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Human Smoking Behavior and the Development of Dependence on Tobacco Smoking.

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t i v R. STEPNEY Unirersit.t• ojCamhridge Clinical School. Department ojMedicina Addenhrookes Hospital. Hills Road. Cambridge CB2 2QQ. England Plri..wr. rArr. Vol. I 3. r ts3.w :nn FvNJ• _ 016172S8i1t2,o20163-2at2.00.0 Prinud in Grcat BrNain. A nE v,kmr.ed CoryriEht q 1992 Perpmon Preu Lid Specialist Suhjt•ct Editor: D. J. K. BALFOUR HUMAN SMOKING BEHAVIOR AND THE DEVELOPMENT OF DEPENDENCE ON TOBACCO SMOKING/ NOTICE This material may be protected -bp -copyright law (fitle 17 U.S. Code). 1. MAN THE SMOKER For every adult in the world there are more than one thousand cigarettes smoked each year (Wickstrom, 1980). In terms both of amount consumed, and the health conse- quences, the cigarette is now by far the most important form in which tobacco is used. In Britain in 1978, 125 thousand million manufactured cigarettes were sold, accounting for 88% b.y weight of all tobacco goods (Research Services Ltd., personal communication). The country's 18 million smokers, composing 40% of the adult populatiqn, consumed these cigarettes at an average rate of 19 per day. This prevalence and frequency of smoking, combined with clear evidence of the role of the behavior in causing ill-health, has led medical authorities to conclude that cigarette smoking constitutes the largest single remaining preventable cause of death and disease (Royal College of Physicians, 1977). In the United States, one third of adults are regular smokers of cigarettes (Surgeon General, 1981). The prevalence of cigarette smoking is therefore less than in the UK, and the fall in prevalence (of around one quarter over the last 16 years) has been greater. On the other hand, those who do still smoke cigarettes smoke a far greater number of them (Table 1). Forms of tobacco consumption other than cigarettes are of some importance, accounting for 15-20% by weight of all tobacco sold. Nevertheless, cigarette smoking is the most common form of tobacco use, and (as in the UK) the form most clearly and consistently related to disease (Surgeon General, 1979). In the developing world, the prevalence of cigarette smoking and the consumption of cigarettes are both rising steeply, giving rise to fears that the epidemic of smoking-related disease will soon become world- wide (Taha and Ball, 1980). It is in this context that it is important to develop a more adequate understanding of smoking behavior, the factors which initiate, develop, and maintain the cigarette habit. and ways in which smoking may be discouraged (Ashton and Stepney, 1982). 1.1. THE HISTORY OF TOBACCO USE In the 500 years Western man has been acquainted with tobacco, its use has undergone surprising transformations, and the cigarette is a relatively novel form of consumption (Corti, 1931; Brooks 1953; Corina, 1975). In the sixteenth and seventeenth centuries. pipe-smoking was the most common form of use. In the eighteenth century, however, the 'snuffing' of finely-chopped tobacco became prevalent, and, in the nineteenth, the chew- ing of the tobacco quid and cigar smoking were rivals in popularity. It was not until 1881, with the introduction of cigarette-making machines, that tobacco use started to assume its present form. The convenience and low cost of this mass-produced commo- dity, together with increasing leisure and prosperity and more rapid communications, provided unprecedentedly favorable conditions for a massive growth in consumption. 183
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0 184 R. STl:YWiY TAntx: I. Cigarette Smoking in the UK ond USA UK USA Pre•ralrnce, (1978. UK: 1979. US) no. or smokers (millions) 18" 54' proportion of population smoking (';) men 41" 36' women 40" 29, proportion or population smoking men 54' 53• (1963: ",) women 43• 33' Crnixumption (1978. UK: 1979. US) daily consumption per smoker 19" 33` Nature ojcigarc•tte•s filters as proportion of market (1978:'a) 91" 90° lower tar cigs. market' as prop. of (1977: 21' 23' sales-weightcd average nico- tine yield' (1965: mg) 2.1' 1.4' (1975: mg) 1.4' 1.3` sales-weighted average tar yield' (1965: mg) 31' 24' (1975: mg) 18' 19•' Attitude ru smoking proportion of population agreeing smok- ing damages health (°a) 77' . 851 proportion disagreeing (°;) Se I 1` 'Lee (1976). 'Research Services Ltd_ personal communication. (RSL have continued to collect and prepare data in the manner of Lee. 19761. 'Surgeon General (1981). °Maxwell (1979). 'Capell(1978). 'General Household Survey (1980). *UK figures show the proportion or the populaiion aged 16 yr and over smoking manufactured cigarettes: US figures show the proportion qr the population aged 18 yr and over who are regular cigarette smokers. "For UK. a lower-tar brand delivers 16 mg tar or less: for USA. IS mg or less. 'The tar and nicotine yields of cigarettes are determined by the standardized smoking or a smoking machine. The puffing par- ameters (puff volume. frequency. duration and profile) used by the Laboratory of the Government Chemist in the UK are the same as those used by the US Federal Trade Commission. However. the procedures for determining the butt length to which cigarettes are smoked are different in the two countries. For this reason. a direct comparison between smoke yields in the UK and US should be treated with caution. Over the same period, changes in plant culture and in leaf curing practices led to the development of milder tobaccos and encouraged the inhalation of smoke. 1.2. THE COMPOSITION OF THE CIGAR.ETTE SMOKING POPULATION In both the UK and USA the proportion of males who smoke has declined more than the proportion of females, such that there is now little difference in smoking prevalence between the sexes (Table 1). The difference in age of starting to smoke, and in number of cigarettes smoked, has also narrowed considerably (Surgeon General, 1981: Capell. 1978: General Household Survey, 1980). Ocer the period during which the effect of sex has become less pronounced. there has emerged a difference in smoking prevalence based on social class (Lee. 1976). This is especially clear in the case of male. smokers. Amongst UK higher professional and t
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, Human smoking behavior and dcpcndcncc on tobacco smoking 195 managerial workers in 1976, 29% smoked cigarettes; amongst semi- and unskilled manual workers the figure was 52% (Capell, 1978). In the US, the pattern of smoking prevalence is similarly distorted, although the difference there is expressed in terms of educational level, which is inversely related to likelihood of smoking (Schuman, 1977). The per capita consumption of cigarettes in the USA is now at its lowest since 1957 (Surgeon General, 1981). In Britain, it has fallen to the levels of 1966-7 (Research Ser- vices Limited, personal communication). However, the consumption of cigarettes per smoker has increased markedly over the same period (Lee. 1976; Surgeon General, 1981). In the UK, the annual consumption of cigarettes per female smoker increased 51% between 1959 and 1969; in the case of male smokers the increase was 17%. Part of this increase is undoubtedly attributable to changes in the composition of the smoking popu- lation, and in particular to the replacement of older, lighter-smoking women by younger and heavier-smoking ones. However an effect due to the marked changes in the nature of the cigarettes themselves cannot be excluded (Stepney, 1977). 1.3. CHANGES IN THE CIGARETIES SMOKED 1.3.1. Standard Tar and Nicotine Deliveries Cigarettes differ greatly in the kind of tobacco used in their manufacture, the efficiency with which their smoke is filtered (if at all), and in the extent to which smoke is diluted by air drawn from outside the cigarette. These differences affect the amount of tar, nicotine and carbon monoxide present in their smoke. In an attempt to enable the tar, nicotine and CO yields of different products to be compared, machines are employed to smoke cigarettes to a standard butt )ength, using puffs of uniform volume, duration and interval. Although the deliveries obtained by machine smoking provide an objective measure of the relative yields of different kinds of cigarette smoked under identical conditions, they do not represent the yields of smoke constituents to which any particular human smoker is exposed. Neither do they necessarily represent the average exposure of smokers. More- over, there is good reason to suppose that smokers (unlike the machine) alter the way they smoke when faced with differing kinds of cigarette. 1.3.2. Trends in Standard Delivery The past 40 yrs have seen a clear and continuing reduction in the average standard tar and nicotine delivery of commercially available cigarettes. This is a result of the almost complete switch from plain to lower-yielding filtered cigarettes (Table 1), of the increased use of efficient filters and ventilation, and of the selection of tobaccos with lower tar and nicotine content. In the US, the reduction in delivery appears to have occurred earlier than in Britain (Table 1), and to have recently b.ecn given fresh impetus. Thus, whilst the fall in delivery of UK cigarettes levelled off at 1.3-1.4 mg nicotine, the 1980 sales-weighted delivery of US cigarettes is expected to drop below 1 mg nicotine and 14 mg tar (Surgeon General, 1981). 1.4. IMPLICATIONS FOR SMOKING BEHAVIOR Although standard nicotine and tar deliveries have been halved over 20 years, it is not clear what effect this reduction has had on the smoking behavior of the general popula- tion. In short-term experiments, subjects switched to cigarettes which produce smoke with a reduced concentration of tar and nicotine, respond.by increasing the number of cigarettes smoked. This increase, however, is relatively small. A 50% reduction in stan- dard yield leads to a rise in consumption of roughly 10% (Stepney. 1980a). The major adaptation occurs in the way in which individual cigarettes are smoked. Faced with 0
