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Thursday, January 31, 2019

Expert advice on how to quit smoking

It can be awkward or difficult to welcome back a colleague who has been absent for reasons related to mental health. These issues, historically, have been taboo, and are loaded with stigma. It is hard to know how to act toward a colleague who has returned from treatment for a mental health issue. Do I ask about it? Do I pretend that nothing happened? Do I say that I hope they are feeling better? Usually, none of these options feels right.

This difficulty is particularly true when colleagues return from being treated for problems with drugs or alcohol. The stigma in our society against people suffering from addiction is rampant and deadly. I have experienced such stigma myself and have written about it here. Many people view “addicts” as morally impaired and deserving of scorn and derision, and not worthy of compassion and care.

Fortunately, as our society comes to understand addiction as a brain disease, and as a medical problem much like diabetes or cancer, our unhelpful attitudes about addiction are starting to change. Addiction has nothing to do with a lack of morals or character, and people certainly shouldn’t be blamed for having an addiction any more than you would blame them for having cancer. But prejudices fade slowly. Even progressive people with the best intentions can still have implicit bias toward people suffering from substance use disorders who are returning to their workplace.
What can I do to support my coworker?

A good first step toward successfully supporting a person in recovery is to honestly examine your own beliefs and feelings about addiction, and to make sure that your response to the colleague you are about to welcome back isn’t hampered by any hidden negative attitudes. If you find yourself uncomfortable with the idea of working with an addict, there are many ways you can learn more about addiction to become more comfortable and educated about the subject.

It is critically important to try to understand what your colleague might be experiencing as they reenter the workforce. Most people who are early into their recovery process suffer from guilt, embarrassment, and shame, and it takes a lot of courage for them to walk through the front door on their first day back at work. They most likely feel quite vulnerable and fragile, and it is helpful to be sensitive to their state of mind, and to be as open and welcoming as possible.

There is no fixed formula for how to help someone who is returning to work after suffering from a substance use disorder. It partly depends on your relationship to them, both personally and professionally. It also depends on a keen reading of the returning person’s personality, as some people are going to want everything out in the open from day one, and others are going to feel more comfortable being discreet. If you are comfortable offering a listening ear, then be receptive to any overtures they might make to discuss their addiction. You can welcome any discussions they might start about their experiences, their addiction, struggles they may be having, and help they might need, including the possibility that they are struggling with a relapse. Colleagues can be a critical source of strength and support, and it’s important not to miss any opportunities that arise where you can help.
What can we learn from people in recovery?

As more people with substance use disorders recover and return into the workforce, it will be increasingly understood that recovery from addiction is about far more than not taking drugs. Recovery is about learning to listen, having humility, and connecting with other people. These are ideal traits that foster a healthy and productive work environment. Rather than being a burden, the employee who is recovering from addiction can very likely be a role model for other workers, and should be welcomed with open arms to any job in today’s economy, where communication and being a team player are highly valued. I predict that today’s stigma will give away to tomorrow’s embrace.

Today is Valentine’s Day and many of us turn our thoughts to hearts and love. But there is more than one day this month to think about the heart and heart health.

February is Heart Month, and with it, I hope many people make a commitment to getting heart healthy. As a cardiologist, many well-intentioned people will come to my office seeking guidance, especially about weight loss. While January sees an uptick in gym memberships, by the time February rolls around, dedication to working out becomes challenging. Exercise is, of course, heart healthy and everyone should make an effort to stay physically active. But, few people can lose weight with exercise alone, and for weight loss, this dreaded phrase still rings true: count your calories.

After a decade of devising many approaches to help motivate my patients, it turns out that perhaps the simplest plan has been our most successful. Sharing is caring, as my father-in-law used to say, so here we go.
Three simple steps toward weight loss and a healthier heart

1.  Picture a plate as a peace sign (or Mercedes sign if you prefer), with three equal sections. If you have trouble picturing thirds, then I recommend buying a set of sectional plates for the house. They work for those under the age of 10 as well, should you have picky eaters (also known as children). Now, place a different food group or item in each section. I am friendly with many of my patients, so the smart alecks will sometimes ask: does splitting a burger into thirds count? (It doesn’t.)

2.  No seconds. It’s really that simple. Mindful eating is an exciting method that is catching on, generally with people who already are into a healthy lifestyle. I myself took a class in it. While it is fun in the moment … it is very hard to teach others. However, if family and friends are partaking in “seconds” while you are at the table … slowing down your pace and enjoying your food is your only defense. “No seconds” breeds mindful eaters.

