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This chapter presents the rationale for conducting research on barriers to smoking cessation amongst people who should know better. Since the famous 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. My 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. This is an area though widely researched, that has seemed to neglect the views of smokers themselves concerning these issues.
It is needless to say how several governments worldwide have taken up the resolve to tackle the tobacco epidemic. Strict laws have been set up, increasing tobacco tax to as high as 400%, the smoking ban, ban on media advertising of tobacco products. 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 d 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 illiterate and people of low socio-economic status will also be observed to smoke tobacco than the literate and the rich. Putting into consideration these already set up biases, I sought to find out barriers to quitting tobacco smoking in an environment that is fast becoming anti-smoking.
HISTORY OF TOBACCO
The history of tobacco is important to this study as I would with it discuss its origins, how it has gained popularity and mention the most influential studies done in this area in the mid-twentieth century. Tobacco smoking as we know it today has become a major public health concern. Just a couple of decades ago, it was fashionable to smoke tobacco, and was associated with higher social class. According to Gene Borio in his article “the tobacco timeline”(Gene, 2006), tobacco smoking dates back to about 1000BC amongst native Indians of central America. As the natives dispersed round the Americas, the plant was taken with them, thus becoming widespread. It was then discovered during the time of the great explorers hundreds of year later, who after being fascinated with this plant brought it to their respective countries. By the turn of the 17th century for example, about 38million pounds of tobacco had been imported into the United Kingdom creating room for competitive marketing and production on a large scale. In London, tobacco consumption in the form of pipes, cigars and snuff was increasingly popular and eventually, cigarettes as we know it today were produced. By the end of the two world wars, soldiers who had been offered cigarettes to help with motivation and kill past time brought the habit back home and introduced to their families, further strengthening the trend (Musk and De Klerk, 2003).
By the 1950’s, two prominent studies suggested that this ever popular trend was not healthy and in fact dangerous to health. Wynder and Graham reported that cigarette smoking was an important etiological factor for bronchiogenic carcinoma (Wynder and Graham, 1950), while Richard Doll and Bradford Hill conducted a prospective study involving over 30,000 British doctors and reported that both lung cancer and heart disease were more prevalent in smokers than non-smokers (Doll and Hill, 1954).
These studies led to a new era, the era of acceptance. Slowly the realisation of the hazards of tobacco smoking started sinking in. The relationship between tobacco smoking and more and more disease conditions were being discovered and by 1964, the US Surgeon General warned that tobacco smoking was a cause factor for cancer (Witschi, 2001). More and more policies have been put in place to help curb the trend ranging from the banning of tobacco advertisements, health warnings on tobacco products, increase in tobacco tax and to most recently, the smoking ban.
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.
Since the studies conducted by Doll in the mid-twentieth century, a lot of recommendations and interventions have been put in place to help reduce the incidence and prevalence of tobacco smoking. I will be dividing these into smoking cessation interventions and anti-smoking policies. Each of these will then divided into subgroups and analysed based on their effectiveness.
Smoking cessation interventions include
– Individual methods
Cut down to quit
– Psychosocial and Behavioural therapy
Self help materials
– Aversion therapy
– Alternative therapy
Nicotine Replacement Therapy Gum
Nicotine Replacement Therapy Patch
– Tobacco substitutes
Smoking herb substitutions.
Just as the name suggests, these methods are methods undertaken by the smoker himself usually after passing the pre-contemplation stage of behaviour change. Cold turkey refers to the abrupt stopping of an addiction and in this case, tobacco smoking. It is reported to have high quit rates and is the quitting method for about 80% of long term successful quitters in certain populations (Doran CM et al., 2006). It however has the disadvantage of having relatively higher relapse rates in comparison to the cut down to quit methods. This is possibly because a sudden withdrawal from a drug of addiction will lead to withdrawal symptoms which are uncomfortable and sometimes unbearable, leading the individual to resume his/her habit.
The cut down to quit approach on the other hand, involves slowly reducing the daily intake of nicotine. This can be achieved by either reducing the number of cigarettes or by repeatedly changing to cigarettes with lower nicotine content. Studies that have been conducted to compare these two methods have shown that the quit rates are comparable with no method having better results than the other (Lindson N et al., 2010).
