askjoel

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I didn't quit cold turkey (I'm on the patch) so I don't know if that disqualifies me from posting on here but here's my question:

Since quitting (just under three weeks ago), I have felt depressed....actually, apathetic is probably a better term. I can't get motivated to do much and I don't enjoy things I used to. A friend of mine said this is normal when quitting and suggested Welbutrin (Sp?). Have you heard of depression being linked to quitting and if so, what do you recommend?

First, I do answer questions from people who are using other approaches in hopes to quit smoking. Actually, I have set up this board so that I can help people who are in any stage of smoking or quitting.

I am going to attach a series of commentaries below addressing the quitting and depression issues that may follow. There is a normal feeling of depression that many people feel when first quitting smoking. It generally is not long lasting. There are some people though who are dealing with a more organic form of depression that can occur after quitting and this can last a long time if left untreated.

The problem is that with you still using nicotine, you are in a prolonged state of withdrawal, so it may be very difficult for you to determine what is actually going on in your case.

I am going to attach a number of articles below too that address the NRT issue too, for the way you titled this post makes it clear that you feel that you have quit for three weeks now, when in reality what you have done is transferred your method of delivering nicotine. Hope the following articles help.

Normal depressive reaction or a real organic depressive episode

I see we had some recent issues with quitting and depression and anger at the board. The fact is everyone who ever quit smoking faced these issues to some degree. I am creating a string here that covers depression from a number of angles. Some of these letters were written to my clinic graduates and others were specific answers to people who wrote questions with background histories. I think they will give everyone an overview of different physical and emotional issues around depression while quitting.

Again, some of the emotional reactions are a simple adjustment period. But some people have histories of emotional problems that may take more than the individual alone to overcome. The people involved may need to be working very closely with their doctors and medical professionals. These articles should give a little overview of those issues too.

Joel

The first letter here is in response to someone who wrote me a question regarding depression who had a past history of depression.

I take it from your post that you had been on medication for depression prior to smoking cessation. While becoming depressed upon smoking cessation is common, this depression normally subsides over time. But, when depression is a preexisting condition there are special considerations that need to be addressed. First, you may have been on a medication that initially took time to adjust, to find the right dosage for you. Now, when you quit smoking and stay on that dosage you can initially become depressed as part of the normal separation process from smoking, in a sense, feeling bad but not thinking anything is wrong. But when it doesn't subside over time you may assume that nothing can be done, its part of not smoking, you are already on an adjusted dose of depression medication and you just have to put up with it. This is a wrong assumption. Chances are even though you are on your normal dosage of medication, that dose was set while you were a smoker. This may not be the proper (normal dose) for you as an ex-smoker.

This dosing issue is not just about depression. People with many conditions may find that after cessation they must find what is normal for them. A person who is diabetic or on thyroid medications often find that the dose required as a smoker needs to be adjusted after quitting. Anyone who is on various medications that effect mood, hormonal and blood sugar levels needs to pay special attention to symptoms. Once through the first few days, and especially into the second week, if physical symptoms normally attributed to withdrawal are still manifesting, it is advisable that their doctor checks out those individuals.

I have put a few articles on the board here that I suspect you saw. There are others that I am not sure I put here or not, they were written to individuals who wrote with specific questions. While they may not apply to your specific situation, they cover a range of different depression issues. I am going to attach a string of letters here that were written to a few such individuals. If you have read part of them, keep going further down there may be more that you hadn't seen yet.

One other thing I would like to note that applies to emotions when quitting. If anyone lets emotions solely dictate actions, nobody would quit smoking. Part of the skill needed by all ex-smokers is the ability to override normal emotions, desires, impulses or urges, whatever we want to call it, the individuals wanting a cigarette or just a puff. Everyone feels it from time to time. It is going to be your intellect that is going to override the craving. That is where keeping your ammunition and focus of why you quit smoking is paramount. You have to keep remembering what smoking was doing to you making you sick and tired enough to go through initial quitting. Then you have to remember what continued smoking was capable of doing to you in the future, thoroughly capable of robbing you of your health and your life. When in emotional turmoil it is harder to keep that perspective. It is hard for everyone when in such turmoil but it is a skill that has to be honed day by day by everyone. Life will throw curves throwing people into despair. But smoking won't solve any of these curves. Smoking can cause problems that will throw your life further into despair and if left unchecked will throw your loved ones life into a premature loss of you.

Keep focused on this fact that quitting smoking is a fight for survival. It may be hard at times, but it is worth the effort. Bad times may make it harder to see this, but bad times will pass. You've experienced them before and you know they got better. Hang on to those memories that they do get better.

Again, talk to your doctor letting him or her know you have quit and have questions on the medications. Keep focused on your quit. One other thing to consider too, considering you were on medications before, you were depressed as a smoker. Never delude yourself into thinking life was always perfect before. Smoking didn't cure your depression before and it won't do it now either. For you, other medications were necessary to help with those feelings, smoking was not able to do it. Anyway, the following articles deal a little with the medication issues. Again, they may not all apply to you but kind of covers a range of reactions.

Hope this helps.

Joel

The following is another article written to a specific person who was experiencing a longer-term depression. This person was being encouraged by his or her doctor to go on an antidepressant but was resistant to the idea of needing medication.

Depression is normal in the cessation process. Almost everyone feels it to a degree, and the period of time that it lasts varies from person to person. Unlike the physical withdrawal, which is quite predictable in duration, the psychological reactions have tremendous individual variability.

I am attaching a letter here about the emotional phases of cessation. But since your reaction has been going for so long now, I would advise checking with your doctor. While quitting can be causing depression, it is possible that you do have an organic basis for depression that in a sense you were self-medicating with cigarettes for years.

If your doctor feels this is a possibility he or she may want to prescribe something for it. There are a lot of medications out there that are effective. As for safety or side effects, considering you may have been using smoking for this therapeutic purpose, a product that kills 50% of its users, the prescribed alternatives will pose minimal risks in contrast.

Or, the other hand, there may be some emotional conflicts in your life that have never been adequately addressed that are manifesting for the first time since quitting. I am attaching another letter I wrote to another person a few weeks ago that had some serious losses and was having some exaggerated reactions since quitting. I had more of a history on this person making me able to write this with some feeling that it really applied to this persons situation. I don't know if it applies to yours, but maybe in reading it you will see if it strikes a chord.

Anyway, hope this helps.

Joel

Understanding the emotional loss experienced when quitting smoking.

