Brief outline: Paul Aveyard - Professor of behavioural medicine Paul is a public health physician and GP working in the field of behavioural medicine and has interests in tobacco control, obesity management, and promotion of physical activity.
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And can you talk to me a little bit about what it is that people are actually addicted to when it comes to smoking?
Yes. Well there’s probably a number of processes involved, but we’re pretty certain that the main driver of sort of addiction if you like, is this nicotine that’s released. And nicotine by itself, is probably not that addictive. So nicotine gum or things that you can buy in the shop, nobody seems to start using nicotine gum and carry on using it if they have never used cigarettes. It’s only when it’s been, they’ve smoked, getting the nicotine from cigarettes that it’s a problem.
And what nicotine does, it’s not actually a fantastic drug. So from an experience of the user’s point of view, people don’t always get a huge pleasure from it. But it takes over a part of the brain that is used as our reward system and that brain does some automatic learning which tells the brain to notice what they were doing just a few seconds earlier. Now it only takes a few seconds from inhaling the smoke into your lungs. It is then absorbed into your blood stream and immediately goes straight to the heart and then is pumped up the arteries that run into your head. So within a few seconds of smoking the nicotine is hitting that reward system in your head. And that is creating this acquired drive as we say. This feeling what you experience as a person who smokes is a feeling of needing to smoke.
And then certain changes take place. After a while of smoking your brain adapts to the level of nicotine and when you go without nicotine you begin to feel certain unpleasant symptoms like feeling grumpy is one of things that people notice. Some people feel down in the dumps when they haven’t smoked or anxious and agitated.
So people feel these symptoms and that can also help drive smoking because what they notice is that when they have another cigarette, they feel okay again.
And one of the things that leads to it actually is a feeling that smoking is stress relieving, because one of the symptoms of stress, well they are feeling agitated, feeling irritable, feeling sometimes a bit down in the dumps. And all of those feelings are suddenly relieved by smoking. But it’s the smoking that caused those symptoms in the first place.
Can you tell me a little bit about what sort of the role of behavioural prompts in that sense?
Yes, well the bit of the brain that does this sort of learning that says oh well you know, nicotine, let’s go with that, let’s keep smoking these cigarettes, is the bit of the brain that is involved in this conditioned response learning. It’s the bit of the brain when a lot of people have heard of Pavlov’s Dogs, and what Pavlov did, was every time he fed his dogs, he rang a bell, and he noticed my dog does this when I give him his food or before he gets his food he’s dribbling. Right well, Pavlov noticed that after a while, he could just ring the bell and the dogs would dribble. And the dogs had come to associate the bell with the reward which was the food. Now that’s what happens when a smoking learns to smoke. They learn to smoke in characteristic spaces so they’re not thinking about smoking. They go to a place where they normally smoke, outside a building nowadays, quite often people will smoke in their cars or they’ll get up in the morning and they’ll go downstairs and put the kettle on and they’ll reach for a cigarette and they won’t really be thinking about smoking, it’s just this kind of automatic learning that has gone on, and it’s that kind of learning that makes it so hard, when you are trying to stop smoking, because you go through all your familiar routines and you are doing the things that you normally do and low and behold you’re suddenly faced by the need to smoke a cigarette. And that’s what the problem is. So it’s why sometimes changing your routines can be so helpful to people, when they are trying to stop smoking because they’re avoiding these in the jargon we say cues to smoke, but the situations and places and sometimes mood states, when you normally have smoked previously.
Can you talk about sort of the health risk connected to, to do with pregnancy?
Okay. Well let’s start with the health risk then. It’s really important for pregnant women to stop smoking. We know that smoking in pregnancy can do a variety of things. Primarily it reduces the blood flow, down the placenta to the baby and that restricts growth and that may have a number of long terms effects but in the short time can increase the risks of certain complications in pregnancy. And is quite likely to cause a growth restriction of the baby.
Now there may also be subtle neurological effects that exposure to the drugs in cigarettes, the nicotine and the other substances that cross through the barrier to the baby may have a neuro development and there’s increasing evidence that subtle things, relatively subtle things, not major developmental abnormalities, but relatively subtle things like ADHD hyperactivity problems for example, or conduct problems in childhood are more common in the offspring of smokers.
So there may also be a minor degree of blunting of IQ.
So, it’s important that people stop and as soon as there’s a pregnancy the sooner they stop, the less they are likely to do to their baby that’s developing. In fact ideally they should stop before hand.
There are special services the NHS Stop Smoking Service will have somebody whose dedicated to helping pregnant women stop smoking. They do all the usual sorts of things that we’ve talked about already, although if they are actually pregnant then some of the medications may need to be slightly adjusted or only used for example the nicotine replacement treatment. So there are small differences, but in essence the support is the same. And it’s really important that women stop as soon as they can and the NHS is there to help them do that.
Can you tell me what are the main risks that are involved with smoking?
Well people do know that smoking is risky. What they often don’t quite appreciate is, firstly how risky it is, and secondly how beneficial stopping smoking is. So in terms of risk, essentially smoking knocks years off your life. And how many years, well if you take a lifetime smoker they will lose about ten years of life from a lifetime of smoking.
To put that into context of other things, for example, obesity, that’s the equivalent of being what we call morbidly obese, in other words about as fat as about 1-2% of the population. So really the largest people in our society, run roughly the same kind of risk of smoking. So, smoking is, you know, as a widespread behaviour, about the sort of riskiest of those sort of things that we all know about as sort of bad behaviours that we do.
