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So why do we still smoke? |
| Posted on Mar 12 2009 |
| Blog, News and Articles >> Stop Smoking |
One in four people in the UK still smoke, even though they know the habit will reduce their quality of life and raise the risk of premature death. The figure is only a fraction of the one in two of the population who inhaled regularly when smoking reached its peak popularity in the 1950s. But while seven out of 10 of today's smokers want to stop, the rate of decline has flattened in the past decade, revealing a core of hardened smokers who cannot or will not quit. Are they just plain stupid? The picture is more complex – with a mix of the following factors keeping this minority puffing.
Addiction
Smoking is at least as addictive as heroin, cocaine or alcohol. Almost no one enjoys his or her first cigarette, and perseverance is usually down to peer pressure. "But by the time the novelty of smoking has worn off, you're likely to be hooked," says Professor John Britton, chair of the Royal College of Physicians' Tobacco Advisory Group.
It's the nicotine, a chemical that is less harmful than caffeine, that creates the dependence. But the method of delivery is also part of the addiction. The tobacco industry has invested heavily to make the smoke easier to inhale, speeding the nicotine into the bloodstream to hit the brain in around seven seconds. As well as being more harmful and creating greater dependency, this also ensures that other nicotine products – patches, gums and sprays – simply don't hit the spot.
Once delivered to the brain, a range of brain receptors are able to use the nicotine to help stimulate production of dopamine, the brain chemical that plays a part in making us feel pleasure. "As the effect wears off, you need another cigarette to stave off withdrawal symptoms including anxiety, nervousness, agitation and depression," explains Professor Britton. "What people experience as pleasure or relaxing is really the sensation of going from feeling really crappy to just about normal," he says. The brain learns to tolerate nicotine quite quickly, and there are different degrees of addiction, depending on the age you start smoking, how many cigarettes you smoke, and how deeply you inhale.
Undiagnosed depression
Nicotine is undoubtedly a mood-altering drug, and according to clinical psychologist and author Oliver James, has antidepressant properties, "probably many times more effective than Prozac". Back in 2005, he claimed that 80 per cent of smokers are actually self-medicating for depression when they smoke. Having a cigarette, he said, is the only way "people who find socialising difficult can enjoy company, or those who are easily irritated or shamed can ease negative, paranoid or depressive ideas".
Among those diagnosed with a depression or anxiety disorder, around half smoke. The figure is even higher for schizophrenics (around 80 per cent) and those with psychosis living in institutions (70 per cent).
When the ban on smoking in pubs was still just in the pipeline, James argued that stopping people from smoking in public would further isolate chronically depressed smokers. With little evidence that this has happened, James's view now seems to be only part of the story. Psychologists today question whether smoking contributes to emotional well-being. "Smokers learn slowly but surely to titrate their blood nicotine levels to keep themselves in a comfortable state through difficult and stressful situations," says Dr Alan Norris, consultant clinical psychologist at Nottingham Woodthorpe Hospital. "It's an unconscious process where people learn the right dose for their mood in the process of inhaling hundreds of thousands of times."
Inhaling deeply and frequently, for instance, has a calming effect when you're shocked, while a slower deep puff can create an antidepressant or relaxing effect. "This works without the nicotine if you are not a smoker, simply by breathing appropriately. But for smokers, the discomfort of abstinence at critical moments can be intense. It undoubtedly persists after quitting smoking – and is one of the main reasons for relapse," he says.
But Dr Norris says that there is no evidence at all that smokers stay happy by carrying on smoking. "On the contrary, giving up is likely to be a better strategy. As well as feeling better physically, ex-smokers develop greater self-esteem."
Smoking behind the bike sheds has been a rite of passage for generations of rebellious teens, allowing them to flout school rules and show just how early they can anticipate adulthood – both at the same time. The anti-smoking legislation, it seems, has brought out the rebellious teen in adults.
Forced out of the workplace, smokers discovered that they tell better jokes and have more fun than their boring non-smoking colleagues. The barrister and writer Sir John Mortimer was said to have taken up smoking in his eighties, a couple of years before his death, as a protest against the smoking ban in pubs. Even the non-smoking journalist Dame Joan Bakewell recently admitted that the latest government attempts to "denormalise" smoking by banning vending machines and packets of 10, brought out "a wish to subvert the rules and behave badly just to demonstrate an independence of spirit".
The sad thing, according to Dr Norris, is that "the tobacco industry has always encouraged smokers to feel like a persecuted minority". The industry-funded Forest (Freedom Organisation for the Right to Enjoy Smoking), which currently carries a quote from Jeremy Clarkson on its website saying: "I smoke because I am not a coward", was deliberately modelled on the Civil Rights Movement when it was set up in 1979.
