Health Psychology Smoking Chapter 7


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  • Burning of cigarette release small droplets of tar
  • Nicotine has a lower abuse potential in other forms such as patches and gum Cigarette manufacturers spend considerable resource in developing the Nicotine in other forms such as patches & gum has a lower abuse potential technology eg: additives, buffering etc to maximise the effects. Products tailored to the perceived client eg: new user, established smoker pH from most cigarettes is acidic and not absorbed through buccal mucosa unlike that from pipes and cigars which is alkaline and is well absorbed form the mouth Nicotine from chewing tobacco and snuff is absorbed through the oral and/or nasal mucosa. Plasma nicotine concentrations rise more slowly with these products than with cigarettes, reaching plateau levels by about 30 minutes, declining slowly over approximately two hours. Nicotine is continually released throughout the time of exposure. The rapid absorption of nicotine from cigarette smoking, and the high arterial levels which reach the brain as a result, allow for rapid behavioural reinforcement from smoking
  • A strong desire to take the drug. the desire to smoke plays a crucial role in relapse of smokers trying to give up smoking, is a manifestation of nicotine withdrawal and is clearly related to underlying dependence on nicotine. Difficulty in controlling use. Majority want to stop smoking 80% of smokers have made at least one attempt to quit Only a tiny proportion of quit attempts succeed Continued use despite harmful effects most smokers are aware of the health risks smokers continue to smoke after diagnosis of smoking related disease Tolerance. manifested by absence of nausea, dizziness and other symptoms Withdrawal major motives for continued smoking is the relief of the nicotine withdrawal syndrome Substance taken in larger amounts or longer than intended - not applicable to smoking, although smokers often use up packets of cigarettes quicker than intended A higher priority given to drug use than to other activities and obligations - not applicable to smoking – may reflect the desire to smoke even when the passive effects may harm others eg: children A great deal of time is spent in obtaining, using or recovering from effects of substance - less relevant to smoking as can do other things at the same time and cigarettes are easily available, but see people standing outside in rain smoking and as smoking becomes less acceptable in workplaces etc will have to make a special effort to go an smoke
  • Health Psychology Smoking Chapter 7

    1. 1. Health Psychology Smoking Chapter 7 PY470 - Hudiburg
    2. 2. Who Smokes? – F 7.1, p. 215
    3. 3. Who Smokes? <ul><li>20.9 % of American adults – about 45.1 million (CDC 2005) slight decline since 2003 (21.6%). </li></ul><ul><li>Rates higher in Males (23.9%) than Females (18.1%), highest in American Indian (32.0%) White (21.9%), African Americans (21.5%), Hispanic Americans (16.2%) and Asian Americans (13.3%). </li></ul><ul><li>Rate drop since mid 1960s (42.4%) but rate has dropped slightly since 1990 (25.5%). </li></ul><ul><ul><li>Which state has the highest rate and which state has the lowest rate? Where is Alabama, Tennessee, and Mississippi? </li></ul></ul><ul><li>Smoking related to education and SES – F 7.2, p. 216 </li></ul><ul><li>1.3 million quit each year </li></ul><ul><li>3,000 teens start each day, 70% of adult smokers started in adolescence – Johnston et al. (1998), but use decreasing </li></ul><ul><ul><li>8 th grade (9.3%), 10 th grade (14.9%), and 12 grade (23.2%) - 2005 </li></ul></ul><ul><ul><li>8 th grade (19.1%), 10 th grade (27.9%), and 12 grade (33.5%) - 1995 </li></ul></ul><ul><li>There are more ex-smokers (52.4%) than current smokers (20.9%). </li></ul>
