Motivation and emotion/Book/2017/Nicotine withdrawal and negative emotion

Overview
Smoking tobacco can lead to nicotine addiction and adverse health consequences. There are obvious benefits, both financially and health wise, in being a non-smoker. However, a smoker faces enormous challenges in giving up smoking because of the  addictive nature of nicotine and also the related psychological aspect of "negative emotion" which can be an enormous impediment in successfully giving up smoking. Understanding the psychological and environmental factors associated with smoking and smoking cessation will help in the development and improvement of therapeutic strategies and education programs.

This chapter examines relevant factors associated with smoking and the contribution psychology can make in cessation programs, particularly in dealing with "negative emotion" and the application of motivation.

Challenges in Giving up Smoking
Smoking can result in nicotine addiction and also serious adverse health consequences. There are health and financial benefits in giving up smoking – but changing from a smoker to non-smoker presents great challenges. Many ex-smokers say quitting is the hardest thing they ever had to do. Understanding the challengers can place a person in a better position to quit. However motivation is a key component in giving up smoking but the smoking habit is interrelated with other factors such as hereditary, physiological, environmental, and psychological variables.

"Smoking is indispensable if one has nothing to kiss"  (Sigmund Freud)

What is Nicotine?
Nicotine is a chemical compound of the alkaloid type which occurs naturally in varied concentrations in several plants that includes tobacco, potatoes, eggplant and cauliflower. The tobacco plant has a relatively high nicotine content of about 5 percent of its weight. Alkaloids are a class of nitrogenous organic compound and various alkaloids including nicotine will cause a pronounced effect on the human body.

How is Nicotine Absorbed?
Typically a cigarette contains about 10 milligrams of nicotine and when smoked about 1 to 2 milligrams of the chemical is absorbed into the human body (British Psychological Society) .  Smoking a cigarette is a very effective method of absorbing nicotine into the human body. The pathway of absorption is through the lungs into the bloodstream where it then quickly travels to the heart and brain. The effectiveness of the absorption is equivalent to an intravenous injection (Rose et al., 2000). Once absorbed, the half-life of nicotine is about 2 to 3 hours which means that the amount of nicotine present in the body decreases by one-half in that length of time (Lynch et al., 1994)

Is Nicotine Addictive?
Yes. Nicotine is an addictive substance.

Addiction is broadly defined as physical and/or psychological dependency on a drug. Nicotine meets the addiction criterion established by both the World Health Organisation (WHO) in its International Classification of Diseases (ICD) and the American Psychiatric Association (APA) in its Diagnostic and Statistical Manual (DSM-IV & DSM-IV-TR). A report by the US Surgeon General states ‘nicotine is the drug in tobacco that causes addiction’ (USDHHS 1988). Furthermore, a report by the Royal College of Physicians of London has classified nicotine as among the most addictive of substances known (RCPL 2000).

What Makes Nicotine Addictive?
Nicotine acts on nicotinic acetylcholine receptors in the brain which are involved in the release of dopamine which is a neurotransmitter that helps control the brains reward and pleasure centres, known as reward pathways (Corrigall et al., 1994). Nicotine increases the levels of dopamine released in the reward pathways to produce not only pleasurable feelings but to take action to move towards them. The greater the level of dopamine released, the greater the pleasurable experience felt by people (Nestler, 2005). This mechanism operates outside of conscious awareness that results in a strong desire to smoke which may be in conflict with conscious desires (NIDA (2010)). The pleasurable experience gained from the dopamine release may also act to reinforce the smoking behaviour. Repeated use of tobacco builds tolerance to the effects of nicotine and as consequence this increases the number of cigarette needed to be smoked to maintain the same pleasurable experience (Henningfield et al., 2002).

Although nicotine is very addictive, the health risks associated with smoking are attributed to the associated carbon monoxide (CO) produced in smoking which blocks oxygen from being transported around the body and the tar which contains carcinogens that are deposited in the airways and lungs. (Victoria State Government – Better Health Channel).

Nicotine Withdrawal and Associated Symptoms
The US Government Centres for Disease Control and Prevention report of 2011 found that about 70% of smokers in America want to quit and that around half had tried to quit in the previous year, but only some 6% had achieved success.



Cessation in cigarette smoking will result in a withdrawal period that can last for more than a month and can begin within a few hours after the last cigarette. Withdrawal symptoms usually peak within the first few days. The Cancer Institute of NSW has listed the common symptoms of nicotine withdrawal as being:
 * Cravings;
 * Anger, irritability and frustration;
 * Anxiety, feeling nervous and tense;
 * Depressed mood;
 * Difficulty concentrating and feeling confused;
 * Impatience and restlessness;
 * Insomnia and waking up at night.

