00:00:20 David B. Feldman:
Today our topic is vaping, E-cigarettes and tobacco – learning how to quit. Most of us have known someone who smokes. Smoking is of course a practice that’s been with us for a very long time. Cigarettes have even been around for centuries. And no wonder nicotine one of the main substances in tobacco is super addicting. Happily in this country at least we’ve made a lot of headway in reducing this killer habit. Nonetheless it remains a killer.
Smoking is still the leading cause of cancer related deaths in America. But these days lighting up a cigarette isn’t the only way people get nicotine. The relatively new phenomenon known as vaping or e-cigarettes poses new challenges to people’s health and new difficulties for quitting.
Today we’ll talk with an expert in tobacco related lung diseases about how smoking and vaping affect us. But even more importantly we’ll talk about how to find the personal motivation and the tools to kick the habit. Indeed joining me in studio today is Dr. Paul Brunetta. Dr. Brunetta is a physician and clinical researcher with 14 years of experience in clinical care and 18 years of experience in drug development. He’s a graduate of Johns Hopkins University in Baltimore and Tufts University School of Medicine in Boston. He first came to UC San Francisco in 1990 for his internship and medical residency. Dr. Brunetta became chief medical resident at San Francisco General Hospital and then completed a pulmonary and critical care fellowship at UCSF before joining the faculty there, focusing on lung cancer, tobacco related lung disease and smoking cessation.
He co-founded the UCSF Fontana tobacco treatment center with Suzanne Harris, who is also the co-author, of his book “Learning to Quit” how to stop smoking and live free of nicotine addiction, which will spend much of our time today talking about Dr. Paul Brunetta. Welcome to about health.
Dr. Paul Brunetta:
Thanks so much for having me here today Dave.
David B. Feldman:
It’s my pleasure and it’s such an important topic so I’m glad that we are able to talk about it. I want to say right off the bat that I really loved your book. I love a few things about it. I love how personal and real it is and most importantly how non-judgemental it reads. It shows real compassion for how hard it is to quit smoking but I do want to ask why write this book now?
Let me give you some context for the question. The impression that many people listening might have is that people don’t smoke anymore. I mean we have laws prohibiting people from smoking in schools and restaurants. In fact there’s a new law that raises the age of buying tobacco to 21. You don’t see ashtrays lying around anymore like you used to in the old days. So people may perceive it as not a problem anymore so. So I want to get your take on that. What’s your read on that.
03:20 Dr. Paul Brunetta:
So smoking really is a global health issue and there are more than a billion people smoking today even though at least in the U.S. the rates have declined over time. And there was a point in the 50s and 60s where almost half of all males were cigarette smokers. You know we’re now down to around 14 or 15 percent of adults that smoke and that’s about 34 35 million people in the U.S. but globally there are a billion smokers. And that’s why this is a massive public health issue.
I agree that we live a bit in a bubble, in part because California has been very very progressive about some of the things that you mentioned but that doesn’t mean that’s the same around the world. And if you look at different states in the U.S. Some have significantly higher smoking rates than we find in California even Nevada next door has higher smoking rates than California. So this is a huge problem and I would describe it as a pandemic and by pandemic what I mean is that it’s something that is existing chronically in our society. That’s leading to really severe terrible life threatening fatal disease. But it’s been around so long that after a while people kind of go to sleep to the issue.
04:36 David B. Feldman:
And I think one of the amazing thing is I read that sort of statistic at the beginning which was this idea that it’s the leading cause of cancer related deaths. And you have this stat in your book that says more than 430000 Americans die every year from smoking related diseases and that’s now. And you say that’s like three jumbo jets crashing every day. That’s an astounding stat.
05:00 Dr. Paul Brunetta:
It’s astounding. So that’s 1300 people roughly every day. But again that’s kind of what a pandemic is. It’s something that’s existing and it’s relatively chronic and other new stories come and go and take the attention away from it. Obviously the vaping epidemic. So an epidemic is an acute spike in the occurrence of something really concerning that gets a lot of the news and the background news about how critically important know smoking cessation is gets less attention. That’s why I really appreciate you kind of bringing focus back to this issue.
05:31 David B. Feldman:
Well that’s great. And I do and we will we’ll talk about all forms really of tobacco and smoking and nicotine today. But you mentioned vaping so I wanted to kind of get to that like right away because that may be what’s on a lot of people’s minds. You know most listeners will recognize exactly what you just said that there seems to be this sudden spike in the number of people vaping or using e-cigarettes as they’re sometimes called you know what is what is the estimate of the number of people who vape and who is it that’s vaping. My impression is it’s by and large young people but I’m not sure if that’s right or not.
06:05 Dr. Paul Brunetta:
Yeah. So it largely has been young people and there’s been a lot of focus recently on the number of middle school and high school students that are beginning to use e-cigarettes. And as of 2019 those numbers were about 25 percent of high school seniors. One in four high school seniors that’s used in e-cigarette or vaping to within the past 30 days. So you know we’re watching this incredible epidemic now more than five million young people that are using e-cigarettes. And it’s an extraordinarily concerning public health problem.
What happened largely in the spring of 2019 was additional cases of acute lung injury that really got the notice of the Centers for Disease Control the CDC and as of January of this year there are twenty six hundred confirmed cases of what’s called EVLI or e-cigarettes or vaping acute lung injury and more than 50 confirmed deaths with many other deaths being investigated. This really is a serious epidemic related to e-cigarettes and vaping use.
