Quitting smoking without help is hard: Effects of motivation and other personality factors

Quitting smoking is hard, but that suggestion probably isn’t terribly exciting all on its own since most of our readers probably knew it already. Still, while we’ve talked about quitting smoking using nicotine replacement and medication, we haven’t really touched the subject of all those people out there who just decide to give quitting smoking a try one day without those patches, gums, or pills.

Since something like 95% of those who try their hand at quitting smoking relapse within one year, and most of these people try to quit unaided, I think this is an important topic to touch on. Fortunately, recent research conducted in the U.K. tried to assess the personality and cognitive aspects that end up predicting who will succeed, or fail, in their quit attempt.

The effects of expectation, motivation, and impulsivity when quitting smoking

Quite a bit of research has already shown that when smokers are trying to quit (so we’re talking early on during abstinence), their brains react differently to stimuli in the environment depending on the relationship between those stimuli and nicotine. Stimuli that aren’t associated with smoking (or some other form of nicotine intake) get less attention and show overall less activation of important brain circuits while nicotine associated cues light up the brain just as if nicotine was on board (even though participants were drug free at the time). Essentially, if a stimulus predicts getting a hit, the brain gets smokers to pay attention to it so that they can do whatever is necessary and get a little drug in. Throw in some of that reduced ability to control behavior that we talk about so much (like impulsivity), and which is common not only in smokers but in users of almost every other drug (heroin might be the exception) and you have a recipe for disaster, or at least for a good bit of smoking relapse. And yet if we want to fight the horrible health consequences of cigarettes, then quitting smoking has to be made easier, which nicotine replacement and medications like bupropion have done to some extent.

As part of this equation, knowing the specific predictors of early relapse in people who are quitting smoking may be useful so that professionals planning smoking interventions can do a better job of targeting the most important factors. The study recently published the journal Psychopharmacology tried to assess the relationship between the severity of smoking, the above-mentioned personality factors, and the success of the quitting attempt.

The cool thing about this study is that the 141 people who participated were assessed on a whole set of these cognitive tests twice – once after a smoking free night and a nicotine lozenge and another time after a smoking free night followed by a nicotine-free lozenge. While they couldn’t tell which was which, the procedure gave the researchers an assessment off how different participants’ reactions were with or without nicotine on board. Following the assessments participants were directed to begin their attempt at quitting smoking. While they were asked not to use nicotine replacement options or other medications, they were allowed to use any other resource available and were given a set of information pamphlets that explained expected side effects and likely difficulties during the quit attempt. They were then followed up after 1 week, 1 month, and 3 months. Quitting was identified as minimal smoking (less than 2 cigarettes per week) and was verified both by self report and cotinine testing. There was a small financial incentive to quitting, with people who relapsed after a week getting only £40 (about $60) and those who made it through month 3 getting £150 (about $250), though I’m pretty sure that if $200 was enough to make people quit we’d have just paid up already…

The first thing to note in the results was that 24% of the participants were still not smoking at the 33 month followup. This seems to be about on par with the usually low success rates at 1 year though I’m sure this research group will try to continue following these participants at least up to the 1 year mark and hopefully produce another paper.

The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interfering with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After the 1-week follow-up, at the 1 and 3 month assessment, the odds of quitting had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.

The take-home: Quitting smoking is hard for different reasons in the first week and later on

If you’ve ever tried to quit you’ve been told you that the first week is the hardest and that once you make it through that the rest is a piece of cake. While this research doesn’t necessarily support that notion, since about 25% of the sample relapsed between each of the followups, it does seem to indicate that the reasons for relapse change after that first week.

It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking seems to be associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward.

Overall, these findings suggest that the cognitive function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.

Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can reduce relapse numbers at 1 week we can have a more gradual fall-off for the following month resulting in significantly higher quit rates.

Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medications like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?

Citation:

Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.

 

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The first thing to  note in the results was the 24% of the participants were still not smoking at the 33 month followup. This seems to be about on track for the normally low success rates at 1 year though I’m sure this group will try to follow these individuals up at that point and hopefully produce another paper. The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interruption with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After that point, at the 1 and 3 month follow-ups, had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.

