This chapter presents the rationale for conducting research on barriers to smoking cessation amongst people who should know better. A review of current and relevant literature was done to assess current smoking cessation policies and initiatives, barriers to accessing treatment for nicotine dependence, and barriers to quitting.
Following the studies by Doll and Hill in the mid-twentieth century that suggested the detrimental effects of tobacco smoking(Doll and Hill, 1954), educational and clinical researchers have for decades studied the burden of tobacco smoking and the smoking habit in general. The relationship between tobacco smoking and morbidity/mortality, policy making regarding tobacco smoking regulations and their effectiveness, statistics concerning smoking cessation are amongst topic that have all been studied. This thesis is a study of smoking habits and barriers to smoking cessation amongst people who have an understanding of the health implications of tobacco smoking and also to retrieve a firsthand perspective of the effectiveness of already set down policies and tobacco smoking regulation.
Though smoking rates though reduced in comparison to the mid-twentieth century, there still exists high and alarming incidence and prevalence of tobacco smoking with more young people picking up the habit.
Indeed the view of the individuals primarily involved in tobacco smoking is very important in setting up more effective interventions than are present at the moment. Smoking behaviour differs from class to class and from individual to individual. Several studies have suggested that the strength of the habit is dependent on other influencing factors such as gender, age, employment etc. Because of this, we can find that men have a higher tendency to smoke than women, the less educated and people of low socio-economic status will also be observed to smoke tobacco than the educated and people of a high socio-economic class. Putting into consideration these already set up biases, the author sought to find out barriers to quitting tobacco smoking in an environment that has become anti-smoking.
BURDEN OF TOBACCO SMOKING
Tobacco is a greater cause of death and disability than any single disease (WHO, 1997. WHO fact sheets: fact sheet number 154). It is one of the top causes of preventable death globally and is estimated to kill more than 5 million people every year worldwide, most of which are in between low and middle income countries. It is projected that by the year 2030, this figure will rise to about 8 million people. The burden of tobacco cannot go without mentioning its financial implications and costs to the economy. According to the WHO, tobacco’s cost to governments, employers and to the environment includes social, welfare and health care spending, loss of foreign exchange in importing cigarettes, loss of land that could grow food, cost of fire and damage to buildings caused by careless smoking, environmental costs ranging from deforestation to collection of smokers’ litter, absenteeism, decreased productivity, higher number of accidents and higher insurance premiums. It is said to cost America, Germany, and the UK about $76 billion, $14.7billion and $2.26billion respectively (Mackay and Eriksen, 2002).
Apart from the financial burden of tobacco smoking and related illnesses, the quality of life of the smoker who will be exposed to cancer, organ malfunction and failure, loss of life, is also affected.
AWARENESS AND WHAT HAS BEEN DONE
With the appreciation of death, disability and the financial burden of tobacco smoking, various strategies have been placed by countries to help reduce the trend. Mass awareness campaigns have caused a growing number of people to appreciate the ills of tobacco smoking. Following the scientific reports linking tobacco smoking to ill health in the 1960’s, cigarette packs have been carrying health warnings (Mackay and Eriksen, 2002) such as cigarette smoking causes stroke, tobacco smoking hurts babies, cigarette smokers are liable to die young.
Another major intervention following the scientific reports of the 1960’s, was the introduction of tax on tobacco products. In the UK alone, where tax accounts for about 80% on the price of tobacco, and with a 5% annual increase, about 10billion pounds was generated from excise duty and tax on tobacco products in the year 2009 according to the tobacco manufacturers association. Various studies such by researchers have confirmed an inverse relationship between the price of tobacco and it’s consumption (Chaloupka and Warner, 2000).
EFFECTIVENESS OF ANTI SMOKING INTERVENTIONS
Tobacco use is one of the leading causes of preventable illness and death in the world. Once users become addicted to tobacco, quitting becomes hard. Nicotine dependence resulting from tobacco use hampers efforts to sustain abstinence from tobacco for a prolonged period or a lifetime. Many users make multiple attempts to quit, often without the assistance that could double or even triple their chances of success. Proven individual cessation strategies include counselling and behavioural therapy and, except when contraindicated, first-line and second-line medications.