    4. 4. Prevalence of adults (18 and older) smoking in U.S. 2004 & 2006 – CDC MMWR report
    5. 5. Health Effects of Smoking <ul><li>Heart disease </li></ul><ul><li>Lung disease – COPD, asthma </li></ul><ul><li>Cancer </li></ul><ul><ul><li>Lung, ENT, pancreas </li></ul></ul><ul><ul><li>Cervix, colorectal </li></ul></ul><ul><ul><li>Skin (squamous cell) </li></ul></ul><ul><li>Vascular disease - impotence </li></ul><ul><li>Stroke </li></ul><ul><li>Cataracts </li></ul><ul><li>Gum disease </li></ul><ul><li>Dementia </li></ul><ul><li>Early menopause </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Wound healing </li></ul><ul><li>Anxiety </li></ul><ul><li>Miscarriage </li></ul><ul><li>SIDS </li></ul><ul><li>Hearing loss </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>Macular degeneration </li></ul><ul><li>Tooth decay </li></ul><ul><li>Depression </li></ul><ul><li>Multiple sclerosis </li></ul>
    6. 6. What are the health consequences of smoking? <ul><li>Leading cause of preventable mortality </li></ul><ul><ul><li>Smoking related illnesses cause 440,000 deaths per year, CDC (2003) </li></ul></ul><ul><ul><ul><li>These deaths occur 12 years earlier than would be expected, so the aggregate annual loss exceeds 5 million life-years. </li></ul></ul></ul><ul><ul><li>Linked to numerous types of cancer cause by smoking – 155,000 deaths per year among smokers </li></ul></ul><ul><ul><ul><li>The majority of cancers of the lung, trachea, bronchus, larynx, pharynx, oral cavity, nasal cavity, and esophagus from tobacco </li></ul></ul></ul><ul><ul><li>linked to increase risk of developing heart disease and strokes </li></ul></ul><ul><ul><li>linked to other major illnesses </li></ul></ul><ul><ul><li>linked to numerous pregnancy complications </li></ul></ul>
    7. 7. What are the health consequences of smoking? (cont.) <ul><li>What causes the health consequences of smoking? </li></ul><ul><ul><li>constricts blood vessels </li></ul></ul><ul><ul><li>increases heart rate and blood pressure </li></ul></ul><ul><ul><li>increases cardiac output </li></ul></ul><ul><ul><li>hardens the arteries (arteriosclerosis) </li></ul></ul><ul><ul><li>disrupts the ability of the cilia to clear lungs </li></ul></ul>
    9. 9. Healthy lung Smoker’s lung
    10. 10. Oral Cancer Squamous cell & Leukoplakia 90% are squamous cell carcinomas buccal mucosa of heavy smoker buccal mucosa smoker of 2 packs/day
    11. 11. Erythroplakia <ul><li>Patient has long history of chronic white and red lesions of soft palate </li></ul><ul><li>more likely for malignant transformation than white patches </li></ul>
    12. 12. Smoking changes: BLACK HAIRY TONGUE <ul><li>BLACK HAIRY TONGUE </li></ul><ul><li>Overgrowth of filiform papillae </li></ul><ul><li>can be black, brown or yellow. </li></ul><ul><li>will disappear on cessation of smoking </li></ul>
    13. 14. Smoking concerns <ul><li>Smoking and pregnant women – lower birth weight of child,  miscarriage,  rates of ADHD, hyperactivity, and SIDS – MacDorman et al. (1997) </li></ul><ul><li>Passive smoking (second-hand smoke) is a serious problem </li></ul><ul><ul><li>Effects on children & infants – respiratory problems – CDC report </li></ul></ul><ul><ul><ul><li>Almost 60 percent of U.S. children aged 3–11 years—or almost 22 million children—are exposed to secondhand smoke. </li></ul></ul></ul><ul><ul><ul><li>About 25 percent of children aged 3-11 years live with at least one smoker, as compared to only about 7 percent of nonsmoking adults. </li></ul></ul></ul><ul><ul><ul><li>Secondhand smoke exposure is responsible for an estimated 150,000–300,000 new cases of bronchitis and pneumonia in children aged less than 18 months, resulting in 7,500–15,000 hospitalizations. </li></ul></ul></ul><ul><ul><li>The California Environmental Protection Agency estimates that secondhand smoke exposure causes approximately 3,400 lung cancer deaths and 22,700–69,600 heart disease deaths annually among adult nonsmokers in the United States. </li></ul></ul><ul><ul><li>Maternal smoking – 700 SIDS cases each year in U.S. – Grunberg at al. (1997) </li></ul></ul>
