Tobacco and Smoking
Theories, Models and Interventions for Health Behaviour Change
’Tobacco is the only legal drug that kills many of its users when used exactly as intended by manufacturers.’
World Health Organization (2015c)
This chapter examines the extent of smoking, its major health impacts, explanations of smoking and interventions to help smokers to quit. Smoking prevalence is increasing throughout the developing world and many people continue to smoke in the industrialized world. Measures to reduce smoking prevalence have met with substantial success, in spite of deceitful practices and disinformation from the tobacco industry. The primary methods to assist smokers to stop are reviewed, together with research on electronic cigarettes.
Brief History of Tobacco and Smoking
Among recreational drugs, tobacco is by far the biggest killer and nicotine the most addictive substance. Yet tobacco has been in use for millennia and, in spite of the certain knowledge that it can kill, it is used by around 2 billion people, 6 million of whom die each year. If discovered for the first time today, tobacco would definitely be banned. According to the Centers for Disease Control and Prevention (CDC), in 2015 22,073 people died of alcohol, 12,113 died of AIDS, 43,664 died of car accidents, 38,396 died of drug use — legal and illegal — 18,573 died of murder and 33,300 died of suicide. That brings us to a total of 168,119 deaths, far less than the 480,000 who die from smoking annually (CDC, 2016a).
How did the fatal attraction to tobacco begin?
In the first century BC the Mayans in Central America are alleged to have smoked the tobacco in religious ceremonies. The Aztecs took the smoking custom from the Mayans, who later settled in the Mississippi Valley, and smoking was adopted by neighbouring tribes (Figure 12.1). Amazonian Indians also used tobacco in their religious rituals. This group colonized the Bahamas, later discovered by Columbus in 1492.
Figure 12.1 Aztec guests being presented with a tobacco tube and a sunflower
Source: The Florentine Codex
The English adventurer Sir Walter Raleigh is alleged to have introduced both potatoes and tobacco to England. Raleigh’s public health legacy of tobacco and potato (when cooked as chips or fries) would be hard to rival. Raleigh popularized tobacco at court, and apparently believed that it was a good cure for coughs so he often smoked a pipe. Indeed, it is alleged that Raleigh’s final request before his beheading by James I at the Tower of London in 1618 was a smoke of tobacco, a legacy to all subsequent prisoners facing execution.
Cigarette smoking was reintroduced to England by British soldiers returning from Wellington’s Napoleonic campaigns in the Iberian Peninsula (1808—1814). Following this, veterans returning from the Crimean War (1853—1856) increased cigarette smoking in Britain. In addition to bringing many millions of deaths and injuries to service personnel, war has always been a great addictor to tobacco and, in the case of the Royal Navy, to rum.
The economics and politics of tobacco are complicated with many dilemmas and contradictions. Over the last 450 years tobacco has been a major contributor to the economy. Tobacco tax makes a significant contribution to wealth, exceeding the cost of treating smoking-related diseases in health systems. Tax revenue from tobacco products in the UK reached £12.3 billion in 2012/2013. Until 2010, tobacco farmers in 12 European Union (EU) countries, including Bulgaria, Greece, Romania and Italy, were receiving £260 million in subsidies. At the same time, the EU has a policy of discouraging smoking by restricting tobacco advertising and mandating health warnings on cigarette packets.
Although many other factors are involved, the greatest disincentive to smoking, especially among children, has been increased taxation to raise the retail price (Figure 12.2).
Figure 12.2 Tobacco consumption by price in the USA, 1970—2007
Freedom and Choice
The freedom to smoke or to vape is a basic human right. Each individual has freedom of choice. The main goal of health care interventions must be to facilitate informed choice. This involves offering people information about the possible health consequences of smoking and/or vaping, explanations about the addictive properties of nicotine, methods that could be helpful in stopping the habit, and support while going through the process of cessation. The health psychologist can play a significant role in these activities.
Prevalence and Distribution
Although tobacco was popular during the nineteenth century, it was largely smoked by men with pipes. The development of cigarettes towards the end of the nineteenth century led to a rapid increase in tobacco consumption. In the first half of the twentieth century, cigarette smoking became hugely popular, especially among men. In the USA, cigarette consumption doubled in the 1920s and again in the 1930s, peaking at about 67% in the 1940s and 1950s. However, between 1965 and 2004, cigarette smoking among adults aged 18 and older declined by half from 42% to 21%, and rates declined to 20% in 2007. In 2015, about 15% or 36.5 million US adults aged 18 years or older currently smoked cigarettes (CDC, 2016a). More than 16 million Americans are living with a smoking-related disease and there are 480,000 deaths every year, or one in every five deaths (CDC, 2016a). In recent years smoking prevalence has been highest in China.
In Britain, it was estimated that the prevalence among men reached almost 80% during the 1940s and 1950s (Wald et al., 1988). Since then, the prevalence has declined overall, with sex, social class, regional and other differences. There are about 10 million adult cigarette smokers in Great Britain and about 15 million ex-smokers. Since 1990 there has been a steady increase in the number of smokers using mainly hand-rolled tobacco. In 1990, 18% of male smokers and 2% of female smokers said they smoked mainly hand-rolled cigarettes, but by 2011 this had risen to 40% and 26%, respectively.
The 2012 Opinions and Lifestyle Survey found that 38% of men and 24% of women smoked hand-rolled cigarettes (Action on Smoking and Health, 2014). Much of the tobacco used by hand-rollers is smuggled across borders duty free.
The World Health Organization (2013) estimated that tobacco kills approximately 6 million people and causes more than half a trillion dollars of economic damage each year. The WHO report in 2013 estimated that tobacco will kill as many as 1 billion people this century if the WHO Framework Convention on Tobacco Control is not implemented rapidly. Prevalence in developing countries is rising dramatically where there is extensive promotion of smoking by Big Tobacco.
