The Submarine Service Smoker’s Dilemma: to Quit or Nic?
A message to smoking submariners: if you want to both quit smoking and end all nicotine use then the time for action is now.
As all smoking sub sailors are by now aware, per order and policy of the Commander of Submarine Forces (ComSubFor), smoking will be banned below decks on all 71 U.S. submarines no later than December 31. It’s estimated that 40 percent of sub sailors – possibly as many as 5,000 – are addicted to smoking nicotine. Between now and the start of that first smoke-free deployment each will be compelled to make a decision. “Do I quit and arrest my chemical dependency or instead attempt to survive until patrol’s end by use of nicotine replacement products?”
A veteran of seven cold war smoking patrols and former thirty-year heavy smoker whose dozen serious failed attempts included four while using nicotine replacement products, I departed on my second patrol without any cigarettes or money, confident I’d succeed in quitting. I was horribly wrong. I write to explain why and to suggest that if you want to arrest your dependency that the time to get qualified is now, before that first smoke-free dive.
Somewhat similar to what’s about to happen aboard subs, I watched during 2008 as South Carolina prisons went tobacco-free. But I did more than just watch. I presented 63 quitting seminars before roughly 15,000 inmates. Our goals? Transform forced stopping into a personal desire to quit, teach how to minimize common withdrawal symptoms, and prepare inmates for the day they’d be released. You see, arrested as smokers, none had yet extinguished their pre-incarceration smoking cues. Study evidence suggested that 97% of inmates compelled to quit by imprisonment would relapse to smoking within 6 months of release.
My qualifications? I’m a former three pack-a-day smoker who in July 1999 founded WhyQuit.com, Google’s #2 ranked quit smoking forum. I studied for a decade under America’s leading cessation educator, Joel Spitzer, am a director of Freedom, a 5,000 member online quitting support group, and author of the free e-book “Freedom from Nicotine – The Journey Home.”
The Secret to Success
Regarding qualifications, what if I told you that you could qualify subs by simply slapping on a patch, chewing gum or sucking on a lozenge? You’d laugh, right? So ask yourself, what learning takes place by using a quitting product?
The reason I fell flat on my face during attempt after attempt was that I never once invested the time needed to get qualified on my chemical addiction. In fact, although I admitted I was “hooked,” I didn’t then realize it was a “real” addiction. Instead, I toyed with quitting in ignorance and darkness. I pretended it was just some nasty little habit I could modify, manipulate, mold and control.
There’s simply no way to sugar coat this. Nicotine addiction is a permanent disease, a brain “wanting” disorder. Our brain dopamine pathways were designed to create enduring “want” for critical species survival activities such as seeking food, water, accomplishment and reproduction. But by chance, once inside the brain the nicotine molecule activates those pathways. Repeated activation by nicotine tied nicotine use to the most durable memories the mind appears capable of generating. Doing so quickly suppressed all memory of life without nicotine. Soon, we were left totally convinced that smoking that next cigarette was as important as eating, with quitting akin to starvation.
Smoking nicotine is extremely addictive. An alarming 26% of youth report signs of loss of control over continued smoking after just 3 to 4 cigarettes, rising to 44% after 5 to 9 cigarettes. There’s growing consensus among addiction experts that nicotine dependency is as permanent as alcoholism, that it hijacks the same brain dopamine pathways as illegal drugs, and that successfully arresting nicotine dependency is as hard or harder than quitting heroin.
Scientists are just now documenting how nicotine physically alters the brain. Nicotine activates, saturates and desensitizes dopamine pathway receptors. This is followed by growth or activation of millions of extra receptors, a process known as up-regulation. One cigarette per day, then two, then three, the longer and more nicotine we smoked, the more receptors become saturated and desensitized, the more that were grown, and the more frequently a new supply of nicotine became needed to satisfy “want” for replenishment.
Although we’ll never be stronger than nicotine’s influence over brain dopamine function, we don’t need to be as it’s only a chemical with an IQ of zero. Nicotine cannot think, plan, plot or conspire and is not some monster or demon that dwells within. Our greatest weapon has always been our vastly superior intelligence but only if put to work.