    14. 15. Chemistry of tobacco smoke <ul><li>Cigarette smoke is composed of volatile and particulate phases. </li></ul><ul><li>Contains some 500 gaseous compounds including nitrogen, carbon monoxide (CO), carbon dioxide, ammonia, hydrogen cyanide and benzene. </li></ul><ul><li>There are about 3,500 different compounds in the particulate phase, of which the major one is the alkaloid nicotine. </li></ul><ul><li>The particulate matter without its alkaloid and water content is called tar . </li></ul><ul><li>Many potential cancer inducing substances have been identified in cigarette tar. </li></ul>
    15. 16. Nicotine <ul><li>Nicotine is an amine consisting of two rings (pyridine and pyrrolidine) </li></ul><ul><li>Two stereoisomers of nicotine </li></ul><ul><li>(S)-nicotine is the active isomer which binds to nicotinic cholinergic receptors and is found in tobacco. </li></ul>
    16. 17. Absorption of nicotine from tobacco products <ul><li>Small droplets of tar containing nicotine are inhaled and deposited in the small airways and alveoli of the lungs. </li></ul><ul><li>Nicotine is a weak base & absorption across cell membranes depends on the pH </li></ul><ul><li>When nicotine reaches the small airways and the alveoli of the lung, it is buffered to physiological pH </li></ul><ul><li>Absorbed into the pulmonary alveolar capillary and venous circulation </li></ul><ul><li>Nicotine is distributed quickly throughout the body. </li></ul>
    17. 18. Nicotine dosage delivery forms <ul><li>Speed of delivery of nicotine from cigarettes is fast, providing nicotine 'hits' to the brain within 10 -19 seconds of smoke delivery to the lung </li></ul><ul><li>Cigarettes are designed to ensure the delivery of nicotine to maximises the addictive effect </li></ul><ul><li> </li></ul><ul><li>Cigarettes can readily deliver approximately 1-3 mg of nicotine, as desired by smokers </li></ul><ul><li>The smoker can manipulate the intake of nicotine from different cigarettes to achieve and maintain the desired level of nicotine </li></ul><ul><li> </li></ul><ul><li>nicotine, tar, carbon monoxide by brands (U.S.) </li></ul>
    18. 19. Stop smoking? <ul><li>Two-thirds of smokers would like to quit </li></ul><ul><li>30-33% try to quit in any year, 2/3 smoke in two days, 97% in 6 months </li></ul><ul><li>Only about 2% succeed </li></ul><ul><li>Relapse rate lower in smoking cessation programs with 20-30% success in long-term abstinence – Cohen et al. (1989) </li></ul><ul><li>Over 40% continue to smoke after laryngectomy, more 50% after a heart attack </li></ul><ul><li>Smokers make repeated attempts with a period of abstinence followed by relapse </li></ul>
    19. 20. How do psychological factors lead to the initiation of smoking? <ul><li>To try out a new identity - adolescents </li></ul><ul><ul><li>glamorous, older and more mature – grades 5 to 7, need of role models </li></ul></ul><ul><li>Distinct personality types – Burt et al (2000) </li></ul><ul><ul><li>risk-takers (sex, drugs, etc.), extraverted </li></ul></ul><ul><ul><li>higher rates of depression – Windle & Windle (2001) </li></ul></ul><ul><ul><li>weight concerns (for women in particular) – 7 to 10 graders smoke with weight issues </li></ul></ul><ul><li>Social factors </li></ul><ul><ul><li>modeling and peer pressure, more likely if a friend smokes – Mittelmark et al. (1987) </li></ul></ul><ul><ul><li>Smokers get more offers of cigarettes (4.22/week) v. non-smokers (.16/week) – Ary & Biglan (1988) </li></ul></ul>
