0:00:00.666,0:00:03.546
>> Hi, I'm Dr. Mike Evans and I[br]think quitting smoking is a journey.

0:00:04.106,0:00:06.736
For some, it's a short journey[br]full of resilience.

0:00:06.736,0:00:11.116
But I think for most it's a long journey, a long[br]affair, if you will, of quitting and relapse.

0:00:11.636,0:00:14.856
A complicated relationship that can have[br]as much to do with a person's relationship

0:00:14.856,0:00:16.476
with themselves, as with the cigarettes.

0:00:17.386,0:00:21.276
What starts as a pleasant sensation, an[br]opportunity to rebel or even to belong,

0:00:21.966,0:00:24.266
is replaced by less pleasure[br]and a feeling of being trapped.

0:00:24.876,0:00:29.016
A daily or hourly ride of nicotine withdrawal[br]and then another cigarette, which brings relief.

0:00:29.806,0:00:33.356
Most teens who smoke, think they will in their[br]twenties and actually don't until their forties.

0:00:34.266,0:00:38.516
Stopping smoking is about making a change[br]and that is something we're not too good at.

0:00:38.516,0:00:40.506
When I think of change, I think of two concepts.

0:00:40.626,0:00:43.706
Where you are at and the[br]mechanics of how we change.

0:00:44.296,0:00:46.106
So, we should start where you are at.

0:00:46.306,0:00:49.656
When I started medical school, I thought I[br]could take somebody who smoked and convert them

0:00:49.656,0:00:51.386
into a non-smoker in one fell swoop.

0:00:51.836,0:00:52.886
Now I see it differently.

0:00:53.096,0:00:55.226
I focus on where the person is at.

0:00:55.346,0:00:57.246
You may be in what we call pre-contemplation,

0:00:57.846,0:01:00.366
where you're not really even[br]thinking about change.

0:01:00.876,0:01:03.166
Approximately 75% of smokers want to quit.

0:01:03.586,0:01:05.346
But 25% are not interested.

0:01:06.126,0:01:09.336
Maybe you're at the contemplation stage,[br]thinking about it, but not quite ready to act.

0:01:10.096,0:01:11.216
Next is preparation.

0:01:11.686,0:01:16.006
This is critical with smoking, especially in the[br]likely event that you've tried to quit before.

0:01:16.146,0:01:17.866
What has worked in the past and what hasn't?

0:01:17.976,0:01:19.116
What caused the relapse?

0:01:19.746,0:01:21.146
Maybe you're at the action stage.

0:01:21.686,0:01:23.416
This is when you're ready to make your move.

0:01:24.346,0:01:25.626
There's never a perfect time to quit.

0:01:25.626,0:01:27.086
And at one point you just have to jump.

0:01:27.316,0:01:29.906
I'll tell my patients, "Hey,[br]it's going to be a challenge now

0:01:29.906,0:01:31.336
and it's going to be a challenge in five years.

0:01:31.336,0:01:32.326
So, why not do it now?"

0:01:32.566,0:01:34.736
And then finally, there's the maintenance stage,

0:01:34.736,0:01:37.176
where you become a non-smoker[br]and are trying to stay that way.

0:01:38.526,0:01:41.016
[cheers]. When we make changes[br]it's critical to stop and think,

0:01:41.126,0:01:42.716
how important is this change to me?

0:01:42.716,0:01:45.216
And how confident am I in making this change?

0:01:45.596,0:01:47.186
What we call your self-efficacy.

0:01:47.606,0:01:48.716
Your job is to be honest.

0:01:48.716,0:01:51.236
My job is to see if I can[br]move your score towards ten.

0:01:53.876,0:01:56.466
The second concept is about[br]the different parts of change.

0:01:56.466,0:01:58.076
So, there's the what.

0:01:58.576,0:01:59.306
What are we changing?

0:01:59.506,0:02:01.846
With smoking, I suppose it is[br]straight forward, stopping.

0:02:02.586,0:02:04.866
But if you think about it, you[br]might be changing lots of things.

