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More than 40% of smokers under the age of 18 smoke menthol cigarettes. The FDA has concluded that although menthol itself does not cause disease, it makes cigarettes more palatable.  Thus, menthol in cigarettes posed a public health risk.  The FDA is currently considering regulating menthol in cigarettes.  So, why all the “fuss” about menthol cigarettes?  What concerns are there about these tobacco products?  Let’s just consider a few facts about these products.


39% of menthol smokers reported they would quit smoking if menthol cigarettes were banned.  Prevalence of menthol cigarette smokers is higher among African-Americans, younger, and female smokers.  African American smokers favor mentholated cigarettes by a 3-fold margin.  Menthol cigarette smokers had significantly lower odds of stopping smoking than non-menthol users. 


Menthol cigarette use was associated with increased concentration of blood cadmium (a carcinogen) and higher levels of Carbon Monoxide with having smoked fewer cigarettes.  Women who smoked menthol cigarettes showed signs of greater tobacco dependence than non-menthol smokers.  Young people who first tried menthol cigarettes are at greater risk of progression to regular smoking and tobacco dependence. 


Tobacco companies continue to perform active research to identify the product that would be least “irritating” to the throat and most addictive to promote lifelong use of their product.  Menthol cigarettes are a “perfect” fit.  They entice people to smoke and keep people smoking cigarettes – the only product that will kill more than 60% of its consumers

Hello EXers,


I apologize for having disappeared during the past six weeks.  Frankly we were short on staff and not able to keep pace with the weekly blogs.  We’re back up to full staff and we plan to be back to our regular blogging schedule.  Here is some food for thought for our first week back:


Mindfulness, a concept originating from Buddhism and other eastern spiritual traditions, has gained a great deal of attention in recent scientific research.  Mindful eating involves deliberately tuning in to your own inner experiences; including thoughts, feelings, and behaviors. With this focus, you begin to be more aware of the sensory aspects of eating, such as the taste & texture of food, when you feel hungry and full, and whether you are actually hungry or just bored, anxious, sad or angry.


Below are some mindful principles that can help you manage your weight when you quit smoking.


  1. Control portions. people eat much more food when given unlimited quantities. Try to purchase food in smaller packages and use smaller serving dishes.
  2. Eat when you’re hungry. Let actual hunger cues, not emotions, guide you’re eating. Substitute a quick walk for a snack until actual hunger sets in. Do you eat while multitasking, such as watching TV, texting, driving, or working? Do you gulp the food down quickly without really tasting it? Begin to notice your automatic patterns & habits around eating that stop you from being fully present.
  3. Plan. Prepare healthy snacks ahead of time to eat throughout the day. A 200-calorie, whole grain, high-fiber snack can satisfy hunger between meals.
  4. Keep a food diary. Write down everything you eat and what was happening at the time to identify food triggers – hunger, stress, excitement or boredom.
  5. Slow down.  During each meal, chew slowly, savoring each bite; put your fork down between bites. This gives the body enough time to signal to the brain that it’s satisfied, not stuffed.
  6. Pay attention. Don’t eat in front of the TV or computer, while standing at the kitchen counter or talking on the phone. This can lead to losing track of how much you’ve eaten.
  7. Use technology. There are now apps that manage food records, count calories, help you track what you eat and even provide guidance on healthy food choices at the grocery store and restaurants.


The process of quitting smoking and lifestyle change can be long and sometimes difficult. Begin by trying to accept and love yourself right now, as you exist in this moment.  Give yourself credit for all that you are doing! Make a list of your reasons for wanting to be healthier and carry it with you. Focus on the realistic benefits you can achieve when you quit smoking such as improved health, mood, and energy. Imagine yourself in the future living a more vibrant, energetic life without smoking.


Stress and resilience

Posted by Dr.Hays Feb 15, 2017

Often we think of stress as something that is happening to us: too many demands, situations that aren’t resolving as we hoped, or a series of unfavorable events. However we might benefit from seeing stress in a different light, as how we react to events, rather than how events are happening to us.


