Theories of substance abuse

1. Theories of substance abuse THEORIES OF SMOKING

2. Smoking • The resistance shown by smokers to large-scale campaigns to discourage the practice has prompted a massive amount of research to help to explain the continuing popularity of smoking. It is agreed that smoking is an extremely complex practice involving a mixture of biological, psycho­logical and social processes.

3. Biological theories of smoking • Nicotine, the main active ingredient in tobacco smoke, is a substance which if taken in large quantities can be toxic.

4. Biological theories of smoking • However, delivered in small amounts via cigarette smoke it has a range of psychophysiological effects including tranquillization, weight loss, decreased irritability, increased alertness and improved cognitive functioning (Rose, 1996).

5. Biological theories of smoking • The apparent conflict between the stimulant physiological effect of nicotine and reports of relaxation has been called the 'nicotine paradox' (Nesbitt, 1973).

6. Biological theories of smoking • One explanation for this paradox is that smoking appears relaxing because the smokers are often in a state of mild nicotine withdrawal which is relieved by the cigarette which returns the nicotine level in the body to 'normal' (Hughes, 1991; Foulds and Ghodse, 1995).

7. Biological theories of smoking • Over time the smoker seems to develop a physical dependence on nicotine. In the USA several tobacco companies have publicly admitted that smoking is addictive. In 1997 the smallest of the big five US tobacco companies (the Liggett Group) admitted that it had raised the nicotine content in cigarettes to increase their addictiveness (Porter, 1997).

8. Consumption • In terms of consumption patterns, in the early 1990s male smokers were averaging 17 cigarettes per day while female smokers were averaging 14. Very few smokers were less than daily smokers indicating the ongoing need to smoke. Further, within five minutes of waking approximately 14% of smokers reported having a cigarette and over 50% within 30 minutes (NOP, 1992).

9. Consumption • Even after the occurrence of a serious smoking induced disease, many smokers return to smoking. For example, Davison and Duffy (1982) found that 50% of smokers who had undergone surgery for lung cancer resumed smoking.

10. Smokers try to give up • According to survey evidence most adult smokers (83%) claim they wish they had never started and almost one-third report that they had given up smoking for at least a day in the past year (Gallup and Newport, 1990). Even for those who manage to quit, the long-term success is poor.

11. Smokers try to give up • Hatziandreu et al. (1990) found that 93% of those smokers who try to give up resumed regular smoking within one year. This figure is supported by a large number of randomised controlled trials which find that only 5-6% of smokers trying to stop without treatment can remain abstinent for one year (Law and Tang, 1995).

12. Nicotine regulation model • The experimental work of Schachter and his colleagues (e.g. Schachter et al.,1984) developed the nicotine regulation model of smoking. According to this model there is a physiological regulatory mechanism which monitors the level of nicotine in the brain. When this falls below a certain level the individual feels the need for another cigarette.

13. Nicotine regulation model • Admittedly, this model is not so straightforward since smokers will smoke nicotine-free cigarettes when there are no others available and will go for lengthy periods without a cigarette, e.g. on an airline flight.

14. Nicotine regulation model • Hajek et al. (1995) drew attention to the 10-18% of smokers who have been classified as light smokers. These smokers smoke five or less cigarettes a day which would not be sufficient to maintain a high level of nicotine. Further, these light smokers are not distributed randomly in the population but are more common among those from higher levels of education and among blacks (Kabat et al., 1991).

15. Genetics • Admittedly, not all people smoke or exhibit a desire to smoke. This raises the suggestion that perhaps there is a genetic component. A number of twin studies from different continents have produced evidence of strong genetic link in the risk of smoking.

16. Genetics • Heath and Madden (1995) reviewed the evidence from national twin studies in Scandinavia and Australia. In their predictive model genetic factors increased both the likelihood of becoming a regular smoker ('initiation') and of these smokers becoming long-term smokers ('persistence').

17. Genetics • In a large follow-up survey of the smoking practices of male twin pairs from the US Vietnam Era Twin Registry, True et al. (1997) found that genetic factors accounted for 50% of the risk of smoking and environmental factors accounted for a further 30%. In addition, genetic factors accounted for 70% of the risk variance of becoming a regular smoker whereas environmental factors were not important.