Although fewer women than men are smokers, there have been dramatic increases in smoking among women and the gap in smoking rates between men and women is narrowing in most places. In Europe, there was a consistent decline in the prevalence of smoking among men from about 70—90% to about 30—50% between 1950 and 1990. However, among women the same period saw a rise in the prevalence of smoking followed by a slow decline, reaching 20—40% in 1990. The initial rise in prevalence was led by women from professional backgrounds, but they have also led the decline such that today smoking is more common among women from poorer backgrounds.
National surveys have established a growing link between smoking and various indicators of social deprivation. In Britain, a national survey of health and lifestyles found that smoking is more prevalent among people on low incomes, the unemployed and those who are divorced or separated.
Health Effects of Smoking
The health effects of smoking have been studied for over 100 years. There is hardly a single organ in the body that is not deleteriously influenced by tobacco smoking.
Effects on Active Smokers
Cigarette smoking accounts for more than 480,000 deaths each year in the USA and 120,000 deaths in the UK, nearly one in every five deaths. More deaths are caused each year by tobacco than all deaths from HIV, illegal drug use, alcohol use, motor vehicle injuries, suicides and murders combined. The risk of dying from lung cancer is at least 22 times higher among men who smoke, and about 12 times higher among women who smoke, compared with those who have never smoked.
Figure 12.3 Harm from Tobacco
Source: Erikesen et al. (2015: 19)
Chemicals and radiation that are capable of triggering the development of cancer are called ’carcinogens’. Carcinogens initiate a series of genetic alterations (’mutations’) that stimulate cells to proliferate uncontrollably. A delay of several decades occurs between exposure to carcinogens in tobacco smoke and the onset of cancer. People exposed to carcinogens from smoking cigarettes generally will not develop cancer for 20 to 30 years. In the USA there have been 29 Surgeon General’s reports on smoking and health during the period 1964—2006. Tobacco is the leading preventable cause of illness and death in the USA, resulting in an annual cost of more than $75 billion in direct medical costs. Nationally, smoking results in almost 6 million years of potential life lost each year. More than 6.4 million children living today will die prematurely because of their decision to smoke cigarettes.
The 2004 US Surgeon General’s report on smoking and health revealed that smoking causes diseases in nearly every organ of the body (US Department of Health and Human Services, 2004). Published 40 years after the Surgeon General’s first report on smoking — which had concluded that smoking was a definite cause of three serious diseases — the 2004 report found that cigarette smoking is conclusively linked to leukaemia, cataracts, pneumonia as well as cancers of the cervix, kidney, pancreas and stomach. On average, men who smoke cut their lives short by 13.2 years and female smokers lose 14.5 years. Statistics indicate that more than 12 million Americans have died from smoking since the first (1964) Surgeon General’s report, and another 25 million Americans alive today are likely to die of a smoking-related illness. The report concluded that quitting smoking has immediate and long-term benefits, reducing risks for diseases caused by smoking and improving health in general. Quitting smoking at age 65 or older reduces by nearly 50% a person’s risk of dying of a smoking-related disease.
Effects on Passive Smokers
For obvious reasons, tobacco smoke does most damage to the person who is actively inhaling. However, those consistently breathing second-hand smoke (SHS) also have a higher risk of cancer, heart disease and respiratory disease, as well as sensory irritation. The Surgeon General estimated that exposure to SHS killed more than 3,000 adult non-smokers from lung cancer each year, approximately 46,000 from coronary heart disease, and an estimated 430 newborns from sudden infant death syndrome. In addition, SHS causes other respiratory problems in non-smokers, such as coughing, phlegm and reduced lung function. Passive smoking causes the premature death of thousands of non-smokers worldwide.
The Scientific Committee on Tobacco and Health (SCOTH) (Poswillo, 1998) commissioned a review of the impact of secondary smoking on lung cancer. This review analysed 37 epidemiological studies of lung cancer in women who were life-long non-smokers living with smokers. The review found that the women had a statistically significant excess risk of lung cancer of 26%. The analysis also showed that there was a dose—response relationship between the risk of lung cancer and the number of cigarettes smoked by a person’s partner, as well as the duration over which they had been exposed to their smoke. The report also concluded that parental smoking caused acute and chronic middle ear disease in children. Furthermore, it concluded that sudden infant death syndrome (SIDS), the main cause of post-neonatal death in the first year of life, is associated with exposure to environmental tobacco smoke. The association was judged to be one of cause and effect.
Big Tobacco Campaign of Disinformation
Big Tobacco carried out a disinformation campaign over several decades. The campaign deliberately sought to create doubt in the minds of legislators and the public about the effects of smoking. However, through litigation and the action of whistleblowers, and with the release of thousands of tobacco industry documents, the details of the disinformation campaign were revealed. The anti-tobacco organization Action on Smoking and Health (ASH) carried out a survey of the documents, extracted 1,200 relevant quotes, and grouped these under common themes (Action on Smoking and Health, 2010) (see Box 12.1).
Box 12.1 Tricks of the Tobacco Trade
Big Tobacco routinely denied that tobacco is addictive, yet it has known this since the 1960s. The idea of nicotine addiction destroyed the industry’s stance that smoking is a matter of personal choice, e.g., ’the entire matter of addiction is the most potent weapon a prosecuting attorney can have in a lung cancer/cigarette case. We can’t defend continued smoking as “free choice” if the person was “addicted”’ (The Tobacco Institute, 1980, cited by Action on Smoking and Health, 2010).
The companies deny that they target the young. Yet company documents revealed the companies’ preoccupation with teenagers and younger children and methods to influence smoking behaviour in these age groups, e.g., ’If the last ten years have taught us anything, it is that the industry is dominated by the companies who respond most to the needs of younger smokers’ (Imperial Tobacco, Canada, cited by Action on Smoking and Health, 2010).
The industry maintains that advertising is used only to fight for brand share, not to increase total consumption, while academic research shows otherwise, e.g., ’I am always amused by the suggestion that advertising, a function that has been shown to increase consumption of virtually every other product, somehow miraculously fails to work for tobacco products’ (Emerson Foote, former Chairman of McCann-Erickson, which handled US$20 million of tobacco industry accounts, cited by Action on Smoking and Health, 2010).
