Helping the Hard-core Smoker

A Clinician's Guide

Daniel F. Seidman, Lirio S. Covey, Daniel F. Seidman, Lirio S. Covey

• Publisher: Routledge
• Year: 1999
• Topic: Psychology
• eBook ISBN:
  9781135682866
• Subtopic: Clinical Psychology
• Index: Psychology

This book constitutes a major new resource for professionals working with hard core smokers and their families. It is designed as a practical, clinically useful and up-to-date guide for all those in a position to intervene: mental health professionals, physicians, dentists, nurses, pharmacists and other health care professionals, clergy, human resource and employee assistance program corporate staff, and teachers and guidance counselors.

New research suggests that difficult-to-treat smokers often have emotional problems adjusting to stopping smoking. Some also have psychiatric diagnoses or abuse other substances. These are factors which interfere with their efforts to quit.

Because these difficulties have been poorly understood, hard-core smokers have not been provided with adequate resources and skills to overcome their addiction. These smokers are in need of increasingly comprehensive assessment and treatment.

Despite massive public health education about the dangers of cigarette smoking, rates of smoking among the population are no longer declining in the United States and the success rates of clinical programs for smokers remain low. Helping the Hard-Core Smoker seeks to explain why current approaches are often inadequate and how best to help today's highly nicotine-dependent smokers who are struggling with their addiction quit.

Part I
Background Conceptual Issues

CHAPTER ONE
Biological and Clinical Perspectives on Nicotine Addiction

Daniel F.Seidman

Jeffrey Rosecan

Lorna Role
Columbia University

Although smoking cigarettes continues to be portrayed as glamorous in advertisements and to attract a new generation of smokers, it has undergone a transformation in public awareness from bad habit to drug addiction. The health consequences of smoking have also been well established and publicized. This chapter provides a foundation for understanding nicotine addiction by examining two different approaches to the same phenomenon. One approach looks at nicotine addiction from the perspective of the cell, and the other from the perspective of the whole person. One approach examines nicotine addiction viewed from recent developments in neuroanatomy and neurophysiology. In the other approach, cigarette smoking is examined as a clinical disorder.

Promising patients to address their smoking addictions “later,” or admonishing them to “just stop smoking,” can mean missed opportunities (Fiore, Epps, & Manley, 1994). This applies not only to helping patients with their cigarette addiction, and to teaching new clinicians about effective interventions, but also to a lost opportunity to deepen the relationship between patient and doctor, dentist, or other health care professional.

Although some smokers can and do quit on their own, increasingly, many others are in need of clinical assistance. This is especially the case for the hard-core smoker.

In this chapter we define hard-core smokers, and distinguish between the habit of smoking and nicotine addiction. We also compare the rates of addiction and relapse in smokers with those of people addicted to other drugs and alcohol.

We then review recent developments in basic research science to provide the practicing clinician with new insight into the underlying biological foundation of nicotine addiction. Finally, we develop a clinical perspective that views nicotine addiction as a complex interaction among three factors: (a) the brain pathways that are altered by smoking tobacco, and the impact of smoking the drug nicotine on mood, perception, arousal, and attention; (b) the psychological adjustment of the individual and the use of smoking as a “psychological tool”; and (c) the role of the sociocultural context in the initiation, maintenance, and relapse back to smoking behavior. This clinical perspective on nicotine addiction concludes with a brief review of four practical criteria for diagnosing cigarette smoking as an addictive disorder.

DEFINING HARD-CORE SMOKERS

The first group of smokers defined here as hard core are smokers who are medically ill but who continue to smoke. The literature contains a number of studies of cancer patients who continued to smoke at high rates even after diagnosis and treatment (Davidson & Duffy, 1982; Spitz, Fueger, Chamberlain, Goepfert, & Newell, 1990). Several studies also report high rates of continued smoking after myocardial infarction (Havik & Maeland, 1988; Taylor, Houston-Miller, Killen, & DeBusk, 1990).

The second group of smokers we define as hard core are those who score greater than 7 on the Fagerstrom Test for Nicotine Dependence (Fagerstrom & Schneider, 1989). According to this test, smokers high in nicotine dependence often smoke more than 20 cigarettes per day and begin smoking within 5 min of awakening in the morning. Highly nicotine-dependent smokers also report severe symptoms of nicotine withdrawal (U.S. Department of Health and Human Services, 1996).

Finally, the third group we define as hard-core smokers are those with comorbid psychological or psychiatric conditions, which are associated with increased risks of becoming addicted to, and difficulties in cessation from, cigarette smoking (see chap. 2, this volume). This group of smokers includes those depressed smokers referred to in the 1990 JAMA editorial “Blue Mood, Blackened Lungs.” This editorial concluded that “about 20% of smokers have high depressive symptom scores, this means that depression may be a contributing factor to the smoking of more than 10 million Americans, who are 40% less likely to quit smoking than are nondepressed smokers” (Glass, 1990, p.1584).

HABIT VERSUS ADDICTION

Cigarette smoking often appears to be only a habit—an automatic behavior pattern influenced primarily by learning and reinforcement—because it is a repetitive behavior, it is learned, and in many smokers it tends to increase under stress. It is used as a tension reducer in anxiety-provoking situations. It is also pleasurable for many people, and this pleasure is reinforced when smoking accompanies activities such as a meal, coffee, or sex. The constant repetition of smoking behavior many times per day involves tremendous habit strength and conditioning and can become an automatic part of life, a ritual. In fact, smoking behavior is so “overlearned” that smokers often light up a cigarette and let it burn down in an ashtray without even realizing it.

