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Have you heard people talk about the birth of a baby saying that the infant came into this world “kicking and screaming”?   I wonder how babies must feel being born; they have been protected and safe in their mother’s womb for nine months.  What a shock to their tiny little bodies! The world that they once knew is forever changed; no wonder they come out kicking and screaming!!  


I believe that this analogy can be used to someone who is trying to quit using tobacco. Using tobacco for many years becomes comfortable; the user develops a sense of security over time.  Quitting may feel like that baby being born – a shock to the system –  giving up what was once thought as safe and secure, now becomes foreign; giving up the old, comfortable way of living to embark on something new, that  maybe you have never experienced it before.


What can help as you get through the process?

  1. Visualize yourself free from tobacco; what will you be doing when you are free from the perils of tobacco addiction?  How will you be spending your time? Remind yourself why you want to live a tobacco free life.
  2. Get active!  Physical activity can reduce withdrawal symptoms and urges to smoke.
  3. Consider the utility of Nicotine Replacement and /or medications to help with those cravings and urges.  
  4. Surround yourself with people who will support your efforts as you cope with the challenge of stopping tobacco use.  Your new support network can help you through the difficult times. Don't overlook the members here on EX as sources of support.


 Come out on the other side free from tobacco, “kicking and screaming”, ready for the new life you are about to embark on! You deserve it!


Therese Shumaker, MA

Supervisor/ NDC Counselor/ CTTS

Cigarettes are truly one of a kind. No other product- When used correctly kills more than ½ of its customers! However they do not receive the “recognition” they deserve.  News, social media and other outlets often focus on other terrible addictions. A prime example is the opioid epidemic. It seems like you cannot go 5 minutes without hearing about opioid use and abuse. While, this is certainly a very serious problem that needs attention and solutions it unquestionably is not the “biggest killer” around. That title is reserved for none other than-Tobacco! Tobacco is still the number 1 leading cause of preventable death in the United States. Nevertheless tobacco gets very little press or public outrage.


How can this change? Well we know that the tobacco companies would prefer that it does not. One thing that can be done is to not place blame or guilt on ourselves. Often many people are desperate to quit smoking and get stuck in a vicious cycle of not being able to quit and then feeling guilt and shame. Instead of blaming ourselves let’s take a closer look at who is to blame- Tobacco Companies!


Tobacco companies chemically engineered their products to produce maximum addictive properties. One tricky way they achieved this was by free-basing nicotine to the brain. Tobacco companies added ammonia to cigarettes to change the pH, thus allowing free-basing to occur. If you hear the words free-basing and instantly think of crack cocaine you are not alone! Actually the methods drug dealers and tobacco companies’ use are one in the same. They both add ammonia to their products to increase absorption and thus speed up the delivery to the brain. Tobacco companies also go to great lengths to ensure that there is a consistent amount of nicotine in each and every cigarette to maximize addictiveness. All of these manipulative and tricky processes add up to making it harder to quit smoking. While quitting smoking can be very challenging and the tobacco companies certainly are not making it any easier, it is important that you quit smoking. Use every tool and resources available to you and do not be afraid to ask for help. Because you too are “one of a kind”.


Laura McConahey MS

NDC Counselor/CTTS

You may have seen news reports this week about a petition to the Federal Trade Commission (FTC) from major public health groups to stop 4 major tobacco companies from using deceptive social media ads to target young people.   An international team of researchers, led by a professor from the University of Southern California found evidence of highly sophisticated and deceptive campaigns using social media posts on Instagram and Facebook to influence young people to smoke.


The study finds that posts and hashtags connected with tobacco industry products have been viewed 8.8 billion times in the U.S.  The companies use paid and unpaid ‘influencers’ and ‘public opinion formers’ to deceptively market their products.  The petition asserts that tobacco companies are violating federal law.  The practices certainly belie the industry’s promises to stop inducing young people to smoke and their claims that ‘We’ve changed’.


