Health Psychology

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Health Psychology

• Smoking
• Chapter 7
• PY470 - Hudiburg

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Who Smokes? F 7.1, p. 215
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Who Smokes?

• 20.9 of American adults about 45.1 million
  (CDC 2005) slight decline since 2003 (21.6).
• Rates higher in Males (23.9) than Females
  (18.1), highest in American Indian (32.0) White
  (21.9), African Americans (21.5), Hispanic
  Americans (16.2) and Asian Americans (13.3).
• Rate drop since mid 1960s (42.4) but rate has
  dropped slightly since 1990 (25.5).
• Which state has the highest rate and which state
  has the lowest rate? Where is Alabama, Tennessee,
  and Mississippi?
• Smoking related to education and SES F 7.2, p.
  216
• 1.3 million quit each year
• 3,000 teens start each day, 70 of adult smokers
  started in adolescence Johnston et al. (1998),
  but use decreasing
• 8th grade (9.3), 10th grade (14.9), and 12
  grade (23.2) - 2005
• 8th grade (19.1), 10th grade (27.9), and 12
  grade (33.5) - 1995
• There are more ex-smokers (52.4) than current
  smokers (20.9).

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Prevalence of adults (18 and older) smoking in
U.S. 2004 2006 CDC MMWR report
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Health Effects of Smoking

• Heart disease
• Lung disease COPD, asthma
• Cancer
• Lung, ENT, pancreas
• Cervix, colorectal
• Skin (squamous cell)
• Vascular disease - impotence
• Stroke
• Cataracts
• Gum disease
• Dementia
• Early menopause

• Osteoporosis
• Wound healing
• Anxiety
• Miscarriage
• SIDS
• Hearing loss
• Rheumatoid arthritis
• Macular degeneration
• Tooth decay
• Depression
• Multiple sclerosis

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What are the health consequences of smoking?

• Leading cause of preventable mortality
• Smoking related illnesses cause 440,000 deaths
  per year, CDC (2003)
• These deaths occur 12 years earlier than would be
  expected, so the aggregate annual loss exceeds 5
  million life-years.
• Linked to numerous types of cancer cause by
  smoking 155,000 deaths per year among smokers
• The majority of cancers of the lung, trachea,
  bronchus, larynx, pharynx, oral cavity, nasal
  cavity, and esophagus from tobacco
• linked to increase risk of developing heart
  disease and strokes
• linked to other major illnesses
• linked to numerous pregnancy complications

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What are the health consequences of smoking?
(cont.)

• What causes the health consequences of smoking?
• constricts blood vessels
• increases heart rate and blood pressure
• increases cardiac output
• hardens the arteries (arteriosclerosis)
• disrupts the ability of the cilia to clear lungs

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TOBACCO KILLS
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Healthy lung Smokers lung
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Oral CancerSquamous cell Leukoplakia
buccal mucosa of heavy smoker
90 are squamous cell carcinomas
buccal mucosa smoker of 2 packs/day
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Erythroplakia

• Patient has long history of chronic white and red
  lesions of soft palate
• more likely for malignant transformation than
  white patches

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Smoking changes BLACK HAIRY TONGUE

• BLACK HAIRY TONGUE
• Overgrowth of filiform papillae
• can be black, brown or yellow.
• will disappear on cessation of smoking

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Smoking concerns

• Smoking and pregnant women lower birth weight
  of child, ? miscarriage, ? rates of ADHD,
  hyperactivity, and SIDS MacDorman et al. (1997)
• Passive smoking (second-hand smoke) is a serious
  problem
• Effects on children infants respiratory
  problems CDC report
• Almost 60 percent of U.S. children aged 311
  yearsor almost 22 million childrenare exposed
  to secondhand smoke.
• About 25 percent of children aged 3-11 years live
  with at least one smoker, as compared to only
  about 7 percent of nonsmoking adults.
• Secondhand smoke exposure is responsible for an
  estimated 150,000300,000 new cases of bronchitis
  and pneumonia in children aged less than 18
  months, resulting in 7,50015,000
  hospitalizations.
• The California Environmental Protection Agency
  estimates that secondhand smoke exposure causes
  approximately 3,400 lung cancer deaths and
  22,70069,600 heart disease deaths annually among
  adult nonsmokers in the United States.
• Maternal smoking 700 SIDS cases each year in
  U.S. Grunberg at al. (1997)