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I 186 R. STEPNI:Y lowered yield, the smoker can (and does) increase the amount of nicotine available by taking larger and more frequent puffs, inhaling more deeply, and smoking to a shorter butt length. Ashton et al: (1979) measured blood plasma and urine nicotine levels in smokers of medium-delivery cigarettes who were switched to a low-tar low-nicotine brand. By relative "over-smoking" of the lower delivery brand, smokers compensated for roughly two-thirds of the between-brand difference in standard delivery. In contrast to a brand-switching experiment, the reduction in delivery which the wider smoking population has faced has been effected gradually and over a long period. More- over, for the bulk of the population, the change has been from high to medium-delivery cigarettes, rather than from medium to low (Table 1). It is therefore not clear whether smokers in general are likely to have followed the pattern shown by subjects in brand- switching experiments by increasing the frequency and intensity of smoking during the period of declining delivery. The increased consumption of cigarettes per smoker (noted in Section 1.2) is consistent with the view that a similar process of adaptation has taken place. However, the large number of factors which influence consumption precludes any firm conclusion. 1.5. SMOKERS OF LOW-TAR CIGARETTES In addition to the general gradual decline in tar and nicotine delivery, specifically low-tar brands of cigarette have been introduced over the past 10 years. Some smokers have voluntarily switched to these cigarettes; others will have begun their smoking career by using a low-tar brand. There is now an important need to establish whether users of low-tar cigarettes are less likely to suffer from the diseases caused by smoking. There is a clear dose-response relationship between total exposure to smoke and the risk of disease (Surgeon General, 1981). This suggests that cigarettes yielding smaller amounts of toxic smoke components will be less hazardous. However, it is possible that habitual smokers of low-delivery cigarettes may nullify any potentially beneficial effect by smoking in a way which compensates for the reduced standard delivery. 1.5.1. Smoking Behavior The Surgeon General (1981) reports there is no evidence that long-term smokers of lower delivery cigarettes smoke more heavily than others. This conclusion is supported by data from Australia (Gray, 1978). and the UK (Wald et al., 1980). However, it would appear that long-term lower-delivery smokers smoke each cigarette relatively more inten- sively, taking a greater total volume of smoke and smoking to a shorter butt length (Stepney. 1980b). This has the effect of reducing the difference in actual exposure between middle and low-tar smokers: whether the difference in smoke intake is effectively elimin- ated is subject to debate (Russell et al., 1980a: Wald et al., 1980: Stepney. 1980b). Russell et al. (1980a) argue strongly that standard nicotine delivery is substantially irrelevant to how much nicotine a smoker will actually take into his body. accounting for only 4% of the variation in plasma nicotine concentration in a group of 300 smokers smoking cigarettes covering a wide range of delivery. However, the population of smokers studied by Russell et al. (1980a) had a cigarette consumption twice the national average and consisted largely of people attending an anti-smoking clinic. Although ex- clusively male, the group of smokers studied by Wald et al. (1980) was probably more representative of the wider smoking population. By relating carboxyhemoglobin levels to standard CO delivery it was possible to demonstrate that smokers of lower delivery cigarettes were inhaling more than smokers of higher delivery brands. However, the proportionately greater inhalation was not sufficient to equalize exposure to tar and nicotine. This finding appeared to justify the conclusion that, although more intensive smoking was likely to reduce the expected health benefits associated with low-delivery cigarettes, it was unlikely to abolish them completely. ~
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Human smoking behavior and dependence on tobacco smoking 187 1.5.2. Di,Q'erences between Low and Middle-Tar Smokers ' Smokers who choose low-tar cigarettes are probably not typical of smokers in general. In the United States, low-tar smokers started smoking later than people who smoke higher-tar cigarettes. There is also a strong association between higher educational level and greater prevalence of low-tar smoking (Surgeon General, 1981). This suggests that low-tar smoking may reflect generally more health-conscious attitudes, and may be associated with other factors such as good diet, exercise and low occupational exposure to health hazards. As the Surgeon General has commented, epidemiologists are already faced with a continually changing population. of smokers who smoke a continually changing cigarette in a continually changing manner. Their task in interpreting any association which may emerge between lower delivery cigarettes and reduced mortality will be further complicated by the potentially confounding variables noted above. 2. THE DEVELOPMENT AND MAINTENANCE OF CIGARETTE SMOKING Cigarette smoking is a behavior influenced by many factors and with many aspects (Fig. 1). In particular, it involves a variety -of possible sources of reward (Table 2; Fig. 2). Cigarette smokers are an equally diverse group of people. Most smoke with great regu- larity, but some do not. The majority inhale, but others derive sufficient satisfaction to maintain the habit without drawing smoke into their lungs. Smokers themselves attribute their smoking to a variety of causes and report a range of pleasurable consequences. Any comprehensive account of smoking motivation will therefore necessarily be complicated. PHARMACOLOGICAL nicotine - omount ~ 1*1 PSYCHOLOGICAL personality ./ usefuhes ~of ciqorettte as o 'tool self image • ' - effect, addiction SMOKING BEHAVIOUR SOCIOLOGICAL Status:oqe, class sex, religion ottitud's.• influences: fo!nily • fr~M S MEDICAL onti-smoifinq advice POLITICAL/LEGAL onti- smokinq legislation Govt. health policy ~toxotion COMMERCIAL attitude of ciqarette or companies price a0ver tisinq Fto. t. Factors influencing smoking behavior. This 'spider's w•eb' of influences can be expected to affect all aspects of smoking•-from whether a particular individual will smoke at all to how long an unsmoked butt he leaves. (Reproduced by kind permission of the authors (Ashton and Step- ney. 1982) and the publishers.) f
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t . - , R. STLPNI:Y TABLE 2. Aapects ojthe Smoking Act unJ Po.csihle Suurcrc of Re.curJ Social Sensorimotor Pharmacological Symbolic Oral and manual Intake of smoke constituents. manipulation especially nicotine Communal Taste and aroma Appearance of smoke 2.1. STARTING TO SMOKE: SOCIAL FACTORS, SELF IMAGE AND PERSONALITY There is strong evidence that whether or not an individual will experiment with smok- ing is determined largely by social factors, and in particular by the influence of parents and peers. However, personality and possibly genetic factors play a role in determining who will go on to become a regular smoker. 2.1.1. The Influence oJthe Family Considerable information on the onset of smoking has come from a series of recent studies, by Bewley and her colleagues, of schoolchildren in the counties of Kent and Derbyshire. Eleven to sixteen year old boys were more likely to be smokers if their fathers smoked; girls, if their mothers smoked. Whether or not siblings smoked also had a great influence, irrespective of parental smoking (Banks et al., 1978; Murray and Cracknell, 1980). In an earlier study it had been found that only one non-smoking child came from a household in which more than two people smoked (Bewley et al., 1974; Murray and Cracknell, 1980). The example set by a child's teacher may also be impor- tant, especially amongst boys (Bewley et al., 1979). The increased likelihood of smoking if other family members smoke is presumably due in part to imitation. although direct encouragement seems to play a surprisingly large role. Although in the study of Bewley et al. (1974) 55% of children said they smoked their first cigarette with friends, Murray and Cracknell (1980) report that 23% of 11-14 yr old smokers were sometimes given a cigarette by their parents and 30-40% by their brother or sister. Pe« onss~.e: cvbsny. im+oh«+, devre a od+ieve ord srroaee oanhood ~ FtRST ~~INCREASM4G CWARETTE FREOUENCY OF SMOKING REGUTAR DEPENDENT SMOKING Fw. 2. Factors affecting different stages in the development of smoking. (This figure first appcarcd in an article by Stepney (1980c1 and is reproduced by kind permission of the editor and publishers). 0