3.  Have three bites of anything yummy and delicious. Whether you have a sweet tooth or it’s the savory items that excite you, three bites is the limit. The first bite is because you want it. Enjoy it. The second bite is an act of defiance. Revel in it. The third bite is the last and should be savored the most. It is the last one because you respect yourself and have a laudable goal that you will achieve. Some people have asked whether we could stretch that out to five bites. A few thoughts. In five bites, I could finish a large slice of pumpkin pie (and this is in fact a diet). We don’t like calling it this, but in essence we are curbing calories. So no. Three bites it is.
Finding your plan for a healthy weight and a healthy heart

This plan may not work for everyone. For those who can afford dieting systems with prepared foods, or are facile with calorie-counting apps, those may be better. But for the average person, who just wants to see some progress in his or her weight loss, this might be for you. Some people hear this and think it will be easy, until they start. Others are concerned that it seems too restrictive, but the process is actually easier than they thought. Most people are able to stick with it long enough to see some small gains (actually, losses), which is sometimes all the motivation you need to dedicate yourself to the plan for a bit longer. Whatever your plan, make it approachable, stick with it, and forgive yourself if you stray — but get back on board quickly.
When I saw the headlines about this recently published study on bone health saying “Vitamin D and calcium supplements may not lower fracture risk.” I thought: Wait, that’s news? I think I remember seeing that headline a few years ago.

Indeed, in 2015, this very blog reported on similar studies of calcium supplements, noting that calcium supplements have risks and side effects, and are not likely indicated for most healthy community-dwelling adults over 50. These folks are not in a high-risk category for vitamin deficiencies, osteoporosis, and fractures, and we usually advise them to get their calcium from food. Dietary sources of calcium are everywhere, including milk and yogurt, but also include green leafy veggies like collard greens, legumes like black-eyed peas, tofu, almonds, orange juice… the list goes on (and you can check it out here).
What’s new with this most recent study?

This research found that taking vitamin D supplements did not protect against fractures in people over 50. The authors examined 33 research studies including over 50,000 people for their analysis. However, and it’s a big however, study investigators note several times that their research included only healthy people out in the community, and that their findings do not apply to elderly people living in nursing homes who may have a poorer diet, less sun exposure and mobility, and who are at particularly high risk for fractures. Indeed, the original recommendations for calcium supplementation were based on a study of elderly, nursing-home bound women with vitamin deficiencies and low bone density, for whom calcium and vitamin D supplements did significantly reduce fracture risk.
What is the takeaway?

Well, simply, not much has changed. My advice to my healthy patients is still to get calcium from foods, and the best diet for this is a Mediterranean-style diet rich in colorful plants, plenty of legumes, and fish. This plus high-protein, low-fat, and low-sugar dairy (yogurt is ideal) can supply plenty of calcium. As far as vitamin D, well, vitamin D supplementation continues to be a topic of lively and livid debate among everyone, including competing guideline-authoring endocrine experts (see my Harvard Health Blog post on this). I hesitate to wander into that minefield again. But here goes…
The scoop on vitamin D deficiency

There is a large group of people who are likely to be deficient in vitamin D. It includes people with eating disorders; people who have had gastric bypass surgeries; those with malabsorption syndromes like celiac sprue; pregnant and lactating women; people who have dark skin; and those who wear total skin covering (and thus absorb less sunlight). In addition, people with or at risk for low bone density (perimenopausal and postmenopausal women, people diagnosed with other skeletal disorders, or who take certain medications), should discuss whether they need supplements and to have blood levels of vitamin D monitored.

Many New England-dwelling (and Northern hemisphere) residents are at risk for a dip in vitamin D levels during the long, dark winter months. In my own practice I do consider that a risk factor, and I advise a vitamin D supplement of 1,000 IUs daily. For people who would rather avoid a supplement but may need a boost of vitamin D, it is also found in some common foods, including sardines, salmon, tuna, cheese, egg yolks, and vitamin-fortified milk. I will add that, for those who fall into the “healthy community-dwelling adult” category, a supplement of anywhere from 400 to 2,000 IUs of vitamin D daily is not likely to cause harm. Yes, vitamin D toxicity is a thing, usually seen at levels above 80 ng/ml, which causes excessive calcium to be released into the bloodstream. This is rare, but I have seen it in patients who took high-dose vitamin D supplementation of 50,000 IUs weekly over a long period of time.
Other important and effective ways to protect your bones

There are other methods that may be more effective at maintaining bone health and reducing fracture risk. One that we can likely all agree on is regular physical activity. Weight-bearing exercise like walking, jogging, tennis, and aerobics definitely strengthens bones. Core exercises like yoga and Pilates can improve balance. All of this can help reduce falls and fracture risk.