This section of the literature review will talk about the various smoking cessation policies and treatment for nicotine dependence with a view to analyse them based their effectiveness from previous research.
Smoking cessation interventions include
Cut down to quit
Psychosocial and Behavioural therapy
Self help materials
Nicotine Replacement Therapy Gum
Nicotine Replacement Therapy Patch
Smoking herb substitutions.
Below is a tabular summary of these treatment options for nicotine dependence.
TOBACCO CONTROL POLICIES
Three important studies from the mid twentieth century provide the first real links between smoking and lung carcinoma. In 1950, Morton Levin publishes first major study definitively linking smoking to lung cancer. In the same year, Ernst L. Wynder and Evarts A. Graham of the United States, found that 96.5% of lung cancer patients interviewed were moderate heavy-to-chain-smokers in their study “Tobacco Smoking as a Possible Etiologic Factor in Bronchiogenic Carcinoma: A Study of 684 Proved Cases,”. Richard Doll and a Bradford Hill publish first report on Smoking and Carcinoma of the Lung in the British Medical Journal, finding that heavy smokers were fifty times as likely as non-smokers to contract lung cancer. (Doll and Hill, 1954).
These studies led to an increased awareness of the link between smoking and cancer subsequently leading to the introduction of policies to help reduce the incidence and prevalence of tobacco smoking.
WHITE PAPER: SMOKING KILLS
In 1998, the UK government released one of the most influential papers and the first of its kind which was designed to tackle head on the problem of smoking in the UK. The policies proposed by this paper and which have been implemented will be discussed briefly.
NON PRICE INTERVENTIONS
COMPREHENSIVE BAN ON ADVERTISEMENTS
BETTER CONSUMER INFORMATION
WARNING LABELS ON CIGARETTE BOXES AND TOBACCO PRODUCTS
HELP FOR SMOKERS WHO WISH TO QUIT.
This has been said to be the most effective policies for tobacco regulation especially for the younger generation and people from economically disadvantaged backgrounds. A price increase of 10% can reduce smoking rates by 8% in low and middle-income countries (Bank, 2003a) while it could be 4% in high-income countries (Joossens et al., 2004).
The UK tax paid tobacco market is worth about £14 billion (Association, 2010), with the tax currently accounting for 73-80% of cigarettes.
Although it has been argued that the demand for tobacco is highly inelastic as there is not a good enough substitute for tobacco and as such a rise in price will give just a small reduction in smoking rates (Gwartney et al., 2009), other studies have shown that while the demand for tobacco is inelastic, it will respond well to an increase in price (Chaloupka and Grossman, 1996).
These are policies set up to inhibit tobacco smoking in the work place and public spaces. They exist also to reduce the rate of second hand smoke. The whole of the United Kingdom became subject to a ban on smoking in enclosed public places in 2007, when England became the final region to have the legislation come into effect. A review of more than 900 studies and government reports looking at the impact of smoking bans across the world showed that there is ample evidence which proves they work, without hurting businesses such as restaurants and bars and the implementation of no-smoking policies have broader benefits for a wider population by increasing smoke-free environments.
COMPREHENSIVE BAN ON ADVERTISEMENT
Comprehensive bans on advertising and promotion of tobacco products have also been shown to reduce smoking. Empirical evidence shows that a fully comprehensive advertising ban covering all media and all forms of direct and indirect advertising reduces tobacco consumption. Similarly, a comprehensive advertising ban also reduces the rate of initiation and maintenance of the habit, in particular among young people. Along with the promotion of a smoke-free environment, the regulation of advertising contributes to making tobacco smoking less attractive, and making non-smoking an accepted social norm. The World Bank estimates that comprehensive bans can reduce tobacco consumption by around 7% (Harris et al., 2006).
BETTER CONSUMER INFORMATION
Sustained and well founded mass media campaigns have been shown to be effective in the fight against tobacco. Mass media campaigns have been used to better enlighten the public about the facts concerning tobacco smoking, and the associated ill effects of smoking. Macaskill et al buttressed this point in their study suggesting that mass media based health promotion campaigns have the potential to reach a wide segment of the population including those from disadvantaged backgrounds or people with barriers to accessing health services (Macaskill et al., 1992).