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Human smoking behavior and dcpcndcncc on tobacco smoking 189 In an American Cancer Society survey (reported by Mausner and Platt, 1971), the median age of first experimentation with smoking was 12 yrs, identifying the time around puberty as the critical point for initiating the habit. Thirty two per cent of the teenage children of mothers who smoked were cigarette smokers, compared with only 23% of the children of non-smoking mothers. The smoking of fathers and older siblings also influenced the likelihood children would use cigarettes. 2.1.2. The Wider Social Context Both English and American studies show that childhood smoking is related to lower levels of perceived and real academic achievement (e.g. Bewley and Bland, 1977). Adoles- cent smoking appears to be part of a more general pattern of behavior in which out-of- school activities are emphasized at the expense of school-work, and in which the company of older children is sought (Mausner and Platt, 1971; Russell, 1971). Banks et al. (1978) studied smoking in over 6,000 11-16 yr old children. Having a part-time job, more money and spending leisure time with a mixed-sex peer group were all associated with an increased likelihood of smoking. However, the best predictor of smoking was attending a youth club. Smoking was also associated with higher rates of truancy. 2.1.3. Self Image Schoolchildren who smoke see themselves as "tough" compared with those who do not (Bland et a/., 1975). In the American Cancer Society survey (cited by Mausner and Platt, 1971) adolescents thought that 72% of adults smoked, when the true percentage was 40%. Smoking and being adult are therefore clearly identified in children's minds, and it is likely that smoking is partly an 'anticipation of adulthood'. Nevertheless, there is evi- dence that, at least in the early stages, young. smokers do not think of themselves properly as smokers, since their self-image and their image of the smoker continue to differ (Bland et al., 1975). 2.1.4. Reasons Given for Smoking Perhaps surprisingly, only 7% of smokers aged 11-13 yr reported that they smoked out of curiosity, whilst 62% agreed they smoked 'to show off or look big' (Bewley and Bland, 1977). Between a third and a half of smokers said that smoking with friends was pleasant or that they smoked because their friends did (Bewley and Bland, 1977; Bewley et al., 1974). This supports the view that the sharing of cigarettes plays a part in establishing friendships in early adolescence and in improving the cohesion of social groups. Asked whether they had enjoyed their first cigarette, 19% said they had, 27% that they had felt nothing, and 34% that they had felt sick (Bewley et al., 1974). The rewards derived from early smoking would therefore seem to be obtained in spite (and not because) of nicotine. However, after the rapid development of tolerance to nicotine's unpleasant effects, more positive reasons for smoking come to the fore. Amongst teenage smokers, more than half reported smoking was'very enjoyable'. The proportion claiming that smoking could 'help people when they feel nervous or embarrassedr increased with age amongst both smokers and non-smokers (Murray and Crackncll, 1980). 2.1.5. Personality and Genetic Factors <.As:4dults;°tmokers diRe~ from-'non-smokers-in personalay. Although the difference is small, smokers are consistently found to be more extravert than non-smokers (Eysenck et al.. 1960: Smith. 1970). They are also probably, on average, more 'emotionally labile', anxious. or'neurotic' (Smith, 1970; McRae et al., 1978; Haines et al., 1980) . There-is good evidence tha~.the~s, personality differtncet ' precede rather 'than Tollow the establis}imeflt pftmokirtig. This is most clearly shown by the work of Cherry and Kiernan (1976) who 411
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190 1t: STIANI:Y demonstrated that higher levels of extraversion (E) and neuroticism (N) at age 16 influenced the likelihood that an individual would start to smoke before the age of 25 (Fig. 3). M 60r- ~ 0 Male ~ S0 M L J Femote g r _ ~ 40 ~ 7 I I ~ i I Scores 1 Low E 0-6 30 ( I HighE 10-12 ~ r- I t I Low N 0-3 ~ 20 I 1 I I ( 1 I 1 ( t High N 7 -12 ~ I 1 I 1 I I I to I I 1 1 t I 1 I 1 ~ I i I I I 1 I i I I ~ 1 - Low E HiphE Low E HiQh E rlow N •low N•hiqh N•hph N Values for subjects with Intsrmediote E and N scores (not shown here) conform to the relationships indicated by the low and high seorinp groups Fic. 3. Likelihood of becoming a smoker between the ages of 16 and 25. related to personality at age 16. (Fitted model based on observed proportions-see Cherry and Kiernan (1976) Table VIB.) This figure has been reproduced by the kind permission of the authors (Ashton and Stcpney. 1982) and the publishers. Since per.sonality dimensions such as extraversion and neuroticism'are thought to`have a constitutional basis determined:.at Ieastt in part by heredity, it is not surprising t'hat genetic factors seem related to'smoking behavior. Fishe'P (1958) and Friberg et al. (1959) found from studies of monozygotic and dizygotic twins that genetic identity increased the similarity of smoking habit. This conclusion has recently been reinforced by the various studies reported by Eysenck and Eaves (1980). When classified into smokers and non- smokers. 74% of identical twins, but only 50% of non-identical twins, were found to have the same smoking status. Moreover, identical twins 'reared apart (and therefore exper- iencing different family environments) showed the same concordance in smoking habit as identical twins reared together. Further evidence that family environment might not in itself be as important a factor as had been thought is provided by the finding that although there was a small but significant correlation (r - 0.21) between the cigarette consumption of parents and that of their natural children, there was no correlation (r = 0.02) between that of foster children and their adoptive parents. Neither was there a correlation between the consumption of foster children and that of siblings with whom they shared the same family environment but to whom they were not genetically related. 2.2 THE DEVELOPING HABIT 2.2.1. The Importance of Nicotine Whatever the role of personality and constitution, social factors (including the influence of family and friends and the smoker s image of himsell) are clearly implicated in the origins of smoking. These factors are likely to continue to be of some importance. However, there are four major reasons for supposing that nicotine plays a crucial role in establishing the cigarette habit: (1) Measuring levels of nicotine in blood and urine shows that smokers habitually absorb quantities of nicotine sufficient to have important. if subtle. pharmacological cticcts (Armitage et al., 1975). (2) In terms of the prevalence and persistence of its use, tobacco has a unique status amongst the great variety of vegetable substances which would produce a pleasant taste 0
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I Human smoking behavior and dcpendcncc on tobacco smoking 191 and smell if smoked. The fact that tobacco is so generally preferred is probably not unrelated to the active pharmacological agent in its smoke. (3) Given that the smoking of tobacco predominates, there is nevertheless a wide variety of tobacco products available. Yet, despite the fact that smokers have for ten years been encouraged to use lower-yielding cigarettes, the great majority have continued to smoke brands delivering substantial amounts of nicotine, and have avoided those which do not (Table 1). Thus 80% of cigarettes sold in the UK in 1977 had nicotine deliveries of 1.2 mg or greater (Capell, 1978). (4) Seventy-seven per cent of male cigarette smokers report inhaling moderately or deeply; amongst women, the proportion inhaling is only slightly less (Lee. 1976). This prevalence of inhalation suggests that the intake of nicotine is the underlying purpose (and not the unintentional by-product) of smoking. The smell and taste of tobacco, and any satisfactions derived from having something to manipulate, put in one's mouth, or suck at, can be obtained without drawing smoke into the lungs. Inhaling smoke is not a natural behavior and is learned at the cost of initial discomfort. lt is, however, an extremely fast and efficient means of administering a drug to the brain, and in this respect resembles intravenous injection. It is for these reasons that cigarette smoking should be considered essentially as a means of nicotine self-administration. There is nevertheless some justification for con- sidering the possible role of non-pharmacological factors, and these ought briefly to be reviewed. 