0:02:04.866,0:02:06.896
And I think it is like a relationship breakup.

0:02:06.896,0:02:09.196
You start by just keeping[br]things simple and low risk.

0:02:09.196,0:02:11.086
You might breakup your routine a little bit.

0:02:11.396,0:02:12.766
Avoid certain places.

0:02:13.276,0:02:15.616
Maybe use that juicer every[br]morning to distract yourself.

0:02:15.866,0:02:19.156
But you will need to change more than[br]your smoking, to stop your smoking.

0:02:21.306,0:02:22.336
The next is the why.

0:02:22.766,0:02:23.426
Why change?

0:02:23.936,0:02:26.376
I feel like I could do a ten-minute video just

0:02:26.376,0:02:28.816
on all the medical reasons why[br]not to smoke and they are legion.

0:02:28.816,0:02:29.826
But I'm going to spare you.

0:02:30.056,0:02:31.516
Partly because you already know.

0:02:31.706,0:02:33.246
Partly because you don't need anymore guilt.

0:02:33.246,0:02:36.776
And partly because in clinic, I actually[br]spend more time asking people what they

0:02:36.776,0:02:37.836
like about smoking.

0:02:38.096,0:02:39.636
Which sounds funny, but I think we have

0:02:39.636,0:02:42.476
to recognize there are positives[br]or at least perceived positives.

0:02:42.476,0:02:46.046
And I think it's important to reframe these[br]perceptions, if we are to make a change.

0:02:46.046,0:02:47.966
So, let's run through a few of the common ones.

0:02:48.746,0:02:49.946
Cigarettes are my friend.

0:02:50.156,0:02:51.086
They destress me.

0:02:51.306,0:02:52.116
They relax me.

0:02:52.116,0:02:55.576
Hmm, I'm not going to deny that[br]you may feel a sense of relief

0:02:55.576,0:02:57.316
and satisfaction, when you have a cigarette.

0:02:57.736,0:02:58.896
But I see it a bit differently.

0:02:59.086,0:03:00.326
You have a nicotine addiction.

0:03:00.716,0:03:02.776
The nicotine in tobacco is highly addictive.

0:03:02.936,0:03:06.946
Within a few seconds of inhaling, it travels to[br]your brain causing you to have a temporary high.

0:03:07.756,0:03:12.786
Over time, your brain changes, causing[br]you to smoke more to get the same effect.

0:03:12.816,0:03:15.486
We rate your addiction to nicotine[br]with a few simple questions.

0:03:15.516,0:03:17.436
Do you smoke more than 15 cigarettes a day?

0:03:17.576,0:03:20.166
Or smoke within 30 minutes[br]of getting up in the morning?

0:03:20.296,0:03:23.576
Do you find it difficult to go more[br]than four hours without a smoke?

0:03:24.346,0:03:28.226
The power of nicotine comes from the repeated[br]small doses you give yourself when you smoke.

0:03:28.896,0:03:33.576
It may seem innocent at first, but if you[br]take 15 puffs from a cigarette and smoke, say,

0:03:33.576,0:03:36.376
20 cigarettes a day, that's[br]300 drug doses a day.

0:03:37.126,0:03:39.436
You think smoking relieves[br]your stress or is satisfying.

0:03:39.436,0:03:40.376
But it actually isn't.

0:03:40.376,0:03:43.056
The cigarette is just making[br]your nicotine addiction go away.

0:03:43.666,0:03:45.616
Smoking doesn't make your concentration better.

0:03:46.106,0:03:48.576
It just calms your nicotine[br]receptors cry for more.

0:03:49.616,0:03:51.356
Smoking makes your heart beat faster.

0:03:51.456,0:03:53.636
Increases blood pressure and breathing.

0:03:53.856,0:03:56.446
These are all symptoms of[br]stress, not stress reduction.

0:03:56.916,0:03:57.766
Let me repeat that.

0:03:58.416,0:04:00.946
The cigarette just reduces your[br]nicotine stress, not your real stress.