Let’s not beat around the bush. The most critical dependency qual card siggy of all is for mastering the Law of Addiction, that “administration of a drug to an addict will cause re-establishment of dependence upon the addictive substance.”
Just one puff and within seconds, up to 50% of brain dopamine pathway receptors become occupied by nicotine. After quitting, while most walk away from relapse thinking they’ve gotten away with smoking just once, they soon find their brain begging for more.
The New Policy and Enforcement
News accounts suggest that the Navy intends to make an ample supply of nicotine replacement products (NRT) available for patrol. It knows that calmness, clarity of thinking and concentration are critical to accomplishment of the mission. It hopes smokers quickly adapt to new, slower forms of nicotine delivery. If NRT helps some in quitting altogether great, but the primary objective does not appear to be nicotine cessation but elimination of cigarette smoke via smoking cessation.
Apparently commanding officers are expected to supply policy details. While COMSUBFOR is discouraging transfer to smokeless oral tobacco products, the policy statement is silent as to nicotine delivery via the electronic or e-cigarette. While there is no express prohibition against possession of cigarettes below decks, there will likely be no shortage of volunteers for lookout or maneuvering watch if smoking is permitted topside while underway.
Obviously, compliance with the new policy is of concern if possession of cigarettes is permitted below decks. If not permitted, contraband possession becomes an issue. My experience with prison wardens suggests that each skipper will vary in zealousness of enforcement ranging from “don’t ask, don’t sniff,” to ordering outright bans on cigarette possession below decks, with captain’s mast for violators.
Keep in mind that some commanding officers are smokers themselves while others have been ardent anti-smokers their entire lives. Statistically, some have lost loved ones to smoking. But I suspect that even the CO hooked on cigars will have concerns about crew non-enforcement complaints getting filed with his superiors, or worse yet, being leaked to the media.
Although I doubt any CO or XO will resort to carboximeter breath testing, overall, enforcement is likely to be taken seriously. As for thinking you’ll be able to get away with a puff or two in the head, shower, your rack, a frame bay, bilge or in low traffic or isolated spaces, keep in mind that similar to the stale stink of smoking night clubs before arrival of smoke-free indoor air laws, permanent extinguishment of the smoking lamp below decks is about to produce dramatic atmospheric changes.
No longer will the combined effects of up to 40% of the crew smoking be a normal part of the boat’s environment. The burning cigarette’s 3,500 chemical particles and 500 gases will no longer coat every surface of the boat in a yellowish tar. A few bulkhead scrubbing field days and one puff may no longer melt into background odors. Absent the sensory diminishing effects of scores of potent cigarette toxins, expect the entire crew’s sense of smell to be a bit more heightened, with the recent smoker’s unique odor far easier for all to discern.
The Decision Options
To quit or nic, that is the question. Your options include:
- To use replacement nicotine to both quit smoking and arrest your chemical dependency;
- To permanently transfer your dependency to a cleaner form of nicotine delivery;
- To quit during patrol but smoke when in port or during off-crew; or
- To become qualified now, to become smarter than your addiction is strong, and then bear witness to the power of knowledge.
Option 1: Quit by Use of Replacement Nicotine
Before examining quitting with replacement nicotine, if feeling that life threatening medication side effects are depriving you of more effective quitting options, Chantix (varenicline) and Zyban (bupropion), don’t. Although Chantix prevailed in head-to-head competition against Zyban, in the only study to exam long-term point prevalence abstinence when competing against replacement nicotine, researchers found “no significant differences between Chantix and nicotine patch users at either 6 months or one year.”
So, how effective are nicotine replacement products at helping smokers quit? Sadly, not nearly as effective as advertising suggests. A 2003 study by GlaxoSmithKline consultants combined and averaged all over-the-counter patch and gum studies. It found that only 7 percent of users remained smoke-free at 6 months. Interestingly, a second 2003 study by the same consultants found that 6.7 percent of nicotine gum quitters remained chronic long-term gum users for at least six months.
