Psychology and Smoking Behavior
Psychology and Smoking Behavior
Cigarette smoking causes more premature disease and death worldwide than any other known human behavior. Although the damage caused by smoking is the subject of biology and medicine, smoking is a behavior, and thus has also been the subject of much behavioral research.
The Behavior of Smoking
Modern psychological science concerns itself primarily with the study of behavior, attempting to answer questions such as: Why do individuals engage in a given behavior? What factors lead individuals to stop or continue an undesired behavior? And finally, can we use this knowledge to develop more effective treatments to help people cease the unwanted behavior?
With respect to cigarette smoking, distinctions between "psychological" and "biological" factors have given way in the late twentieth century to perspectives that view smoking as a biobehavioral, or, even more broadly, a biopsychosocial, disorder. Thus, smoking is best viewed as a behavior that is governed by multiple, intertwined factors, including physiological (biological), social, and psychological ones. Researchers have clearly demonstrated that nicotine (the ingredient of cigarette smoke most responsible for affecting mood or thought) exerts influence on multiple brain systems, all of which, in turn, affect behavior, thinking, and feeling. It follows that in the study of smoking behavior, attempts to disentangle psychological from biological factors ultimately create a false and unnecessary distinction. Instead, modern psychological science attempts to understand the interplay between various social, individual, and biological influences that, together, promote smoking and tobacco use.
Tobacco Smoking as an Addictive Behavior
The once controversial question of whether cigarette smoking may constitute an actual addiction has been universally answered with a resounding "yes." Indeed, an accumulation of well over 3,000 scientific papers has led to the unequivocal conclusion that cigarettes and other forms of tobacco use are addicting, that nicotine is the drug in tobacco most responsible for addiction, and that the pharmacological and behavioral processes that cause addiction to tobacco are similar to those responsible for addiction to other drugs. These facts do not necessarily imply that every smoker is dependent on nicotine (see sidebar). However, the vast majority of smokers who smoke with any degree of regularity ultimately progress to nicotine addiction. To fully appreciate this conceptualization of smoking, a brief overview of precisely how drug dependence (or addiction) is defined by research scientists is necessary.
Simply stated, addiction arises when, for a given individual in a given set of circumstances, drug use results in a powerful rewarding (reinforcing) experience and abstinence from the drug (even for relatively short time periods) causes unpleasant physical and emotional experiences that are alleviated by taking the drug once again. When this leads to compulsive drug use that seems to take over the person's behavior and is difficult to stop, addiction has taken hold. Does this pattern of addictive behavior hold for cigarette smoking? Indeed, it does. For example, research has demonstrated the existence of a reliable withdrawal syndrome that results when the smoker goes without smoking for a given period of time. These withdrawal symptoms include: (1) dysphoric or depressed mood; (2) insomnia; (3) irritability, frustration, or anger; (4) difficulty concentrating; (5) restlessness; (6) decreased heart rate; and (7) increased appetite or weight gain. Craving,—an intense, often uncontrollable desire—for the drug is also frequently reported by smokers who are deprived of nicotine.
Another hallmark of addiction is difficulty in stopping the behavior. That is, people who are addicted to a drug often report that, whereas they may sincerely want to quit, they are unable to do so. Do smokers have a difficult time quitting? Yes. Most U.S. smokers say they want to quit, but only 3 percent are actually able to stop permanently each year. According to a literature review by John Hughes and colleagues (2004), smokers who try to quit without treatment have as high as 97 percent failure rate. Even people facing imminent life-threatening consequences often are unable to quit: Most smokers who have had heart attacks ultimately return to smoking. In sum, then, tobacco smoking is a behavioral disorder typified by persistent desires and unsuccessful efforts to quit, thus resulting in resuming smoking.
Cigarette smokers also meet other criteria for being considered addicted. These include development of tolerance (that is, a need for increased amounts of the drug to achieve desired effects), a great deal of time spent in activities necessary to obtain or use the substance (for example, chain-smoking), willingness to give up other things in favor of smoking (for example, avoiding events in nonsmoking venues, risking their health), and use of the drug despite knowledge of having a physical problem (for example, lung disease) that is likely to have been caused by the substance. Relative to the users of other drugs, a higher percentage of smokers are considered addicted. Interestingly, many drug abusers who also smoke say that it would be harder to stop smoking than to stop using their other drugs (even though they find other drugs like alcohol or cocaine more pleasurable). In sum, tobacco smoking can be a highly addicting behavior, comparable to, or even exceeding, the addictive potential of other, "harder" drugs of abuse, such as cocaine or heroin.
