Tobacco dependence

Tobacco use is a major avoidable cause of mortality and morbidity, accounting for more than 480,000 deaths each year in the United States and Canada. Smoking is the cause of many diseases including cardiovascular diseases, chronic obstructive pulmonary disease, stroke, and lung cancer. Tobacco dependence mimics a chronic disease with only a minority of tobacco users abstinent permanently after a first quit attempt, while, most of them fail or relapse since first quit attempt. Tobacco use causes a huge economic burden to individual smokers and the whole society, accounting for 96 billion dollars’ expenditure in direct medical cost each year and 97 billion dollars in lost productivity.

Tobacco dependence

It was reported that more than 70% of the 45 million smokers were willing to quit in the United States and almost half of these smokers had an attempt to quit. Unfortunately most of those attempting failed, only 4-7% of the 19 million adults who tried to quit in year 2005 achieved successful cessation.

 

The Tobacco Use and Dependence Clinical Practice Guidelines of 2008 updated Public Health Service Clinical Practice and recommended the use of pharmacotherapy for all smokers who want to make attempts to quit, except those having contradictions or some specific population for whom insufficient evidence of effectiveness exists (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). It has suggested smoking cessation intervention should include at least one Food and Drug Administration (FDA) approved first-line smoking cessation Viagra medication online here.

Currently, there are seven first-line medications approved by the U.S. FDA which can help increase long-term smoking abstinence rates reliably. They are varenicline, bupropion SR, and nicotine replacement therapy (NRT) including: nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, and nicotine patch.

There are a few review and clinical trial studies, which provide such evidence that increased smoking cessation medication use led to higher abstinence rates. For instance, a review of 132 trials indicated that the risk ratio (RR) of abstinence for any form of NRT compared to control was 1.58 (95% confidence interval [CI]: 1.50-1.66). A systematic review and meta- analysis of effectiveness of smoking cessation therapies identified 12 randomized control trials, which used bupropion versus placebo and yielded odds ratios (OR) ranging from 1.72 to 2.64 compared with placebo at 3 months and yielded ORs ranging from 1.10 to 2.21 compared with placebo at 1 year. Bupropion can also delay relapse after successful abstinence for the smokers.

Racial/ethnic disparities in smoking cessation have been consistently documented in epidemiologic studies. The 2008 Clinical Practice Guideline recommended evaluating and enhancing smoking cessation interventions among racial and ethnic minority populations. A study conducted by Cokkinides et al which examined racial and ethnic disparities in smoking cessation interventions using 2005 National Health Interview Survey data has shown that black and Hispanic smokers are less likely to seek advice for quitting or use any smoking cessation intervention in the quit attempt compared to white smokers and this result is consistent even after controlling for socioeconomic and health care related factors. A review of published studies examining smoking cessation treatment interventions among ethnic and minority populations in the US has concluded that racial and ethnic minority populations are interested in smoking cessation and willing to quit. However, variations existed in the quitting outcomes across different studies among minority population due to variations in intervention and study design, also, the evaluations of outcomes by using pharmacotherapy are quite limited. Moreover, evaluation of racial disparity in using pharmacotherapy is limited.

Although there were limited evaluations of pharmacotherapy, the existing data supported use of pharmacotherapy in addition to counseling for enhancing abstinence outcomes. Further attention to the level of individual smoking, variability in smoking patterns, and use of other tobacco products is needed. Our study aims to assess whether there is also racial/ethnic disparities in smoking cessation medication use, which may affect smoking cessation treatment outcome. The primary hypothesis is race is a significant factor of using smoking cessation pharmacotherapy. There is variation in pharmacotherapy use between different ethnic groups. Secondary hypothesis is except race, there are also some other factors that might affect the use of pharmacotherapy for smoking cessation, for instance, health insurance. Understanding the racial disparity in smoking cessation medication use among different racial groups can help us identify certain specific minority groups who may have a barrier to receive smoking cessation medication and develop culturally appropriate interventions to these minority groups.

Thus, understanding racial and ethnic differences in the provision or utilization of smoking cessation medication is integral in reducing tobacco use among minority groups.