07:22 David B. Feldman:
So talk to us a little bit about that, That epidemic of these cases of like fairly it seems like sudden lung diseases that happen because I think everybody anybody listens or watches the news will we’ll know about this. And yet I think there’s so much speculation and misinformation out there. Why is this happening what’s causing this do we know?
07:43 Dr. Paul Brunetta:
Sure. So I think the best place to get information about this is the CDC Web site because they really this is their job is to really understand epidemics of disease and try to understand the cause for it. They have us state maps showing the distribution of cases. And basically there were case reports of individuals that had acute lung injury in 2017 and 2018 so minimal case reports. But then the numbers really began to spike. They began to look into who was using what products which ones were basically from local vape stores that had vaping and e-cigarettes that are not regulated, but had different formulations different flavors different THC compounds vs. nicotine compounds. They began to really do a deep investigation and they found that the majority of these cases seemed to be related to THC exposure in vapes.
08:45 David B. Feldman:
Right. So this is the substance in marijuana.
08:47 Dr. Paul Brunetta:
The substance marijuana a smaller proportion were nicotine only. Many of them were mixed. And then in the last couple of months you began to see statements from the CDC about something called Vitamin E acetate and Vitamin E is a very oily substance. And so that was an oily substance added into some vapor formulations. There’s a suggestion that may be really part of the reason why you’re seeing such an epidemic.
There were also some cases that were non THC related, just nicotine specifically related. That accounts for a good proportion of these cases, but probably not all of them. That makes sense. There are other aspects we can get into about what an e cigarette is the toxicity of metal fumes from a e-cigarette and then other issues like that.
09:34 David B. Feldman:
You were telling me sort of off line before this interview that part of what you’re doing when you’re inhaling and e-cigarettes as you’re getting the vapors but you’re also potentially inhaling metal from the coil. How does that work?
09:48 Dr. Paul Brunetta:
That’s Right, So basically e cigarette is a battery charge superheated typically metal coil and that metal coil will look like you know either have nickel chromium or led or the three main metals that are superheated and then polyethylene glycol is this kind of solvent. I guess you’d call it that in which nicotine or THC gets dissolved. OK. So you know that makes sense. That’s the way you create these plumes of vape from an e cigarette or you know a tank vapor other types of vaping compounds. But you’re directly inhaling in metal vapor and there’s very good information showing that inhaling these these metal fumes is directly toxic to the airways.
10:33 David B. Feldman:
So. So I’m trying to sort of square this in my mind with a phrase that probably a lot of people have heard and it’s often trumpeted by the tobacco companies and I think it may appear on you know boxes when you buy the vape and it says e-cigarettes may be safer than cigarettes. That’s the quote and I know you really have a problem with that framing of the issue in the first place. Sort of like saying well you have two choices cigarettes or e-cigarettes. But let me ask. I mean, is it true that e-cigarettes are in any way safer than cigarettes? Are they in some ways more dangerous? Do we even know? And what’s wrong with this framing the issue.
11:16 Dr. Paul Brunetta:
We really can’t say that they’re safer. You know for you to say that something is safer you would have to do really good studies to try to understand the difference. And those studies are really really have not been carefully conducted whatsoever. So it’s really concerning to people you know that are 40s 50s 60s who remember the height of the cigarette epidemic basically and all the marketing and all the false information all the background that went into that. I mean, if you think about tobacco companies and the tobacco epidemic if you think about crack cocaine and the cocaine epidemic.
Now, if you think about the vaping epidemic, what I would say is don’t take health advice from a company that is selling you an addictive compound. If someone’s addicted to something that you know they’re kind of suggestive to messages that go along with continuing that behavior. And I think that’s really not good. So many of these companies early on and really vaping associations were really using that terminology it’s safer and now they understand that’s not appropriate probably not the best legal approach and they’ve stopped that messaging.
I really think there are three choices. So there are cigarettes intensely addictive clearly dangerous. There are smoking cessation medications that are designed to not be addictive have been proven and tested by the FDA. Some of them are available over the counter
12:40 David B. Feldman:
What are some of them. Just as an example.
12:42 Dr. Paul Brunetta:
Two general categories. One is called nicotine replacement therapy so that’s nicotine patch gum lozenge. There are two that are often forgotten which is nicotine nasal spray and a nicotine oral inhaler. And the irony of those two last ones they’re only available by prescription because they’re thought to be slightly more addictive whereas you know we just have e-cigarettes just out there. OK. So nicotine replacement therapy is one category. And then there are two oral medications one called Zyban or bupropion or Wellbutrin S.R. another one called Chantix or Varenicline. You’ve probably seen those commercials on TV the cold turkey discussion right. So then there are combinations of many.
There are a lot of different combinations of medications that are useful to help people quit. So there’s a lot to do there that’s been in you know highly investigated reviewed by the FDA you know labels and understanding about safety and then in the middle category are E-cigarettes unregulated intensely addictive. And what’s emerging data that suggests that they are not safe because of risks of lung disease and heart disease.
13:51 David B. Feldman:
And I think you know what you’re pointing to is something that came up. Yeah. Whenever I host a show on any topic I always kind of run the topic by friends and see what their questions are and what they have to discuss. And one of the things that kept coming up is this idea that people use e-cigarettes or vaping as a sort of stepped down from cigarettes as a way of helping them quit smoking cigarettes and what you’re saying is it sounds if I’m getting you right is no don’t do that. Like there if you need to step down but still get some nicotine, the nicotine replacement gums and patches and things like that arm are a much better option.