The take-home: Quitting smoking is hard for different reasons in the first week and later on

If you’ve ever tried to quit you’ve heard someone telling you that the first week is the hardest and once you make it through that the rest is a piece of cake. Well, this research doesn’t really support that notion since about 25% of the sample relapsed between each of the followups, but it does seem to indicate that the reasons for relapse change after that first week. It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking was associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward. Overall, these findings suggest that the brain function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.

Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can bring the relapse numbers down at 1 week we can have a more gradual fall-out for the following month resulting in significantly higher quit rates. Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medication like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power that nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?

Citation:

Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.

Talking to kids about teen smoking: The FTAS (Family Talk About Smoking) paradigm

Newsflash: Kids don’t like being preached to – especially when it’s done hypocritically

A recent study assessed the impact parents have over the decisions their teenagers make concerning whether or not to ‘experiment’ with smoking cigarettes and to continue smoking in the long term, once they have tried it.

Experimenting with smoking represents a form of risk-taking for some teens while it can serve as the onset of long-term chronic cigarette smoking for others. Deciding which group a given teenager is a part of during the initial stage of experimentation is difficult, and figuring out whether it is possible to influence the trajectory of future behavior in teens is the focus of this line of research. The researchers theorized that variations in communication between parents and their teenagers might shine some light on these all-important issues.

So the researchers developed the Family Talk about Smoking paradigm, or FTAS, a method of standardizing the interaction and communication between teen smokers and their parents who had either smoked in the past or currently smoke. It’s a neat method that allowed them to study parent-teen interactions in a natural setting.

What is the FTAS – Assessing parent-teen communication

The FTAS is a 10-minute, semi-structured family interaction paradigm. It employs using a flip card the parent or teen are asked to read to one another. They take turns and each flip card initiates a conversation ‘trigger’ designed to stimulate smoking-related conversation. The cards focused on five triggers: a) “How people in our family feel about cigarette smoking,” (this is read by the teen), “My experiences with cigarette smoking” (by the parent), “How today’s teens make decisions about cigarette smoking,” (by the teen with this wording used to break open discussion without forcing teen to expose his own experience unless he wants to), and “What parent do if they find out their teen has become a smoker” (by the parent).

The families were given 10 minutes for each topic and were encouraged to use the entire time. Some families used the full ten minutes for some topics, and used less for others while other families sped through them all without lingering on specifics.

It may seem a little contrived and forced, but steps were taken to allow free-flowing conversations between parents and their teens. The FTAS discussion took place in the home environment in order to make the family more comfortable and there was a warm -up exercise to get everyone talking about their family life. When the time came for the FTAS discussion, the field staff left the room and observed the interaction remotely.

So, let’s look at what was measured.

A coding system was used to measure the:

  • Level of disapproval the teenager received from the parent
  • Just how clearly the parent elaborated on consequences for smoking cigarettes
  • Whether the parent conveyed to the teen that he expected she would or wouldn’t be a smoker
  • The quality of personal disclosure by the parent about his own smoking struggles or non-smoking

The teens and their parents were assessed initially and were then revisited 6 months after the baseline assessment to determine whether the family’s communication affected teen smoking 6 months later. It’s important to note: 90% of parents involved in the study had had some involvement with smoking at some point in their lives.

The patterns of communication between the teens involved in the study and their parent(s) varied depending on whether the teen (and his parent ) were smokers themselves. The teen’s receptivity to his parent’s attitude and communication about teenage smoking, and about his/her particular smoking, was directly affected by whether the parent smoked currently, or in the past, and what the parent’s attitude about it was as well as how openly the parent opened up to his teen about it.

While the study was a controlled assessment of teen-parent communication about smoking cigarettes, it’s important to note its implications for family communication about substance abuse, and other taboo issues. There’s no doubt that communication is extremely important when it comes to these topics and that open communication often leads to better outcomes than ignoring or avoiding these issues.

