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We are met daily with irritating and frustrating experiences that heighten our sense of feeling stressed.   We have our “go to” actions we do to feel better, calm our tempers, soothe our emotions, and clear our heads.  These actions can give us a moment to escape the stressful situation or process our thoughts so that we can think through how to best respond to ensure our well-being (so that we keep our jobs, relationships and stay out of jail).  It is easy to get into the “rut” of smoking being the only way we use to respond to stress in the moment. After years of smoking, it may be the only or primary stress response behavior you have practiced.  Thus, smoking may feel like the only tool you have at your disposal to relieve stress in the moment.  You may be in a mental rut when trying to identify alternative and healthy ways to calm yourself when stress creeps up on you and you only have a few moments to react.  To help you get started, here are a few quick and healthy stress relievers ex-smokers have shared that they find works to take the place of smoking to deal with stress in the moment. :

  • Deep breathing
  • Meditating, praying
  • Playing phone games
  • Laughing (Watching comedy - even short YouTube videos on your phone)
  • Listening to music, singing or whistling
  • Taking a short walk
  • Looking at pictures (on the phone) of loved ones

What are some ways you can deal with stress in the moment instead of smoking/vaping/chewing? You are most likely to use the ideas you come up with on your own, but it helps to have suggestions to get you started with ideas of your own.  This EX community is a great resource for getting ideas that work.


Jennifer Burden, PhD

NDC Counselor/CTTS

Most spouses or partners of smokers would like it if there loved one would quit. However they may be unsure of the best way to help their loved one. When looking to be supportive - Here is some information that may be helpful for your quitting spouse.


Despite the difficulties in quitting, 40% of those who are successful attribute their success to having appropriate support. So partners can play a greater role at successfully quitting than they might realize.


  • Express concern without lecturing- Most smokers already know the health risk associated with their addiction. Having a judgement-free conversation and expressing concern about wanting to live a healthy long life together may be beneficial.
  • Help manage withdrawal symptoms- Being patient with your spouse during the period of withdrawal and longer (quitting is a process and often a major change). Encourage the use of NRT (nicotine replacement therapy) or other smoking cessation medications, if your partner is using them.
  • Together come up with distractions- Distractions can be very helpful in battling withdrawal and cravings. Together establish a few fun activities such as; exploring nature, watching a new movie, cooking meal together…etc.
  • Find the appropriate level of encouragement- Having unrealistic expectations for your partner can really have negative effects. If your partner feels that you are “nagging” constantly this may shut down open communications- Ask them what they would like encouragement to look like. If they are seeing outside help for smoking cessation, ask them if you would be able to join.
  • Be supportive during the “hard times”- Often people working towards quitting are not successful on their first try, quitting can take multiple attempts. Your understanding and ongoing support will make it more likely that your spouse will keep trying and ultimately succeed.
 “Addiction is a family disease, one person may use but the whole family suffers”
– Shelly Lewis

Laura McConahey

NDC Counselor/CTTS

The older I get, the more concerned I become about taking care of myself.  I am realizing that the body I have been given is what I am living in day in and day out! And a large part of the protection of that body is the wrapping – i.e., YOUR SKIN!  The skin is the body’s largest organ – making up 16% of its total weight!   Our skin performs many invaluable functions including protecting us from extremes of temperature, UV rays, and chemicals in the air. 


And so it goes that quitting smoking is paramount to protecting that body of yours, and the relics of smoking are no more obvious than on your skin. 


Wrinkles are the first thing people notice – especially on your face.  Again, those toxins in cigarette smoke damage the collagen and elastin in the skin which can lead to wrinkles.  Carbon monoxide in cigarette smoke inhibits blood and oxygen flow to the skin cells, leading to this premature aging of the skin.   Vertical wrinkles around the mouth, sometimes called “Smoker’s Lines”, are due to years of pursing the lips to smoke.   The lack of oxygen also plays a role in the greyish skin tone of someone who smokes. 


And if your appearance is not enough to say on this topic – skin cancer just might be.  Among the most common of skin cancers, squamous cell carcinoma, is over 50% more likely to develop if you smoke.


While stress is a culprit for developing psoriasis; people who smoke, on average, double their chances of getting this condition characterized by red, itchy, scaly patches on the skin.  Therefore there is some thought that those who smoke as a stress management strategy may increase their risk of developing psoriasis.


Your risk of developing acne inversa (boil-like nodules caused by skin rubbing against skin), is increased with smoking.  Another condition is vasculitis, one form of which is Buerger’s disease, in which skin ulcers develop; and in extreme cases, can cause one to even lose fingers or toes!   


