Health-Compromising Behaviors - Meagher Lab

Chapter Five:
Health-Compromising Behaviors
characteristics
substance abuse and dependence
opponent process theory
alcohol abuse and dependence
smoking

Characteristics of
Health-Compromising Behavior
Many of these behaviors share a
window of vulnerability in adolescence
Drinking to excess
Smoking
Illicit drug use
Unsafe sex
Risk-taking behaviors
Tanning
Eating disorders

Characteristics of
Health-Compromising Behavior
Behaviors are tied to the peer culture
Image of these behaviors as “cool”
Insecure more vulnerable to peer pressure
Behaviors, though dangerous, are pleasurable and
often reduce anxiety
Linked to major causes of death
Behaviors develop gradually rather than being
acquired “all at once”
Substance abuse of all kinds are predicted by some
of the same factors
Interventions need to be matched to stage of
vulnerability

Substance abuse: Links
Conflict with parents and family problems
Impulsivity
Stress
Seems to serve as a coping mechanism,
other coping skills are lacking
Deviance in adolescence is linked to low
self-esteem and conflict in the family
Poor academic performance
Difficult temperament
Low SES, but less common among culturally
identified ethnic minorities
Unemployment

What Is Substance Dependence
Physical dependence
Body has adjusted to substance and
incorporates its use into normal functioning of
body’s tissues
Tolerance: Larger doses needed to produce
same effects
Craving: Conditioning process is involved so that
environmental cues trigger intense desire

What Is Substance Dependence
Addiction
A person has become physically or
psychologically dependent on a substance
following use over a period of time
Withdrawal
Unpleasant symptoms, both physical and
psychological, that people experience
when they stop using a substance on
which they have become dependent

Opponent Process Theory
Solomon & Corbit, 1974, 1978
Theory of acquired motivation/emotion
Emotions opposite pairs (fear/relief)
Standard pattern of affective dynamics
a-process
b-process
Grows with experience
Application to addiction
Heroin Addiction

Opponent Process Theory

skydivers jump from planes.
Beginners experience extreme fear on 1st jump, followed by extreme relief when they land.
With experience, the fear decreases and the post-jump pleasure increases.
Addiction Examples
thrill-seeking behaviors, runners high, drugs
Drug addiction
The drug initially produces pleasurable feelings, but followed by negative
emotions.
With repeated drug use the drug user takes drugs not for their pleasurable effects,
but to avoid withdrawal symptoms.

B-process grows in strength with repeated drug use
Cancels out euphoric effects of drugs (a-process)

Alcoholism and Problem Drinking:
Scope and Costs of the Problem
>20% of Americans drink at levels that exceed
government recommendations
Alcohol consumption is linked to
high blood pressure, stroke, cirrhosis of the liver,
fetal alcohol syndrome, some cancers, cognitive
impairments, 15% of health care costs = Etoh
abuse treatment, underestimate of health costs
Alcohol-related accidents:
1 in 2 Americans will be in one in their lifetimes
41% of traffic-related deaths related to alcohol
50% of all MVAs
Economic: $42 billion annually in lost productivity,
absenteeism

What Are Alcoholism and Problem
Drinking
Alcoholic
Physical addiction to alcohol
Withdrawal symptoms when abstaining from
alcohol
High tolerance for alcohol
Little ability to control drinking
Problem drinkers: may not have symptoms listed
above, but do have substantial social, medical or
psychological problems resulting from alcohol
More information:
http://www.nlm.nih.gov/medlineplus/substanceabuseproblems.html

DSM-IV Definitions
ALCOHOL ABUSE:
episodic problems, no physical symptoms of withdrawal or
tolerance, but social & occupational impairments, problem
drinkers
ALCOHOL DEPENDENCE (Alcoholics)
i) TOLERANCE -need to increase amounts
ii) DRUG WITHDRAWAL -affective and physical symptoms
following use: DTs, gross disorientation, cognitive
disruption, impaired motor coordination, tremor, fleeting
hallucinations
iii) Blackouts
iv) memory impairment
v) loss of control over drinking
vi) over involvement with the alcohol
vii) impaired social, occupational, physical/emotional f(x)

