Saturday, April 21, 2018

Preparing to Quit


Copy the times you smoked from the previous chart onto the left 24-hour circle. Then pick out the situations that you can target as the easiest to modify. Then select trigger situations that must be avoided or changed.


This is your battle plan. It is you versus addiction. If reducing your dosage of nicotine, by smoking less each week, is not making satisfactory progress, it is time to pick apart your behavior.
Smoking situations include not only the times you smoke, but also, the place and the activity. If you smoke more than one cigarette in a place or activity, target reducing one cigarette.
Trigger situations are more difficult to handle. They require CREATIVITY. They require breaking out of your addiction; a change in your behavior.
You cannot see your addiction, but you can see the behavior it controls. Some trigger situations can be changed. Some trigger situations must be avoided until you are no longer smoking.
Creativity is needed to sort out your triggers and to replace many of them. This requires becoming very conscious of your surroundings and your feelings each time you smoke.
Take a week to mark on the PREPARE TO QUIT sheet your trigger situations. Make it as complete as you can. A missing trigger situation may upset your long term quitting.
Also create alternate activities. Practice them. Practice avoiding other trigger situations.





Friday, April 20, 2018

Before Preparing to Quit


You control when and where you smoke before addiction sets in. You have no problem with smoking restrictions or being considerate of other people.
Then something happens. You start to smoke more or more often. You may like the response your body makes to a toxic smoke.
Can your body’s response be obtained in some other less harmful way? Can you just stop smoking? Can you change habits?
If not, you have become addicted. Your “habit” is now also an addiction. That addiction is the number one cause of preventable illness and early death.
This is a serious public health matter. Yet, each cigarette only shortens your life by 11 minutes. The smoke, and your smoking, affects everyone around you.
Breaking free from nicotine addiction requires some planning. Your nicotine requirement needs to be judged. This is different for each person.

Make a short bar across the left 24 hour circle for each time that you feel the need for more nicotine (a smoke).
Make a short bar across the right 24 hour circle for each time that you do smoke a cigarette.
If the markings on these two circles are the same, you are responding to your addiction. If they are different, they are telling us that you still have some control.
Use that sense of control to manage your nicotine dosage. You can reduce the number of times you smoke and/or reduce the amount you smoke each cigarette.
This method allows many people to end their use of tobacco. Others need more planning.
Characterize (THINK, ACT, FEEL) the times you need to smoke on the BEFORE PREPARING TO QUIT sheet. Do the same for the times you smoked.
We now know enough to plan for breaking out of you nicotine addiction. We know your dosage and something about the circumstances in which you smoke.
Pick out any situations you can target for dosage reduction. Pick out trigger situations that can be avoided or changed. Enter on the PREPARING TO QUIT sheet.

Wednesday, April 18, 2018

Missouri Tobacco Control Laws


Missouri tobacco control laws permit setting limits from the local level up; just the opposite from the Missouri tobacco excise tax laws that preempt any change in the state law by lower levels of government. They were written at different times and for different purposes ($0.17 state excise tax per pack, the lowest in the nation back in 1993. Columbia merchant tax, $0.10 per pack in 19??).
Health Care Facilities
Smoking is restricted to designated areas in health care facilities, health clinics or ambulatory care facilities including, but not limited to, laboratories associated with health care treatment, hospitals, nursing homes, physicians offices and dentists’ offices.
MO. REV.STAT. AA 191.765 & 191.767 (1992).

I have been using “residential health care” to characterize the large full- service sites in Columbia, MO. There appears to be no such thing!! The term “health care” seems to be restricted to “getting people well”. “Residential care” is a neat place to life and a pleasant place to die.

[“Long term care (LTC) assisted living facility (ALF) memory care” is the correct classification for our apartment; it is neither health nor residential but behaves like a mixture of both.]

This statute provides no protection, at the state level, from third hand tobacco smoke exposure for a person in memory care. This statute only segregates smokers, not the smoke carried by the smokers. [The same situation seems to apply in the smoke free city of San Antonio, TX.]

Nothing in sections 191.775 and191.776 shall prohibit local political subdivisions or local boards of education from enacting more stringent ordinances or rules.
MO. REV.STAT A 191.777 (1993).

