How full do you want your recovery to be?

Bill White on the importance of primary care:


The Philadelphia survey goes beyond affirming the significant prevalence of recovery in the general population to provide a detailed profile of the health of people in recovery.  The results are sobering.  People in recovery, compared to citizens not in recovery, are twice as likely to describe their health as poor and report higher rates of asthma, diabetes, high blood pressure, obesity and past-year emergency room visits. They are also more likely to report lifetime smoking (82% vs. 44%), current smoking (50% vs. 17%), exposure to smoke in their residence, no daily exercise and eating fast food three or more times per week.

At its most practical level, the survey findings suggest that every person entering recovery should have an ongoing relationship with a primary care physician who is knowledgeable about addiction recovery and who can serve as an ongoing consultant on the achievement of health and wellness.


Smoke Screens

No Smoking - American Cancer Society's Great A...
No Smoking – American Cancer Society’s Great American Smoke Out (Photo credit: Wikipedia)


Bill White recently posted on tobacco use in recovery. He’s been way ahead of the field on this and challenges not only treatment providers, but recovering people as well:


People in recovery are dying from smoking-related diseases in large numbers, but they are also dying from conceptual blindness:  the failure to see the contradiction between claiming recovery status in the presence of continued addiction to nicotine.  Too many recoveries and too many lives are going up in smoke.


Anna David recently posted a first-person account of her path to becoming tobacco-free:


Then, when I was nine months sober, I met an older woman who’d been sober, it seemed, forever. She and I were at dinner with a few other sober friends after a meeting and I did what was routine behavior at that point: I went outside several times throughout the meal to smoke. And one of the times that I returned, this woman started, in the most direct and yet gentle way imaginable, confronting me about the fact that I smoked. People had of course brought the topic up with me before but there was something different about her approach. She said things that made a lot of sense—things like that every time I inhaled on a cigarette, I was telling myself that I hated myself and that getting sober but not quitting smoking was like switching seats on the Titanic. “Honey,” I recall her saying as she leaned forward on the table, “You’re putting a smoke screen between you and your Higher Power.” It was just the kind of thing that I would have mocked before sobriety but which made a lot of sense to who I was becoming. At the end of dinner, she offered to meet me at a Nicotine Anonymous meeting the following evening.


The benefits of harm reduction are not as obvious as they seem

Warning: This Area Contains Tobacco Smoke
Warning: This Area Contains Tobacco Smoke (Photo credit: tbone_sandwich)

Theodore Dalrymple points out the inconsistency in the British Medical Journal’s vigorous advocacy for harm reduction where heroin is concerned and its squeamishness with harm reduction for nicotine. He pulls a passage from BMJ and inserts comments:

What, then, does the BMJ, so much in favour of harm reduction for heroin addicts, say about harm reduction for smokers?

A broad perspective suggests potential problems [from a public health perspective].

Firstly, the new nicotine containing products are not intuitively appealing; smokers will need to be persuaded of their benefits. For public health there is a key benefit: it is easier to use them than to   quit. Here I interject that the same is true of the methadone or other substitute for heroin. But for most smokers quitting is the best option and should be presented as achievable and attractive.

   So rolling out harm reduction puts public health in the contradictory position of having to emphasise both the difficulties and attractions of quitting. Why should harm reduction for heroin addiction be any different, one might ask? A related danger is that children will pick up on this apparent confusion. While previous generations were told simply that tobacco is bad, new ones would learn that nicotine is acceptable – just be careful how you access it. This is precisely the burden of public health “education” with regard to heroin and other drug addiction. Moreover, promotion of harm reduction might reduce the perceived “cost” of uptake. Would not the same effect apply to the medical treatment of drug addiction, to say nothing of the provision of free needles? Finally, the fact that e-cigarettes deliberately mimic conventional ones (even to emitting fake smoke) may result in the inadvertent modelling of smoking. Would not the prescription of injectable methadone not do the same? More broadly, the media, which in the UK have become a reliable supporter of comprehensive control measures, might also struggle with this more complex position. How much media effort, one is inclined to ask, ‘reliably’ goes into supporting ‘comprehensive control measures’ with regard to illicit drugs? Thus the benefits of harm reduction are not as obvious as they seem.

The article goes on to criticise harm reduction in tobacco because of the obvious, if not entirely consistent, commercial interests that the tobacco and pharmaceutical industries have in it.

Dead space is the part of the syringe where fluid is retained once the plunger is fully depressed. High-dead-space syringes retain fluid both in the syringe itself and in the needle; low-dead-space syringes expel all the fluid in the syringe, retaining only a small amount of fluid. (In low-dead-space syringes, the needle is not detachable.)

In experiments that mimicked drug injections, the high-dead-space syringes retained 1,000 times as many microliters of blood, even after rinsing. For people carrying HIV with viral loads between one million copies and 2,000 copies per milliliter, the capacious syringes could carry multiple copies of HIV, “whereas,” William A. Zule and his coauthors write, “low-dead-space syringes would retain even a single copy only a fraction of the time.”