14:27 Dr. Paul Brunetta:
I think that they are a much better option as it relates to safety. You know what we understand about safety the fact that they have been evaluated and are not addictive or have very very low addiction potential. So there are those other choices I totally understand why somebody would think that that you can progress from normal cigarettes to e-cigarettes as a means of quitting. But the problem we see is that any time you inhale nicotine it’s the most addictive way to deliver nicotine. So you know your ability to get off of it becomes compromised and now you may be addicted to something that is not good for your health even though you’re trying to improve your health. Does that make sense. So I think you have to be. Let’s just learn as much as we can about this so people make good choices, my point.
15:15 David B. Feldman:
You keep saying that this is very addictive stuff. And again a lot of people listening out there may have may have heard like two different messages like one message that we sometimes hear is that vaping is less addictive than smoking traditional cigarettes. But I’ve also heard and I’m sure other listeners have as well. Just the opposite that it’s can be more addictive. I mean it all has nicotine in it which is addictive. So I guess I have a few questions for you and you can kind of take them in whatever direction you want. Just how addictive is this nicotine stuff? How does it hook us biologically without going into too much technical detail and does it even matter really what form it’s in. It sounds like it might it matters a little bit if inhalant form.
16:00 Dr. Paul Brunetta:
Right. Nicotine is intensely addictive and it’s thought to be up in the same category of addictiveness as cocaine and heroin. And the way I think about nicotine is that there are nicotinic receptors in your and my brains. So there are receptors and nicotine is provided through a cigarette or an e cigarette and nicotine binds to those receptors and it changes the level and number of those receptors and density of those receptors so basically it changes your brain structure. And now that you have more receptors waiting for that nicotine to come in and bind if you’re not getting nicotine you’ll begin to have nicotine withdrawal so symptoms of anxiety possibly depression restlessness difficulty concentrating.
16:48 David B. Feldman:
So this is when people say that they’re sort of jonesing for a cigarette. Yeah they really like they feel like they really need one.
16:54 Dr. Paul Brunetta:
That’s right you’ve kind of provided and exogenous neurotransmitter and that’s really changed the structure of your brain. And now if you’re not giving your brain that neurotransmitter you begin to have side effects and so it’s intensely intensely addictive. The most addictive way to deliver nicotine is through your lungs your lungs have us the surface area of about a tennis court huge surface area you inhale in nicotine from a cigarette or an e cigarette it gets absorbed rapidly by that tennis court surface area right up to your brain. So what makes something intensely addictive is how quickly it gets delivered to your brain. That’s why if you snort cocaine it’s clearly addictive. But if you inhale crack cocaine it is intensely addictive and that’s what we saw with the height of the crack epidemic. You see I mean it’s really it’s the lung delivery.So it’s a critical element.
17:54 David B. Feldman:
Right. and that it’s getting to your brain very quickly in its quickly changing your brain. And really hooking you so does it. Does it matter what? So this question of is vaping more or less addictive than traditional cigarettes. Is that just like a nonstarter of an issue. That’s just a nonsensical question.
18:11 Dr. Paul Brunetta:
It’s a bit of a non-starter in the sense that we were in this place years ago when they were talking about low yield cigarettes and lower nicotine cigarettes and multiple studies done and so this was done with nil benefits and other colleagues at UCSF and other centers around the U.S.. When people are exposed to a lower level of nicotine and they’re addicted to nicotine they naturally just inhale deeper and inhale longer. So no matter what the level is your brain is trying to adjust itself to get what it needs. And the other really important point to learn and we kind of carefully go through this in chapter 14 in the book is nicotine is a really short half life meaning and it just a couple hours most of it’s gone. So then you’re swinging back and forth between kind of feeling somewhat better and then and then feeling worse and then wanting to have another cigarette. Does that make sense. It’s both the lung delivery and the short half life that really set up people to become intensely addicted.
19:13 David B. Feldman:
And you know we’ve been talking about the sort of biology of vaping and the biology of addiction. But if it’s ok I Dr. Brunetta I’d like to get a little personal with you as well because I’d ask about your own story what you’re really open and vulnerable about in your book, Learning to Quit. You yourself were a smoker for some years and it started when you were pretty young. So when did you start smoking. Why did you start. What led you to start and how did you realize it was a problem.I think the stories are important.
19:48 Dr. Paul Brunetta:
They are, and so that’s why in part one of the book we have 25 different stories they’re all relatively short. Mine is included in there. I had my first cigarette when I was nine. I remember it like it was yesterday. You’ll see through all these stories that people kind of very distinctly remember their first cigarette for an interesting reason around memory and experience but I was at that you know in a religious day class and we were you know listening to different stories from the mother of one of my best friends. And then we would take a break and have milk and cookies and there was a kitchen window and she would go out into the garden and have a cigarette while we were all watching. And then she’d come in and just be really relaxed and much more focused and Smiley. You were like, “What is she doing?” You know like what is that. What are these adults doing.
You know obviously we see other people smoking. It turns out if you’re young and exposed to adults that smoke you have a higher likelihood of becoming a smoker. My parents weren’t smokers. But you know I was able to steal one of her cigarettes out of her purse almost as a dare. And I remember taking it home and lighting it up as a fourth grader as a lot of people do. And just feeling this wave of like you know power of nicotine just flooding my brain feeling nauseated feeling dizzy and thinking wow that’s why that’s why adults do this.
