2005-10-06

Health: Smoking is a Complex Addiction

Smoking is often characterised as little more than a bad habit with some nasty, self-inflicted side-effects. But in recent years a growing body of evidence has emerged to demonstrate that smoking is a very complex addiction... And, if cigarettes were invented today, former tobacco industry scientist and whistleblower Dr.Jeffrey Wigand, whose story was told in the film 'The Insider', is convinced they would be banned.
'Nicotine is five to six times more addictive than cocaine or heroin,' he says. 'Think of the way it is delivered -- the most efficient delivery system for any drug to a human is through the lungs.'
Professor Mr.Robert West, director of tobacco studies at the 'Cancer Research UK' 'Health Behaviour Unit' at 'University College London', says non-smokers may have difficulty understanding why people need cigarettes.
'Nicotine lies at the heart of it. 'What happens when you ingest nicotine from the lungs, as opposed to a patch, is you get a rapid nicotine hit which activates a part of the brain, which is talked about as a 'reward pathway'. 'That pathway's job is to say "what-ever you were just doing is a good thing to do -- do it again". 'It is the way animals have learned to adapt to their environment -- it's the way we can learn from our experiences. 'The fascinating thing about it is you don't even have to feel anything -- it's completely subconscious. 'What nicotine then does is distort this pathway to create a drive for nicotine, a bit like hunger. 'So, even if the more intelligent part of your brain is saying, "hang on a minute, I don't want to do this, it's going to kill me and it's costing me a fortune", that part of your brain is competing with this more basic mechanism. 'Those two come into conflict and which of them wins depends on how strong the various forces are. 'I would say to a non-smoker who is trying to understand what it is like to be a smoker, "stop yourself eating and see how you like it, because it is really tough".'
The level of dependency on cigarettes varies between individuals -- while some chain-smoke, others only smoke 'socially' and can take or leave it. Mr.West says much of this variation can be explained by genetic susceptibility to nicotine.
'If you are looking at the difference between why someone becomes nicotine dependent and someone else doesn't, although both have tried smoking, you will find about 50 per cent of the difference between them is due to genetic factors. 'But what seems to be clear is that your reaction and physiological reaction to nicotine is part of it. 'For some people it is quite strongly rewarding and it just doesn't do it for others.'
Besides a basic craving for nicotine, those smokers who do struggle to quit also have to overcome a range of other social and psychological factors if they want to give up, he says, not least the fact that cigarettes are widely available and many other people may be smoking around you. Mr.John Bery, a GP in Kirkcaldy, who helped draft Scotland's smoking cessation guidelines, says those who started smoking at a young age may find it more difficult to quit.
'People don't realise how addictive it is. They start smoking at 12 or 13 because they think it's cool and then they are caught in an addiction they find very difficult to get out of. 'These are the people who concern us most, because they are the ones who will most probably end up with a chronic disease and the ones who find it remarkably difficult to give up.' 'Someone who is at university who starts smoking at 23 by having a few fags in the bar is in a very different environment to someone who starts smoking in the bike sheds at 12 or 13.'
Mr.West, who also helped draft the guidelines, says the best chance of quitting lies in accessing National Health Service (NHS) smoking cessation services.
'Scotland has really excellent smoking cessation services, which are free. People can get nicotine replacement or Zyban on the NHS. And it's nothing wacky, you don't have to stand up and say, my name's Robert West and I'm a smokaholic. It is very practical, it's evidence-based and it does work.'
Ms.Nicky Connor, smoking cessation co-ordinator for 'Kirkcaldy and Levenmouth Community Health Partnership', says smokers have to be realistic about their chances of quitting. But, with treatment and support, they can maximise their chances.
'If you look at the evidence, somebody who had no treatment at all and just stops 'cold turkey' has a 5 per cent chance of quitting. 'If somebody has face-to-face behavioural support, and also uses medication, that increases to more than 20 per cent. 'A lot of people need several attempts to stop smoking. There is a cycle of change you go through. A lot of it is about learning from past experience. 'What's recommended is that, at least one or two weeks before you stop, you set a quit date. When you access a smoking cessation service, they will assess your dependency and probably measure carbon monoxide, discuss a treatment plan and look at suitability for medication, and set positive but realistic expectations. 'You would give advice on common withdrawal symptoms. We use the philosophy that the more prepared people are, the better.'
She adds that, while nicotine leaves the body within 48 hours, psychological withdrawal symptoms can last several weeks.
'The withdrawal can start within 20 minutes and take up to four weeks. 'It is a long period of time. A lot of people can experience things such as irritability, or a dip in mood, which can last for four weeks. 'Things like waking up in the night or feeling cravings might last for only one or two weeks. 'Smoking also has a very strong social and psychological component; people smoke for different reasons and there are different triggers. The average person who smokes 20 a day puffs on a cigarette 200 times -- they do it when they socialise, they do it when they're stressed -- and when they get around to stopping they have probably smoked for years.'
When the health risks are so well publicised, the motivation should be there for many people to quit, or not to start smoking. But Mr.Bery says younger people do not usually care about their future health and dire warnings don't always work.
'People have said in the past, if you don't stop smoking, your leg is going to fall off, or you are going to have another heart attack. I agree that that sort of approach can work with some people, but it can be highly counterproductive with others.'