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Chemistry of tobacco smoke

• Cigarette smoke is composed of volatile and
  particulate phases.
• Contains some 500 gaseous compounds including
  nitrogen, carbon monoxide (CO), carbon dioxide,
  ammonia, hydrogen cyanide and benzene.
• There are about 3,500 different compounds in the
  particulate phase, of which the major one is the
  alkaloid nicotine.
• The particulate matter without its alkaloid and
  water content is called tar.
• Many potential cancer inducing substances have
  been identified in cigarette tar.

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Nicotine

• Nicotine is an amine consisting of two rings
  (pyridine and pyrrolidine)
• Two stereoisomers of nicotine
• (S)-nicotine is the active isomer which binds to
  nicotinic cholinergic receptors and is found in
  tobacco.

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Absorption of nicotine from tobacco products

• Small droplets of tar containing nicotine are
  inhaled and deposited in the small airways and
  alveoli of the lungs.
• Nicotine is a weak base absorption across cell
  membranes depends on the pH
• When nicotine reaches the small airways and the
  alveoli of the lung, it is buffered to
  physiological pH
• Absorbed into the pulmonary alveolar capillary
  and venous circulation
• Nicotine is distributed quickly throughout the
  body.

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Nicotine dosage delivery forms

• Speed of delivery of nicotine from cigarettes is
  fast, providing nicotine 'hits' to the brain
  within 10 -19 seconds of smoke delivery to the
  lung
• Cigarettes are designed to ensure the delivery of
  nicotine to maximises the addictive effect
• http//www.washingtonpost.com/wp-dyn/content/
  article/2006/08/30/AR2006083001418.html
• Cigarettes can readily deliver approximately 1-3
  mg of nicotine, as desired by smokers
• The smoker can manipulate the intake of nicotine
  from different cigarettes to achieve and maintain
  the desired level of nicotine
• http//home.att.net/rdavis2/cigra.html
• nicotine, tar, carbon monoxide by brands
  (U.S.)

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Stop smoking?

• Two-thirds of smokers would like to quit
• 30-33 try to quit in any year, 2/3 smoke in two
  days, 97 in 6 months
• Only about 2 succeed
• Relapse rate lower in smoking cessation programs
  with 20-30 success in long-term abstinence
  Cohen et al. (1989)
• Over 40 continue to smoke after laryngectomy,
  more 50 after a heart attack
• Smokers make repeated attempts with a period of
  abstinence followed by relapse

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How do psychological factors lead to the
initiation of smoking?

• To try out a new identity - adolescents
• glamorous, older and more mature grades 5 to 7,
  need of role models
• Distinct personality types Burt et al (2000)
• risk-takers (sex, drugs, etc.), extraverted
• higher rates of depression Windle Windle
  (2001)
• weight concerns (for women in particular) 7 to
  10 graders smoke with weight issues
• Social factors
• modeling and peer pressure, more likely if a
  friend smokes Mittelmark et al. (1987)
• Smokers get more offers of cigarettes (4.22/week)
  v. non-smokers (.16/week) Ary Biglan (1988)

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How do psychological factors lead to the
initiation of smoking?

• Family history of smoking 26.6 (smokers) v.
  12.6 (nonsmokers) as adults Chassin et al.
  (1998)
• NASCAR changes Winston Cup to Nextel
• Media influences movies and product placement
• Box 7.2, p. 220-221
• JAMA study of 50 G rated films, 56 had tobacco
  use and all films during 1996 to 1997
• http//scenesmoking.org/
• http//smokingsides.com/asfs/m/
• Joe Camel study Grunberg et al. (1997)

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What constitutes addiction?