A review of smoking prevention and control strategies concludes that the available literature suggests that mass media interventions increase their chance of having an impact if the campaign strategies are based on sound social marketing principles; the effort is large and intense enough; target groups are carefully differentiated; messages for specific target groups are based on empirical findings regarding the needs and interests of the group; and the campaign is of sufficient duration. (Lantza et al., 2000)
WARNING LABELS ON CIGARETTE BOXES AND TOBACCO PRODUCTS
Evidence from several countries show that the large warnings introduced recently are effective in reducing smoking rates and increasing public awareness of the dangers of smoking (Bank, 2003b). Hammond et al found out that there were gaps of knowledge about the health risks of tobacco smoking and people who noticed the health warnings on tobacco packs were more likely to appreciate the health risks of tobacco smoking (Hammond et al., 2006)
HELP FOR SMOKERS WHO WISH TO QUIT
This has been an area that has been well invested in by the UK government. The inception of the NHS smoking cessation followed the recommendation of the White Paper Smoking Kills in 1998 (Health, 1998). The service enabled GP’s to refer smokers who really want to give up for a course of specialist counselling, advice and support. The service provided a week’s NRT course for those unable to afford them. Through this service, thousands of people were able to set up quit dates.
BARRIERS TO SMOKING CESSATION
Most of the smoking cessation interventions and policies mentioned above have proven effectiveness, some have showed greater effectiveness when used as combined therapy, while other have no proven form of effectiveness at all.
Statistics on smoking incidence and prevalence rates have clearly shown a decrease over the past years, but smoking rates have been declining by 0.4% annually in the UK (Stayner. et al., 2007). The latest figures for 2008 show that around 10 million adults in Britain smoke cigarettes (Office for National Statistics, 2010) with the highest rates amongst the 20-24 year olds who have 30% of this age group recorded as smokers. This prevalence declines with age to 13% amongst people who are 60 years and over. An increase in smoking cessation rates amongst the elderly group along with an increased incidence rate amongst the younger generation particularly amongst children and teenagers can be said to be responsible for this difference.
These figures are high in spite of the awareness and action on the part of both the government and individuals which has led to the focus of this research which is ‘to find out why smokers who are aware of the hazards still smoke regardless’.
Smokers can be categorised into three groups; those who are aware of the hazards of smoking and want to stop but can’t, those who are aware of the hazards and don’t want to stop, and those who are unaware of the negative effects of tobacco smoking. It will be safe to assume the UK would either fall into the first or second categories. This group of smokers will have considered stopping or even tried stopping at a time but have been unsuccessful at achieving smoking cessation. Surveys have shown that about 70% of smokers will like to stop but can’t (Lader, 2008). Interestingly, 40% of people who have had a laryngectomy and 50% of people who have had lung cancer will resume smoking after undergoing surgery (Stolerman and Jarvis, 1995). Similarly, 70% of smokers who have had a heart attack resume smoking within a year (Stapleton, 1998). When people neglect their health to repetitively satisfy a need gives strong evidence of dependence and addiction.
Tobacco smoking is woven into everyday life and can be physiological, psychological, and socially enforcing.
Physiological dependence: Tolerance / Dependence / Withdrawal symptoms
Nicotine addiction is the primary source of physiological dependence in relation to tobacco smoking and serves to play a major role in continued tobacco use because of its physiological effects on the body. Nicotine is a stimulant drug with the ability to cause both stimulation and relaxation. In smaller doses smoking heightens feelings of excitement and thus relieves fatigue and depression. In larger doses nicotine exerts a calming effect and reduces tension and stress however, the mental and physical state of the smoker can influence the person’s perceptions of the effect of smoking hence the overall experience will be different for different people (CDC, 1988). What seems to be certain is that nicotine is very addictive with tobacco being its method of administration (Physicians, 2000) and is characterised by a compulsive drug seeking behaviour even in the face of negative health consequences. Further buttressing its addictive nature, nicotine has been compared to other drugs of addiction such as heroin and cocaine in relation to their action as a mood/behaviour altering agent. Nicotine’s pharmacokinetics also enhance its potential as a drug of abuse as tobacco smoking causes a rapid distribution of nicotine into the effect achieving its desired effect of pleasure. The effect is short lived because of the short half life of the drug in the system, leading the smoker to want more and more of the drug so as to sustain its pleasurable effects, and this accounts for the tolerance and dependence bit of physiological dependence. Perhaps the hardest part of quitting is dealing with the withdrawal symptoms. High relapse rates have been largely attributed to the inability to deal with withdrawal symptoms. These symptoms include irritability, craving, depression, anxiety, cognitive and attention deficit, sleep disturbances, and increased appetite and may begin within a few hours after the last cigarette, quickly driving people back to the habit. Symptoms peak within the first few days of smoking cessation and usually subside within a few -weeks. For some people, however, symptoms may persist for months. Although withdrawal is related to the pharmacological effects of nicotine, many behavioural factors can also affect the severity of withdrawal symptoms. For some people, the feel, smell, and sight of a cigarette and the ritual of obtaining, handling, lighting, and smoking the cigarette are all associated with the pleasurable effects of smoking and can make withdrawal or craving worse.