While this is in no means an exhaustive list – it is enough to cause one to consider the risks with smoking to your skin and overall health.  Surprisingly, many do notice the appearance of their skin improving within just days of quitting; and it is very exciting and encouraging to see such improvement so quickly after quitting smoking.  So give quitting a try – and watch that healthy glow return to your skin!


Barb Dallavalle, MA, LP

NDC Counselor/CTTS



How Much Does Your Skin Weigh? | Live Science 

Structure And Function Of The Skin | Wound Care Education | CliniMed 

9 Ways Smoking Effects Your Skin 

Your brain has a built in reward based learning system that is geared towards immediate gratification.  Since nicotine is fast acting, individuals that use tobacco get stuck in a habit loop that is difficult to interrupt. As most of us know too well, the immediate reward from the tobacco trumps the knowledge of the long term consequences of smoking.


A tool that I use to help patients break the habit of using tobacco is mindfulness. Mindfulness works because it teaches you to be more accepting of unwanted thoughts and behaviors.


The first step of mindfulness begins with starting to pay attention to your smoking.  What do you notice when you smoke?  For example, some of my patients describe the burning sensation of the smoke down their throat and into the lungs; some will notice the taste.  Paying attention and being present in your experience instead of unconsciously smoking while talking on the phone or driving helps you learn skills to help manage your cravings.


Avoiding a craving without mindfulness will make it much more difficult to break free from tobacco.  Instead be aware, acknowledge and accept the craving to smoke and allow the thoughts and feelings to come and go. Each time you ride out a craving it gets weaker. Think about the things that you value about not smoking and use that to motivate your decision to quit and to help get through the cravings. Mindfulness could be the key you need to break the loop between habit and behavior.


Heather Kraling-Coons, MA

NDC Counselor/CTTS

The recent and growing epidemic of serious lung injury apparently related to electronic nicotine delivery devices, AKA electronic cigarettes or e-cigarettes, has caused us to rethink a lot of our assumptions in the tobacco control community. 

For example, we assumed e-cigarettes were considerably safer than the standard combustible tobacco cigarettes.  This assumption was based on reasonable science.  Public Health England made the assertion in 2017 that e-cigarettes were “95% safer” compared with tobacco cigarettes. (1)  This statement was based on the fact that the level of many toxic chemicals that are known to be disease causing and found in tobacco smoke were orders of magnitude lower in concentration in the e-cigarette aerosols tested.  What we did not know at that time with how rapidly e-cigarette technology would advance and how widely e-cigarettes would diffuse in the population, particularly among youth.  New devices and new electronic cigarette solutions used in those devices have come on the market in great numbers with uptake of these devices among our teenagers and young adults in astounding numbers. 


We also assumed that e-cigarettes would provide a means for adult tobacco cigarette users to quit smoking tobacco in a way that was much more acceptable than the pharmacological treatments that are available.  In fact, some early data suggests this might be possible. (3)  But in this largely unregulated industry we have also seen products marketed to youth using attractive flavors and advertisements to entice young people to use them.  The four-fold rise in the prevalence of current e-cigarette use among high school students in the United States from 2017 to 2018 (4), coupled with the report from the National Academy of Science, Engineering and Medicine showing that young people who use e-cigarettes are more likely to use tobacco cigarettes (5), has made us wonder whether we can “thread the needle” -- make e-cigarettes widely available to adults as an aid to smoking cessation, while keeping them out of the hands of teenagers.


I have abandoned most of my assumptions about e-cigarettes and the role they may play in ending the scourge of tobacco caused death and disease.  My hope is that the current news grabbing had lines about the dangers of e-cigarettes will spur execution on effective regulation and awaken healthcare community to the role they should play in advising their patients about the dangers of e-cigarettes and in helping them to quit.


Dr. Hays


  1. McNeill A, Brose LS, Calder R, Bauld L & Robson D (2018). Evidence review of e-cigarettes and heated tobacco products 2018. A report commissioned by Public Health England. London: Public Health England.
  2. Centers for Disease Control and Prevention. Outbreak of severe pulmonary disease associated with using e-cigarette products: investigation notice. August 30, 2019 (link).
  3. Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med 2019; 380:629-637. DOI: 10.1056/NEJMoa1808779.
  4. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018. MMWR November 16, 2018 / 67(45);1276–1277.
  5. National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. DOI: Public Health Consequences of E-Cigarettes | The National Academies Press .