I mean anybody who has something this acutely intoxicating like that remembers that really well as a high school student we would go to parties drink a beer have some cigarettes on the weekends I began to think know I can do this or I’m doing this but not really that addicted. And it wasn’t until I went off to college kind of really intense pre medical studies a lot of tension a lot of late nights for sure that I began to use it as a tool and then I got addicted and I had real difficulty quitting and that kind of fascinated me.
And what led you to start to realize I need to quit and kind of motivated you to start to toy with giving it up.
22:00 Dr. Paul Brunetta:
I began to notice when I wasn’t smoking, I was getting even more anxious until I had my next cigarette. Sometimes when I wasn’t smoking I would get kind of morose and just sort of feel you know I was listening more to a voice in my head about failure. I had anxiety restlessness I began to really notice that when I wasn’t smoking I didn’t really feel like myself on some level. And then, knowing that I shouldn’t be smoking as a pretty med student you know just feeling like I was getting drawn into the corner store to buy a pack of cigarettes you know and just really sort of moving away from my values of wanting to become a healthy future health care practitioner.
That was probably when I moved away from Baltimore into Boston. Some of the pressure of my next stage in life was relieved by getting into medical school that I was like OK you know I just don’t want to be a smoking doctor. I just really began to sort of find a center of motivation. And you see this in multiple people in their stories in the book as well they grab onto something important and they use that to really try to take a next step in getting healthy.
23:12 David B. Feldman:
And perhaps this is a good time to open up the phone lines to allow you the audience to take part in the conversation. I’m David B Feldman. And this week on about health my guest is Dr. Paul Brunetta:, a physician and co-author of the book Learning to Quit: How to Stop Smoking and Live Free of Nicotine Addiction.
If you’ve successfully quit smoking we’d love to hear from you. What helped you to quit and stay quit and on the flip side, What seemed to get in your way of staying quit. Of course we’re also open to answering any of your questions. You can join our conversation by calling (510) 848-4425.
Dr. Brunetta, in your book you have a fantastic quote that I think really cuts to the heart of what’s unique about the way you approach quitting smoking or vaping. You write that quote stopping smoking is a very personal process. I mean at first blush at first blush I can’t talk. It might seem to people who have maybe never smoked that quitting is a simple one size fits all task you just put the cigarettes down. But of course it’s way more complicated than that. And I really like how your book takes a very personal approach to this complexity. Specifically you address eight questions that you suggest can be helpful for people when they’re considering quitting. And you use personal stories as you mentioned to illustrate how people have answered these on their journeys. And I just want to list these out now just so people know have a sense of the scope of them.
What motivates you to be a non-smoker?
Who would you be without cigarettes?
What do you like about smoking?
What is your denial story?
What keeps you tied to smoking?
If you’re already sick what would be the difference if you were able to stop smoking?
Who other than yourself is affected by your smoking and how could they benefit if you stopped?
What is your power and how do you choose to use it?
We definitely don’t have time to go through all of these. But I wanted to at least ask you about a few of them and I’d like to start with the first question because it seems really essential. What motivates you to be a non-smoker. You make this really intriguing distinction in your book between two kinds of motivation. Fear based motivation and desire based motivation. So what’s the difference and why is why is this difference important?
26:03 Dr. Paul Brunetta:
One of the great things about my experience has been working with Suzanne Harris. So Suzanne and I started the program at UCSF which is really a clinical program group therapy and individual therapy in helping people through this process. But Suzanne had been in this process long before I joined her. And she’s really an expert in motivational interview and in all of her experience. In part one we pulled together 25 interviews and it was really her thought process around what are the most common questions that seemed to keep addressing over the years.
This is part of the way the group has been conducted through Fontana over the years these are really what we think are the most important questions that come up over and over and over again. We were able to group people into those specific questions within the construct of the book. With each one of those topics, there are at least two or three people that explain and demonstrate exactly what I’m talking about.
You know, I do think that where I was coming from as a physician early on was from a fear based place. Most physicians a lot of healthcare workers are most comfortable with discussions about oh a risk of lung cancer or risk of heart disease risk of lung disease. But it turns out that often makes people feel small and afraid and doesn’t do a lot to give them the energy to really take the next step in really making a big change in their health. That’s one of the most important things that I think Suzanne taught me is around trying to find somebody center on what do I want to do, instead of I have to do. It’s not out of fear, but out of seeing some real possibility of a better health better control a better sense of being yourself you know attached to your values.
Part one is these interviews and part two is the medical information about tobacco related disease. We put it in the back. We refer to it if you want to review it but it’s not the first thing.
28:11 David B. Feldman:
I think that’s beautiful because when you think about often at least I think about in my life and I don’t know about others who are listening but when i think about in my life what motivates me to make changes. To move forward in my life. It’s often my values, something things I care about. It’s often things I want to move toward.
You know, fear can motivate you for a while, but I think of fear like a bright burning flame, it might push you forward intensely for a little while, but it tends to burn itself out. So I think it’s a really powerful observation that what may motivate people, a lot of people to quit smoking or vaping is actually a desire to improve rather than a fear of what happens if I don’t try.