The results – Talking to teens about smoking can help if it’s done right

Communication patterns and their effect depended greatly on who the teen was speaking to – with mothers, expressing more positive expectancies about cigarette smoking predicted more persistent smoking while with fathers more disapproval during conversations predicted lower chances of persistent smoking.

The researchers found that non-smoking parents who had frequent and quality communication with their teenager about smoking had a consistently positive effect on reducing the chances that their teen will continue to smoke. However, the results revealed that if the parent smoked their influence through communication was much more complicated. For fathers, past smoking combined with a lot of teen disclosure predicted much greater likelihood of continued smoking – it’s the “war story” sort of effect with parent and teen sharing experiences and little disapproval leading to no reduction in experimentation. For currently smoking mothers the important factor was also disclosure but this time by the parent – if the mother shared little about her experiences, the effect on teen smoking was small but if she shared a lot, the odds of persistent teen smoking went way down. When non-smoking mothers talked a lot about the consequences of smoking, the probability of persistent teen smoking went up – kids don’t like being preached to.

What does it all mean?

Overall, the study’s results suggest that teens are highly suspect of hypocritical preaching and are very much influenced by communication patterns with their parents. Specifically, the study revealed that when a mother was a current smoker, if she communicated openly to her teenager that she had struggles about smoking and the difficulty of quitting, there was a positive effect on the teen’s eventual decision to stop. But for former smoking fathers and non-smoking mothers, talking at length about the teen’s experiences smoking and about the negative consequences of smoking respectively were not productive and actually increased the probability that the teen would still be smoking six months later.

As the authors note: “… current smoking mothers who are highly disclosing may acknowledge their own struggles around smoking and their difficulty asking their teens to “do what I say not what I do.” Openness about this struggle may help adolescents deal with the issue of “mixed messages” when a parent is a smoker. In contrast, the impact of maternal elaboration of rules may be attenuated when mothers have been active smokers because the parents’ own behavior is contradictory.” Reducing hypocritical messages and communicating openly about these difficult issues seems to be the way to go.

When taking all these findings into account it would seem that passivity on the part of a parent rather than communicating with the teen seems to be received by the teen as a silent approval of smoking. However a parent’s open and transparent sharing with his teen about his own regretted decisions, and the difficulty that has resulted, can have a very positive effect on the decisions the teen makes.

The bigger picture

If these things are true with cigarette smoking, would they not also be true regarding experimentation with other substances? Can parents open up about their experiences to their teens, expose their difficulties and vulnerabilities, and give the teen the gift of a loving parent’s experience?

Maybe more importantly, when thinking about the right ways to engage in teen-parent communication about difficult issues, a little insight into family dynamics that may have an impact on the discussion seems crucial. I often get questions from parents I know about the most appropriate way to talk to kids about drug use. This research seems to carry the following message – don’t preach if you haven’t been there and don’t be hypocritical if you have – open communication that guides the teen toward the desired behavior without letting them discount the impact of their choices seems the best idea.

Before we go, it’s important to note that this study used only a six-month follow-up and that future studies should really examine more long-term effects of family communication patterns in order to increase our confidence in these results. It’s possible that family communication can have a long-lasting effect or that it needs to be re-enforced on an ongoing basis. This study doesn’t tell us much about that.

Citation:

Lauren S. Wakschlag, Aaron Metzger, Anne Darfler, Joyce Ho, Robin Mermelstein, and Paul J. Rathouz (2010). The Family Talk About Smoking (FTAS) Paradigm: New Directions for Assessing Parent–Teen Communications About Smoking. Nicotine and Tobacco Research.

Tobacco smoking alone isn’t enough: More than smoking important in lung cancer death

Christopher Russell and Adi Jaffe

The tobacco epidemic already kills 5.4 million people a year from lung cancer, heart disease and other illnesses. By 2030, the death toll will exceed eight million a year. Unless urgent action is taken tobacco could kill one billion people during this century. (The World Health Organization Report on the Global Tobacco Epidemic, 2008)

These are some scary numbers, right? Cigarette smoking, according to the WHO, is the single most preventable cause of death in the world today, and in conveying these deadly statistics to the general public, cigarettes have come to be alternatively referred to by smokers and non-smokers as “cancer sticks”, “nicotine bullets”, and “coffin nails”.