2.2.2. Views of Smoking Motivation not lnuolving Nicotir* The view that smoking is important simply as an activity has two aspects. First, smoking can be used in excusing and legitimizing relaxation. Secondly, there is a sense in which smoking can be seen as a 'displacement activity' analogous to the irrelevant behaviors such as scratching and pawing the ground which ethologists have observed in animals in situations of conflict and uncertainty (Chein, 1969; Morris, 1977). The importance of the taste and smell of tobacco ought also to be considered. Humans actively seek substances offering a variety of tastes and can become 'dependent' on tastes such as those of salt and sugar. (Brill, 1922). Smokers often claim taste and smell as sources of satisfaction, and they are able to discriminate between the taste of different brands of cigarette (Prothro, 1953). In addition, the irritation caused by holding smoke in the mouth, and the sensations obtained when smoke hits the back of the throat, may be perceived as pleasurable. The role nicotine plays in producing these sensations is unclear (Cain, 1980). Renewed interest in the role of non-pharmacological factors has followed the recent publication of studies showing that cigar and pipe smokers who have not had previous experience of cigarettes do not inhale smoke and do not absorb significant amounts of nicotine from the buccal mucosa (Turner et at., 1977;1981).' Pipe and cigar smokers can be as committed to their particular form of tobacco consumption as the cigarette smoker is to his. The absence of nicotine absorption shows that noit-pharmacological factors must be important, at least for these less widespread forms of tobacco consumption. Finally, brief consideration must be given to the psychoanalytic view of smoking. Freud, who was an ardent smoker of cigars, considered smoking an 'auto-erotic' manifes- tation of primitive sexuality (Freud, 1905) with its origins in the oral stage of develop- ment. With one exception however (McArthur et al., 1958), attempts to correlate adult smoking with childhood experiences (such as age of weaning), or with an 'oral person- ality', have produced unconvincing results. (For reviews see Brecher, 1972; Stepney 1980d). •Although nicotine cannot be absorbed from acidic cigarette smoke in the absence of inhalation, it had previously been thought that nicotine could be absorbed from alkaline cigar and pipe smoke held in the mouth (Armitage and Turner, 1970; Armitage 1974 !
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192 R. STIEPNIEY 2.2.3. Two Approaches to Smoking Motiration There are many often-repeated behaviors which individuals find difficulty in retraining from, frequently despite unpleasant long-term consequences. Many such habits involve the consumption'of drugs, but others (e.g. gambling) do not (Stepney, 1981). Cigarette smoking is clearly habitual. To the extent that nicotine is centrally involved, it is tempt- ing to see the behavior as a form of compulsive drug-seeking. On this view, smoking is an easily acquired but pQwerful addiction to nicotine, and the motivation to continue smok- ing is based on the recurrent need to prevent the aversive effects of nicotine withdrawal. However, there is a second approach which sees reasons for continued smoking in,the usefulness of.nicotine in the control of arousal and the manipulation of psychological state. The, addiction and 'psychological "tool' models ar6 compatible` to the `eztent thht they,both regard nicotine as of central importance. Moreover the arousal control model does not preclude consideration of smoking as a dependence disorder since smokers may be regarded as becoming reliant on the use of nicotine as a means of manipulating their psychological state. However, the two approaches differ to the extent that the addiction view holds that smoking is rewarding because it staves off the consequences of nicotine deprivation, whilst, according to the psychological tool model, the effects of nicotine continue to be rewarding, in the appropriate context, in their own right. 2.3. SMOKING AS NICOTINE ADDICTION 2.3.1. Animal Studies In animals, experiments involving the administration of nicotine following the per- formance of a learned behavior have shown that the drug has some intrinsic reward value and rhesus monkeys have been induced to self-administer nicotine, either by injec- tion or by puffing on a lighted cigarette (Deneau and lnoki, 1967; Jarvik, •1967; Ando and Yanagita, 1981). It has, however, been difficult to demonstrate-the type,of depera dence on nicotine which other drugs of addiction may produce (Jaffe, 1978). 2.3.2. Studies oJWithdra%ral oJSmoking In man, support for the addiction model is provided by the development of withdrawal effects in many smokers who give up the habit and the role these effects play in encourag- ing a return to smoking. Most descriptions of smoking withdrawal lay emphasis on heightened irritability, inability to concentrate, craving, tremors, palpitations and de- pression (e.g. Finnegan et al., 1945; Knapp et al., 1963). There is some evidence that chewing gum containing nicotine can be a helpful aid in cigarette withdrawal (Schneider et al., 1977) and that smokers who have successfully given up cigarettes may in turn become dependent on nicotine gum (Russell et al., 1976a). There were two surprising findings, however, in a study of the time course of withdrawal effects (Shiffman & Jarvik 1976). Firstly, there was no difference in the severity of withdrawal between light and heavy smokers. Secondly, withdrawal effects were felt more severely by those who reduced but did not completely stop smoking than by those who abstained totally. Neither result would have been expected if withdrawal effects were due solely to nicotine deprivation. TherG.are other reasons [or,qugstioning_thc vlew.;4klat. stoppitig srnoking is equivalent to wltl~dravval,f,mtta 1he:conventional drugs of addiction.~The kind of withdrawal effects reported on sto~ptnp~smok't,ng,~~ ~eLatively ~~ld;,t;nd.~are ~l: tt ktpc~,,yv~tsh,,,mightRbe e~cpccted to~cilfovt~•theioss'of psYct6'rekl't'ewitrds #rom,any.~loved',<obJect -to whiclaa perjgrs was 4ottg vtWtt(imed 'aiid *h1'ch-had -perhaps e:om.tro.lorm a=~central 'part of Ms `seU-image'AAd-;bis4npptift it1~-faCirig-Ahe-Avorld..•Secondly,::there:are:intriguing eases~ot heavy,, srnokcrcwho Sare :up:: ibe:.:habit -,suddenly: 4nd t:vvitho.u.t {cxperiencing -w ithdra*al. Fin.4ily,.maQy.-sewokt'r'sLgre'~'b'fextd~refrain°`trorri~tmakin g'b'fextd~refrain°`trorri~tmaking forrelativeiy long periods fqr 0
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f Human smoking bchavior and depcndcncc oq tobacco smoking 193 practical or religious reasons, apparently, without-experiencing hardship (Schachter et at., )... 1977 2.3.3. Effects of Providing an Alternative Source of Nicotine On the view that the smoking habit is maintained by a continual need for nicotine, one would expect that providing nicotine from some source other than smoking would obviate the need for it to be obtained in the habitual way. Much human experimental research on the addiction model has therefore been based on the attempt to show that compensatory adaptation of smoking behavior occurs if nicotine can be provided from sources other than smoking. Absorption of nicotine following oral administration is slow, and the effect on smoking slight (Jarvik et aL, 1970). However, the most efficient method of nicotine administration, which most closely resembles that following the inhalation of cigarette smoke (and which might therefore be expected to substitute most effectively for smoking) is the use of pulsed intravenous injection. Providing nicotine in this way has recently been shown not to reduce the total volume of smoke subsequently taken from cigarettes. This suggests that smoking behavior is maintained by factors independent of the need to obtain a stable intake of nicotine (Kumar et at., 1977). 2.3.4. Cigarettes oJDi'erent Strengths An alternative approach is to determine whether smokers faced with cigarettes of reduced nicotine delivery seek to restore habitual levels of nicotine intake by compensa- tory adaption of smoking behavior. As we have seen (Sections 1.4 and 1.5), low-delivery cigarettes are smoked more frequently and more intensively. However, experiments which have varied the availability of nicotine from the cigarette have failed to dissociate the importance of nicotine from that of other smoke constituents. Cigarettes which differ in nicotine delivery also differ in other ways. Most importantly, nicotine yield co-varies with that of tar. Although as far as is known the•tar phase of cigarette smoke contains no substances which are psychologically active, the tars presumably contribute to taste and aroma and to the particular sensations accompanying smoking. Smokers seeking merely to maintain the intensity of the pleasurable sensations involved in smoking (rather than the nicotine intake) would respond to changes in brand strength in exactly the way observed. Such experiments therefore cannot conclusively establish the importance of a stable level of nicotine intake. 