• Addictive drugs exhibit two important
  characteristics
• They cause effects within the brain which are
  pleasant or rewarding, and which reinforce
  self-administration of the drug in both
  experimental animals and human beings
• Following a period of chronic exposure,
  withdrawal of the drug may cause an abstinence
  syndrome which an addict may also seek to avoid
  by continuing to take the drug.

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Does nicotine use through smoking meet diagnostic
criteria for addiction?

• A strong desire to take the drug.
• Difficulty in controlling use.
• Continued use despite harmful effects
• Tolerance need larger dose 2/4 cigarettes
  initially but need 20/40 cigarettes after long
  term smoking
• Withdrawal
• Substance taken in larger amounts or longer than
  intended
• A higher priority given to drug use than to other
  activities and obligations
• A great deal of time is spent in obtaining, using
  or recovering from effects of substance

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Ranking of nicotine in relation to other drugs in
terms of addiction
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Markers and measures of dependence in smokers

• Daily cigarette consumption
• Time to first cigarette of the day
• Smoking even when ill
• Smoking more in the morning
• Difficulty not smoking in no smoking areas
• Which cigarette would hate to give up?
• Those who smoke more cigarettes per day are less
  likely to be able to stop

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Consequences of nicotine addiction

• Morbidity and mortality caused by active and
  passive smoking
• Smoking prevalence is higher and nicotine use
  heavier among poorer smokers.
• This difference in smoking behavior accounts for
  about two-thirds of the excess premature
  mortality associated with deprivation.
• Nicotine addiction is therefore responsible for
  significant health inequalities

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Tobacco and nicotine addiction

• The unique selling point of tobacco is its
  nicotine content.
• Tobacco products without nicotine are not
  commercially viable.
• Nicotine is an addictive drug.
• The purpose of smoking tobacco is to deliver a
  dose of nicotine rapidly the brain.

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Nicotine withdrawal

• Withdrawal syndrome is a collection of signs and
  symptoms caused by abstinence.
• Nicotine or cigarette withdrawal?
• Nicotine replacement reduces severity of
  withdrawal symptoms.

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Nicotine-based models

• Nicotine fixed-effect model
• nicotine has many reinforcing physiological
  effects
• smoking feels good, so people continue to smoke
• F 7.4, p. 223 Schachter et al. (1977) heavy
  smokers more low nicotine cigarettes in 2 week
  period when High smokers given low nicotine
  cigarettes were more irritable and anxious
• Nicotine regulation model
• smoking is rewarding only when level of nicotine
  is above a set-point
• smokers must smoke to maintain a certain level of
  nicotine to feel good
• Limitations
• based on these models, quitting should be easy
• ignores environmental pressures
• nicotine replacement methods are not 100
  effective

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Affect-regulation model

• Developed by Tomkins (1966, 1968)
• Smoke to attain positive affect or to avoid
  negative affect
• Box 7.3, p. 226 studied stress on smoking
• Leventhal Avis (1976) dipped cigarettes in
  vinegar persons motivated by pleasure smoked
  significantly less than usual persons not
  motivated by pleasure smoked a the same level
• Relaxation and coping with anxiety
• Depression and smoking 40 less likely to quit
  as compared to non depressed
• Schachter et al. (1977) found more stressed
  students smoked more cigarettes and puffed more
  the difference was profound for heavy smokers.

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Combined models

• Psychological/physiological factors combined
• Predicts that smoking initially used to regulate
  emotions and over time links how smokers feel in
  how much nicotine they have in the their blood
• Can be paired with both positive and negative
  emotional states
• Biobehavioral model Pomerleau Pomerleau
  (1989)
• Both psychological and physiological factors lead
  people to continue to smoke makes them feel good
  physiological effect ? dependence
  (psychological physiological) to use nicotine
  to experience positive emotions
• nostalgia for smoking estimated 8.5 month
  half-life -- cause of relapse over 1st year

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What are some strategies for preventing smoking?