This statute permits creating a city ordinance that can protect residents in residential/health care communities as well as provide an environment free of third hand tobacco smoke for employees, in general, and for those wanting to quit, quitting, and wanting to stay quit. This is an essential part of smoking cessation.
(See draft copy of such a city code for Columbia, MO, on the preceding post. There is no need for such an ordinance when these residential/health ALF communities act within current laws to eliminate third hand tobacco smoke.)
Smoking Protection Law
It shall be an improper employment practice for an employer to hire, to discharge, or to otherwise disadvantage any individual with respect to compensation, terms or conditions of employment because the individual uses lawful tobacco products off the premises of the employer during hours such individual is not working for the employer, unless such use interferes with the duties and performance of the employee, the employee’s coworkers, or overall business operation, except that, nothing in this section shall prohibit an employer from providing or contracting for health insurance benefits at a reduced premium rate for employees who do not smoke or use tobacco products. Religious organizations and nonprofit health promotion organizations are exempt from this section. The provisions of this section shall not be deemed to create a cause of action for injunctive relief, damages or other relief.
MO. REV. STAT. A 290.145 (2005)

This law provides special privileges to people addicted to nicotine and in no way promotes health or smoking cessation.  Nicotine addicts are to be paid the same wage as other employees; at the same time they put in less time on the job (smoking breaks, personal illness and family illness).
“. . . unless such use interferes with the duties and performance of the employee, the employee’s coworkers, or overall business operation;” where it does interfere in assisted living memory care.
“. . . nothing in this section shall prohibit an employer from providing or contracting for health insurance benefits at a reduced premium rate . . .” Or more accurately stated, “. . . health insurance benefits at an extra risk rate for smokers than for employees who do not smoke or use tobacco products.”
“The provisions of this section shall not be deemed to create a cause of action for injunctive relief, damages or other relief” or if you do not wish to believe in the myths of the tobacco cult, this law, preempts you from doing anything about it in Missouri courts.
This law was passed by people addicted to nicotine, who still smoke in their offices in Jefferson City, MO, and who have yet to come to grips with their addiction; let along be concerned about the health of other people.
[Neighboring states such as Kansas, Illinois, Arkansas and Iowa have smoke-free capitols. Forty one states nationwide do not allow smoking anywhere in their capitol building. 10JAN17 Fox2Now]
Four border states do and four do not have smoking protection laws. The federal government has no such laws.
Nicotine addiction is a serious public health illness. Education seems to be the best way to battle the promotion of smoking and the cigarette smugglers. Educated people, who understand nicotine addiction, do not smoke and do not carry third hand tobacco smoke in their hair, clothes and bodies.
Airlines and most restaurants learned from experience that operations were more profitable without smoking. Only one out of 90 residents smoke at Provision Living at Columbia, yet about half of new hires smoke with a turnover rate greater than 100% a year.
The law allows hiring with the stipulation employees do not smoke on their shift, at anytime, so as to not carry third hand tobacco smoke into the building. A suitable smoking cessation program is being designed for this transient workforce with alternate, free of toxic smoke, nicotine sources used during their work shift.
An alternative to all of this is to stay at home and continue using home health care where we hire caregivers, that “match” or bond with the patient, instead of being hired by the ALF. Home health caregivers are not allowed to smoke on duty or to bring third hand tobacco smoke into the house. In our case this might have worked for about another year with Home Instead (but we would have missed all the benefits of residential living the past two years).



City Tobacco Ordinance


DRAFT                                                17 APRIL 2018                                      DRAFT
Introduced by _____________________________
First Reading _______________________       Second Reading _________________________
Ordinance No. ______________________       Council Bill No. _________________________

AN ORDINANCE
Amending Chapter 11 of the City Code relating to third hand tobacco smoke exposure in residential (health) care facilities.
BE IT ORDAINED BY THE COUNCIL OF THE CITY OF COLUMBIA, MISSOURI, AS FOLLOWS:

            Chapter 11 of the Code of Ordinances of the City of Columbia, Missouri, is hereby amended as follows:
Material to be deleted in strikeout; material to be added underlined
ARTICLE IX. – CLEAN INDOOR AIR
Sec. 11-293. – Responsibility of proprietors.
            Definitions:
            As used in this division, the following terms mean:
            Smoke Free. No smoking and no ashtrays in designated areas.
            Tobacco Free. No smoking anywhere on the property and no ashtrays within the area, yielding no tobacco smoke exposure anywhere within the property.
            Second Hand Tobacco Smoke. Airborne tobacco smoke not consumed by the smoker (also called passive smoking and environmental tobacco smoke).
            Third Hand Tobacco Smoke. The tobacco smoke deposited on everything where smoking occurs, and is carried from place to place in the hair, clothes and bodies of anyone exposed to tobacco smoke. Third hand tobacco smoke can be released into the air for hours to days resulting in additional exposure after the smoker has stopped smoking.
            Nicotine Addicted. A person requiring nicotine to calm the craving for nicotine and, when quitting, nicotine needed to reduce withdrawal symptoms.
            Quitting. Reducing the number of cigarettes needed to relieve craving, learning an alternate way to handle stress, and unlearning smoking cult rituals.
            Smoker. Anyone burning tobacco as a toxic source of nicotine. Vaping without nicotine is an excellent example of pure ritual.
            Nicotine Replacement Therapy. The use of non-toxic nicotine sources to relieve withdrawal symptoms when quitting smoking; also replacing each cigarette with a lozenge, or several other alternate nicotine sources.
Smoking Cessation Program. A process of preparing a smoker to successfully quit by a variety of methods including determining the what, why, and how of a smoker’s behavior; a plan for behavior modification during quitting and after quitting; and the best time to quit. Mental preparedness is far more important when working with addiction than trying to buy a commercially available quitting potion.
     (e)             No one carrying third hand tobacco smoke shall work, in close contact (within 5 to 9 feet), with a patient or resident in a residential (health) care facility in Columbia, MO, including, but not limited to, long term assisted living memory care, assisted living, and memory care. This restriction is exempted by a release signed by a patient, resident, or responsible person acting for the patient or resident containing these two statements: "Tobacco smoke exposure is the number one cause of preventable illness and early death from heart attack, stroke, slow healing, and the aggravation of several illnesses. There is no risk free level of tobacco smoke exposure."

Richard Hart, PhD  www.residentialcarefortwo.blogspot.com  rahart1@outlook.com 

Tuesday, April 10, 2018

Inventory Story Addiction Management


The quickest way to maintain clean indoor air, free of tobacco smoke, is to not have smoking. Nicotine replacement therapy (NRT) uses nicotine lozenges and other smoke free sources to calm withdrawal symptoms during a shift at work. Using these only at work is only a bit less expensive than smoking all the time (see prior post).
Quitting is the ultimate goal of smoking cessation, the least expensive, and the most rewarding. But to quit, a person addicted to nicotine, must want to quit.


The “My Inventory Story” worksheet was designed to externalize the stories carried in the mind of a person addicted to nicotine. The worksheet can be used in two ways:
It can be used as a survey of all employees; documenting that they have had a hand in the initial cessation program, as well as new hires. It can be used as a weekly progress report for those getting ready to quit, for those quitting, and for those trying to stay quit in a self-help group setting.
The worksheet is designed to gain information that is of importance in designing the cessation program and setting the date for no tobacco smoke on the property, including third hand tobacco smoke carried in hair, clothes, and body.
[Smoking cessation counseling in a clinical setting (doctor or hospital) is found in the 5A's and the 5R's. Call the city/county public health department for free individual counseling and for free  company group cessation counseling. Call 1-800-QUIT NOW for national counseling.]

One of the three Osher courses (1) I am attending this semester taught me to look for a primary cause: Why take up smoking?
 [Smokers do not breathe in smoke. They avoid breathing smoke with their noses. They take the smoke into their mouths to let it cool and reduce the throat irritation that new smokers experience.]

The first three items cause respondents to reflect on how an activity (that became an addiction) got started in the first place. Is that reason still valid? Why am I still smoking?
Item 4 yields the amount of smoking in the respondent’s terms.
The cost by the month is specified, in item 5, as it makes the amount for a week four times as large; $140/mo is a more impressive number than $35/week or $5/day.
A smoker may not have to buy cigarettes during the 12-week cessation period. This money is now available for other uses when using health insurance. “Next month” requires a different answer than “today”.
Items 7 and 8 are related and at the same time independent. They require a bit of thinking too. Only if the “ready (desire) to quit” is high, and higher than the strength of addiction is a person ready to quit with a high chance of being successful.
Another Osher course (2) I am attending this semester pointed out that people need to be consistent in what they think, feel, and act to avoid stress and psychological problems. Item 9 is therefore a fully open ended question.
A single reason for continuing to smoke, or to quit, or to have never smoked is asked for in Item 10. Responses to this item can yield both quantitative and qualitative results.
Item 11 is again an open question to capture what is important to the respondent at this time and circumstance. It can be modified by a group smoking cessation leader.
The last seven items are important in tobacco smoking cessation. Weekly sessions are anticipated to collect changes in attitude and readiness to endure a few days of withdrawal in exchange for a lifetime free from an expensive, stressful, and harmful addiction.
This one page instrument is designed to capture the facts (numbers) and the stories needed for individuals quitting, for a residential health care facility to eliminate tobacco smoke exposure (especially in memory care units) and to prepare a city ordinance on tobacco smoke exposure.
My third Osher course (3) is on preparing a Missouri house or senate bill in such a way that the resulting law actually does what was intended. The state of Missouri is currently at the bottom of all the other states in promoting health with respect to tobacco smoke. Columbia, MO, is near the top!!
All five House of Representatives in the Columbia area have shown an interest in extending legislation from smokers to tobacco smoke exposure. They need examples (and stories) from residential health care facilities and residents.
These “health care” facilities can act on their own under existing law. Education is needed here as much as it is for individuals. Further legislation is only needed when facilities fail to protect residents from third hand tobacco smoke exposure for a number of reasons.