The obvious question becomes, how many nicotine gum or lozenge users are able to arrest their underlying dependency upon nicotine by chewing or sucking it? Those considering replacement nicotine need to keep in mind that NRT studies were not about breaking free from nicotine but only from the most deadly form of delivery, smoking it. Rarely did any study examine blood, saliva or urine nicotine levels at study’s end to determine the percentage of NRT quitters who became hooked on the cure.
As to NRT effectiveness, in fairness, combining counseling or ongoing support with any quitting product makes the product superior to when used as a stand alone quitting aid. For example, according to U.S. Guideline evidence tables, counseling programs having contact time of up to five hours generate six month quitting rates of nearly 30 percent, while programs having eight or more sessions produce rates in the neighborhood of 25 percent. According to the Guideline, combining eight or more counseling sessions with NRT can produced six month rates of 32 percent.
The theory of gradual stepped-down nicotine weaning via NRT is that it allows the smoker to postpone dealing with chemical dependency, while permitting time to overcome broader addiction issues associated with habituation, psychological, emotional and environmental ties to the act of smoking.
NRT’s most glaring problem is the fact that while smoked nicotine always arrived and satisfied “wanting” within ten seconds of a puff, that by the time chewed or sucked replacement nicotine penetrates mouth tissues and enters the bloodstream the crave or urge is likely to have passed. Additionally, it’s questionable whether or not oral nicotine extinguishes use cue conditioning if able to use nicotine on those occasions during which we’ve trained our brain to expect arrival of a new supply.
Obviously, regular patch use doesn’t present cue perpetuation concerns. But unless supplemented with oral nicotine, the user remains subject to the acidic influences of stress, vitamin C and alcohol use (during off-crew), in accelerating renal (kidney) elimination of the alkaloid nicotine from the bloodstream. Picture acid generating events removing nicotine from the bloodstream faster than the patch replaces it.
While recent studies have focused on creative new ways to use NRT, each has involved researchers with financial ties to the pharmaceutical industry and close examination reveals mixed results. For instance a June 2009 study examined pre-quitting patch use for two weeks, versus pre-quitting placebo patch use, followed by ten additional weeks of patch use by both groups. The study’s summary (abstract) asserts that pre-patch use “doubled” placebo group quitting rates. But according to the full text of their study, “results showed that precessation nicotine treatment … did not significantly affect 10-week point abstinence (30% vs. 31%).” Additionally, “point (7-day) abstinence at 6 months was also analyzed and did not show a significant difference between precessation patch conditions.”
A November 2009 study examined success rates when using three individual quitting products, the nicotine patch, nicotine lozenge and Zyban (bupropion), and two combinations, the lozenge plus patch and the lozenge plus Zyban. News headlines reported that combining the nicotine patch with the nicotine lozenge provided the greatest “bang for the buck.” But according to they study’s fine print, “it is important to note that [the patch plus lozenge group's] 6-month outcome did not differ significantly from the other active cessation treatments in head-to-head comparisons.”
Most recently, a February 2010 study examined extended use success rates when the nicotine patch was worn for six months. The study concluded that “transdermal nicotine for 24 weeks … reduced the risk for smoking lapses.” The problem isn’t success while using the patch but staying free once off. What went unreported in news articles was the fact that only 2 of 282 participants who wore the nicotine patch for 24 weeks were able to stop smoking for an entire year, an extremely dismal one-year continuous cessation rate of less than 1 percent.
Yes, using nicotine to fight nicotine addiction is like using gasoline to fight fire. In this study, 99% of the time the house burned down.
If I’m giving you the impression that it isn’t easy to break free from nicotine while replacing it, it isn’t. My objective here isn’t to discourage you, but to open your eyes and mind.
I’m sure some unknown percentage of alcoholics have the ability to gradually wean themselves off alcohol too. But even if the smoker successfully adapts to the 21mg patch, and then steps down to the 14mg patch, before finally adjusting to the 7mg patch, they still face ending use of the nicotine equivalent of smoking seven cigarettes per day.
But like prison inmates, once underway, NRT’s effectiveness won’t matter much as smoking cessation becomes mandatory, with smoking violating a COMSUBFOR April 8 standing order, an Article 92 offense.
Unless the quitter gets hooked on replacement nicotine, at some point chemical stimulation of brain dopamine pathways must end. At that moment they too become cold turkey quitters.