Why Do Smokers Smoke?
Research has clearly revealed that nicotine is reinforcing in both animals and humans. Even among addicted smokers, however, not all cigarettes are smoked solely in response to nicotine withdrawal. Indeed, when asked, cigarette smokers themselves consistently attribute their smoking to a variety of other motives. These motives are governed by both negative reinforcement (for example, smoking to reduce stress) and positive reinforcement (for example, smoking to celebrate when already feeling good) processes.
The most commonly cited reason for smoking (among both novice and nicotine-dependent smokers) is smoking's alleged ability to reduce subjective stress and anxiety. Smokers often report that they smoke more when angry, depressed, or anxious, and that smoking helps to alleviate these negative mood states. It is not clear that either part of this statement is true, however. Some field studies have shown that negative feelings do not make smokers more likely to smoke. Laboratory studies assessing smoking's effect on anxiety have yielded inconsistent results. Thus, although most smokers clearly believe that smoking reduces negative emotions, this effect has been difficult to reliably produce under controlled, laboratory conditions. There is one exception: When negative emotions are due to nicotine withdrawal, nicotine provides quick relief.
Another interesting aspect of smoking's reputed relaxing properties is that nicotine is a central nervous system stimulant. Thus, smoking a cigarette actually increases autonomic nervous system arousal (for example, heart rate), generating something resembling the "stress response." But how can a drug that produces a "stress response" be perceived as relaxing? More research will clearly be needed in order to adequately answer this question. Of course, some smokers also attribute their smoking to nicotine's stimulant (arousing) properties.
Researchers believe that some of the pleasurable experiences associated with smoking are not solely attributable to nicotine. For instance, research suggests that the sensorimotor aspects of smoking (for example, the taste, the smell, the handling of the cigarette) can become reinforcing in and of themselves, largely as a result of their association with smoking. Through repeated pairing, the act of smoking likely becomes "conditioned" to a variety of emotional states (such as anxiety) and situations (such as after eating). In other words, the smoker associates a particular situation with the act of smoking a cigarette. Consider for a moment a typical pack-a-day smoker, who smokes 20 cigarettes a day. At 10 puffs per cigarette, this adds up to 200 administrations of nicotine a day, or over 72,800 "hits" a year. (No other drug of abuse is self-administered at such a high rate.) As a result of such frequent administrations of nicotine across a variety of situations, smoking invariably becomes linked to specific cues, causing the smoker to smoke some cigarettes "out of habit" rather than out of a craving for nicotine.
The Mystery of Tobacco "Chippers"
I n the 1990s, Saul Shiffman and colleagues described a group of smokers, called "chippers," characterized by their apparent invulnerability to developing nicotine dependence. These smokers smoked regularly for years, yet rarely smoked more than five cigarettes a day and did not appear to suffer from nicotine withdrawal when they went without smoking. How did they do it? Although research is still attempting to answer this question, Shiffman and his colleagues made the following observations about chippers:
They typically smoke their first cigarette of the day hours after waking (whereas most addicted smokers smoke much sooner).
They metabolize nicotine at the same rate as regular smokers.
They report frequent casual abstinence (for example, not smoking for several days) from smoking (unlike addicted smokers).
Based on self-report questionnaires, chippers evidence more self-control, and are less impulsive (more able to resist temptation), compared to regular smokers.
Whereas regular smokers show marked changes in mood, craving, sleep disturbance, and cognitive performance when deprived of nicotine, chippers show none of these changes.
Finally, it is important to note that the majority of research on smoking motives (and other aspects of smoking behavior) has been conducted in developed Western countries, primarily in the United States, Europe, and Australia. Researchers do not know the extent to which smoking to reduce stress, for example, is a potent motive for smoking among smokers in developing countries. Moreover, well-validated measures of nicotine dependence that are suitable for use in the United States, for example, may be unsuitable in other countries, where smoking practices and beliefs differ. The lack of information about smoking behavior in other countries is another serious research gap that warrants attention.
