Health Psychology Smoking Chapter 7

Health Psychology Smoking Chapter 7 PY470 - Hudiburg

Who Smokes? – F 7.1, p. 215

Who Smokes?
20.9 % of American adults – about 45.1 million (CDC 2005) slight decline since 2003 (21.6%).
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%).
Rate drop since mid 1960s (42.4%) but rate has dropped slightly since 1990 (25.5%).
Which state has the highest rate and which state has the lowest rate? Where is Alabama, Tennessee, and Mississippi?
Smoking related to education and SES – F 7.2, p. 216
1.3 million quit each year
3,000 teens start each day, 70% of adult smokers started in adolescence – Johnston et al. (1998), but use decreasing
8 th grade (9.3%), 10 th grade (14.9%), and 12 grade (23.2%) - 2005
8 th grade (19.1%), 10 th grade (27.9%), and 12 grade (33.5%) - 1995
There are more ex-smokers (52.4%) than current smokers (20.9%).

Prevalence of adults (18 and older) smoking in U.S. 2004 & 2006 – CDC MMWR report

Health Effects of Smoking
Heart disease
Lung disease – COPD, asthma
Cancer
Lung, ENT, pancreas
Cervix, colorectal
Skin (squamous cell)
Vascular disease - impotence
Stroke
Cataracts
Gum disease
Dementia
Early menopause
Osteoporosis
Wound healing
Anxiety
Miscarriage
SIDS
Hearing loss
Rheumatoid arthritis
Macular degeneration
Tooth decay
Depression
Multiple sclerosis

What are the health consequences of smoking?
Leading cause of preventable mortality
Smoking related illnesses cause 440,000 deaths per year, CDC (2003)
These deaths occur 12 years earlier than would be expected, so the aggregate annual loss exceeds 5 million life-years.
Linked to numerous types of cancer cause by smoking – 155,000 deaths per year among smokers
The majority of cancers of the lung, trachea, bronchus, larynx, pharynx, oral cavity, nasal cavity, and esophagus from tobacco
linked to increase risk of developing heart disease and strokes
linked to other major illnesses
linked to numerous pregnancy complications

What are the health consequences of smoking? (cont.)
What causes the health consequences of smoking?
constricts blood vessels
increases heart rate and blood pressure
increases cardiac output
hardens the arteries (arteriosclerosis)
disrupts the ability of the cilia to clear lungs

TOBACCO KILLS

Healthy lung Smoker’s lung

Oral Cancer Squamous cell & Leukoplakia 90% are squamous cell carcinomas buccal mucosa of heavy smoker buccal mucosa smoker of 2 packs/day

Erythroplakia
Patient has long history of chronic white and red lesions of soft palate
more likely for malignant transformation than white patches

Smoking changes: BLACK HAIRY TONGUE
BLACK HAIRY TONGUE
Overgrowth of filiform papillae
can be black, brown or yellow.
will disappear on cessation of smoking

Smoking concerns
Smoking and pregnant women – lower birth weight of child,  miscarriage,  rates of ADHD, hyperactivity, and SIDS – MacDorman et al. (1997)
Passive smoking (second-hand smoke) is a serious problem
Effects on children & infants – respiratory problems – CDC report
Almost 60 percent of U.S. children aged 3–11 years—or almost 22 million children—are exposed to secondhand smoke.
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.
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.
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.
Maternal smoking – 700 SIDS cases each year in U.S. – Grunberg at al. (1997)

Chemistry of tobacco smoke
Cigarette smoke is composed of volatile and particulate phases.
Contains some 500 gaseous compounds including nitrogen, carbon monoxide (CO), carbon dioxide, ammonia, hydrogen cyanide and benzene.
There are about 3,500 different compounds in the particulate phase, of which the major one is the alkaloid nicotine.
The particulate matter without its alkaloid and water content is called tar .
Many potential cancer inducing substances have been identified in cigarette tar.

Nicotine
Nicotine is an amine consisting of two rings (pyridine and pyrrolidine)
Two stereoisomers of nicotine
(S)-nicotine is the active isomer which binds to nicotinic cholinergic receptors and is found in tobacco.