More than 1,000 people under the age of 18 begin smoking every day, and many of them will become addicted to tobacco.  The tobacco industry knows that if they can get people to start smoking their brand while young, they will have a customer for life. And, despite promises to the contrary, they don’t show any real concern that the young smokers’ lives may well be plagued by the many dreadful illnesses caused by their products.  Let’s hope the FTC takes the steps needed to protect our children. If not, I plan to write the FTC and make my feelings known.  How about you?


Mike Burke, Ed.D

Program Director and NDC Counselor/ CTTS

This article is adapted from the Truth Initiative article “4 things parents need to know about JUUL and nicotine addiction.


For those of you who are parents, there’s a new four-letter word you need to know: JUUL. It’s a brand name, a noun and even a verb: JUULing. It refers to a popular new e-cigarette that is reigniting concerns about nicotine addiction in youth.


We’ve seen lots of healthy discussion here on EX about e-cigarettes and their role as a quitting method. JUUL’s manufacturer says its product is marketed to help adult cigarette smokers quit, and we’re interested to hear whether you have experience using it in your quit.


But for those of you who are parents, there are good reasons to be concerned specifically with how much JUUL appeals to teenagers, and the increased risk of nicotine addiction that e-cigarettes may pose among youth. Here are the key things to know:


JUUL is “everywhere”

For those of you who are not familiar with it, here are the basics. JUUL manufacturers make about 20 million devices per month. The JUUL device looks like a USB memory stick and is relatively inexpensive. The cost for a new pod is $4 to $5 — less than a pack of cigarettes — after an initial outlay of about $35 to buy the JUUL product.


It has two components: a rechargeable heating element and a replaceable cartridge or pod. When charged and puffed, a solution contained in the pod is heated to create a vapor designed to be inhaled into the lungs. Each pod contains a high amount of nicotine, as well as benzoic acid, glycerol and propylene glycol, and a flavor, such as crème brulee, mango, fruit medley, cool mint, classic menthol or classic tobacco.


With its slick design and lower price point, JUUL has captured 68 percent of the e-cigarette market in just two years and caused alarm in schools across the country.


JUUL is easy to hide

JUUL is easy to hide from parents and teachers because it looks like a flash drive and can be charged in a USB port. It also does not produce a strong odor. These characteristics make it easy for kids to use is discreetly, especially in school. Kids can hide it in their pocket and take a couple of hits in a bathroom or even in the classroom. In fact, almost one-fifth of middle and high school students have seen JUUL used in school, according to a Truth Initiative® survey.


Kids are attracted to flavored e-cigarettes and believe they are less harmful

Flavors in tobacco products, including e-cigarettes, have been proven to attract kids. Research shows that young people are more likely to try flavored e-cigarettes and believe that they are less harmful than tobacco-flavored e-cigarettes. Many youth e-cigarette users also incorrectly believe they aren’t consuming nicotine when they vape. The majority of youth e-cigarette users think they vaped only flavoring, not nicotine, the last time they used a product, according to an annual national survey of more than 40,000 students from the University of Michigan Monitoring the Future study.


JUUL is incredibly addictive

While e-cigarettes are less toxic than cigarettes, they still contain toxins and the addictive chemical nicotine, which is harmful to adolescent brain development. The adolescent brain is also more susceptible to addiction. The amount of nicotine in one JUUL cartridge is roughly equal to a pack of cigarettes, or about 200 puffs, according to the product website. That’s double the concentration of nicotine found in other e-cigarettes, the American Academy of Pediatrics found.


Teenagers who use JUUL and other types of e-cigarettes are more likely to use combustible cigarettes.


Pediatricians are still learning about JUUL

Detecting and monitoring JUUL use can be a challenge for pediatricians. A Truth Initiative study published in Tobacco Control found that many young people refer to the use of JUUL as "JUULing," indicating that it is so distinctive, it is perceived as its own category. 


As a result, the people who use JUUL don’t consider themselves smokers. They use the term ‘JUUL,’ and if parents and pediatricians aren’t aware of what JUUL is, they might not even ask the right questions.


