Western North Carolina has followed the country in making strides in eliminating cigarette smoking, but it’s still a presence. And now the state is beginning to worry about the cigarette’s trendy younger sibling: e-cigarettes.
According to studies conducted by the N.C. Department of Health and Human Services, they’re the most frequently used tobacco product in both the country and the state. In North Carolina, the rate of usage of e-cigarettes has increased by 888 percent in the last six years.
The handheld devices have become commonplace in Asheville, and licensed clinical addiction specialist Sheila McKeon notes, “You can’t walk downtown without seeing people pouring out of bars using their vapes.”
E-cigarettes have become increasingly popular in recent years, and many say they have used them to quit smoking, but, while e-cigarettes lack carcinogens, they are just as addictive as traditional cigarettes.
McKeon has worked with different types of drug addictions, but she says nicotine is still one of the toughest addictions to work through.
“I don’t see as many people for tobacco as you’d think, but it’s still one of the hardest habits I’ve found to kick,” she says.
McKeon cited emotional associations, trauma and peer pressure as some of the biggest causes of becoming addicted. She also says her patients have typically been smoking for the majority of their adult lives, making the addiction that much stronger.
A study conducted by the state DHHS found that the highest percentages of smokers are between 18 and 54 years old.
McKeon says a large number of her clients have been previously exposed to tobacco, most often in the home, and the research backs her up. According to the national Centers for Disease Control and Prevention, if your parents or peers smoke, you’re more likely to pick up the habit yourself.
“If you see your parents smoke, you’re more likely to do it,” McKeon says. “These kids are getting less supervision in certain ways, and that’s giving them the freedom to pick up a cigarette.”
According to the state DHHS, there are about 8,000 junior high students smoking in the state. That number jumps to 42,000 in high school. McKeon said her clients typically start smoking or using tobacco products in junior high, and it almost always starts as a social habit.
“People see their friends doing it, and they start building this positive association with smoking,” she says. “That’s actually the hardest part of my job, because I have to break these extremely strong associations saying that cigarettes are helpful. Positive connections are much harder to work through because everyone already knows the negative effects.”
The percentages of teens smoking in Buncombe County have dropped from 31.6 percent to 9.3 percent since 1999, but according to Jan Shepard, Buncombe County Health Division director, young people are replacing traditional cigarettes with e-cigarettes at an alarming rate.
According to McKeon, many people use e-cigarettes as a way of cutting tobacco use, but Shepard says, “E-cigarettes have not been proven to be a safe or effective way to quit tobacco use.” The American Heart Association released its first official policy on e-cigarettes in 2014 and deemed them a last-resort method of quitting cigarettes.
McKeon said the culture around e-cigarettes is tricky for her to navigate with clients because the devices are more acceptable in public than other forms of tobacco.
There is a statewide ban on smoking in bars, restaurants and other indoor spaces. McKeon says that has contributed to the shame culture that’s been growing around smokers since the early 1990s. She said her clients typically hide their smoking because they’re embarrassed, especially in Asheville.
“This town is incredibly health-conscious, so when you do see someone smoking [cigarettes], it’s tucked away in a corner outside,” she says.
There are several tobacco cessation products approved by the Food and Drug Administration that have helped stop tobacco addictions. Nicotine replacement therapies — including nicotine patches, gum, lozenges, inhalers, nasal spray and oral medications — are effective, but McKeon says there is often a deeper root to smoking, which she works with her patients to find.
“If you’re not getting emotional or physical needs met, you’re going to reach for something else,” she says.
McKeon uses a variety of tools, along with the tobacco cessation products, to treat her patients. She uses behavioral therapy and hypnosis; she also helps them make structural and practical changes to their lives that she says make it easier for them to stick to their quit date, a date established in their very first session.
“You have to know exactly when you want this to be done,” she says. “If you don’t have a date, you won’t have anything to measure yourself by and you’ll lose accountability.”
According to the CDC, there is a strong relationship between smoking and mental health. People who smoke are more prone to suffer from depression, anxiety or acute stress. McKeon’s program almost always includes at least two separate sessions about the patient’s mental health.
“There’s a good chance you’ll have to do some trauma work because many people will start an addiction based on a trauma,” she says. “Anxiety is part of the cycle.”
According to Shepard and studies conducted by the state DHHS, there are several correlations between smoking and environmental factors. People who live below the poverty line are twice as likely to smoke and to smoke three times longer than people who live above the line; blue-collar workers are more likely to start smoking cigarettes at a younger age. They’re also more likely to smoke more heavily than their white-collar counterparts.
“It’s pretty prominent in certain types of environments,” she says. “Your neighborhood and social circles affect your habits, and I find that a lot of my patients did grow up in at least relative poverty.”
Studies have also found that the more educated people are, the less likely they are to start smoking and continue.
McKeon says her biggest obstacle in helping people quit their addiction is, and has always been, keeping her patients engaged through the end of her program. She says she’s had trouble getting her patients to take it seriously.
“You have to decide that’s the change you’re making and stick with it,” she says. “You have to be really tenacious.”