In her 1969 book, On Death and Dying, Elizabeth Kubler-Ross identified five distinct phases which a dying person encounters. These stages are "denial," "anger," "bargaining," "depression," and finally, "acceptance." These are the exact same stages that are felt by those mourning the loss of a loved one as well.

Denial can be recognized as the state of disbelief: "This isn't really happening to me," or "The doctor doesn't know what he is talking about." The same feelings are often expressed by family members and friends.

Once denial ceases and the realization of impending death is acknowledged anger develops. "Why me?" or "Why them?" in the case of the significant others. Anger may be felt toward the doctors, toward God, toward family and friends. Anger, though, doesn't change the person's fate. They are still in the process of dying. So next comes bargaining.

In bargaining, the person may become religious, trying to repent for all the sins that may be bringing about their early demise. "If you let me live, I will be a better person, I will help mankind. Please let me live, and I will make it worth your while." This stage, too, will come to an end.

Now the patient, becoming aware he is helpless to prevent his impending fate, enters depression. The patient begins to isolate himself from his surroundings. He relinquishes his responsibilities and begins a period of self mourning. He becomes preoccupied with the fact that his life is coming to an end. Symptoms of depression are obvious to anyone having contact with the patient in this stage. When the patient finally overcomes this depression he will enter the last stage, acceptance.

The patient now reaches what can be seen as an emotionally neutral stage. He almost seems devoid of feelings. Instead of death being viewed as a terrifying or horrible experience, he now peacefully accepts his fate.

As stated above, these stages are not only seen in the dying person but likewise in the family members mourning the loss of a loved one. However, on careful observation we can see these same stages in people who lose anything. It doesn't have to be the loss of a loved one. It could be the loss of a pet, the loss of a job, and even the loss of an inanimate object. Yes, even when a person loses her keys, she may go through the five stages of dying.

First, she denies the loss of the keys. "Oh, I know they are around here somewhere." She patiently looks in her pockets and through her dressers knowing any minute she will find the keys. But soon, she begins to realize she has searched out all of the logical locations. Now you begin to see anger. Slamming the drawers, throwing the pillow of the couch, swearing at those darned keys for disappearing. Then comes bargaining: "If I ever find those keys I will never misplace them again. I will put them in a nice safe place." It is almost like she is asking the keys to come out and assuring them she will never abuse them again. Soon, she realizes the keys are gone. She is depressed. How will she ever again survive in this world without her keys? Then, she finally accepts the fact the keys are gone. She goes out and has a new set made. Life goes on. A week later the lost keys are forgotten.

What does all this have to do with why people don't quit smoking? People who attempt to give up smoking go through these five stages. They must successfully overcome each specific phase to deal with the next. Some people have particular difficulty conquering a specific phase, causing them to relapse back to smoking. Let's analyze these specific phases as encountered by the abstaining smoker.

The first question asked of the group during the smoking clinic was, "How many of you feel that you will never smoke again?" Do you remember the underwhelming response to that question? It is remarkable for even one or two people to raise their hands. For the most part the entire group is in a state of denial-they will not quit smoking. Other prevalent manifestations of denial are: "I don't want to quit smoking," or "I am perfectly healthy while smoking, so why should I stop," or "I am different, I can control my smoking at one or two a day." These people, through their denial, set up obstacles to even attempt quitting and hence have very little chance of success.

Those who successfully overcome denial progress to anger. We hear so many stories of how difficult it is to live with a recovering smoker. Your friends avoid you, your employer sends you home, sometimes permanently, and you are generally no fun to be with. Most smokers do successfully beat this stage.

Bargaining is probably the most dangerous stage in the effort to stop smoking. "Oh boy, I could sneak this one and nobody will ever know it." "Things are really tough today, I will just have one to help me over this problem, no more after that." "Maybe I'll just smoke today, and quit again tomorrow." It may be months before these people even attempt to quit again.

Depression usually follows once you successfully overcome bargaining without taking that first drag. For the first time you start to believe you may actually quit smoking. But instead of being overjoyed, you start to feel like you are giving up your best friend. You remember the good times with cigarettes and disregard the detrimental effects of this dangerous and dirty habit and addiction. At this point more than ever "one day at a time" becomes a life saver. Because tomorrow may bring acceptance.

Once you reach the stage of acceptance, you get a true perspective of what smoking was doing to you and what not smoking can do for you. Within two weeks the addiction is broken and, hopefully, the stages are successfully overcome and, finally, life goes on.

Life becomes much simpler, happier and more manageable as an ex-smoker. Your self esteem is greatly boosted. Your physical state is much better than it would ever have been if you continued to smoke. It is a marvelous state of freedom. Anyone can break the addiction and beat the stages. Then all you must do to maintain this freedom is simply remember, NEVER TAKE ANOTHER PUFF!

The letter to the other person mentioned above.

Dealing with emotional loss has similarities to dealing with anger in regards to smoking cessation and its aftermath. When a smoker encounters a person or situation that angers them, they initially feel the frustration of the moment, making them, depending on the severity of the situation, churn in side. This effect in non-smokers or even ex-smokers is annoying to say the least. The only thing that resolves the internal conflict for a person not in the midst of an active addiction is resolution of the situation or, in the case of a situation which doesn't lend itself to a quick resolution, time to assimilate the frustration and in a sense move on. An active smoker though, facing the exact same stress has an additional complication which even though they don't recognize it, it creates real significant implications to their smoking behavior and belief structures regarding the benefit of smoking.

When a person encounters stress, it has a physiological effect causing acidification of urine. In a non-smoker or non-nicotine user, the level of urine acidity has no real perceivable effect. It is something that internally happens and they don't know it, and actually, probably don't care to know. Nicotine users are more complex. When a person maintaining any level of nicotine in their body encounters stress, the urine acidifies and this process causes nicotine to be pulled from the blood stream, not even becoming metabolized, and into the urinary bladder. This then in fact drops the brain supply of nicotine, throwing the smoker into drug withdrawal. Now they are really churning inside, not just from the initial stress, but also from the withdrawal effect itself. Interesting enough, even if the stress is resolved, the smoker generally is still not going to feel good. The withdrawal doesn't ease up by the conflict resolution, only by re-administration of nicotine, or, even better, riding out the withdrawal for 72 hours totally eradicating nicotine via excretion from the body of metabolizing it into bi-products which don't cause withdrawal. Most of the time, the active smoker more often uses the first method to alleviate withdrawal, taking another cigarette. While it calms them down for the moment, its effect is short lived, basically having to be redone ever 20 minutes to half hour for the rest of the smokers life to permanently stave off the symptoms.