Fishbein states that
‘’while one may question the values that some place on certain outcomes or the accuracy of some of their beliefs, a decision to smoke is actually quite reasonable if the decision maker believes that the net effects of smoking are more positive than the net effects of not smoking” (fishbein, 1979).
This statement is in line with the theory of reasoned action which was proposed by Azjen in 1988 suggesting that individuals consider the implications of their actions before they decide to engage in certain behaviours or not (Ajzen & Fishbein, 1980), clearly suggesting that knowing that smoking kills might not be enough to deter an individual to stop smoking. Balancing the positive effects of smoking with negative effects, and eventually favouring the positive effects can lead to continued smoking. Some of these perceived positive effects will be discussed below.
Smoking as a pleasurable activity: nicotine as mentioned above has the ability to combine with a number of neurotransmitters in the brain and may contribute to the following reinforcing effects: Dopamine which is responsible for Pleasure, suppress appetite, Norepinephrin which is responsible for arousal, Acetylcholine for arousal and cognitive enhancement, serotonin for mood modulation, appetite suppressant, Beta-endorphin to reduce anxiety. In smaller doses smoking heightens feelings of excitement and thus relieves fatigue and depression. In larger doses nicotine exerts a calming effect and reduces tension and stress. Much of its positive effects as an anxiety reducer, or a mood enhancer or relaxant has been argued to be contained in nicotine’s fast ability to counter the symptoms of nicotine withdrawal. Symptoms of withdrawal when repetitively relieved by a nicotine fix, the individual tends to attribute these good effects to the act of tobacco smoking.
Stress relief and tension reduction: In addition to pleasure, the somatic sensations created by smoking produce a feeling of relaxation. This seems to indicate that smoking fulfils some need in persons who are in need of stress-relief, for whatever reason. It has been noted that smoking is more prevalent in persons under stress: it is more frequently a habit among more arousable and more anxious persons than it is among more tranquil people, and those whose careers entail more pressure are more frequently smokers. It is a relief from the body’s response to stress, which the smoker is seeking in his/her cigarette. This psychological need for stress-relief in a smoker may be one element to explain why beginning smokers persevere with the habit, given that it is initially not a pleasurable experience for them, and force themselves to overcome the initial feelings of disgust. Beginning smokers are aware that smoking can provide a relief from the stress in their lives and will pursue that stress-relief ignoring the now ubiquitous health warnings: they perceive their need for relief to be the greater need, thus outweighing the possible health hazards or at least putting such warnings to the back of their minds.
Weight suppressant: as earlier mentioned, active components of tobacco can act as appetite suppressants and thereby reducing food intake, ultimately leading to weight suppression. On stopping smoking, this effect wears off and along with better taste appreciation, there is increased appetite, more eating and eventually weight gain. Weight gain has been a recurring theme in past studies on smoking cessation.
Habitual: this is when smoking becomes a habit and is linked to other activities for example people who have a need to smoke when drinking. A repetitive and predetermined sequence of events is hard to break. The intimate coupling of behavioural rituals and sensory aspects of smoking with nicotine uptake gives ample opportunities for secondary conditioning. For a smoker who smokes about 20 sticks a day, “puff by puff” delivery of nicotine to the brain is linked to the sight of the packet, the smell of the smoke, and the scratch in the throat some 70 000 times each year. Similarly, if smoking is linked to a particular feeling or emotion, a recurrence of that emotion can serve as a trigger to smoke.