If I’ve given you the impression that placebo-controlled NRT studies have been less than honest, I wish it wasn’t true. But ask yourself, if you joined a quitting study hoping to get 3 months worth of free nicotine gum, would you have been able to tell whether or not the gum you were chewing was the real thing or an inert placebo? So could they. In fact, in the pre-quitting patch study reviewed above, four times as many assigned to receive placebo patches correctly guessed their randomized assignment (112), as guessed wrong (26).
The simple truth is that we cannot blind drug addicts with lengthy quitting histories as to absence or onset of full-blown withdrawal. We became experts at knowing exactly how it feels. While placebo controlled trials are the gold standard in most study areas, in drug addiction studies they’ve been a license to cheat, make headlines and steal. These studies did not measure product worth. Their “double your chances” findings likely reflect and flow from a tripling to quadrupling of frustrations, as 80-90% of the placebo group often threw in the towel within the study’s first week.
Forgive me, but your health and life are on the line. You deserve the truth. Placebo is not a real quitting method. The truth is that NRT has failed to prevail against cold turkey quitters in nearly every real-world quitting method survey conducted to date. Most recently see: a 2009 GlaxoSmithKline survey; a 2007 UK NHS survey (see Table 6); a 2006 National Cancer Institute survey; a 2006 general practice physician patient survey; and a 2005 study of UK NHS quitters (see Table 6).
Still, we’re each different and some will succeed in quitting smoking after having used replacement nicotine, while others will succeed in spite of it. Whether an NRT user or not, in the end, the only path to freedom from nicotine is to at some point permanently end its use.
Option 2: Permanently Transfer Your Dependency to Cleaner Delivery
While still unable to quantify relative risk, there’s no doubt among researchers that permanent use of replacement nicotine is vastly less lethal than smoking. The cigarette is clearly the most destructive drug delivery device ever devised. Still, informed consent requires awareness of nicotine’s known harms before selecting this option.
Drop for drop nicotine is more lethal than diamondback rattlesnake venom, strychnine or arsenic. While a stimulant providing short-term concentration benefits, over the long haul it’s also an angiogenic super toxin that may be responsible for destruction of brain gray matter, cognitive impairment and early dementia.
Nicotine is known to prevent unhealthy cells throughout the body from dying natural deaths (a process known as apoptosis). It promotes lung, breast and pancreatic cancer, hinders bone healing, and induces angiogenesis which causes plaque build-up within arteries to harden.
A 2007 study of hospital intensive care unit patients discovered a 24-fold increase in death among patients using NRT. More recently, a November 2009 animal study reported that nicotine caused cancer to grow three times faster, to spread through the body nine times quicker, and that once the tumors were removed, it increased the odds by three-fold that the cancer would reoccur.
Online comments by long-term nicotine gum users list a host of concerns. The most common complaints are addiction, hair loss, and tooth and jaw damage.
While science has yet to link many of their health concerns to NRT use, they include: addiction with intense gum cravings, anxiety, irritability, dizziness, headaches, nervousness, panic attacks, hiccups, ringing in the ears, chronic depression, heart burn, elevated blood pressure, a rapid or irregular heart beat, diabetes, insulin intolerance, sleep disruption, tiredness, a lack of motivation, a heavy feeling, recessed, bleeding and diseased gums, diminished sense of taste, tooth enamel damage, tooth loss, jaw-joint pain and damage (TMJ), canker sores with white patches on the tongue or mouth, oral cancers, bad breath, dry mouth, sore or irritated throat, difficulty swallowing, swollen glands, bronchitis, stomach problems and pain, gastritis, severe bloating, belching, achy muscles and joints, pins and needles in arms and hands, uncontrollable foul smelling gas that lingers, a lack of energy, loss of sex drive, acid reflux, stomach ulcers, fecal impaction from dehydration, scalp tingling, hair loss, acne, facial reddening, chronic skin rashes and concerns about immune system suppression.