What’s interesting here, is that needle exchange advocates have been so busy arguing that they are the obvious answer to injection disease transmission on pragmatic and moral grounds, while insisting that there are no social costs (ignoring the fact that needle sharing persists among exchange users, discarded syringes are a problem, they often ignore treatment access problems and that they make convey despair to addicts and communities), that they seem to have never stopped to ask if we could make syringes safer.

These low-dead-space syringes in universal use might be much more effective than needle exchanges and prevent transmissions through accidental pokes. If so, will they follow the evidence?

What what?

A new study looking at the comparative effectiveness of various coping skills for dealing with urges to drink in preventing relapse reports some counter-intuitive findings [emphasis mine]:

…relying on going to a meeting or talking to a sponsor or counselor when experiencing an urge was not correlated with improved drinking outcomes.


Ineffective skills in this population included exercising regularly, living with clean/sober people…


Two strategies were only helpful in the short run in this population: relaxation/meditation or smoking a cigarette. The smoking strategy is consistent with a past study where we found that the subset of patients who said they use smoking to cope with urges to drink were more likely to be sober a month later (Monti et al., 1995). For this subset, it may be useful to delay attempts to get them to quit smoking until after sobriety is well established.

Take 12 step facilitation off the table for a moment. Getting together with abstinent friends or talking to an abstinent mentor isn’t associated with improved outcomes?

They ignore the many studies finding that quitting smoking improves outcomes, cite one study and suggest that quitting smoking may be associated with with relapse and suggests delaying attempts to quit?

Exercise and living with other sober people ineffective too.

Yikes. Now that this has become “evidence”, I hope there are some follow-up studies.

Related articles

The social cost of smoking


English: This photo illustrates smoke in a pub...
English: This photo illustrates smoke in a pub, a common complaint for those concerned with passive smoking. (Photo credit: Wikipedia)

Apparently, Singapore was an early adopter of designated smoking areas and non-smoking areas. However, this wasn’t driven by health concerns. Rather, it was driven by aesthetic concerns–primarily smell.

In a fascinating paper published recently in Urban Studies, Qian Hui Tan observes that smokers are “purveyors of sensory pollution” – creating a scent that, like all odors, can invade and take over. When that space is public, the impact can be immense, segregating and stratifying public spaces.

Tan visited some of these places and interviewed both smokers and non-smokers about how they think about the segregation of smokers to certain areas and the impact of smoking scents on people nearby.

Based on these conversations, Tan has compiled a collection of anecdotal evidence about smokers’ experiences being made to feel unclean or burdensome on those around them, and some of the efforts they take to reduce the olfactory impact their smoking on people they come into contact with. From smoking downwind to keeping more space from people after smoking, the smokers questioned said they had become sensitive to the way they are perceived after coming back from a smoke break.

And because of the invasive unavoidability of smell, the presence of cigarette smoke or its odor results in an inevitable “sensory appraisal” by others, according to Tan.

It doesn’t take a huge leap to imagine that this might be a non-significant factor in the relationship between smoking and relapse.


No. 1 Littered Item in the United States is on Roads and Beaches?

…cigarette butts are the No. 1 littered item every year on U.S. roadways and beaches.

Cigarette butt. ‪Norsk (bokmål)‬: Sigarettsneip.

It had to be about 19 years ago that I flicked a cigarette butt to the ground and stepped on it outside of a meeting. My sponsor ran over and picked up and threw it out saying, “What’s wrong with you. Don’t you know that’s littering?”

I didn’t.

I had some weird blindness to the fact that every time I tossed a butt out the car window or onto the ground, I was littering. Littering was outside of my values and I was so obviously littering and was completely blind to it. Not even a twinge of shame.

I knew he was right and I was embarrassed. I never did it again after that day.

Smoking cessation + exercise = quit

Another ingredient to be added to tobacco quit plans:

Quitting smoking is one of the healthiest things a person can do, but it’s also among the hardest, especially for teenage smokers who battle not only addiction but also the social pressure to keep lighting up.

Now new evidence that suggests a way to make their efforts easier: exercise. In a study involving 233 teens aged 14 to 19 in West Virginia (which has one of the highest smoking rates in the country, at more than 22%), teens who participated in a smoking cessation program combined with exercise were on average up to three times more likely to quit smoking than those who were provided only minimal stop-smoking counseling.


Left behind

Good news for the country:

Fewer American adults are smoking cigarettes, and those who still smoke have cut back on the number of cigarettes they smoke, but the rate of decline has begun to slow, health experts said on Tuesday.

The report by the Centers for Disease Control and Prevention shows 19.3 percent of American adults over age 18 — roughly 45 million people — smoked in 2010, down from 20.9 percent in 2005.

Too bad we aren’t quitting with the rest of the country. I ran a quick report of Dawn Farm’s residential discharges for 2010 and more than 86% were smokers at admission. The good news is that more people are trying to quit while in treatment and this is associated with eventual quitting. However, the smoking rate to still way too high.