18. Genetics • Carmelli et al. (1992) found that the evidence for a genetic component was stronger among light smokers.

19. Evolutionary explanations • According to evolutionary psychologists, the persistence .of behaviour patterns such as smoking must reflect some evolutionary value. With the decline in the overall prevalence of smoking there has emerged what Pomerlau (1979) has described as a group of 'refractory' smokers who are more likely to have a variety of other problematic patterns of behaviour and cognition such as depression, anxiety and bulimia/bingeing.

20. Evolutionary explanations • In ancient times these patterns may have been biologically adaptive or neutral. However, in contemporary society, a more active fight or flight response is inappropriate. Smoking would be valuable to this population because it can produce small but reliable adjustments to levels of arousal.

21. Evolutionary explanations • Evolutionary approaches to addictions tend to ignore the psychological and social influences that create the conditions for tobacco use (Marks, 1998).

22. Psychological theories of smoking • Probably the most frequently used model of smoking is that based on learning theory. Basically, it argues that people become smokers because of the positive reinforcement they obtain. Initially, smoking is physically unpleasant (to a greater extent than is the case for alcohol) but this is overruled because of the social reinforcement from peers.

23. Psychological theories of smoking • The pleasant associations of smoking then generalise to a range of other settings. In addition, the smoker learns to discriminate between those situations in which smoking is rewarded and those in which it is punished. He or she also develops responses to a number of conditioned stimuli (both internal and external) which elicit smoking.

24. Psychological theories of smoking • Smoking can be conceptualised as an escape/avoidance response to certain aversive states (Pomerlau, 1979). The smoker will light up a cigarette to escape or avoid an uncomfortable situation.

25. Psychological theories of smoking • In 1966 Tomkins proposed his affect management model of smoking which was subsequently revised and extended by Ikard et al. (1969) who conducted a survey of a national (US) probability sample.

26. Psychological theories of smoking • In a factor analysis of the responses they identified six smoking motivation factors: • reduction of negative affect, • habit, • addiction, • pleasure, • stimulation • and sensorimotor manipulation.

27. Psychological theories of smoking • Subsequent surveys by Coan (1973) and Costa et al. (1980) produced similar factors. Livison and Leino (1988) found that women more than men reported that they smoked for reduction of negative affect and pleasure.

28. Psychological theories of smoking • In their study of smoking among young adults, Murray et al. (1988) added two additional reasons: boredom and nothing to do. In a survey they asked young adults to indicate which of these factors were important reasons for smoking in different situations. In all situations relaxation and control of negative affect were considered the most important reasons.

29. Psychological theories of smoking • At home boredom was also considered important, perhaps reflecting these young people's frustration with family life. At work addiction was considered important, perhaps reflecting the extent to which it disrupted their work routine, while socially habit was rated important.

30. Psychological theories of smoking • According to Zuckerman (1979) individuals engage in sensation seeking so as to maintain a certain level of physiological arousal. More specifically, Zuckerman (1984) emphasized that sensation seeking was designed to maintain an optimal level of catecholaminergic activity. Carton et al. (1994) found in a French sample that smokers scored higher on a measure of sensation seeking, in particular on disinhibition, experience seeking and boredom susceptibility subscales.

31. Psychological theories of smoking • They suggest that from a physiological perspective these sensation seekers have a low level of tonic arousal and seek exciting, novel or intense stimulation to raise the level of cortical arousal. This argument is very similar to that of Eysenck et al. (1960) who found that smokers scored higher on measures of extraversion. This personality dimension is also supposed to reflect a lower level of cortical arousal which could be raised by engaging in risky activities such as smoking.

32. Psychological theories of smoking • Besides sensation seeking and extraversion, a variety of personality characteristics have been found to be associated with smoking. In a sample of Scottish adults, Whiteman (1997) found that smoking was associated with hostility. However, they accept that 'presence of an association does not help in determining if the relationship is causal'. Indeed, they hypothesize that deprivation of smoking which was required for the study may have increased hostility.

33. Psychological theories of smoking • A variety of different types of studies have found that stress is associated with smoking. Schachter et al. (1984) found that among smokers, consumption was higher in experimental stressful laboratory situations.

34. Psychological theories of smoking • Lindenthal et al. (1972) found in a survey that people with higher self­ reports of stress were more likely to be heavy smokers. • In a study of nurses' smoking practices, Murray et al. (1983) found that those who reported the most stress were more likely to smoke. This relationship remained after controlling for the effect of family and friends' smoking practices.

