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Clinicians who want to encourage people to quit smoking are likely to be more successful if they have some understanding and empathy for why people start smoking and continue to smoke. This understanding and empathy is unlikely to come from experience as statistics show only 3.4% of New Zealand medical practitioners are regular smokers and 81.4 % have never smoked.1

In this article we look at what are commonly perceived by smokers as the “benefits” of smoking, along with some of the more significant barriers to quitting.

Why do people start smoking?

It has been estimated that 80% of adult smokers begin smoking as children, and about 30% of children have tried smoking by the age of 11.2

There is no single reason why young people begin to smoke.

Predisposing factors such low socioeconomic status, adverse childhood experiences and mental illness are generally not easily changed. Knowing about these factors is useful because they can help identify which young people might be at greatest risk for smoking and in greatest need of support to resist smoking.

Influencing factors provide the opportunity for young people to experiment with smoking. Friends and the presence of people around them who smoke are major influencing factors. Understanding these influencing factors is useful as many of them are able to be changed.3

It is important to ensure young people avoid starting to smoke in the first place as nicotine addiction can occur rapidly. In one study, 10% of children who became regular smokers showed signs of nicotine dependence within two days of first inhaling from a cigarette, and 25% within a month.4 Within a year of starting to smoke, it has been reported that children will be inhaling the same amount of nicotine as adults, will experience cravings when they do not smoke, will make quit attempts and will suffer withdrawal symptoms.5

Why do people continue to smoke?

Because of the effects of nicotine

The primary reason why people smoke is that they are nicotine dependent.

When inhaled, nicotine reaches the brain in 10 to 16 seconds (faster than if it was delivered intravenously), and has a terminal half life of about two hours. Given this short half life, regular cigarettes are required to maintain nicotine levels and avoid symptoms of withdrawal.

Nicotine activates nicotinic acetylcholine receptors in the midbrain, inducing the release of dopamine and exerting dependence producing effects, in a similar way to amphetamines and cocaine. Nicotine demonstrates a biphasic effect, meaning it can both invigorate and relax a smoker, depending on how often they smoke. In new users, nicotine improves reaction time and sustained performance, but tolerance soon develops and these effects are not seen in chronic users.

Nicotine withdrawal has significant physical and psychological effects starting within hours of the last cigarette and peaking within the first week.

Table 1: Symptoms of nicotine withdrawal5
Symptom Duration Incidence (%)
Lightheadedness <48 hours 10
Sleep disturbance <1 week 25
Poor concentration <2 weeks 60
Craving for nicotine <2 weeks 70
Irritability or aggression <4 weeks 50
Depression <4 weeks 60
Restlessness < 4 weeks 60
Increased appetite < 10 weeks 70

Because of the behavioural rewards

Continued smoking is also influenced by non-nicotine effects, including the sensory-motor effects of smoking as well as smoking-associated behaviours that become reinforced.

A person smoking a pack of cigarettes a day can accrue over 70 000 deliveries of nicotine per year. The sight, smell and sensations of smoking have a behavioural conditioning effect on the brain. While nicotine replacement therapy can be very successful in achieving smoking cessation, it does not address the non-nicotine effects of smoking.

Smoking has been shown to elicit a strong Pavlovian response for many people. For example, having a cup of coffee, concluding a meal, seeing another person smoke or smelling smoke may trigger the psychological desire to smoke. The Pavlovian response is considered a reason a number of light smokers, with low nicotine dependence, continue to smoke.6

Social norms play a role in continued smoking. In some cases this will discourage smoking, e.g. the increasing number of smoke free public areas and work places and the increasing number of smoke free messages. On the other hand, in groups where the smoking prevalence is high, this may constitute the social norm; therefore there may be less of an expectation to quit.

Because cigarettes help people deal with stress

Many people think they need cigarettes to help them relax and cope with stressful situations. Many smokers report they feel calmer and have improved concentration after a cigarette. However, it is more likely that declining nicotine levels begin to cause symptoms of withdrawal including agitation, and smoking another cigarette simply restores nicotine levels alleviating these effects.