What Are Alcoholism and Problem
Drinking
Symptoms of Alcohol Abuse
Difficulty in performing one’s job because
of alcohol consumption
Inability to function well socially without
alcohol
Legal difficulties encountered while
drinking
Drunk driving convictions: DUI, DWI

EPIDEMIOLOGY
Stats:
1 out of 10 is a problem drinker/alcoholic
90% of HS seniors have tried it, but a small number do most of
the drinking. 1/10th drinks 1/2 of the alcohol consumed
other estimates suggest problem drinkers = 9 million, alcoholics
= 9 million; 3:1 male:female ratio
Ethnicity/SES
higher rates =native Americans, Europeans, Irish, lower rates
among southern Europeans, Jewish. Lower rates among Latino
and African Americans. More prevalent in middle class.
Gender
women tend to develop drinking problems later, but progress
more rapidly, usually with mood disorders in women and
antisocial PD in men.

Lifetime prevalence of alcohol
dependence by age and sex

High School Alcohol Use
80% of 12th, 2/3 of 10th graders

High School Alcohol Intoxication

Prevalence of alcohol use and dependence by age
Men
Women

Alcohol Use by Ethnicity 26 or >

Epidemiology
Personality factors
longitudinal studies indicate that childhood hyperactivity
and antisocial behavior are evident in alcoholics,
especially males
Dual diagnosis issues
most secondary to other psychopathology
30-50% Major Depression
33% Anxiety Disorders
Antisocial PD; Polysubstance abuse; Bipolar
http://www.nlm.nih.gov/medlineplus/dualdiagnosis.html

Alcohol and the brain

Physiological Aspects of Alcohol
Consumption
CNS Effects:
CNS depressant, slows the activity of the CNS, high doses
can cause a reduction in tension & inhibitions, and impair
judgment, motor control, and concentration.
Reduces anxiety by increasing the synaptic activity of
GABA, an inhibitory neurotransmitter and by decreasing
excitatory neurotransmission by both NMDA and non-NMDA
receptors
The GABA-benzodiazepine receptor complex contains
separate binding sites where alcohol, barbiturates &
benzodiazepines bind to make it more sensitive to GABA.
Because GABA is an inhibitory neurotransmitter the final
effect is to increase neural inhibition and decrease anxiety.

Physiological Aspects of Alcohol
Consumption
Absorption & Effects:
Alcohol (ETOH) is absorbed into the blood by the
stomach and small intestine
Initial effects = higher CNS, control of judgment
& inhibition & fine motor control, DISINHIBITION.
Increased ETOH = effects on lower CNS confused,
inappropriate, memory impairment, emotionally
labile, motor & sensory impairment.
Extent of impairment determined by blood ETOH,
intoxication=0.09%, at 0.55% = death, due to
depression of respiratory centers in the medulla.

How alcohol affects the brain

Moderate drinking and health
health benefits pf moderate ETOH use
Nondrinkers & heavy drinkers have poorer health
more strokes, higher rates of CHD,
J-shaped relationship.
Mortality rates of nondrinkers and moderate drinkers are
50% higher
200% higher in heavy drinkers.
Due to accidents, cancer, respiratory, and cirrhosis
Alameda county, Framingham, and Albany studies
confirmed results.
relationship is stronger in men under age 60. Seen in
smokers & non-smokers.
Albany study -abstainers = high CHD, but non-CHD
mortality didn't differ; mod ETOH reduces CHD, may
elevate HDL, prevents arterial blockade heart attacks.
Mechanism

J-Shaped Curves
J-shaped associations between alcohol intake and adverse health
outcomes, including CHD, diabetes, HTN, congestive heart
failure, stroke, dementia, Raynaud’s phenomenon, and allcause
mortality."
O’Keefe JH et al.,"Alcohol and cardiovascular health: the razorsharp
double-edged sword", Journal of the American College of
Cardiology, 2007;50(11) [in press].
Graphs examine only the effect of alcohol consumed, not other
benefits of those documented for red wine.
One "drink" contains 15 grams of alcohol (ethanol): approximately
12 oz. of beer, 5 oz. of wine, 1.5 oz. 80-proof liquor, or 1 oz.
100-proof liquor.