And obviously people have a number of other health conditions, which can be affected by smoking. Can you talk me through some of the effects of that, say diabetes, heart conditions, COPD?
Yes, yes, yes. Well a lot of people will know that all of the things you mentioned, perhaps not diabetes, is so widely known, but I think we’re now clear that smoking is a relatively minor but important risk factor for diabetes. It’s the main risk factor for chronic lung disease called COPD or Chronic Obstructive Pulmonary Disease. And it’s a very important risk factor for heart disease. So many people know that. What’s really important for them also to know, is that they’ve already developed these, again like I said before, it’s just not too late to stop smoking. We know that the only real treatment that makes any difference to the long term outcome of COPD for example is stopping smoking. Doctors will give patients with COPD various inhalers. And they help. They help with the symptoms and make people feel less breathless, but they don’t alter the long term decline in lung function which is what’s happening in COPD. Only stopping smoking does that.
People with heart disease, if they stop smoking that reduces their risk of a heart attack by about a third, within a year or two of them stopping smoking. So, even though you’ve already got diseases that are caused by smoking, it can make quite an important difference to the outcome of those diseases, in helping getting better from asthma, a very common disease, lots of people smoke who’ve got asthma. Much less like to need the inhalers, often can reduce the dose of the preventer inhaler that people are using, and certainly improve the symptoms of asthma when you stop smoking.
So there’s lots of good reasons for people to want to stop when they have got diseases that they kind of know smoking is bad for.
The thing is that stopping smoking is remarkably effective at reducing the risks that arise from smoking. So even if you stop smoking when you’re 60 years of old, then you probably smoke for at least 40 years then. You still get a benefit you still seem to live about three years longer.
So from about middle age, well let’s say early middle age onwards, 35 years of age onwards, a smoker can think of their remaining life as one day. So whatever their length of life, think of it as one day. If they continue to smoke during that whole day they will lose six hours of their day, and if they stop when they are 35 or 40 or so they will get all of those six hours back, so they won’t have lost anything. Even though they smoked for may be 15 or 20 years at that sort of age.
So what the main message is that stopping smoking is remarkably good at reversing a lot of the damage that smoking has done. And the sooner you stop, the better the benefits are of course. But even stopping in older ages is still worthwhile.
Well a lot of people are slightly nervous about going to a group, it sounds of a bit weird, you know, ‘Hi my name’s Jim, and I’m a smoker’. You know, it’s a bit like Alcoholics Anonymous or something. They don’t really work quite the same way as Alcoholics Anonymous. And actually the people I’ve seen, because we’ve like persuaded to go to a group treatment, in the end have really, really enjoyed it. It’s no that commonly used in the NHS nowadays, because when you offer people a choice, do you want to go to a group or do you want to go to a clinic, people think, oh well, you know, one to one, one to one must be better.
In fact there’s no evidence that it is. And perhaps it may be slightly less effective than the group. Probably because one of the things that groups do, is create a feeling of being in a team. So if it’s you and me in a group and you know, you’re trying not to smoke, not just for yourself, but also because you’d feel like you were letting me down and the other group members down by smoking and it’s that sort of, if you like, that pressure against smoking that we feel when we’re engaged in this behavioural support process. There’s probably part of the ingredients that just sometimes make that difference between giving in to temptation, and having a cigarette or managing to resist the temptation type of cigarettes.
So groups definitely can work, individual support can work, the main thing is to get some kind of support whichever that is, but don’t be afraid of groups would be my sort of personal advice because people do enjoy them.
Well we used to believe that cutting down altogether wasn’t really a great idea and that the best way to stop was to smoke as normal and then have a quit day and then take it from there. And to be honest that probably is still the best way to go for most people. But if you feel you can’t do that, then it isn’t necessarily and I think we can say now, it is helpful in fact, to cut down.
So some people will cut down more slowly, some people will cut down vigorously. I think in the end people have got to come to a realisation that what they are going towards is a quit day where they smoke their last cigarette and then don’t smoke again.
One of the things that’s really important for people for people is understand, we call it the ‘not a puff rule’. But what that really means is once I pass this quite day, whatever the day that is I’ve set myself, I will not smoke again. It’s a bit like becoming a vegetarian. You don’t eat meat because that’s who you are. You are a vegetarian. It’s part of your sense of self, and your values and so on, and if you can set that rule for yourself that’s great.
So the danger about cutting down is that it’s always hard to get to that day where you think right that’s the day that they’ll be zero, because you can, I was cutting down and then I’ve had another one. What happens is people have the odd one as they’re trying to stop, is often but not always that will increase again, just as you manage to cut them down. So cut them down by all means but in the end realise there has to be a day which is a quit day.
The other thing we know about cutting down is when you cut down without any kind of support for example, medication in particular is what I’m thinking about, you tend to smoke the remaining cigarettes more intensively without really noticing that’s what you’re doing. And that doesn’t do a lot then for the amount you’re smoking, and won’t necessarily make that day after quit day easier. So using nicotine replacement to help you cut down – there’s advert on the TV at the moment as we speak about doing it one day at a time I think it is, but whatever the slogan is. But it’s advertising nicotine replacement. And the reason they can do that, the reason that they are allowed to do is we know from randomised trials again that cutting down that way, will tend to give people a better chance of being off cigarettes and long term, than cutting down without that kind of nicotine replacement.