Even though this is a false calming effect, since it doesn't really calm the stress, it just replaces the nicotine loss from the stress, the smoker feels it helped them deal with the conflict. It became what they viewed as an effective crutch. But the implications of that crutch are more far reaching than just making initial stress effects more severe. It effects how the person may deal with conflict and sadness in a way not real obvious, but real serious. In a way, it effects their ability to communicate and maybe even in someway, grow from the experience.

Here is simple example of what I mean. Let's say you don't like the way a significant other in your life squeezes toothpaste. If you point out the way it's a problem to you in a calm rational manner, maybe the person will change and do it a way that is not disturbing to you. By communicating your feeling you make a minor annoyance basically disappear. But now lets say you're a smoker who sees the tube of toothpaste, get a little upset, and are about to say something, again, address the problem. But wait, because you are a little annoyed, you lose nicotine, go into withdrawal, and before you are going to deal with the problem, you have to go smoke. You smoke, alleviate the withdrawal, in-fact, you feel better. At the same time, you put a little time between you and the toothpaste situation and on further evaluation, you decide its not that big of a deal, forget it. Sounds like and feels like you resolved the stress. But in fact, you didn't. You suppressed the feeling. It still there, not resolved, not communicated. Next time it happens again, you again get mad. You go into withdrawal. You have to smoke. You repeat the cycle, again not communicating and not resolving the conflict. Over and over again, maybe for years this pattern is repeated.

One day you quit smoking. You may in fact be off for weeks, maybe months. All of a sudden, one day the exact problem presents itself again, they annoying toothpaste. You don't have an automatic withdrawal kicked in pulling you away from the situation. You see it, nothing else effecting you and you blow up. If the person is within earshot, you may explode. When you look back in retrospect, you feel you have blown up inappropriately, the reaction was greatly exaggerated for the situation. You faced it hundreds of times before and nothing like this ever happened. You begin to question what happened to you to turn you into such a horrible or explosive person. Understand what happened. You are not blowing up at what just happened, you are blowing up for what has been bothering you for years and now, because of the build up of frustration, you are blowing up much more severe than you ever would have if you addressed it early on. It is like pulling a cork out of a shaken carbonated bottle, the more shaken the worse the explosion.

What smoking had done over the years was stopped you from dealing early on with feelings, making them fester and grow to a point where when the came out, it was more severe than when initially encountered. Understand something though, if you had not quit smoking, the feelings sooner or later would manifest. Either by a similar reaction as the blow up or by physical manifestations which ongoing unresolved stress has the full potential of causing. Many a relationships end because of claming up early on effectively shutting down conflict resolution by communication between partners.

As I said, anger is not the only emotion effecting urine acidity. Sadness does this too. The losses of your family members likely increased your smoking consumption at the time. By smoking you too may have suppressed numerous feelings and emotions during the losses. In a sense, not only did smoking impact your communication with others, but also maybe with yourself, coming to grips with certain feelings. In a sense, you may have interfered to some degree with your own personal growth at the time. And now, by quitting, these feeling are manifesting. While it may hurt at the time, it may be essential that these feeling are coming out. Beneficial in fact, making you face feelings in a way more constructive than smoking and suppressing them. And again, understand, if they are there deep seated all this time, if they didn't come out now, they were going to come out eventually. In what manner no one can predict. But the sooner you deal with the feelings, the less severe the reactions will generally be.

This above text doesn't resolve the feelings, it may just help you understand the possible problem. Talk with people here if that helps. Maybe there are more personal issues, you may find it more helpful to talk to a local professional, a doctor or therapist. Whatever you do and who ever you work with, understand, everyone will have greater interest in helping you than cigarettes will.

I know people who are afraid to take medications for mood disorders but will smoke in its place. No matter what drug would be prescribed for them, none of them would carry the risk that self-medicating oneself by nicotine carries. Smoking is lethal. Don't give cigarettes the legitimacy to treat feelings. They don't. They make them worse. They in effect minimize your ability to communicate and grow. Growth may hurt, but it beats carrying on unresolved feelings that slowly may deteriorate the quality of your life.

Hope this helps explain why it hurts so much but also helps you to understand why it is still so important not to smoke.

Will talk to you again soon.

Joel

Summary:

I don't want to give the impression that the majority of people become clinically depressed or need medications to deal with the normal depression phase that accompanies initial smoking cessation. The fact is that only a small percentage of people will have a full-blown organic depression occurring just after quitting smoking. But that fact is not important if you are one of these individuals. What is important is that if you believe you are organically depressed get checked out by your doctor.

Especially if you are a person with a past history of treatment for depression or if your depressive episode is lasting more than a week and is causing a real disruption in your life, get checked out. You may indeed benefit from treatment or maybe your physician will just give you the reassurance that you are really okay. Either way it doesn't hurt to get the situation professionally assessed.

Joel

There are some people who are depressed from an organic basis and medications may be indicated and beneficial for them. What is the difference between taking a prescribed medication to treat depression as opposed to using cigarettes to treat it? First, a prescribed medication must be approved by the FDA and must show some record of being SAFE and EFFECTIVE for treating a specific ailment. Being effective means that it has been shown to clinically help people who have depression-being safe means that there are generally low risk of dangerous side effects and that it is generally not a life threatening treatment. Using cigarettes to treat depression is not likely to be as effective as a prescribed medication and more importantly, carries a mortality rate of 1 in 2. No drug for any purpose would be prescribed that killed one in two people who use it, or even one in one hundred or a thousand if it were not being used to treat a life threatening illness treatable by other less dangerous means.

Depression can be a chemical imbalance in some people, just as some other mental illness like schizophrenia or bipolar diseases can be caused from improper balances of certain substances normally present in people who don't have such illnesses. Using medication for these people may be as necessary as a diabetic needing insulin to treat what is basically a chemical imbalance causing a medical condition as opposed to mental illness.

It cannot be determined online by anyone whether an individual is in fact experiencing a normal adjustment period or an organic based depression and so it is imperative that if the question is raised by an individual that he or she may be depressed that he or she gets attention from a person in the real world who has more to go on that words written on a bulletin board. Nobody is qualified to make a definitive diagnosis of mental illness or any diseases without getting more information both history wise and possibly physical measures only available by a physician who actually can test the patient.