Alcohol and Mortality

Alcohol and all cause mortality
The relationship of daily alcohol consumption to the relative risk of all-cause
mortality in men and women. DiCastelnuovo A, et al., "Alcohol dosing and total
mortality in men and women", Archives of Internal Medicine 2006;166:2437-45.

Risk of Stroke
Relationship between daily alcohol and ischemic stroke.OR = odds ratio.
Sacco RL, Elkind M, Boden-Albala B, et al.,
"The protective effect of moderate alcohol consumption on ischemic stroke",
JAMA: the Journal of the American Medical Association 1999;281:53-60.

Alcohol:Incidence of Diabetes II
Alcohol intake and incidence of new type 2 diabetes.
Koppes LL, Dekker JM, Hendriks HF, Bouter LM, Heine RJ,
"Moderate alcohol consumption lowers the risk of type 2 diabetes:
a meta-analysis of prospective observational studies",
Diabetes Care 2005;28:71925.

Wine and Cholesterol

Alcoholism and Problem Drinking:
Is Modest Alcohol Consumption a Health
Behavior
Modest alcohol intake (1-2 drinks/day) may
add to a long life
For older adults
Coronary artery disease reduced
HDL “good” cholesterol increased
Fewer strokes, etc
Moderate drinking among younger adults
Enhances risks of death, probably due to alcoholrelated
injuries

Alcohol increases other risks
Bofetta, P, and Garfinkel, L. "Alcohol drinking and mortality among men
enrolled in an American Cancer Society prospective study."
Epidemiology 1:342-348, 1990.

Heavy Drinking and Health
Alcohol intoxication
-50% of suicides, homicides, and accidental deaths.
Poison to nearly all organ systems
Neural effects- brain and neuropsychological dysfunction
ANTEROGRADE AMNESIA-blackouts impaired consolidation
CNS PATHOLOGY DUE TO B VITAMINE DEFICIENCY -
Thiamine, 10% of alcoholics are affected by this syndrome,
treat with thiamine
-WERNICKE'S ENCEPHALOPATHY - short term- acute occular
disturbances, ataxia, confusion, excitement untreated =
Korsakoff's syndrome
-KORSAKOFF'S SYNDROME -extreme confusion, memory
impairment, confabulations not affected by thiamine,
damage to mammilary bodies, thalamus, -CORTICAL
ATROPHY -especially frontal lobes

Heavy Drinking and Health
Neuropsychological Impairments
even when sober, chronic alcohol abuse/dependence
results in cognitive impairments
While verbal abilities & IQ in normal range
Impairment in abstract reasoning, executive functions:
concept formation, cognitive flexibility, and perceptualmotor
abilities.
Improves w/abstinence
Increased Mortality
heart disease, stroke, cancer, and cirrhosis of the liver.
cofactor in cancer of larynx, pancreatic cancer, increased
accidental death.

Alcoholism and Problem Drinking:
Origins
Genetic factors appear to be involved
Twins studies
if one twin is alcoholic, the likelihood that the other
twin is alcoholic is 2 times as high if identical (54%) vs.
fraternal (28%), relationship not always this strong
genetics=20% of the variance some studies, 50% others
What is inherited GABA, serotonin gene that regs
dopamine receptors Early environment
Frequency of alcoholism in sons of alcoholics
Men traditionally were at greater risk
With changing norms, women are “catching up”
Multifactorial: Physiological, behavioral, and
sociocultural factors are involved