Our body provides us with one underlying mechanism to address emergencies or ‘stressful’ situations. When challenging events happen, our sympathetic nervous system (SNS) becomes activated. At its core, this system is designed to focus our energy to manage potentially life-threatening situations. When faced with a difficult or ‘stressful’ situation, a cascade of neurochemical messengers and hormones signal our heart to begin racing, our pupils to dilate, our digestive system to slow and our mind to more narrowly focus upon danger. This response is more fitting to being surprised by an animal in the jungle rather than to reacting to ‘stressors’ of the modern day like needing to balance a checkbook, or organizing a busy workday. Many ills of our modern day can be attributed to an overactive SNS –flailing to address crises or stressors with a system built for different types of demands.


But there is a solution. The mind and body are equipped with a cognitive ability to reappraise threats and a parasympathetic nervous system (PNAS), which can turn-off the SNS with a relaxation response. Good stress management can be understood as using our reasoning to realistically appraise the demands in our life, and most importantly, building our ability to activate our PNAS. With our patients we try to formulate specific goals for recreation, physical activity, enjoyable social connections, and practiced relaxation such as deep breathing or meditation; all of which strengthen the PNAS.


There are many good books on resilience and stress management, some of which you might recommend in comments. One I would recommend is ‘Why Zebra’s Don’t Get Ulcers’ by Robert Sapolsky. Now in it’s third edition, the book provides a very accurate scientific description in a fun easy to read format.  


I would like to hear from you about strategies you have found helpful to manage stress and develop your 'relaxation response'.

A colleague of mine recently asked about a good book on the history of tobacco. She was especially interested in the battle waged to establish the scientific evidence about the health effects from tobacco use within the context of tobacco industry deceit and public relations efforts.  At the risk of providing TMI, I shared 3 titles (among a dozen I might have suggested).  I thought our community members might also be interested. 


Richard Kluger won the Pulitzer Prize for his extraordinary book: Ashes to Ashes: America's Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris.  The book has been called a tour-de-force, and I found it to be captivating and compelling.  Kluger narrates a sweeping history of tobacco from it's discovery in the 'New World' through its development as a financial behemoth.  He focuses on the 20th century battle for truth about tobacco and health by looking at the political, financial, medical, legal, social, and marketing issues through the eyes and actions of the key players involved in this fascinating story.


Another enjoyable read, published in 2007 is The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America by Allan Brandt.  The cigarette century is identified as the 20th century, in which 100,000,000 people died from tobacco ( THE TOBACCO ATLAS) and it takes the reader through to the early 21st century in which the World Health Organization predicts a death toll of 1 billion people, 10 x greater than the 'cigarette century.'  Dr. Brandt provides a clear view into the strategies and tactics used to cloud the truth and allow this enormous human tragedy to unfold.


One last book I would recommend is The Cigarette Papers by Stanton A. Glantz, John Slade, Lisa A. Bero, Peter Hanauer, Deborah E. Barnes, and C. Everett Koop.  It gives the real time history of the investigation and fact-finding from secret documents smuggled from the tobacco industry which gave the first shocking glimpses into the planned deception of the public regarding the dangers from tobacco and the extensive effort to develop a more addicting product. 


Or if you would rather just watch a good movie, The Insider with Russell Crowe, and Al Pacino tells the true life story of Dr. Jeffrey Wigand.  He was a Senior Vice President of a tobacco company.  His courageous defection from the  industry and subsequent truth telling cost him a great deal personally, but gave us access to those documents.  

As a support person, you can play a very important role in your friends or family member’s effort to stop smoking.  Partner support is shown to have a positive effect, but how best to help can be a challenge.


Here are some specific suggestions we have found that are helpful.


Be positive! Offer encouragement; affirm how proud you are of their effort.  Avoid bringing up past failed attempts; these past experiences are an important part of the learning process for becoming tobacco free for good.  Give your friend or family member some extra attention. If your significant other has just stopped, do something to celebrate his or her commitment to living a healthier, tobacco-free life. Believe in their ability to succeed, and realize that stopping can be very difficult.


