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Goodbye Old Friend, I've Known You Far Too Long

Posted By Peter Fifield, Thursday, May 12, 2011
Updated: Wednesday, May 25, 2011
We are all aware of the dangers of smoking. Yet the CDC reports that in the United States over 46 million people (20.6%) over the age of eighteen and 2.7 million (17%) of all high school students are current smokers. Out of the 46 million adult smokers, the CDC reports that over 40% of them tried to quit in the past year. The implication here is that to some degree they wanted to quit, but were unable to to actually stop smoking. It is hard, very hard, to separate oneself from the addictive nature of nicotine.

First hand exposure is not the only danger. Second hand and the newly implicated third hand smoke exposure endangers a much higher number of individuals; putting even the innocent at risk for many acute and chronic health conditions. The knowledge of these hazards is not new. We have been well aware of them for years yet about 21% of our adult population continues to puff away.

There is no doubt that everything we do, we do for a reason. Therapeutically as a Behavioral Health Consultant in a primary care office I see behavior as less of an issue regarding right or wrong but more so does it or does it not work. So with the known risks of smoking there must be a pretty good reason why people continue to smoke, right? Nicotine has psychoactive properties that are very addictive; most likely related to how it effects the brain’s pleasure/reward center---the mesolimbic dopamine system.

Smokers smoke because it works! Some say it "relieves stress”, even though it is a stimulant. Some admit they smoke for "something to do” when they are "bored”, Others report that they smoke when they are "feeling down” and depressed and even when they are "feeling great”--a reward system for feeling both crappy and wonderful. People smoke when they drive, they smoke when they sit at the computer, they smoke when they are having coffee, tea or a beer with a friend. Some even smoke because "as sad as it is, smoking is really the only thing in my life I enjoy doing”.

After many years assisting patients in the smoking cessation process, I have becoming more convinced that most individuals, even though they are not consciously aware of it, relate to cigarettes as a friend—an unconditional friend that is always there when they need them. What I find most interesting is the one sided, almost masochistic nature of this obliging yet very pernicious friendship.

Tobacco use is the single largest cause of morbidity and mortality in the United States; as touted by the CDC "the only legal product that when used as directed will kill one-third of users”. Each year smoking cigarettes accounts for 1 in 5 deaths--that is about 438,000 people. Just to give you a relative benchmark, deaths related to alcohol and illicit drug-use combined total 44,000 per year. This is surely a dubious friendship but it is one that comes with minimal conditions. It is a relationship that for most has no perceived incentive to change.

Below is a letter written by a client:

We've been friends and co-dependents for a very long time, 46 years to be exact. I remember the first time we met...I was five and boy did you get me in a lot of trouble. First I climbed high to reach you and then I gave you a try. I got yelled at and spanked because your partner burned my mummy's rug.

My mom knew you first and I wanted you to be my friend too. You seemed to be liked by my mom and almost all of her friends, but I was forbidden to associate with you...until 5 years later when I was 10, I snuck you away from my mom and we bonded in the basement. We lived in the projects. It made me cool with the other kids to be your buddy. You hung around until I couldn't get rid of you...but I didn't want to because you felt good, you calmed me and you made me look cool. Little did I know you were the controlling one in our sick relationship.

It took me years to realize that we were unhealthy together but I seemedto overlook it. Even when my mother cut her ties with you; when she begged me to do the same, I refused. I tried but you were stronger than me.

Today I want to tell you that..."you're killing me" and I don't want to have anything to do with you anymore. Very soon you can rest assure that I won't let you send me to my grave. I can't take the pain I've seen you cause so many other people.

In a nut shell I want to say "watch out" because you'll soon lose out in this friendship. I can't wait for the day I say...NICOTINE-I QUIT!!!

Your soon to be ex-friend.

Peter Fifield is an integrated Behavioral Health Consultant at Families First Health and Support Center; an FQHC in Portsmouth NH. In his off time he is the Managing Editor of CFHA Blog and makes all attempts to keep up with his wife and two sons.

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Comments on this post...

Randall Reitz says...
Posted Saturday, June 25, 2011
Pete, I love your patient’s letter. It’s an intriguing technique that seems to merge the gestalt empty chair with a narrative externalization. Did the cigarettes ever respond to this missive? How is your patient doing?
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Ajantha Jayabarathan says...
Posted Friday, July 8, 2011
Pete, you have aptly presented what I have heard from many people in my practice of family medicine. A real nice way to "reframe" and motivate change while respectfully "humanising" and acknowledging the strength of the relationship with tobacco.
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