Alcoholism and Problem Drinking:
Origins
Drinking occurs as an effort to buffer
the impact of stress
Drink to enhance positive emotions
Drink to reduce negative emotions
Alcoholism is tied to the drinker’s
social and cultural environment.
Window of vulnerability: Ages 12 to 21
Window of vulnerability: Late middle age

Alcoholism and Problem Drinking:
Origins
Depression and alcoholism may be
linked
Alcoholism may represent untreated
symptoms of depression
OR
Depression may act as an impetus for
drinking to improve mood
Symptoms of both disorders
must be treated simultaneously

Gene Environment Interactions
Early environment:
Maternal and neonatal stress.. Impact on twin
studies
Stress:
Exposure to chronic uncontrollable stress
increases the reinforcing properties of most drugs
of abuse, relation to early risk factors
Learning:
classical conditioning of craving to drug cues
withdrawal symptoms when exposed to drug cues
plays a role in relapse
how to prevent

Prevention of Alcohol Abuse
Legal barriers
drinking age 21, enforcement, DUI, DWI
Inoculation programs
help reduce drunk driving, but work best
with light drinkers
If you catch drinking early, before a
heavy use pattern develops, people
can control it

Alcoholism and Problem Drinking:
Treatment of Alcohol Abuse
“Maturing Out” of Alcoholism
10 to 20% of dependent/alcoholics stop drinking
on their own
32% can stop with minimal help
Can be treated successfully through
cognitive-behavioral modification
But
High rate of recidivism – as high as 60%
Alcoholic’s environment must be considered
Without employment or social support, prospects for
recovery are dim

Alcoholism and Problem Drinking:
Treatment Programs
700,000
people
in U.S.
receive
treatment
on any
given
day
Self-Help Groups are most
commonly sought source of
help
especially AA
(Alcoholics Anonymous)
Hard-Core Alcoholics
Detoxification
Short-term, Inpatient Therapy
Continuing Outpatient
Treatment

Detox and Medical Management
Alcohol Withdrawal Syndrome- physical dependence, hours
later withdrawal: shaking of hands, tongue, and eyelids, weak,
nauseous, sweat & vomit. HR & BP rise, anxious, depressed or
irritable, hallucinations, convulsions 2-3 days
Delirium Tremens - DTs - gross memory disturbance, mental
confusion, clouded consciousness, disoriented, hallucinate
seizures, loss of consciousness, 2-3 days
Treatment- Symptom management: -relief of agitation,tremors
w/ sedative-hypnotics, benzodiazepines; B vitamins,
anticonvulsants, delirium - tranquilizers
after withdrawal, goals = sobriety & treat psychological conditions
serotonin reuptake blockers reduce drinking (Prozac)
Buspar anti-anxiety drug not related to benzos
RO 15-4513 drug reverses alcohol intoxication by blocking a type of
benzodiazepine receptor which modulates the activity of
GABAergic neurons
Naltrexone - opioid antagonist, dampens high

Psychological Treatments
Insight Treatment
treat associated psychological & personality problems. Brownell
(1982) indicates success rates varied from 65% to 82% at 1-year followup,
but cut in half (40%) at 3-year follow-up (Armor et al., 1978;
Wiens & Menusik, 1983).
Behavioral & Cognitive Treatment
Self-Monitoring
Person begins to understand situations that give rise to drinking
Self-Management
rewards and punishments, control stimuli, develop other coping
responses
Contingency contracting
Person agrees to a costly outcome (financial or psychological) in
the event of failure, can involve family
Systematic Desensitization and relaxation
cope with tension/anxiety

Psychological Treatments
Aversion therapy
Antabuse, conditioned aversion, 63% success rate at 1 year
follow-up (Wiens & Menustik, 1983), adherence problems
Relapse Prevention -
50% drop out, less than 50% finishing are successful at 1
year follow-up.
Successful = best adjustment, older, higher SES, no other
substance abuse hx, stable relationships and
employment, no psychopathology/only depressed, no hx
treatment failures, motivated (Holden, 1987, Stark,
19992, Nathan, 1986).
Social and problem-solving skills training:
most relapse in 90 days when encounter high risk
situations. Teach social and problem-solving skills
training -use imagination, role playing and rehearsal.
Multicomponent Treatment
best chance of long-term success = combining variety of techniques