First days

Posted by NDC.Treatment.Team Sep 25, 2019

I love the month of September, not because it is the end of summer (which I also really enjoy too) but because it is a time of year for firsts.  It was always exciting when my kids were getting ready to go back to school; everything was new – teacher, shoes, school supplies. It was as exciting for me as it was for the kids!


As I get older I still really enjoy this month as it signifies a time that I can begin new things and have those first days just like my kids did with school.  I started running regularly again after taking a long break from my daily runs- it feels really good to get back into a routine with running.


What a great time of year to try something new!  Maybe a great time to renew your commitment to quitting tobacco?  Take a fresh look at the resources on BecomeAnEX.  Review what you enjoy about not smoking, or the good things you envision for when you are quit.  Use this time of fresh start for a new look at being tobacco free and make it as enjoyable as going back to school!


Therese Shumaker, MA

Supervisor/ NDC Counselor/ CTTS

Vaping is increasing at an alarming rate as are the related health concerns. The CDC has received almost 500 reports on severe pulmonary problems being caused by e-cigarette products.  A sixth death suspected to be caused by vaping has now been reported in Kansas.  The Surgeon General has declared e-cigarette use among young people as an epidemic, and advises immediate action.


As September unfolds, and our children settle into the school routine, it may be a good time to ask your school what they are doing to address e-cigarette use.  School policy and education can have an important impact for protecting our young people and preventing the spread of e-cigarette use.


Two good resources for schools have become available.  The Public Health Law Center has developed suggested school policies to address tobacco use and vape products in school.    The policy model includes suggestions for helping students who are found to be using tobacco products on school grounds and progressive responses for students who violate the policies.


The American Lung Association has developed an educational program for schools INDEPTH (Interventions for Nicotine Dependence: Education, Prevention, Tobacco and Health.).  The program provides step by step guides to implement an educational and counseling program in schools.  It requires prior completion of an online training for adults prior to their delivering the curriculum.


If you have children in school, know what your school is doing to address vaping and e-cigarette use. 



Dr. Hays

Do you remember the song by Sheryl Crow, “a change would do you good”?   If you are here on the EX site, you are likely at least thinking about making a change to quit smoking. 


The thought of quitting can be daunting and it may even seem impossible to do.   What if you decide to stay the same and not change? That too may be hard to imagine as it might mean a shorter life, more health concerns, or less time spent with family and friends.


I would like to suggest trying change “ON” for a short time. Yes, try change ON like you would try ON a new pair of shoes.  Experiment with it, set a date and try quitting. Use the nicotine replacement products, medications, BecomeAnEx and other tools you might need to help you, and just go for it.  How does it feel?  How do your senses respond to the change? Take it all in, and process what is working well, what needs to be different.  Make adjustments as needed, you might need to go back and start over, but that is OK! 


You might find that it is easier than you thought. This change might do you good in more than one way, but you won’t know unless you try!


Therese Shumaker, MA

Supervisor/ NDC Counselor/ CTTS

What happens to people who smoke sometimes “ain’t very pretty.”  That is the point of the new labeling rules for cigarettes that the FDA is considering.  The label changes for cigarettes would include the requirement of having a graphic pictorial image showing 1 of 12 serious complications of smoking or secondhand smoke exposure along with a text warning describing the complication.  Many other countries have had graphic images on cigarettes package labels for many years.  The evidence supporting the effectiveness of these kinds of cigarette labels is quite clear.  When smokers are exposed to graphic images of potential serious and chronic diseases that are caused by smoking they make more quit attempts and they quit smoking more often than people who are not exposed to these labels.


Until now in the United States cigarette package labels have contained a text warning only that is quite small and on the side of the package.  The rotating warnings required under current law contain messages such as cigarettes can cause heart disease or cigarette smoking can cause lung cancer.  For the most part, smokers completely ignore these labels.  The messages about the health risks of smoking on our current cigarette package labels do not really convey the true risks of smoking like pictures.  The saying about pictures being worth 1000 words is really true when it comes to describing the health risks of smoking.  Simply reading the words that smoking can cause fatal lung disease is an abstract concept, but seeing a pair of hands in surgical gloves holding diseased lungs from someone who has died from chronic lung disease makes the potential deadly consequences of smoking very real.


The tobacco companies will fight this new rule just as they fought the previous attempt by the FDA to include graphic labels for cigarette packages in 2010.  Big tobacco convinced an appeals court that requiring these graphic images was infringing on their 1st amendment rights to free speech.  Of course, no one cares to mention that the tobacco companies have taken away from smokers the most important right, which is the right to life.