0:04:05.926,0:04:07.396
I've got a lot of trigger times.

0:04:07.936,0:04:10.886
Coffee, sex, meals, certain people.

0:04:11.006,0:04:13.476
Break times, telephone calls, the car.

0:04:13.726,0:04:16.086
There are a lot of triggers you're[br]going to have to prepare for.

0:04:17.016,0:04:18.875
You got to change your coffee routine.

0:04:18.875,0:04:21.005
Plan something to do right after meals.

0:04:21.076,0:04:22.446
Throw out your car ashtray.

0:04:23.106,0:04:25.976
I have no advice on sex,[br]but make a plan for breaks

0:04:26.026,0:04:28.136
or the telephone, with lots of distractions.

0:04:29.336,0:04:32.586
Know that when you have a hunger or[br]caffeine or other types of pangs,

0:04:32.586,0:04:35.146
you also have a nicotine pang[br]that needs to be satisfied.

0:04:35.506,0:04:37.776
You have associated these,[br]but they're actually separate.

0:04:38.526,0:04:42.506
Alcohol and parties double the[br]risk, as you have the association.

0:04:42.506,0:04:45.086
Plus, you're imbibing something[br]that intends to lower your resolve.

0:04:46.756,0:04:47.996
I want something in my hand.

0:04:49.146,0:04:52.126
Yes, you are making maybe[br]300 hand motions a day.

0:04:52.586,0:04:57.006
You may need to replace this by chewing gum[br]or chewing on a straw or a cinnamon stick.

0:04:57.006,0:05:01.116
Or playing on your cellphone, to keep your[br]hands busy, to replace this daily habit.

0:05:02.596,0:05:03.376
I will gain weight.

0:05:04.946,0:05:05.616
Yes, you might.

0:05:05.686,0:05:08.106
But I think this is actually[br]more marketing than reality.

0:05:08.106,0:05:09.876
What I call the Virginia Slims effect.

0:05:10.496,0:05:14.156
On average, people who quit, gain[br]about 2.5 kilograms or five pounds.

0:05:14.696,0:05:15.866
So, two thoughts on this.

0:05:16.266,0:05:19.616
Firstly, if this is a concern for you,[br]you might want to focus on strategies

0:05:19.616,0:05:21.416
that affect calories in and calories out.

0:05:21.416,0:05:24.006
Such as your new daily routines[br]might focus on walking.

0:05:24.486,0:05:27.126
A special emphasis on being[br]mindful of emotional eating.

0:05:27.666,0:05:30.546
Or that your hand mouth routine[br]includes carrots or celery sticks.

0:05:31.096,0:05:32.676
My second point is about perspective.

0:05:32.836,0:05:35.906
A possible five pounds may be[br]important from a vanity perspective.

0:05:36.336,0:05:37.866
But from my doctor perspective,

0:05:38.076,0:05:41.186
the health return is spectacularly[br]higher, when you stop smoking.

0:05:41.986,0:05:43.946
Remember, we said smoking was a relationship.

0:05:44.146,0:05:46.646
Part of the healing of stopping[br]a damaging relationship,

0:05:46.646,0:05:48.216
is start a new healthy relationship.

0:05:48.766,0:05:52.706
So, now it's the time to start a deeper[br]relationship with your bicycle or salads

0:05:52.706,0:05:55.586
or walking or gardening or[br]your support of friends.

0:05:56.956,0:05:58.026
Next is the how.

0:05:58.276,0:06:00.206
What do the skills require to change?

0:06:00.206,0:06:02.286
How do I change, with the emphasis on I?

0:06:03.306,0:06:04.086
So, what works?

0:06:04.086,0:06:05.596
Well, let's start with willpower.

0:06:05.906,0:06:06.896
It's a strange word.

0:06:06.896,0:06:11.016
On the one hand, it permeates behavior change[br]and all of the interventions we talked about.

0:06:11.516,0:06:14.026
It's also a word I don't love, as[br]people see it as black and white.