Inpatient treatment
Evidence suggests that inpatient therapy is not
essential for most alcoholics, only extremely
impaired ones (Holden, 1987).
Nor is there any advantage to long treatment
programs (Miller and Hester, 1986).Women
do better in separate programs (Dahlgren &
Willander, 1989).
However, some recent finding challenge this
notion.
Recent approaches treatment matching, stage
of change, relapse prevention, mindfulness
meditation, combination therapy

Motivational Enhancement Therapy
MET helps develop intrinsic motivation to change to lead client to
initiate, persist, and comply with behavior change. 5 principles
1) Express Empathy
2) Develop a Discrepancy – help client see discrepancy between where
they are and where they want to be – raise awareness of personal
consequences of drinking for pre-contemplators. Such information can
create a crisis that will motivate change. The person will be motivated
to enter into frank discussions of change options in order to reduce the
perceived discrepancy and maintain emotional equilibrium. When client
enters tx in the later contemplation stage, it takes less time and effort
to move client along.
3) Avoid Argumentation - if handled poorly, ambivalence and
discrepancy can turn into defensive coping (rationalization, denial)
which will reduce discomfort but not alter drinking. This happens when
the client perceives that your are attacking them.

Motivational Enhancement Therapy
4) Roll with Resistance- don’t confront resistance head on,
rather work toward shifting patients perceptions, allow
patient to invite new ways of solving the problem.
Ambivalence is viewed as normal not pathological – openly
explored -- reflected. Solutions are evoked from the client
rather than provided by therapist.
5) Support Self-Efficacy – people who are persuaded that
they have a serious problem won’t move toward change
unless they believe there is hope for success. Belief that
you can perform a particular behavior or task --- it is
possible to change your drinking and thereby reduce other
problems. Without it, patients use defensive coping.

Alcoholism and Problem Drinking:
Profile of Alcoholics Anonymous
Philosophy
The best person to reach an alcoholic is a
recovered alcoholic
Immersion: Attend 90 meetings in 90 days
12-step program - spiritual focus, conversion
Disease model
Recovery depends on staying sober
Members provide social reinforcement for one
another's abstinence
Alcoholism
A disease that can be managed, not never cured
Alcohol plays no part in the person’s future

AA 12 Steps
1. We admitted we were powerless over alcohol - that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure
them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we
understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message
to alcoholics and to practice these principles in all our affairs.

AA
Dropout rate unknown
Comparing AA to insight oriented, behavior, and
nontreatment (Brandsma et al., 1980).
AA highest drop out (68%) other groups =57%; AA was
no more successful than any of the other group
therapies for those finishing study
Project Match found all performed about the same
AA claims 2 out of 3 stop who want to stop
Recent evidence
show better outcomes when patients participate in AA
rather than in a formal treatment program alone
Treatment costs are lower for AA group(45%)
How does it work
Conversion, meaning, maturity, social support, etc

Alcoholism and Problem Drinking:
Treatment Programs: Relapse Prevention
Relapse rates
50% or more relapse 2-4 years after treatment
50% or more relapse within first 3 months
Helpful for problem drinkers to know
An occasional relapse is normal
Relapse doesn’t signify failure
Important relapse prevention skills
Learning “drink-refusal skills”
Learning nonalcoholic beverage substitutions
ID high risk situations, develop skills to manage
them, and advanced planning

PROJECT MATCH
Compared 3 manualized treatments: CBT,
Motivational Enhancement, and AA 12-step
Randomly assigned
Monitored for a year and longer
Found improvements in all groups at one
year in all groups, but no overall differences
between treatments
Patient selection of treatment
Need to focus more efforts on prevention!!