Although withdrawal symptoms are a consequence of nicotine absence in the body, many behavioural factors can also affect the severity of withdrawal. For some people, the feel, smell, sight, handling, lighting and physical action of smoking a cigarette are all associated with a pleasurable experience and can worsen the withdrawal process. Nicotine replacement methods, such as gum and patches are available to help alleviate the pharmacological aspects of withdrawal; however, behavioural therapy may be necessary deal with the behavioural aspects of withdrawal. However, the initial process in quitting is difficult as a study showed that smokers are most likely to relapse within the first three months (Abrams et al., 2003).

“Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times.”  (Mark Twain)

Benefits in Giving-Up Smoking
Smoking is associated with a wide range of health conditions that has been estimated by the Australian Bureau of Statistics (ABS) to cost Australia some $31.5 billion in social, medical and economic costs in 2004-05. This is an enormous figure. Moreover in 2003 smoking was responsible for 7.8% of the total medical costs in Australia. This is a significant portion of the national health bill. In monetary terms, enormous national financial benefits would be gained if the smoking rate was reduced.On a personal level, smoking cessation brings near immediate and long term health benefits for a better quality of life. On a timeline basis some of the health benefits in quitting are (Baca et al., 2009):
 * 20 minutes after smoking -  blood pressure decreases
 * 8 hours after smoking – carbon monoxide levels drop in the blood stream;
 * 24 hours after smoking – chance of heart attack reduced;
 * 1 to 9 months after smoking  – ciliary function in the lungs return to normal reducing the chance of infection;
 * 1 year after smoking - risk of coronary heart disease drops to one half of a smoker.
 * 5 to 15 years after smoking – risk of stroke is reduced to the level of a non-smoker.

Applicable Psychological Models for Smoking Cessation
Factors associated with the uptake and cessation of smoking can be complex involving a mix of biological, psychological, social and cultural components. Proven psychological models are important as they allow for the application of effective interventional programs in dealing with the smoking issue. Common psychological models are:
 * Behavioural Theories (or behaviourism).  This theory is based on the premise that all behaviours are acquired through conditioning. Behaviourists hold the view that our responses to environmental stimulus shape our actions.  Its approach to smoking cessation is to replace smoking with a different more desirable activity that emphasises the benefits of quitting.  A review of the behavioural approach found that it provided moderate success rate in the cessation of smoking (Murthy et al., 2010).
 * Social Cognitive Theory. This theory postulates that people learn from one another through observation, instruction, or modelling.  An essential principle of the theory is the belief or expectation that a person can successfully perform a task.  Its approach to smoking cessation is to target a person's thoughts that play a role in smoking, for example, a person may believe they have no control over the smoking habit.
 * Theory of Planned Behaviour. This theory is based on the principle that a person's behaviours and intention are determined by attitude, social pressure and the amount of control a person is perceived to have over the behaviour.
 * ·Health Belief Model.  This model is based on the principle that a person’s value and expectations drive motivation and was developed to explain and predict health behaviours.  The Health Belief Model is structured with four constructs representing the perceived health threat and benefits being: perceived susceptibility, perceived severity, perceived benefits and perceived barriers.  Its approach to smoking cessation, the Health Belief Model would predict that smoking is determined by a person’s perception regarding: susceptibility to tobacco related diseases, costs, benefits, and barriers to engaging in smoking or quitting behaviours, and prompts to alter the smoking behaviour.
 * Social Ecological Model.  This model emphasises the reciprocal relationship between behaviours and social environment. Proponents of this model are of the position that tradition models (e.g. Health Belief Model and Theory of Planned Behaviours) over emphasise the individual aspect of behaviour and ignore the powerful ways the tobacco industry can shape the social environment and influence smoking behaviours.
 * Trans-theoretical Model.  This model postulates that behavioural change involves sequential change being: pre-contemplation (not even thinking about change), contemplation (thinking about change), preparation (planning for change), action (adopting new habits) and maintenance (ongoing practice of the new behaviour).  In treatment, people may not always progress through the stages in a sequential manner as some may relapse to an earlier stage which can depend on their level of motivation and self-efficacy.
 * Psychoanalytic Theory.  The Psychoanalytical Theory (developed by Sigmund Freud) assumes that unconscious psychological processes and early childhood experiences determine a person’s personality and behaviour.  The theory contends that children progress through sequential developmental stages of – oral, anal, oedipal, latency and genital and that frustration or over gratification during one of the stages leads to fixation at that stage.  Proponents of the theory view smoking as caused by fixation at the oral stage.

