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Tobacco smoking

Introduction
Smoking presents numerous paradoxes. Its possibly the most prevalent and lethal
form of drug dependence in the world, yet for years was regarded as a social habit. In
the past was litte awareness of the psychoactive component in nicotine. In many ways
it is the invisible drug, which lacks obvious effects on the cognitve abilities of the user
yet is it snow regarded as the purest example of drug dependence.
Nicotine is a stimulant drug which users say calms them down. However, there is no
evidence that nico possesses any form of anxiolytic or antidepressant properties.
!espite evidence of any form of euphoric effect, smoking is very recalcitrant to
change. "ost smokers want to give up but find it hard to do so, despite numerous
attempts. #ven those with lt smoking related diseases often fail to $uit. . #ven in anti
smoking countries, only half of those who have ever smoked regularly manage to stop
before the age of %&. 'his feature is of particular interests to psychologists.
Smoking has long been an area of active research into methods of (r change, as well
as the interplay between pharmacological, psychological and social determinants of
(r. However, despite recent advances in costeffective treatments for smoking
cessation, failure to $uit or relapse seems to be the norm. 'he smoking problem shows
no signs of going away.
Worldwide prevalence
'he manufactured cigarette, and with it its epidemic of worldwide smokig is largely a
phenomenon of the )*
th
century. +nnual percapita consumption in developed
countries rose from %**,*** between -.)* and peaked in -./*. since then there has
been a modest decline fo some -%0 12oleshaw 3 lope4, -..%5. In developing
countries on the other hand, smoking increased dramatically in the -.%*s and -./*s6
so the gap in the percapita consumption rate is narrowing, with developed countries
being expected to exceed that of the western world within the next few years.
7H8 1-../5 estimates worldwide prevalence of smoking at 9/0, with higher levels
being seen in china and former sovietblock countries. 7omens smoking is at much
lower levels than that of males 1approx -)05, with higher rates being seen in
developed countries, and lower rates in +frica, India, 2hina and other parts of +sia,
where cultural traditions still frown upon female smokers.
In terms of the total world market, a decline in smoking has been observed at -.&0
per annum in +merica, and *.%0 in other westernised nations. However, this decline
has been mro9 than offset by the rapid growth in 2hina 19.:05 per annum, and other
less developed countries.
Smoking as a cause of death
Increase in death rates from smoking seems to lag behind the onset of regular use by
about ,*9* years. +s a result, different pattersn of smokingrelated deaths are
currently being seen in men and women. In -.&&, smoking was responsible for about
&**,*** deaths per year, mostly among men 17H8, -../5. Since that time, this figure
has risen dramatically, and by -..& almost ) million people in developed countries
were dying each year from tobacco addiction.
'he rate of increase is now slowing somewhat in men. In the mid -..*s about )&0 of
male deaths, and .0 of female deaths, in developed countries, were due to smoking.
'he proportion of deaths in middle age 1,&%.5 is higher, at ,% and -,0 respectively.
#stimates of smokingrelated deaths in the developing world are less than certain, but
it is already clear that the increasing prevalence of smoking behaviour shall lead to an
e$uivalent rise in smokingrelated mortality. It is, however, estimated that deaths due
to smoking addiction shall increase to -* million by )*)*, and that the bulk of these
deaths will be in the developing world 1;eto et al., -..96 7est et al., )**-5.
Diseases caused by smoking
'he royal college of ;hysicians 1-./-5 suggested that a young man who persists in
smoking run a - in 9 chance of bening killed prematurely by tobacco. "ore recent
studies have extended this understanding and forced a reevaluation of the risk. It is
now apparent that persistent smokers run a - in ) chance of being killed by
cigarettes, losing on average : years of life 1!oll et al., -..96 'hun et al., -..&6 2lark
et al, -...5.
Smoking is thought to cause :*0 of all lung cancers, with a relative risk of ))0 in
men and -)0 in women. In addition, it is responsible for most cancers of the upper
respiratory tract 1lip, tongue, larynx, pharynx5 and for a smaller fraction fo cancers of
the bladders, pancreas, esophagus and kidney. +mong both men and women,
smokingattributable deaths from 2<!, outnumber those of all other causes,
including lung cancer. Smoking is a sig risk factor for 2<!.
+s well as being the single largets cause of preventable premature death, cigarette
smoking is a cause of a number of disabling nonfatal conditions. 'hese include
cataracts, 2rohns disease, gastric and duodenal ulcers, hip fracture in the elderly and
periodontitis 17ald 3 Hakshaw, -..%5.