• Targeting adolescents many studies
• The message is not relevant they will quit
  before long-term consequence
• If at risk ? smokers focus on short-term benefits
• Social influence programs Flay (1987)
• Short-term effects ? more effective in altering
  the attitudes
• Types of persons who smoke duped by advertisers
  saying no ? independent and self-reliant
• Overestimates of norms in adolescent smoking by
  adolescents
• Best et al. (1989) 6th graders who received
  social influence training less likely to smoke in
  the 8th grade

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What are some strategies for preventing smoking?

• Life Skills training
• Assumption is that lack of self-esteem and
  self-confidence ? increase smoking
• Smoking to feel better about themselves
• Training enhances self-esteem
• Batvin et al (1984) gave 15 life skills sessions
  to 7th graders, this group smoked less after 1
  year (10 ) v. 22 for no training group

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What are some strategies for preventing smoking?

• Problems
• Problems with continuing effects increase
  levels of smoking as students progress through
  grades need of booster sessions in HS
• Mass media approaches are least effective Box
  7.4, p. 231 adds run at low viewer times
• U.S. tobacco companies spend 7.12/person for ads
  but only .50/person for prevention
• Government programs are not very effective
• Cigarettes are easy to get but increase cost
  (10) might lead to decrease use Tavas et al.
  (2001)

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Benefits after quitting

• Health benefits
• cough, DOE resolve in weeks
• exercise tolerance improves rapidly
• bladder cancer 50 reduction in 5 years
• lung cancer 50 reduction in 10 years
• heart disease 50 reduction in 1 year!
• No excess risk of heart disease by 10-15 years
• vascular disease 50 reduction in 5 years
• mortality - same as never smokers by 10-15 yrs
• Non Health benefits
• COST!!!
• inconvenience
• self-esteem
• role model

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Smoking cessation

• Treatment options
• Level of use lt 1 pack/day have many attribute
  that might lead to successful cessation
• gt 1 pack/day more difficult to quit
• Motivation, social support and advice
• Weight gain concerns 1/3 gain 5 8 lbs. -
  Jeffery et al. (2000) those not concern 21
  cessation v. 13.1 for those concerned with
  weight gain
• Gradual reduction less nicotine in cigarettes
  49 success v. 22 cold turkey
• Treatment products such as NRT, bupropion the
  patch and gum - Box 7.6, p. 234 235 chain
  chewer

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NRT Bupropion (Zyban)

• Stop or reduce the symptoms of nicotine
  withdrawal.
• Assist in stopping smoking, but without having
  unpleasant withdrawal symptoms.
• Do not 'make' the client want to stop smoking.
• Still need to address the psychological issues
  combine with counseling
• Still need motivation and determination to
  succeed in breaking the smoking habit.

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NRT Bupropion

• Inhalator - 10mg cartridges
• Gum - 4mg, 2mg mint, original or fruit
• Patch - 16hr 15mg, 10mg, 5mg and
• 24hr 21mg, 14mg, 7mg
• Microtab - 2mg
• Lozenge (2 types) - 1mg, 2mg, 4mg
• Nasal Spray - 0.5mg per spray
• Bupropion (Zyban)
• 150mg per tablet

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Smoking cessation

• Treatment options
• Aversion strategies
• Rapid-smoking method take a puff every 6 seconds
  creating an aversive stimulus
• Electric shock pairing - ? rates of cessation
  Welter et al. (1998)
• Self-management stimulus control of situations
  for smoking or not smoking
• Stimulus substitution taking a walk after
  dinner, chewing gum
• Contingency-contracting give money to someone
  who give it back if cessation goal is reached
• Large scale programs varying success may
  initially reduce smoking but usually returns
  Gomel et al. (1993)