The industry promoted ’low-tar’ cigarettes knowing that they were lacking any health benefits, or even made cigarettes more dangerous, e.g., ’Are smokers entitled to expect that cigarettes shown as lower delivery in league tables will in fact deliver less to their lungs than cigarettes shown higher?’ (BAT in 1977, cited by Action on Smoking and Health, 2010).
The industry refused to accept the evidence of the harm caused by SHS, e.g., ’All allegations that passive smoking is injurious to the health of non-smokers, in respect of the social cost of smoking as well as unreasonable demands for no smoking areas in public places, should be countered strongly’ (BAT in 1982, cited by Action on Smoking and Health, 2010).
With reducing smoking levels in the West, the companies moved aggressively into developing countries and Eastern Europe, e.g., ’They have to find a way to feed the monsters they’ve built. Just about the only way will be to increase sales to the developing world’ (ex-tobacco company employee, R. Morelli, cited by Action on Smoking and Health, 2010).
Source: Action on Smoking and Health (2010)
Another study reached similar conclusions. Tong et al. (2005) discuss Big Tobacco’s use of scientific consultants to attack the evidence that SHS causes disease, including lung cancer. SHS has been linked causally with sudden infant death syndrome (SIDS) in major reports such as that of the 2004 US Surgeon General. Tobacco industry documents included 40 million pages of internal memos and reports made available in litigation settlements against Big Tobacco in the USA. From their analyses of these documents, Tong et al. concluded:
PM executives responded to corporate concerns about the possible adverse effects of SHS on maternal and child health by commissioning consultants to write review articles for publication in the medical literature. PM executives successfully encouraged one author to change his original conclusion that SHS is an independent risk factor for SIDS to state that the role of SHS is ’less well established’. (Tong et al., 2005: 356)
Balbach et al. (2006) argued that the health belief model (see Chapter 8) helped Big Tobacco through its theoretical stance regarding individual choice and ’information’. Balbach et al. analysed trial and deposition testimony of 14 high-level tobacco industry executives from six companies plus the Tobacco Institute to determine how they used the concepts of ’information’ and ’choice’ in relation to theoretical models of health behaviour change. They concluded that tobacco industry executives deployed the concept of ’information’ to shift full moral responsibility for the harms caused by tobacco products to consumers. The industry executives characterized Big Tobacco as:
that of impartial supplier of value-free ’information’, without regard to its quality, accuracy and truthfulness. … Over-reliance on individual and interpersonal rational choice models may have the effect of validating the industry’s model of smoking and cessation behaviour, absolving it of responsibility and rendering invisible the ’choices’ the industry has made and continues to make in promoting the most deadly consumer product ever made. (Balbach et al., 2006)
Discourses about smoking have a powerful influence on attributions of responsibility, whether the consumer or the provider is ultimately to blame. Our ’blame culture’ can easily swing in either direction.
Tobacco Promotion to Children and ’Third World’
Big Tobacco spends billions worldwide on advertising and promoting tobacco products. The US Federal Trade Commission (2016) reported that the major tobacco companies now spend $9.1 billion per year — nearly $25 million every day — on promoting tobacco products, and much of this activity is directed towards children. Research shows that tobacco advertising encourages children to start smoking and reinforces the social acceptability of the habit among adults. The US Surgeon General (1989) stated that tobacco advertising increases consumption by:
· encouraging children or young adults to experiment with tobacco and thereby slip into regular use;
· encouraging smokers to increase consumption;
· reducing smokers’ motivation to quit;
· encouraging former smokers to resume;
· discouraging full and open discussion of the hazards of smoking as a result of media dependence on advertising revenues;
· muting opposition to controls on tobacco as a result of the dependence of organizations receiving sponsorship from tobacco companies;
· creating, through the ubiquity of advertising and sponsorship, an environment in which tobacco use is seen as familiar and acceptable and the warnings about its health are undermined.
Hastings and MacFadyen (2000) analysed internal tobacco company documents and found that the companies worked with advertising agencies to target young people. The companies used advertising to increase overall consumption as well as brand share, in contrast to their public assertions that they only advertise to encourage existing smokers to switch brands.
Econometric studies find that increased advertising expenditure increases demand for cigarettes, while banning advertising leads to a reduction in tobacco consumption. In 1991, a meta-analysis of 48 econometric studies found that tobacco advertising significantly increased tobacco sales. The UK Department of Health’s Chief Economic Adviser found that there was a drop in tobacco consumption of between 4% and 16% in countries that had implemented a tobacco-advertising ban (Smee et al., 1992). Given the huge numbers of people who die from smoking-related diseases, it seems illogical that tobacco companies are allowed legally to advertise their harmful products. However, many issues are intertwined and the abolition of tobacco advertising has not been as simple and straightforward as it might first appear.
First, Big Tobacco argues that there is a lack of evidence to suggest that tobacco advertising significantly influences smoking behaviour. The ’magical potency’ of tobacco advertising could be questioned since most advertisements are directed at target audiences who already use the product. Researchers claimed that econometric studies have found either no overall relationship between advertising and sales or a small, statistically significant positive relationship. However, this view can be contested and the results of such studies are equivocal, as much depends on who supplies data for the studies: Big Tobacco or the public health authorities.
The issue of banning tobacco advertising is further tangled when politics are included. The epitome of this can be seen within the European Union, which on the one hand has supported and finances Big Tobacco through the Common Agricultural Policy, and on the other hand recognizes the health effects of tobacco in funding its ’Europe Against Cancer’ campaign. However, in financial terms, the former greatly exceeds the latter. Despite this, attempts have been made to persuade tobacco growers to change their crops. Yet the fact remains that in 2000 the EU provided €984.5 million in tobacco subsidies and a mere €64 million to the ’Europe Against Cancer’ campaign. The 15-fold greater expenditure on tobacco subsidies surely cancelled out any benefit from the anti-cancer campaign. Crazy!
Theories of Smoking
Smokers’ resistance to large-scale anti-smoking campaigns led to research to explain the popularity of smoking. Smoking is an extremely complex practice involving a mixture of processes. The ’biopsychosocial model’ (BPS model) suggested three interrelated influences on health that are mirrored in theories of smoking: the biological, the psychological and the social theories of smoking (Table 12.1).