Absorption of nicotine from tobacco products
Small droplets of tar containing nicotine are inhaled and deposited in the small airways and alveoli of the lungs.
Nicotine is a weak base & absorption across cell membranes depends on the pH
When nicotine reaches the small airways and the alveoli of the lung, it is buffered to physiological pH
Absorbed into the pulmonary alveolar capillary and venous circulation
Nicotine is distributed quickly throughout the body.

Nicotine dosage delivery forms
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
Cigarettes are designed to ensure the delivery of nicotine to maximises the addictive effect
http://www.washingtonpost.com/wp-dyn/content/article/2006/08/30/AR2006083001418.html
Cigarettes can readily deliver approximately 1-3 mg of nicotine, as desired by smokers
The smoker can manipulate the intake of nicotine from different cigarettes to achieve and maintain the desired level of nicotine
http://home.att.net/~rdavis2/cigra.html
nicotine, tar, carbon monoxide by brands (U.S.)

Stop smoking?
Two-thirds of smokers would like to quit
30-33% try to quit in any year, 2/3 smoke in two days, 97% in 6 months
Only about 2% succeed
Relapse rate lower in smoking cessation programs with 20-30% success in long-term abstinence – Cohen et al. (1989)
Over 40% continue to smoke after laryngectomy, more 50% after a heart attack
Smokers make repeated attempts with a period of abstinence followed by relapse

How do psychological factors lead to the initiation of smoking?
To try out a new identity - adolescents
glamorous, older and more mature – grades 5 to 7, need of role models
Distinct personality types – Burt et al (2000)
risk-takers (sex, drugs, etc.), extraverted
higher rates of depression – Windle & Windle (2001)
weight concerns (for women in particular) – 7 to 10 graders smoke with weight issues
Social factors
modeling and peer pressure, more likely if a friend smokes – Mittelmark et al. (1987)
Smokers get more offers of cigarettes (4.22/week) v. non-smokers (.16/week) – Ary & Biglan (1988)

How do psychological factors lead to the initiation of smoking?
Family history of smoking – 26.6 % (smokers) v. 12.6% (nonsmokers) as adults – Chassin et al. (1998)
NASCAR changes: Winston Cup to Nextel
Media influences – movies and product placement
Box 7.2, p. 220-221
JAMA study of 50 G rated films, 56% had tobacco use and all films during 1996 to 1997
http://scenesmoking.org/
http://smokingsides.com/asfs/m/
“ Joe Camel” study – Grunberg et al. (1997)

What constitutes addiction?
Addictive drugs exhibit two important characteristics
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
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.

Does nicotine use through smoking meet diagnostic criteria for addiction?
A strong desire to take the drug.
Difficulty in controlling use.
Continued use despite harmful effects
Tolerance – need larger dose – 2/4 cigarettes initially but need 20/40 cigarettes after long term smoking
Withdrawal
Substance taken in larger amounts or longer than intended
A higher priority given to drug use than to other activities and obligations
A great deal of time is spent in obtaining, using or recovering from effects of substance

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 )

Markers and measures of dependence in smokers
Daily cigarette consumption
Time to first cigarette of the day
Smoking even when ill
Smoking more in the morning
Difficulty not smoking in no smoking areas
Which cigarette would hate to give up?
Those who smoke more cigarettes per day are less likely to be able to stop

Consequences of nicotine addiction
Morbidity and mortality caused by active and passive smoking
Smoking prevalence is higher and nicotine use heavier among poorer smokers.
This difference in smoking behavior accounts for about two-thirds of the excess premature mortality associated with deprivation.
Nicotine addiction is therefore responsible for significant health inequalities

Tobacco and nicotine addiction
The unique selling point of tobacco is its nicotine content.
Tobacco products without nicotine are not commercially viable.
Nicotine is an addictive drug.
The purpose of smoking tobacco is to deliver a dose of nicotine rapidly the brain.

Nicotine withdrawal
Withdrawal syndrome is a collection of signs and symptoms caused by abstinence.
Nicotine or cigarette withdrawal?
Nicotine replacement reduces severity of withdrawal symptoms.