Alcohol-Related Problems of College
Students

Alcoholism and Problem Drinking:
The Drinking College Student
Most U.S. college students drink alcohol
15%-25% are heavy drinkers
45% engage in occasional binge drinking (vs.
15% of overall adult population)
Successful interventions:
Encourage students to gain self-control over
drinking rather than eliminating alcohol
Self-monitoring often reduces drinking

Alcoholism and Problem Drinking:
The Drinking College Student
Skills Training
Identify circumstances when drinking to excess
occurs
Placebo drinking
Consuming nonalcoholic beverages while others are drinking
Alternating alcoholic and nonalcoholic drinks
Lifestyle rebalancing
Excessive alcohol consumption is incompatible with
a healthy lifestyle
Add exercise, mindfulness meditation, smoking
cessation, social experiences without alcohol

Alcoholism and Problem Drinking:
Treatment of Alcohol Abuse
Minimal Interventions
Success of brief interventions remains
unclear
Oslin et al, 2003 study results produced
beneficial changes
Curry et al, 2003 study had high drop out rates
About 85% of alcoholics don’t receive
formal treatment

Alcoholism and Problem Drinking:
Treatment of Alcohol Abuse
Social engineering may represent the
best approach
Banning alcohol advertising
Raising the legal drinking age
Strictly enforcing the penalties for drunk
driving
These approaches reach the untreated
majority

Alcoholism and Problem Drinking:
Can Recovered Alcoholics Drink again
Alcoholics Anonymous Philosophy
An alcoholic is an alcoholic for life
Drinking in moderation seems possible
For young, employed problem drinkers
Who have not been drinking for long
Who live in supportive environments
Drinking in moderation
May be a more realistic goal for college students
May prevent high dropout rates in more
traditional programs

Alcoholism and Problem Drinking:
Preventive Approaches
Social influence programs in Junior Highs
have shown some success
Adolescents’ self-efficacy enhanced (drink
refusal skills)
Programs can change teens’ social norms
focus on controlled drinking/abstinence rather than
excessive consumption
Approaches are low cost programs for low-income
areas
Social engineering promise for prevention
Higher taxes on alcoholic beverages

Alcoholism and Problem Drinking:
Drinking and Driving
Mobilizes the public against alcohol abuse
50% MVA fatalities result from alcohol abuse
Political impact from groups like MADD
Pressure for hosts and friends to intervene
Self-regulatory techniques
Designated driver
Taxis
Delaying driving after consuming alcohol

Smoking
Role of Psychologists
Disease Management Model
Prevention
Single greatest cause of preventable death
USA – accounts for about 1 in 5 deaths
Smokers, compared to nonsmokers are
Generally less health-conscious (drink, sedentary)
More likely to engage in other unhealthy behaviors
Drinking cues
Smoking

Smoking
30% of all Americans
Low SES (income/education)
Pediatric disease
3000 children/teens per day
1/5 at the end of High School
1 in 5 adults die each year from tobacco use
Approx 450,000 premature deaths each year

20 year lag for smoking and lung
cancer deaths

Smoking and Health Problems

Smoking
Smokers: risks and costs
CHD and 30% of all cancer deaths (4 x risk of breast c)
Bronchitis, emphysemia, asthma, etc
Low birth weight infants & retarded fetal development
More accidents and injuries at work
Take off more sick time
Use more health benefits
Studies of secondhand smoke reveal that family
members and coworkers are at risk for a variety
of health disorders.