But does smoking really ‘kill’ anybody in the literal sense with which we use this word?  To an epidemiologist, tobacco smoking (nor many other drugs of abuse for that matter) does not “kill” a person or “cause” illness or death in the way the words “kill” and “cause” are typically understood by the media and general public. For example, if I shoot someone in the head, stab another in the heart, and strangle a third till he stops breathing, it is reasonable to say that my actions were the direct, sole, and sufficient causes of death – I would have killed them. Smoking, however, is often neither a sole nor sufficient ‘cause’ of lung cancer, coronary heart disease, or myocardial infarction because non-smokers die from these diseases, and for example, because only 1 in 10 heavy smokers die from lung cancer when one looks at the overall numbers. Continue reading “Tobacco smoking alone isn’t enough: More than smoking important in lung cancer death”

Quitting smoking ‘on the spot’ is more likely to succeed than a quit attempt planned in advance

Christopher Russell

Readers who are smokers will likely have heard that if you approach stopping smoking like any other major life change, with careful preparation and planning, you can succeed, and that quitting depends first on putting together a plan that will work for you. These beliefs stem from the prevailing model of how people stop smoking which states that smokers moves through a succession of motivational stages involving contemplating stopping, preparing to stop, and then subsequently trying to stop (Prochasksa & Velicer, 1997). Consequently, physicians, GPs and smoking cessation therapists have been charged with using the model’s ‘four As’ – ask, advise, assist, and arrange – to guide smokers through these stages of change (Royal College of Physicians, 2000). This typically involves assisting smokers to anticipate potential difficulties in the early stages of quitting (e.g. identify the people, places, and things which stimulate craving), make plans to avoid/resolve these difficulties, set a date on which they plan to have stopped smoking completely, and plan rewards for maintaining abstinence between now and the quit date.

Based on this philosophy of “fail to prepare, prepare to fail”, the overarching goals of current cessation guidelines are to identify the smoker’s current stage, make recommendations appropriate for this stage, and guide the smoker sequentially through to the final stage of putting the quit attempt into action. However this model has been criticised on many grounds, the most notable being the lack of evidence that most smokers actually plan their quit attempts in advance and that doing so increases their chance of success. Indeed, this model conflicts with the accounts of many ex-smokers who say they just decided to stop smoking one day and have not looked back since.  In response to this gap in the literature, two relatively recent studies – one each in Canada and England – investigated the extent to which smokers plan their quit attempts and the extent to which planning increased the  success of quit attempts.

 The benefit of deciding to stop smoking immediately

Larabie (2005) found that while the majority of smokers (63%) planned their quit attempts in advance, the interesting finding was that the 67% of ex-smokers (i.e. successful quitters, defined as those who had not smoked in the past six months) had not planned their successful quit attempt in advance compared to 33% of ex-smokers who planned their successful quit attempt in advance. The three most commonly reported types of planning were (1) planning to quit on a significant date (e.g. birthday, New Year’s Day); (2) planning to obtain nicotine replacement medication in the near future); and (3) planning to quit once they had smoked all the cigarettes in their current carton.

Some examples of the unplanned quit attempts reported are given below, and more are available at the link in the references:

“I found out I was pregnant and I just quit” (LV, age 36).

 “I just felt like I had had enough and it was not going to kill me” (CB, age 36).

“I got ‘the scare’. I went out from work to have a cigarette and got a severe dizzy spell and had difficulty walking for 20 minutes. I quit on the spot. I still had cigarettes left in my pack” (LF, age 40).