Nicotine, the main active ingredient in tobacco smoke, is a substance that if taken in large quantities can be toxic and even fatal. However, delivered in small amounts via cigarette smoke it has a range of psychophysiological effects, including tranquilization, weight loss, decreased irritability, increased alertness and improved cognitive functioning. However, tolerance to the effects of nicotine develops such that there is less evidence of performance improvements among regular smokers (Jarvis, 2004). Over time the smoker develops a physical dependence on nicotine. In 1997 the smallest of the big five US tobacco companies (the Liggett Group) admitted that it had raised the nicotine content in cigarettes to increase their addictiveness. Nicotine is a naturally occurring colourless liquid that turns brown when burned and smells of tobacco when exposed to air. It has complex but predictable effects on the brain and body. Most cigarettes contain 10 milligrams (mg) or more of nicotine. The typical smoker takes in 1—2 mg of nicotine per cigarette. Nicotine is absorbed through the skin and lining of the mouth and nose or by inhalation in the lungs. In cigarettes nicotine reaches peak levels in the bloodstream and brain rapidly, within 7—10 seconds of inhalation. Cigar and pipe smokers, on the other hand, typically do not inhale the smoke, so nicotine is absorbed more slowly through the mucosal membranes of their mouths. Nicotine from smokeless tobacco also is absorbed through the mucosal membranes.
Nicotine is addictive because it activates brain circuits that regulate feelings of pleasure, the ’reward pathways’ of the brain. A key chemical involved is the neurotransmitter dopamine that nicotine increases. The acute effects of nicotine disappear in a few minutes, causing the smoker to repeat the dose of nicotine to maintain the drug’s pleasurable effects and prevent withdrawal symptoms.
The cigarette is an efficient and highly engineered drug-delivery system. By inhaling, the smoker can get nicotine to the brain rapidly with each and every puff. A typical smoker will take ten puffs on a cigarette over a period of five minutes that the cigarette is lit. Thus, a person who smokes 30 cigarettes daily gets 300 ’hits’ of nicotine every day. That is over 100,000 hits a year or one million every ten years! This is why cigarette smoking is so highly addictive. Smoking behaviour is rewarded and reinforced hundreds of thousands or millions of times over the smoker’s lifetime. An enzyme called monoamineoxidase (MAO) shows a marked decrease during smoking. MAO is responsible for breaking down dopamine. An ingredient other than nicotine causes the change in MAO, since it is known that nicotine does not dramatically alter MAO levels. Smokers may be increasing central dopamine levels by reducing monoamineoxidase inhibitor activity, reinforcing smoking by keeping high satisfaction levels through repeated tobacco use.
There is evidence that tobacco is a highly addictive drug. More than 30% of people who try tobacco for the first time develop a dependency on tobacco, while for other drugs, this percentage is generally lower. However, there are variations in the speed and strength of addiction to nicotine among smokers. One obvious way to explain individual differences in smoking is our genetic makeup. Genetic factors may play a role in several aspects of nicotine addiction, from the tendency to begin smoking to the chances of quitting.
Twin studies produced evidence of a genetic link to smoking. Heath and Madden (1995) found that genetic factors increased the likelihood of becoming a regular smoker (’initiation’) and of these smokers becoming long-term smokers (’persistence’). In a large follow-up survey of male twin pairs from the US Vietnam Era Twin Registry, True et al. (1997) found that genetic factors account for 50% of the risk of smoking and environmental factors accounted for a further 30%. In addition, genetic factors accounted for 70% of the risk variance of becoming a regular smoker whereas environmental factors were not important.
With the decline in the overall prevalence, a group of ’refractory’ smokers has emerged. They are more likely to have other problems, such as depression, anxiety and bulimia (Pomerlau, 1979). In ancient times, these patterns may have been biologically adaptive or neutral. However, in contemporary society, a more active fight or flight response is inappropriate. Smoking would be valuable to this population because it can produce small but reliable adjustments to levels of arousal. Evolutionary approaches to addictions tend to ignore the psychological and social influences that create the conditions for tobacco use (Marks, 1998). It is to these influences that we now turn.
The most frequently used model of smoking is based on learning theory. It argues that people become smokers because of the positive reinforcement they obtain from smoking. The mechanisms are similar to those described in Chapter 11 in reference to alcohol drinking. Initially, smoking is physically unpleasant but this is overruled because of the social reinforcement from peers. The pleasant associations of smoking then generalize to a range of settings. In addition, the smoker learns to discriminate between those situations in which smoking is rewarded and those in which it is punished. The smoker also develops responses to conditioned stimuli (both internal and external) that elicit smoking. Smoking can be conceptualized as an escape/avoidance response to certain aversive states (Pomerlau, 1979). The smoker lights up a cigarette to escape or avoid an uncomfortable situation.
In 1966, Tomkins proposed his ’affect management model’ of smoking that was subsequently revised and extended by Ikard et al. (1969), who conducted a survey of a national (US) probability sample. In a factor analysis of the responses, they identified six smoking motivation factors: reduction of negative affect, habit, addiction, pleasure, stimulation and sensorimotor manipulation. Subsequent surveys produced similar factors. Women more than men reported that they smoked for reduction of negative affect and pleasure.
In their study of smoking among young adults, Murray et al. (1988) added two additional reasons: boredom and nothing to do. In a survey, they asked young adults to indicate which of these factors were important reasons for smoking in different situations. In all situations, relaxation and control of negative affect were considered the most important reasons. At home, boredom was also considered important, perhaps reflecting these young people’s frustration with family life. At work, addiction was considered important, perhaps reflecting the extent to which it disrupted their work routine, while socially, habit was rated as important.