[There is a curious, and clever, use of terms in tobacco smoke legislation. Businesses that promote health (prevention) and businesses that cure diseases related to tobacco smoke are treated differently.  Until recently doctors and hospitals did not promote health and did not get reimbursed by medical insurance for promoting health. The classification of residential health care is also murky.]
For legislation to be effective, it must not be compromised by the usual tobacco company tactics of supporting a bill that looks good but which is deceptive. Residential health care facilities need to be active now before work on a bill starts this summer: clean up the air (profitably) or create laws with unknown consequences.
If interested, please comment on this post or email rahart1@outlook.com.  We have a lot of work to do before someone else does it for us and not necessarily for our benefit.

Thank you.


Osher Lifelong Learning Institute at the University of Missouri, Spring 2018.

Osher 1: John Kultgen, Life Choices from Existential Perspectives: Kierkegaard and Sartre.

Osher 2: Cindy Claycomb, Understanding Behavior and Change Through Trans-State Induction Theory. [grounded in existentialism]

Osher 3: Michael Connelly, Before and After "How a Bill Becomes a Law:" The "How, What, Why and Why Not?" for Regular People.

Thursday, April 5, 2018

The Cost of Tobacco Addiction and Cessation


Addiction is being forced to buy cigarettes to relieve withdrawal symptoms. This sets in after every cigarette. It trains the addicted person to fear quitting.
Quitting requires, in general, a three-day withdrawal, and a strong desire to quit. The emotional desire to quit must be greater than the fear of withdrawal symptoms, to successfully quit and stay quit.
Successful cessation programs span “cold turkey” at zero cost to several hundred dollars (often covered by insurance), that include hypnotism, directed meditation, alternative nicotine sources, drugs, counseling, and a variety of help groups. All of these have a very high rate of failure, if the addicted person has not had the time to unlearn smoking behavior and/or find a replacement behavior, or had a significant emotional event of sufficient magnitude.
The short-term cost of addiction is simple to calculate. In this discussion it is set at $5 per pack in Columbia, MO. In 12 weeks, Chart1, the cost is over $400 for a pack-a-day smoker. [The 12 week period makes all the charts have the same time as given in some product insert instructions for nicotine lozenges.]
About 30% of smokers do not plan on quitting. They can buy cartons and save $100.
Preventing people from experimenting with tobacco eliminates the cost of addiction and cessation. The price barrier of a 20 cigarette pack was set by stopping the sale of “singles” and smaller packs.
The price of a carton stops people from buying a carton, as well as, the desire to quit smoking. Each pack just might be the last pack. There is no need for a carton.
The cost of maintaining no third hand tobacco smoke in memory care or other residential health care facility, is set as 35 cents per lozenge (Chart 2). Using three lozenges a day, the cost would be about $1.05 per day; and using 5 for $1.75. These two rates are comparable to smoking 5 cigarettes (25 cents each) per day on the job.

Chart 3 doubles the number of lozenges to cover a 24-hour day. The cost for nicotine replacement therapy (NRF) now compares to smoking cigarettes ($1.75 to $1.25 per day).  By prescription, this is covered by many health insurance policies (in fact, twice per year).


Columbia/Boone County, MO, Health Department provides a 14-day supply of patches with counseling free. This removes the price barrier ($35) posed by the first box of lozenges when ready and prepared to quit. Paying for each box of lozenges from a $3/day contribution to your own savings removes the next barriers.

