Sunday, December 10, 2006

Nutrition and Holistic Health as Dimensions in Smoking Cessation Interventions: Why Western Medicine is Not the Only Answer–Cindy Crowninshield

According to the World Health Organization’s 2003 Policy Recommendation for Smoking Cessation and Treatment of Tobacco Dependence: Tools for Public Health tobacco use in 2003 was expected to kill 5 million people worldwide, which was one in ten adult deaths (Costa e Silva, 2003). By 2030, this figure is expected to increase to ten million deaths each year, which is one in six adult deaths. These deaths will surpass projected death tolls from tuberculosis, pneumonia, diarrhoeal diseases, and childbirth complications for that year combined. If trends continue on the upswing, 500 million people alive in 2003 will eventually die from tobacco use. For smokers to quit, they need support. A reduction in tobacco-related deaths over the next 30-50 years cannot be realized unless adult smokers are encouraged to quit. Quitting attempts are made yearly by one-third of smokers with a small percentage achieving lasting abstinence.

The Policy reports that pharmacotherapy and behavioral methods and techniques enable cessation of tobacco use that will lead to improved health. The Policy reports that evidence-based pharmacotherapy offers a variety of options for individuals including several forms of nicotine-replacement therapy (gum, lozenge, patch, nasal spray and oral inhaler) and nicotine and non-nicotine medications that provide effects for which patients previously relied on cigarettes to sustain desirable moods and attention states, and coping with stressful situations and depression. Efficacies of these pharmacotherapy efforts support the probability of long-term smoking cessation. Pharmacotherapy success can be increased if combined with behavioral treatment like motivation, advice and guidance, counseling, telephone, and Internet support; although, behavioral treatment can be effective on its own. No single approach should be singled out over another even though a wide variety of behavioral and pharmacotherapy treatments have proven effective. These treatments vary in cost, efficacy, acceptability, and form. Matching an appropriate treatment form with cigarette smokers is difficult and they often will switch from one form to the next until they find one that is effective for them.

The Policy suggests that a wide variety of methods and techniques have proven effective so far to help with this public health priority and that more emphasis and resources should be placed on these same methods and techniques to help people quit smoking. Why is the Policy making these suggestions when the statistics of deaths from tobacco use are projected to worsen?

In reading literature and analyzing content of the WHO Policy and approximately 50 peer-reviewed articles and several book chapters, and Internet articles relating to smoking cessation and behavioral and drug therapies were reviewed and analyzed. The author of this paper found only one reference on the use of Recovery Discourse (Keane, 2000) as part of the addiction treatment process. Recovery Discourse looks at the root of addiction and how one has been hurt, why they need to cope, and why they feel so depressed. People are encouraged to work on identifying unfulfilled needs, because they give rise to negative feelings about the self, which lead to addictive behavior as a form of self-medication (Keane, 2000). In exploring the kinds of techniques and technologies available to help people behaviorally stop smoking, one suggestion is to emphasize wholeness of self (Keane, 2000) and tailor treatment programs to individuals whenever possible and not to rely on a blanket application of a common, mass attack (Hunt, 1973; Goreczny, 1995). Keane further describes how the fully functioning person, as constituted in Recovery Discourse influenced by humanist psychology, can provide a model of balance by focusing on an addict’s feeling of depression, loneliness, shame, anger, and guilt, and identifying their genesis, usually in early childhood experiences. Recovery Discourse is contrasted to the typical 12-step program (i.e., Stages of Change/Transtheoretical Model outlined by Whitlock) that is used in smoking cessation treatment programs and alcohol anonymous treatment programs. A typical 12-step program looks at broad character traits and focuses on admitting wrongdoing and making mistakes.

