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Butt Out That Smoking Habit with Acupuncture (of course!)

Its hard to believe that as I write this, that summer is just a little under month away here in Toronto. For awhile, it sure seemed that the long, cold winter was never going to leave and venturing to the great outdoors was nothing more than a pipe dream. I know there are those among us that would choose to live our lives in semi-permanent hibernation in our indoor caves. But for the majority of people that I know and speak to, summer is often looked upon with great anticipation and is often a time of activity, outdoor sports and adventure-seeking (think marathons, half-marathons, obstacle courses, dirt biking, running, basketball or swimming. I think gardening counts too to some degree!).

For some of us looking to get fitter and healthier, oftentimes our thoughts will turn towards that lofty goal of perhaps starting to run again, or to do a charity walk or race. And what is better motivation for participating in such noble causes than having clean, healthy lungs? Which, due to the fact that I lack a good segway into my next section, leads me to the topic of “quitting smoking”.

I have encountered many in my line of work who open up an acupuncture consultation with questions about that very topic. And more often than not, I have found that the start of a new season (such as the upcoming Toronto summer) together with the wish to better one’s physical or mental health, are often good prompts for patients to inquire about this if they smoke but wish to stop. As an acupuncturist, I often get asked a ton of questions about smoking cessation. Though I thought about writing about this topic up in a starchy, pressed and scholarly article, there are just so many topics within smoking cessation to cover. Coupled with the way I write gargantuan filibusters, most of the folks reading would've probably had kids by the time they reached the end of it!

So, I figured the easiest (and least-ish time-consuming) way to summarize smoking cessation treatments - what they do, what they involve, how often you need to visit, whether they require you to do “homework” outside of the clinical setting (the answer very often is yes) - is to try and do this in super casual Q and A format. This list is not the definitive, be-all and end-all list of all questions involving the task of quitting smoking but I hope that it is a good place to start if this topic has been floating around in your mind recently.

Q1: Can acupuncture help a person stop wanting to smoke?

A: Yes, if the person is committed to the idea of wanting to go smoke free and is willing to put in some elbow grease into the process of making it so. However, no, if the person is seeking a single, one-shot treatment that will “magically” make the urge to stop craving cigarettes go away in a flash.

Q2: Why doesn’t it do so in one treatment if acupuncture is so amazingly good at helping people I have talked to manage their cigarette cravings?

A: Acupuncture is great! Don’t get me wrong. It does do magical things like: make you feel calmer, lower your blood pressure and heart rate, as well as energize you if you have been feeling flustered or tired (all code phrases for, it'll make you smarter and more charming). These are the good side effects that happen anyway when someone comes in for treatments irregardless of whether they want treatment for smoking cessation or not. But acupuncture is ultimately a tool to help one get to their goals faster and with more ease and efficiency. It works well so long as you stay committed to your health goals (and I do a lot of goal setting as part of the treatment process in addition to the treatments themselves) and keep your eyes on the small incremental gains that you achieve as the number of cigarettes start to drop during the course of treatment.

Acupuncture slows you down enough so you learn how to relax through cigarette cravings - something that we don’t get a chance to do during our stressful work week. You start associating that feeling of relaxation with the ability to “ride out a wave of craving” so that the body learns that you can be relaxed when a wave hits. The more often you learn to relax, lower your sense of urgency and drop your anxieties, the chances of needing a cigarette to try and achieve just those same goals also reduces. It just helps you do this in a less harmful way. According to Frenchman Paul Nogier (who pioneered the development of modern auricular, meaning ear, acupuncture), the ear is actually a somatic map of the developing human fetus. Imagine the top of the ear as representative of the extremities of the developing fetus and the earlobe mapping out the head. There is a word for this somatic map of the human body and all its bits and parts, homunculus; which is a fancy way of saying, "little man". The ear therefore, is a great way for acupuncturists to access the areas innervated by the limbic system, the brainstem and the cranial nerves of "the little man". These are all areas that mediate our emotional responses to external stimuli (such as the rewards we get as a result of lighting up a cigarette in response to stress or anxiety). ** data from: Wagner, Kim and Sue Cox, Auricular Acupuncture and Addiction: Mechanisms, Methodology and Practice, Edinburgh, London, New York, Oxford, Philadelphia, St Louis, Sydney, Toronto, Churchill Livingston Elsevier, 2009.