It is also worth considering the actions associated with smoking. For example people may go outside to smoke, removing themselves from the stressful environment and creating an opportunity to “clear their head”. Furthermore, the smoke is often inhaled and exhaled in a slow and often deliberate manner – similar to relaxation breathing techniques. Each of these are useful methods in their own right for dealing with stress, so it may be useful to remind people they already have the skills to manage stress, even if they don’t realise it.

Because of concern of weight gain on stopping

Many people, especially young women, believe that smoking helps them to maintain a lower body weight. Following smoking cessation, weight gain occurs in approximately 75% of people,7 with an average gain of around 7 kg.8

It is thought some of this weight gained is caused by a decrease in metabolic rate following smoking cessation. In some people the metabolic rate may slow down even further and return to normal over a period of weeks or months.

The lifetime benefits of quitting

Many of the major risks associated with smoking decrease within two to five years of quitting smoking. For some conditions a residual risk remains and never returns to the level of a non-smoker. This is summarised in Table 2.

Following smoking cessation, many people have an increased appetite, which may last for two to three months.

There are also several behavioural aspects that may influence weight gain. Ex-smokers may miss the familiar mouth and hand actions of smoking and replace this with snacking. People that smoke to deal with stress, boredom or loneliness may replace their smoking rituals with increased food intake.

While smokers should be aware they may gain weight when they stop smoking, it is not inevitable. It is important to incorporate advice on a healthy diet and exercise into a quit-plan. However a recent Cochrane Review concluded that advice alone on healthy lifestyles is not effective and may reduce abstinence. More focused intervention is required.8

Table 2: Modification of risk upon quitting smoking (adapted from Dresler et al 2006)9
Disease Risk lower in former smokers than continuing smokers Time for risk reduction Returning to level of non-smoker
Lung cancer tick 5–9 years Never
Laryngeal cancer tick 60% after 10–15 years after cessation Not for at least 20 years
Oral and pharyngeal cancer tick Inadequate data 20 years
Stomach cancer tick Decreases with continued abstinence, lower risk associated with younger age at cessation Inadequate data
Pancreatic, renal cell, and bladder cancer tick Decreases with continued abstinence Pancreatic – 15 years
Renal cell – 20 years
Bladder cancer – 25 years
Coronary heart disease tick 35% in 2–4 years Variable: 10–15 years, others small risk after 10–20 years
Cerebrovascular diseases tick Marked reduction in 2–5 years Variable: some say 5–10 years, other say residual risk after 15 years
Abdominal aortic aneurysm tick Inadequate data Residual risk may always remain higher
Peripheral arterial disease tick Inadequate data Residual risk may always remain higher
COPD tick Improvement in FEV1 during first year After 5 years, the age related decline in FEV of ex-smokers reverts to that of never-smokers
Chronic bronchitis tick Symptoms reduce rapidly within a few months Prevalence of symptoms are same as never-smokers within 5 years

Barriers to quitting

There are a number of barriers that make it difficult for people to stop smoking. These barriers vary depending on age, gender and number of cigarettes consumed.

In a survey of 1500 smokers, over 80% wanted to quit, but factors such as enjoyment, craving and stress relief reduced their desire to attempt quitting (Figure 1).7

Figure 1: Barriers to quitting smoking (adapted from UW Center for Tobacco Research and Intervention, 2005)7

People who live with other smokers find it more difficult to quit and this is associated with a higher incidence of relapse.

Conclusion

Understanding why an individual smokes and what their barriers are to quitting will assist in counselling them to stop smoking and stay stopped.

