Tobacco Free, Drug Free
Elizabeth (Libby) Stuyt, MD is President of NADA (National Acupuncture Detoxification Association) and Medical Director, Circle Program, Colorado Mental Health Institute, Pueblo, CO. She is one of the few addiction experts in the country who has seen the benefits of tobacco cessation to improve outcome and maintain recovery during and after treatment for other addictive substances and has published her findings:
Dr. Stuyt found that of 140 patients who completed the follow-up, 86% were using tobacco daily upon program entry and 73% picked up tobacco again during the year after treatment. Most striking was the difference in relapse rates for other drugs between those who returned to tobacco use after leaving the program (69%) and those who refrained from returning to tobacco (45%). In significant numbers, those who remained tobacco-free after release were more likely to remain abstinent from their other former drugs of choice throughout following year.
Tobacco Free, Drug Free
By Dr. Elizabeth (Libby) Stuyt
Director, Circle Program, Colorado Mental Health Institute
President, National Acupuncture Detoxification Association
My patients in the Circle Program are in a controlled environment for 90 days and have to stop using everything, including tobacco. There is a high correlation between smoking tobacco and relapse to every other drug. So, I think it is of paramount importance to stop smoking during drug treatment.
Tobacco works like all the other addictive drugs. It suppresses neurogenesis in the hippocampus, which suppresses learning.
In animals, researchers study the effect of drugs by using a Morris water maze. It’s a big tank of water in the middle of the room with a little block of wood under the surface. They see how long it takes for the animal to find the block of wood, get on it, and say to themselves, “Finally, I’m saved.”
Animals, once on the wood, can figure out where it is inside the tank from pictures that are posted along the edges of the tank, and go directly to the block of wood the next time they are placed in the water. However, if you fill their brains with drugs, including nicotine, they cannot find the block of wood to save their lives. If you get them off of drugs, exercising and eating right, the rats can find the block of wood again.
If you have got someone in substance abuse treatment, regardless of the drug, and that person is still using tobacco throughout the entire treatment program, you have suppressed neurogenesis in their hippocampus which makes it difficult for them to learn anything new. The hippocampus is where you put memories of anything that is important.
When you use an addictive substance for the first time you get dopamine in the nucleus accumbens area of the brain that sends the message to the hippocampus, “This is really great!” The message includes, “Next time you see the guy that gave that to us, remember him!” It sends a message to the prefrontal cortex part of the brain too, where consequences are stored, but the prefrontal motor cortex isn’t fully developed until early adulthood, ages 21 to 25. Most patients started using addictive substances during adolescence. Use of addictive substances hijacks the proper development of the learning and memory part of the brain so even though they may be in their 30s or older the brain never was able to mature adequately in those areas. The next time you see that same guy all you remember is the good part of using so you go right up to him to get more drugs. The more times you do this on a regular basis then the more profound the suppression of neurogenesis in the hippocampus and the harder it is to learn from the consequences of your behavior.
It takes 90 days for stem cells to grow in your hippocampus to differentiate and allow for new learning tracks to be laid down. Alcoholics Anonymous has known this intuitively forever. They say, “If you stop drinking, go 90 for 90.” They mean you need to go to 90 meetings in 90 days.
One reason 12 Step programs alone don’t always work is that meetings include a cup of coffee in one hand and a cigarette in the other. The ideal is to stop every addictive substance. If you can go through a 90-day period to allow the brain to heal, new neurogenesis will happen, and you will be able to rewire new neurons and learn new things. Most people don’t have the beauty of getting locked up for 90 days and even if they do, most programs allow them to drink as much caffeine or smoke as many cigarettes as they like.
I am adamant that treatment has to be tobacco-free. Tobacco is a very powerful drug. It is the hardest drug to quit, even heroin addicts admit that. It’s the only one addicts of all kinds use all day every day so it is reinforced.
I’ve forbidden the use of tobacco both in the inpatient and outpatient settings I’ve directed. Initially, for the first week or so, they are angry, can’t stand it. Ear acupuncture is really helpful for people at this stage. Once they are past the bad withdrawal period, the NADA 5-point ear protocol can continue to help with cravings and allows them start thinking differently.
