On January 4, 2000 I celebrated my 10th anniversary of living as a non-smoker. During my last few years of smoking I often exceeded two packs of cigarettes a day. I was 43 years old and had been smoking since I was 19. As with so many people, my January 4, 1990 attempt to quit smoking wasn’t my first.

I describe my quitting experience here in the hope that I can communicate how complex it is for a person with a serious mental illness to stop smoking.

My motivation to quit was high for many years: self-respect, my health and my family’s health, long-term quality of life issues, and the prospect of losing my voice. (I have been blessed with a beautiful singing and speaking voice, and my voice was becoming rougher and rougher.)

However, fear was the strongest motivator, and it immobilized me. Fear of what? I feared the return of the worst symptoms of my illness—the feeling of impending doom and loss of control. I also feared failure. What kind of person was I that smoked knowing the health risks to my family and myself? Worse yet: What would it mean if I weren’t successful? If I resumed smoking, everyone would now that I was weak. The fear was real, gut wrenching and it tore me up. I cried and cried. There was no solution: continue to smoke and be “bad,” or quit smoking, fail, and be “bad.” (Although these thoughts reflect, I believe, the experience of the faulty thinking of depression and generalized anxiety, I had in fact often experienced that smoking helped me concentrate when my internal and external environments were confusing. I could make decisions more easily and better understand conversations. These are important details because retaining one’s ability to function is so attached to feelings of self-worth.)

My dear husband, Jim, understood and respected that my experience of a dilemma was real. I made more progress when my family practice physician allowed me to express the seriousness of my fear as an impediment to quitting. She recognized my dilemma as real also. Dr. A______ volunteered to meet with me often for supportive consultation during the decision making phase and as long as needed after I quit. She and I knew my insurance coverage with my psychiatrist was limited and was soon to expire for the year. We had good rapport and mutual trust.

I began to have great troubles speaking, and I could not sing. Depressive thoughts told me I would never recover my voice. I believed I had done irreparable physical damage to myself. My doctor referred me to a speech pathology clinic. There an otolaryngologist determined I had a polyp on my one of my vocal folds. A simple surgery followed by speech therapy would likely restore my voice. My doubt eased. Hope tempered my fears.

In talking with my husband and my physician, I learned to accept that a sincere attempt to quit could be a positive accomplishment, even if I couldn’t quit permanently. If I stopped, then started smoking in a month or two, I could stop again. I would have gained experience. I set my quit day as the day of the surgery!

During the two months of lead time my doctor, Jim, and I planned the strategies I would use, first to decrease and then to stop smoking altogether. They gave me active support: We discussed, planned, and implemented approaches and techniques together. I had the final say as I was able to target the habits most troublesome to me and knew my limits of discomfort.

Most of the techniques were adopted from recommendations of the National Cancer Institute; they were cognitive and behavioral in nature. I scheduled changes in smoking behaviors on my calendar. Here are a few strategies I implemented: I prepared a list of personal reasons to quit and reviewed them daily. I switched to a distasteful cigarette brand. I cut down slowly on the number of cigarettes I smoked. As the day grew nearer I smoked only half a cigarette each time I smoked. Then I smoked only every other hour. Buying a new carton, and then buying a new pack, was forbidden until I was completely out. As I succeeded with each small change, I gained confidence. Family and colleagues expressed admiration of my courage. I was surprised as I had not thought of courage being involved.

Not everything went easily. I did experience a return of some depressive symptoms. I was ill-at-ease and restless for almost nine months. However, I kept track of pleasant changes, as did my children and Jim. My son Ben coached me through speech exercises. I faithfully deposited my former smoking money into a reward savings account. A year later I began a new medication, one that worked for me. Two years of cognitive restructuring training followed. Both of these treatments helped sustain my non-smoker status.

However, the best benefit was unexpected. I learned I could put into practice techniques that would help me manage my illness. I wasn’t helpless; nor was I hopeless. I could take action. The process of generating strategies to facilitate smoking cessation served as a template for learning other techniques to use as I adapted to my disability.