0:06:14.026,0:06:17.506
If a person succeeds, they have willpower[br]and if they fail, they have no willpower.

0:06:18.076,0:06:20.566
The science of willpower and[br]smoking gives a mixed message.

0:06:20.566,0:06:23.486
Approximately 5% of smokers[br]who try to quit cold turkey,

0:06:23.486,0:06:26.026
achieve prolonged abstinence[br]for six to 12 months.

0:06:26.696,0:06:29.486
With most relapsing in the first[br]eight days of attempting to quit.

0:06:29.486,0:06:32.706
And the other hand, most people[br]who quit, do so unassisted.

0:06:32.736,0:06:35.946
Maybe 2/3 to 3/4 of people do so by themselves.

0:06:36.786,0:06:41.276
Reconciling these two stats reveal the natural[br]history of smoking cessation, that quote,

0:06:41.526,0:06:43.986
"failures" are part of this process.

0:06:43.986,0:06:46.916
And can be seen as dress[br]rehearsals for the eventual success.

0:06:48.686,0:06:51.536
Another key pearl here is the data[br]which tells us that a perception

0:06:51.536,0:06:54.706
of the quitting smoking experience[br]is often much darker than reality.

0:06:55.666,0:06:58.696
In a British study of people who were[br]surveyed about their quit experience,

0:06:59.046,0:07:02.386
53% said that it was not[br]at all difficult to stop.

0:07:02.996,0:07:05.286
Twenty seven percent said[br]it was fairly difficult.

0:07:05.286,0:07:07.316
And the remainder found it very difficult.

0:07:07.606,0:07:10.236
So, to summarize, you can do it by yourself.

0:07:10.236,0:07:12.016
And it may be less difficult than you think.

0:07:12.356,0:07:16.316
On the other hand, it looks like your chances[br]are better if you layer on some other tactics.

0:07:16.316,0:07:17.556
So, if you fail, try again.

0:07:17.556,0:07:19.226
And think about adding another strategy.

0:07:20.476,0:07:22.276
Some say there are two types of cigarettes.

0:07:22.276,0:07:24.746
Those that are dealing with your[br]nicotine addiction and those

0:07:24.746,0:07:26.076
that have become part of a routine.

0:07:26.736,0:07:28.996
So, let's see what works for[br]both these types of cigarettes.

0:07:30.756,0:07:33.226
Let's start with treatments that[br]have not been proven affective.

0:07:33.676,0:07:35.276
And where you may be wasting your money.

0:07:35.466,0:07:37.736
Now, some of my patients have found they help.

0:07:37.736,0:07:41.206
And to be honest, if they stop your[br]smoking, I suppose I don't really care.

0:07:41.646,0:07:45.156
But under this category I put laser[br]therapy, acupuncture and hypnosis.

0:07:45.616,0:07:49.276
When we compare these treatments to a placebo[br]or just compare them to the quit rates

0:07:49.276,0:07:51.536
on waiting lists, the rates[br]don't appear to be improved.

0:07:52.266,0:07:54.396
Next is medications to help stop smoking.

0:07:55.156,0:07:58.666
The data shows that medications, especially[br]when combined with behavioral support,

0:07:58.666,0:08:00.306
can double your chance of success.

0:08:01.206,0:08:03.246
Many patients are resistant, which I get.

0:08:03.666,0:08:05.776
But I also see an irony in the[br]fact that people are willing

0:08:05.776,0:08:07.876
to inhale chemicals much, much worse for them.

0:08:08.276,0:08:10.706
But they won't take a medication[br]for a few weeks or months

0:08:10.706,0:08:12.446
to stop smoking for the rest of their life.

0:08:13.406,0:08:16.796
If we use nicotine replacement therapy[br]as an example, it allows people to deal

0:08:16.846,0:08:18.506
with the addiction of nicotine, without having

0:08:18.506,0:08:22.366
to inhale the other 7,537[br]chemicals in cigarettes.