Understand that stopping smoking can create a great deal of unexpected change.  Using tobacco fills many hours and is often used to cope with a variety of situations and emotions—from boredom, to stress, to anger, to joy. Your friend or family member is working to learn new methods of coping, and may be irritable, particularly during the early withdrawal period (up to a month following ending tobacco use). This irritability will ease as your friend or family member adapts to life as a nonsmoker. Be as understanding and supportive as you can.


Try to be open to how they feel you can be helpful.  During our residential treatment program for tobacco use, we have one session in which we invite family members.  We meet separately with family members, and ask each the family members what do they do to be helpful, and we ask the patients what can family members do to be helpful.  The lists are often dramatically different. Try to create an atmosphere in which they can tell you what will be helpful. As with it may be hard for him or her to share the difficulties and challenges that go along with ending tobacco use.


Being there for your loved one during this difficult time can be challenging.  But it can make all the difference.

Wow, the new site looks wonderful!  


Our team at the Mayo Clinic Nicotine Dependence Center heartily commend the EX Team for all the hard work that has brought about this new chapter in the ongoing mission to create a world where everyone who wants to stop smoking has all the support and capacity to make that happen.  


We also are very pleased to partner with the EX Team and all the community members and visitors to the BecomeAnEX site.  Tobacco use remains the leading cause of death in the United States.  Our work with patients and families often makes this statistic too very real.  Daily we see patients who are suffering, or dying, from the effects of an addiction that could have, and should have, been treated sooner.  This work is vitally important.


We look forward to working with you to provide hope and to deliver proven strategies that will correct the misunderstandings about the addiction, stop the blaming of the person suffering from the addiction, and change the current state in which there is too little access to support and treatment for this deadly addiction.  Together we can make a difference. 

Stopping smoking for even a short time before surgery significantly improves surgical outcomes and increases the likelihood that a patient will survive surgery.  Because of this, and because surgery can provide a good opportunity to effectively connect with smokers, the Society for Vascular Surgery and the Society for Vascular Nursing this week issued a joint statement encouraging vascular surgery teams to provide treatment for tobacco dependence for all smokers who are considering surgery.

Unfortunately, too often the manner in which smokers are approached within health care is ineffective, or even detrimental.  Sometimes patients are lectured about the health risks they face if they don’t stop.  If the person being lectured has tried to stop and ‘failed’ or if they feel stopping smoking is too difficult, this can cause shame, discouragement, or even unconscious discounting of the message.  None of which are helpful.

Other times people are given a limited ‘yes or no’ choice. ‘Do you want help to stop smoking?’  Unfortunately the lack of accurate information about treatment, or the fear that treatment means more lectures about smoking and health, too often results in a ‘no’, or ‘not at this time’.  Also, people usually think, incorrectly, that tobacco dependence counseling means they must be already committed to stopping or a 'quit date'.

We are looking at more proactive ways to make referrals within surgical groups, or other medical areas in which stopping smoking can be of enormous benefit.  We are piloting projects in which we automatically provide treatment as usual care, or ‘opt-out’ rather than ‘opt-in’ approaches.  For example, prior to surgery a patient who smokes will automatically have scheduled a visit with a Tobacco Treatment Specialist (TTS).  The TTS is trained to connect with patients, engender hope, provide education and options, respect a patient’s personal choice, and provide treatment as indicated.  A trained TTS doesn’t admonish a person for smoking, instead the TTS uses an empathic strength based approach to inform and build confidence.

Here we would like your opinion.  What are your thoughts about ‘opt-out’ rather than ‘opt-in’?  Should patients automatically be referred to treatment and support for stopping smoking? Or should we first ask if they ‘want help’ with the ‘yes or no’ as a final answer? Or, should we just give them a brochure or contact information and encourge them to call a tobacco quitline?  

We would also like to hear from you about any good and bad experiences you have had in health care encounters when tobacco use was broached.

Thanks as always!