Pharmacological Crutches

Due to the recent release of Nicorette ^®, a chewing gum containing nicotine, I feel it is necessary to issue a special warning to all clinic participants who may be considering experimenting with this product. The gum is intended to be used by smokers to ease the severity of symptoms encountered during initial smoking cessation.

But the ex-smoker occasionally desires a cigarette months and even years after quitting. He may feel that the urge is due to a physiological residual effect of withdrawal. This thought may lead to the idea that trying the gum may help get rid of the desire. But, the actual cause of the thought for a cigarette is due to a psychologically triggered response. Some situation, person or event is causing the thought for a cigarette. While these occasional triggers may be annoying, they pass in seconds and may not occur again for hours, days or even weeks.

If the ex-smoker tries the gum, the end result will be tragic. For once he takes the first piece, his addiction to nicotine will be re-established. Once again he will be in nicotine withdrawal. Then he will have to make a choice--either relapsing into full fledged smoking or once again encountering the two week nicotine withdrawal. All this because he wanted to ease a thought for a cigarette which would have only lasted seconds.

Even the intended use of nicotine gum presents certain problems. Many hope the gum will be a panacea for the truly addicted smoker. But caution must be given to the indescriminate use by any smoker who feels that this new aid will help him break free from cigarettes. For while the gum may reduce the severity of initial withdrawal, it does so at a cost.

Normally, when a smoker quits, physical discomfort will peak within 72 hours and totally subside within two weeks. While the first three days may be traumatic, with proper support any smoker can successfully get through this period.

Use of the gum may reduce the initial severity of withdrawal when quitting. The ex-smoker may continue chewing the gum for months, never reaching peak withdrawal. But because blood nicotine never reaches the levels maintained by cigarettes, nor totally leaves the body, he feels minor withdrawal symptoms on a chronic basis. When he finally quits using the gum, he will probably experience the same withdrawal he would have originally encountered when quitting cigarettes.

The gum may help an addicted smoker break some of the psychological dependence and conditioned responses before experiencing potential difficult withdrawal. But the cost for this easing of initial symptoms is a prolonged chronic withdrawal followed by peak symptoms when giving up the gum. This is a lot of long term discomfort which could be avoided by simply ridding the body of all nicotine by quitting cold turkey.

When you quit smoking, you broke free from the addiction to nicotine. As long as you keep all nicotine out of your body you will never again have to worry about the health consequences of smoking or deal with the withdrawal of quitting. If you wish to stay free, don't try the gum, and as for cigarettes, cigars or pipes - NEVER TAKE ANOTHER PUFF!

NOTE: This was originally published in 1984. Since then, a number or similar products, (e.g., patches, gums, other devices are currently under development), have been introduced as over the counter cessation aids. The same principal applies to them all - they are transferring the delivery system of the drug nicotine. If the smoker simply stops, withdrawal will peak and start to subside within 72 hours. Use of the agents will unnecessarily prolong the cessation process as well as add to the expense.

Pharmacological Aids:

Prolonging Withdrawal Syndromes

“I could ring your neck! What is this 72 hour garbage you are preaching about. It is not getting any better! You lied to me from day one!�? This warm greeting was thrust upon me on a Sunday night by an irate clinic participant. Sure, she had reason to be mad. After all, being in constant withdrawal for five days is enough to make any person lose her composure.

While she had every right to be angry, it was aimed at the wrong person. She had only herself to blame for this prolonged agony. For unlike the majority of people in her group, she did not throw out her cigarettes during the clinic session Tuesday night. Instead, she had a couple of cigarettes that evening. Then on Wednesday she took a couple of sticks of Nicorette chewing gum. I then told her that due to the administration of nicotine from the cigarettes and then the gum, she was back at square one. She was angry at me then, too. She wanted to know what right I had to tell her she was failing. But she said she would throw out the cigarettes and get rid of the gum.

Unfortunately for her, she did not dispose of the gum and continued to chew a couple of sticks a day. The next three days were horrendous. Every night she came back to the meeting and complained bitterly. But this is nothing out of the ordinary, many people are suffering in the initial three days. On Saturday, she still complained of bitter symptoms. But she knew that she quit a day late, so this too could have been expected. But by Sunday, it should have been getting better. It was not though, and she was fuming.

I told her the gum was prolonging the withdrawal process. "But it's only a couple of sticks, and it's not like I am smoking." It was her failure to recognize this point that was causing all of her problems. Chewing the gum was exactly like taking a couple of puffs. She was administering a small amount of nicotine - not enough to reach the peak nicotine level she desired, but just enough to reinforce her addiction and cause chronic withdrawal symptoms.

After the explanation she was still defiant. She would not accept that the nicotine gum was causing her problem. The next day, though, she came back to the clinic. All of the other participants had successfully overcome the first weekend. They all talked about how they still occasionally desired a cigarette but no longer were suffering the powerful cravings they had encountered the first few days. As usual, they were visibly calmer and enthusiastic about the progress they had made.

Almost everyone in the group expressed similar sentiment. Everyone except our friend with the gum, who still complained bitterly. And she still insisted she needed a cigarette or the gum to make quitting possible and bearable. In the beginning of the meeting she tried to monopolize the discussion. But soon she realized the group had no desire to sit and listen to her complain of the horrors of quitting. It was history to them, and they had more pertinent issues to address.

Finally, after sitting and listening to all the positive feeling expressed by her other classmates, she started to realize that she was the only one suffering. Our predictions of easing of withdrawal after 72 hours were true. And the only difference between her and the other group members was her first few cigarettes and her subsequent nicotine gum use.

Quitting smoking should be done in a manner which is as easy and effective as possible. Cease all administration of nicotine in any form. In a few days withdrawal symptoms will ease up, and in two weeks will stop all together. Then, to avoid ever having to quit again - NEVER TAKE ANOTHER PUFF!

NOTE: This was originally published in 1986. Since then, a number of similar products, (e.g., patches, gums, nasal sprays, and inhalers currently under development), have been or are soon to be introduced as over the counter cessation aids. The same principal applies to them all - they are transferring the delivery system of the drug nicotine. If the smoker simply stops, withdrawal will peak and start to subside within 72 hours. Use of these agents will unnecessarily prolong the cessation process as well as add to the expense.

Quitting Methods - Who to Believe?