E-cigarettes are putting an entire generation at risk of nicotine dependence. This is why Truth Initiative, the American Academy of Pediatrics and other public health and medical groups and individual pediatricians are calling on the Food and Drug Administration to take immediate action to address the rising popularity of JUUL among youth. 

The bottom line for those of you who are parents: know about JUUL, ask about JUUL and be on the lookout for something that looks like a USB drive. We don’t want your kids to need EX down the road.


Dr. Hays


A mistaken belief

Posted by NDC.Treatment.Team Aug 16, 2018

People trying to quit smoking frequently use e-cigarettes to help them stop. Often they then become dual users of both e-cigarettes and regular cigarettes. They may consider this a ‘success’ in terms of reducing their health risk, but a recent study from researchers at the University of California found this belief to be mistaken. 


The researchers analyzed data from almost 40,000 participants in an ongoing online longitudinal study of heart health.  The study asked the participants about different health concerns including breathing difficulties, chest pain, a number of specific cardiovascular problems, COPD, asthma, hypertension, sleep apnea. 


Among the participants 1,693 were cigarette smokers only and 514 reported that they used both e-cigarettes and smoked cigarettes. Compared with cigarettes only,  dual use was associated with worse scores for general health and similar scores for breathing difficulties, chest pain, cardiovascular problems, COPD and asthma.  The “dual users” actually reported smoking more regular cigarettes than the cigarette only smokers.


The conclusion is that dual use of cigarettes and e-cigarettes does not reduce health risks.  Stopping both e-cigarettes and cigarettes is the healthy choice.


Mike Burke, Ed.D

Program Director and NDC Counselor/ CTTS

You have decided to make this big change in your life and like any other big change it can be important to have closure.  There are many ways one can experience a sense of closure. One place to find closure is through the art of letter writing. Letter writing can be therapeutically beneficial, especially in circumstances that are resistant to change, such as quitting smoking.   Writing a “goodbye letter” gives you the ability to fully disclose all of your thoughts and feelings. If you are not at the point of goodbye, maybe just a letter to tobacco- what are your thoughts and feelings towards it?  It can help with self-acceptance and promotes empowerment to assume greater responsibility for abstinence.  The best part about the letter is that it does not need to be sent – just putting it down on paper is cathartic enough.  I’ve even known people to burn this letter as a symbol of “good riddance.”


I ask all of you at what would your “goodbye letter” look like to tobacco? Feel free to share bits and pieces as you feel comfortable to the community.


If you have officially said goodbye to tobacco, what kinds of things or rituals did you partake in to make the goodbye stick?


Heather Kraling-Coons MA, CTTS

NDC Counselor/CTTS

We know quitting is not as easy as 1, 2, and 3, although others may think so.


Adding another layer of complexity: RITUALS! There is research to suggest that by doing rituals it reduces performance anxiety, people do better on test, perform better in sports, and the sense of failure is less…. Thinking in terms of tobacco, this can be very much a ritual: wake up cigarette, drink coffee, get ready, smoke, drive to work- smoke, work break suck down 1 or 2 cigarettes with x amount of time, lunch go for a walk- smoke a cigarette, drive home, etc.  This happens almost 365 days a year for “x” number of years. Meaning your brain is very used to this “habit loop” and did I mention our brains love habits! It keeps us feeling normal by executing our everyday routine.  This is because by completing the behavior, there tends to be a secondary reward; not only is your brain being rewarded by the chemicals itself (in this case nicotine) but it is rewarded by doing the behavior.


One can certainly develop a new positive “habit loop” by:


  1. Noticing the trigger or craving - Think about what you would normally do when this arises, bringing the experience to your cognitive awareness to then-
  2. Engaging in a different action or ‘ritual’ - Anything to get your mind off the craving or to avoid a trigger
  3. Providing a reward- Think small people- it does not have to be a trip to the Bahamas, it could be calling a good friend to tell them of your success or posting on BecomeAnEx at how much you ROCK since you made it through a really tough craving.


 After practice and time, this can become the new habit loop! Our brains then break pathways to the “old loop” and form stronger pathways to the “new loop” so after a while you naturally choose the new “healthier” loop. Yes “old dogs can learn new tricks.”

