Smoking still is a major cause of preventable illnesses and diseases related to the cardiovascular and pulmonary system, such as lung cancer. Despite these known health risks, 21% of the world population is smoking tobacco according to the World Health Organization (WHO) (“Tobacco Use,” 2016). This hasn’t to be so as addiction to smoking isn’t just a given biological circumstance, but a personal and social experience that can be influenced. The goal of this article is to look at tobacco consumption as a human behavior possible to address with holistic intervention combinations including biological, psychological, and social factors.
2 Why do people smoke? A biopsychosocial (BPS) evaluation
People start smoking tobacco often during adolescence as a developing psychosocial process. Group pressure from friends and the wish to appear mature and cool, and rebellion against the rules of the adult world may be reasons. Regularly continued cigarettes consumption develops into an obsessive behavior that today is attributed to nicotine as the main addictive behavioral factor for smoking persistence. It is then addiction that is individuals preventing from making cessation attempts at all or from succeeding over the long-term in such effort of quitting smoking.
West and Brown (2013) do define addiction as a disorder of motivation whose underlying pathologies can be associated with a (1) dispositional abnormal motivational system, (2) addiction caused abnormal motivational system, and (3) a motivational system that is unable to cope with specific distressful situations. Answers given by smokers for the reason why they smoke revealed the biopsychosocial composition of the motivational system of addiction. Reasons for continued smoking in a sample of pregnant women as captured with the Modified Reasons for Smoking Scale (MRSS) were “tension reduction, addiction, pleasure, habit and social function” (De Wilde et al., 2016, p. 403). In another study, the main perceived obstacle to quitting was worded “handling stress” (Dupont et al., 2015, p. 609).
From each cigarette, a nicotine dose reaches the blood, which is affecting brain neurochemistry. Nicotine as a psychomotor stimulant may have some calming and performance improvement (e.g., concentration) physical effects, as other drugs do too (Jarvis, 2004). However, for chronic smokers, these effects may diminish over time and smoking serve the satisfaction of the addiction only. Simply said, the addiction is the result of the brain’s reward system. Nicotine activates the production of dopamine in the brain that regulates reward-motivated behavior (Burke, Hays, and Ebbert, 2016). In other words, dopamine is required for the sensation of pleasure. If the supply of nicotine stops, the nervous system reacts with withdrawal syndromes such as “irritability, restlessness, feeling miserable, impaired concentration, and increased appetite” (Jarvis, 2004, p. 278).
Svyryd et al. (2016) found a statistically significant correlation between smoking behavior and gene variants in a Mexican population that is suggesting a specific genetic predisposition for smoking. There are other studies too that are searching for genes roles in the persistence of smoking. Genetics is playing an indirect role for smoking initiation and to a lesser extent also maintenance by the mechanism of gene dependent friend selection resulting for example in not only genetically similar groups but also a similar social environment regarding substance use (Wills and Carey, 2013). Furthermore, gender factors influencing smoking behavior may be pregnancy, menstrual cycle, and hormone variation, as well as different behavioral patterns in women with different potential effects on smoking compared to men.
When emotions create an unhealthy mental state dominance, compensation may be required. Psychological influences can moderate the effect of nicotine. Leventhal and Zvolensky (n.d.) describes vulnerabilities such as anhedonia, anxiety sensitivity, and distress tolerance. These emotional vulnerabilities are consistent with the above-mentioned pathologies related to defective motivational systems and may be regarded as underlying mechanisms that explain the link between emotional symptoms and smoking. For example, increased anxiety sensitivity may reinforce low motivation for smoking cessation or even pathologically undermine the motivational system. Anhedonia can increase cravings and amplify the effect of effect, e.g. when experiencing the feeling of relief from nicotine intake. The psychological vulnerability of distress tolerance would aggravate the reported main reason for the difficulty in quitting smoking (Dupont et al., 2015, p. 609) that is the loss of support in handling stress from smoking.
The processes impacting the condition of the motivational system, as suggested by West and Brown (2013), are “learning through reward and punishment and by associations; feelings of compulsion and desire; the exercise of self-control, beliefs, decisions and plans” (p. 5).
Borland et al. (2010) found that motivational factors’ relevance varies for smoking cessation attempts and smoking abstinence maintenance. They also demonstrated that remaining off cigarettes isn’t easily under volitional control to the smoker. Indeed the strength of nicotine addiction is often compared to that of other drugs like cocaine, hence the difficulty to overcome nicotine addiction with willpower. Rather, predictors for maintenance seem to be related to a non-smoking lifestyle (Borland et al., 2010). Changing one’s lifestyle eventually means a adopting a new identity, respectively giving up the smoker identity that was socially learned to potentially compensate for various factors as discussed in this article. Therefore the transition from a smoker to a non-smoker identity implies at the same time the need to balance possible motivational deficiencies and replace the smoking behavior with new sources of calming effects, anxiety reduction, and stress relief. There is a risk of difficulties in maintaining the personal belief system and keeping up self-esteem, which is especially relevant regarding self-esteem’s mediating effect on anxiety (Bajaj, Robins, and Pande, 2016).
