokers is the social stigma that can be overwhelming to them. The stigma inhibits some from seeking out help. Dr. O'Sullivan references a study that looked at how many people who come to a cancer center for throat or bladder cancer will say that they are a smoker. The results showed that 50 percent of smokers told their doctors that they did not smoke.
The chemistry of nicotine addiction and its impact on oral health
In order to clarify this complex disease, Dr. O'Sullivan describes the chemical process: There are a variety of neurotransmitters, chemical substances that allow nerve cells to talk to each other, involved in the process of smoking. The one most referred to is dopamine.
Nicotine stimulates the release of dopamine in the pleasure circuit of the brain, producing pleasure and influencing mood. Nicotine can also activate receptors called nicotinic acetylcholine, effectuating modulation of cognition. It regulates so many components of thinking and our ability to operate. In absence of nicotine, i.e. in withdrawal, the brain responds by releasing another neurotransmitter called acetylcholine in excess, which makes the individual irritable, anxious and really agitated. This agitated state is physically unpleasant. Some people say it’s like walking on broken glass.
Just as we all have the same skin but different shades, and two people with the same sun exposure on the same beach might result in one being blistered and the other nicely tanned, the affinity of nicotine to the receptors in different people can vary significantly. This might make one person highly addicted to nicotine, while another can quit easily and not look back.
Dr. O'Sullivan noted that “since the brain has plasticity, you actually develop physical pathways that tell your brain it’s time to smoke, just like Pavlov’s dog [experiments]. Or a stressful situation gives you a craving, which leads to the release of excess acetylcholine, which puts the person in an agitated state. Few people can handle it. But now you know that if you take a puff, because of the inhaled delivery system of nicotine in tobacco, the relief is so fast that you feel better and can cope. All this makes the addiction as tough as a heroin addiction.”
And if the individual is trying to quit, then the feeling of shame and helplessness ensues.
“A lot of those people can’t even begin to think about quitting,” Dr. O'Sullivan says. “It’s just a total impossibility for them.”
Incorporating smoking cessation programs into dentistry
Refractory cases are best addressed both behaviorally and pharmacologically. The commonly used medications either replace the nicotine in tobacco or eliminate the patient's craving for it. Others help release dopamine while removing the pleasure of inhaling tobacco smoke. Coupled with therapies to teach smokers how to avoid stressful triggers and increase their repertoire of coping mechanisms, Dr. O'Sullivan feels that smoking cessation programs are making headway in this fight.
It is equally important for the patient to not feel stigmatized or shamed. Dr. O'Sullivan suggests trying to broach the subject through open-ended questions posed to the patient, such as, “what do you think would happen if you quit?”
For too long, too many people have suffered from this terrible disease. While here in New York we have had much success in driving down the rate of smoking via good policies and an effective Quitline, among other things, much work remains. Dr. O'Sullivan posited that the remaining cases of smokers are more refractory cases of the disease.
Helping these individuals requires us to train physicians, dentists and allied health professionals. Smoking cessation treatment has either been missing from or not been very prominent in the curricula of many medical and dental schools for decades past.
To move forward more successfully requires cultural changes at our medical institutions to treat smoking as the rampant epidemic disease that it actually is and not a low-grade pestilent habitual issue. Creating effective smoking cessation programs with teams of physicians, psychiatrists and psychologists, all of whom are specifically trained to treat this disease, can have far-reaching effects in both training other physicians and dentists in the community who will act as first responders, as well as in treating patients who are suffering.
Nima Dayani, DDS, MS of Advanced Endodontics of NYC PC.