Health effects of passive smoking
Since the early -.:*s there has been an explosion of research into the effects on non
smokers of breathing other peoples smoke. 'hese studies of the uptake of smoke
constituents have shown doseresponse relationships with the extent of exposure to
passive smoking 1=arvis, -.:.5. + number of reports of independent scientists have
reviewed the evidence linking passive smoking with nonsmokers spouses exposed to
their partners smoke. +ll have concluded that passive smoking causes lung cancer in
otherwise healthy nonsmokers, with an estimated number of deaths each year of
,*** in the >S 1>S#;+, -..)5 and ,** in the >? 1@roggatt, -.::5.
'he association of heart disease is of a similar magnitude to that observed for lung
cancer, with exposed spouses have a ,*0 increased risk. 8n causal interpretation of
this association, passive smoking may kill far more people through 2H! than through
lung cancer alone A %**, *** deaths per year in the >S+ 17ells, -..96 Steenland
-..:5. >ncertainty remains regarding how much of this observed association is truly
causal.
The health benefits of smoking cessation
Stopping smoking benefits health at any age. 'hose who gave up by their mid,*s had
a life expectancy indistinguishable from nonsmokers 1!oll et al., -..95. Similar
benefits have been observed for a variety of conditions. 'he lunghealth study, a trial
of smoking cessation among people at increased risk of chronic respiratory disease,
showed that on stopping smoking the rate of loss of ventilatory capacity reverts from
the accelerate rate of smokers to that of the slower agerelated decline of nonsmokers
1+nthonisen et al., -..95.
Bung cancer has a somewhat different picture. 'he extra risk incurred from a smoking
career is never lost 1Halpern et al., -..,5. However, since the risk would have
escalated exponentially with continued smoking, a marked reduction in risk is
observed by comparison with persistent smoking. @or heart disease the risk in ex
smokers declines toward that of never smokers over time. 'here is uncertainty about
how fats this occurs and why 1!obson et al., )**-5.
Cigarette smoking and nicotine dependence
!rug taking aspects of smoking were largely ignored until the mid-./*s. since then,
work has led to a consensus that cigarette smoking is essentially a form of addiction
to nicotine. 'he processes underlying this addiction are similar to that of other drugs,
including heroin, cocaine, and alcohol 1>S dept of health and leaht services, -.::5.
>nderstanding nicotines role is essential to an appreciation of smokings uptake,
maintenance and cessation. It does not follow, of course, that cigarette smoking is
explicable solely in tersm of pharmacological factors. Nicotine effects provide a rich
substrate for conditioning and social learning mechanisms, and for braod socio
economic, and societal influences. In this respect, it is no different from any other
drug dependency.
#vidence to support nicotines properties as an addictive drug come from a number of
sources 1Stolerman 3 =arvis, -..&5.
1 !rain neurochemistry
(oth animal and human studies have shown that chronic nicotine increase leades to an
increase in the number of nicotinergic receptor sights within the brain 1Slotkin et al.,
-.:/5. 'his has been supported by postmortem examination of dopinergic systems
that seem to indicate that these systems are thought to be important in reward
mechanisms, much like that of cocaine 1;ontieri et al., -..%5 .
" #nimal self$administration
>nder appropriate schedules of reinforcement nicotine functions as a primary
reinforcer 12orrigal 3 2oen, -.:.5 in variety of animal species. #arly difficulties in
demonstrating this effect seems to have stemmed from the narrow range of rewarding
blood concentrations and the ease in provoking adverse overdose.
% &egulation of nicotine intake
Bevels of blood nicotine maintained by cig smokers and users of oral snuff are very
similar, averaging in each case at ,& ngCmlC give the different sensory characteristics
of burnt and nocombustible tobacco, the different routes of absorption, and the
absence s from snuff of components such as tar, this points strongly to nicotine
dictating the dependantbehaviour 1Holm et al., -..)5.
"anufactured cigs contain about -*-9mg of nicotine, and amount that doesnt vary
greatly between different brands. (ut, by techni$ues such as filtration and ventilation,
yields of nicotine when smoked by a machine range from *.- A - mg 17ithey et al.,
-..)5.
Naturalistic studies of smokers smoking their own selected brands and of people who
have temporarily switched to lower yield brands have both shown that the slope
relating machinesmoked yield is either very flat or shallow. Smoker can and do
adDust the way they smoke so as to maintain similar nicotine intakes from cigs with
widely differing deliveries. 'his is also found when smokers reduce the number of
cigs smoked 1Eussel, -.:*5.
' ac(uisition of nicotine inhalation in novice smokers
It is well established that children take up smoking for mainly psychosocial reasons.