According to Zuckerman (1979), individuals engage in sensation seeking so as to maintain a certain level of physiological arousal. More specifically, Zuckerman emphasized that sensation seeking was designed to maintain an optimal level of catecholaminergic activity. In a French sample, smokers scored higher on a measure of sensation seeking, in particular on disinhibition, experience seeking and boredom susceptibility sub-scales. From a physiological perspective, these sensation seekers have a low level of tonic arousal and seek exciting, novel or intense stimulation to raise the level of cortical arousal. This argument is similar to that of Eysenck et al. (1960), who found that smokers scored higher on measures of extraversion. This personality dimension is also supposed to reflect a lower level of cortical arousal that can be raised by engaging in risky activities, such as smoking.
Besides sensation seeking and extraversion, a variety of personality characteristics have been found to be associated with smoking. In a sample of Scottish adults, Whiteman et al. (1997) found that smoking was associated with hostility. However, they accept that ’presence of an association does not help in determining if the relationship is causal’. Indeed, they hypothesize that deprivation of smoking that was required for the study may have increased hostility.
A variety of different types of study have found that stress is associated with smoking. For example, among smokers, consumption is higher in experimental, stressful laboratory situations. In surveys, people with higher self-reports of stress are more likely to be heavy smokers. In a study of nurses’ smoking practices, Murray et al. (1983) found that those who reported the most stress were more likely to smoke. This relationship remained after controlling for the effect of family and friends’ smoking practices. Finally, in a macro-social study, US states that have the highest levels of stress, as measured by a range of social indicators, also have the highest levels of smoking and of smoking-related diseases.
Other researchers have looked for evidence of personality differences between people who smoke and non-smokers. Sensation seeking, neuroticism and psychoticism are all correlated with smoking (Marks, 1998). However, the relationships are fairly weak and it can be concluded that anybody has the potential to become addicted to nicotine.
Across almost all theories, a key concept has been craving, or having the urge to smoke. Urges and cravings are subjective, emotional-motivational states that are normally followed immediately with overt smoking, or within a few minutes. Urges and cravings are normally attributed to drug withdrawal or the positive reinforcing effects of drugs. Tiffany (1990) hypothesized that drug use in the addict is controlled by automatized action schemata. Automatized behaviour is stimulus bound, stereotyped, effortless, difficult to control and regulated largely outside awareness. This theory helps to explain why stopping smoking is so difficult. Interventions that focus on the automatic nature of smoking behaviour invite the smoker to actively become aware or to be mindful of the automatic nature of smoking (Marks, 2017a).
Smoking is a social activity. Even when the smoker smokes alone, he/she still smokes in a society where cigarettes are widely available and promoted. A number of qualitative studies have considered the social meaning of smoking. Murray et al. (1988) conducted detailed interviews with a sample of young adults from the English Midlands. These suggested that smoking had different meanings in different settings. For example, at work going for a cigarette provided an opportunity to escape from the everyday routine. For these workers, to have a cigarette meant to have a break and, conversely, not to have a cigarette meant not to have a break. The cigarette was a marker, a means to regulating their work routine.
Outside work, smoking was perceived as a means of reaffirming social relationships. For those young people who went to the pub, the sharing of cigarettes was a means of initiating, maintaining and strengthening social bonds. Those who did not share cigarettes were frowned upon.
Graham’s (1976) series of qualitative studies has provided a detailed understanding of the meaning of smoking to working-class women. In one of her studies, she asked a group of low-income mothers to complete a 24-hour diary detailing their everyday activities. Like the young workers in the study by Murray et al. (1988), smoking was used as a means of organizing these women’s daily routine. Further, for these women smoking was not just a means of resting after completing certain household tasks, but also a means of coping when there was a sort of breakdown in normal household routines. This was especially apparent when the demands of childcare became excessive. Graham describes smoking as ’not simply a way of structuring caring: it is also part of the way smokers re-impose structure when it breaks down’ (Graham, 1987: 54).
Graham (1987) argued that for these women smoking is an essential means of coping with everyday difficulties. It is also a link to an adult consumer society. Through smoking the women were reaffirming their adult identity. Similarly, in Bancroft et al.’s (2003) Scottish study, both men and women reported integrating smoking into contrasting periods of their lives. They smoked as a means of coping with stress at work and often because of boredom at home.
Smoking is embedded not only in the immediate material circumstances in which the smoker lives, but also in the wider social and cultural context within which smoking is widely promoted. Admittedly, in most Western societies there are considerable restrictions on the sale and promotion of cigarettes. Despite these, tobacco manufacturers continue to find ways to promote their products, e.g., through the sponsorship of sporting and cultural activities. Big Tobacco is a powerful lobby group that has considerable influence on government and policy making.
Integrative Theory of Homeostasis
The three main drivers of addiction are integrated into a single theory of homeostasis (Marks, 2016). In an addicted smoker, the act of smoking is a restorative behaviour in which the body’s nicotine level is increased to produce a feeling of satisfaction (Figure 12.4). With each puff on a cigarette, the habit strength is reinforced by the pleasure received from the nicotine. Thus, a system of homeostasis is established wherein the habit is reinforced by the restoration of nicotine in the body.
Figure 12.4 Homeostasis theory of smoking
Source: Marks (2016)
In the last 20 years smoking has been driven downwards in the majority of countries (World Health Organization, 2016). The highest prevalence rate occurs in Indonesia with 76% smokers; the lowest prevalence rate is Ethiopia with 8.9%. In the UK and the USA, the current prevalence is around 19%. Yet millions are still being harmed by tobacco, and to an increasing extent in developing countries, deepening health inequalities. This has led to attempts to develop a more sophisticated understanding of the process of giving up smoking. There is more clarity today about the best ways to help individual smokers.
The majority of smokers spend a considerable portion of their lives wishing they could quit. When they do quit, the vast majority do so on their own, without professional help, and they quit using ’cold finally turkey’, i.e., by abrupt withdrawal (’cold turkey’). The American Cancer Society (2009) reported that 91.4% of former smokers quit ’cold turkey’ or by slowly decreasing the amount smoked. Doran et al. (2006) surveyed adult patients attending Australian general practitioners in 2002 and 2003. Over a quarter of patients were former smokers and one in five were current smokers. Doran et al. reported that 92% of former and 80% of current smokers used only one method in their last quit attempt, ’cold turkey’ being the most common method used by both former (88%) and current (62%) smokers.