28:52 Dr. Paul Brunetta:
Here’s a really quick example. Maybe let’s say you’re young, a young person, your 20s, you’re smoking or you’re using e-cigarettes, you have a young child or you’re thinking about having a child. And then you’re thinking about, well, what do I want to be as a parent? What example do I want to set? You’re kind of beginning to think about your values and your child’s health. And so if you really focus on that youth center and you have much more strength of making a change as opposed to only thinking about illnesses that make sense, like who do I want to be? Yeah. And you begin to recognize that nicotine can really limit some of your capability.
29:29 David B. Feldman:
Great. Well, we have our first caller on the line. So let’s go to him. This is I think it’s pronounced Evar or Ivar from Oakland. Welcome to about health.
29:40 Caller 1 (Evar):
Yeah. Hi there. I. So I quit smoking and I did use a nicotine vapor to do so. And I know a number of people who’ve done that. And I have to say, it’s really bothers me that those who are, you know, trying to basically nip the vaping epidemic in the bud claim make these claims that it doesn’t help people quit smoking. I know it does. And it’s just like you’re talking about how you want to learn as much as possible about it. But it just doesn’t seem like you’re really talking to smokers. And I don’t know how you’re going to learn as much as you can about it if you’re not really talking to the people who actually have the addiction. And the second thing I want to say about it is that, you know, it’s like cigarettes have a lot of carcinogenic compounds in them and they are a smoke, whereas e-cigarettes are not a smoke. And you’re now you’re only talking about nicotine, which is I’m actually not really sure about this. You can answer this. Is nicotine a carcinogen? I don’t know. And but, you know, it’s like whereas there’s some questions about the, you know, like the propylene glycol and vegetable glycerin and things like that are in vapes. And I don’t vape anymore nicotine at all anymore. But, you know, it’s like you’re dealing with a lot less carcinogenic stuff than smoking. That said, I am very worried about a bunch of kids getting hooked on this stuff. But just, you know, comparing apples to oranges here, it’s like talking about a nicotine delivery thing versus like a zillion carcinogenic substances in the smoke of a cigarette.You know,big difference
31:14 David B. Feldman:
We’re starting to lose you, your phone starting to break up, But thank you Evar for your question. I think Evar brings up a number of issues that I think are super important, right? Yeah. Because there are people and I know because I’ve spoken to some of them too, as I’ve talked to friends preparing for this episode of about health who say no, actually going onto vaping for a while was really important in helping me quit smoking. And I want to congratulate Evar for giving up nicotine altogether. And it sounds like in his journey this was an important, important step. So of course, researches is never based on one person, right? It’s based on like general trends.But would you sort of address Evars concerns, which probably a lot of people have?
32:02 Dr. Paul Brunetta:
I really congratulate him as well. I think that his framework was I want to get off of cigarettes. I’m going to use e-cigarettes. And then he eventually stopped the use of e-cigarettes. And, you know, that’s great in the sense that you had a goal. What I’m concerned about is the idea of transitioning to e-cigarettes that don’t have a known safety profile and the sense that, oh, this is safer. I can do this for years and years when we don’t know the toxicity. So he raises a really important point. And in the book, we work through different cessation medications. I do talk about a really important New England Journal of Medicine study in 2019 that demonstrated that e-cigarettes in a in a study in London where the regulation is very, very different and they haven’t by large seen any EVALI cases, which is fascinating or interesting, where it’s suggested that there was some efficacy of e-cigarettes in, you know, within a really reputable journal. So I hear what you’re saying. I’m trying to have a conversation where we understand nicotine addiction, and I’m just really cautioning against the idea. Go ahead and just transition to e-cigarettes. And there’s nothing to worry about because that’s not the case.
33.19 David B. Feldman:
Now, it’s a good point. We have another caller. This is Tirrell, I believe, from Santa Rosa. Terrill, welcome to about health care.
33:29 Caller 2:
Hi. Thank you.
33.31 David B. Feldman:
Yeah, it’s our pleasure.
33:33 Caller 2 (Tirrell):
I just wanted to share a couple anecdotes that I found interesting about quitting, and I’ve I’ve never been a smoker myself, but my sister and her husband both for smokers, and they both had instant success using hypnosis. And this was over in England and it seemed you know very That forced them to quit and they’ve quit ever since. I mean, that was maybe 10 years. And then my favorite theory was that my uncle was at the airport and he was in line for one of those rooms where you go in and smoke. He was watching the man in front of him being extremely agitated and fidgety with his cigarette out, ready to go in and have a smoke. And the man in front of my uncle was watching in the room to see who was going to finish first so he could go in and he watched the man finish the cigarette, put it out. He was so eager and excited to go in. And then the man lit another cigarette. And so the guy in front of my uncle was so dejected. My uncle was observing all of that and had been a very long time Pack a per day smoker. He saw that and he just was disgusted with it all threw his cigarettes out and hasn’t smoked since at least five years. And I think, you know, he just he the way he described it was that you just saw these people as losers. And just behaving you know really poorly in that I don’t want to have anything to do with that. So I think it’s fascinating how some people can quit, just with the mental quit and other friends of mine talk about quitting for years and years and just cannot.
35.18 David B. Feldman:
Thank you Tirrell for your questions and for the observations, it sounds like, from your uncle. And I want to be careful not to use the word loser here, although, I mean, I respect that that’s your experience here. And perhaps your uncles. But at the same time, I mean, this is actually really hard to quit smoking. I mean, this is not something that that’s like an easy thing. And if you if you’re having trouble doing it, you’re a loser. You’re right. I mean, this is actually super difficult.
