University of Southern California Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
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Smoking

You don't need us to tell you that smoking is bad for you. People still start smoking because their friends smoke, or because they think it will make them look older or more sexy, or because they enjoy going against the grain or doing risky or extreme activities, even though cigarette packs and other packages of tobacco have carried warning labels for years. For example, one of our study participants, Helen, has smoked cigarettes since her days of partying and doing drugs, when smoking was just something she did with friends who also smoked and partied. Frank carefully checks his skin daily for redness or other trouble signs, uses a watch with an alarm in it to remind himself to do pressure reliefs every 15 minutes and eats a diet high in protein to help avoid pressure ulcers (which means the same thing as "pressure sores" or "bedsores"); even though Frank has made all these healthy lifestyle choices, he admits that he has not yet quit his long-time smoking habit. The truth is that smoking is addictive, not only because of the nicotine that is contained in the tobacco, but also because of other chemicals that are added to cigarettes, cigars, rolling tobacco and pipe tobacco to help them burn evenly and taste better. All the bad effects of smoking can occur whether you are a heavy smoker, or a light smoker; the health of a smoker starts to be affected soon after they start the habit 1. And most of the bad effects of smoking also apply to people who chew tobacco instead of smoking.

It is well known that smoking cigarettes, cigars or pipes can cause many forms of cancer, including cancers of the lung, mouth, tongue, throat and breast, and can increase the chances of getting many other potentially deadly health problems, including stroke, heart attack and emphysema (a severe lung disease). Evidence shows that "second-hand smoke," that is, the smoke inhaled by someone who is in a room with a person who smokes, can also cause cancer and these other health problems; children of smokers can develop asthma and other breathing problems. Smokers develop persistent coughs, have their voices become lower and rough-sounding, get yellowed teeth and bad breath, have clothing and home furnishings that smell of smoke, and can start accidental fires with stray sparks or ashes. In many states, people cannot smoke in their workplace, in a restaurant or in a bar; nationwide, all airlines and almost every hospital, rehabilitation center and skilled nursing facility forbids smoking (although some facilities provide outdoor smoking areas). And after July 1, 2005, inmates and guards in the state of California will not be allowed to smoke in state prisons 2.

So those are the reasons smoking is bad for everyone. But there are even more ways that smoking can harm the health of people with spinal cord injuries. Smoking can even contribute to getting a pressure ulcer, as recent research has proven 3. And once a pressure ulcer develops, healing is much slower for smokers than for nonsmokers 4. It just doesn't seem to be worthwhile, especially when you know more of the details.

One of the effects of smoking is that it interferes with the proper circulation of the blood. To be specific, studies have found that the skin temperature of smokers is more than 1° Centigrade cooler than non-smokers 1 (which is equal to 1.8° Fahrenheit, the temperature scale usually used in the United States; put another way, if someone who doesn't smoke has a temperature of 98.6°F, a smoker's temperature would probably be 96.8°F). Researchers studying skin's reaction to pressure found that blood leaves an area that is under pressure, causing ischemia, or a temporary loss of oxygen. If the ischemia lasts too long, some tissue, or flesh, can actually die, which can be the start of a pressure ulcer. When pressure is relieved, a large amount of blood pours back into that area of the skin and stays there for a short while to help the skin and other tissue recover from the ischemia, because oxygen is carried to tissue by blood. (If a person's sense of touch is still good, this can be noticed as the feeling of "pins and needles" after an arm or leg has "fallen asleep.") For smokers, however, when pressure was taken off the skin, less blood returned, and for a shorter amount of time, than in the non-smokers. In other words, there's less oxygen getting to the area of the pressure, and the chance of healing the damaged tissue is much lower. The result is that smokers have a much higher chance of developing pressure ulcers 1.

There is another danger for smokers with a spinal cord injury. If a person's sense of touch has been damaged, then they may not notice if a spark or hot ash falls from a cigarette, cigar or match and lands on their body. Like any other injury to the skin, a burn can be the start of a pressure ulcer. If the spark catches a person's clothes, bedding or furniture on fire, they could get serious burns that could cause severe pain, numerous surgeries, long hospitalization, loss of body parts, or even death.

That's the bad news. The good news is that every day many people do quit smoking, even though it is hard because of the addictive chemicals in cigarettes, cigars and pipe tobacco. There are many ways to be successful at quitting smoking, depending on your personality and how you like to do things. For some people, "going cold turkey," that is, just quitting completely, works well. For others, tapering down, that is, gradually smoking less and less until they finally stop all tobacco use, works best. Some people like to do it on their own; others like to join a support group, work with a therapist or coach, or find a friend who also smokes and quit together as "buddies" who support each other. There are people who use "alternative" health methods to help them quit, such as acupuncture, hypnosis, guided imagery, meditation or prayer. Statistics show that using some of the over-the-counter (that is, without a prescription) aids to quitting smoking, such as "the patch," gum (the most commonly known brand is Nicorette) and lozenges, double a person's chances of successfully quitting. While three out of four people report that these products didn't help them to quit smoking, studies have shown that it might have been because they didn't use these aids correctly. Many people believe that they can cut a patch in half to save money, or that they only need to chew nicotine gum or lozenges when they have a tobacco craving, but the studies showed that these items work best if they are used as directed on the package, which means going by the clock to decide when it's time for your next piece 5.