PSYCHOSOCIAL AND BEHAVIOURAL THERAPY
Individually delivered smoking cessation counselling can assist in smoking cessation. This has been demonstrated by studies done by Soria et al (Soria R et al., 2006) and Stead et al (Lancaster T and LF., 2005)
The main objectives of group therapy are to analyse motives for group members’ behaviour, provide an opportunity for social learning, generate emotional experiences, and impart information and teach new skills. A review of sixteen studies comparing individual counselling and group therapy showed that while both groups are better than no intervention, there was no evidence that one was better than the other (Stead and Lancaster, 2005).
The self help method is dependent on materials that help to guide the smoker on the path to successfully quitting the habit. Such materials can include books, interactive web based programmes designed to help the individual quit. Standard self-help materials may increase quit rates compared to no intervention, but the effect is likely to be small. Also self help materials that have been tailored to a particular individual tend to be more effective than when not tailored (Lancaster and Stead, 2005)
This is the form of psychological therapy where the individual is exposed to a stimulus while simultaneously being subjected to some form of discomfort i.e. smoking is paired with negative sensations with the objective of quenching the urge to smoke. Of the 25trials reviewed by stead and Hajek, there was no conclusive evidence of the effectiveness of this method (Hajek and stead, 2004).
Acupunture and related methods
This is one of the oldest and most commonly used medical procedures in the world and involves the insertion of fine needles into specific acupuncture points. It is used in smoking cessation with the aim of reducing the withdrawal symptoms people experience after quitting tobacco smoking (White et al., 2003). Treatment involves inserting the needles at the acupuncture sites for about 15-20minutes at the time of cessation. Studies conducted by Clavel and Paoletti (Clavel, 1990), showed no significant effect of acupuncture on smoking cessation rates at 1week, 1month and a year in comparison to sham acupuncture which is acupuncture not intended to have any real clinical effect. However, studies by Cottraux (Cottraux et al., 1983) and Lamontagne (Lamontagne et al., 1980) showed an appreciable effect of acupuncture on smoking cessation in relation to having no intervention at all.
Laser therapy is a similar method to acupuncture but with the use of laser technology instead of needles.
Hypnotherapy is widely promoted as a method for aiding smoking cessation. It is proposed to act on underlying impulses to weaken the desire to smoke or strengthen the will to stop. Additionally, it is said to help with the withdrawal symptoms after quitting. A Cochrane review of eleven studies that compared hypnotherapy with eighteen different control interventions by Barnes et al (Barnes et al., 2010, Barnes J et al., 2010) revealed that there were conflicting results for the effectiveness of hypnotherapy when compared to no treatment, advice, or psychological treatment and direct comparisons of hypnotherapy to smoking cessation methods that were considered effective had a wide confidence interval, leading to inconclusive results about the effectiveness of hypnotherapy in comparison to no treatment and alternative methods. Barber however, emphasizes that “the single most important factor that will insure treatment success is the patient’s own interest in and motivation for success” and specifically, if a person desires to stop smoking, hypnosis aids the patient through withdrawal and encourages continued abstinence from smoking (Barber, 2001).
This is the treatment or prevention of disease by use of essential oils. It is believed our sense of smell plays a role in how it works. The “smell” receptors in the nose communicate with the limbic system of the brain that serve as storehouses for emotions and memories. When essential oil molecules are inhaled, some researchers believe that they stimulate these parts of your brain and influence physical, emotional, and mental health. The other is the direct pharmacological effects of the essential oils (Prabuseenivasan S et al., 2006). While precise knowledge of the synergy between the body and aromatic oils is often claimed by aromatherapists, the efficacy of aromatherapy remains unproven. Research on effectiveness of aromatherapy on smoking cessation by Kwon et al showed no statistical difference between the use of essential oils and placebo in relation to smoking cessation (Kwon GI et al., Jul 2001). However, some preliminary clinical studies of aromatherapy in combination with other techniques show positive effects.
NICOTINE REPLACEMENT THERAPY
This is the form of smoking cessation intervention that uses special products to give a steady dose of nicotine to help stop cravings and relieve symptoms that occur when a person is trying to quit smoking (Institute, 2009). NRT is available in a range of methods of administration which include nicotine gum, patches, inhalers, intranasal sprays and sublingual tablets, which may all vary in dose and method of administration. A review of various studies clearly suggests the effectiveness of NRT in any form in comparison to placebo or no NRT in increasing smoking cessation rates (Silagy C et al., 2004).