35:45 Dr. Paul Brunetta:
And that’s why we wanted to have many, you know, different stories that people could look at so that they you know, sometimes people get isolated in their process and to have people have some empathy and understanding for what the process can be. So for the first question around hypnosis and hypnotherapy, I do mentioned this in the medication chapter of the book, and there aren’t great studies of whether it’s effective or not, but it has been around a long time. It’s safe. There are some studies suggesting that it’s effective. So our approach has usually been if that’s what you want to do, then we wouldn’t recommend against it. But if you find that it’s not working for you, then recognize there are as so many different other options that you can use. And then for the second person, you know, there are many different people. People experience addiction many different ways. Some people do find it relatively easier to quit. And some people feel as though it’s nearly impossible with terrible, terrible withdrawal. And there may be some genetics that goes into that. There may be things like, is there somebody else in your home environment that’s smoking that makes it harder for you to to quit? There’s some recent studies around relapse suggesting if you’re single, if you’re in a smoking household, those are obvious reasons for relapse. So this is a complicated topic that’s really worth stopping and learning about in the anecdotes are really helpful.
37:13 David B. Feldman:
And I think it’s one of the powerful messages of your book, Learning to Quit is that this is very personal and there isn’t a one size fits all solution. And I think that’s part of what we’re hearing.
37:23 Dr. Paul Brunetta:
And I’m certainly I’m certainly not trying to say there’s only one way to do it. There are many ways to do it. And we congratulate anybody that’s focused on making an effort to get to the next step. It is a learning process. It’s not about criticism is really about support. What are different things to different people have tried and how do we help people make good choices along the way?
37:44 David B. Feldman:
You’re listening to about health. I’m David Feldman and my guest is Dr. Paul Brunetta:, physician and co-author of the book “Learning to Quit”. And of course, we’re talking about the various options that people have and the various motivations for people quitting smoking and staying quit. So, Dr. Brunetta, along with the question of what is your motivation for quitting? Another question that you advise people ask themselves when they’re trying to quit smoking is what is your denial story? And this word denial, you know, has so is so loaded when it comes to quitting smoking and drinking and substances. So what is a denial story when it comes to smoking or vaping? Vaping. And I wonder if you could give some examples.
38:35 Dr. Paul Brunetta:
So a denial story is something that you may tell yourself that is really there to continue the behavior that you have to suggest that you don’t need to take the next step. So a typical denial story might be, you know, my uncle Bill smoked until he was in his 80s and never got sick. So I’m not. And it gets sick or another denial story might be. I’ve tried to quit a few times and I really haven’t been successful. I’ll never be able to quit. There are things that you kind of say to yourself almost like I wouldn’t say a mantra, but something is repetitively that will undermine the likelihood that you’re going to get to the place where you really are deeply motivated. And just being mindful of it and understanding it can really help you bring it out into the light.
Recognize that somebody else’s lack of a particular medical outcome doesn’t actually protect you from anything, even though you’d like to believe that. And it just really helps to frame the issue for you in a way that can get you to the clarity of your purpose in wanting to be healthy.
39:46 David B. Feldman:
I like this idea of denial, and I think it’s different from what I have maybe naively thought of as denial, which is denying that there’s any problem. It sounds like, you know, what you’re saying is that you can admit there’s a problem. You can say, like, I smoke, I wish I didn’t smoke, but still have an internal story you’re telling yourself that gets in your way of quitting.
I think about, say, a friend of mine way back when, you know, we smoked together in high school, I stopped smoking in high school and college. You know, he has kept smoking. And one of the things he tells himself is and this is almost verbatim, quote, Smoking is an addiction, which is a disease. I can’t help it that I’m prone to that disease. So there’s nothing I can do about it.
Of course, in part that’s true. Cigarette addiction is definitely a biological process. As we talked about, the brain really gets hooked, addicted to the nicotine. But it’s also only part of the story. Right, because there are a lot of things that we can do. So.
Do you have any tips for somebody is listening out there and there and there. And they have a story that they’re telling themselves about that that’s holding them back from quitting. And they recognize that. They recognize that. Any tips for how they can go about authoring a different story or changing that narrative that might push them forward towards giving up smoking if they want to?
41.15 Dr. Paul Brunetta:
I think the best way to do this would be to, if you’re aware of a denial story, you know, to write it down, just write it down and look at it and then begin to probe it and decide whether there’s truth or not truth in that statement. And I think you’ll find that there is not truth. And that’s some of it is really undermining your ability to move forward. And if you feel as though there isn’t a truth in it, then come up with something that’s that’s different and more positive. Okay. Something that might lead to action, because a lot of this can be sort of like circular mental thinking where you’re thinking and thinking, but you’re not actually doing anything. And what we find and you’ll see multiple, multiple denial stories in the book is that if you begin to just take the next step of action, it really can reframe the way that you’re thinking.
42:05 David B. Feldman:
That’s good advice. We have another caller on the line who’s been patiently waiting for quite a long time. This is Mary in San Francisco Mary. You’re on about health. Welcome.