People smoke because;

  • They are addicted to nicotine
  • Withdrawal from nicotine causes unpleasant symptoms
  • Smoking is associated with strong behavioural rewards
  • Smoking is perceived to help deal with stress
  • Concern about weight gain upon stopping

The Prevalence of Smoking in New Zealand

Contributed by Sharon Ponniah

Smoking is the single largest preventable cause of death and disease and is a major contributor to health inequalities. The burden of smoking on the public health system is substantial and approximately 5000 deaths are attributable to smoking in New Zealand every year. While a comprehensive approach to tobacco control including preventive health, education strategies and cessation interventions has been employed to reduce prevalence rates, wide social and ethnic inequalities in New Zealand continue.

Trends in smoking

Large decreases in the prevalence of smoking were observed between 1976 and 1990. These decreases have slowed and between 1996 and 2006, the prevalence of daily smoking in New Zealand decreased by 3% (from 23.7% to 20.7%), which represents around 100,000 less smokers.

The smoking population

A current snapshot of smoking in New Zealand indicates smokers to more likely be aged 20–49 years, identify with Māori and Pacific ethnic groups, have lower personal incomes and be unemployed. Smoking prevalence increases with level of socio-economic deprivation, a trend that is particularly marked among Māori.

Prevalence of daily cigarette smoking, 15+ years (%) by ethnic group and socioeconomic deprivation (NZDep06)
Deprivation decile European Māori Pacific Peoples Asian Other Ethnicity Total
Decile 1 10.8% 21.9% 19.9% 7.5% 9.7% 10.7%
Decile 2 13.7% 28.2% 24.2% 8.9% 12.1% 13.6%
Decile 3 15.4% 30.3% 25.8% 9.7% 13.3% 15.3%
Decile 4 17.1% 33.4% 25.9% 9.7% 15.1% 17.0%
Decile 5 18.8% 35.9% 26.9% 10.6% 16.3% 18.8%
Decile 6 20.8% 38.8% 28.8% 11.4% 18.3% 21.0%
Decile 7 22.8% 41.0% 28.9% 11.9% 19.7% 23.1%
Decile 8 25.5% 43.7% 30.6% 12.5% 21.9% 26.1%
Decile 9 28.1% 46.8% 31.2% 12.9% 23.9% 29.5%
Decile 10 33.9% 52.9% 32.8% 15.1% 27.6% 36.5%
Total 19.4% 42.2% 30.3% 11.1% 16.5% 20.7%
Source: Ponniah S, Bloomfield A. Sociodemographic characteristics of New Zealand adult smokers, ex-smokers and non-smokers: results from the 2006 Census. N Z Med J 2008;121(1284): 34-42.

References

  1. Ponniah S, Bloomfield A. An update on tobacco smoking among New Zealand health care workers, the current picture, 2006. N Z Med J 2008;121:1272.
  2. Conrad, Km, Flay BR, Hill D. Why children start smoking cigaretteS: predictors of onset. Br J Addict 1992;87:1711-24.
  3. Health Canada. Youth and Tobacco Report. 1999. Available from http://www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/youth-jeunes/index-eng.php (Accessed February 2009).
  4. DiFranza JR, Savageau JA, Fletcher K, et al. Symptoms of Tobacco Dependence After Brief Intermittent Use. Arch Pediatr Adolesc Med 2007;161:704-10.
  5. Jarvis MJ. ABC of smoking cessation. Why people smoke. BMJ 2004;328:277-9.).
  6. Thewissen R, Havermans RC, Geschwind N, et al. Pavlovian conditioning of an approach bias in low-dependent smokers. Psychopharmacology 2007;194:33-9.
  7. UW Center for Tobacco Research and Intervention. Barriers to Quitting Smoking. February 2005. Series 2, Paper Number 2. Available from: http://www.ctri.wisc.edu/Publications/publications/BarrierstoQuitting.2.28.pdf (Accessed December 2008).
  8. Parsons A, Shraim C, Inglis J, et al. Interventions for preventing weight gain after smoking cessation. Cochrane Database Syst Rev 2009;CD006219.
  9. Dresler CM, Leon ME, Straif K, et al. Reversal of risk upon quitting smoking. Lancet 2006;368:348-9.