And so, in the end, I am recommending what I always end up recommending: a Mediterranean-style diet rich in colorful plants, plenty of legumes, fish, plus low-sugar, low-fat dairy and plenty of varied physical activity throughout your entire life… and maybe calcium and/or vitamin D supplementation for certain people, following a discussion with their doctors.
In the winter months, I wash my hands regularly and use a squirt of hand sanitizer from time to time in an effort to ward off colds. It may be a good health habit, but it also pretty much guarantees that I’m plagued by dry, cracked skin and tiny cuts around my fingers until spring.

Dry skin in the winter months is common, partly because people ramp up their hand washing, but the combination of cold air and the lack of humidity also plays a role. Your skin spends the winter months fighting to retain moisture, not to mention fending off other insults from cold-weather staples like scratchy wool clothes and crackling wood fires.

How can your skin survive the season? We asked Dr. Barbara Gilchrest, senior lecturer on dermatology at Harvard Medical School, to weigh in with her best tips to help you protect your skin from winter dryness.
1.  What’s the most common winter skin problem?

For most people, it’s dry skin and itching, says Dr. Gilchrest. You can blame cold air and low humidity for stripping the water away from the surface of your skin. Instead of lying flat and smooth and then shedding from the surface inconspicuously, dead skin cells from the many layers that make up our protective skin barrier form small but visible partially attached clumps that make your skin feel dry and rough.

Eczema craquel√© is another problem to watch for in the winter months. It’s essentially an extreme manifestation of dry skin, usually occurring on the lower legs. With this condition, the dryness actually causes cracks in the top layer of skin, known as the stratum corneum. Blood may rise up beneath the skin, appearing as squiggly red lines, which give the skin a mottled appearance. Some people with this condition experience itching and stinging.
2.  How can you prevent dry skin in the winter months?

Combating the problem starts with keeping your home environment moist. Use a humidifier if you can. But the most effective strategy is to use skin moisturizers, which slow water loss and also physically smooth the skin, making it feel less rough, says Dr. Gilchrest.
3.  Do you have any tips for choosing a moisturizer?

Choose the heaviest moisturizer that’s comfortable to wear, and use more on your lower legs and hands, which are most prone to dryness. After a bath or a shower, pat the skin dry and immediately apply a moisturizer. Reapply as needed throughout the day, says Dr. Gilchrest.
4.  Do expensive, brand-name moisturizers work better than lower-cost options?

“It doesn’t have to be expensive to work,” says Dr. Gilchrest. “To my knowledge, while there are some extremely expensive moisturizers, there are none that are proven to be magically better.” But if you can, she says, look for moisturizers with alpha hydroxy acids, also called fruit acids, such as lactic acid or glycolic acid. Creams with alpha hydroxy acids tend to hold moisture in the skin longer than other moisturizers. You can get them at fairly high concentrations, she says. Use small amounts until your skin gets used to them, so you can apply them and they don’t sting.
5.  Any other winter tips you can offer?

Keeping the outer skin barrier well hydrated is crucial. Also keep your skin covered in cold temperatures, and don’t forget to wear gloves when you’re out, says Dr. Gilchrest. For people with Raynaud’s syndrome, where blood vessels in the fingers overreact to cold temperatures, gloves help prevent fingers from becoming painful and turning white, which happens more often in the winter. Keeping the hands warm can also ensure healthy nail growth during the colder months, she says.

In addition, as cozy as it may be, it’s best to avoid sitting next to a fire or a radiator all day, because that type of direct heat can be damaging to your skin. Avoid super-hot baths for the same reason, says Dr. Gilchrest. Whenever possible, try to wear soft fabrics. Wool is warm, but it can scratch and irritate the skin. If you do wear wool when you go outside, be certain to remove it as soon as possible when you go back inside, or layer it over softer fabrics.
Okay, everyone knows smoking is bad for you, the number one cause of preventable death in the US and the world, a direct cause of lung and heart disease and cancer… et cetera. So let’s get right down to the nitty-gritty: quitting smoking is tough. What can people do to quit?

To answer this question, I spoke with my colleague Nancy Rigotti, MD. Dr. Rigotti is director of the Massachusetts General Hospital Tobacco Research and Treatment Center. She has extensively researched nicotine and tobacco, evaluated public policies on tobacco, contributed to US Surgeon General’s Reports, and authored clinical guidelines on smoking cessation.