Just as interesting was Larabie’s finding that 79% of successful quit attempts were made unassisted (defined as no use of Bupropion, nicotine patches, nicotine gums, tapering, or hypnosis). Larabie’s findings therefore argue against the prevailing model that successful smoking cessation depends on receiving assistance to quit (from medications, counselling etc) and planning quit attempts in advance. Rather, the most effective quit attempts were found to be those done without prior planning and without assistance! The paradox in this, noted by Larabie, is that health care providers may actually be hindering smokers’ chances of quitting by dissuading unassisted quitting (and promoting the uptake of formal treatment programmes) and by discouraging sudden, unplanned quit attempts. These assumptions deserve testing in their own right.

 A similar story in England

West and Sohal (2006) observed a similar success of unplanned quitting in their survey sample of 918 smokers and 996 ex-smokers in England. Almost half of all quit attempts (48.6%) were made without prior planning. Of the 611 quit attempts made between six months and five years previously, 65.4% of unplanned attempts lasted at least six months without smoking compared with 42.3% of planned attempts. This means that smokers who made unplanned quit attempts were 2.6 times more likely to still be not smoking six months later than those who made planned quit attempts. Likewise, smokers who made an attempt to stop smoking between six and twelve months previously were 2.5 times more likely to still be not smoking six months later than smokers who planned their quit attempts.

 Conclusion

A sudden decision to not smoke any more cigarettes was both common and more likely to be successful than were quit attempts made after a period of planning. While this does not necessarily suggest that planning and forethought and promoting treatment options are counterproductive, it does provide a strong case for health care providers going against current guidelines to encourage smokers, particularly those on the cusp of wanting to quit, to recognise and act upon opportunities to quit on the spot. In challenge to the prevailing ‘stages of change’ model, findings from these two studies should encourage smokers to consider the benefits of not thinking ahead, not waiting until Monday or the New Year, not waiting till the carton is empty, but instead, quitting now, without warning, or a running start, or a few days to prepare. West and Sohal state that even small changes in a smoker’s motivation to quit can trigger big changes in his/her behaviour and so smokers should be encouraged to capitalise on any desire to stop smoking. For those readers who are thinking about stopping smoking, planning may help, but consider the larger benefit of quitting today, right now.

Please write your comments in the box below.

 Just for fun

The questions asked of smokers and ex-smokers in West and Sohal’s study are provided below. If you have tried to stop smoking or are an ex-smoker and feel comfortable answering, how would you answer?

Q1. Which of these statements best describes how your most recent quit attempt started?

(a)    I did not plan the quit attempt in advance; I just did it.

(b)   I planned the quit attempt for later the same day

(c)    I planned the quit attempt the day beforehand

(d)   I planned the quit attempt a few days beforehand

(e)    I planned the quit attempt a few weeks beforehand

(f)    I planned the quit attempt a few months beforehand

(g)   Other

(h)   Cannot remember.

Q2. How long did your most recent quit attempt last?

References:

Larabie, L. (2005). To what extent do smokers plan quit attempts? Tobacco Control, 14, 425 – 428.

Larabie, L. (2005). To what extent do smokers plan quit attempts? Appendix A: Examples of responses. Accessible at:

http://tobaccocontrol.bmj.com/content/suppl/2005/11/23/14.6.425.DC1/146425_datasupplement_appendix.pdf

Prochaska, J. O. & Velicer, W. F. (1997). The transtheoretical model of health behaviour change. American Journal of Health Promotion, 12, 38 – 48.

Royal College of Physicians (2000). Nicotine addiction in Britain. London: RCP.

West, R. & Sohal, T. (2006). “Catastrophic” pathways to smoking cessation: findings from national survey. BMJ, 332, 458 – 460.

Does current smoking among health care providers limit their ability to dissuade smoking to the general public?

