Research on Smoking Behavior pptx

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE • Public Health Service • Alcohol, Drug Abuse, and Mental Health Administration Research on Smoking Behavior Editors: Murray E. Jarvik, M.D., Ph.D. Joseph W. Cullen, Ph.D. Ellen R. Gritz, Ph.D. Thomas M. Vogt, M.D., M.P.H. Louis Jolyon West, M.D. NIDA Research Monograph 17 December 1977 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute on Drug Abuse Division of Research 5600 Fishers Lane Rockville, Maryland 20857 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 Stock Number 017-024-00694-7 The NIDA Research Monograph series is prepared by the Division of Research of the National Institute on Drug Abuse. Its primary objective is to provide critical re views of research problem areas and techniques, the content of state-of-the-art conferences, integrative research reviews and significant original research. Its dual publication emphasis is rapid and targeted dissemination to the scientific and professional community. Editorial Advisory Board Avram Goldstein, M.D. Addiction Research Foundation Palo Alto, California Jerome Jaffe, M.D. College of Physicians and Surgeons Columbia University New York Reese T. Jones, M.D. Langley Porter Neuropsychiatric Institute University of California San Francisco California William McGlothlin, Ph.D. Department of Psychology. UCLA Los Angeles, California Jack Mendelson, M.D. Alcohol and Drug Abuse Research Center Harvard Medical School McLean Hospital Belmont, Massachusetts Helen Nowlis, Ph.D. Office of Drug Education. DHEW Washington, D.C. Lee Robins, Ph.D. Washington University School of Medicine St. Louis. Missouri NIDA Research Monograph series Robert DuPont, M.D. DIRECTOR, NIDA William Pollin, M.D. DIRECTOR, DIVISION OF RESEARCH, NIDA Robert C. Petersen, Ph.D. EDITOR-IN-CHIEF Eunice L. Corfman, MA. EDITOR Eleanor W. Waldrop MANAGING EDITOR Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857 Research on Smoking Behavior ACKNOWLEDGEMENT This monograph is derived from papers presented at a conference on smoking behavior convened at the University of California at Los Angeles, June 24 and 25, 1977. (An indication of their impact is that the editor of the NIDA Research Monograph series has stopped smoking .) Ms. Toby-Ann Cronin played a critical role in the coordination of the conference and in the development of this publication, under NINA contract #271-77-3422 with UCLA. Library of Congress catalog number 77-090890 DHEW Publication No. (ADM) 78-581 Printed 1978 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of Biosciences Information Service, Chemical Abstracts, Psychological Abstracts, and Psychopharmacalogy Abstracts. iv Foreword In the 14 years since the 1964 Advisory Committee’s Report to the Surgeon General on smoking, awareness of the important effect of this widespread behavior on the nation’s health has moved in op- posite and paradoxical directions. On the one hand, the Report triggered significant changes. sumption occurred in that year, A distinct drop in cigarette con- and since then consumption has de- creased for adult males from 52 per cent to 39 per cent and for adult females from 32 per cent to 29 per cent. A 1975 study shows the number of physicians still smoking has decreased from 30 per cent in 1967 to 21 per cent, dentists from 34 per cent to 23 per cent, and pharmacists from 35 per cent to 28 per cent. On the other hand, the knowledge has become trite and the magnitude of the dam- age lost sight of. Fifty million Americans still smoke. Ominously, smoking by girls between 12 and 18 nearly doubled between 1968 and 1974, eliminating the difference in smoking behavior between the two sexes. The age at which many children begin regular smoking is down to 11 to 12 years. Not only is early onset of a drug habit often predictive of heaviness of use and difficulty of cessation, but cigarette smoking is often a precursor or gateway substance to use of stronger drugs. Most people, including health officials, are startled when the fig- ures on smoking damage are put into perspective. For example, the number of people who annually die prematurely from smoking is es- timated at 300,000. For comparison, annual automobile fatalities are estimated at about 55,000, overdose deaths attributed to bar- biturates are estimated at about 1,400, and to heroin