Habit LoopVirginia Fitch-Braun, MS

NDC Counselor/CTTS

Check out more from the Mayo Clinic Blog 

What does tobacco do for you? Is a common question I ask.


Get the wheels turning ask yourself to identify the beliefs you have surrounding tobacco.


It could be feelings of stress and the belief that the only thing that will cure the stress is to have a cigarette. Or “I feel pretty good today,” “I completed all the laundry, cooked, cleaned washed every dish in the house,” leads to “I deserve a cigarette. “ We all carry our own beliefs and rules to nearly every situation, e.g. if I don’t do this than this… or If I do this than this…. A constant running tally whether its work, home, school, or play and cigarettes or other forms of tobacco, fit right into the equation because they have been there- planned- thought about- made time for.


Think perception, if you perceive the above statements as true, try asking yourself this; what is the probability that it is actually true? See what you come up with and find the evidence for or against the statement. For example: I actually found I am more anxious when I have to find a place to smoke so then by doing the smoking I have 1) found a place and 2) I am easing my cravings. This takes time and practice; you may find you have to avoid places or thing until you are comfortable in your new routine to then insert those things in again. 


For those of you actively quitting or have quit what are some of these beliefs you hold about your tobacco products whether positive or negative and how do they fit into your day to day routine?


Stay tuned for next week’s blog and think just how these beliefs/perceptions play into the rituals of smoking.


Virginia Fitch-Braun, MS

NDC Counselor/CTTS

Check out more from the Mayo Clinic Blog 

When considering a time to quit, many tobacco users often first pause to consider what stresses they are dealing with at the time, and attempt to “time” their quit attempt around those stresses.


For example, I often hear patients say that they wish to “get through” this particular difficult situation, or stressful time, first prior to quitting.  Their reason being that, for as long as they have been smoking, the cigarette has been a chief coping skill for handling the stress in their lives, and so they want to wait until the stress passes prior to quitting.


However, the opposite is really true:  Those that have quit smoking, often find that they feel less stressed after quitting. 


Read on to see why -   


First let’s consider why some feel that the cigarette is the key for their stress management: 


When experiencing an urge or craving to smoke, the nicotinic receptors in the brain, which crave nicotine and so cause the withdrawal symptoms that are all too familiar, simply will not be satisfied until the user begins to smoke again.


Therefore many, understandably, think that the cigarette worked well in taking care of their stress.  However in reality, smoking actually re-introduced more stress, for that bolus dose of nicotine in which the cigarette is uniquely designed to deliver to the brain in 7-10 seconds, reactivated those receptors again. In fact, causing “stress” on the body.


Not only does the neurochemistry of the brain become re-set in this way, but those that quit smoking often notice that their entire lives become less stressful as there is no longer the urgency and anxiety associated with the cravings and urges to smoke, and the need to find a place to smoke where no one will see them.  Yes, their lifestyle can indeed be calmer, and less stressful, as they find themselves able to engage more fully in a hobby, play with their children or grandchildren, or attend social gatherings, without needing to take time away from them to smoke.


While the path to quitting is very individualized, some pleasant surprises are often noted by many of those who have quit smoking.  So it is important to be open to the many possibilities of what a smoke-free lifestyle could be.


Surprisingly, quitting smoking could be the stress management tool that many who smoke have been looking for!


Barb Dallavalle, MA, LP

NDC Counselor/CTTS

Check out more from the Mayo Clinic Blog 

Australia has won an important battle against the tobacco industry.  In 2011 Australia passed a law which required ‘plain packaging’ for all cigarette packs sold in the country.   That means the pack must have a graphic health warning, be one drab color, with the brand name in standard size and font.  Plain packaging has been shown to make it less likely young people start smoking, more likely that smokers will stop.  It also helps people who are trying to stop by reducing relapse risk from point of sale marketing.  It is very good for public health and will substantially reduce the cost of health care in the country.