Certain social and cultural factors can influence smoking habits. The focus theory of
norms predicts that making a norm more prominent will increase its influence on
behaviour as long as the norm remains prominent (Cialdini et al., 1991).
The effect of social influence on healthy behaviour and attitude is explained more explicitly by the Fishbein’s Theory of Reasoned Action (Fishbein and Ajzen, 1975) which proposed that the attitude toward a behaviour and the subjective norm for that behaviour combine to predict behavioural intention. Behavioural intention in turn is predictive of actual behaviour (Sheppard, Hartwick & Warshaw, 1988). This theory and a later refinement of it termed the Theory of Planned Behavior (Ajzen, 1991) have been tested across a wide variety of contexts.
These theories put forward an important role for what they termed the subjective norm in determining behavioral intentions. The subjective norm consists of the individual’s beliefs about whether persons who play important roles in the life of the individual would want him or her to engage in the behavior in question as well as the individual’s motivation to comply with these people. As such, a subjective norm can be said to be a form of an injunctive norm (Rimal and Real, 2003) that is, a code of behavior that brings with it implied social rewards and repercussions.
These models tend to account for social reasons for smoking such as the influence of
family, friends, colleagues, culture, geographic location, profession, gender, etc. an
example would be that an individual is more likely to smoke if close family members,
peer groups, and/or colleagues at work smoke uninhibitedly. Similarly that individual
will find it harder to attain smoking cessation when his immediate sphere of contact
do not regard that as something worth doing.
Other barriers to quitting.
Barriers to seeking help for nicotine dependence
Roddy et al’s study on barriers to gaining access to smoking cessation services amongst deprived smokers concluded that these smokers generally had a low awareness of the services available to help them, and despite this, had misconceptions about their availability and effectiveness. Other findings from this study showed that these smokers did not seek treatment for fear of being judged or stigmatized and a fear of failure at quitting(Roddy et al., 2006).
Appreciation of health hazard
A study on socio-economic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke from the 2002 International Tobacco Control four country survey revealed that lower economic status was associated with a lower awareness and misunderstanding surrounding the hazards or effects of smoking.
Another possible barrier to quitting smoking in spite of an awareness of the health risks to smoking, these health risks of smoking may not immediate and as such might not be seen as relevant to the individual at smoking initiation and progression to a smoking habit. Jamieson and Romer found that there was no evidence to show that the perception of risks of smoking amongst adolescents aged 14 – 22 had no effect on smoking initiation and progression to a smoking habit. According to them, young people do not take into account the health risks of smoking before smoking initiation, but as the addiction kicks in, the smoker becomes aware that he or she is addicted and eventually leads to a consideration of the health risks. In contrast, adults see these health risks as a more immediate threat possibly because of age and tend to appreciate these risks better than adolescents. This perception of risk is a major influence on the decision to quit smoking as the smoker will consider quitting if the perceived risk is higher than the positive effects of smoking.
Finally, the addictive properties of tobacco can be underestimated with smokers thinking quitting tobacco is something they can decide to do at anytime, leading to a further indulgence in the habit.
With increasing health warnings, smoking trends have significantly reduced. Great Britain in 2005 had about 24 per cent of adult 16yrs and over smoking. This is in contrast to 45 per cent in the 1970’s (survey, 2005). Still an alarming number of people smoke and if current smoking patterns continue, there will be more than one billion deaths attributable to tobacco smoking in the 21st Century compared with 100 million deaths in the 20th Century (Vineis, 2008)
There have been many documented reasons why the incidence and prevalence
rates are still high. Some of these reasons include that smoking patterns in some
particular classes have increased for example women, teenagers, and the younger
adult population (UK, 2010). Others have argued the effectiveness
of smoking cessation initiatives and policies that have been put in place, and the relapse rate of quitters has also been questioned.
What seems to be increasingly obvious now is that mere knowledge of the health implication of smoking is not enough to reduce the incidence and prevalence of tobacco smoking. The author with this study, attempted to find out what issues prevent a smoker from quitting despite knowing the health implications of smoking.
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