2.4. SMOKING AS A PSYCHOLOGICAL TOOL The concept of smoking as a psychological tool is supported by experiments which show that cigarettes, under certain circumstances, have a stimulant effect, increasing a subject's ability to attend and maintaining high levels of performance on monotonous or fatiguing tasks. There is also evidence which suggests that smoking can act as a depress- ant or sedative in reducing the disruptive efTects of stress on behavior. In order to account for these varied findings it is necessary to argue, as smokers do (Frith, 1971), that smoking is capable of having either arousal-increasing or arousal- reducing properties (Fig. 4). Recent work concerned with the effect 'of smoking and nicotine on the electroencephalogram (EEG) has provided a measure of objective •sup- port for this.claim. 2.4.1. EEG Evidence In man, frequency analysis of the EEG shows that smoking and nicotine generally have an activating effect (Knott and Venables, 1977). Smoking abstinence produces a change in the EEG indicative of reduced arousal (Ulett and Itil, 1969). Using a different 0
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194 r inc arousat rease Smoking facilitates arousal control • R. STEPNEY maintained vigilance in f ace of monotony; increased selectivity of attention disruptive effecta on behaviour ) attenuation of stress _ (including its Increased psychological ' comfort' Fto. 4. Smoking as a psychological tool. [This figure first appeared in an article by (1980) and is reproduced by kind permission or the editor and publishers.] Stepney EEG measure, the frequency with which the photic driving response could be elicited, Vogel et af. (1977) also judged the effect of smoking to be stimulant and suggested that smokers suffered from a central adrenergic insufficiency which could be countered by smoking. However, Mangan and Golding (1978) demonstrated that the effect of smoking depends on the circumstances in which a cigarette is smoked. Smoking had a depressant effect on the EEG (increasing the proportion of alpha activity) when subjects were stressed by exposure to white noise, but a stimulant effect (decreasing percent alpha) under conditions of low arousal induced by mild sensory isolation. This finding sup- ported that of Ashton et a/. (1974) who had earlier found an interaction between nicotine effect, personality and total dose, when studying the Contingent Negative Variation (CNV), a slow potential shift in the EEG occurring in the few seconds between an alerting stimulus and a stimulus to which the subject must respond. The CNV was consistently decreased in some subjects (depressant effect) and consistently increased in others (stimulant effect). Moreover, the effects of smoking could be replicated by intra- venous injection of 'smoking doses' of nicotine and a dose-response relationship was established in which smaller doses of nicotine had a stimulant effect on the EEG and larger doses a depressant one (Ashton et al., 1980). More extraverted smokers have a somewhat slower rate of nicotine intake from smoking than introverts. supporting Eysenck's view of the extravert as 'stimulation hungry' and the introvert as 'stimulation shy' (Eysenck, 1973). 2.4.2. Smoking, Nicotine and Performance Work on mice and rats has indicated that nicotine in doses of 100-400 ieg,/kg has a generally facilita'tory effect on spontaneous and learned behavior. The precise effect, however, is dependent on the particular behavior considered, baseline levels of activity, sex, strain (Bovet et a(., 1967; Battig and Schlatter. 1978), early environment (Essman. 1973), and the ratio of task reinforcement (Morrison and Armitage. 1967). The effects of chronic and acute administration differ and are clearly dose dependent. larger.doses tending to have a depressant effect. The effect of smoking on performance in man has been extensively studied. Although smoking does not appear to have any*consistent effect on stiort-term reaction time tasks, there is evidence that smoking maintains performance under conditions requiring sits- tained vigilance and attention. The performance of subjects smoking is enhanced not only 0
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Human smoking bchavior and dFpendcncc on tobacco smoking 195 in relation to smokers not smoking (Frankenhaeuser et at., 1971)-a comparison which may confound positive effects of smoking with negative effects of abstinence-but also in relation to non-smokers (Tarriere and Hartemann, 1964; Wesnes and Warburton. 1978). Increased behavioral efficiency accompanying smoking has been demonstrated in terms of both speed of reaction and the accuracy of signal detection (Mangan and Golding. 1978). Smoking has also been shown to counteract slowed reactions and impaired mental arithmetic performance due to alcohol intoxication (Myrsten and Andersson, 1975). The effects of smoking on learning and memory in man, like the apparent usefulness of cigarettes in maintaining vigilance and attention, can be explained by the arousal- increasing properties of nicotine. Smoking has little (and possibly even a detrimental) effect on the acquisition of material, but seems to improve retention and later recall (Andersson, 1975; Mangan and Golding, 1978). High arousal is disruptive of initial learning, but facilitates the consolidation of the memory trace and therefore enhances ultimate memory. Work involving nicotine administration in mice supports this view of the effects of smoking on memory (Flood et at., 1978). The injection of nicotine (or of caffeine or amphetamine) was found to block anisomycin-induced amnesia following training on an avoidance task. A greater intensity of electric shock (which was expected to be a more arousing stimulus) had an effect similar to that of stimulant drugs in decreasing amnesia. 2.4.3. The Attenuation oJStress Experimental evidence links the arousal-increasing properties of smoking with enhanced performance on certain tasks. Where success in a task is at a premium, the facilitatory effects of smoking on performance could be expected to reduce stress arising from real or feared failure. In terms of a more direct association, anecdotal evidence of the relationship between smoking and stress in individuals is prolific, but controlled studies less so. An exception to this is the work of Thomas (1973) who followed 600 medical students through 10-24 years of practice and showed that continuation of the smoking habit through the period of study was associated with high levels of awareness of feelings of anger and anxiety on initial examination. The attribution of mood states and emotion to animals begs philosophical questions and may lead to the unjustified generalization of findings. Nevertheless, interesting parallels have emerged between experiments involving the effects of nicotine administra- tion on 'stress' in animals, and those of smoking in man. Nicotine selectively reduces aggressive behavior in animals. ln the cat, nicotine sup- presses both natural and arecoline-induced predatory behavior (Berntson et at.. 1976). In the squirrel monkey, nicotine reduces the frequency and duration of the biting-attack following electric-shock (Hutchinson and Emley, 1973). A parallel is perhaps the finding by the same authors that 5 mg nicotine administered to human subjects in drinking water reduces the frequency and force of the jaw-contraction response to loud noise in both smokers and non-smokers. Of more direct relevance to the disruptive effect of aggression on behavior, is an experiment reported by Dunn (1978) in which subjects were systemati- cally cheated of points they could later convert to cash. All subjects experienced increas- ing feelings of aggression; the smokers, however, differed from deprived and non-smoker groups in that their increased aggression did not interfere with continued proficient performance on the task. Complementary to results on the attenuation of aggression are those which suggest that nicotine can reduce the disruptive effects of anxiety on performance. This is illus- trated by an experiment in which monkeys and rats were trained to lever-press for food over a period in which occasional tone stimuli were paired with electric shocks. In the post-training period the tone, as a conditioned stressor, disrupted food acquisition-but markedly less so when nicotine was administered (Hutchinson and Emley, 1973). An analogous effect has been found in the reduction of the rat freezing response to the i...T• 1 S: 2 c 0 fo