at about 1,750. Over 37 million people (one of every six Americans alive today) will die from cigarette smoking years before they otherwise would. If tobacco-related deaths were eliminated, there would be: 300,000 Americans each year who would not die prematurely 1/3 fewer male deaths from 35 to 59 85 per cent fewer deaths from bronchitis or emphysema 1/3 fewer deaths from arteriosclerosis 1/3 fewer deaths from heart disease 90 per cent fewer deaths from cancer of the trachea and lungs 50 per cent fewer deaths from cancer of the bladder Given the extent of the problem, a consensus is growing that the national effort to cope with it has been defective. Not qualita- tively, since good people have done substantial and important work, and many lives have been saved. But quantitatively the effort has v been too little and its priority insufficiently urgent. Cigarette smoking is the largest preventable cause of premature death, ill- ness, and disability we have. These smoking damage figures are so large because of heavy promotion, governmental protection and sub- sidy,. a health industry largely preoccupied with other things, and an entrenched and overlearned addictive behavior that has proven extraordinarily hard to reduce or extinguish, But what should we think of ourselves, individually or collectively as a nation, if we concede, therefore, that we are helpless to change this toll and must learn to tolerate it? The NIDA Division of Research has given increased priority to this issue during the past few years for several reasons: the increasing identification of smoking as a prototypic addiction, the status of smoking as a gateway drug to use of stronger or illicit drugs, and our focus on substance abuse as a generic phenomenon that includes tobacco. The Royal College of Physicians 1977 report on Smoking and Health says of the habit, " . tobacco smoking is a form of drug dependence different from but no less strong than that on other drugs of addiction " The current International Classification of Diseases (ICD) now lists tobacco smoking disorder as a drug prob- lem, and, as Dr. Jerome Jaffe tellingly recounts in this monograph, so, at last, does the new psychiatric Diagnostic and Statistical Manual (DsM)III draft revision. Public health policy on smoking should probably recognize that ex- tinction of the habit is an unrealistic goal and even undesirable, given the adjunctive coercion such a goal would require. But we should take care to devote a degree of concern and excellence to understanding and dealing with the problem that is’ commensurate with its size. The idea of control appears central, whether this is ex- ercised in brain and CNS responses, by genetic or psychological pre- disposition, through learning or reinforcing factors in the cultural and institutional environment. Cur research agenda needs to address all these levels. Correspondingly, one measure of the usefulness of the papers in this monograph is their scope, from the basic opponent process theory formulated by Dr. Joseph Ternes to the activist prevention policy presented by Dr. Ellen Gritz; from the differently impressive syn- optic views of Drs. Russell and Van Lancker to the valuable particu- lar cost figures calculated by Drs. Lute and Schweitzer. To have put between two covers a set of papers of such high caliber, time- liness, and utility is a welcome achievement. William Pollin, M.D. Director Division of Research National Institute on Drug Abuse vi Preface The National Institute on Drug Abuse has been given the lead role in the Federal Government to carry out and support research on tobacco smoking behavior. Unlike other Federal efforts in this area of public health, NIDA will focus its effort on the dependence pro- cess associated with tobacco smoking. Tobacco smoking can be viewed as a prototype dependence ‘process which has a significant impact on the public health. The morbidity and premature mortality figures associated with this habitual behavior ark high. It is estimated, for example, that some 250,000-300,000 premature deaths can be di- rectly or indirectly related to tobacco smoking. While much re- search has been devoted to the biomedical and pathological conse- quences of smoking (early onset of cardiovascular and pulmonary di- sease and lung cancer), relatively little Federal research support has been provided for