Please keep in mind that, when you have a spinal cord injury, your system might react in a different way to any form of medication, even over-the-counter medicines. Before deciding to use any remedy at all, it is extremely important that you check with your doctor for their advice! They might be able to tell you the best dosage for you to use, or they might tell you that you need to stay away from one particular anti-smoking product. For example, the patch might be too strong to use if your skin has past damage or if you have limited or missing sensation. But, whatever way you and your doctor agree is best, and even if you have to try more than one method before you succeed, it really is going to boost your overall health and help protect you from pressure ulcers if you do whatever it takes to stop smoking. Your body (and the people who are close to you) will thank you!

If you would like more information about quitting smoking, there are toll-free phone numbers you can call to get booklets or talk to nonprofit or government organizations who help people who want to improve their health. For example, to get a free print copy of the consumer self-help kit called "You Can Quit Smoking," you can call either the Agency for Healthcare Research and Quality at 1-800-358-9295 for information in English y información en Español; the Centers for Disease Control and Prevention (CDC) at 1-800-CDC-1311 for smoking, tobacco and health information in English y información en Español; or the National Cancer Institute (NCI) at 1-800-4-CANCER for information in English y información en Español. If you don't mind making a long distance (toll) phone call, you can reach The National Heart, Lung and Blood Institute, a part of the National Institutes of Health, at 301-592-8573 (or the TTY number 240-629-3255) and order a copy of any of the following bilingual booklets at no cost: "Kick the Smoking Habit" (in Spanish and English, Publication Number: 55-745), Nais ng mga Pilipino ang Malusog na Puso (smoking cessation for Filipino families, in Tagolog and English, Publication number: 04-5080) or "Don't Burn Your Life Away" (about heart health and tobacco use, in Vietnamese and English, Publication Number: 04-5204). You can also download these booklets for free by going to the NHLBI's search page and typing in the name of the booklet you want in the search terms box. BeTobaccoFree.gov is a website from the U.S. Department of Health and Human Services that provides help for quitting smoking.

As far as finding help in getting medications or counseling to stop smoking is concerned, there's good news there, too. Many (but not all) state Medicaid (or, in California, MediCal) programs provide coverage for doctor-prescribed drugs that help someone to stop smoking, and, as of 2006, Medicare will also cover these prescription medications. As of March 2005, many people who are recipients of Medicare will be eligible for up to 12 counseling sessions with a health care professional trained in helping people to stop smoking 6. With help from these and other sources, like your family, friends and personal physician, you really can quit smoking!

If you want to find more information on smoking on the Internet, there are lots of websites on the subject. Some good websites that specifically talk about how smoking affects people with spinal cord injuries include: an online list of 10 Ways to Stay Healthy (hint: stopping smoking is so important that it's mentioned in three out of the ten!) in the online edition of New Mobility magazine; and this very well-researched page about Smoking, on the website of Craig Hospital in Denver, Colorado. For more technical reading, an abstract - or short summary - of a published medical study, Lifestyle risks for three disease outcomes in spinal cord injury. This Canadian study found that "cigarette smoking is the most damaging lifestyle behaviour in the spinal cord-injured population" 7 (that's pretty strong evidence, isn't it?!).

1 Noble, M., Voegli, D., & Clough, G. F. (2003). A comparison of cutaneous vascular responses to transient pressure loading in smokers and nonsmokers. Journal of Rehabilitation Research and Development, 40, (3), 283-288.

2 New laws for the new year. (2005, January 1). Los Angeles Times, p.B6.

3 Krause, J. S., & Broderick, L. (2004). Patterns of recurrent pressure ulcers after spinal cord injury: Identification of risk and protective factors 5 or more years after onset. Archives of Physical Medicine and Rehabilitation, 85, 1257-1264.

4 Consortium for Spinal Cord Medicine. (2000). Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health-care professionals. Washington, DC: Paralyzed Veterans of America.

5 Duenwald, M. (2004, 31 August). The nicotine patch didn't work? You may not have used it enough. The New York Times. September 10, 2004. http://www.nytimes.com/2004/08/31/health/31cons.html

6 Pear, R. (2004, 24 December). Medicare to add help for smokers. The New York Times. Retrieved December 23, 2004 http://www.nytimes.com/2004/12/24/politics/24smoke.html

7 Davies D. S., & McColl M. A. (2002). Lifestyle risks for three disease outcomes in spinal cord injury. Clinical Rehabilitation, 16, (1), 96-108.