“It’s never too late nor too early to quit,” she emphasizes. Research shows that even people who quit after age 65 can enjoy a longer, healthier life span.
Two-pronged approach is best

Behavioral strategies can help, medicines can also help, but what’s best is a combination of both. Behavior strategies can include counseling from a healthcare provider, self-help from websites or text message services, and/or social support. If someone has an underlying psychological issue like depression, anxiety, alcohol, or another substance use disorder, addressing those issues at the same time makes it more likely they can successfully quit smoking. As far as hypnosis or acupuncture, there is not a lot of evidence showing that they work.

Medicines that can help people quit include nicotine replacement therapy and the oral medications varenicline (Chantix) and bupropion (Zyban, Wellbutrin). Each is recommended for about 12 weeks.
Nicotine replacement (“the patch” and others)

Forms of nicotine replacement therapy (NRT) include patches, gum, lozenges, inhaler, and nasal spray. Dr. Rigotti points out that it’s safe to use more than one type of NRT at the same time. Combination NRT is a patch (which is long-acting) plus a short-acting agent (like gum, lozenges, inhaler, or nasal spray), and is more effective than a single form of NRT alone. “In addition, smokers are able to adjust nicotine intake to avoid both nicotine withdrawal and nicotine overdose, as they have done this throughout their years as cigarette smokers.”

When considering NRT, smokers need to consider what dose of each product they may need. For example:

Using nicotine patches. For the long-acting patch, someone who is smoking more than 10 cigarettes per day should start with the highest-dose patch (21 mg/day) for at least six weeks. However, those who smoke less than 10 cigarettes per day or weigh under 99 pounds should start with the medium-dose patch (14 mg/day) for six weeks, followed by 7 mg/day for two weeks.

How one applies the patch is also important. Change the patch site daily to avoid skin irritation, a common side effect. If leaving the patch on overnight causes insomnia and vivid dreams, take it off and replace it the next morning (smoking quit rates are the same whether the patch is left on for 24 hours or taken off at night). If the patch is removed at night and morning nicotine cravings occur, use the gum or lozenges while waiting for the new nicotine patch to take effect.

Using gum and the lozenges. For the nicotine gum, someone who is smoking more than 25 cigarettes per day should use the 4-mg dose. Those who smoke less than that should use the 2-mg dose. Chew one piece of gum whenever there is an urge to smoke (up to 24 pieces of gum per day) for at least six weeks, then taper off.

For best results, Dr. Rigotti recommends the “chew and park” method: “Chew the gum until the nicotine taste appears, then “park” the gum between your teeth and inner cheek until the taste disappears, then chew a few more times to release more nicotine. Repeat this for 30 minutes, then discard the gum, because by that time all nicotine has been released.”

Smokers with dental issues or who use dentures may do better with the nicotine lozenge. Smokers who smoke within 30 minutes of awakening should use the 4-mg dose, while smokers who wait more than 30 minutes after awakening to smoke should use the 2-mg dose. Place a lozenge in the mouth for 30 minutes. Let it melt, no need to chew. Use up to one lozenge every hour or two for six weeks, with no more than five lozenges every six hours or 20 lozenges per day, and then gradually taper.
Medications that can help you quit

Many studies have shown that 12 weeks of the prescription medications varenicline and bupropion are effective and safe in patients who want to quit smoking. A recent, large, high-quality study helped alleviate concerns about varenicline and psychiatric or cardiovascular side effects; the FDA removed that black box warning in December of 2016. Although one 2017 study suggests a risk, the methods have been called into question. Smokers are at significantly increased risk for CV events as it is, and it is difficult to correct for this using the methods this most recent study used. Dr. Rigotti emphasizes that varenicline “is our most effective agent and no riskier than any other agent, even in patients with psychiatric issues. This message needs to get out to patients and doctors.”

She explains that NRT can be used with either varenicline or bupropion. One other medication worth mentioning is nortriptyline, an older antidepressant that is also used for chronic pain. It is modestly effective, but is associated with side effects such as dry mouth, constipation, and weight gain. As with any medication, doctors and patients need to consider medical history, current medications, and personal preferences.

To increase your chances of success, Dr. Rigotti suggests taking the medication for at least one week before you even try to quit. In fact, for people who want to quit but are not ready to set a quit date, varenicline or NRT can help them smoke less, and can actually improve their chances of quitting successfully. “Encouraging smokers who are not ready to quit to try meds anyway is a new idea with increasing data,” she points out.

I asked Dr. Rigotti about e-cigarettes. While these are not FDA-approved for smoking cessation, experts agree that, for smokers unwilling or unable to attempt to quit, they are almost certainly safer than continuing to smoke cigarettes. However, anyone switching from cigarettes to e-cigarettes must do so completely. You should not use both together.

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