understanding the biological, behavioral, psychological, and societal factors which may be substantial in the etiology and maintenance of this habitual behavior. Little, if any, research has been focused on elucidating withdrawal phenomena associated with cessation of smoking or factors leading to relapse and recidivism. Other areas of research which are ripe for develop- ment are innovative treatment procedures for teaching people how to stop smoking and pharmaco-therapeutic techniques for maintaining abstinence. Development of biological assays to detect tobacco, nicotine, and its metabolites is essential. Such technology would afford researchers a way to validate self report data in follow-up studies and epidemiological surveys of smokers. NIDA is currently developing an extra-mural funding program targeted for research on tobacco smoking as a dependence process. Part of our effort in this area of smoking research is exemplified by this conference. Norman A. Krasnegor, Ph.D. Division of Research National Institute on Drug Abuse vii Monograph Contributors Ransom J. Arthur, M.D. Professor and Executive Vice Chairman, Department of Psychiatry and Biobehavioral Sciences; Associate Dean for Curricular and Student Affairs UCLA School of Medicine 760 Westwood Plaza Los Angeles, California 90024 Joseph W. Cullen, Ph.D. Deputy Director -UCLA Cancer Center Center for the Health Sciences Los Angeles, California 90024 Emerson Foote Life Member, Board of Directors American Cancer Society Gipsy Trail, Camel, New York 10512 Bernard H. Fox, Ph.D. Manager, Social Science Office of Field Studies and Statistics National Cancer Institute National Institutes of Health Bethesda, Maryland 20014 Dorothy E. Green, Ph.D. Consulting Research Psychologist 3509 N. Dickerson Street Arlington, Virginia 22207 Ellen R. Gritz, Ph.D. Assistant Research Psychologist Department of Psychiatry and Biobehavioral Sciences, UCLA; Psychologist, Veterans Adminis- tration Hospital Brentwood Los Angeles, California 90073 viii Jerome H. Jaffe, M.D. Chief, Psychiatric Research Department of Biological Psychiatry, New York Psychiatric Institute 722 West 168th Street New York, New York 10032 Murray E. Jarvik, M.D., Ph.D. Professor of Psychiatry and Pharmacology, UCLA; Chief, Psychopharmacology Unit Veterans Administration Hospital Brentwood Los Angeles, California 90073 Robert P. Liberman, M.D. Research Psychiatrist, UCLA Camarillo-Neuropsychiatric Institute Research Center, Box A Camarillo, California 93010 Edward Lichtenstein, Ph.D. Professor of Psychology University of Oregon Eugene, Oregon 97403 Bryan R. Lute, M.S., M.B.A. Doctoral Candidate, Department of Health Services, School of Public Health, UCLA Center for the Health Sciences Los Angeles, California 90024 Leo G. Reeder, Ph.D. Professor of Public Health School of Public Health, UCLA Center for the Health Sciences Los Angeles, California 90024 Michael A.H. Russell, BM, MRCP? MRCPsych . The Institute of Psychiatry, The Maudsley Hospital Addiction Research Unit 101 Denmark Hill London, England Leonard H. Schuman, M.S., M.D. Professor and Director, Division of Epidemiology School of Public Health University of Minnesota 1360 May Memorial Bldg. 420 Delware Street: S.E. Minneapolis, Minnesota 55455 Jerome L. Schwartz, Dr. P.H. Chief, Health Care Research Office of Planning and Program Analysis, Department of Health, State of California 714 P Street Sacramento, California 95814 Stuart 0. Schweitzer, Ph.D. Associate Director of Health Economics, School of Public Health, UCLA Center for the Health Sciences Los Angeles, California 90024 Kenneth I. Shine, M.D. Chief, Division of Cardiology Associate Professor of Medicine, UCLA Center for the Health Sciences Los Angeles, California 90024 Joseph W. Ternes, Ph.D. Clinical Psychologist Drug Dependence Treatment and Research Center Philadelphia V.A. Hospital University & Woodland Avenues Philadelphia, Pennsylvania 19104 Phoebus N. Tongas, Ph.D. Chief Psychologist Department of Psychiatry Kaiser-Permanente Medical Center 1515 N. Vermont Avenue Los Angeles, California 90027 Julien L. Van Lancker, M.D. Professor and Chairman Department of Pathology, UCLA Center for the Health Sciences Los Angeles, California 90024 Thomas M. Vogt, M.D., M.P.H. Assistant Professor of Epidemiology School of Public Health, UCLA Center for the Health Sciences Los Angeles, California 90024 Louis Jolyon West, M.D. Professor and Chairman Department of Psychiatry and Biobehavioral Sciences UCLA School of Medicine Director, The Neuropsychiatric Institute, 760 Westwood Plaza Los Angeles, California 90024 Ernst L. Wynder, M.D. President. American Health Foundation 1370 Avenue of the Americas New York, New York 10019 ix [...]