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Now, interestingly enough, I did have one incident in my past where a patient did come in and asked for help to quit smoking and the results were actually instant! I did standard acupuncture treatment, and explained that it is all a process and may require a few more steps before he would be able to achieve this goal. He promptly disappeared and never came back - until literally a year later. I asked him about his smoking, which I assumed was something he didn’t get around to quitting. He completely turned my head over on its side when he told me that he suddenly lost the urge to smoke shortly after that one treatment.I was blown away.

Q3: So what happens in an acupuncture treatment when someone comes in for help trying to quit smoking?

A: Normally I start off the consultation with a few basic questions. I am pretty sure that most practitioners of acupuncture often start their treatments off with wanting to know what prompted their patient to want to quit smoking and I am certainly no exception. For instance, I often ask:

  • Why is it important for you RIGHT NOW to quit smoking

  • What do you want to achieve as a result of being free of the urge to smoke

  • What triggers the urge to smoke

  • How much do you smoke in a day and when are the cravings the worst

Now these may seem like completely random questions. They most certainly are not. I often find that most of us are creatures of “reward-seeking” behaviours. For most of us, reward seeking behaviours often cause us to feel elated, happy and somewhat high. Smoking falls into a category of seeking calming behaviours as their ultimate reward. And most of us, are creatures of habit, seeking out those very same behaviours that either bring us joy and elation or calm and anxiety-release because we need to put out very little effort in making that reward happen.

Something big needs to really override that need to seek out that reflexive reward seeking behaviour in order to convince a patient that their urge to quit smoking is indeed larger than their urge to light up anther cigarette. And oftentimes, asking that question helps me to zero in on those very few patients who feel they are ready to ditch their bad habit and adopt healthier and more life affirming ones.

Those who don’t convince me that they are ready to commit to a program of quitting smoking, I often look them right in the eye and just tell them that I will treat them today but ask them to return when they feel they no longer have any other reasons standing in the way of them dropping this habit. Very often these reasons will sound something like: my work is hectic and this is way better than me eating a candy bar to alleviate stress; I only have one or two and only when I am in social settings with workmates; I run my own business and sometimes I do this when I cannot leave my desk and I just need to keep my fingers busy; I will quit but can I still have one or a few when I have free time with my friends during our weekend fishing/wine tasting/kite-flying/birdwatching etc trips.

I choose to focus instead, on the few that look me right back in the eye, and tell me that their most important motivation is their health (seeing how much their friend benefited from quitting smoking, the fact that they want to have better cardiovascular health and be around when their kids graduate, that they don’t want to have issues with lung failure/emphysema/lung cancer/COPD or, that they want to run a 5K or a 25K but have a minor problem with walking up the stairs and losing pretty much all the air in their chest after they get to the top). They are usually ready to set some health goals, set some progress milestones and stay the course and I feel therefore, would ultimately benefit the most from the acupuncture treatments.

Q4: That’s really interesting. But that still didn’t quite answer my original question of what happens in an acupuncture treatment (and the quitting smoking part of the treatment.)

A: I was just about to get to that. Forgive me, I am a saga queen and sometimes forget my place in the Q and A world.

I pretty much find out the meta questions of why one wishes to quit and what triggers them to smoke in the first place. Then I find out the nitty gritty details like at what times are their urges the worst and how many cigarettes one has in a day or a week. Oftentimes, little details like this help me to form a treatment plan that focuses on the particular pattern triggering the urge to smoke in an individual. Treatment plans involve acupuncture (of course!), weekly and daily goals, finding alternative reward replacement behaviours (in place of the cigarettes) and sometimes I throw in TCM (Traditional Chinese Medicine) dietary advice to help the patient with their individual plan.

For instance, if so-called Angry Woman (AW) tells me that she wants to quit smoking because she has high blood pressure, but loses her patience easily and has outbursts of anger if she doesn’t get a cigarette to alleviate her irritability, I will treat her with a very different protocol and set of acupuncture points than I would with someone, let’s call him Nervous Man (NM), who faints easily when he gets nervous or scared and smokes because he constantly wants to eat but can’t at his place of work so he chooses to smoke instead to suppress his nervous stomach and appetite.