Costs
Direct medical cost
estimated >50 billion/year
$2.00 every pack sold US
Life time medical costs (more medical problems,
dental, medications, co-pays) higher for smokers,
even they die young
Life insurance, health insurance, home owners, and
car insurance higher
Loss in home and car resale, earn less money, some
employers refuse to hire smokers (ACLU 6,000
employers)
Curtailing teen smoking is the cheapest and easiest
way to slash health care costs
Readily reach kids and teens in public schools

BENEFITS OF QUITTING
Research results show that just 20 minutes after
you’ve smoked that last cigarette, your body begins an
ongoing series of beneficial changes:
> 20 MINUTES
o Blood pressure drops to normal
o Pulse rate drops to normal
o Temperature of hands and feet increases to normal
> 8 HOURS
o Carbon-monoxide level in blood drops to normal
o Nerve endings start regrowing
o Ability to smell and taste is enhanced
o Walking becomes easier
> 2 - 12 WEEKS
o Circulation improves
o Lung function increases up to 30%
> 1 - 9 MONTHS
o Coughing, sinus congestion, fatigue, shortness of breath
o Decrease Cilia regrow in lungs, increasing ability to handle mucus
o Clean the lungs, reduce infection
> 1 YEAR
o Risk of coronary heart disease is half that of a smoker

Smoking: Synergistic Effects
Smoking enhances the impact of other risk
factors in compromising health
Nicotine stimulates release of free fatty acids, in
turn decreases HDL
Nicotine increases men’s reactivity to stress
Increases BP in women, risk of CHD and stroke
Smokers engage in less physical activity
Smoking is considered a potential cause of
depression, especially among youth
Smoking is related to an increase in anxiety
among adolescents

Smoking: A Brief History
A sophisticated habit of the male gentry until
WWII
1940s
Large numbers of women smoke
Advertised as symbol of feminine sophistication
1964
First U.S. Surgeon General’s warning is issued
Male smoking declines, female smoking increases
1994
Female teen smokers, 22.9%
Male teen smokers, 28.8%

Smoking: Why Do People Smoke
Smoking begins early (adolescence)
15% of teens smoke regularly
Initial experimentation
Tries out cigarettes
Experiences peer pressure to smoke
Develops attitudes about smokers
Only some become heavy smokers

Smoking: Why Do People Smoke
Peer influence
70% of all cigarettes smoked by teens are
smoked in the presence of a peer
Adolescents are more likely to start
smoking if
Their parents smoke
They are lower-class
They feel social pressure to smoke
There has been a major family stressor

Smoking: Why Do People Smoke
Chippers: term used to describe light
smokers
High value placed on academic success
Supportive relationships at home
Little smoking among parents and peers
Number of “chippers” has increased
Surprising trend given addictive nature
of smoking

Smoking: Why Do People Smoke
To preadolescents, the image of a
smoker
Rebellious
Tough
Mature
Smoking cigarettes may help convey
the image that an insecure teen longs
to display

Smoking: Why Do People Smoke
Smoking is clearly an addiction
It is reported to be harder to stop than heroin
addiction or alcoholism
The exact mechanisms of nicotine addiction are
not known
Nicotine may be a way of regulating performance
and affect
Smoking is also maintained by social learning
Smoking is paired with rewarding experiences

Smoking:
Interventions to reduce smoking
Media campaigns have helped instill
antismoking attitudes among the general
public
Even adolescents view smoking as addictive
Changes in social norms (from largely
positive to strongly negative) have motivated
many people to quit
BUT attitude-change campaigns by
themselves don’t help smokers quit

Smoking:
Interventions to reduce smoking
Nicotine-Replacement Therapy
Nicotine gum is disliked because the
nicotine is absorbed very slowly
Transdermal nicotine patches release
nicotine in steady doses
Nicotine-replacement therapy
produces significant smoking cessation

Nicotine Patch

Smoking:
Interventions to reduce smoking
Multimodal Interventions
Specific interventions are geared to the stage
of readiness with respect to smoking
Precontemplation
to Contemplation
Focus is on
attitudes.
Emphasis on
adverse health
consequences
Contemplation to
Action
Smoker develops
a timetable to
quit and a
program of how
to go about it
Action Phase
Cognitivebehavioral
techniques
will be used