By Christopher Russell

In 2003, the US Department of Health and Human Services (USDHHS) set a goal of reducing cigarette smoking among US adults (18 years +) to 12% by 2010, which if achieved would halve the adult smoking prevalence rate reported in 1998 (24%). Achieving this current smoking reduction may depend on the extent to which health care providers (doctors, nurses, and such), who are charged with promoting smoking cessation and dissuading the uptake of smoking among to the general public, are themselves current smokers. For example, health care providers’ anti-smoking and pro-quit messages will likely be more persuasive and credible to the smoking public when the messengers practice what they preach about smoking. Such messages may also better motivate quit efforts if the health care providers have had personal success in quitting smoking using the methods and information they are now endorsing. Conversely, smokers may intuit that when health care providers advise quitting but continue to smoke themselves despite enjoying ready access to all the resources, information, and tools which should facilitate quitting, then smokers, without this luxury of access to education and resources, will be even less likely to successfully stop smoking.

Therefore, significant strides in increasing the number of quit smokers and never smokers in the general population may somewhat depend on reducing current smoking among the health care providers who act as both educators and trusted role models to the general public. It is therefore important to know how the prevalence of smoking among health care providers compares to the prevalence of smoking in the general population, which health care providers are charged to reduce.

Current smoking among health care providers

Using US population survey data, a recent study published in Nicotine and Tobacco Research reports estimated changes in the prevalence of current smokers, former smokers, and never smokers among eight groups of health care provider  – physician, physicians assistant, registered nurse (RN), licensed practical nurse (LPN), pharmacist, respiratory therapist, dentist, and dental hygienist – between 2003 and 2006/07. While the majority of these health care providers have never smoked a single cigarette, the authors report that, in 2006/07, approximately one in every five licensed practical nurse (20.55%) and respiratory therapist (19.28%) was a current smoker. Current smoking rates among LPNs and respiratory therapists were marginally higher than the rate of current smoking in the general population (18.01%) and near double the Healthy People 2010 goal of 12% current smoking in the general population. Four groups of health care provider – physicians (2.31%), dentists (3.01%), pharmacists (3.25%), and registered nurses (RNs) (10.73%) were all on course to be below the 12% prevalence goal. Furthermore, seven of these eight health care groups in 2006/07 showed higher quit rates than was found in the general population (52%) – only LPNs had a lower quit rate (46%). However, the concern from a public health perspective, is that while current smoking rates among these health care groups and in the general population have dropped considerably when compared to data reported in a similar cohort study in 1990/91, these decreases in current smoking appear to have leveled off in recent years; current smoking did not significantly decrease in any health care profession or in the general population between 2003 and 2006/07.

An important methodological note about this study is that results reflect weighted population estimates (WPE), not actual data. WPEs allow researchers to make inferences about an entire population group given only some data for that group simply by scaling up the actual data, (i.e. data reported by around 4000 health care providers in each collection year were used to estimate smoking statuses for over 2 million actual individuals). Of course, this technique likely overgeneralizes behavior in the sampling group, but is nonetheless a standard, valuable tool of health epidemiologists when they want to make inferences about how entire populations are behaving. Indeed, many of our health policies have derived from WPEs.

Current smoking among licensed practical nurses

Among the most important findings of this study is that one in five licensed practical nurses in the US is currently smoking. Of the estimated 754,000 LPNs in the US, this equates to roughly 155,000 current smokers in this profession, illustrating that health campaigns designed to depict smoking as socially unacceptable, readily available access to education and empirical research on the health consequences of smoking, working in smoke-free health care campuses, and being charged with task of persuading clients to stop smoking, all appear insufficient to reduce current smoking among LPNs and respiratory therapists to below the rate of current smoking in the general population.

In contrast, 10.73% of registered nurses are current smokers. The discrepancy between LPNs and RNs begs two questions: why are LPNs nearly twice as likely as RNs to be current smokers, and should we expect RNs will be better able than LPNs to persuade current smokers to quit and dissuade smoking to would-be smokers? Certainly, researchers should now ask whether a health care provider’s smoking status is related to his ability to produce cessation in health care recipients. If we assume that health care workers have a central role to play in producing mass behaviour change of whatever kind, then it is plausible to reason that reducing smoking prevalence at the national level will significantly depend on first reducing smoking prevalence among health care providers, our first responders to public health concerns. Testing this hypothesis seems the logical extension to capitalise on these smoking prevalence data.