Life isn’t only about how we die but life’s quality while lived. While this option is vastly preferable to smoking’s 50% risk of an adult male losing 13 years of life, it isn’t without its own price. Rarely considered is the need to interrupt nearly every waking hour of the rest of our life in order to replenish nicotine reserves that decline by half every two hours. What isn’t mentioned is never again knowing the beauty of a calm and quiet mind, the silence of addiction’s chatter after time, life and truth bury old “wanting” memories.
But if this or option 3 is your choice, I recommend taking the time to adjust to NRT use prior to that first dive. It takes time, patience and practice to adapt to slower delivery. Also remain mindful that acidic fruit juices and foods diminish NRT’s effectiveness.
Option 3: Quit During Patrol and Smoke in Port
Frankly, to me, this is the scariest option of all. Imagine every patrol bringing with it the dread of needing to quit again. Talk about a glutton for punishment. But some will resist being forced to quit, with the moment of smoking resumption reflecting their mark of defiance. The price ultimately paid in terms of ongoing craves, urges, anxieties and bodily damage could be tremendous.
And it won’t be long before those reluctant to quit are seen as an oddity. Soon, the sub service will proudly boast the lowest smoking rate, lowest health care costs, and healthiest service members of any arm of the U.S. military.
If considering this option, reflect on your motivations for returning to smoking following patrol. Why would you do so? Because you smoked for flavor and taste? How many taste buds are inside human lungs? None. Absolutely none.
Maybe it’s because you love or like smoking. Is it possible you’re confusing “need” for love? Is it that you like smoking or that you don’t like what happens when you don’t smoke? If like or love, then what honest basis remains for comparison? I challenge you to try hard to recall the calm and quiet that filled your mind before getting hooked, what it was like to go days, weeks and months without wanting to smoke. You can’t do it, can you!
Before selecting this option, what do you have to lose by going the distance and seeing what it’s like living here on Easy Street, among our nation’s 47 million comfortable ex-smokers? Your enslaved compulsive limbic mind is telling you that smoking is important, while your rational, thinking prefrontal cortex keeps telling you that you’re committing slow suicide. Which should you believe?
During pregnancy we see a substantial percentage of smoking women who decide to stop for the baby. It’s somewhat akin to temporarily stopping for COMSUBFOR. Imagine the anticipation after having waited months for that next smoke. As one mom recently wrote, “By the time I had delivered him I was absolutely desperate for a smoke. So that special bonding moment after you’ve given birth and they hand you your baby, then leave you to have some quiet time to get to know each other, I handed him over, found the closest most absorbent thing I could find, and snuck out the back door for a smoke.”
Why is that next smoke more important than family, friends or life itself? With half of us smoking ourselves to death, isn’t that what addiction to smoking nicotine is really all about? How many thousands of times did we interrupt life in order to comply with our enslaved brain’s mandatory chemical need for more? What’s it like being the “real” you? What’s it like when all “wanting” ends?
Option 4: Get Qualified and Experience the Power of Knowledge
When flooding, fire, steam or radiation threaten life inside the people tank we want our most qualified on scene and handling the situation. But they didn’t become the best by chance or by sucking on a lozenge. It took knowledge, study, reflection and skills development.
Forty percent of our nation’s 36 million daily smokers attempt quitting each year. Seventy percent of surveyed smokers say they want to quit. The fact that most adult daily smokers already know the cause of death that’ll be printed on their death certificate bears witness to the fact that far too many fail to learn how.
Contrary to pharmaceutical industry marketing, more successful ex-smokers will quit smoking cold turkey during 2010 than by all other quitting methods combined. In fact, 80 to 90% of the world’s long-term ex-smokers quit smoking without use of products or procedures.
I’ve prepared a quitting qual card that I hope you’ll consider. I’m not trying to qualify you diving officer here, just prepare you, in advance, so that nicotine dependency recovery has an opportunity to become a positive experience, possibly the greatest personal awakening you’ve ever known.
You see, I’m convinced that once you understand where you now find yourself, that the quickest and most efficient path home will become clear.
But before able to even think about coming home you’d need to at least temporarily put aside any anger or frustrations toward the new policy. Somehow you’d need to sense that what may have felt like a hard slap in the face, could be one of your best opportunities ever.