Developing Flexible Scenarios

Illustration: Ivan and Dawn

In his career, Ivan thought of himself as an excellent problem-solver. He had seen too many work projects become stalemated by the blame – counter blame dynamic. He didn’t want that to happen between him and Dawn but feared “talking sex to death.” Ivan’s first attempt to get information and help was not beneficial a for profit male sex clinic where he was prescribed a pro-erection medication, an antidepressant, testosterone, and penile injections. Ivan decided to do careful research on the Internet and was surprised and confused by the very contradictory information and advice. Ivan chose to undergo a complete physical. His internist was aware that erectile dysfunction can be a first symptom of a serious vascular or cardial condition so he was very thorough in his assessment. Happily, there were no major medical problems. He counseled Ivan that erectile problems are best understood and treated as a biopsychosocial problem. He prescribed Viagra but also suggested that Ivan and Dawn consult a certified couple sex therapist for guidance and counseling. Dawn was enthusiastic, but Ivan was reluctant.

He wanted to see if the Viagra alone would be enough. After 3 weeks, Ivan realized the medication was helpful but was not a stand-alone intervention. In making the couple appointment, Ivan was clear that he didn’t want long-term therapy but a focused intervention about regaining erectile confidence and couple sexuality. The therapist was both competent and flexible. He helped Ivan and Dawn to view the erectile problem as a challenge to build a new couple sexual style that would not only help them regain comfort and confidence with erections but inoculate them against sexual problems with aging. Ivan found this approach both intellectually and emotionally appealing.

The hardest concept to accept was the Good-Enough Sex model of variable, flexible sex with 85% of encounters flowing to intercourse. Dawn’s enthusiasm for an intimate, interactive couple sexual style and realization that her sexual experience was congruent with the 85% guideline finally won Ivan over. He was not a perfectionist in the rest of his life, so why would being a sexual perfectionist help him? The single most important thing the therapist said was “Wise men learn to enjoy grow-up erections rather than show-up erections. When intercourse doesn’t flow, they enjoy erotic, non-intercourse sex.”

Exercise: Create Your Sexual Scenarios

Take a moment to think about three sexual scenarios you would enjoy. Ask your partner to do the same. Prod yourselves to be creative and flexible by allowing only one of the three to include intercourse. Then take turns sharing these scenarios, alternating one at a time. Be careful not to judge, but enjoy a variable, flexible, couple sexuality.

Better Quality of Sex with Age

The traditional cultural theme is that a real man is totally sexually confident and performs with the regularity and predictability of his teens and 20s. The erroneous belief is that anything less is a failure. Other, more sophisticated, men realize that sex is different in their 60s and still enjoy sex but are disappointed and believe they have to settle for second-class sexuality. We believe just the opposite. Sex after 60 is more genuine and human, more of an intimate, interactive experience. You need each other in a way that you didn’t in your 20s. Although sex is less predictable and controllable, in many ways it is more affirming, involving, and rewarding. For individual and relationship satisfaction, it is very much a first-class experience.

Many women surprise their partners by saying that they enjoy sex now more than they did 30 years ago. A woman likes the fact that you need her stimulation for arousal and orgasm. Give-and-take sex can be a powerful aphrodisiac for you and for her. A wise man learns to piggy-back his arousal on hers. Through most of your sex life, a man’s arousal is easier, quicker, and more predictable than a female’s. Now you can enjoy and take advantage of this role enhancement. It is the perfect example of being intimate, interactive friends. You need each other and can enjoy each other more as pleasuring and eroticism build more slowly. This process, which involves more genital (especially penile) stimulation, can be particularly enjoyable.

Men under 35 enjoy receiving penile stimulation — whether manual or oral — but only when they are already aroused. Being receptive and responsive to penile touch as a way to develop and reinforce arousal is a new experience for most men. The healthy approach is to accept and enjoy this variable, flexible sexual response. This includes accepting creative and sometimes unpredictable sexual scenarios. A common mistake aging men make is to jump on their developing erection so they can insert before they lose the erection. This is equivalent to the “sexual drag racing” of younger men, who are afraid of premature ejaculation, going to intercourse as soon as possible to be sure they ejaculate inside the woman.

Sexual Wisdom

As men mature and become sexually wiser, they find that sexual response and control are based on relaxation, slowing down expands the pleasuring/eroticism process, and learning to understand your body and sexual response increases psychosexual skills. Men over 60 learn to accept and enhance the body’s sexual response. Rather than trying to start intercourse when you can, the sexual technique is to transition to intercourse when you should. Arousal (subjective and objective) is conceptualized on a 10-point scale, where 5 is the beginning level of arousal signaled by start of an erection, 7 is higher arousal with a firm erection, 9 is high levels of erotic flow, and 10 is orgasm. Rather than transition to intercourse at 5, we suggest transitioning at 7 or 8. The strategy many couples use is for the woman to decide when to initiate intercourse and to guide intromission. This stops you from playing the spectator role and allows you to fully engage in the process of giving and receiving pleasurable and erotic touch.