Dr James Schaller
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    • Smoking nicotine undermines the development of neurons from fetus to adolescence. Damage is done to serotonin neurons that increase biological depression in smokers. A father or coworker who smokes near a pregnant woman can cause fetal injury.
    • Nicotine has properties in common with antidepressants. Roughly 1/2 of smokers have biological depression. Mere nicotine replacement is often too limited.
    • Smoking damages more than one neurotransmitter system. Antidepressants that target only one neurotransmitter are often incomplete treatment.
    • Recommended starting doses of antidepressants are often far too high and increase anxiety–a symptom of nicotine withdrawal. For example, some patients can barely tolerate starting with 37.5 mg of Zyban/Wellbutrin.
    • Only a few medical contacts a year ignores that the smoker needs people and things to replace the pleasure and nurture of smoking–what will replace smoking?
    • Life dissatisfaction or physical pain must be aggressively treated. Pain causes relapse.
    • Key Triggers must be written out and specific prevention planned.
    • Nicotine withdrawal is associated with significant anxiety and smoking often exists alongside an anxiety disorder--treat the anxiety.
    • Ruminations to smoke over 2 minutes are a sign of under-treatment.
    • Nicotine replacements can be compounded into special delivery forms–sprays into nose, throat misters or other options, which can have buffering agents to decrease irritation. What is available over the counter might not be the best form or dose and many patients need to rotate or use more than one form. Blood pressure, pulse and heart evaluations should be checked for excess dosing. The nicotine should be significant enough for comfort but not excessively raising blood pressure and pulse. Give a useful educational handout to the patient to explain the signs of withdrawal and excess nicotine.
    • Smoking will kill your patient--tell them gently but honestly.

Smoking introduces carcinogenic heavy metals and other carcinogens and depletes critical essential nutrients. The suggestion to "Fill this Zyban script or start a patch" in a brief consult often is too little treatment for a fatal addiction. Finally, addressing nutritional depletion should also be part any treatment in willing patients together with obesity prevention.

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