42:15 Caller 3 (Mary):
Thank you for taking my call and especially for the non-judgmental approach. And I think compassion should be sort of the baseline of any discussion. Vapes are toxic and so or so as tobacco and you’re not-or cigarettes-and you’re not smoking tobacco or marijuana or vitamin E, which is totally safe. Did you think vitamin E for half a century and 70 years old. Were smoking chemicals And if the person at the bus stop is vaping or smoking tobacco, I’m being exposed to the passive. And when we quit, I want to bring the environmental concern into it. We’re doing something wonderful for the environment because we’re not no longer supporting really toxic agro business the tobacco and the plastic and the metals and the led that people are inhaling. Please. I have to wonder this. As a person who’s been using marijuana for over half a century and smoking it, doesn’t anybody know how to roll a joint. And I’m saying this quite seriously that I think, first of all, I’m for the legalization of marijuana on a federal level so that people can have access to it. Lowering the age to 18 from 21, although veterans can get it. And introducing marijuana literacy into the curriculum. Not so the 14 year old, the 16 year old can go out and smoke. But the same way that sex education is so important to understand what a rolling paper is. You know what’s bad for you, what’s good? Just to have this step? No alternative because I quit smoking years ago and I’ve never regretted it. It’s about chemical. And I don’t want my money to go to R.J. Reynolds. But marijuana grows from a seed. It’s a plant. It’s sequesters carbon. It bio generates the soil and a part of the green new deal. But that’s being suppressed.
Just for an option.
44:24 David B. Feldman:
Mary, thanks. Think thanks for calling and sharing that. Now, I I really want to keep, you know, less on the topic of nicotine and tobacco in particular. But Mary brings up a number of important points and I think one of them is this to the degree to which this is big business and that business isn’t necessarily environmentally good for the environment. And that, you know, one of the reasons and you talk about this in your book that motivates some people to stop smoking is they don’t want to support the tobacco the companies and their misinformation. And they’re sort of making money in a way that hurts people.
45:03 Dr. Paul Brunetta:
You know, there’s there is a lot in what she was saying. The thing that I’m going to grab on to most is empathy. Just trying to understand what people are going through in different situations. Try to have an open mind and learn as best you can. When I quit smoking, I didn’t really I didn’t really feel any special anger against Marlboro. But it wasn’t until I really began to understand tobacco related disease, lung cancer, the tragedy of these illnesses that I’m like, wow, you know, I really didn’t I did not understand what was going on and wanted to try to turn it around to just at least improve a better understanding of what these diseases are and how severely addictive nicotine can be. And I do think, you know, based on the stories in the book, certainly for people in the process of quitting. But if you’re somebody in that in a household of a smoker, you know, there could be ways in which you’re doing things that are not especially helpful to that person. Maybe you’re making it even more stressful with some of your messaging. I think you’ll find if you have more empathy and find the right messages, you really can support people on a different path.
46:06 David B. Feldman:
And that’s I think empathy is so important. I think it’s so it’s so important for changing almost any behavior that you do. There’s you know, there’s lots of research in the field of psychology that shows anytime we try to change our behavior, whether it’s, you know, eating or exercise, taking care of ourselves in various ways. Smoking, any kind of substance use that if we beat ourselves up for it. Yeah. If we tell ourselves we’re no good. That actually works against us rather than for us. And I think that’s such an important message here. We only have about 10 minutes left. And and towards the end of each show, I always like to get really practical. We’ve spent most of the hour talking about, you know, the dangers, obviously, of smoking and vaping and how people can keep up their motivation. And of course, motivation is super important and understanding. I think the dangers is super important. But the tools and techniques that people use to quit smoking are are also really important. You have this great quote in your book, which which I just love. It’s it’s strategy trumps willpower. And I think that’s so beautiful because so many of us think that if you’re going to quit smoking, if you’re going to start exercising, you’re going to change anything hard in your life. What you need is willpower. You need to, like, grin and bear it and force yourself to just do these hard things. But strategy can make that a bit easier. Maybe a lot easier. And you talk about a number of clever strategies, which I guess in our modern day culture we might call mind hacks or life hacks. And I wanted to ask you about at least some of them. And. And one of them, which was really intriguing to me, was the day you quit. Take a different route to work. Yeah. Talk a little bit about that.
47:56 Dr. Paul Brunetta:
So we do think setting a quit date is very important. I mean, it’s a pretty important event. If you’re not willing to set a quit date. It’s hard to be successful in your process. Right. Because you may have. And you would have had multiple behaviors on any regular day, repetitive behaviors. And now you’re focused on changing those behaviors and trying something very different. So setting a quit date, setting yourself up for a successful quit date is really worth spending some time and effort into doing that properly. So, you know, we would recommend if you’re going to set a quit date, you might consider something like a Friday, a day that might be slightly easier for you during your super busy work week than, let’s say a Monday. If you’re going to do it on a Friday, perhaps you’ll try to have a regular routine and maybe you can take off some time, go to a place that does not allow smoking, like a couple of movies that are rewarding yourself, that are enjoyable, hang out with a non-smoking friend and really work to just get through that day and at the end of that successful day to stop and say, you know, I made it through this day and the next day, it’s just about, well, I’m going to be successful today.
You can begin to string those together in a way that is supportive and positive as opposed to negative and overly critical. Right. So take a different route to work. If you find that you’re used to smoking in your car, then think about some other way to get to work that is different. Maybe same car, but now you roll your windows down and play your music loud, which you don’t normally do. Maybe your normal routine is you wake up, have a cigarette, have a cup of coffee, have a cigarette, have a shower, maybe what you could do would be to immediately take a shower first. Just something to change your routine.