The tragedy continues

Posted by Dr.Hays Jan 11, 2017

A blockbuster report, The Economics of Tobacco, and Tobacco Control was just released by the National Cancer Institute in collaboration with the World Health Organization.


The findings are that the number of smokers worldwide is not decreasing, and that the deaths caused by smoking will increase in the next 10-15 years from 6 million to 8 million each year.   The report describes how the health and financial burdens caused by tobacco increasingly and disproportionately hurt low and middle-income countries. 


This is especially dismaying because the tactics to prevent this are well understood. Countries that implement policies to provide effective health warnings, raise the cost of cigarettes, stop second hand smoke exposure, help people stop smoking, and eliminate tobacco smuggling can dramatically reduce smoking rates, prevent many deaths and illnesses and gain financially.


So why do countries not put in place these proven policies that will improve the public health and save them money?  The main reason is that the power of tobacco companies in the market is greater now than ever before.   In addition to marketing and lobbying, tobacco companies have become very adept at undermining effective policies and intimidating governments with legal threats and measures that could bankrupt poor countries.  It seems preposterous that an international company can take legal measures to undermine countries wanting to improve their public health, but that is happening.  Marketing, lobbying, and lawsuits are causing increases in illness, and burdensome economic distress.


In closing I’ve provided a link below to a John Oliver video that makes this point more eloquently than I could.  It has some risqué language, but will make you laugh while illustrating a public health tragedy which has simple, effective, but neglected remedies.



Weight and stopping smoking

Posted by Dr.Hays Jan 4, 2017

Happy New Year!

As many of you know, stopping smoking can be quite challenging.  Adding to that, fear of gaining weight can make a person pause when considering a quit attempt, or even relapse after a time of being tobacco free.  Since weight gain and healthy lifestyle planning are a general concern at this time of year, I thought it would be useful to discuss some of the facts and myths about smoking and weight gain and next week have a discussion about managing weight.

Studies have found that concerns about gaining weight discourage about half of women and 25% of men from stopping smoking and just about the same percentage of people report that weight gain is a cause of relapse to tobacco. 1, 2Studies do find that people who smoke and who are in clinical trials to stop smoking gain on average between 6 and 12 pounds one year after stopping smoking and studies of  people in real life find an average gain of 9 pounds over five years after stopping smoking. 3, 4

There are probably a few reasons that people gain weight after stopping smoking.  Most of it is because of more calories in and fewer calories out. Nicotine can serve as an appetite suppressant so people may eat more once they stop.   Food can also serve as a distraction from craving. The calorie equivalent of one additional slice of bread per day for one year can increase weight by ten pounds, just the average amount gained after stopping smoking. And, it takes calories to smoke.  People get up, go outside, pound the pack, walk back into work or into their home, and all these little activities burn calories.

It does seem that the medications used to treat tobacco dependence can delay weight gain, and one medication, bupropion lessens weight gain after stopping smoking.  Being physically active, cognitive behavioral strategies, and eating snacks that are less calorically dense, all help reduce weight gain for people stopping smoking. 

Next week we’ll talk more about managing weight in general.

I wish you all the best!


1.         Cooper TV, Dundon M, Hoffman BM, Stoever CJ. General and smoking cessation related weight concerns in veterans. Addict Behav. Apr 2006;31(4):722-725.

2.         Pisinger C, Jorgensen T. Weight concerns and smoking in a general population: the Inter99 study. Prev Med. Apr 2007;44(4):283-289.

3.         Aubin HJ, Farley A, Lycett D, Lahmek P, Aveyard P. Weight gain in smokers after quitting cigarettes: meta-analysis. BMJ. Jul 10 2012;345:e4439.

4.         Tian J, Venn A, Otahal P, Gall S. The association between quitting smoking and weight gain: a systemic review and meta-analysis of prospective cohort studies. Obes Rev. Oct 2015;16(10):883-901.


New Year and Resolutions

Posted by Dr.Hays Dec 28, 2016

New Year resolutions are meant to be personally rewarding; unfortunately, too often they begin as wished-for results, use ‘willpower’ as a sole strategy for success, and gradually fade causing regret or self criticism.  If you decide to set a new years resolution or two, first of all remember, the purpose is to be good to yourself, not self-critical. Secondly, if you plan on setting goals for the new-year, using a simple formula based upon behavioral science can help your wishes bear fruit.