Smoking and Psychopathology
Research shows that smokers suffer more mental illness than nonsmokers. Smokers are more likely to suffer from depression, anxiety disorders, substance abuse, conduct disorder, and schizophrenia, to name but a few. As an example, whereas approximately 23 percent of the United States population smoke regularly, as many as 90 percent of schizophrenics are heavy smokers. According to one analysis, persons with a psychiatric diagnosis smoke the majority of cigarettes consumed in the United States. Of course, questions arise as to what these associations mean and whether they inform scholastic understanding of smoking behavior. Given that virtually all of these psychological disorders are accompanied by negative mood states, the most common interpretation of the mental illness relationships is that smokers smoke in order to regulate their mood (self-medicate). However, the empirical evidence that smoking genuinely alleviates unpleasant mood is scant. It is important to note, however, that several longitudinal studies have suggested that some forms of psychopathology (for example, depression and delinquency problems) significantly increase the chances that someone will go on to become a smoker.
Whereas these studies suggest that suffering mental illness increases the risk of becoming a smoker, investigations conducted in the 1990s suggest this relationship goes the other way, too: Smoking itself can predict the onset of anxiety and depressive disorders. This fact suggests that the link between smoking and psychopathology may be attributable, at least in part, to other factors (such as genetic variations) that render individuals vulnerable to both smoking and psychopathology. Several biologically based personality variables, particularly neuroticism (anxiety) and psychoticism (distorted thinking), are associated with both smoking and various psychological disorders, including depression and anxiety. Thus, it is conceivable that genetically transmitted vulnerabilities may predispose people to both smoking and to psychopathology.
What Factors Promote Smoking Initiation?
The factors that promote smoking among regular, adult smokers likely differ from those associated with smoking initiation (which typically occurs during adolescence). So, why do individuals begin smoking in the first place? No one is born addicted to smoking, so addiction-related motives can be ruled out as an explanation for smoking onset. Research suggests other factors: (1) peer influence, which is arguably the most important predictor of who becomes a smoker; (2) sibling (and parental) smoking; (3) beliefs that smoking confers advantages in social life; (4) perception that tobacco use is the norm (at least in one's own social circles); and (5) prior experimentation with cigarettes, which is a strong predictor of subsequent smoking. Finally, some of the smoking motives expressed by adults are probably applicable to understanding smoking uptake among adolescents as well.
According to the leading scientific theories, smokers typically proceed through stages of smoking on their way to becoming nicotine-dependent (see figure). Broadly stated, during the early stage, smokers smoke for psychosocial motives, prompted by friends and social situations in which smoking is viewed as normal behavior. Most smokers are believed to progress rapidly to the next stage, in which their smoking is driven by the positively reinforcing pharmacological effects of nicotine. At this stage, smokers appear to seek both the relaxing and stimulating effects of the drug. Some smokers then progress to the final stage where their smoking is primarily governed by the need to stave off or escape from withdrawal symptoms; that is, addiction-related motives.
Most research has focused on understanding factors that make it more likely that a person will begin smoking. Less effort has gone into understanding factors that act to protect individuals from smoking in the first place. Identifying these factors may ultimately improve smoking prevention and intervention programs.
The Changing Landscape of Smoking
One landmark in the history of smoking behavior was the 1964 publication of the United States Surgeon General's report, Smoking and Health, wherein the link between smoking and cancer was first widely disseminated. As a result of this groundbreaking health information, many people began to quit smoking. Indeed, since the 1960s, the public's recognition of the health dangers attributable to smoking has grown significantly. One need only look at social policy change since the 1990s to see profound societal and legal shifts in attitudes toward smoking. And society has been witness to a gradual, yet steady, decline in overall smoking prevalence rates, at least in the United States. Analyses suggest that the decline in smoking prevalence is due to multiple factors: increased awareness of risk; rising cigarette prices; restrictions placed on smoking in public (and some private) places; promotion of quitting; and help in quitting. Together, these factors have made smoking a far less appealing and affordable behavior.
Cigarette smoking is a destructive, complex behavior that is governed by multiple, interrelated factors. As such, understanding the psychology of smoking demands a multidisciplinary approach that considers biological, psychological, and social factors. As a field, psychology has made tremendous strides in the understanding of the processes that promote and maintain tobacco smoking. However, psychologists and behavioral scientists have more work to do. Millions of people die every year from diseases directly attributable to smoking. Whereas state-of-the-art smoking cessation treatments are available (including nicotine replacement therapy and behavior therapy), far more research into the mechanisms underlying smoking initiation, maintenance, and cessation is still needed.
▌ JON D. KASSEL
▌ SAUL SHIFFMAN
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physiology the study of the functions and processes of the body.
dysphoria a feeling of unhappiness and discomfort; being ill-at-ease. Cigarette smokers can experience dysphoria when deprived of cigarettes.