This can be said to be a drug in gum form. It has enough nicotine to reduce the urge to smoke. the nicotine is released while chewing the gum and slowly absorbed through the oral mucosa. This cuts down on withdrawal symptoms, making it easier to break the addiction. The dosage can be tailored to individual requirements, with people who are highly dependent benefitting from the 4mg dose form and people with low dependence benefitting from the 2mg dose form (Silagy C et al., 2004). The evidence related to NRT gum suggests that the efficacy of its action is inhibited by acidic beverages such as orange juice or grape juice (cessation, 2005).
This is placed over the skin and over a period of time, slowly releases nicotine which dissolve through the skin and enters the body system. They come in a range of strengths and are worn for various hours of therapy per day for the duration of a smoking cessation programme. This can relieve physical some of the physical symptoms associated with quitting tobacco smoking. Research by Fiore et al concludes that active patch subjects were twice likely to quit tobacco smoking when compared to individuals with placebo patches (Michael C. Fiore et al., 1994).
Other forms of NRT
Nicotine inhalers consist of a plastic mouthpiece which contains a rechargeable nicotine cartridge. The user is directed to inhale from the inhaler while holding it like a cigarette to intake nicotine and to relieve withdrawal symptoms and craving to smoke. Schneider et al conclude in their study of ‘the efficacy of a nicotine inhaler in smoking cessation’ that “The inhaler is clearly useful for short-term smoking cessation with potential for long-term efficacy. Extended access to the inhaler and relapse prevention training could improve success rates. Another promising approach would be to combine the inhaler with a nicotine patch.” (Schneider et al., 1996)
Nicotine lozenges are dissoluble tablets that are put in the mouth and allowed to dissolve with a similar mode of action as those already outlined above and has been studied to be an effective method for smoking cessation in low and high dependent individuals (Saul Shiffman et al., 2002). Nicotine sublingual tablets work in the same way but are placed sublingually.
Nicotine nasal spray is a nicotine containing liquid that is administered nasally.
This drug was initially intended for anti-hypertensive purposes but has been used in the management of withdrawal symptoms because of its ability to act on the central nervous system to help reduce CNS related withdrawal symptoms. Even though clonidine has been shown to be effective in smoking cessation, trials have been found to show a high incidence of dose related side effects including dry mouth and sedation with results having a wide confidence interval and as such it cannot be recommended in the presence of other alternatives (Gourlay et al., 2004, Gourlay SG et al., 2004).
Lobeline is a partial nicotine agonist, which has been used in a variety of commercially available preparations to help stop smoking. It effects its action by mimicking the effect of nicotine. A review of the available literature shows that there is no evidence of its effectiveness in smoking cessation (Stead LF and JR., 1997)
Antidepressants (Buproprion and Nortryptiline)
Buproprion is an atypical antidepressant which inhibits reuptake of dopamine, noradrenaline, and serotonin in the central nervous system, and is a non-competitive nicotine receptor antagonist. The exact mechanism of action is not clear but it is believed that its inhibition of dopamine, noradrenaline and serotonin is the way with it effects its action (Roddy, 2004). Though studies by woolacott et al have shown buproprion to be both clinically effective and cost effective (Woolacott et al., 2002), the clinical benefits of antidepressants are not strong enough to use as a frontline method for smoking cessation in the place of NRT (Hughes and Stead, 2007).
This is the type of tobacco is that is used without being smoked. It comes in two forms which are the snuff and the chewable tobacco. The smokeless tobacco has raised arguments about its use as a method for smoking cessation and also its link to malignancies. Smokeless tobacco has been linked with pancreatic and oral carcinomas (SCENIHR, 2008) and has been argued to be ineffective in smoking cessation. Smokeless tobacco products are addictive and their use is hazardous to health. Evidence on the effectiveness of STP as a smoking cessation aid is insufficient
The electronic cigarette is a battery powered device that provides inhaled doses of nicotine without actually smoking. It has generated quite a lot of controversy as many countries have banned its importation and even the WHO in a statement through its Assistant Director-General of WHO’s Non-communicable Diseases and Mental Health Cluster will not endorse it as a method of smoking cessation (WHO, 2008) as very little research has been done in this field and also.
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. The world bank fact sheet ‘tobacco at a glance’ lists 6 cost effective tobacco control interventions
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.
(World Bank, 2003a)
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 (World 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 (Tobacco Manufacturers 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
The warning signs on the tobacco pack are also an effective way of reducing the incidence and prevalence of tobacco smoking. 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 (World 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 1999 (Department of 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% 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 more likely falls into the first category. 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 (Royal College of 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 pharmacologica
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