Smoking:
Interventions to reduce smoking
Social Support and Stress Management
Would-be ex-smokers enlist support from others in
their efforts to stop
A strong image of oneself as a “nonsmoker” helps
treatment effectiveness
Maintenance and Relapse Prevention
Many people relapse on the road to quitting
A single lapse reduces perceptions of self-efficacy
When self-efficacy wanes, vulnerability to relapse is
high

Smoking: Who is best able to induce
people to stop smoking
Recall the
concept of
the teachable
moment
Physician
recommendations
Especially effective
for pregnant
smokers
Patients with
symptoms of CHD
more likely to stop
Hospitalized
patients

Smoking:
Why is smoking so hard to change
Deeply entrenched behavior that may be
influenced by
Addiction that makes it difficult to stop
Mood, since it elevates mood
Weight control, it keeps body weight down
But more than 45 million Americans have
successfully quit
Those who quit on their own have good selfcontrol
skills, self-confidence in their ability to
stop, and a belief that the benefits to quitting
are substantial

Smoking Cessation
Patch alone is not enough, since
smoking is more complex than just the
physical addiction.
Psychological factors such as stress that
can trigger a desire to smoke. Social and
environmental factors (e.g., group of
friends, meal, type of gathering) that
make a contribution, too.
Treating the physical addiction doesn't
address these psychological influences,
which can trigger a relapse to smoking
months or years after a person has quit.

Hall, S.M., et al. Extended nortriptyline and
psychological treatment for cigarette smoking.
American J of Psychiatry 161(11):2100-2107, 2004.
Assigned 160 trial participants to one of four conditions.
All the participants received nicotine replacement therapy
(transdermal patch) and took part in five group counseling
sessions during the first 12 weeks of the study. 90-minute
sessions concentrated on understanding health issues
associated with smoking and quitting, developing personalized
quit strategies, and avoiding relapse.
Half received placebo and half nortriptyline, an antidepressant
that helps smokers to quit. Adjusting doses to maintain blood
concentrations of 50 to 150 ng/L.
At the end of 12 weeks, treatment ended for half of the
participants.
The remaining half continued their regimens of nortriptyline
(40) or placebo (41) for 40 more weeks. Continued to
participate in monthly 30-minute group counseling sessions and
were contacted by phone 2 weeks after each session to
reinforce counseling lessons.

Extended combination treatment
At weeks 24, 36, and 52, far fewer of the
participants in extended treatment were smoking
than were participants whose treatment ended after
12 weeks.
At the end of 1 year, 50 percent of patients who
had received nortriptyline and counseling
throughout were abstinent, compared with 18
percent who got this treatment for only 12 weeks.
Forty-two percent of patients who received
extended counseling and placebo were abstinent at
1 year, compared with 30 percent of those who got
them for 12 weeks.

FINDINGS

Extended combination treatment
"The highest success rate was with nortriptyline and
counseling for 52 weeks," Dr. Hall says. "Extended
treatment with placebo and counseling came in a
very close second, suggesting that prolonged
psychological support and counseling are important
components in improved treatment outcomes."
"Simply treating the physical addiction doesn't
address these psychological influences, which can
trigger a relapse to smoking months or years after a
person has quit."
Findings show that combination treatment provided
over an extended period improves smoking cessation
rates.

Smoking Prevention

Smoking:
Prevention
Social Influence Intervention
(Richard Evans/Houston School District)
Two Theoretical Principles:
Model “High Status” nonsmokers
Behavioral inoculation
expose students to a weak version of a
persuasive message so they can resist the
message in its stronger form

Smoking:
Prevention
Social Influence Intervention Program
Information about negative effects of
smoking (appealing to adolescents)
Image of nonsmoker is presented as
independent and self-reliant
But a smoker falls for advertising gimmicks!
Peer group is used to facilitate non
smoking rather than smoking

Smoking:
Prevention
Life-Skills-Training Approach
Rationale: If adolescents are trained in selfesteem
enhancement, then they will not feel
the need to bolster self-image by smoking
Social Engineering and Smoking
Liability litigation
FDA Regulation of tobacco as a drug
Heavy taxation