    20. 21. How do psychological factors lead to the initiation of smoking? <ul><li>Family history of smoking – 26.6 % (smokers) v. 12.6% (nonsmokers) as adults – Chassin et al. (1998) </li></ul><ul><li>NASCAR changes: Winston Cup to Nextel </li></ul><ul><li>Media influences – movies and product placement </li></ul><ul><ul><li>Box 7.2, p. 220-221 </li></ul></ul><ul><ul><li>JAMA study of 50 G rated films, 56% had tobacco use and all films during 1996 to 1997 </li></ul></ul><ul><ul><ul><li> </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul><ul><ul><li>“ Joe Camel” study – Grunberg et al. (1997) </li></ul></ul>
    21. 22. What constitutes addiction? <ul><li>Addictive drugs exhibit two important characteristics </li></ul><ul><li>They cause effects within the brain which are pleasant or rewarding, and which reinforce self-administration of the drug in both experimental animals and human beings </li></ul><ul><li>Following a period of chronic exposure, withdrawal of the drug may cause an abstinence syndrome which an addict may also seek to avoid by continuing to take the drug. </li></ul>
    22. 23. Does nicotine use through smoking meet diagnostic criteria for addiction? <ul><li>A strong desire to take the drug. </li></ul><ul><li>Difficulty in controlling use. </li></ul><ul><li>Continued use despite harmful effects </li></ul><ul><li>Tolerance – need larger dose – 2/4 cigarettes initially but need 20/40 cigarettes after long term smoking </li></ul><ul><li>Withdrawal </li></ul><ul><li>Substance taken in larger amounts or longer than intended </li></ul><ul><li>A higher priority given to drug use than to other activities and obligations </li></ul><ul><li>A great deal of time is spent in obtaining, using or recovering from effects of substance </li></ul>
    23. 24. Ranking of nicotine in relation to other drugs in terms of addiction Dependence among users nicotine >heroin>cocaine>alcohol>caffeine Difficulty achieving abstinence (alcohol=cocaine=heroin= nicotine )>caffeine Tolerance (alcohol=heroin= nicotine )>cocaine>caffeine Physical withdrawal severity alcohol>heroin> nicotine >cocaine>caffeine Deaths nicotine >alcohol>(cocaine=heroin)>caffeine Importance in user's daily life ( alcohol=cocaine=heroin= nicotine )>caffeine Prevalence caffeine> nicotine >alcohol>(cocaine=heroin )
    24. 25. Markers and measures of dependence in smokers <ul><li>Daily cigarette consumption </li></ul><ul><li>Time to first cigarette of the day </li></ul><ul><li>Smoking even when ill </li></ul><ul><li>Smoking more in the morning </li></ul><ul><li>Difficulty not smoking in no smoking areas </li></ul><ul><li>Which cigarette would hate to give up? </li></ul><ul><li>Those who smoke more cigarettes per day are less likely to be able to stop </li></ul>
    25. 26. Consequences of nicotine addiction <ul><li>Morbidity and mortality caused by active and passive smoking </li></ul><ul><li>Smoking prevalence is higher and nicotine use heavier among poorer smokers. </li></ul><ul><li>This difference in smoking behavior accounts for about two-thirds of the excess premature mortality associated with deprivation. </li></ul><ul><li>Nicotine addiction is therefore responsible for significant health inequalities </li></ul>
    26. 27. Tobacco and nicotine addiction <ul><li>The unique selling point of tobacco is its nicotine content. </li></ul><ul><li>Tobacco products without nicotine are not commercially viable. </li></ul><ul><li>Nicotine is an addictive drug. </li></ul><ul><li>The purpose of smoking tobacco is to deliver a dose of nicotine rapidly the brain. </li></ul>
    27. 28. Nicotine withdrawal <ul><li>Withdrawal syndrome is a collection of signs and symptoms caused by abstinence. </li></ul><ul><li>Nicotine or cigarette withdrawal? </li></ul><ul><li>Nicotine replacement reduces severity of withdrawal symptoms. </li></ul>