The author of this paper could not find any reference in the literature mentioned referred to earlier that examines the role of nutrition behavior theory, smoking cessation, and managing addictions. This paper examines the author’s theory about how if one understands their negative emotions like depression and anger behind the root of their addiction, that these emotions could probably be managed partially through healthy eating habits and their craving of nicotine to help them cope with the same like emotions of depression and anger would decrease. In light of this theory, this paper criticizes the way in which the World Health Organization and the Stages of Change/Transtheoretical Model (Whitlock, 2002) approaches smoking cessation interventions and limits methods and techniques that do not emphasize wholeness of self. This paper suggests ideas to help public health professionals look at treatment for smoking cessation in a new way. We will first discuss the concept of healthier living through balanced eating and then how nutrition as a behavioral intervention benefits smoking cessation by providing people control & balance, confidence & motivation, and self-efficacy.

These days, people are constantly on the road and on the go. They usually don’t have time in the mornings to make breakfast. They end up getting a coffee and a bagel because it’s quick and convenient. If they have time to make breakfast, they don’t know what to make. By lunchtime, they are starving and will often grab something quick from the local deli, vending machine or skip eating all together. A cup of coffee or candy gets them through the rest of the afternoon. Some day’s people work so late that cooking dinner is the last thing on their mind and they often end up getting takeout, heating up a frozen meal, or wanting to prepare and cook dinner under 20 minutes. They think they eat fairly healthy at home and in general. People just eat food for the sake of eating because they are so hungry, but don’t pay attention to what they eat because they don’t have time to plan. There are too many projects, demanding co-workers, and mile-long lists of things to do. Hectic lifestyles at home also make it difficult for everyone to sit down for a family dinner at home. People often feel stressed, depressed, and anxious all of the time and have low energy, feel fatigued and constant cravings. When people often feel this way, they often rationalize these emotions, moods, and physical symptoms as being normal and reach for the nearest comfort item they can find like food, alcohol, cigarettes, sugar or a chemical dependence to feel better about themselves.

Living a rollercoaster schedule has dramatic affects on performance in life including job, relationships, health, and physical activity. Eating healthy means a nutritious, well-balanced meal. There are linkages between how people feel and what they eat (Somer, 1995). As Somer continues to explain, extreme depression, fatigue or other emotional stumbling blocks can be related to more serious underlying illnesses that require medical attention. However, people ignore the profound benefits that food can have on mood, intellect, and energy level and provide support to help them manage their depressions, fatigue and other emotional issues. Not eating healthy triggers imbalanced eating habits that trigger a vicious cycle of healthy behaviors to derail, which make people continue to feel worse and turn repeatedly to the wrong comfort items for a quick fix. People can have energy levels that are consistent and dependable from day to day by integrating simple healthy habits into their daily life and they start with the way they eat. When people understand what motivates them to choose the foods they do, they become more aware of unknown triggers that may perpetuate less-than-healthy behaviors.

In helping people to understand linkages between how they feel and what they eat, they should think about how balanced their food choices are (Turner, 2002). Do they eat a sweet food then suddenly crave something salty? A healthy body craves and relies on balance. Imagine a seesaw with foods on the left and right ends, as well as in the middle. These foods can be categorized by intensity. Extreme foods to the left are alcohols, chemicals, sugar, coffee, and butter/oils. Extreme foods to the right are salt, eggs, red meat, fish, and poultry. In the center of the seesaw are moderate foods such as whole grains, beans, vegetables, fruits, and nuts. If someone eats something moderate, they will crave something moderate. When someone eats an extreme food on the right like salt (potato chips), they will crave something on the other that is also extreme like alcohol (beer). Their seesaw is in a constant state of flux if they are frequently drawn to either of the extreme options. Many Americans eat this way today, forcing their body to expend more energy than necessary to process the foods they eat. This state of flux consumes much more energy than eating and balancing foods close to the center. Habitual eating and mindless selection of extreme foods is wasteful, stressful, and exhausting and causes people to live in an erratic state sapping their energy resources. Another way to think about the seesaw is room temperature and assigning temperatures to different areas of the seesaw. The left of the seesaw is 100 °F and the right of the seesaw is 32°F. The center is 68-72°F. Would someone rather be in Room A with temperatures ranging consistently from 68-72°F? Or would someone rather be in Room B with temperatures fluctuating between 100-32°F?