35. Psychological theories of smoking • Finally, in a macro-social study, Colby et al. (1994) found that those US states which had the highest levels of stress as measured by a range of social indicators also had the highest levels of smoking and of smoking related diseases.

36. Social theories of smoking • Smoking is a social activity. Even when the smoker smokes alone he or she still smokes in a society where cigarettes are widely available and pro­moted. A number of qualitative studies have considered the social meaning of smoking. Murray et a1. (1988) conducted detailed interviews with a sample of young adults from the English Midlands. These suggested that smoking had different meanings in different settings. For example, at work going for a cigarette provided an opportunity to escape from the everyday routine.

37. Social theories of smoking • As one young factory worker said: • ‘We would say we were going to the toilet and have a quick cigarette. As long as they [management] didn't catch you. If they caught you, well, you'd be in trouble, sort of thing. But it was alright. We used to go in about every hour, something like that.’ (Murray et al., p. 49)

38. Social theories of smoking • For these workers, to have a cigarette meant to have a break and conversely not to have a cigarette meant not to have a break. The cigarette was a marker, a means to regulating their work routine.

39. Social theories of smoking • Outside work, smoking was perceived as a means of reaffirming social relationships. For those young people who went to the pub, the sharing of cigarettes was a means of initiating, maintaining and strengthening social bonds. Those who did not share cigarettes were frowned upon.

40. Social theories of smoking • One young man explained when he smoked: • Only, basically, when somebody else has one. Say we're all out in a group, say ,and we're all crashing [sharing] the fags [cigarettes] and that. Say it's somebody else's turn, I'd wait for them to get one out. I wouldn't light one of my own. I'd wait for him to get his out and if it's my turn, I'd just wait about ten minutes and get mine out. . . I can't handle that, people who just smoke on their own. It doesn't seem right. (Murray et al., 1988, p. 65)

41. Social theories of smoking • Graham's (1976, 1987) series of qualitative studies has provided a detailed understanding of the meaning of smoking to working-class women. In one of her studies (Graham, 1987) she asked a group of low-income mothers to complete a 24-hour diary detailing their everyday activities.

42. Social theories of smoking • Like the young workers in the study by Murray et a1. (1988), smoking was used as a means of organizing these women's daily routine. For example, one woman said: • I smoke when I'm sitting down, having a cup of coffee. It's part and parcel of resting. Definitely, because it doesn't bother me if I haven't got a cigarette when I'm working. If I'm busy, it doesn't bother me, but it's nice to sit down afterwards and have a cigarette. (Graham, 1987, p. 52)

43. Social theories of smoking • Further, for these women smoking was not just a means of resting after completing certain household tasks but also a means of coping when there was a sort of breakdown in normal household routines. This was especially apparent when the demands of child care became excessive.

44. Social theories of smoking • Graham describes smoking as 'not simply a way of structuring caring: it is also part of the way smokers re-impose structure when it breaks down' (p. 54). She gives the example of one woman who said:

45. Social theories of smoking • If it's nice, I send them [children] out or ask them to play in the bedroom but normally I will sit in the kitchen and have a cup of coffee and a cigarette. The cup of coffee calms me best, then a cigarette and then it's just being on my own for a few minutes to sort of count to ten and start again. (Graham, 1987, p. 54)

46. Social theories of smoking • Graham (1987) argues that for these women smoking is an essential means of coping with everyday difficulties. It is also a link to an adult consumer society. Through smoking the women were reaffirming their adult identity.

47. Social theories of smoking • Smoking is not only embedded in the immediate material circumstances in which the smoker lives, but also in the wider social and cultural context within which smoking is widely promoted. Admittedly, in most western societies there are considerable restrictions on the sale and promotion of cigarettes.

48. Social theories of smoking • Despite these, tobacco manufacturers continue to find ways to promote their products, e.g. through the sponsorship of sporting and cultural activities. In the USA it is estimated that the tobacco companies spend approximately $6 billion per annum on advertising and promotion (Emmons et al., 1997).

49. Society • Society places different values on drugs. The ones that receive most attention may not necessarily be the most dangerous. For example, it is considered politically correct to expend a good deal of energy attacking ecstasy. Ecstasy can kill, but has killed far fewer people than those who are killed on the roads.

50. Society • A political party who attacked the individual right to run a private car at an affordable cost would be committing political suicide, whereas an attack on ecstasy would contribute to their success in the next elections.