Professor Mr.Alan Rodger, medical director at 'The Beatson Oncology Centre' in Glasgow, suggests that instead of focusing on the risks, perhaps the spotlight should shift towards encouraging people to ask themselves why they smoke.
'You might say, well, what is the point of smoking? 'When you smoke, you are turning yourself into an addict -- do you want to do that? And is there any pleasure to be gained from it other than assuaging the withdrawal symptoms and giving you the kick from nicotine? 'Is it a stylish thing to be seen doing? 'Is there a style to smoking? 'What about the young girls who are smoking more than young boys? 'Is it because they think it is an appetite suppressant that will keep them slim? 'Is it wise to try to stay thin by giving yourself something that will take a significant number of years off your life if you don't stop? 'We are seeing 50 per cent of smokers who have smoked for 40 years -- so that's usually in their late fifties -- dying from their smoking.'
Professor Mr.Gerard Hastings, director of 'The Institute of Social Marketing and Centre for Tobacco Control Research' at Stirling University, agrees that there is a danger that the health warnings can backfire.
'We are very complex beings, and there is some attraction in the very fact that it is bad for you. It is kind of edgy to go down that route, and you are rebelling in quite an obvious way. 'What we have got to head towards is a situation where tobacco is, for everybody in Scotland, beyond the pale.'
For more information visit www.clearingtheairscotland.com or www.ashscotland.org.uk
'I was spending 30_GBP/week' CASE STUDY: QUITTING 'COLD TURKEY' When the price of cigarettes went up yet again earlier this year, Mr.Josh Jones decided he was wasting far too much of his hard-earned money on feeding his nicotine addiction. After ten years as a smoker, the 25-year-old civil servant made up his mind to quit two months ago, and has not had a cigarette since. But he admits it wasn't easy.
'When I gave up, I was smoking about 14 or 15 cigarettes a day, so it was quite a lot. I could smoke at work, though you had to go outside.
'I'm used to smoking outside, because I live with my girlfriend and I don't smoke in the flat -- she does smoke, but only when she's out.' 'Although you're told it damages your lungs, that doesn't really affect people my age, so the reason I stopped was the cost.
'It was getting to be almost a fiver a packet or about 30_GBP/week.'
Josh didn't like feeling that he was controlled by his need for cigarettes.
'The thing is you are like an addict. I would wake up and have a set routine in the morning where I would always have a cigarette on the way to the bus stop and I'd probably have two before 07:30. During the day, I'd have certain times where I'd have one.'
Josh decided not to use nicotine replacement therapy, because he was worried about the cost.
'I just decided to "go cold turkey" -- I had no help or any leaflets or advice. I did get withdrawal symptoms. I felt generally "crap". I was always clammy, and uncomfortable and fidgety. 'After a week or so, I started feeling "totally rubbish" and I kept thinking something was missing -- I was dying for a cigarette. I had a cold for about two weeks and I'm sure that had something to do with it. 'But I was prepared for it and I am well past the worst; I don't crave one until I have a drink or I am sitting next to other smokers. 'I have definitely done the right thing; I play football two or three times a week and I can run a lot further now. 'I have only given up for about two months, but I am pretty proud of myself.'
Giving up 'cold turkey' What is it? 'Cold turkey' is nothing more than good old-fashioned willpower alone. But only highly motivated and determined people can quit using this method. Nicotine is out of the system after 48 hours, and the most intense cravings will be in the first two or three days. However, smokers quitting this way should be prepared for withdrawal symptoms to last for two or three weeks as they kick the habit. Does it work? Studies have shown that quitting using willpower alone has a success rate of around five per cent. But most people who successfully quit do give up using this method. If you have tried and failed giving up smoking this way, remember there is help available on the NHS, in the form of nicotine replacement therapy (NRT) or Zyban, as well as the advice and support from trained smoking cessation workers. How much does it cost? The good news is that 'going cold turkey' is completely and utterly free of charge -- although the high relapse rate means you might end up spending more on cigarettes in the long run. What do the experts say? There is no doubt that 'cold turkey' can work for some people who are determined to give up. Professor Mr.Alan Rodger of 'The Beatson Oncology Centre' says:
'It is up to individuals. Long before nicotine replacement therapy, people went cold turkey and for some people it works. NRT seems to be an improvement on that, and counselling and support seems to be even better if you do the two together.'
Smoking your looks away Smoking doesn't just damage internal organs like the heart or the lungs, it can also age the appearance to the point where physicians don't need to look at a patient's medical notes to know whether someone lights up. Some look for the 'Rothman's sign' to spot patients who smoke -- it's a slang term for tar-stained fingers. The smell of cigarette smoke on someone's hair, clothes and breath are also hard to disguise. Premature ageing of skin is common in smokers, because it reduces both the amount of oxygen in the blood and collagen. The skin may become 25 per cent thinner than that of non-smokers, leading to a 'hardening' of the features. Many smokers will have deep lines around the eyes and mouth, and their complexion may appear grey or yellow. And repeated puckering of the lips can leave tell-tale lines. Medical experts hope to appeal to younger smokers' vanity. In his 2003 annual report, England's Chief Medical Officer, Sir Liam Donaldson, said 'smokers' skin can be prematurely aged by between ten and 20 years. Smoking discolours the teeth and is also a major cause of oral cancer and gum disease, which can lead to tooth loss. For more information visit: hebs.com or clearing the air scotland.com 'Why don't we realise how addictive smoking is?', Jennifer Veitch, The Scotsman, 2005-10-05, We Links: Scottish Exec smoking in public places consulation Scottish Executive tobacco control action plan ASH Scotland FOREST

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