In our inpatient program, I also use a nicotine patch for the first three weeks, if they have been smoking a pack a day or more. They get a 21 mg patch the first week, every day a new one. The next week they are down to 14mg every day for a week, then down to a 7mg patch every day along with NADA ear acupuncture 5 days a week. My perception is that the worst cravings occur during the first three days and get slowly better after that. We definitely see the folks who participate in NADA’s ear acupuncture reporting very minimal cravings and those who don't, reporting more significant cravings. We have many people refusing the patch after the first 1-2 weeks so the patch isn't that necessary in an inpatient setting where no one is exposed to other people smoking or being triggered by cues to smoke.
In the outpatient setting it’s the same model but it is harder for them. I make the Intensive Outpatient (IOP) patients come for treatment three hours a day, and they can’t use any tobacco during those three hours. I give them a patch and offer NADA, but they go back to using when they leave. They can’t seem to hear anything about the drug while they are using the drug. They can’t incorporate that information. So, most don’t quit a substance until they have a consequence. If people wait until they get consequences from tobacco it could be a heart attack or cancer.
The beauty of forced tobacco cessation is that quickly they can run, breathe, and feel so much better. At least jails and prisons are tobacco-free. That gives people the experience that they cannot smoke. That is the best benefit, when sitting in jail three or four months not using anything, they have the ability for their brain to heal, and can start learning right away.
I have gone around the country talking to treatment programs about stopping smoking on their campuses and it is a hard sell because they have the false impression people aren’t going to come there if they don’t allow them to smoke. If they have a good program people will come! CeDAR (Center for Dependency, Addiction, and Rehabilitation), for example, is a beautiful inpatient program in Aurora, Colorado, affiliated with the University of Colorado. That was the first place we started doing a NADA training for nurses, back in 2008 or so. They have been doing NADA there ever since. When they took me on a tour I saw a big sign in front of their gorgeous administration building: “University of Colorado is a tobacco free campus.” I was so excited, but then they told me, “We are the only place that has a smoking exemption.”
Soon thereafter I met the medical director at a conference and told her, “We in Circle are treating all your CeDAR failures because they have spent all their money at CeDAR, relapsed right away, and are now in Circle. Since they are allowed to smoke in your program, they don’t learn anything new.”
They finally went tobacco-free about three years ago, on Valentine’s Day. We have not been seeing CeDAR failures in my program, since! The CeDAR medical director actually published a poster in another conference revealing that they have saved money, made more money, and have better outcomes since forbidding smoking.
Tobacco plant leaves are dried, cured, fermented, and jazzed up with flavors and sugars then smoked, chewed, or sniffed. The pleasure that derives from them has been coveted for millennia. Tobacco contains nicotine, a drug that satisfies many different cravings. Need stimulation? Check! Need relaxation? Check! Need comfort? Check! All of this is due to nicotine’s effects on our pleasure-producing neurotransmitters: Dopamine, GABA, endorphin, and serotonin.
In his book “the brain chemistry plan”, physician Michael Lesser, MD suggests some people who are nervous or upset smoke because the nicotine in cigarettes can also convert into the B vitamin niacin (called nicotinic acid) which has calming qualities.
Tobacco constricts the flow of blood to the brain and body parts, can contribute to depression, miscarriage, infertility, heart disease, emphysema, cancer, high cadmium levels, and wrinkles, and, in addition, to nicotine contains some 4,000 different toxic chemicals that may not only adversely affect the smoker’s health in multiple ways it even influences the lives of people who are exposed to it after the fact in the rooms in which cigarettes were smoked by others. Third hand smoke exposure from carpet, drapes, and sofas, may change a person’s DNA and create cancerous tumors.
In spite of all these negatives, most drug treatment programs allow clients to smoke, and many counselors in recovery smoke as well. However, research by Elizabeth Stuyt, MD, Medical Director of the Circle Program at Colorado Mental Health Institute at Pueblo in Pueblo, Colorado, suggests smoking while in treatment for addiction is counterproductive. In multiple research studies including Dr. Stuyt’s own, smoking cessation is associated with significantly greater abstinence from all drug use after graduation from a treatment program.