0:08:22.906,0:08:24.106
And that's what I worry about.

0:08:24.266,0:08:29.566
People die, two full 747's of people a[br]week in Canada, from smoking, not nicotine.

0:08:30.906,0:08:33.126
Nicotine replacement therapy[br]comes in multiple forms.

0:08:33.126,0:08:35.645
And there is usually less nicotine[br]then what you get in a cigarette.

0:08:36.296,0:08:38.306
You can put on a patch, which[br]is easy and discreet.

0:08:38.306,0:08:41.126
You can chew gum, although in a[br]different way than you usually chew gum.

0:08:41.666,0:08:43.866
You can suck on a lozenge[br]or you can use an inhaler.

0:08:44.285,0:08:47.396
The patch gives you a nice baseline[br]nicotine level to lower your cravings.

0:08:47.676,0:08:50.146
The latter three, offer the[br]advantage of flexible dosing,

0:08:50.146,0:08:51.426
when you have a nicotine craving.

0:08:51.826,0:08:55.036
And a familiar routine of opening packages[br]and putting something in your mouth.

0:08:55.546,0:08:59.736
The important thing people need to know about[br]nicotine replacement therapy are, firstly,

0:08:59.736,0:09:01.436
you can design your own nicotine program.

0:09:01.786,0:09:03.016
You do not need a prescription.

0:09:03.476,0:09:07.166
Prefer the patch and then the gum or lozenge[br]or inhaler for breakthrough cravings?

0:09:07.166,0:09:09.706
Great. Maybe you smoke under[br]ten cigarettes a day

0:09:09.706,0:09:11.256
and just want to use the gum when you need it.

0:09:11.846,0:09:13.606
Your pharmacist can really help here.

0:09:14.286,0:09:16.036
People get a bit confused with the cost.

0:09:16.036,0:09:19.686
NRT is generally cheaper than smoking,[br]but you might be buying a month at once.

0:09:20.526,0:09:22.226
Moneywise, of course, it's a no brainer.

0:09:22.226,0:09:24.706
A pack a day is maybe $3,600 a year.

0:09:25.366,0:09:26.886
imagine what you would do with that money.

0:09:26.886,0:09:29.526
Imagine what you would do with[br]ten years of that savings.

0:09:30.396,0:09:34.056
Secondly, with nicotine replacement,[br]you can stop cold turkey

0:09:34.056,0:09:35.766
or you can wean down your smoking.

0:09:36.326,0:09:37.876
Taking nicotine and smoking together,

0:09:37.876,0:09:40.736
does not increase your risk of[br]heart attacks, smoking does.

0:09:40.736,0:09:43.216
You probably started smoking gradually.

0:09:43.216,0:09:45.176
And I guess the same can be true of stopping.

0:09:45.616,0:09:48.126
If you feel you need another[br]month of NRT, then that's fine.

0:09:48.126,0:09:51.376
I'm not going to go into details[br]of pills for smoking cessation.

0:09:51.376,0:09:53.906
But I will give you a quick[br]overview of the two most known ones.

0:09:54.296,0:09:56.126
The first is Zyban or bupropion.

0:09:56.796,0:09:58.436
This started just as an antidepressant.

0:09:58.436,0:10:01.896
And then users found their desire for smoking[br]dropped and they were able to quit more easily.

0:10:02.486,0:10:06.046
Champix or Chantix, in the U.S., is varenicline.

0:10:06.046,0:10:10.296
It is a newer option that may be even more[br]effective, but also has some side effects

0:10:10.296,0:10:11.866
that may make it not for everyone.

0:10:12.566,0:10:15.386
You can discuss these options with your[br]doctor or other healthcare providers.

0:10:15.386,0:10:17.076
The counseling needs to be individualized.

0:10:17.926,0:10:20.066
The final approach is the[br]behavioral interventions.

0:10:20.066,0:10:24.856
I covered some of this ground, but I don't think[br]people realize how many fantastic resources are

0:10:24.856,0:10:25.536
out there for them.