Why are licensed practical nurses twice as likely as registered nurses to be currently smoking?

If one’s smoking status is important for persuading change in others, we need to know why smoking is more prevalent among LPNs than RNs, why LPNs have a lower quit ratio than the general population, and so, which factors should be addressed to reduce current smoking among LPNs to below the 12% level. The authors of this study suggested that LPNs’ fewer years in education and lower annual income may be associated with their current smoking status since they mirror socioeconomic factors known to associate with higher smoking rates. Comparably large proportions of LPNs and RNs are female, thus ruling out an important effect of gender. In my opinion, given that nicotine produces positively reinforcing psychoactive effects and that smokers commonly report smoking to alleviate affective distress, another consideration may be that LPNs and RNs differ in their exposure to stressful work events and environments, and/or differ in their emotional reactivity and sensitivity to these events, and/or differ in their bias to perceive work events as stressful. Furthermore, as smoking staus is known to be associated with socioeconomic status and socioeconomic status is known to be associated with many health and wellbeing factors including stress, then stress may be important both as a direct influence on smoking behavior and indirectly as a mediator of the effects of socioeconomic variables on smoking behavior. A good start to exploring these hypotheses would be to simply ask LPNs and RNs of their main reasons for smoking in short open-ended interviews; if reliable differences in smoking attributions emerge then we may begin the harder task of counseling LPNs to think of smoking in ways which alter their reasons to smoke, the reasons which may currently be maintaining smoking in one in five LPNs.

Questions for the reader; please give your comments below

1)      Why do you think current smoking is more prevalent among licensed practical nurses than in the general population?

2)      Does a health care provider’s status as a current smoker make him/her more or less able to persuade smoking cessation in others?

3)      Will reducing current smoking nationally depend on reducing current smoking among health care providers?

References:

U.S. Department of Health and Human Services. (2003). Healthy People 2010, Retrieved from http://www.healthypeople.gov/

This report is free to download at: http://www.healthypeople.gov/document/pdf/uih/2010uih.pdf

Sarna, L., Bialous, S. A., Sinha, K., Yang, Q., & Wewers, M. E. (in press). Are health care providers still smoking? Data from the 2003 and 2006/2007 Tobacco Use Supplement-Current Population Surveys. Nicotine and Tobacco Research.

Depression and smoking relapse: Anhedonia doesn’t feel good.

A recent study published in the Journal Nicotine & Tobacco research suggests that a particular aspect of depression, namely anhedonia, a.k.a “inability to feel good,” plays an important part in predicting how quickly smokers will relapse after trying to quit smoking. When it comes to addiction research, you can’t get much clearer than these results.

Quitting is smoking is difficult, especially when you're depressed.

The researchers specified a number of factors in depression including: negative affect (feeling down), vegetative state (not moving much), and anhedonia, measuring that last one by making participants rate their expected pleasure to hypothetical pleasurable situations they were asked to imagine. They then split up the participants into three different treatment conditions that included slightly different procedures meant to help them quit smoking. All participants quit smoking immediately after attending the one-day assessment and instruction session. Following that day everyone returned to the lab after 24 hrs, 48 hrs, and then weekly for a total of four weeks to assess their smoking using fancy lab equipment.

When the researchers looked at the results, they saw that when separated into “high-anhedonia” and “low-anhedonia” groups, participants in the “high-anhedonia” group relapsed to smoking much more quickly, even when controlling for depression symptoms before quitting. In fact, 20 days after that initial session, more than half of the “low-anhedonia” participants were still not smoking while essentially none of the “high-anhedonia” participants had managed to quit.

As if it is isn’t hard enough to quit smoking, apparently, feeling like $&%@ just makes it harder… Hey, I never said addiction research would always bring good news!

Citation:

Cook, Spring, McChargue, and Doran (2010). Effects of anhedonia on days to relapse among smokers with a history of depression: A brief report. Nicotine & Tobacco Research.