    28. 29. Nicotine-based models <ul><li>Nicotine fixed-effect model </li></ul><ul><ul><li>nicotine has many reinforcing physiological effects </li></ul></ul><ul><ul><li>smoking feels good, so people continue to smoke </li></ul></ul><ul><ul><li>F 7.4, p. 223 – Schachter et al. (1977) – heavy smokers more low nicotine cigarettes in 2 week period; when High smokers given low nicotine cigarettes were more irritable and anxious </li></ul></ul><ul><li>Nicotine regulation model </li></ul><ul><ul><li>smoking is rewarding only when level of nicotine is above a “set-point” </li></ul></ul><ul><ul><li>smokers must smoke to maintain a certain level of nicotine to feel good </li></ul></ul><ul><li>Limitations </li></ul><ul><ul><li>based on these models, quitting should be easy </li></ul></ul><ul><ul><li>ignores environmental pressures </li></ul></ul><ul><ul><li>nicotine replacement methods are not 100% effective </li></ul></ul>
    29. 30. Affect-regulation model <ul><li>Developed by Tomkins (1966, 1968) </li></ul><ul><li>Smoke to attain positive affect or to avoid negative affect </li></ul><ul><li>Box 7.3, p. 226 – studied stress on smoking </li></ul><ul><li>Leventhal & Avis (1976) dipped cigarettes in vinegar – persons motivated by pleasure smoked significantly less than usual; persons not motivated by pleasure smoked a the same level </li></ul><ul><li>Relaxation and coping with anxiety </li></ul><ul><li>Depression and smoking: 40% less likely to quit as compared to non depressed </li></ul><ul><li>Schachter et al. (1977) found more stressed students smoked more cigarettes and puffed more; the difference was profound for heavy smokers. </li></ul>
    30. 31. Combined models <ul><li>Psychological/physiological factors combined </li></ul><ul><li>Predicts that smoking initially used to regulate emotions and over time links how smokers feel in how much nicotine they have in the their blood </li></ul><ul><li>Can be paired with both positive and negative emotional states </li></ul><ul><li>Biobehavioral model – Pomerleau & Pomerleau (1989) </li></ul><ul><ul><li>Both psychological and physiological factors lead people to continue to smoke; makes them feel good – physiological effect  dependence (psychological & physiological) to use nicotine to experience positive emotions </li></ul></ul><ul><ul><li>nostalgia for smoking: estimated 8.5 month half-life -- cause of relapse over 1st year </li></ul></ul>
    31. 32. What are some strategies for preventing smoking? <ul><li>Targeting adolescents – many studies </li></ul><ul><li>The message is not relevant – they will quit before long-term consequence </li></ul><ul><li>If at risk  smokers focus on short-term benefits </li></ul><ul><li>Social influence programs – Flay (1987) </li></ul><ul><ul><li>Short-term effects  more effective in altering the attitudes </li></ul></ul><ul><ul><li>Types of persons who smoke: duped by advertisers; saying no  independent and self-reliant </li></ul></ul><ul><ul><li>Overestimates of norms in adolescent smoking by adolescents </li></ul></ul><ul><ul><li>Best et al. (1989) – 6 th graders who received social influence training less likely to smoke in the 8 th grade </li></ul></ul>
    32. 33. What are some strategies for preventing smoking? <ul><li>Life Skills training </li></ul><ul><ul><li>Assumption is that lack of self-esteem and self-confidence  increase smoking </li></ul></ul><ul><ul><li>Smoking to feel better about themselves </li></ul></ul><ul><ul><li>Training enhances self-esteem </li></ul></ul><ul><ul><li>Batvin et al (1984) gave 15 life skills sessions to 7 th graders, this group smoked less after 1 year (10 %) v. 22 % for no training group </li></ul></ul>