Using Walmart prices, in March, 2018, people addicted to nicotine are forced by their addiction to spend between $913 to $1,825/year to manage their blood nicotine levels (sales tax not included).

It would cost them about $1,095/year to switch to nicotine lozenges at work. This eliminates third hand tobacco smoke exposure for residents and for people wanting to quit (70% of smokers), quitting, and wanting to stay quit.

With insurance, it costs zero to quit and only $209 without insurance; smokers burn this much in the same 12 week period suggested by the makers of nicotine lozenges! [After considering when, where, why, and how they got addicted. Are any of those conditions still valid?]

This pricing of nicotine lozenges to cigarettes over a 12 week period is not just a chance event in Missouri; the state with the lowest cigarette tax. Tobacco companies need to keep their nicotine addicted customers away from the current fad of vaping. The federal government helps by providing free counseling and a 2 week supply of safe nicotine sources in nicotine replacement therapy (NRT).

There is no tobacco smoke when there are no smokers. Visitors wanting to smoke and immediately return to a resident’s apartment are offered a nicotine lozenge in some facilities.

Australian Nicabate lozenge label: “For adult smokers who want to stop over several months. Use a lozenge whenever you have a strong urge to smoke instead of smoking a cigarette.” (Effective before 2018) [A nicotine lozenge is always safer than the toxic smoke from a cigarette.]

Every smoker will quit someday. It is only a matter of grief and denial of the addiction. Non-smokers are healthier, more productive, and less expensive to maintain. The public health effects are now recognized as so severe that free help is available to any smoker to start to become a former smoker (CALL 800-QUIT-NOW).

Saturday, March 31, 2018

Fitness Training 27FEB18


I have started to write about fitness and my back problems several times. Always there was a nagging shadow of pain that continued to follow me.
My Provision Living trainers could make we feel real good, but progress on the back pain was leveling out again. I signed up the in-house physical therapist and a chiropractor. Again progress was great and then slowed.
Last Tuesday, a week ago [a month ago!], the chiropractor “graduated” me down to one session a week. He also found and treated two trigger points near my shoulder blades.  Now my shoulders are free to rock back and forth.
I also have an exercise shared between the physical therapist and the chiropractor. Stand with your back against a wall. Hold your hands, with their backs against the wall, and your arms straight by your sides. Now “snow angel” with the back of your hands remaining against the wall.
Start
Several Days Later
 I could not even get my arms and hands above my shoulders, to start!! Just move my hands away from the wall a few inches and there is no problem raising them up to where my hands can meet.

It took the physical therapist to train me to stand properly while doing this exercise. She could do this, but I needed to learn to do it properly on my own.
For most of two years now, I have been slowly learning to recognize muscle groups that I have had no sense of feeling. How can I do what is called for if I cannot feel what is going on? [muscle cells do not have sensory cells like on your skine.]
“Stand up straight,” but without over compensating!!! “Relax,” and really relax!!! Doing things wrong does not improve things.
It was failure to do those two things that I now know were the basis for my failure to progress after a few weeks of many exercises I learned from the Internet and the Provision Living fitness classes. I plan to write more on the details later.
Yesterday we went for a walk at 3:00 instead of working in the Fitness Center. The fitness director said, “Better sit on the bench,” when he noticed, but I had not, that my shoulders were bending over.
I knew my back had started hurting. He knew that a short rest reversed this so if I carefully stood up “straight” I could walk on without pain for some period of time and distance.
A bit farther, “You are holding your right arm out. Relax it.” And farther on, the residual back pain began to fade away. I need to walk more outside, away from all the stuff in the air in the building?
We visited the edge of the milkweed plantings on the Monarch Butterfly Sanctuary, that borders the walking park. Soon I will get lots of exercise again spraying and cutting weeds.
The chiropractor has loosened up my joints and relaxed muscle trigger points so the physical therapist can help retrain my muscles that the fitness director can strengthen and coordinate for better balance.
Basically I have finally experienced being at the point where I should be, when under their direct attention. Now to practice, practice, and practice until this becomes a habit, muscle memory; or my conscious attention remains on the job until I master the fine art of walking correctly.
Conscious attention costs a lot less than building muscle memory in 60-minute gentle therapy sessions.

[I have been very busy organizing people needed to eliminate third hand tobacco smoke exposure in memory care. I had a productive one-hour meeting with the executive vice president Thursday.]