Four key characteristics for achieving goals are making the goal important, being specific in planning your goal, putting reminders or nudges’ in your daily path, and tracking your progress.  

Important: Sometimes the biggest challenges to achieving a goal or two, is having too many goals or tasks to accomplish.  Ask yourself, ‘What makes this goal important enough to me, to make it a priority within the array of tasks, projects, demands, and distractions, that I will inevitably face each day’.  Do you want to exercise more because you want more energy, because you want to look better, be healthier, be there for your children…..?   Understand ‘the why’ in detail.  Using the five ‘Why’ tool can help.  For example, ‘I want to be tobacco free in 2017’ Why – because I want to be healthier; Why – because I feel better when I am healthier; Why is that important – because I will be able to do more things I enjoy; Why – because my life will feel engaged and fulfilling; Why- because feeling engaged and fulfilled will make me a better family person.  Be clear about how the goal applies to your personal values.

Specific:  Specific goals are much more likely to be brought to fruition when compared with vague goals.  ‘I will exercise more this year’ may be a good goal, but ‘I will plan to go to the fitness center 2 x per week’ makes the plan more likely to come alive.  Of course, the specifics should be achievable, and realistic.  As with most things, under promising is better than over promising.

Nudge:  A human reality is that our memory, attention, and actions are most likely to be evoked by things that are right in front of us.  We can use this to our advantage by placing reminders in places that they won’t be missed.  Place a picture that reminds you of the benefits of being tobacco free right by your toothbrush so you see it every day.  Put your exercise clothes out the night before, and nudge yourself to do that by leaving a reminder where you won’t miss it before you go to bed.

Track:  Keeping track of our accomplishments toward a goal is a proven strategy for success.  Each day or week you are tobacco free, mark it on your calendar and remind yourself of the benefits.  Keep a log of your exercise.  Use a fitness tracker.  You can make this tool even more powerful by sharing it with others, either in-person or through social media.

I wish you a happy and healthy New Year.  If you are setting a resolution for the New Year, use these simple tools and you’ll find that success ISNT so difficult.


Now the days grow longer

Posted by Dr.Hays Dec 21, 2016

Today it begins.  Yesterday was the shortest day of the year.  Now we begin the turn to longer days.  With each new day there is more sunlight and an assurance of brighter times ahead.

The season always reminds me of the kindling of hope that happens as a person begins the journey from addiction to recovery.  A faint beginning at first, doubts about ever getting to a brighter place, but with each day the hope and confidence in new possibilities and better days builds.

I wish you all a wonderful holiday season.  Enjoy the accomplishments and build upon the challenges of the past year.  Kindle the hope and make sure plans for a happy and healthy New Year.


Look Beyond the Headlines

Posted by Dr.Hays Dec 14, 2016

A recent article based upon a doctoral dissertation by a student at Victoria University in New Zealand created misleading headlines that could have grave implications for some people who struggle with both schizophrenia and tobacco use.  The headlines “High rates of smoking among schizophrenia patients attributed to nicotine's ameliorative effect”; and “Smoking may alleviate symptoms of schizophrenia, new research suggests.”  Both articles under these headlines suggested that measures intended to help people with schizophrenia stop smoking should be reconsidered.

The research to which the articles refer, is actually research done on rats, some of whom had ‘tendencies toward schizophrenia.’  Now certainly the doctoral student who conducted the research is not to blame for the very misleading headlines and storylines.  In fact, she is quoted in one of the articles saying “Even if it is true (that this research might be applicable to humans) the effects of smoking massively outweigh the potential benefit,” and she goes on to rightly say that schizophrenics lose 17 more years of life than mentally healthy counterparts, mostly due to smoking. 