    33. 34. What are some strategies for preventing smoking? <ul><li>Problems </li></ul><ul><ul><li>Problems with continuing effects – increase levels of smoking as students progress through grades – need of “booster” sessions in HS </li></ul></ul><ul><ul><li>Mass media approaches are least effective – Box 7.4, p. 231 – adds run at low viewer times </li></ul></ul><ul><ul><li>U.S. tobacco companies spend $7.12/person for ads but only $.50/person for prevention </li></ul></ul><ul><ul><li>Government programs are not very effective </li></ul></ul><ul><ul><li>Cigarettes are easy to get but increase cost (10%) might lead to decrease use – Tavas et al. (2001) </li></ul></ul>
    34. 35. Benefits after quitting <ul><li>Health benefits </li></ul><ul><ul><li>cough, DOE resolve in weeks </li></ul></ul><ul><ul><li>exercise tolerance improves rapidly </li></ul></ul><ul><ul><li>bladder cancer: 50% reduction in 5 years </li></ul></ul><ul><ul><li>lung cancer: 50% reduction in 10 years </li></ul></ul><ul><ul><li>heart disease: 50% reduction in 1 year! </li></ul></ul><ul><ul><li>No excess risk of heart disease by 10-15 years </li></ul></ul><ul><ul><li>vascular disease: 50% reduction in 5 years </li></ul></ul><ul><ul><li>mortality - same as never smokers by 10-15 yrs </li></ul></ul><ul><li>Non Health benefits </li></ul><ul><ul><li>COST!!! </li></ul></ul><ul><ul><li>inconvenience </li></ul></ul><ul><ul><li>self-esteem </li></ul></ul><ul><ul><li>role model </li></ul></ul>
    35. 36. Smoking cessation <ul><li>Treatment options: </li></ul><ul><ul><li>Level of use: < 1 pack/day – have many attribute that might lead to successful cessation </li></ul></ul><ul><ul><li>> 1 pack/day – more difficult to quit </li></ul></ul><ul><ul><li>Motivation, social support and advice </li></ul></ul><ul><ul><li>Weight gain concerns – 1/3 gain 5 – 8 lbs. - Jeffery et al. (2000) – those not concern 21 % cessation v. 13.1 % for those concerned with weight gain </li></ul></ul><ul><ul><li>Gradual reduction – less nicotine in cigarettes – 49 % success v. 22 % “cold turkey” </li></ul></ul><ul><ul><li>Treatment products such as NRT, bupropion – the “patch” and “gum” - Box 7.6, p. 234 – 235 “chain chewer” </li></ul></ul>
    36. 37. NRT & Bupropion (Zyban) <ul><li>Stop or reduce the symptoms of nicotine withdrawal. </li></ul><ul><li>Assist in stopping smoking, but without having unpleasant withdrawal symptoms. </li></ul><ul><li>Do not 'make' the client want to stop smoking. </li></ul><ul><li>Still need to address the psychological issues – combine with counseling </li></ul><ul><li>Still need motivation and determination to succeed in breaking the smoking habit. </li></ul>
    37. 38. NRT & Bupropion <ul><li>Inhalator - 10mg cartridges </li></ul><ul><li>Gum - 4mg, 2mg mint, original or fruit </li></ul><ul><li>Patch - 16hr = 15mg, 10mg, 5mg and </li></ul><ul><li>24hr = 21mg, 14mg, 7mg </li></ul><ul><li>Microtab - 2mg </li></ul><ul><li>Lozenge (2 types) - 1mg, 2mg, 4mg </li></ul><ul><li>Nasal Spray - 0.5mg per spray </li></ul><ul><li>Bupropion (Zyban) </li></ul><ul><li>150mg per tablet </li></ul>
    38. 39. Smoking cessation <ul><li>Treatment options: </li></ul><ul><ul><li>Aversion strategies </li></ul></ul><ul><ul><li>Rapid-smoking method take a puff every 6 seconds – creating an aversive stimulus </li></ul></ul><ul><ul><li>Electric shock pairing -  rates of cessation – Welter et al. (1998) </li></ul></ul><ul><ul><li>Self-management – stimulus control of situations for smoking or not smoking </li></ul></ul><ul><ul><li>Stimulus substitution – taking a walk after dinner, chewing gum </li></ul></ul><ul><ul><li>Contingency-contracting – give money to someone who give it back if cessation goal is reached </li></ul></ul><ul><ul><li>Large scale programs – varying success – may initially reduce smoking but usually returns – Gomel et al. (1993) </li></ul></ul>