AW would get a protocol focusing on acupuncture points to soothe the liver (anger is often associated with a stagnant, frustrated liver) and also to clear out all that internalized heat. Goals would probably also be set to help her find ways to re-focus and distract herself from her reflexive anger response and from seeking cigarettes to alleviate the internalized anger. I often find that treatments to move stagnant liver qi work well with physical techniques like vigorous exercise (running, kickboxing or spin classes or even expressive arts like singing or even improv.)

NM however would get a treatment to focus on his lack of energy and lack of a sense of groundedness which constantly prompts him to need to eat out of stress (and possibly raise his blood sugar if he has low blood sugar and possibly very low blood pressure) and treatments like his would probably focus on strengthening Heart (spirit or consciousness) Qi and Spleen Qi (often used for strengthening one’s focus and aiding in absorbing the nutrients from one’s daily intake). Goals would be set for calming down his nervous system through meditative techniques so that a cigarette would not be his first option for calming down his frazzled mind. I’d probably set some meal planning goals too to help him manage his energy levels too (obviously following the TCM dietary framework for those with a weak Heart and Spleen Qi constitution).

I always use a protocol on the ear for helping a patient quit smoking called the NADA protocol. This would be an example of what I would use in the ears (just one ear required per person!) of AW or NM.

** Don't laugh! I had to hand-draw this because my laptop absolutely refused to download some of the much nicer pictures that I has saved up for this article! My drawing skills are to be worked on I admit but it gives you a roundabout idea of where on the ear some of the auricular acupuncture points would go if you were to come in for a smoking cessation treatment.

But this is just a protocol on its own. It can be used, one size fits all, on just about anybody for the aim of helping someone quit smoking. But what really helps a person on their path, is a more or less tailored treatment, focusing on THEIR specific needs and not a cut and dried ear protocol treatment that may not always address one’s underlying energy or qi blockages in their bodies and minds. This is where acupuncture points on a patient’s body are also used in addition to the NADA protocol to help patient AW or NM get to their individualized and tailored goal-focused plan to achieve smoke-free status.

Q5: Do the needles hurt when they go in?

A: If I had a dollar for every time I hear that question asked! Yes. And no. They don’t always “hurt” in the traditional sense of pain (like dropping a hammer on your toe or walking into a steel door). What you normally will feel is a very quick and very short-lasting burst of pin-prick sized discomfort. Normally, as you move way from the extremities and towards the mid-line and trunk, the acupuncture points irritate the surface of the skin less. These are areas that are more or less closer to the thighs, upper arms, shoulders, back, stomach and abdominal areas. As you start to approach the extremities like the fingers, toes, hands and feet (and to some degree the head and scalp), there are more nerve endings here in these areas. Think about how quickly you’d react when someone tells you that you are about to step on a snake! That’s how fast the nerve endings fire and when there is an acupuncture point on a finger or the joint of the finger, the top of your foot or the ankle, you will bet that this part of your body will respond ASAP! Some people will tell you its like a very quick 1-2 second sharp prick and then it turns dull or disappears completely. Most of the time, its not so much a pain but a twitch-like discomfort.

I should know this. I have been kicked once by a fast twitch foot so I am definitely very aware of this. And that’s very normal because we need to react fast to “perceived impending danger”. That’s why, yes, needles “hurt” a little more the farther out from the midline you go and no, they do not “hurt” (as much) the closer you get to the midline of the body. Aside note for those of you who are worried about us getting kicked or smacked: Rest assured, we learn how to dodge flying feet and arms in “Secret Acu Ninja School” so there is no need to worry about us Acupuncturists. We move stealth fast!

Q6: How long does it take to lessen the body’s craving for nicotine (i.e. how many treatments will it normally take to drop a person’s dependency on cigarettes by at least 50% or more)?