Since 2011 Australia has been in litigation with tobacco companies who sued Australia for ‘theft of property’. The Supreme Court in Australia decided against the tobacco industry in 2012.  In anticipation of this, the tobacco companies relocated their local corporate headquarters to other countries and subsequently sued Australia for ‘theft of property’ meaning their packaging color schemes and branding.  The industry sponsored countries such as Honduras and Indonesia as plaintiffs in the suit.

Last week the World Trade Organization decided in Australia’s favor.  It did cost the country almost 40 million dollars, a cost which many other countries might have found too burdensome.  You can read more about the court decision: Australia wins landmark World Trade Organization ruling on tobacco plain packaging laws .

John Oliver on his show ‘this Week Tonight’ aired in 2015 a very funny and insightful discussion of the Australia plain packaging legal battles. He deftly illustrates the threat to other countries posed by the tobacco industry, while the pose as representatives of the public interest. You can view the episode: Tobacco: Last Week Tonight with John Oliver (HBO)

Don’t forget to celebrate your independence from tobacco on July 4th


When you stop smoking, you truly gain independence.  You no longer depend upon cigarettes to help you get going in the morning, to manage stress, to help you drive the car, or to enjoy your coffee.  You are no longer hounded to make a long march outside of our smoke-free buildings to alleviate withdrawal and are no longer bound to pay the tobacco company so that you can just feel normal.


If you have already stopped smoking, take a moment this July 4th to celebrate your freedom and think of all that you have gained since stopping smoking.  If you are considering quitting, use this day as a jumping off point.  Use all the tools available at to develop a plan and then begin to work on your plan for independence from tobacco.  Join in the independence celebration this year so that you will be around to celebrate for many years to come.

Tobacco use remains the #1 cause of preventable death in the United States and across the globe.  In 2015, tobacco was estimated to account for 7.2 million deaths worldwide.  By 2025 it is projected to cause 10 million deaths per year.  Tobacco use may kill 1 billion people in the world during this century.  And, do you know that most of those people, who will die from tobacco use, have not yet started to smoke.  You are never too young or too old to help your heart by quitting all tobacco use!


If you have known heart disease of any kind, or if you want to remove the #1 cause of heart disease, stroke, cancer, many major lung problems, as well as other illnesses, you want to quit all tobacco use. 


We know that when tobacco is burned, there are over 7000 chemicals released, including 60 cancer-causing agents.   The nicotine in tobacco narrows your body’s blood vessels while the carbon monoxide in tobacco can damage the inner lining of your blood vessels, around your heart and all over your body.  This damage to your vessels makes your coronary arteries, which supply oxygen and nutrition to your heart, more likely to narrow causing “hardening of the arteries” to develop. 


People who smoke are far more likely to have a heart attack than those who do not smoke.  Breathing in secondhand smoke can also cause changes in blood vessels and blood flow in people who do not smoke.  And, today, we are learning more about third-hand smoke, which is also very damaging.


What is your plan to stop smoking and stay quit?  Use the many tools available on EX to develop a plan that will work for you.  Reach out for support.  If you are interested in using medications, talk to a trusted professional, who is specialized in treating tobacco to discuss options for quitting.  Set a stop date and get ready to enjoy the many benefits of stopping.


Remember that quitting tobacco will improve blood pressure, lower your heartrate, lower cholesterol levels, and improve your overall health and well-being.


Taking care of yourself FIRST, is the BEST thing you can do for those you love and for the other priorities in your life!  Best of luck!


Want to learn more? Feel free to leave a comment!


Kathy Zarling, MS, APRN



Let’s face it- non-smokers are often not very nice to those who do. Smokers get judged, ignored, and even called names.  People who smoke are often the target of stigma and stereotypes. This stigma can have devastating consequences. Stigma is associated with reduced treatment adherence, potential delays in asking for help, getting treatment, and can increase the risk for depression.  Stigma can cause one to feel guilty and shameful. What can you do to prevent this stigma from getting the best of you?