0:10:26.186,0:10:28.566
Governments make a lot of[br]money from people who smoke.

0:10:28.566,0:10:30.356
And they fell into superb programs.

0:10:30.596,0:10:32.616
You want a text message, a supportive e-mail?

0:10:32.956,0:10:35.486
You want expert counseling, want to[br]be connected with other people going

0:10:35.486,0:10:37.756
through the same thing or[br]who have just been there?

0:10:38.496,0:10:39.916
Or maybe you just want to talk to someone?

0:10:40.266,0:10:40.926
Go online.

0:10:41.086,0:10:41.936
Call the help line.

0:10:42.036,0:10:42.606
Buy the book.

0:10:42.646,0:10:43.456
Get the message.

0:10:44.016,0:10:46.676
In the first months following[br]quitting, I want you to prepare

0:10:46.676,0:10:48.546
for the roadblocks of risk and stress.

0:10:49.206,0:10:51.056
So, avoid high-risk situations.

0:10:51.206,0:10:51.956
You know what they are.

0:10:52.276,0:10:54.596
You might want to tell the[br]people involved in advance.

0:10:54.976,0:10:57.026
And then I want you to focus[br]on stress reduction.

0:10:57.626,0:11:00.456
Stressful things are going to happen[br]to you, but you create the stress.

0:11:01.076,0:11:03.546
Tell people, "Hey, I'm quitting[br]smoking this month."

0:11:03.546,0:11:05.726
So, what's the least stressful[br]strategy that works.

0:11:06.106,0:11:08.416
I also get people to think about the three A's.

0:11:08.986,0:11:11.136
Avoid situations you know are stressful for you.

0:11:12.136,0:11:13.476
Alter expectations.

0:11:13.586,0:11:15.716
So, when you look at your[br]to do list, be realistic.

0:11:15.986,0:11:18.416
Manage the expectations up[br]front before it's stressful.

0:11:18.716,0:11:20.506
And the final A is acceptance.

0:11:21.386,0:11:26.316
If we use driving as an example, traffic[br]jams, bad drivers and flat tires happen.

0:11:26.316,0:11:26.946
Take a deep breath.

0:11:27.466,0:11:28.796
Focus on what you can control.

0:11:28.796,0:11:30.806
And accept what you can't.

0:11:31.216,0:11:33.886
Now, let's say you quit smoking,[br]that's excellent.

0:11:34.256,0:11:34.886
You've broken up.

0:11:34.886,0:11:36.246
So, what now?

0:11:36.706,0:11:38.086
Well, first of all, you're great.

0:11:38.656,0:11:41.296
Secondly, there's going to[br]be some ups and downs.

0:11:41.296,0:11:43.446
More ups, especially after you[br]get through the first month.

0:11:43.516,0:11:46.716
But some of the things to expect with[br]nicotine withdrawal are cravings.

0:11:46.716,0:11:48.626
And these don't follow a perfect line.

0:11:49.336,0:11:52.246
Headaches, nervousness, irritability,[br]trouble sleeping.

0:11:52.246,0:11:53.546
And you may want to eat more.

0:11:53.546,0:11:54.916
So, have some healthy foods ready.

0:11:54.916,0:11:58.686
And then also people tend to have more[br]of a cough, as their lungs self-clean.

0:11:59.566,0:12:03.576
Finally, the Japanese have a[br]proverb that success is falling

0:12:03.576,0:12:05.496
down seven times and getting up eight times.

0:12:06.186,0:12:07.826
If you get derailed, don't feel guilty.

0:12:08.396,0:12:10.436
As I said in the beginning, this is a journey.

0:12:10.656,0:12:11.666
Come back and see us.

0:12:11.816,0:12:13.466
This is the best thing I can do for you.

0:12:13.996,0:12:15.016
Don't learn helplessness.

0:12:15.016,0:12:17.006
Learn about yourself and get[br]ready for the next round.

0:12:17.976,0:12:18.816
And thanks for listening.