Information on Smoking and Smokers
An Australian Bureau of Statistics National Health Survey for the 2011-12 calendar period showed that 16.1% of Australians aged 18 years smoked on a daily basis. Considering the well-known adverse health consequences, why do people take up smoking? The determinants associated for the reasons in taking up smoking can be a mix of biological, psychological and social/cultural factors in developing and maintaining smoking.

Teenage Smoking
Evidence shows that most adults who smoke started the habit when they they were teenagers. In the Unites States as many as one third to one half of young people who experiment with smoking will become regular smokers (Davis et al., 2002) and more than 90% of current adult smokers commenced smoking before reaching 18 years of age (Kessler et al., 1997). The evidence is that the younger the person who experiment with smoking, the more likely they become regular smokers. Furthermore, smoking is more prevalent amongst young people whose parents or older siblings smoke. Additionally, young people can be influenced by a peer group as part of establishing their social relationship with their peers and also used as a means to display independence or defiance.

Personality and Emotional Factors
Research shows that personality and emotional traits play a role in smoking and nicotine addiction (Dolan, 2004).

On a broad level, emotions can be described as being either "positive" or "negative" in characteristic. Positive emotions include joy, contentment, interest, and the like whilst negatives emotions include anxiety, sadness or despair and the like. It is usual for people to favour positive emotions and engage in activities and actions to instil such positive emotions, whereas people will avoid situations that can cause negative emotions. People can become dependent on smoking because of their expectation that it will produce a positive enhancing effect or reduce negative emotions (Khantzian, 1985, 1997). In these situations, people smoke to manage their emotional mood and the stronger the expectation that smoking will produce positive emotions, and this can lead to a positive reinforcement to smoke and also smoke heavily irrespective of the adverse physical health consequences. However, studies show that there are differentiations in the smoking expectations between light and heavy smokers (Brandon & Baker, 1991).

A study by Nesbitt, 1972 noted that most smoked as means to reduce stress with 80% of smokers using cigarettes when feeling stressed or angry.

There is also a growing body of evidence supporting the influence that non-nicotine factor in smoking behaviour. Parrot & Craig, 1995 reported that some smokers enjoy the sensory and tactile elements of smoking and this if this was removed then there was a decline in smoking satisfaction (Perkins et al., 2001).

Mental Disorders and Prevalence of Smoking
Studies show that in comparison to the general public the prevalence of smoking amongst people with mental disorders is relatively high. The Australia National Drug Strategy Household Survey taken in 2013 showed people with high/very high levels of psychological distress were twice as likely to be daily cigarette smokers compared to the general population (AIHW, 2013). For anxiety disorders, a study shows a 31.5% smoking rate for people with social phobia and a 54.6% for people with generalised anxiety disorder which are well above general population percentage rates (Ziedonis, 2008). Furthermore the severity of the disorder shows a prevalence of increase in smoking (Mendelsohn et al., 2015). With respect to the number of cigarette smoked an Australian study found that a smoker with psychotic illness smoked on average 21 cigarettes per day comparison to an average of 14 cigarettes per day among smokers in the general population (AIHW,2013).

Smoking Cessation – Dealing with Negative Emotions
Although there are various pharmacological treatment methods (nicotine chewing gum, the nicotine transdermal patch, nasal sprays, inhalers, and lozenges) to lessen the nicotine withdrawal cravings, a psychological approach is an important allied tool in smoking cessation programs. Various factors and circumstances apply with respect to taking up and quitting smoking (see section 9). Also people may require different treatment approaches at various points in a smoking cessation intervention (Prochaska et al., 1992).

Studies show that people smoke to reduce negative emotions or experience negative emotions as symptoms of the nicotine withdrawal process (see section 8.0 and sub-section 9.2). Furthermore the experience of negatives emotions is an impediment in giving up smoking and this impediment would need to be address in treatment programs.

For the various psychological theories/models that apply to the cessation of smoking, there are components in each of these theories/models involving motivation. Motivation is an obvious factor in successful quitting and is a method in countering negative emotions. Motivation can take many forms including financial rewards in reaching set goals in cessation program (see Case Study 1)

Motivational interviewing is another technique for intervention use to help motive smokers to quit and to deal with the associated negative emotions. The process is designed to help smokers clarify the need and process for change and move them along the continuum of change for the better. Successful benefits in motivational interviewing are given in Case Study 2.

Conclusion
Negative emotion is a significant factor that needs to be dealt with in smoking cessation programs. Motivation is a significant contributor is combating negative emotion in smoking cessation and must be a central component in strategies applied. Motivation psychology can make major contributions in developing successful quit smoking programs. As smoking appears to have prevalence with teenagers, people with mental health issues and people with particular personality/emotional traits, there appears to be a case for specific motivational programs that are tailored for the mentioned categories.