I believe placing graphic images on tobacco packages is the right thing to do because more smokers will attempt to quit, many people will be successful in quitting and almost all of those who quit will avoid the health consequences portrayed in these pictures.  It is time for cigarette package labeling to ”get real.”


Dr. Hays

The Minnesota Department of Health released an alert this week about severe lung injury in young people related to vaping.   A number of states have now reported similar harm that seems to be caused by e-cigarette inhalation.  


Lungs are vital and very reactive to toxins.  We know very little about the longer term effect of vaping upon these sensitive organs. We know these products are not harmless.  Tragically we seem destined to learn about the extent of the impact of vaping through experimentation by young people, rather than through scientific research. 


One would think that systematic testing for health and safety would be done before a potentially harmful product is marketed and widely distributed.  Unfortunately with e-cigarettes ‘the horse is already out of the barn’.  We should raise our voices to have the FDA issue sensible regulations quickly, and hold the manufacturers responsible for any marketing practices that imply these products are ‘safe’.


Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

We are just completing another of our Residential tobacco treatment programs. This is a 8 day program in which patients reside at the Mayo Clinic in Rochester for 8 days and participate in education sessions, counseling, and medical visits to stop treat their tobacco dependence.  We provide between 8-10 of these sessions per year.


The program has treated more than 1500 patients since it was first offered in 1994. I have been participating as part of the treatment team for the past 15 years. I would like to share a few brief reflections on this program, as I think it provides some unique perspectives on tobacco addiction and recovery.


First, it is always a privilege that these patients share with us their unique stories of tobacco addiction and their intense desire to be free from it. Sharing their stories with others in the program provides a bond that is an important part of the recovery.  


There are strikingly common themes that we hear in these individual stories.  One is that tobacco use can be an awfully difficult addiction from which to recover.  Another is that the hope patients have to recover provides a foundation to help them succeed.  A third common experience is that group support and a comprehensive plan for managing life without tobacco can transform that hope into a vision of success. 


Through the course of the 8 days we see confidence grow, withdrawal symptoms and cravings decrease, energy increase, and rosy cheeks blossom.   We see recovery begin to happen.


Many of our residential patients join the EX community, so you may hear from them soon.


Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

Many people do not realize just how consequential and extensive the health effects of smoking are.  Unfortunately, many smokers will use a bit of information, like a doctor saying ‘your lung screen is normal’ to justify continuing to smoke.  However, compounds from the combustion process of smoking impact every system/organ of the body including the vascular system, the endocrine system,  even the eyes!!  That’s right – your EYES


In conditions such as AMD (or age-related macular degeneration), the part of the retina known as the macula becomes damaged. This impairs central vision. The blood flow to the macular part of the retina (which enables us to see very fine detail) comprised of the tiniest vessels in the body, can be directly impacted by smoking.  According to the British Medical Journal, those who smoke are at an increased risk developing age-related macular degeneration,  and smokers in general increase their chances of going blind in old age by as much as 4 times.  While smoking can directly impact one’s eye health and vision, quitting smoking decreases your risk of developing AMD by 6.7 percent after  1 year, and by 11.7 percent after 5 years.


Similarly, while you probably already know that diabetes can be complicated by smoking, there is also a condition known as diabetic retinopathy which can again affect those tiny blood vessels of the eye.  Here, those fine vessels can break down, leak or even become blocked – which can lead to blurred vision, or worse yet - blindness. 

Smoking also increases the risk of damage to the optic nerve – the nerve that makes communication from the eye to the brain possible.  The possible consequences here are so central to your vision that damage to the optic nerve can lead to glaucoma, or again, blindness. 


Although  many do not consider it, the detrimental effects of smoking on the eyes is very real, and  quitting smoking is indeed one of the most important things you can do to protect your vision for a lifetime.


Barb Dallavalle, MA, LP

NDC Counselor/CTTS



Eye Health | Tips Prevention | Smokers

Another Clear Eyed Reason to quit Smoking | Your Vision

We have written before about how mindfulness can help reduce cravings.


Indeed, mindfulness cannot only help with cravings, but it can reduce stress, anxiety, depression, insomnia, and reduce high blood pressure.  It also seems to help with asthma, pain, and fibromyalgia.  Personally I found that a mindfulness practice significantly reduced my blood pressure from borderline high to consistently in the healthy range. 


And there are many ways to practice mindfulness.   Trying different methods and sticking with the one that seems right to you is the best way to develop a consistent mindfulness practice.


Ironically, one of the biggest challenges to practicing mindfulness is remembering to do it.  Certainly having a regular time to practice helps.  But, it can be a good habit to practice just about any time, and one can benefit from being mindful for only a few moments.  So why not use challenging situations through the day as a reminder to be mindful. 