Nicotine-based models
Nicotine fixed-effect model
nicotine has many reinforcing physiological effects
smoking feels good, so people continue to smoke
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
Nicotine regulation model
smoking is rewarding only when level of nicotine is above a “set-point”
smokers must smoke to maintain a certain level of nicotine to feel good
Limitations
based on these models, quitting should be easy
ignores environmental pressures
nicotine replacement methods are not 100% effective

Affect-regulation model
Developed by Tomkins (1966, 1968)
Smoke to attain positive affect or to avoid negative affect
Box 7.3, p. 226 – studied stress on smoking
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
Relaxation and coping with anxiety
Depression and smoking: 40% less likely to quit as compared to non depressed
Schachter et al. (1977) found more stressed students smoked more cigarettes and puffed more; the difference was profound for heavy smokers.

Combined models
Psychological/physiological factors combined
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
Can be paired with both positive and negative emotional states
Biobehavioral model – Pomerleau & Pomerleau (1989)
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
nostalgia for smoking: estimated 8.5 month half-life -- cause of relapse over 1st year

What are some strategies for preventing smoking?
Targeting adolescents – many studies
The message is not relevant – they will quit before long-term consequence
If at risk  smokers focus on short-term benefits
Social influence programs – Flay (1987)
Short-term effects  more effective in altering the attitudes
Types of persons who smoke: duped by advertisers; saying no  independent and self-reliant
Overestimates of norms in adolescent smoking by adolescents
Best et al. (1989) – 6 th graders who received social influence training less likely to smoke in the 8 th grade

Life Skills training
Assumption is that lack of self-esteem and self-confidence  increase smoking
Smoking to feel better about themselves
Training enhances self-esteem
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

Problems
Problems with continuing effects – increase levels of smoking as students progress through grades – need of “booster” sessions in HS
Mass media approaches are least effective – Box 7.4, p. 231 – adds run at low viewer times
U.S. tobacco companies spend $7.12/person for ads but only $.50/person for prevention
Government programs are not very effective
Cigarettes are easy to get but increase cost (10%) might lead to decrease use – Tavas et al. (2001)

Benefits after quitting
Health benefits
cough, DOE resolve in weeks
exercise tolerance improves rapidly
bladder cancer: 50% reduction in 5 years
lung cancer: 50% reduction in 10 years
heart disease: 50% reduction in 1 year!
No excess risk of heart disease by 10-15 years
vascular disease: 50% reduction in 5 years
mortality - same as never smokers by 10-15 yrs
Non Health benefits
COST!!!
inconvenience
self-esteem
role model

Smoking cessation
Treatment options:
Level of use: < 1 pack/day – have many attribute that might lead to successful cessation
> 1 pack/day – more difficult to quit
Motivation, social support and advice
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
Gradual reduction – less nicotine in cigarettes – 49 % success v. 22 % “cold turkey”
Treatment products such as NRT, bupropion – the “patch” and “gum” - Box 7.6, p. 234 – 235 “chain chewer”

NRT & Bupropion (Zyban)
Stop or reduce the symptoms of nicotine withdrawal.
Assist in stopping smoking, but without having unpleasant withdrawal symptoms.
Do not 'make' the client want to stop smoking.
Still need to address the psychological issues – combine with counseling
Still need motivation and determination to succeed in breaking the smoking habit.

NRT & Bupropion
Inhalator - 10mg cartridges
Gum - 4mg, 2mg mint, original or fruit
Patch - 16hr = 15mg, 10mg, 5mg and
24hr = 21mg, 14mg, 7mg
Microtab - 2mg
Lozenge (2 types) - 1mg, 2mg, 4mg
Nasal Spray - 0.5mg per spray
Bupropion (Zyban)
150mg per tablet

Smoking cessation
Treatment options:
Aversion strategies
Rapid-smoking method take a puff every 6 seconds – creating an aversive stimulus
Electric shock pairing -  rates of cessation – Welter et al. (1998)
Self-management – stimulus control of situations for smoking or not smoking
Stimulus substitution – taking a walk after dinner, chewing gum
Contingency-contracting – give money to someone who give it back if cessation goal is reached
Large scale programs – varying success – may initially reduce smoking but usually returns – Gomel et al. (1993)

Health Psychology Smoking Chapter 7

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