Recently e-cigarettes have attracted young people as a safer alternative because they vaporize the nicotine instead of burning tobacco, but “vaping” is still being researched and no long-term studies have confirmed its safety. In fact, they contain toxins such as acrolein (an irritant to eyes, nose, and skin), formaldehyde (a known carcinogen), and diacetyl (causing problems to lungs). And, addictive nicotine is still addictive.
Unrelenting withdrawal symptoms like irritability, trouble sleeping, inattention, and cravings for food and tobacco drive the vast majority of people quitting smoking to relapse. The Food and Drug Administration has approved a variety of pharmacological aids to stopping smoking, which deliver nicotine in small doses to help prevent withdrawal as the user cuts back. These include nicotine gum, the transdermal nicotine patch, nicotine nasal spray, and a nicotine inhaler. There are also drugs such as Zyban and Chantix, which have different ways of helping smokers quit. Of the two, only Chantix actually works on the same receptors affected by nicotine but both have undesirable side effects such as nausea, dry mouth, and headache, with Zyban also causing muscle pain, itching, and loss of interest in sex while Chantix also can cause insomnia. That is why taking targeted amino acids to nourish the nervous system and replenish neurotransmitter stores will help the smoker become a nonsmoker more easily and successfully than simply stopping cold turkey or using pharmaceutical aides.
Alliance cofounder Charles Gant, MD, PhD, devotes an entire chapter of his book End Your Addiction Now to stopping smoking. He tells the story of a patient who didn’t want to stop smoking but was in a hospital-based recovery program for alcoholism and receiving nutrients daily as a part of his alcohol recovery program. Dr. Gant slipped in specific nutrients (listed below) to help reduce nicotine cravings, and within three days the patient was noticing he was burning cigarettes out of habit, not out of need. In addition, they were beginning to taste like cardboard. Replenishing the missing nutrients after years of smoking quickly begins to relieve cravings.
Here are the six nutritional supplements Dr. Gant recommended to help reduce nicotine withdrawal cravings and symptoms: B Complex, multi-mineral, l-glutamine, l-tyrosine, 5HTP, and phosphatidyl choline. For specific dosages, see End Your Addiction Now. Some smokers require DL-phenylalanine (DLPA) or GABA supplementation instead of or in addition, depending on which neurotransmitters are most depleted (as per the amino acid assessment questionnaire).
B Complex – nourishes the nervous system
Multi-mineral – helps transform amino acids into the neurotransmitters that affect mood
L-glutamine – keeps blood sugar even and increases energy
L-tyrosine – builds more dopamine and a sense of reward and energy
5HTP – builds more serotonin for a sense of happiness and improves sleep
Phosphatidyl choline – a phospholipid important for improving all brain cell function, including neurotransmitter production.
DLPA – helps increase pleasure and comfort by maintaining endorphin levels.
GABA – for natural relaxation.
End Your Addiction Now: The Proven Nutritional Supplement Program That Can Set You Free; Charles Gant, MD, and Greg Lewis, PhD; Square One; 2010.
The brain chemistry plan by Michael Lesser, MD, Perigee, 2003, p.167
American Chemical Society (ACS). "Major 'third-hand smoke' compound causes DNA damage and potentially cancer." ScienceDaily. 16 March 2014
The Health Effects of Electronic Cigarettes
Chitra Dinakar, M.D., and George T. O’Connor, M.D.
N Engl J Med 2016; 375:1372-1381October 6, 2016
American Chemical Society. "Exposure to toxins in e-cig vapor varies depending on scenario." ScienceDaily, 2 August 2017. www.sciencedaily.com/releases/2017/08/170802082930.htm
Enforced Abstinence from Tobacco During In-Patient Dual-Diagnosis Treatment Improves Substance Abuse Treatment Outcomes in Smokers. Elizabeth B. Stuyt, MD, The American Journal on Addictions, XX: 1-6, 2014
Am J Addict. 1997 Spring;6(2):159-67.