Who should you believe on what is the most successful technique for quitting smoking - the government and most smoking cessation experts in the world and the professional health organizations of the world and the pharmacological industry and almost anyone whose career seems to be based in smoking cessation or me?

I guess using this standard it would be best not to believe me. But before jumping ship there is one other important group of people that you may find that will back me up and who are already quite credible to you. It's the people in your family and your friends in your real world who have successfully quit smoking and been off all nicotine products for at least one year or longer.

Find out how the people you know who are long-term ex-smokers actually stopped smoking. By long-term I mean people who are currently off all nicotine for at least a year or longer. You'll likely find that few if any of them have ever heard of me. You will see that many of them had previous quits and relapsed, using all sorts of methods that are endorsed by professionals and maybe even a few of them had professional help with previous attempts. You will find that almost all of them did not follow what is considered the standard recommended advice on how to quit yet they did quit and are still going strong. You'll find that they most likely quit by simply stopping smoking one day for one reason or another and then have been able to stay off by sticking to a commitment that they made to themselves to not take a puff.

Talk to every long-term ex-smoker you know. Do your own surveys. While you are at it, talk to the current smokers you know too. See how many of them have used products and followed the advice of the professionals. Keep in mind, most professional literature will advise people to use pharmacologic aids like nicotine replacement products. Try to see how many long-term successful quitters in your real world encounters actually followed this advice.

Another piece of advice written in most literature produced by smoking cessation experts is something to the effect that temporary slips are common and that you should not let a slip put you back to smoking. People who write advice like this do not understand addiction. A person needs to understand that taking a puff is likely going to kill a quit.

Try to find one smoker who once had quit but are now smokers again who didn't one day take a puff. Finding one such person who fits this criteria is going to take you forever. On the other hand finding current smokers you know who had once had quits that actually lasted for months, years or decades who lost their quits by taking that first puff are quite easy to find. Understand, some of these people had heard comments like, "don't let a slip make you go back to smoking," but sadly, found out from experience that they had little control of the matter once they took that puff.

Our advice if to successfully quit smoking is to simply stop smoking. Our advice for staying off cigarettes is simply to stick to a commitment to never take another puff. So talk to long-term ex-smokers and find out how they quit and hear how they have managed to stay off. Pretty soon you will see it is not a matter of pitting all of the world professionals against me. It becomes a matter of pitting every long-term ex-smoker you know who has successfully quit against the world's professionals. Do the surveys and then I will just become another voice in the crowd of real people who have proven to you that they way to quit smoking and to stay smoke free is to never take another puff!

So how did most successful ex-smokers actually quit?

If you look around the Internet or even request information from professional health organizations on how to quit smoking you are likely to find that the standard advice given is to use a pharmacological approach, i.e., nicotine replacement products and or Zyban. Each time you see this advice you will also be told that these approaches double your chances of quitting. Some sites and groups come out and almost say, point-blank, do not go cold turkey--basically leaving the reader with the impression that nobody could possibly quit this way.

The American Cancer Society's Cancer Facts & Figures 2003 report contains the chart to the right which shows the percentage of current smokers who have tried different routes at quitting smoking and also indicates the percentage of current ex-smokers who quit by different techniques.

The numbers that are highly telling are the percentages that indicate how former smokers had actually quit. Keep in mind that this chart is limited. It does not tell us how long they had quit or other key pieces of information, such as, did the people who used quitting aids such as NRT ever actually get off the NRT. But I am not concerned about that at this moment.

According to the American Cancer Society report, how did former smokers actually quit? Those using drug therapies and counseling had a 6.8% quitting rate while those using other methods 2.1%. The remainder quit cold-turkey or cut down. In that it is generally accepted that cutting down techniques do not work, we can safely assume that they had an extremely limited impact upon the overall number. So, approximately 90% of the people who are successfully classified as former smokers quit cold turkey. On the same page as Table 3 is located you will find the following recommendation:

"All patients attempting to quit should be encouraged to use effective pharmacotherapies except in the presence of specific contraindications."

You have to ask yourself how many of the successful ex-smokers in the world today would have actually succeeded if they sought out and listened to "professional" advice such as this.

If you are trying to determine what is the best way to quit, you have a choice. You can go with the "experts" or you can go with what 90% of successful quitters have done.

Take Your Own Survey

So how do most people really quit smoking? Don't take our word for it, or the American Cancer Society's, but instead talk to every long-term ex-smoker you personally know. See how many of them fall into one of the following three categories:

1. People who woke up one day and were suddenly sick and tired of smoking. They tossed them that day and never looked back;

2. People who get sick. Not smoking sick, meaning some kind of catastrophic smoking induced illness. Just people who get a cold or a flu and feel miserable. The feel too sick to smoke, they may feel too sick to eat. They are down with the infection for two or three days, start to get better and then realize that they have a few days down without smoking and decide to try to keep it going. Again, they never look back and stuck with their new commitment; or

3. People who leave a doctors office given an ultimatum. Quit smoking or drop dead--it's your choice. These are people who some sort of problem has been identified by their doctors who lays out in no uncertain terms that the person's life is at risk now if they do not quit smoking.

All of these stories share one thing in common--the technique that people use to quit. They simply quit smoking one day. The reasons they quit varied but the technique used was basically the same. For the most part they are clear examples of spur of the moment decisions elicited by some external, and sometimes unknown circumstance.

I really do encourage all people to take their own survey, talking to long-term ex-smokers in their real world: people who you knew when they were smokers, who you knew when they were quitting and who you still know as being successful long-term ex-smokers. The more people you talk to the more obvious it will become how people quit smoking and how people stay off of smoking. Again, people quit smoking by simply quitting smoking and people stay off of smoking by simply knowing that to stay smoke free that they must Never Take Another Puff!

Joel

Whatever you do don't quit cold turkey!

Most medical professionals believe that the way to quit smoking is to use pharmacological aids. They think that pharmacological aids are an effective tool for smoking cessation. Why do they believe this? They believe it because almost all of the smoking professionals of the world tell them that they work. Even the Surgeon General of the United States says that they work. If almost all world experts believe that they work, and the Surgeon General says that they work, well then they must really work. Right?

Well, I look at it like this. Lets say I see a published story come out that says a specific pill prevents colds in 100% of the cases in human trials. Then another study verifies it. In fact, every expert in the world comes out and says colds no longer exist -- the pill has eradicated them.