David B. Feldman:
Break the chain, break the cycle, break the routine in any way you can
Dr. Paul Brunetta:
Tell yourself. Okay.Things are different now. I need a different environment, a different approach, and you’ll find that it’s useful.
49:50 David B. Feldman:
Another tip that you give, which has to do with that quick date thing which is starting. Start quitting place by place. And this relates to your own quick story, because you said a quit date. If I’m not mistaken for yourself. Back when you quit smoking. But then you began slowly to cut out place by place. Even before that. So talk a little bit about that strategy.
50:11 Dr. Paul Brunetta:
So, you know, people do smoke in many different environments, in different places throughout the day. What we try to do is to have people smoke only in places where they’re just being very mindful that their smoking they’re not sort of sitting the couch for the TV in a comfortable place. They force themselves to go out onto the balcony or some place that is different for them. So change your routine so that you’re much more mindful of what you’re doing that day. And that’s one tip of, you know, literally dozens that we’ve got included in the book, as well as all the things that the people interviewed did in their process. And on the website for the book, we have a whole bunch of free information, free quick tips. We have some audio content. We have the five D related to drinking water, deep breathing and other activities. There are many, many things you can do to just set up the right strategy to to be successful.
51:05 David B. Feldman:
And another one help. I’m not, you know, sort of giving away too much from your book, but I know you’re actually giving away your book for free. Right. On that website as well. Did you share that Website address? Go ahead. And you if you’d like.
51:17 Dr. Paul Brunetta:
It’s www.learningtoquit.com/free to just thank you and your audience for listening and for today. It’s the e-book that’s available for free. And on the Web site, there’s a lot of other free content that we think could be useful.
51:32 David B. Feldman:
And another tip you give in the book is Practice Deep Breathing. And I found this one so intriguing, because if I’m if I’ve got you right, you say in the book, one of the things that people find rewarding about smoking is they take a break from their day and they just breathe. And part of what you do when you smoke is you take deep breaths. And and that by itself, just breathing is a powerful sort of tip for getting yourself to stop smoking as well.
52:02 Dr. Paul Brunetta:
It is so deep breath, sort of deep abdominal breaths are very relaxing. So if you put yourself in an environment where you’re able to be somewhat quiet and take very, very deep breaths, a series of 5 to 10, you’ll actually feel sort of a flood of relief that can be useful as part of a break during the day that you might have normally filled with a cigarette. And that’s a skill. That skill actually take some time. But it really can make people relieve anxiety and stress that can be part of nicotine withdrawal while you’re on your path. I do want to also say there are many people that try to quit cold turkey and we’re not against cold turkey by any means if that’s something that you want to do for sure do. But really concerned that people tries a couple of times and then find that it’s extremely difficult and that they think there’s nothing else to do. Only a third of all people trying to quit use medications and counseling and those are proven to be effective. So we just try to have a broad view of all the options available to people. And if you don’t feel like the only way to quit is to quit cold turkey, because that’s actually the hardest way to do it.
53:17 David B. Feldman:
And we only have about three minutes left. But I also wanted to bring out the issue of courage, because all of these ways of quitting all of them, no matter if you quit cold turkey or if you go to a therapist or program like in Fontana or if you read a book, they take courage. Right. And in your book, you give a kind of mathematical equation for what courage is, which is courage equals desire plus doubt plus action. Take just like a minute here at the end, because I think it’s an inspiring message. Talk a little bit about why this perspective encourage, particularly why is doubt part of the equation?
54:00 Dr. Paul Brunetta:
Well, I think doubt is something that really can just put barriers in your way. You know, courage on some level means facing the unknown or facing something that’s not familiar to you, of being committed to make a difference in your behavior or to do something that you think could be extremely difficult to do. And despite that fear or doubt, you move forward anyway. You know, we’re not on this planet for that long of a period of time. And if there’s something in your journey where you feel like I want to change my behavior and you’re gonna take steps to do that. That is courage. And that’s that should be celebrated and supported. And I’m constantly really energized by and motivated by people that are shifting their behavior towards something that’s better. I can’t get enough of it personally. You know, I’d love all the stories that I hear all the time of people that have shifted. And then along with these shifts, can can come huge benefits that they didn’t even expect,basically.
55:02 David B. Feldman:
I just love this definition of courage because it emphasizes that change is hard. And part of making difficult changes in our lives is doubting ourselves. I mean, it’s just part and parcel of doing hard things and having doubt is okay. It’s human. But this doesn’t mean we have to give up. And I think that’s just such a beautiful message. And it’s a good message for us to end our conversation on this hour as well. Dr. Paul Bernina, thank you so much for taking the time to be with us today. If people want to learn more about you, your book, your work, how would they go about doing that?
55:40 Dr. Paul Brunetta:
I think the best way is just simply get on the website, which is www.learningtoquit.com/free. There’s a lot of content, there’s audio content, there’s a lot of background, that’s probably the easiest way. That also has links into Fontana, UCSF. You just Google, Fontana, UCSF, you’ll also find it. So you know, and there are other 1800 quit numbers people can use. There are a lot of other resources that we’ve made available in the book and on the web site.
56:10 David B. Feldman:
That’s great. Well, thank you again for being with us.
56:20 Dr. Paul Brunetta: Thank you. Thank you, Dave.