And, in fact, research on human beings who suffer with schizophrenia demonstrates that they, and others with serious mental illness can stop smoking.   People with serious mental illness can experience many potential benefits from stopping smoking such as reductions in anxiety, depression, and stress, some of the medications used to treat schizophrenia will work better and can be administered in lower doses, they will be financially better off, and they will be much less likely to die from the awful illnesses caused by smoking.  Possibly the biggest reason that people with schizophrenia have a more difficult time stopping smoking is that they need more support and treatment, not less. 

So the lesson to me is, read below the headlines.  The stigmatization of people who have schizophrenia suggested by these headlines, that they are too ill to receive treatment for the addiction that is most likely to cause them illness and death, is wrongheaded and deadly. 


Health through the Holidays

Posted by Dr.Hays Dec 7, 2016

The Holidays are a time to celebrate with family and friends – and also a time to celebrate a healthy New Year.  Daylight begins to grow longer in just 14 days.  In addition to committing to a bright new smoke free year, another way to be your best is to take steps to manage your weight as you see best.    

Food is a focal point of the holiday season.  Eating more than you would like is a common 'side-effect' of the holidays. But a bit of planning can go a long way toward preventing holiday weight gain:

  • Eat your favorites at the party, but be picky. Before you fill your plate, think about which items are not your favorites.  Take smaller portions than you usually do.  Have a big glass of water.  Snack on low-calorie foods early to avoid overindulging later, and remember that drinks such as eggnog, fruit punch, sodas and alcoholic beverages can contain a surprising number of calories.
  • Make a single plate of the foods that you really want.  Really enjoy it – chew slowly and savor every bite.  Take a brief walk outside after the meal.  If you're helping with the dishes, pop a piece of gum in your mouth to reduce unconscious snacking.
  • Put out healthy treats for family and friends.  Instead of candies and cookies, put out some colorful fruits and veggies and crunchy nuts.
  • Get moving!  Physical activity can curb urges to smoke, keep your mood up, help manage stress, and also keep off unwanted pounds.  It’s hard to find the time to exercise when your schedule is full of holiday activities, but this is not the time to get sedentary!
  • Make an alliance.  Take time out to talk about your plan to avoid weight gain during the holidays with a like-minded friend, and trade ideas.  Support is important in quitting smoking, and also in making other healthy moves.
  • Start now using an app (e.g. myfitnesspal) to track your food so to be in the habit of observing what you eat.

Weight gain is common when stopping smoking, but it isn’t inevitable.  Use the holidays to your advantage to continue to be the healthy person you want to be.

Rather than reading a blog this week, I thought you might be interested in a PBS show in which Michael Burke from the Mayo Clinic Nicotine Dependence Center discusses the challenges faced by mental health treatment programs in addressing tobacco use, and the importance of making changes to meet those challenges.  You can find the show at the link below and more information about the show below.

How to Quit Smoking When You Believe You Can't

Did you know that smoking affects you mental health as well as your physical health? And not in a good way. Hear from the Mayo Clinic’s Director of Nicotine Dependence Center who joins me to discuss why you should believe you can stop smoking even if you have tried and failed several times before.


Air date: 11/10/16


Gratitude works!

Posted by Dr.Hays Nov 23, 2016

The Thanksgiving holiday is upon us. The day usually includes Food, family, friends and hopefully no fights with infrequently seen relatives.  For you it might be a day you dread, or your favorite holiday.  In any case, on Thanksgiving i would like to recommend to each of you that you add to it a heaping serving of gratitude. 

Gratitude can be like a tonic.  Research by psychologists such as Martin Seligman Barbara Fredickson, and Robert Edmond has found that gratitude can increase happiness, build other positive emotions, reduce depression, and improve health.  Former smokers who review the benefits they experience from having stopped smoking are significantly more likely to continue to not smoke.

And it doesn't take much to tap this healing elixir.  Writing three things for which you are grateful, writing a thank you note or mentally thanking someone, counting your blessings or engaging in a 'loving-kindness' meditation are all strategies that are shown to elicit gratitude. 

So whether you relish or dread this holiday season, take the opportunity to enjoy a bit of gratitude.