But most people I knew who took this miracle pill still got colds. Worse than that, I took the pill myself and all of my friends who were on the pill kept giving the cold to me. Pretty soon I would dismiss those studies and no matter how many times I see it I would not believe it. Sooner or later I would have to believe my own eyes and ears, basically my own instincts, more than expert opinion.

I have seen people use the argument of who should they believe, the Surgeon General of the United States or me. I somehow get the idea that people think that the Surgeon General is a person who has spent years and decades working with nicotine addicts. That somehow being an expert in smoking cessation is a prerequisite for being the Surgeon General.

I have been running stop smoking clinics since 1976. Back in 1976 I told my second group that they were nicotine addicts. If the people in my 1976 clinics were skeptical and wrote the Surgeon General and asked him if it were true that nicotine was a drug addiction he would have answered no it was not.

It was clearly spelled out in the 1964 Surgeon General's Report that cigarette smoking was not an addiction. In the report of the Surgeon General back in 1979 the Surgeon General was starting to say that maybe it was an addiction, but still had put the emphasis on the habit of smoking being the primary problem. In 1988 the Surgeon General finally issued a report stating once and for all that nicotine was an addictive substance.

In all of the programs I did from 1976 through 1987 I was constantly criticized and attacked for saying that cigarette smokers were drug addicts but I had too much first hand contact with smokers trying to quit that was making it abundantly clear that the Surgeon General was wrong. So I accepted the fact that the Surgeon General and most of the experts of the world were not going to agree with me. For eleven years I was wrong that smoking was an addiciton because the Surgeon General said I was wrong yet today I am no longer wrong on this fact.

The same thing is happening now when it comes to issues like the effectiveness of all of the quitting aids available today. The Surgeon General and most of the world experts say that these products increase success and that people should not quit cold turkey. Again, I have still have too much first hand contact with people who are trying to quit using these products as well as too much contact with people who are actually quitting and succeeding without their use. It is still all too obvious that in real world settings these products do not increase success and that people have a much greater chance of success by disregarding the experts advice.

So I think I am going to just take a wait and see attitude on what the Surgeon General will say ten years or twenty years from now on what is the most effective way to quit smoking. Maybe he or she will have come around by then, maybe not. But I know one thing for sure. That all of the people who decided to follow my advice on how to quit, and then stay committed in the interim to the advice that I gave them on how to remain smoke free, that all of these people will still be successful ex-smokers.

My advice to them, that is so controversial today, is simply that to quit smoking and to stay smoke free is no more complicated than just knowing to Never Take Another Puff!

A Quitter's Dilemma: Hooked on the Cure

By PETRA BARTOSIEWICZ

New York Times

Published: May 2, 2004

OR years it was the same routine: wake up, light a cigarette, inhale deeply and start the day. "I wouldn't even get out of bed without a cigarette," said John Palagonia, 53, of Massapequa, N.Y., who was a two-pack-a-day smoker for more than 20 years.

In 1989, Mr. Palagonia, who entertains at children's parties dressed as characters like Barney and Elmo, decided to quit. He turned to Nicorette gum to curb the cravings for a cigarette. The smoke savored between sips of his morning coffee was replaced with a peppery square. On breaks at work, driving his car, after dinner - all the times he had luxuriated in smoke - he would pop another piece.

"I got to the point that I was having problems with my teeth, and my jaw was killing me," Mr. Palagonia said. He eventually returned to smoking for a short time "to get off the gum." What ended up working for him was counseling, not a hit of nicotine.

A third of the nation's nearly 50 million smokers attempt to quit each year, according to the American Cancer Society, and that has made smoking-cessation products an $800 million business in the United States alone. The products include gum and patches sold over the counter; pills, inhalers and nasal sprays sold by prescription; and even more exotic products like nicotine-infused lollipops sold on the Internet.

Still, addiction to nicotine remains. The medical field has accepted that fact since the mid-80's, when the Food and Drug Administration approved, by prescription, products like gum to give would-be quitters a substitute comparable to cigarettes in price and nicotine content, but without other cigarette toxins.

Now some scientists and former smokers are voicing misgivings. No one disputes that cigarettes, which are laced with toxic additives like ammonia, pose far graver health risks than nicotine alone, but nicotine is also classified as a poison, and in recent studies it has been shown to break down into a substance that causes abnormal cell growth. In 2001, researchers at Stanford University found that nicotine speeds the growth of malignant tumors by stimulating the formation of the blood vessels that feed them, a process called angiogenesis.

Dr. John Cooke, the lead author of the Stanford study, said, "As long as people are using nicotine replacements properly, it's a win for all of us, if we can get people to stop smoking. But, I would urge people not to use it long term."

For people addicted to nicotine, using the replacement products properly can be difficult. A study financed by GlaxoSmithKline, the pharmaceutical company that manufactures Nicorette and other stop-smoking products, found last November that more than a third of nicotine gum users continued chewing beyond the 12 weeks recommended under F.D.A. guidelines.

"We estimate 36.6 percent of current gum users are engaged in persistent use," said Dr. Saul Shiffman, a company consultant and the study's primary author. Though the company says on its Web site that nicotine "may promote lung cancer," it insists its products are safe "when used as directed."

Even the companies that make nicotine-replacement products acknowledge problems with treating this particular addiction. Dr. Kenneth Strahs, GlaxoSmithKline's vice president for research and development in smoking control, said, "I wish we could tell you that if you took one piece of our gum it would be enough, but that's not the case. Nicotine addiction is a chronic relapsing condition."

When the F.D.A. approved over-the-counter sales of Nicorette gum and the NicoDerm CQ patch in 1996, sales of the two products soared. GlaxoSmithKline reported $578 million in global sales of over-the-counter nicotine replacements during 2003, down from $606 million the year before as other companies jockeyed for market position.

How effective these products really are remains a debate. Some ex-smokers and smoking-cessation experts oppose using nicotine at all when trying to quit. "It's like the difference between snorting cocaine and freebasing it," said Mr. Palagonia. He has neither smoked nor chewed nicotine gum for a decade now after years of meetings at Nicotine Anonymous, a 12-step program.

"The trick with getting off cigarettes is to stop delivering the drug," said Joel Spitzer, a smoking-cessation counselor and director of education at WhyQuit.com, an online support and education site that advocates quitting nicotine cold turkey.

Mr. Spitzer, who estimates he has counseled 5,000 individuals in stop-smoking clinics he has run in Chicago, says nicotine replacements keep ex-smokers in a protracted state of withdrawal.