Fet studies have shown that pharmacological motivations take on sig important early
in the smoking career 1Bynch et al., -..95. +lready, by the time they are smoking on a
daily basis, children are taking in as much nicotine from a cig as an adult smoker.
@urthermore, they havce also been found to report similar cravins 1"cNeil et al.,
-.:%5.
&5 2ompulsive use
'he typical smoker goes through much the same number of cigarettes per day,
averaging at about -/ per day in the >? 1#vans et al., -..)5, with the exception of
Gchippers. #ven those with severe heart disease persist in smoking, whether it be
heart disease 1(igelow et al., -.:%5 or lung cancer 1!avson 3 !uffy, -..)5.
%5 Nicotine withdrawal syndrome
2essation of smoking reliably leads to a number of signs and symptoms, with an onset
within -) hours and duration of ,9 weeks. SubDects report irritability, difficulty
concentrating, anxiety, restlessness, reporting irritability, difficulty concentrating,
anxiety, restlessness, increased hunger and depressed mood.
'hat the tobacco withdrawal syndrome is due to the loss of nicotine, rather than
behavioural aspects of its use, are shown by the consistent findings that it is relieved
by nicotine replacement but not placebo Eussell et al., -..,5.
The smoking career
&ecruitment of young people to cigarette smoking
>ptake of smoking typically occurs in adolescence, with few people starting to smoke
after the age of )* 1?essler -..&5. In the >? from the prevalence of about -0 at --
years, there is a rapid increase, so that by the age of -& about )&0 of teenagers
smoke. 'here is some evidence that at this age, girls are more likely to smoke than
boys 1!iamond 3 Hoddard, -..&5.
Initiation of smoking is subDect to a number of influencesI environmental influences
include parents, peer pressure, and advertising 1+ltman et al., -..%5 young people
from deprived backgrounds 1where smoking is more common5 are more likely to
smoke. +lso, smoking is linked with poor school performance, truancy, low aspiration
for the future, and early school leaving 1Bynch 3 (onnie, -..95.
;ersonal characteristics consistently linked include low selfesteem, low knowledge
of the adverse effects, and anxiety and depression 1(reslau et al., -..,5.
(oth in the >S+ and the >?, where rates of teenage smoking are on the increase,
there is recognition that preventing uptake is where up until now little has been
achieved. Skills based approaches designed to e$uip children to resist social
influences to smoke have shown some initial success 1(ruvold, -..,5. >nfortunately,
longer term followup has found that these effects dissipate 1Nutbeam et al., -..,6
-...5.
#dult smoking) disadvantage an dependence
the most striking feature of smoking since the -./*s is the increasing association
between cigs and markers of disadvantage, whether they be socioeconomic or a range
of factors indicating stressful living circumstances 1=arvis et al., -..9b5. High rates of
smoking are seen in the unemployed, divorcees, heavy drinkers, prisoners or those
with psychiatric illnesses.
In the general population there is an increasingly strong association between cig
smoking and indicators of deprivation 1;ierce et al., -.:.a6 -.:.b5. between -./, and
-..9, rates of smoking amongst affluent people halved, but among the poorest groups
remained unchanged at /*0 1(ennet et al., -..%6 =arvis, -../5.
2ig smoking is unusual in drug dependency in that high levels of dependence are
typical of most users rather than Dust a minority 1Stolerman 3 =arvis, -..&5. +t least
:*0 of smokers meet the !S"I< for drug dependence 12otter et al., -..&5. 'he
average smoker smokes every day at over one cig per waking hour. Survey data
indicates that one third of smokers have never stopped for longer than one week.
Some -/0 of smokers light up within & minutes of waking6 &*0 within ,* mins 1>S
!HHS, -..*5.
*actors associated with smoking cessation
+bout two thirds of smokers say they would like to give up. Eates of cessation vary
from about -:0 in young people in their early )*s to %*0 among those aged %* and
above 1(ennet et al., -..%5. 8verall, rates of cessation show little difference by
gender, with young women more likely to $uit than men 1=arvis, -..9a5.
2essation is influenced by a number of factors. 'hese include immediate family
circumstance, the broader socioeconomic setting, psychological wellbeing
pharmacological dependence 1=arvis, -../5.
!epressive illness and stressful life circumstances are associated with low rates of
cessation, although there is evidence to suggest that $uitting leads to lower, rather
than higher, levels of perceived stress 12ohen et al., -...5.