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--- -- - - . . .- . .~ . ._........ . _ _. _.-.Y.'ti: 196 tt; STEPNEY presence of a cat (Nelsen, 1978). Interestingly, in the latter experiment, the stress- attenuating effect of nicotine was greater in highly emotional animals. In man, experimental evidence directly linking smoking with stress reduction is sparse. A number of attempts to investigate the effects of smoking on the emotional response to harrowing films have shown no clear effects. However, the anxiety-reducing properties of smoking are suggested by an experiment which showed that subjects were prepared to tolerate higher levels of electric shock when they were smoking, the effect being greater with a cigarette of high nicotine delivery than with one delivering less nicotine (Schachter, 1973). It has also been reported by Heimstra et at. (1967) that subjects smoking during a long and monotonous driving simulation task do not experience the increased feelings of aggression apparent in deprived and non-smokers. The usefulness of nicotine in reducing the disruptive effects of stress on behavior is further suggested by the results of two studies in which levels of stress were manipulated. In the first experiment (Hall and Morrison, 1973), rats were trained to lever-press to avoid shock in a 'stressful' paradigm in which successful avoidance is not signalled. Rats given nicotine performed more successfully than saline-injected controls but showed a deterioration of performance to below the level of the control animals when saline was substituted for nicotine. The rats, however, seemed dependent on nicotine for continued successful performance only under conditions of high stress, since saline-substitution did not have the same effect in a paradigm in which successful avoidance was indicated by a feedback 'safety' signal. A second study (Myrsten et al., 1975) concerned human smoking. Sixteen subjects were chosen, eight of whom (according to questionnaire responses) habitually smoked under conditions of high arousal, and eight who were habitual low- arousal smokers. Both groups performed a task of two levels of complexity (and therefore of inferred stress) under smoking and non-smoking conditions. The low-arousal smokers performed and felt better when smoking, but only under conditions of low task com- plexity, and the high-arousal smokers only under conditions of high task-complexity. The result seemed to show that smokers use cigarettes to obtain a specific effect on arousal in the context of the demands of a specific environment. Such a view is strengthened by the evidence from Mangan and Golding (1978) that a cigarette can have either a depressant or an activating effect (measured by the extent of EEG desynchrony) depending on the degree of stressfulness of the environment in which it is smoked. 3. SMOKING AS A LEARNED BEHAVIOR Smoking is clearly learned. It enters the behavioral repertoire largely through imita- tion, persists for a while as a casual indulgence, but then in many smokers becomes a regularly repeated act. At this stage, it is difficult to reduce the frequency with which the behavior occurs, let alone to abandon it entirely. In terms of learning theory, smoking has a high probability of occurrence and is strongly resistant to extinction. In these respects, behaviors analogous to smoking may be produced in the animal laboratory by appropriate manipulations of learning experience. Considering smoking as a learned response is therefore a potentially fruitful way of attempting to understand the acqui- sition and maintenance of the behavior. Approaches based on the principles of learning theory have also been widely used in the development of techniques designed to aid the smoker in breaking the habit. The fundamental principle of learning theory is that behavior is controlled by its consequences. The probability that an act will be repeated increases if the act results in reward. This reward may take the form of an event which in itself is pleasurable (positive reinforcement). Thus a non-satiated animal will press a bar- to obtain food. water, or access to a mate. The probability that a behavior will be repeated is also increased if the behavior brings to an end, or prevents the occurrence of, an unpleasant stimulus (nega- tive reinforcement). A corollary of this principle of reinforcement is that punishing conse- quences, or the omission of reward, decrease the probability that the related behavior will recur. A behavior followed a sufficient number of times by punishment or non- • 0
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Human smoking behavior and dcpcndcncc on tobacco smoking 197 reward will disappear-a process termed extinction. That so many people smoke so frequently suggests that the behavior is very effectively rewarded, whilst the fact that only a minority of smokers stop (and then with apparent difficulty) indicates that any punish- ments naturally associated with the act are of only minor significance in controlling the behavior. Important determinants of the strength of a learned response are the nature and variety of the reinforcements and punishments involved, and the immediacy, fre- quency and regularity with which they follow the response. What is there in the nature of the rewards which follow smoking (and in the way they are associated with the behavior) which accounts for the strength of the habit? 3.1. PoSiT[VE AND NEGATIVE REINFORCEMENT The direct stimulation of reward pathways in the brain, possibly due to the release of noradrenaline by nicotine (Jarvik, 1970; Hall and Turner, 1972), constitutes a potential source of positive reinforcement. On this interpretation, regular smokers can be seen as behaving rather like rats, who repeatedly press a bar to obtain electrical stimulation of their reward pathways (Olds and Milner, 1954). It has been suggested that activity in the reward centres is the element common to all primary reinforcers such as food, drink, and sex. On this view, smoking, and the use of certain other drugs, would constitute a short-cut to 'pleasure', which could be obtained in other (and more biologically useful) ways. Russell (1976) has pointed out that the smoking of each cigarette, and indeed each inha)ation, may mark a distinct, regular, and invariable association of the behavior with " a reinforcing 'shot' of pleasure. Smoking would therefore be reinforced approximately ten times during each cigarette, for months and years. Supported by reinforcement repeated on such a scale it would not be surprising if the behavior were to become powerfully entrenched. In addition to the frequency and regularity of the association, the delay between a response and its reinforcement is important in determining how effectively a behavior will be learned. Although the optimal period varies, it is generally true that more im- mediate rewards and punishments are more effective than those which are delayed. The interval between inhalation and the onset of nicotine's actions on the brain is less than ten seconds. The close temporal association between smoking and its consequences would therefore be expected to result in effective learning. The possible stimulation of reward centres in the brain provides an instance of positive reinforcement. However, smoking may also be negatively reinforced if the behavior brings to an end a state of noxious stimulation. Such negative reinforcement would occur if the effect of inhaling cigarette smoke was to eliminate the unpleasant consequences of nicotine deprivation. Negative reinforcement offers a plausible account of how smoking behavior may be maintained, and indeed of how the smoker might find himself in the peculiarly vicious circle in which smoking, whilst reinforced by the re)ief it offers from nicotine withdrawal, itself acted to perpetuate the acquired drive for further cigarettes (Logan, 1970). Smoking may be rewarding in virtue of nicotine's direct pharmacological effects. However, the source of reward may derive, as Eysenck (1973) has suggested,,from a nicotine-mediated change from a less-preferred to a more-preferred level of arousal. If there is an optimum level, at which an organism feels most 'comfortable', this shift in arousal may itself be positively reinforcing. On the other hand, the reinforcement may consist, for example, in the fact that the change in arousal enables effective performance to be maintained under conditions of boredom or fatigue. Processes involving negative reinforcement may also have a role. This would be the case if a cigarette enabled smokers to attenuate the aversive states of anxiety or stress. Evidence that smoking may be used as a psychological tool has already been reviewed. Nevertheless, the arousal-control approach to smoking motivation does not imply that ecery cigarette smoked is useful in such a way. Rather, it suggests that cigarettes arc sometimes of great use in manipulating psychological state, and that on these occasions f