Denise Henrie, a mother of four from Owasso, Okla., is familiar with that. Ms. Henrie, 43, tried and failed twice to quit smoking, using nicotine gum for more than a year. "You feel a little hopeless," said Ms. Henrie, adding, "I just don't want to be addicted to anything at all." She has slipped back to her pack-and-a-half-a-day habit, but she remains optimistic. A package of Nicorette sits in her kitchen pantry for a third try.

According to the American Cancer Society, fewer than 5 percent of smokers who attempt to quit each year succeed. Of those who do, the society reported last year, 91 percent quit cold turkey.

Some people succeed only after a long struggle. Jeanne Hutchinson, 59, began chewing nicotine gum in 1984, the first year it was available by prescription. "One of the happiest days of my life was when nicotine gum was allowed to be sold over the counter," said Ms. Hutchinson, a social worker in Chicago.

But, years later, she was still hooked on the gum. "I felt almost like a drug addict," said Ms. Hutchinson, who estimates the 12 pieces she chewed each day cost her more than $15,000 over the years, without curing her habit. Suffering from a receding gum line and worn molars, she joined WhyQuit last January and managed to stop using nicotine.

STILL, when she reached into her coat pocket a few months ago and found a long-forgotten piece of gum, it took all her willpower not to pop it into her mouth.

That may be why analysts say that demand for nicotine-replacement therapies is unlikely to wither anytime soon. "We see it as a market with tremendous potential, but efficacy-starved," said Devesh Gandhi, a research associate at Sanford C. Bernstein, adding that the market - for "a product that really works, that manages both the addiction and the side effects of the withdrawal" - is there for the taking.

http://www.nytimes.com/2004/05/02/business/yourmoney/02smok.html?pagewanted=all&position=

Copyrigtht 2004 The New York Times Company

So what's the harm of just using nicotine for the rest of your life. After all, it is not totally clear if nicotine itself is a carcinogen, and so many medical professionals think that it is relatively harmless when compared to the well established dangers of smoking.

The real danger is an issue that most people asking this question are not taking into consideration. The products are keeping the users in a mild to moderate form of chronic withdrawal. These people are never getting free of nicotine and thus free of the demands that their bodies are going to put on them.

When I first met Jeanne who was talked about in this story it was at a Chamber of Commerce meeting in the city where I live. Jeanne, knowing that I was the person who ran the clinics for the city, came up to introduce herself to me and to tell me that she had been off smoking for 12 years. Jeanne was proud of that fact. She was not looking for help or advice at the time. My guess was that she didn't feel she needed it considering she was off smoking for 12 years.

Her next comment to me though is what triggered our longer term association. She told me that she has still struggles every day and still constantly thinks of smoking. This raised a flag to me. You see, whenever I meet a person who has been off anywhere close to Jeanne's time off, they will generally say that they hardly think of smoking anymore. Or sometimes, they will say that the still think about smoking, and when I pursue the conversation it turns out that they think about it once a month or once every six months, and that it is nothing major or difficult to contend with.

Jeanne's story was different though, she was clearly saying that she was still struggling daily and has been for the past 12 years.

This is when I asked Jeanne how she quit and when she told me that she had used nicotine gum. When I asked her how long she used the gum she said that she was still using it. I think I let out a little laugh and proceeded to ask her if she ever tried to get off the gum. To that she responded that she had at one time tried to get off the gum by using the patch. That one elicited a bigger laugh from me.

Actually, when Jeanne first quit she used the gum as prescribed and pulled off the quit and got off the gum. I talk about this kind of person in the post Is cold turkey the only way to quit? She was off for a number of months, but one day under stress felt that she needed something and took a piece of her left over gum to help her through the moment. That piece of gum is what resulted in a 12 year, $15,000 addiction that kept her in a constant state of relative discomfort.

So is long-term use of NRT going to have the potential of killing a specific individual? No one knows the answer to this for sure at this point in time. But long-term use of NRT is going to have the full potential of making a person suffer years or decades longer and spend a small fortune compared to any person who simply makes and stick to the commitment to never take another puff!

Joel

Is cold turkey the only way to quit?

I have seen it written that we have said that the ONLY way to quit smoking is to quit cold turkey. This is not a totally accurate statement. It is not that cold turkey is the only way to quit,; it is just that cold turkey is the method which gives people the best chance of success. It is the method that all but a small percentage of long-term ex-smokers in the world used to successfully quit smoking.

There are people who have quit using alternative approaches. There are some who cut down gradually and actually succeeded at quitting. For every person who did it like this and succeeded, there are many many many many others who tried it and failed. The individual who used the method will think it is great because it worked for him or her, but since it works for so few people it will generally be recognized as a pretty ineffective technique by most people who do "real world" research into how to quit.

By "real world" research I mean by going to long-term ex-nicotine users who you know personally and finding out how they all got off nicotine. Again, you will very rarely find any who did it by gradual withdrawal. If you find a person like this who is now off years, you should never minimize the person's success. He or she quit smoking, likely doing it in a way that made it much more difficult than it needed to be, but still he or she did pull off the quit. The only advice that I would encourage that you share with the person is that now to stay off he or she must understand the bottom line method of sustaining his or her quit. That message is staying cognizant of the addiction and that the only true guaranteed method to stay off now is knowing never to administer nicotine again.

The same principle here applies to people who use NRT products. There are people who have quit this way. Again, it is a small percentage of the long-term ex-users out there, but they do exist. An individual who pulled it off this way will also feel that it is a great method for quitting. But again, this method works for a small percentage of people who try it and if you look into real world long-term quits you will have a very hard time finding many people who actually successfully got off nicotine this way.

I feel it necessary to use that phrase, "got off nicotine," as opposed to saying, "got off smoking." There are some major experts coming out and advocating that people should be given nicotine supplements forever to stay off of smoking. Can this work? Of course it can. If you can give people enough nicotine via supplements it will satisfy their need for nicotine. After all, this is the primary reason they were smoking at the end--to feed a nicotine addiction. If the smoker can just get nicotine for the rest of his or her life via another route, he or she will avoid going through the three days of nicotine withdrawal.

The question needs to be, why should anyone have to pay what is likely to be tens of thousands of dollars to avoid a few days of withdrawal.? On top of this, these people will never be totally free of the moderate withdrawals that such usage is likely to keep going. These people will in fact tout the use of the product as a great aid, but when compared to what people who are totally nicotine free are experiencing, this victory over cigarettes is just a bit hollow.