+sychological symptoms
+lthough smoking doesnt cause any discernable mental or functional impairment,
that is not to say that there are no negative psychological concerns. ;eople will be
concerned about current and future illness, the effects of passive smoking on children,
finances, pressure to abstain, and dislike of being drug dependant. However, the
clearest psychological impact of smoking arises when individuals try to stop
'here has been much research on the nicotine withdrawal syndrome. "ost studies use
J to investigate this using Bickert or <+S methods. 'he three most widely used are
the Shiffman=arvik 1-./%5, the smoker complainst scale 1Schneider et al., -.:95 and
the "innesota nicotine withdrawal Juestionnaire 1Hughes 3 Hatsukami, -.:%5.
7ithdrawl symptoms are experienced by about :*0 of ex smokers, %*0 of which
will describe these as being sever. Symptoms peak in the first few days of cessation
and, with the exception of craving, hunger and weight gain, gradually subside within
an average duration of about ,9 weeks. 1Snyder et al, -.:.5.
(outs of craving can exist for months, however. 2raving cigarettes is probably the
most troublesome and fundamental symptom and is a maDor factor in triggering
relapse over the coming weeks. Increased weight gain and appetite can continue for at
least -* weeks and exsmokers typically gain approx -*lbs in the first year.
8ther physical changes include decrease in metabolic rate, blood pressure and tremor,
increase in skin temp, changes in E#" sleep, decreases in peak alpha ##H
1indicating less cortical arousal5 and gastrointestinal disturbances. ;erformance on
tasks involving re$uired vigilance, attention or memory is also impaired. Note, all of
these symptoms may be averted to some degree via NE'.
Treatment approaches
@our main approachesI treatments to encourage and support adult smokers,
preventative measures aimed at children, modifications to make cigarettes less
harmful, legistlatory changes.
,icotine replacement therapy
'he most well researched means of altering tobacco addiction is NE'. 'his is most
designed to be used in conDunction with a behavioural program. 'he idea is to
temporarily provide smokers with a safer means of ingesting nicotine. 'he process of
$uitting is therefore broken down into two stagesI giving up the behavioural act of
smoking, and weaning oneself off nicotine all together. 'his cycle usually takes ,9
months.
Success rates are modest, varying according to the setting and psychological support
with which it is combined. It marked a breakthrough in smoking cessation and there
are currently four forms of NE', of which we shall focus upon but two. Note, none of
these methdso can mimic the extremely rapid but transient nicotine peaks in arterial
blood characterised by inhalation, so they do not provide the same satisfaction.
1) Nicotine gum
'he nicotine is absorbed slowly through the lining of the mouth and blood levels
reach a flat peak after about ,* minutes of chewing. (lood nicotine levels rest at
about -*-& ngCml, about one third of the usual smokers level when using )mg 1as
opposed to 9mg gum.
+dverse mood effects and difficulty concentrating associated through craving is not
reliably decreased. @urthermore, if absorption rate is crucial for the individual, then
nothing is gained for the smoker. 'his may explain why most only chew : compared
to recommended -& pieces per day 1Eussell, -.::6 -../5.
Nearly &* randomi4ed trials have now been conducted and a recent meta analysis
concluded that the gum was more effective than a placebo regardless of the setting
1Silagy et al., -..95. However, the gum poses problems for denture wearers, tastes
bad and gives rise to a number of side effects. @inally, some find difficulty in learning
ade$uate chewing techni$ues.
2) Nicotine patches
;rovide therapy from the first day of treatment with minimal effort and instruction.
Smokers start on the highest dose for 9: weeks, followed by a systematic weaning
period of ): weeks using smaller patches. 'wo typesI day time 1-% hour5 patches and
)9 hour patches. (oth appear e$ually effective 1@iore et al., -..95.
<enous blood levels of nicotine build up slowly over several hours to a plateau of
about -*)* ngCml, roughly &*0 of normal levels. Since absorption is very slow, users
are unlikely to experience any of the positive subDective symptoms associated with
smoking. 'his suggests they may be best for people who primarily need to relieve
symptoms of withdrawal rather than the habit of smoking itself. 'he most common
side effect is mild skin irritation 1&05
Numerous controlled studies have demonstrated the efficacy with the highest success
rates being )*)&0 at % month followup. 'his tends to occur when combined with
patches and intensive behavioural treatment. 'he patches have been found to reduce
the cravings of withdrawal and, more surprisingly, craving for cigarettes than nicotine
gum. Its main advantage, however, is its improve patient compliance.
+rospects fo the future
Bike all drug dependencies, cig smoking is a multifaceted problem. whose
understanding re$uires attention to a range of factors. No single policy response can
hope to address the range of issues which determine smoking uptake, maintenance
and cessation. @uture progress will depend on our understanding of the psych process
operating at each stage of the smoking career, and clinical psychology will continue to
have an important role to playC if there is one lesson to be taken from the past, it is
that future progress is likely to be slow and hard won.

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