For those who seek help, guidelines such as those of the Surgeon General can be followed (Fiore, 2008). For smokers who are willing to quit, the ’five As’ are a useful framework:
· Ask about tobacco use: Identify and document tobacco use status for every patient at every visit.
· Advise to quit: In a clear, strong and personalized manner, urge every tobacco user to quit.
· Assess willingness to make a quit attempt: Is the tobacco user willing to make a quit attempt at this time?
· Assist in quit attempt: For the patient willing to make a quit attempt, offer medication and provide or refer for counselling or additional treatment to help the patient quit. For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts.
· Arrange follow-up: For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.
For smokers unwilling to quit, it is recommended to implement the ’five Rs’: explain the Relevance, Risks, Rewards, run over the Roadblocks, and Repeat at every available opportunity. In the following sections we review the three main approaches to smoking cessation, which are available singly or in combination: pharmacological, psychological and social. It should always be remembered, what any smoker does is their own free choice.
The first paragraph to read in any paper reporting a drug study is the ’Declaration of Interests’. Some authors are paid lucrative sponsorship deals by the pharmacological industry which should be declared in this section. Frequently, the reader will find that the authors have received honoraria (= money) from companies such as Pfizer¯, Novartis¯, GlaxoSmith — Kline¯, AstraZeneca¯ and Roche¯, and that they act as speakers, undertake consultancy and research, receive travel funds and hospitality from manufacturers of medications, or receive an unrestricted research grant (= more money) from one or more companies. These financial relationships between corporations and researchers are not conducive to unbiased, impartial science. It has been shown that pharmaceutical industry sponsorship of drug studies is associated with findings that are favourable to the sponsor’s product (Lexchin et al., 2003; Bero, 2013).
Pharmacological approaches aim to minimize the unpleasant symptoms of withdrawal, i.e., the irritability, difficulty concentrating, anxiety, restlessness, increased hunger, depressed mood and a craving for tobacco that accompanies cessation. These withdrawal symptoms are relieved by the administration of nicotine, but not of placebo. There are three kinds of pharmacological treatment for nicotine withdrawal that aim to raise the chances of cessation.
Nicotine replacement therapy (NRT) reduces symptoms of nicotine withdrawal, thereby, in theory, increasing the likelihood of cessation. Six forms are available: gum, patch, nasal spray, inhaler, tablet and lozenge. Evidence from clinical trials has been interpreted as demonstrating that NRT is effective (e.g., Stolerman and Jarvis, 1995). NRT company websites, and ’independent’ sites that are viewed as authoritative, proclaim that the nicotine patch, available over the counter, ’doubles the chances of quitting’. Such sites are unreliable — sadly, even those by government departments. For example, the NHS Smokefree website makes the unsupported claim that: ’If you also use medicines such as patches or gum to manage your cravings, you are up to four times more likely to successfully go smokefree!’ (National Health Service, 2010).
Methodological problems exist within many RCTs that compare NRT to placebos. This is because smokers in the placebo condition can detect that they are not receiving any nicotine (Mooney et al., 2004; Polito, 2008). Dar et al. (2005) found that control group members were 3.3 times more likely to correctly guess that they had received placebo than to incorrectly guess that they had received nicotine (54.5% versus 16.4%). If the trials in an RCT are not double blind, the findings give a misleading picture of treatment effectiveness. Cochrane Reviews, which assess the quality of trials from the written reports (e.g., Cahill et al., 2013), have no way of checking whether double blind requirements have been broken. This fact may help to explain why real-world results for NRT are worse than those obtained in RCTs. The issue of the safety of NRT and other drug therapies also needs to be considered. Bupropion (Zyban) is a weak dopamine and noradrenaline (norepinephrine) reuptake inhibitor. Initially employed as an antidepressant, bupropion was found to have potential as a smoking treatment. Bupropion treatment normally lasts for seven to twelve weeks, with the patient halting the use of tobacco about ten days into the course. Wu et al.’s (2006) meta-analysis claimed that after one year of treatment, the odds of maintaining quitting were 1.5 times higher in the bupropion group than in a placebo group. A third pharmacotherapy is varenicline (Champix), which is a nicotinic acetylcholine receptor partial agonist. Agonists at this receptor may stimulate the release of dopamine to reduce craving and withdrawal while simultaneously acting as a partial antagonist by blocking the binding and consequent reinforcing effects of smoked nicotine. In a direct comparison of buproprion with varenicline, Jorenby et al. (2006) claimed varenicline had superior efficacy: after one year, the rate of continuous abstinence was 10% for placebo, 15% for bupropion and 23% for varenicline.
Another issue concerning NRT is lack of safety. In 2005 the Medicines and Healthcare Products Regulatory Agency (MHRA) relaxed the restrictions on NRT use, allowing the combined use of patches and gum, and permission for its use by pregnant and young smokers, smokers with cardiovascular disease and smokers who want to reduce their smoking. However, a critical review concluded that NRT use by pregnant women and children would pose a significant risk to neurological development in infants and children (Ginzel et al., 2007). That NRT is used so widely in health care systems in spite of the poor outcomes, and lack of safety is profitable for the pharmaceutical industry but a poor return for taxpayers and smokers. This review suggests that a therapeutic strategy for smoking should look beyond a purely medical model. A psychosocial model would yield a radically different approach. Efficacy and cost-effectiveness will be higher when treatment strategies address the causes, not the symptoms.
Quitting smoking or, if that is impossible, reducing cigarette consumption, are both viable targets for a smoking cessation programme. In order to achieve these aims, it is necessary for smokers to control their physical and psychological dependency on smoking. The US Surgeon General’s (2008) guidelines on ’Treating Tobacco Use and Dependence’ recommended the use of individual, group and telephone counselling (Fiore, 2008). The report concluded that two components of counselling are especially effective: practical counselling concerning problem solving and skills training, and social support. The results of the meta-analysis are shown in Table 12.2. While counselling and medication are effective alone, a combination of counselling and medication is the most effective. The report found a strong association between the number of sessions of counselling, when combined with medication, and smoking abstinence. The best abstinence rate was obtained with more than eight sessions of counselling and behaviour therapy plus medication, giving an odds ratio of 1.7 and an abstinence rate of 32.5%.