A: It depends on how much nicotine is in your body to begin with and also to some extent, how anxious or irritated a person gets in the absence of a high-dependency habit. I find that in general, most of my patients who smoke very little (like 1-4 cigarettes a day) tend to need anywhere from 6 to 10 treatments, done biweekly for at least 3-5 weeks. They tend to be pretty much less likely to smash and grab chocolate bars at a convenience store at 11pm at night when craving a cigarette which, frankly, also helps lessen the duration of treatments required.

However, for patients who smoke heavily (this is leaning into the one to two pack a day territory) and who experience negative withdrawal symptoms when they try to stop (like heart palpitations, high anxiety, sweats, racing thoughts, shortness of breath), they may need more support during the week. This may for some, especially for those without a good social support network, look something like 3-4 treatments a week and which may require weekly evaluation to determine just how many ongoing weeks they will need high support treatments for. For those who do have a great support network of good family, friends and caring co-workers or neighbours, despite being intense smokers, they may be able to squeak by with at least a 50-60% drop in cravings on that same schedule for 4-5 weeks.

Again, its all tailored to the individual’s needs. There is no real one size fits all solution for all patients and most of the time, consultation, the diagnosis and the choice of acupuncture points are all determined by the intensity of the habit, the frequency seeking the habit and the reasons for the habit as well as by individual traits and personality quirks.

Q7: Does this same level of treatment frequency continue indefinitely? Or are the treatment frequencies decreased as the patient gets better and craves cigarettes less?

A: Of course! I would never want to make someone literally “go for broke” in their pursuit of a better and more wholesome life. As much as I’d like to be able to comfortably pay my bills (and eventually buy a completely useless giant sodastream slash espresso machine for my lotto-max win mega-mansion), I want just as badly for my patients to do better with each passing week and to feel empowered by their personal lifestyle choices, even if it means I don’t get to see them as often as I’d anticipated. That’s actually good news for me! If I see you less, then we’re both doing something really right! Seriously, in the event that they respond really well (going down from something like one pack of cigarettes a day to half a pack after two weeks, and feeling less highly anxious and nervous as a result), I would be proud to cut down their 3-4 times a week frequency after two weeks to half that frequency, just so they can see how far they have come!

Q8: Has anyone ever had certain cravings develop in place of the cigarette cravings when the urge to smoke goes down? I have heard that some people develop an urge to eat all the time because they have nothing else to put in their mouths and they sometimes gain weight as a side effect of quitting smoking.

A: I’d like to say that I have never heard of such a thing but yes, sometimes patients will substitute one craving for another. Acupuncture can sometimes be used to help alleviate the stresses that accompany the urge to eat too by working on the same reward mechanisms as the urge to smoke in that same individual. However, I always advocate a Plan B if this type of scenario shows up in a patient’s treatment because 90% of the time they do.

I don’t just tell a patient to get acupuncture, leave and carry on as normal. As one old habit is shed, sometimes new ones need to be formed to take the place of the old one. That may not always apply to all individuals. But for some of us, myself included, its a little scary when you suddenly lose that one habit that has followed you around like a faithful side kick for all these years. This is where I ask patients, what triggers them to smoke in the first place and I do suggest keeping a journal or sorts literally listing the reasons why they smoked that day, what day it was, how they felt after they smoked and how many cigarettes they smoked that day. I believe a popular after-school cartoon once said “Knowing is half the battle” and knowing yourself is truly helpful in finding the reasons why the habit even formed in the first place. It may forecast what sorts of habits you may form if you don’t have smoking to fall back on. And avoiding the triggers that cause the new, not so desirable habit to happen in the first place will be useful.

It would be an ideal world if the acupuncture did the work for you and you just got to be a passive robot receiving iOS updates and boom! You suddenly don’t need cigarettes. But in a world as complex as ours, the job is often done as a team (that would be both yourself, and myself working together). Allow me to geek out and use the Matrix as a general metaphor for this process. On our team, I am Morpheus and I present you, Neo (the patient) with the blue pill or the red pill. I say, “I am trying to free your mind Neo. But I can only show you the door. You’re the one that has to walk through it.” **if you're a real diehard Matrix quote fan, here's where I got the quote from: (I think my inner geek is starting to show!)