  1. Understand that most people do not have any understanding of the addictive properties of tobacco and the difficulty involved in quitting.
  2. Stigma and stereotypes have been around for a long time and most likely will not go away – do not let them get in your way!
  3. Focus on YOU – what is in it for you? How will you benefit if you were able to quit? 
  4. Give yourself credit for what you are doing.
  5. Quitting smoking is hard work, it can take a few times before one is able to quit for good.

Think about how stigma may be playing a role in your efforts to quit.  Having the awareness of it may impact how you  react to it next time that you are faced with the  stereotypes or stigma associated with quitting.


Therese Shumaker, MA

Supervisor/ NDC Counselor/ CTTS


Failure to Launch

Posted by NDC.Treatment.Team Jun 13, 2018

In honor of social media terming this week as “men’s health week,” I have decided to inform you of just how smoking can play a lead role in infertility. Granted I will inform you of both men and women, it is something we sparingly see at the clinic but something that can be just as important when considering having a family.  Infertility is often thought of as a “female issue,” however that is not the case. Research suggests 35% of infertility cases are caused by male factors, 35% are caused by female factors, 20% come from both, and 10% is undetermined.


In men- Smoking increases the risk of low sperm count and erectile dysfunction (the inability to get or keep and erection). Toxins from cigarette smoke can also damage the genetic material in sperm, which can cause infertility or genetic defects in your children.


In women- Smoking makes it more difficult to become pregnant and if you are able to become pregnant, smoking increases your chance of having serious pregnancy complications. Such as: Miscarriage and ectopic pregnancy (when the fertilized egg implants outside the uterus, usually in a fallopian tube). Smoking affects each stage of the reproductive process, including egg and sperm maturation, hormone production and the environment in the uterus. It can also damage the DNA in both eggs and sperm.


Together- Smoking tobacco by either partner reduces the likelihood of pregnancy. Smoking also reduces the possible benefit of fertility treatment. Research shows it is much easier for people to stop smoking if they do it with their partner. Deciding to quit together is a great way to increase your fertility and chances of having a healthy baby.


Laura McConahey MS

NDC Counselor/CTTS


Feel free to comment below on other questions you have on this or other topics regarding family, children, or pregnancy and I would be happy to address those in future blogs!

I have had many conversations lately with patients about how powerful their addiction is to nicotine. The conversations have made me think about all of you that are struggling to quit tobacco and the reasons I enjoy being a part of the journey.  I always feel privileged to be a part of someone’s quit attempt and walking beside them working through lapses, relapses, and celebrating triumphs.   Many people feel that you should just be able give up tobacco and it is no big deal to quit.  However, most often that is not the case, because nicotine alters the brain and you crave it.  This judgmental attitude often can lead to pointing fingers and shaming the individual who is trying to quit.  As many of you have experienced the blaming only makes this worse and you may give up.  I encourage you to keep trying because with each quit attempt important insight is gained.  You learn what works and what doesn’t work for you and this information puts you in a better place the next time you try to stop. 

When thinking about quitting, consider all of the tools that you will need to help you be successful.  Do you need medications to help with withdrawals and cravings, behavior therapy to help deal with habit, or support from places like

During your journey, it is important to treat yourself with love and kindness, you owe it to yourself.  Dealing with others can be hard enough; don’t let self-doubt or shame contribute.  Quitting is difficult and we are often our own worst critics.

One exercise to try is when you are feeling down on yourself during this quit is ask yourself, “What is it that I want out of this?” and focus on your answer.  I often use a mantra with many of my patients and maybe it can become one that works for you too, “Whatever follows I am                           is going to come looking for you.” For example, you can tell yourself, “I am not a smoker or I am going to overcome this” and before long it will become your new way of thinking.  The positive thinking will add to your beliefs and help with success.     

One final thought, give yourself time to process this big change, it is definitely something worth taking the time for.  Take a moment, listen to your body – what is it needing? Food, a friend, a good cry, distraction, or someone to listen?  Practicing good self-care by getting your body what it needs is important so you can be successful and get to TOBACCO FREE LIVING.


Heather Kraling-Coons

NDC Counselor/CTTS

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