Box 12.2 Case Study: The National Health Service (NHS) in England’s Smoking Cessation Service
Pharmacologically mediated cessation, primarily NRT, has been promoted through guidelines that have a questionable evidence base. The English NHS smoking cessation service is based on pharmacotherapy in combination with counselling support. The claims for high efficacy and cost-effectiveness of NRT have not been substantiated in real-world effectiveness studies (e.g., Pierce and Gilpin, 2002; Ferguson et al., 2005; Doran et al., 2006). Pierce and Gilpin (2002: 1260) stated: ’Since becoming available over the counter, NRT appears no longer effective in increasing long-term successful cessation.’ Efficacy studies, using randomized controlled trials, do not transfer well to real-world effectiveness. Bauld et al. (2009) reviewed 20 studies of the effectiveness of intensive NHS treatments for smoking cessation published between 1990 and 2007. Quit rates showed a dramatic decrease between four weeks and one year. A quit rate of 53% at four weeks fell to only 15% at one year. Younger smokers, females, pregnant smokers and more deprived smokers had lower quit rates than other groups.
The NHS evaluation data prove that NRT produces poorer outcomes than non-pharmacological methods (Health and Social Care Information Centre, Lifestyles Statistics, 2008). In 2007—2008, 680,000 people set a quit date and 88% of these had received pharmacotherapy at a cost of £61 million. Of these, 49% successfully quit for four weeks compared to 55% of people who had received no pharmacotherapy. Smokers who used NRT had a lower quit rate than those who did not use NRT. The NRT system needs to be replaced by a more effective system.
The guidelines give specific recommendations about particular behavioural and social elements to include in smoking treatments (see Table 12.3). There has been increasing interest in the use of cognitive behavioural therapy (CBT) for the control of smoking and other health-related behaviours. These therapies can be delivered as a brief intervention in one or more sessions to groups of smokers who are at the action stage.
Stop Smoking Now (SSN) is a psychological programme that integrates multiple behavioural techniques (SSN; Marks, 2017b). Based on the earlier Quit For Life Programme (Sulzberger and Marks, 1977; Marks, 1993), SSN uses cognitive behavioural therapy with elements of mindfulness and meditation. SSN encourages a steady reduction of cigarette consumption over seven to ten days followed by complete abstinence. The aim of SSN is the elimination of nicotine addiction without nicotine replacement or pharmaceuticals. SSN methods are listed in Table 12.3. A preliminary observational study with an earlier version indicated that the therapy could be particularly effective when delivered to groups of self-referring smokers (Marks, 1992). Randomized controlled trials later suggested the SSN programme delivered good quit rates at relatively low cost among lower SES smokers with only one intensive session (Sykes and Marks, 2001; Marks and Sykes, 2002a).
Source: US Surgeon General (2008)
Smoking is deeply embedded in everyday social activities. Today, smoking has become almost taboo, and smokers are seen as ’outsiders’. Cessation attempts must take these aspects into consideration, including the increasing social gradient in smoking prevalence. Smoking cessation efforts not only need to provide social support but also attempt to enhance people’s sense of control and mastery through changing their social conditions. Smoking cessation interventions may thus form part of a general community intervention to promote empowerment and health advocacy (see Chapter 17).
Many group treatment programmes use the ’buddy system’, in which smokers are paired up to provide mutual support. A variety of organizations also offer group support for quitters. These are organized at a local level by health care providers and charities. The NHS Stop Smoking Services offer free local group sessions, which start a week or two before the official quit date. The group then meets weekly for four weeks to give advice and motivation. Some people prefer to talk one-to-one with a professional adviser, but many find the group support helpful. Many support systems are provided by hospitals and clinics.
Another social intervention is to invite smokers to quit on a particular national day. Two examples are the ’Great American Smokeout’ (GASO) in the USA and ’National No-Smoking Day’ in the UK. Every year, on the third Thursday of November, smokers in the USA are invited to take part in GASO. An evaluation explored quitting rates from the Great American Smokeout and New Year’s Day (Gritz et al., 1989). The rate of non-smoking declined from 34% at one month to 25% at one year; 21% of participants never stopped smoking, and 68% of those who quit had relapsed by one year.
Another evaluation observed cessation-related news reports, Twitter postings and cessation-related help seeking via Google, Wikipedia and government-sponsored quitlines (Ayers et al., 2016). Time trends (2009—2014) were analysed to isolate spikes during the GASO compared to a control day — a ’simulated counterfactual had the GASO not occurred’. Cessation-related news increased by 61% and tweets by 13% during the GASO day compared with what was expected had the GASO not occurred. Cessation-related Google searches increased by 25%, Wikipedia page visits by 22% and quitline calls by 42%. Cessation-related news media positively coincided with cessation tweets, internet searches and Wikipedia visits; a 50% increase in news for any year predicted a 28% increase in tweets for the same year. Increases on the day of the GASO rivalled about two-thirds of a typical New Year’s Day — the day presumed to have the greatest increase in cessation-related activity. There were about 61,000 more instances of help seeking on Google, Wikipedia or quitlines on GASO each year than would normally be expected. Good news for population health; bad news for tobacco sales!
Quitting Without Help: Cold Turkey
The most popular method of smoking cessation remains ’cold turkey’, i.e., abrupt cessation without any outside help.
The Australian study by Doran et al. (2006) reported success rates among 2,207 former smokers and 928 current smokers as follows: cold turkey 77.2%; nicotine patch 35.9%; nicotine gum 35.9%; nicotine inhaler 35.3%; and bupropion 22.8%. According to these data, NRT and bupropion reduced the odds of quitting when considered across the whole population of quitters. Health care professionals tend to see only those smokers who have the most difficulty quitting by themselves. It is therefore likely that, as the smoking population shrinks over time, those who seek help will become harder to treat.