In other words, the tools are there, but it is up to Neo to know himself well enough to know why in this matrix world of cigarette cravings, he picks up a chocolate bar when he is stressed and trying to quit smoking in the absence of a cigarette. If the patient chooses the blue pill, he or she goes right back into the matrix as Mr Anderson and the reactions to stress, the reflexive choosing of the chocolate bar as his/her choice of stress-relieving activity (instead of smoking) will drive this alternative habit. However, if he/she has chosen the red pill, the patient “wakes up” as Neo and consciously sees that it was the stress he gets from his workplace schedule and the long commutes that caused his smoking habits to begin with. “Woke Neo” now deliberately turns on the reward centres of his brain with salsa lessons or touch football after work instead of reaching for the chocolate bar when a cigarette craving hits. Neo now has a Plan B to work with so that the smoking cravings get replaced by other healthier habits that become rewarding by their own right.

This is what I referred to earlier as “the homework”. Rewarding yourself when you achieve a milestone with an equally rewarding action when you drop your cigarette consumption by, say for example, two cigarettes that week is a great way to avoid overeating in compensation for not getting the anxiety-release from smoking. Plan B homework doesn’t have to be fancy or time-consuming like playing a team sport or learning to dance. It can be something as simple as beating your last gaming console score (my mom actually quit smoking by out-doing her previous game scores on Tetris on an old Gameboy until she became the indomitable Tetris Queen!), or bowling with family, getting a new pair of running shoes or watching a movie you’ve always wanted to see. Your imagination is the limit! The idea of Plan B homework (and some magic by your friendly neighbourhood Acupunk) is to intrinsically reward, and not punish.

Q9: What are some of the weirdest side effects of acupuncture treatments for smoking cessation?

A: That’s a pretty good one because the effects are all so varied and really depend on the patient’s individual makeup and personality. I’d have to say that there were two that struck me as maybe not completely weird but quite positively “visible” in their efficacy. One patient reacted by sleeping - A LOT - after every treatment. “Amelia” (patients real names and genders have been hidden for their protection) was exhausted and found that because she relaxed so much, she ended up napping and sleeping more so that her afternoon cravings and after dinner cravings dropped because she just couldn’t wait to get to sleep. Smoking was her way of managing energy levels and making her stay awake so she would feel like she had more time to work and get through life. What she didn't realize was that as she spent more time awake, the more she would need "a hit" from her cigarettes. Ironically, as those cravings decreased her sleep got more solid and her daytime energy picked up leading to less cigarette cravings as she got more alert and focused during her work day.

The other strange one was the altering of a patient’s tastebuds. “Bud” started to experience a not so pleasant aftertaste after he smoked. After two or three weeks of biweekly treatments, he started to realize that his afternoon and morning cigarettes no longer made him feel good because they tasted really funny. Don't forget that innervation to cranial nerves starts at the ear and small changes there will change one's perception of things like in this case, taste (via the facial nerve, CN VII). He started to smoke less and less because he just didn’t like the way his cigarettes were tasting anymore. And that was a nice side effect because not only did the taste of cigarettes change his need to smoke, they had a great effect on his tastebuds for food so he didn’t experience the food rebound effects that some people do.

Q10: This just about take us to the end of the Q and A. Is there anything else that anyone contemplating acupuncture for quitting smoking should do before they start a program with their Acupuncturist?

A: I sound like a record that keeps skipping and repeating a track but the real truth is, know yourself first. If you know you want to quit and why you want to, then you’re pretty much ready to do this. If you don’t feel you can let that last daily cigarette go, or you get a sense of insecurity about doing it, then that’s perfectly ok too. Its great that you thought about it. Like all things, the seed of intention has been planted in your head and one day, it’ll sprout into a shoot. At that point in time, you may have found your reason to quit and acupuncture will always be there waiting for you. Nothing is ever done overnight. I have a favourite saying that pops in my head. I don’t know who said it but its always quoted on popular positive motivation posts. Every journey begins with a single step. That single step that got you thinking about quitting, that intention gets stronger like a muscle gets stronger when you work it with increasing weights at the gym. Its the one first step taken that really counts the most.

Oh and, always exercise! Uhhh, eat your greens. And, go get acupuncture!

For true blue acugeeks looking for more reading on this fascinating protocol, check these articles out!:

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