Gum chewing also fits the definition of a habit: It is an automatic behavior pattern that is learned, and can be used to reduce tension or for pleasure. People are aware of unwrapping a piece of gum and putting it in their mouths, but tend to forget that they are chewing it until the flavor runs out. People can chew gum for years without thinking twice about it, and aside from minor dental problems suffer no real adverse consequences.

There are, however, important reasons why we feel cigarette smoking is much more than a habit like chewing gum. One principal reason is the presence of nicotine withdrawal after stopping:

The misery of abstinence has been far greater than I ever imagined…suddenly there came a severe cardiac misery, greater than I ever had while smoking. The most violent arrythmia, constant tension, pressure, burning in the heart region, shooting pains down my left arm…and with it a feeling of depression which took the form of visions of death, (quoted in Masson, 1985, p.67)

This unfortunate individual is Dr. Sigmund Freud, founder of modern psychiatry and psychoanalysis, after trying unsuccessfully to stop smoking his famous cigar for a few weeks in 1894. It is, to our knowledge, the earliest description of the nicotine withdrawal syndrome.

A defined withdrawal syndrome establishes a biological basis for addiction. In contrast to what happens when an addicted smoker stops smoking, there is no withdrawal syndrome from stopping the habit of chewing gum. The withdrawal syndrome is thus one of the hallmarks of an addiction, whether it be to alcohol (“the DTs”), heroin (“cold turkey”), cocaine (“the crash”), or nicotine. The common symptoms associated with nicotine withdrawal are:

• Dysphoric or depressed mood

• Insomnia

• Irritability, frustration, or anger

• Anxiety

• Difficulty concentrating

• Restlessness

• Decreased heart rate

• Increased appetite or weight gain (DSM-IV, APA, 1994)

Although the medical and scientific community would prefer not to use the term addiction, the term is widely used to imply a severe drug dependence. The legitimacy of viewing cigarette smoking as an addiction has been increasingly accepted (U.S. Department of Health and Human Services, 1988) and with that acceptance, its comparison to heroin, cocaine, and alcohol addiction has also grown.

RATES OF ADDICTION AND RELAPSE

How addicting is smoking nicotine? There are a variety of ways to measure addiction. One is the graduation rate from recreational, casual, or social use of a substance to daily, compulsive use or abuse of a substance. The graduation rate is a measure of the incidence of addictive use or abuse of a substance, versus its experimental or recreational use.

For nicotine, the graduation rate from experimental or recreational use to daily use for 20-year-olds who are still smoking is 95% (APA, 1994). Further, out of 10 people who become smokers, 9 smoke more than five cigarettes a day (Henningfield, Cohen, & Slade, 1991). The 10% or less of smokers who smoke five or fewer cigarettes per day have been called “chippers.” The term, borrowed from some opiate addicts, refers to light use without becoming addicted (Shiffman, 1989). Seventy-five percent of smokers meet diagnostic criteria for nicotine dependence (see chap. 2, this volume).

For nasal cocaine use, the rate of progression to dependence (i.e., graduation rate) has been estimated at 25% of regular users (Jaffe, 1990). Although difficult to estimate precisely, the graduation rate to compulsive use for crack smoking is undoubtedly much higher. This is because the addiction to crack can be instantaneous on the first try, or a matter of weeks or months, compared with a pattern of escalating use over several years in cigarette, heroin, and alcohol addiction.

For narcotics (heroin and opium), the graduation rate to addiction can be circumstantial (i.e., dependent on social circumstances, e.g., combat service). A study by Robins, Helzer, and Davis (1975), using U.S. army enlistees, found only 14% of those highly addicted to narcotics in Vietnam to be still addicted 10 months after returning to the United States.

Finally, for alcohol, the graduation rate to dependence is conservatively estimated as 5–10% for adult men, and approximately one third of that for adult women (Schuckit, 1989).

A second way to measure addiction is by how difficult it is to stay away from a substance. In one study (Blumberg et al., 1974) polysubstance abusers were asked to compare their need on a 1 (no need) to 4 (need a lot) scale. The results showed the following ratings: tobacco (3.3), heroin (2.8), cocaine (1.5), and alcohol (1.3). In a second study of patients in treatment for drug and alcohol abuse (Kozlowski et al., 1989), 74% of these patients reported that giving up cigarettes was at least as difficult as giving up their primary problem substance. Over half, or 57%, of this patient sample stated that giving up cigarettes would be more difficult than giving up the drug that originally brought them to treatment.

Further, it turns out that heroin, alcohol, and nicotine addiction (smoking cessation) programs have similar outcome rates or rates of success and failure (Hunt, Barnett, & Branch, 1971). Hunt and colleagues, writing in 1971, found rela...

Table of contents

• Contents
• Foreword
• Preface
• Part I Background Conceptual Issues
• Part II Developments in Clinical Research
• Part III Assessment and Treatment: Special Populations
• Part IV Treatment Approaches: Medical and Psychological
• Part V The Smoker and the Health Care System
• About the Contributors
• Author Index
• Subject Index