If someone’s seesaw is in a constant state of flux, their emotions, moods, and physical symptoms will be in a constant state of flux, as well, and they will continue to reach for the nearest comfort item they can find (Weil, 2005) like food, alcohol, cigarettes, sugar or a chemical dependence to feel better about themselves and cope with their emotions like depression and anger. If this state of flux is not balanced, then powerful, addictive forces present that cause people to be hooked on nicotine will exist, no matter how strong their will is for kicking the habit. There is no single smoking cessation technique that works for everyone (Trubo, 2003). Goreczny’s article also discusses how most contemporary stop-smoking programs are multicomponent in nature that combine pharmacological and behavioral strategies and that program content does not vary; although the level of intensities do. The programs include all or some of these behavioral components: self-monitoring, contingency contracting, stimulus control, social support, relaxation or stress management, and relapse prevention. Nutrition is not reflected as one of these components, although, changing diet habits is an important part of the behavioral process. According to Ronda, many people are not aware that their risk behavior is linked with dietary fat intake and physical activity. “Previous research has shown that people who are not aware of their risk behavior are not or less motivated to change their behavior” and “…it is important that information should focus on these misconceptions as a first step towards behavior change motivation” (Ronda, 2003). Additionally, Dr. Weil reports how population studies rank diet second only to smoking as a controllable aspect of lifestyle linked to cancer and if recommended dietary choices are coupled with not smoking, people have the potential to reduce cancer risk by 60 to 70 percent (Weil, 2006).

This paper is not advocating how nutrition should be the end all, be all for managing all emotions, moods, and physical symptoms relating to smoking and nicotine dependence. However, what this paper is suggesting is for public health and healthcare practitioners to consider looking at the person holistically and that their unbalanced eating habits could contribute to fueling unhealthy behaviors that stem from nicotine dependence or vice versa. Perhaps looking at one’s diet and helping them to balance their diet could help them to manage their emotions, moods and physical symptoms in a healthier way. This paper suggests that nutrition be integrated as part of the multicomponent approach in health promotion of smoking cessation. Richard Trubo (Trubo, 2003) discusses other approaches to smoking cessation besides pharmacological and behavioral strategies that have helped a growing number of people permanently stop smoking. Some of these alternative techniques include hypnosis, guided imagery, acupuncture, and nicotine vaccination. One of the main benefits of these unconventional methods is the ability to empower people to change; individuals learn that they have control of their body that they didn’t think they had before. This article doesn’t refer to nutrition; however, integrating it as part of the technique process could potentially be seen as an alternative technique that provides the same benefits to people. Nutrition as a behavioral intervention benefits smoking cessation by providing people control & balance, confidence & motivation, and self-efficacy

One of the biggest shortcomings of awareness programs is not showing people how to develop a behavioral skill, but rather focuses on telling people what to do (O’Donnell, 2005). Dr. O’Donnell further explains how through skill-building programs, showing people how to perform an actual behavior, integrate this behavior within their lives, and change their environment and surroundings is a more effective way in creating opportunities to practice behaviors. In quitting smoking, a skill-building program would “…schedule the change, explain the physical, social, emotional, situational, and other challenges to expect during the withdrawal process, and how to overcome them; how to utilize patches, gum and other aids, how to draw on others for support, how to create new routines and behaviors to replace the smoking behaviors, and how to self-reward for various progress milestones” (O’Donnell, 2005). For nutritious eating, a skill-building program would “…demonstrate how to shop for nutritious foods, how to prepare them to taste great without adding unhealthy ingredients, how to select healthy meals from a restaurant menu, and how to handle social situations….” (O’Donnell, 2005). Successful skill-building programs will teach strategies that overcome barriers, set goals, build skills, practice new behaviors, get feedback, revise goals, and gain and implement new skills. Most program managers overlook developing effective skill-building programs and just focus on awareness/education efforts (O’Donnell, 2005). What healthcare professionals fail to see is if they are trained on Recovery Discourse principles, developing skill-building programs to teach people how to quit smoking and eat healthier, balanced meals and can link these three dimensions, people may approach their addiction in a healthier way that leaves them feeling more in control and motivated to make positive and permanent change. For example, the healthcare professional would try to understand why the patient started to smoke and would identify the primary reason as anger. Parallel to this, the healthcare professional would try to understand the eating habits of the patient keeping the seesaw principles in mind as described earlier. If the eating habits mirrored those of an Atkins diet, for example, the patient would be eating a tremendous amount of protein and not enough carbohydrates. Their seesaw would fluctuate to the extreme right, causing them to crave something on the extreme left of the seesaw, which could be a chemical dependence; hence, nicotine. Too much protein causes people to feel anger (maybe that’s where road rage stems from?) and nicotine helps balance the emotion.