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198 R. Sn:NNCr they are found extremely rewarding. This view of smoking is made plausible by the self reports of smokers. Mausner and Platt (1971) asked smokers to complete a diary describing the circumstances under which they smoked each cigarette, and the degree of pleasure they experienced. Apart from the many cigarettes smoked because others were smoking, or because cigarettes had come to be associated with certain routine activities, certain cigarettes stood out as being particularly 'needed' and especia!ly rewarding. This was especially so in situations in which smoking was thought to have reduced tension. 3.2. PARTIAL AND SECONDARY REINFORCEMENT Experiments in animal learning have shown that the number of reinforcements obtained is not the only determinant of the persistence and frequency of a response. When the schedule of reinforcement is arranged so that rewards occur only intermit- tently, animals respond at a fast and constant rate. Moreover when rewards cease to be provided, the behavior takes longer to extinguish than when the association between response and reinforcement is regular and invariable (Lewis, 1960). That most cigarettes are smoked without much effect on psychological state may therefore not detract from the strength of the behavior, and may in fact make it more resistant to extinction. The effects of partial reinforcement may explain why smoking occurs in situations in which there is no obvious need to smoke, nor pleasure to be drived from it. However such behavior can also be accounted for by reference to the phenomenon of secondary reinforcement. Through constant association with rewards derived from the effects of nicotine, certain other stimuli (the appearance of the cigarette, the act of smoking and the smell and taste of tobacco) may themselves come to have reinforcing properties (Hunt and Matarazzo, 1970). These secondary reinforcers are able to maintain behavior for a long period, even when the primary source of reward is absent. Thus, smokers will continue to smoke lettuce-leaf cigarettes, containing no nicotine, in the absence of the conventional tobacco product (Goldfarb et at., 1970). 3.3. IS SMOKING `PUNISHED'? Smoking is eventually 'punished' in a proportion of smokers by the occurrence of disease and premature death. But since animal experiments inform us that delayed punishment (however severe) generally has less effect on behavior than immediate re- inforcement it is not surprising that this prospect in itself is of only limited usefulness in persuading people to quit. This is perhaps especially so when the punishing consequences are not inevitable in the case of any particular individual. For this reason, certain smoking cessation techniques based on learning theory have sought to associate smoking with various forms of 'artifical' punishment which can be manipulated so as to be invariable, immediate and repeatable. 4. CESSATION TECHNIQUES It is not intended that this section should provide a comprehensive account of cessa- tion techniques. The area is well covered by evaluative reviews such as those of Bernstein (1969), Hunt and Matarzzo (1973), Epstein and McCoy (1975) and Bernstein and McAlis- ter (1976). It is nevertheless of interest to indicate the variety of approaches available (Table 3). - ~ 4.1. BEHAVIOR THERAPY As a maladaptive learned response, smoking ought to be amenable to various forms of behavior modification based on learning theory. Of these techniques, aversive condition- ing is probably the most frequently used. In this form of therapy an unpleasant stimulus is administered as the unwanted behavior occurs. The reaction of anxiety or discomfort 0
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Human smoking bchavior and dcpcndencc on tobacco smoking TABLE 3. Smnkinp Cecwtion Beharior Therapy Aversive conditioning- electric shock --- rapid smoking Systematic dcscnsitisation/'rclaxation training Programmed smoking Contract managemcnt and 'sclf control' Drugs Lobeline Tranquillizers and antideprcssants Nicotine gum Tht Smoking Clinic Psychotherapy Group support Role playing Information and suggestions Srnsort• DrprJration H ypnosis Aeupuneture I99 produced by the noxious stimulus then becomes a conditioned response to the presence of the unwanted behavior itself, replacing the positive reinforcement which would nor- mally accompany and maintain it. The procedure is exemplified by the administration of electric shock when smokers reach for a cigarette, light it, or simply indicate they are thinking favorably about smoking. The problem with aversive conditioning is that the punishment is generally adminis- tered only in the laboratory. Although the hope behind aversive conditioning is that conscious processes can be 'by-passed' (Russell, 1970), even classically conditioned auto- nomic responses are affected by the subject's awareness of the 'rules' governing the administration of punishment (Bandura. 1969). It is therefore likely that the anxiety response to taking a cigarette will rapidly disappear once the subject returns to the situation in which he normally smokes. Aversive conditioning also suffers from the fact that the associatiori between electric shock and smoking is entirely arbitrary. A poten- tially fruitful strategy is therefore to use as punishment a stimulus--cigarette smoke- which will be present in the normal smoking environment (even if only in an attenuated form) and which may aid the transfer of learning from the laboratory. Various attempts to use this technique have required subjects to smoke at a much faster rate than they would choose or have exposed people smoking to a stream of concentrated smoke directed at their faces. The success rates reported are variable. As an alternative to the punishment of smoking, it has been suggested that non- smoking should be reinforced by the provision of rewards contingent on increasingly lengthy periods of abstinence (Barton and Barton, 1978). - Another potentially useful strategy is to devise ways of separating the act of smoking from the cues which usually precede it and the reinforcements which habitually follow. The absence of reward would be expected gradually to decrease the frequency of the behavior. Levinson er al. (1971) employed the technique of 'programmed smoking' in an experiment in which a subject took a cigarette only when signalled to do so by a timer which was activated at random intervals. The treatment was effective in reducing the desire to smoke. However, subjects found it difficult to abandon smoking entirely. Bern- stein and McAlister (1976) attribute this relatively common finding to the fact that gradual reduction in smoking increases the reinforcement value of each cigarette. irres- pective of the circumstances in which it is smoked, making those which remain progress- ively harder to relinquish. Techniques derived from learning theory have been used in attempts to eliminate smoking by punishment, by rewarding non-smoking. and by dissociating the act of 0
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' 200 R.STEPHEY smoking from its usual sources of reward. Complementary to these approaches are forms of behavior therapy designed to remove the need to smoke by training smokers in relaxation as an alternative means of combatting stress (e.g. Wagner and Bragg, 1970). However. tension-reduction is only one of the ways in which smoking is used. It is therefore unlikely that this single approach would be generally effective. 4.2. SELF CONTROL The conventional wisdom is that smoking, ultimately, is conquered only through the exercise of will-power. However to say that someone has will-power is merely another way of saying that they have succeeded where others fail. The concept is therefore of no use in explaining how they have succeeded. Nevertheless, the related concept of self- control has been interpreted in terms of learning theory.. The difficulty in giving up smoking is that quitting (except in terms of expense) is likely to be advantageous only in the long term. However, the gap between present behavior and future consequences can be bridged by using speech or imagery as a way of drawing one's attention to environ- mental events, such as the consequences of smoking, which are not immediately present. Thus a smoker may bring to mind the unpleasant facts about smoking to punish backsliding or reward abstinence. The intending non-smoker can also ensure immediate reward and punishment by entering into a form of'contract', either with himself or with others (Rachlin, 1976). Thus, at a time when the urge to smoke is weak, an individual enters into a commitment to give £10 to a friend if he ever smokes again. Then..in the future, when the urge to smoke is strong, the smoker still has a powerful reason for not smoking. This is also the case when the'contract' relates either to the social approval of others (Tooley and Pratt. 1967) or to loss of self-esteem. 