As is the case with problem drinking, gambling and narcotics use, studies show that at least 90% of smokers who permanently stop smoking do so without any form of assistance (Chapman and MacKenzie, 2010). In 2003, 20 years after the introduction of NRT, smokers trying to stop unaided were twice as numerous as those using pharmaceutical methods, and only 8.8% of US quit attempters used a behavioural treatment. Yet the most common method used by people who successfully stopped smoking is unassisted cessation (cold turkey or reducing before quitting). Great gains could be made if public health authorities highlighted this fact rather than emphasizing NRT and e-cigarettes as methods of smoking cessation.
Electronic cigarettes or e-cigarettes are a commonly used method for cutting down or eliminating conventional smoking. They were first developed in China in 2003. Users are called ’vapers’. E-cigarettes are battery-operated cylindrical devices designed to replicate smoking without combustion of tobacco. Some look like conventional cigarettes, while others with larger tanks are more clunky. They use heat to vaporize a liquid-based solution containing nicotine and flavouring into an aerosol mist, and have been proposed as a way to help smokers quit the habit. They are actively promoted as a smokeless and safer way to inhale nicotine without being exposed to tar and the many other toxic components of standard cigarettes, and as an aid to smoking cessation.
The industry started on the internet, and at shopping-mall kiosks and sales have rocketed. An ASH Fact Sheet published in May 2016 reported that:
1. An estimated 2.8 million adults in Great Britain were currently using electronic cigarettes.
2. Users were fairly evenly divided between smokers (1.4 million) and ex-smokers (1.3 million).
3. The proportion of ex-smokers had increased; in 2014 two-thirds of current vapers were smokers and one-third ex-smokers.
4. The main reason given by ex-smokers who are currently vaping is to help them stop smoking, while for current smokers the main reason is to reduce the amount they smoke.
5. Perceptions of harm from electronic cigarettes have grown, with only 15% of the public accurately believing in 2016 that electronic cigarettes are a lot less harmful than smoking.
Endorsement by celebrities on social media exert a strong influence on e-cigarette uptake. Phua et al. (2017) examined the effects of endorser type (celebrities, non-celebrities, products only) in e-cigarette brand Instagram advertisements on e-cigarette attitudes and smoking intentions. Celebrity endorsers significantly increased positive attitudes towards e-cigarettes and smoking intentions, compared to non-celebrities or products only. Celebrity endorsers rated significantly higher on trustworthiness, expertise, goodwill and attractiveness compared to non-celebrities. Hence the use of celebrity endorsement by companies.
E-cigarettes are subject to limited regulation and are not licensed as a medicine in the UK. In 2014, under regulations by the Food and Drug Administration, the US federal government banned sales of electronic cigarettes to minors and required approval for new products and health warning labels. Researchers are still unsure how effective e-cigarettes are as a quitting aid in comparison to other therapies, such as nicotine patches.
Glynn (2014) summarized current concerns about e-cigarettes. There is a lack of sufficient scientific data about their long-term safety, not only for users, but for infants and children. For example, Bassett et al. (2014) reported nicotine poisoning in an infant who consumed a quantity of e-cigarette liquid. Other areas of uncertainty are: their effectiveness as smoking cessation aids; their ability to deliver enough nicotine to satisfy withdrawal effects; the potential for e-cigarette use to reverse the decades-long public health effort to ’denormalize’ combusted cigarette use; the effects of second-hand vapour from e-cigarettes, as well as the desire of most people to avoid being exposed to this vapour in public places such as restaurants, movie theatres and aeroplanes, whether proven to be a health hazard or not; whether the use of e-cigarettes encourages smokers who might have otherwise quit to continue smoking and only use e-cigarettes when they are in no-smoking environments (i.e., the ’dual use’ concern); and whether young people may use e-cigarettes as an introduction to smoking regular combusted cigarettes. Until we have answers to these questions, it would be wrong to assume that e-cigarettes are the panacea that producers and users like to assume. The jury is still out.
1. There is a need for increased understanding of the social, ethnic and gender variations in smoking among young people and the impact of tobacco advertising on different groups.
2. Much of the research to date on smoking cessation has been biased by industrial interests. Research is necessary by independent investigators on effective methods of smoking prevention and cessation.
3. More real-world research is needed on e-cigarettes as a potential gateway to smoking, on the dual use of e-cigarettes with conventional cigarettes, and on the long-term effects of vaping on nicotine addiction, to clarify the impact of vaping on human health.
4. More evaluation is needed of non-pharmaceutical methods of smoking cessation that aim at nicotine abstinence rather than substitution by vaping or NRT.
1. About 19% of adults smoke in the USA and the UK. Smoking prevalence varies according to sex, social class and ethnicity.
2. A biopsychosocial model focuses on the experience of smoking, its motivation, and its emotional and social associations. Biological, psychological and social factors contribute to the smoking epidemic.
3. Effective tobacco control requires a multi-level approach, including economic, political, social and psychological interventions.
4. Most smokers report difficulty in quitting the habit. However, significant progress has been made in understanding smoking cessation from a psychological perspective.
5. Efficacy and cost-effectiveness are higher when treatment strategies address the causes and not the symptoms.
6. Smokers wishing to quit are helped using the ’five As’: Ask about tobacco use; Advise to quit; Assess willingness to make a quit attempt; Assist in quit attempt; Arrange follow-up.
7. Smokers unwilling to quit are helped using the ’five Rs’: explain the Relevance; Risks; Rewards; run over the Roadblocks; and Repeat at every available opportunity.
8. Health care systems in Western countries have been compromised by experts working with the pharmaceutical industry to promote treatments such as nicotine replacement therapy that are less effective than other available interventions.
9. Evaluation studies using real-world observation have produced outcomes that are significantly less favourable to products such as NRT than randomized controlled trials.
10. The vast majority of smokers who stop smoking have done so without outside help. Self-quitting to become nicotine free is safer than vaping and using nicotine replacement. The self-help route needs to be promoted as a viable alternative to pharmaceutical interventions.