The theories of reasoned action (Ajzen & Fishbein, 1980) and planned behavior (Ajzen, 1985) support the arguments that nutrition as a behavioral intervention can benefit smoking cessation by providing people control & balance and confidence & motivation. These theories focus on the intention to quit or the belief that quitting is possible as an important precursor to change (Slovic, 2001). Smokers who are successful quitting will achieve this because they want to quit and plan on doing so. Unsuccessful quitters often relapse (Slovic, 2001). Also, people can become discouraged as most quit at least three times before finding a way to permanently stop (Trubo, 2003). Slovic discusses how continued smoking leads to addiction, which inhibits the smoker’s ability to quit easily and, as a result, reduces the smoker’s optimism about being able to quit. Slovic describes this process in the form of a negative feedback loop, which he outlines in a catch-22 model. Addictive behavior around smoking as perpetuated by this model could be compared to addictive behavior of the seesaw described earlier. Unhealthy habits related to smoking addiction and food addiction follow a similar feedback loop. Where one is optimistic about quitting and has intention to quit is similar to where one is optimistic to eating healthier and developing better habits and has intention to change their behavior. As described earlier, not eating healthy triggers imbalanced eating habits that trigger a vicious cycle of healthy behaviors to derail, which make people continue to feel worse and turn repeatedly to the wrong comfort items for a quick fix. If people were to learn the skill of the seesaw principle and balancing foods across the spectrum, their food-mood-symptom connections could be evenly distributed on a consistent basis, they could learn new coping mechanisms to handle their negative emotions, and be rewarded with self-control & balance, and confidence & motivation because they will be perpetuating healthier behaviors and intuitively understand how their addictive behaviors and food choices are linked. People might choose to not start smoking or quit smoking if they can control negative emotions like anger through a lifestyle change as opposed to nicotine dependence. Additionally, Birkett (1998) reports that regular smoking is a strong risk factor for cancer. Smokers have an even higher risk of cancer if they eat a diet low in fruit and vegetables. “A comprehensive cancer prevention intervention for smokers should adopt a multifactorial approach and include dietary counseling with respect to increasing fruit and vegetable intake” (Birkett, 1998). It seems that people smoke to receive certain benefits and they would like to continue this behavior because it’s reinforcing and it would be difficult to wean them away from it (Eysenck, 1997). However, as Eysenck describes, if an alternative solution could be given to smokers to obtain similar levels of satisfaction they obtain from smoking, then the effect on smoking would be stronger and more lasting.