4.3. PNARMACOLOGICAL TREATMENTS Drugs have a long history of use in attempts to help people give up smoking. Three classes of substance are employed. Probably the most common are drugs which are similar to nicotine in their pharmacology and which may therefore mimic its effects. The search for a nicotine substitute goes back to the 1930's when lobeline was first used for the purpose. but no drug has proved consistently effective. Thus, although'certain studies have shown a quite marked reduction in smoking rate when oral lobeline preparations were compared with placebo (e.g. Rapp et at., 1959), other. trials have produced entirely non significant results (Bernstein, 1969). Various psychotropic substances which act in ways rather different from nicotine, but whose stimulant or tranquillizing properties may be useful in helping the smoker during the difficult initial period of abstinence, have also been employed (e.g. Whitehead and Davis, 1964). . If part of the pleasure of smoking is mediated by the release of endogenous opiates (which the work of Stein (1978) suggests as a possibility), the administration of an opiate antagonist might be a useful aid in encouraging smokers to quit. There is now evidence that naloxone, administered by subcutaneous injectidn, markedly decreases smoking (Karras and Kane. 1980). 4.3.1. Nicotine chesring gum For reasons-already outlined, the most promising drug to use in smoking therapy may be nicotine itself, and the recent advent of nicotine chewing gum markes a potentially important advance, especially since the. gum is capable of producing blood concen- trations comparable with those obtained from smoking (Russell et af., 1976b). There is general agreement that nicotine gum reduces smoking more than placebo whcn used over a one to three-week period. Ohlin and Westling (1972) and Brantmark et at. (1973) rcport a greater decline in cigarette consumption. whilst Russell et at. (1976a)
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I Human smoking behavior and dependence on tobacco smoking 201 found a significantly greater reduction in smoke exposure (as measured by carboxyhe- moglobin levels) and Puska et al. (1979) a higher rate of total abstinence. However, the true test of any anti-smoking therapy lies in the longer-term success rate. Here the position is less clear. Malcolm et al. (1980) report that only 23% of subjects chewing 2 mg nicotine gum were non-smokers at a six-month follow-up. A success rate of around 20% shows no improve- ment on the abstinence levels routinely reported from smoking clinics and behavior therapy. However, stronger support for the use of nicotine gum comes from work by Raw et al. (1980). One year from the start of treatment 38% of the 69 people who received nicotine gum were confirmed non-smokers, compared with only 14% of the 49 smokers who had experienced 'psychological treatment'. This high rate of success is virtually identical to that reported by Wilhelmsen and Hjalmarsson (1980) for smokers who continued with the gum for more than sixteen weeks. An important determinant of success would seem to be the duration for which the gum is used (Russell et al., 1980b). Brantmark et al. (1973) found that nicotine gum was more successful among heavy than among light smokers, suggesting the usefulness of the gum may also be confined to the treatment of people who habitually consume large numbers of cigarettes. 4.4. THE SMOKING CLINIC AND OTHER TREATMENTS In parallel with the use of drugs and behavior therapy, smoking clinics provide infor- mation, encouragement and support for smokers who wish to quit. Many clinics offer variations on the 'Five-Day Plan' originated in the United States by the Seventh Day Adventist Church, and first described by McFarland et al. (1964). The originators of the therapy claimed 70-80% abstinence after five days, and around 30% at 3 months. How- ever, the proportion of confirmed non-smokers (arbitrarily taken as abstinence one year after the start of therapy) is almost certainly less than this. Russell (1970) reports that the success rates of smoking clinics range from 12 to 28%. Perhaps discouraged by this low rate of success, smokers and clinicians alike have interested themselves in less conventional forms of therapy such as acupuncture. Choy et al. (1978) report that over half a group of thirty-three smokers were abstinent 2-25 months after treatment by the insertion of a stainless steel stud in each ear. The variable interval of follow-up, however, makes this success rate difficult to compare with that using other methods. Although the technique has captured the popular imagination, the usefulness of hypnosis is equally unclear, despite the success reported in individual cases (e.g. Von Dedenroth, 1964). Similar to hypnosis (in that both may increase suggestibility) is the technique of sensory deprivation, which has been used by Suedfeld and Ikard (1974) in the treatment of smoking. In this experiment, smokers were confined individu- ally for 24 hr in a dark and sound-proofed chamber and fed on a liquid diet. One year after the deprivation experience, subjects were smoking only half the number of cigarettes originally consumed. This compares with a reduced consumption of 16% in a control group. 4.5. RELAPSE AND SUCCESS The general problem with smoking cessation techniques is not to obtain an initial change in behavior but to sustain that change. This problem of relapse was considered by Hunt et al. (1971) who collated data from 87 studies which had used a wide range of anti-smoking therapies. They found that as soon as treatment ends there is a steep decline in the proportion of people who are still not smoking, such that after three months only 35% are abstinent and at six months 25%. The rate of relapse then slows, with roughly 20% not smoking at the end of one year. Hunt et al. suggested that these 20% were likely to remain abstinent, and constituted the true average rate of success for conventional approaches. 0
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, R. STEPNF.Y TABLE 4. Factors Which Prrdict Success in Stopping Smoking Sorin(ogicu/ Male sex liigher education Personalit}• Greater extraversion Emotional stability Smoking history Low overall consumption Fewer years a smoker Non-inhalation Orher drug use Low coffee and alcohol consumption If the overall rate of success is low (both for clinic groups and for those quitting spontaneously) there are nevertheless certain kinds of smoker who seem more likely to give up than others (Table 4). Reviewing over thirty studies in which figures for men and women had been separately quoted,.Gritz (1978) concluded that. in the majority of cases. men and women did not differ significantly in success at quitting. Nevertheless, where differences did occur, men were consistently more successful than women. In population surveys. the proportion of ex-smokers is greater among men than among women in both Britain and the U.S.A. (General Household Survey. 1980; Surgeon General. 1981). It is not clear why this should be so, although women and men have been found to differ in the reasons they give for smoking (Ikard et al., 1969). Cigarettes which are used habi- tually to reduce negative affect (more commonly reported by women) may be more difficult to give up than those smoked for other reasons.. . Personality variables also relate to success in quitting. Cherry and Kiernan (1976) reported that the prevalence of ex-smokers was greater among the more extravert. Amongst men, the ability to give up was also positively associated with low neuroticism. In a smaller (and older) group of 120 patients with chest disease. Burns (1969) found a similar association. Cherry and Kiernan also reported that low levels of cigarette consumption were pre- dictive of greater success. This finding is supported by evidence from major prospective studies which are investigating risk factors for heart disease in large groups of American men and women. In the Framingham study. Gordon et at. (1974) concluded that the majority of those who quit smoking over an 18 yr period were men who had originally smoked 20 or fewer cigarettes per day. This result is confirmed and extended by the work of Friedman c•t al. (1979) who have been studying smoking in a population of over 25.000 Californians. Compared to continuing smokers. those who had given up had originally smoked fewer cigarettes, had a shorter history of smoking. and were less likely to report that they inhaled. The group of successful quitters also contained a significantly greater proportion of people with college education, and was composed of individuals who on an avrrage consumed less alcohol and coflce than those who continued to smokc. REFERENCES AattRSSO.. K. (1975) Effects of cigarette smoking on learning and retention. Psi•rhopbnrmura6wi ia 41: I-S. Aax). K. and YAMAtstTA. T. (19811 Cigarette smoking in rhesus monkeys. P<,rchnpheuniac»inyy 72: 117-127. AR%utAOr:. A. K. and Tt'RNt:R. D. M. (19701 Absorption or nicotine in cigarette and cigar smoke through the oral mucosa. Nuturr 226: 1231-1232. AKMutACr. A. K. (19731 Some recent observations relating to the absorption of nicotine from tobacco smoke. In: Smo4inti Bchorinr: AfotFres and Inccntiri•s. pp. 83-9I. Dt;v;4. W. L. lcd). Winston. Washington. AK%IITAOI. A. K. DOI.Ll:RY. C. T_ GtoROt. C. F.. HocstKA.%+. T. H.. Lr:N•ts. P. l. and Tt:R~r.R. D. M. (1V751 Absorption and mctabolism of nicotine from cigarettes. Br. med. J. 4: 313-316. 48
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