Frankly, you can’t quit for the XO, CO, squadron commander or COMSUBFOR, anyway. Attempting to quit for others naturally fosters a growing sense of self-deprivation that gradually eats away at any underlying personal resolve. Recovery must be our gift to us.
You likely had your own long held dream of some day quitting on your own terms, on a date of your choosing. But being told we must quit can feel like we’ve been robbed of that dream. Ask yourself, what do you have to lose by reclaiming your dream, living it now, and making freedom your gift to you?
We never once took a puff off of any cigarette that didn’t destroy more of our body’s ability to receive and transport life-giving oxygen. What do we have to lose by ending our own senseless self-destruction?
It isn’t that we were stupid, that we couldn’t hear the entire world screaming the insanity of us smoking that next pack. It’s that our brain “wanting” disorder was screaming even louder that smoking was important, and that quitting would be horrible. Who were we to believe, them or our enslaved compulsive mind?
Drug addiction is about living a lie. Recovery is about destroying the lie, about gradually learning that everything we did while smoking nicotine can be done as well as or better without it. Even the love in our heart, we get to bring it with us.
Peak withdrawal is experienced within 72 hours of quitting, as the mind and body become 100% nicotine-free. While receptor re-sensitization is rapid, it can take up to 21 days for the number of receptors to down-regulate to levels seen in non-smokers.
The beauty of commencing recovery prior to deployment is that it allows time to meet, greet and defeat subconscious conditioning. You’ve trained your mind to expect a new supply of nicotine when encountering specific times, activities, places, people or emotions. Each has potential to produce a short yet possibly intense crave episode lasting up to 3 minutes. But keep a clock handy as recovery time distortion can make those minutes feel like hours.
Unlike prison inmates, you have an opportunity to extinguish real-world use cues and reclaim most aspects of life before the hatch shuts above you. You’ve been given plenty of notice. By the time patrol arrives you can have both physical withdrawal and the bulk of subconscious cue extinguishment behind you. Yes, a few sub, patrol, seasonal and infrequent cues may remain but by then you’ll be skilled at crave coping.
The final layer of recovery is the longest yet least intense, dealing with fixation upon old conscious thoughts of “wanting.” It’s fueled by lingering nicotine replenishment memories combining with the laundry list of lies we invented to explain why smoking that next cigarette was so important. But the length and intensity of conscious recovery is substantially within our ability to control.
It’s important to appreciate that while a subconscious crave episode will begin fizzling within 3 minutes, conscious thought fixation can last as long as our mind’s ability to maintain focus and concentration. Here, truth and honesty bring potential to accelerate arrival of that first day where we never once “want” for nicotine. The reading and listening materials listed on the Recovery Qualification Guide review in detail most common use rationalizations.
By patrol’s end, when they at last pop the hatch, you won’t be sitting there yearning to suck thousands of chemicals into your lungs, but to allow them to bask in the freshness of air. While heading home, life won’t act as one big continuous smoking cue, but a long overdue invitation, to a deserving patriot, to “suck the marrow from the bones of life.”
This temporary journey of re-adjustment called quitting leads here to Easy Street. It’s a place where you’ll go days, weeks and then eventually months without once wanting to smoke. If true, is that a good thing or bad? If true, why fear, resist or fight coming home? While the Navy’s idea, its ultimate objective isn’t so different from yours.
Picture yourself healthier with significantly improved lung function, able to engage in prolonged periods of brisk physical activity without quickly getting winded. Picture yourself developing an amazing sense of calm during crisis, as you no longer add the onset of physical withdrawal to every stressful event.
In closing, I invite you to visit www.WhyQuit.com and explore the Internet’s largest collection of free quitting tools. Knowledge is power and education a quitting method. The time to get qualified is now. It’s my hope that our free e-books find their way into the ship’s e-library. If going cold, identify and support the boat’s other cold turkey quitters, as the lure of free replacement nicotine, that would foster relapse, may at times feel compelling.
I sincerely hope you’ll choose to use this golden opportunity to fully arrest your chemical dependency and taste liberty’s blessings, as freedom is your birthright. Remember, there was always only one rule that when followed provides a 100% guarantee of success to all … no nicotine just one hour, challenge and day at a time, Never Take Another Puff!