The theory of self-efficacy (Salazar, 1991) supports the third argument that nutrition as a behavioral intervention can benefit smoking cessation by providing people self-efficacy. A central component of this theory represents “…the confidence in one’s ability to perform a behavior in a given situation…Self-efficacy is important for smoking cessation. The confidence in one’s ability to quit smoking predicts actual quitting and relapse after a quit attempt is less frequent when self-efficacy is high (Etter, 2000). If one sees nutrition as a healthy benefit to manage unhealthy behaviors and emotions stemming from nicotine dependence, they will want to develop the skill that supports their behavior change towards food and healthy eating and being more mindful of choices when they are on the road and on the go. The next time, for example, when they have an urge to smoke due to anger or stress, perhaps they will stop and consider what foods they have eaten so far that day, where they fall on the seesaw spectrum and if the nicotine desire results from eating too much food on the extreme right of the seesaw. Perhaps they will choose a green vegetable instead to consume at that moment as oppose to nicotine. Awareness and application of the seesaw principles links back to appropriate skill-building qualities that one must possess and learn from a trained healthcare professional. A major barrier, though, is that over 80% of Western consumers believe they eat a healthy diet (Frewer, 2003). She continues to point out that this belief is a major barrier to consumers changing their food choices for health reasons. Salazar reports that “one’s belief in the ability to perform a behavior is an important link in knowing what to do and actually doing it. Besides knowing what to do, an individual’s feelings of self-efficacy can vary from one situation to another depending on a number of factors involved in any particular set of circumstances. Perceived self-efficacy will determine how much effort persons will expend on a task and how persistent they will be in the face of obstacles.”

This paper offers the suggestion that nutrition as a behavioral intervention benefits smoking cessation by providing people control & balance, confidence & motivation, and self-efficacy. Several social and behavioral theories suggest that one can commit to change their behavior with the right outlook, intention, and trained resources. By working with trained medical practitioners, one can be empowered to make change in their unbalanced eating cycle to help balance moods, emotions, and physical symptoms that would normally be exacerbated by symptoms related to nicotine dependence. By looking holistically at an individual and working with them on specific dietary changes, individuals will see immediate health benefits that decrease cancer and disease risks, empower them to have new eating habits for balanced living, and teach them coping techniques to help them manage depression and other similar states. Their emotions will become more balanced, which will help them to deal more effectively with emotions stemming from nicotine dependence. Integrating nutrition behavior techniques as part of a multi-component program and in the Stages of Change/Transtheoretical Model (Whitlock, 2002) that smoking cessation programs use will create a much needed coordinated approach to looking at prevention, public education, and early intervention. When Bailus Walker took over as Massachusetts’ new public health commissioner in 1983, he was a big proponent of this coordinated approach (McLaughlin, 1983). McLaughlin comments on how Walker noticed that the state had a state cancer registry, but it wasn’t coordinated with a toxic substance control program, a smoking cessation campaign, and a drive to reduce occupational exposure to known cancer-causing agents….”What is needed is information and education at many points along the way.”

In closing, this paper uses sources that have been published in peer-reviewed literature and sources that appear on the Internet and in published books that are not peer-reviewed. Individual components of the author’s theory as described in this paper are supported by sources who work and practice in the healthcare field. There are opportunities for healthcare practitioners to test the author’s theory through experiments that would bridge all of the components of the author’s theory together and show data to support the linkage and application of the Recovery Discourse and seesaw principles in relation to smoking cessation. These experiments can be conducted via evidence-based medicine and the data published in peer-review journals. The output of these experiments would help people to understand root causes of their addictions, healthier coping mechanisms for negative emotions, and understand their lifestyle choices and how these three dimensions are linked together. Perhaps through evidence-based medicine, the author’s theory is real and can be applied. If so, this approach is one that can be considered as a major behavioral intervention by the WHO Policy and the Stages of Change/Transtheoretical Model (Whitlock, 2002) for a patient and healthcare practitioner to integrate within treatment options.


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Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting behavior. As described in Salazar, M.K. (1991). Comparison of four behavioral theories: a literature review. AAOHN Journal, 39(3), 128-135.

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Anonymous Anonymous said...

Interesting paper, Cindy. The role of nutrition in tobacco cessation isn't something I had considered before. It will be interesting to discuss your paper further. I wondered about two things specifically: 1. Food is often used as a coping mechanism for smokers going through withdrawl. It seems as if it is sometimes a draw back for people considering quitting. I have heard people say (whether it is true or not...)that they would rather smoke than gain the weight from quitting. How does this connection fit into your thoughts? 2. It seems as if more people in thie country and throughout the world have access to cigarettes more so than the "middle of the road" food you mention in your paper. How might this impact your intervention?

Great paper!


6:44 PM  

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