Lack of support
Smokers try to give up on average seven times before they finally succeed – and many give up trying along the way, believing they'll always be defeated. Yet the vast majority don't use a free, easily accessible service unique to the UK, and that has been shown to quadruple smokers' chances of quitting. One in eight people give up when they get support from the NHS Stop Smoking Service, which combines medication with behavioural therapy. That is compared with around one in 25 who give up with willpower alone.
"What makes the difference," says Professor Britton, "is that the Stop Smoking Service reinforces the smoker's decision to quit with professional behavioural support, alongside medication to help the cravings." Other support such as hypnotherapy probably has the same effect – though there's no similar evidence hypnotherapy is effective in giving up smoking.
The service, introduced in 2000, is finally being monitored to find out why it's not used properly. The main problem, it seems, is scepticism that a talking therapy can help. And, according to Dr Florian Vogt, a health psychologist at King's College London, smokers' scepticism is often reinforced by GPs, who also don't believe that a talking therapy will help. "GPs are supposed to quiz their patients about smoking habits and urge potential quitters to use the Stop Smoking Service. But most doctors don't bother."
Now, GPs should get a reinforced message. Dr Vogt's team has shown that educating GPs to understand how effective the service can be has doubled referral rates to it.
In the meantime, studies show that varying the medication on repeat attempts at quitting is worthwhile. There are three types of medication available on the NHS: the nicotine-based medication; Zyban (an antidepressant that has been shown to reduce cravings); and Champix, the most recent anti-smoking pill that works by reducing the uptake of nicotine in the brain.
The desire to be cool
One of the main successes of anti-smoking campaigns is to convince people that smoking is smelly, antisocial and unattractive as well as unhealthy. But it's not long since cigarettes were glamorous, and smoking a byword for male virility and female elegance. A new book, The Cigarette Century: The Rise, Fall and Deadly Persistence of the Product that Defined America by Allan M Brandt (Basic Books) shows how the tobacco industry infiltrated Hollywood, among other institutions, to create this alluring image.
According to Brandt, the industry pioneered public relations by convincing Hollywood producers that a cigarette was an essential prop for a range of characters, such as "the bashful hero dragging on his smoke to summon up romantic courage; the villain, smoking in hasty puffs; the lover leaning in to light up the cigarette, and eyes, of his beloved".
Yet despite its fall from grace, women still use one aspect of nicotine to look good: its acknowledged power as an appetite suppressant. Worry about weight gain can be a significant reason to carrying on smoking and for relapsing after quitting, according to Professor Britton. "After quitting smoking, people put on an average of 7lb," he says. "The best way to avoid weight gain is to carry on taking a nicotine product for weeks or even months until your body has adjusted."
Denial
No scientist today would dare to suggest that smoking is not a major health risk and that the warnings on cigarette packets are anything but accurate. Yet many smokers persuade themselves that the statistics don't apply to them. The apocryphal friend of a friend's granny puffing away into her nineties is a persuasive figure, according to Professor Britton – though wrongly so. "Until recently, there were a number of survivors from the Somme. But no one suggests their existence proved that it wasn't dangerous to be a soldier in the trenches in the First World War," he says.
For many smokers, however, denial can be rational, according to Dr Norris. "People feel themselves to be healthy and young enough to be able to give up in the future. Smokers are not stupid –there's always sufficient logic to square the circle, to permit cognitive dissonance."
Many smokers experience a tipping point, a moment that makes them more unhappy to be a smoker than to consider quitting. Success will often depend on how far smokers prepare for acute withdrawal symptoms, he says. "It's essential to be aware of different thinking patterns all the way through to make sure you've got the support for the worst scenarios," says Dr Norris.
Habit
Almost as significant as addiction are the routines smokers associate with their daily 150 or so puffs of cigarette smoke: the coffee, the end of a meal, the sitting down with a drink, the telephone conversation. "All these associations prompt the person to light up, which is why it's so important to prepare to quit,'' says Dr Norris.
Social situation
Deprivation appears to increase the power of nicotine addiction, with a higher rate of dependency in those at the bottom of the social ladder. Eight out of 10 prisoners smoke, and the habit kills a disproportionate amount of people from social classes D and E – including single mothers, immigrants, and those with mental health problems. The rate of smoking among Bangladeshi men, at 44 per cent, is nearly twice that of Indians. Yet the rate among Bangladeshi women is negligible. And 80 per cent of lone parents living on Income Support are smokers.
When he was health minister in 2004, John Reid caused a stir with his claim that smoking was one of the last available pleasures for people living in deprivation. The more likely explanation, however, is that nicotine addiction is part of the cycle of deprivation – with adults from low social classes having a number of risk factors connected with smoking and continuing to live in an environment where smoking is the norm.
Last changed: Dec 07 2009 at 10:23 AM
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