There are a few people though whom you may encounter over your lifetime that did quit using NRT's as intended, weaning down for week after week and eventually quitting. If the person is now off for years, he or she is pretty much in the same state as a person who had quit cold turkey. He or she is nicotine free, and he or she should be thrilled by that fact. In some ways I look at people like this with a bit of awe, for they in all likelihood stuck with a process that was pretty much a gradual and prolonged withdrawal and yet they succeeded.

Again, debating the merits of their method with them is pretty much a moot point. It worked for them and you are going to have a pretty hard time convincing them that it is an ineffective method. But you do have a message that you can share with them that they do need to know. That message is that even though they are off nicotine for years, they still need to recognize that they are not cured of nicotine addiction and never will be. No matter how they had stopped, they must still understand the bottom line message, that the only way to stay free now is staying totally committed to never administer nicotine again via any nicotine replacement source and to never administer nicotine again from the original source that likely started the whole process by knowing to never take another puff!

General Comments About the Use of Zyban

In some ways I am pretty neutral with the use of Zyban. Zyban is not a nicotine replacement so does not perpetuate the withdrawal state. Because there is no nicotine involved I don’t feel it undercuts a person chance of quitting like nicotine replacement products can. I have had people in my clinics that have quit while using Zyban. In all honesty though, I didn’t see them do any better or worse success wise than the others in their groups.

While during the initial quitting period while in the clinic you couldn't really see any differences in the people taking Zyban when compared to those who were not using it. Where differences would sometimes become more noticeable though was a few weeks after the clinic was over. Then I would see that clinic participants who were still on Zyban were having side effects not happening to the other clinic graduates who quit at the same time as them. The most notable complaint was sleep problems that went much longer than one would normally expect for those who do not use Zyban.

Because of the extended side effects I personally question whether it is really worth the longer-term side effects and expense if it isn’t making a real difference in success? On the other hand, would some of these people not have even started their quits without the feeling that it was really going to make the difference?

I do think more people take it than really need to but if a person does not experience unwanted side effects and his or her doctor thinks that he or she should take it and the person does actually quit, well then he or she is off smoking and that is what is important. Again, I suspect that the person could have done it without the medication, but since the person is off that belief is a moot point.

I am troubled when I see people report on the board that they can’t quit smoking because they can’t tolerate the medication. They are feeling handicapped before they start to quit and they are giving the drug too much credit. Again, you can quit with it if it is tolerable and you and your doctor feels it is safe for you to use. You can quit without it too if you really want to stop and are willing to put in the effort it takes to quit. That is the truth in both cases though, with Zyban or without. Your quit will succeed either way if you always understand the importance of knowing to never take another puff!

Joel

NRT and Quit Meters

I received an email question from a newer member who asked about how to set a quit meter considering she had started using nicotine patches five days before actually joining up at Freedom. She had not smoked 120 cigarettes in that time period and she did not feel she wanted to reset her quit meter for it would not accurately reflect how many cigarettes she had not smoked nor how much money she had saved. She also seemed to feel that because she had suffered so much those first five days that they must have to count for something, or that her whole quit was invalid because we seemed to act as if we felt tha the first five days somehow did not count.

I tried to email her back a reply but her email box was full and the message got kicked back to me. So I am posting the response here for in fact the message is important for other people who may have had a similar experience of finding Freedom after they had already had an NRT quit going.

Here is the response I had written:

A high percentage of people I run through clinics have actually tried NRT products in the past-actually over 85% of people who went through my clinics last year had tried NRT products and have now basically written off the experience as a waste of time. They don't try to hang on to past failures but rather now are focused on maintaining current and future success.

I think most people at Freedom are here now too because they are also of the mindset that the day they quit using nicotine is the day they stopped using nicotine. As far as you thinking now that the first few days of using patches is now making your whole quit invalid-your ten-day quit is perfectly valid. The first five days though you just transferred how you delivered nicotine. I think you are somehow working with the idea that the first five days have to be valid and important to your quit because you suffered so much during them. Suffering is not the benchmark that makes a quit valid-getting off nicotine is what makes breaking the addiction valid. People suffocating with emphysema are suffering plenty from cigarettes but if they are still smoking I don't think you would say that the suffering is a good thing or some kind of great accomplishment.

The money saved issue is pretty much a moot point too-you likely spent more on the patches than cigarettes would have cost you-especially considering you probably spent close to $50 for the box of patches and only used a few. So to say you saved money by that purchase is really misleading too.

As far as cigarettes not smoked in the meters, I think our group mindset is not really cigarettes not smoked as much as it is nicotine not used. Cigarettes are just the unit of measure for nicotine. To most of our members counting the time that a patch was used would be like an alcoholic who used to drink whisky exclusively now saying they successfully gave up drinking because all they have daily now is scotch. Alcohol is alcohol and nicotine is nicotine.

Our board is unique. Almost no other site on the Internet would agree with this stand and will gladly welcome you in and allow you to use whatever numbers you want. But people are here because they are done playing games like trying to make themselves feel better about their past ways of maintaining nicotine addiction and are now trying to make themselves actually get healthier by actually taking control of their addiction. I hope you do the same.

If you can come to grip with the concept of measuring from the day you stopped the patch you will likely be happy and successful here, but if this concept is too much of a stumbling block you will likely find yourself happier elsewhere. While you may be happier elsewhere, I am not so sure you are going to be as successful elsewhere-but the choice of what groups fits you best has got to be yours.

One last point, the 120 cigarettes difference is not going to seem important when the number of cigarettes not smoked read 10,000 or 50,000 or 100,000, and maybe more. Those numbers will be real one day if you always remember from now on that to stay smoke free simply requires always staying committed to never take another puff!

Joel

Thanks so much for the reply, that was really helpful. I didn't realize that the patch could actually be prolonging my problem. I am frankly afraid to quit cold turkey...I'm about a quarter of the way through the patch process and I think I'm going to stick with it, even if I don't feel great. It's kept me from puffing although thanks to your message, I understand that I'm still addicted and receiving nicotine the way I am could be prolonging my problem. Just knowing that helps me to deal with it better. A friend of mine who has quit for more than a year first recommended your site to me and I want to thank you for what you are doing. This is a terrible addiction and one I will always be dealing with if I am completely truthful. However, this site and your concern make it easier. Keep it up, Joel. You impact more lives than you will never know. Here's to NEVER TAKING ANOTHER PUFF!

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