The social dimension of a smoker’s identity as a smoker is significantly determining continuous smoking behavior in the sense that the bidirectional relation between the smoker and the social environment may have reinforcing effects on the smoking habit. For example, if there is a prevalence of smokers in a community, smoking can constitute a social norm to which its community members tend to continue to follow. Dupont et al. (2015) put it clear by saying in that context “that the stronger the identification, the greater the resistance to change” (p. 611). The socially learned habit of smoking would need to be unlearned under sufficiently supportive conditions, what could mean to reference a different social environment or to be prepared not to comply with the group’s norms related to smoking. Jarvis (2004) is confirming that family and broader social influences such as economy and politics are often playing a crucial role in determining smoking behavior. The same is true for socio-economic status. There is evidence that there is increased nicotine dependency in poorer people, for example, due to weak psychosocial education and reduced access to infrastructure promoting well-being and health care.
Other distressful social circumstances were identified by studies analyzing gender differences in smoking. As stated by Smith, Bessette, Weinberger, Sheffer and McKee (2016) women are more often victims of sexual harassment, as one example of psychiatric and social distress related to relationships and social contacts. Smith et al. (2016) also list barriers to smoking cessation that come from social and environmental injustices such as gender-based income and poverty gap that is related to distress and substance use (p. 139). The social environment has to be considered an external factor for self-esteem and confidence more or less supporting changes in lifestyle and long-term success in smoking cessation. Finally, the frequency of the smoking activity conditions an individual to habits that require change too. These habits are of psychosocial nature, whereas the social factor may be strong by involving a ritual-like character and even communicative component of spending social community time.
3 Different approaches to smoking cessation
Approaches to smoking cessation can be categorized into nicotine replacing therapies (NRT) and non-nicotine cessation therapies. Both NRT and non-nicotine treatments aim to reduce nicotine craving and mitigate withdrawal syndromes, and both cease the consumption of tobacco, although NRT’s are sustaining the nicotine provision according to a dosage plan. Examples of NRTs are nicotine nasal sprays, skin patches, nicotine gums, and nicotine inhalers. Non-nicotine smoking cessation therapies consist of Bupropion and Zyban. The withdrawal symptoms are reduced through brain nicotine receptor and reward system influence. Similarly, Varenicline is also inhibiting the reuptake of dopamine to break through the reward craving in the form of nicotine intake (Bailey and Mcaulay, 2012).
Approaches to pharmacological cessation therapies differ regarding applying single approach or combined approaches, e.g., the combination of NRT and non-nicotine treatments. A further option is to reduce smoking over time rather than quitting completely at once.
Psychological treatments address the psychological aspects of smoking motivations and related underlying vulnerabilities that lead to defective motivational systems with the goal to create the required mental factors to succeed in the smoking cessation attempt and in implementing a lasting non-smoker lifestyle. Smoking cessation counseling that is providing for positively influencing the psychological vulnerabilities mentioned earlier (anhedonia, anxiety sensitivity, and distress tolerance) seem to be fruitful. Examples of such treatments are for example Behavioral Activation (BA) that represents an approach reinforcing access to healthy and mood-enhancing habits (Leventhal and Zvolensky, n.d.), Positive Psychology therapies, and psychoeducation that enable self-management strategies, and exercises that enhance resilience related to withdrawal symptoms (Leventhal and Zvolensky, n.d.). Leventhal and Zvolensky (n.d.) is also mentioning the possibility for interventions to cultivate acceptance of experienced distress and withdrawal-based exposure exercises (p. 198). Considering the potential complexity and confusion for smokers of smoking cessation interventions, simple approaches are reported to be appealing for participants. Also, the challenge of low cessation success rates in general and the high costs involved, even email counseling should be considered as an effective means to enhance the chances for successful cessation compared to programs without counseling (Polosa, Russo, Di Maria, Arcidiacono and Piccillo, 2008).
Extending the psychological approaches to the social level, ideally, there were population-wide interventions to prevent and control tobacco misuse by addressing the whole motivational system comprising of impulses, desires, evaluations and plans as West and Brown (2013) are proposing. However, such interventions also may be considered in smaller contexts of smokers and involve education, self-help groups, and the removal of addiction triggers as far as possible.
4 Effectiveness of selected smoking interventions
Currently, Varenicline is tested to be the most effective aid for successful smoking cessation. In real-world settings, evidence was gathered that the use of Varenicline over several weeks was enhancing the chance of successful quit compared to NRT (Walker et al., 2016).
Positive Psychotherapy for Smoking Cessation (PPT-S) teaches smokers how to enjoy without reliance on smoking. The related mindfulness training resulted in increased smoking abstinence compared to U.S. Public Health Service clinical abstinence benchmarks (Leventhal and Zvolensky, n.d.).
It has proven effective to discourage smoking in communities and to implement non-smoking policies in public spaces where social interaction takes place (Jarvis, 2004).
5 Conclusion: Towards a smoke-free whole person identity
The article outlined different aspects for successful smoking cessation from a biopsychosocial perspective. Such an overview is important for finding the best combination of treatment approaches that fit an individual’s biological, psychological and social situation. For example, the combination of NRT and non-nicotine therapy including a smoking-specific counseling may provide for a whole person approach increasing the chance for successful smoking cessation. Although personalized and multi-factor treatment may seem costly and complex, first of all, the engagement of the smoker towards a self-reliable quit motivation should be the ultimate goal. Past low success rates of pharmacologically focused approaches and recently increased effectiveness, the emergence of smoking-specific positive psychological therapies, and the recognition of the challenge of a smoker’s identity change towards a non-smoker lifestyle all point toward increasingly holistic approaches. After medical and therapeutic adjustments of morbid and pathological conditions and the mitigation of the most severe withdrawal symptoms in the first time, it all boils down to an exercise of mindfulness that consequently results in a conscious and volitional choice of individual (habitual) behavior.
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