If there is a situation that you find annoying, or you notice you are feeling bored, distracted, or experiencing a craving, try to use that as a trigger, a reminder, to be mindful.  Notice how you’re feeling, then choose to instead attend to your place of mindfulness:  notice your breath, be aware of your surroundings, scan your body for tension, relax your shoulder or forehead.   Triggers, like the cues to smoke, need not be a bad thing to be avoided.  A trigger can be an opportunity to develop the good habit of mindfulness.


Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

The extent of the widespread damage to health caused by cigarette smoke is almost unbelievable.  Smoking kills 60% of people who don’t quit, and cigarette smoke affects almost every organ system in the human body. People are familiar with the most common problems caused by smoking, like cancers, emphysema, and heart disease.  There is less awareness about the impact of smoking on things like vision, diabetes, cholesterol, wound healing, immune diseases, arthritis, to name just a few.


I thought a discussion about some of the less well known health effects from smoking might be of interest.  As there has been some discussion in the community about smoking and the thyroid, we can start there.


The thyroid is a gland that produces hormones which help regulate general metabolism and blood pressure, heart rate, body temperature, and weight. Thyroid hormones are critical for growth, reproduction, development of nerve cells, and regulation of energy. Underproduction of these hormones (hypothyroidism), or overproduction (hyperthyroidism) are relatively common problems which can cause serious health problems.  You can find an overview of the thyroid and associated problems.


Smoking has multiple effects upon the thyroid.  Some of the reported effects on the thyroid are  strongly supported by research, while the research on other effects is somewhat ambiguous.  Reasons for the ambiguity include the fact that there are many different compounds in cigarette smoke, different studies employ different methods to measure cigarette smoking, and studies on the effect of smoking are conducted with different populations such as those with thyroid disease or general populations without disease.  


There is strong and unambiguous evidence that smoking increases a person’s risk for Graves disease (a condition causing goiter and over activity of the thyroid), and will increase the likelihood and severity of thyroid related eye disease (Graves disease can be a cause for bulging eyes that can become severe enough to threaten vision).  In addition, children who have been exposed to cigarette smoke have a significantly higher risk for Graves disease and eye related conditions, as do women who are pregnant.  Stopping smoking seems to reduce the risk and complications from Graves disease, although former smokers do continue to be at higher risk, but more research with consistent measures of ‘former’ smoker are needed.


The association between smoking and enlarged thyroid is strongly supported by evidence, especially among women.  Smoking is also found to have especially damaging effects on the thyroid among people who are iodine deficient.  A number of studies have found that smoking increases the risk of under-active thyroid among people with Hashimoto’s disease (which is the most common cause of hypothyroidism in the United States).  However other studies have not found this association. 


Unrelated to illness, smokers tend to have lower levels of thyroid specific hormones.  Studies are a bit ambiguous on the effects of stopping smoking on hormone levels, but most of the evidence supports a return to normal after smoking cessation, although the time to return to normality is unclear.


Bottom line, is for some people smoking can cause thyroid damage and dysfunction.  Stopping smoking can help.   People who have thyroid symptoms after stopping smoking, should continue not to smoke and talk with their health care provider.


I would be interested in your comments and feedback, including your thoughts on the level of detail in a blog like this.  Ideally we would like to strike a balance between providing information that is generally accessible and describing varied and sometimes complex research findings.  Let us know your thoughts, and here’s to a tobacco free future!


Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

Dr. Hays wrote a blog a couple of weeks ago aimed to arm parents to talk with their children about ‘vaping’.  Let’s keep the lectures to a minimum. It’s worth a read.   


I want to add to the resources referenced in that blog by my colleague,  with a new one that is right here on  EX. Helping a Child Quit Vaping | BecomeAnEX. Parents who are interested in helping children stop vaping, or who want to be more informed about vaping, can register on EX, sign up for text messages, explore all the information and support on the platform, and participate in the community. If you've already registered but didn't opt in at registration you can do so now, go to your EX Profile, then expand Personal Information, change your reason To help my child quit vaping and Save. I think that the wisdom and experience available in the community can be invaluable to a parent worrying about their teen and nicotine addiction. 


I also think the topic is important for us all, not only parents. The surge in vaping by teens, the continuing development of new vape devices, and the duplicitous and seductive marketing may well be harbingers of a public health crises. As the Surgeon General recently warned, “E-cigarette use is a cause of great concern about which we must take action to protect the health of our nation’s young people.”


As always, I’ll be interested to hear your comments.


Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

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