... particular attention to Dr Vogt’s presentation Dr Ternes has presented us with an interesting application of Richard Solomon’s opponent process theory to smoking Solomon 3 demonstrated that in dogs conditioned to punishing electric shock, they not only developed tolerance to the situation but they developed a strong positive reaction to cessation of the negative stimulus which persisted for a long time This... with few constraints Secondly, unlike most forms of psychopathological behavior, there is a clearly definable endpoint, namely non -smoking All the difficulties inherent in most forms of psychotherapy are also present in the therapy of smoking Tongas suggests that we concur that future research on the therapy of smoking behavior might focus upon respondent, cognitive, and operant behavior We’ve only scratched... methods of achieving non -smoking behavior These have included aversive conditioning (rapid smoking) , covert conditioning, behavioral group therapy, and a combined condition The best procedure was the combined one which involved multiple therapies At the end of one year, this group had 77% complete abstinence, and at the end of two years 64% abstinence This study is based upon 72 subjects Tongas points out... Be Banned Emerson Foote 290 339 Current Approaches (A Panel Discussion) Social Learning The Long-Term Maintenance of Nonsmoking Behavior 3 Hypnosis in the Treatment of the Smoking Habit 1 2 Edward Lichtenatein 348 355 Phoebus N Tongas Louis Jolyon West 364 Discussant for Section on Behavioral Change Robert P Liberman 373 Behavioral Change: Session Overview Ellen R Gritz 379 xi Introduction Murray E Jarvik,... Motivational techniques are Only appropriate for those who require motivation This is not the place, nor am I the person, to outline 21 FIGURE 1 Dissonant Smokers Consonant Smokers High Dependence Low Low Motivation to Stop High Figure 1 Two-dimensional model showing motivational (A) and treatment (B) approaches to smoking cessation Consonant smokers are those who are quite happy about their smoking and have... provocative discussion of the economic costs of smoking- induced illness Their analysis is of necessity based upon somewhat limited data and, therefore, entailed a good deal of extrapolation But their final estimate that smoking costs us about 42 billion dollars a year or 2½% of the Gross National Product is really a frighteningly large 5 figure It is evident that economic considerations alone should prompt...Contents v FOREWORD William Pollin PREFACE Norman A Krasnegor vii MONOGRAPH CONTRIBUTORS viii 1 INTRODUCTION Murray E Jarvik Smoking Problems: An Overview Michael A.H Russell 13 I EPIDEMIOLOGY 35 Patterns of Smoking Behavior Leonard M Schuman 36 Interrelationship of Smoking to Other Variables and Preventive Approaches Ernst L Wynder 67 Smoking Behavioral Factors as Predictors... show the cessation rates of men The reason for this sex difference is not evident Male smokers, of course, continue to predominate over female smokers, though the gap is narrowing There is a marked preponderance of smoking among divorced or separated persons, as compared to married 1 or single individuals of either sex Smoking also seems to be more common among persons of lower socioeconomic level and... better long-term results than attention-placebo controls, but our attention-placebo controls have always done substantially better than no-treatment controls whose success rate among 19 our subjects is about 5% It is only by comparison with no-treatment controls that any valid assessment of treatment efficacy can be obtained When this is done the true success rate at one year follow-up seldom exceeds... Session Overview Murray E Jarvik 218 III CONSEQUENCES 220 The Economic Costs of SmokingInduced Illness Bryan R Luce 221 Stuart 0 Schweitzer Smoking and Disease Historical Sketch of the Discovery and the Spread of Tobacco Tobacco Growing and Manufacturing Composition of Tobacco Toxicology of Tobacco Components Effects of Smoking on the Cardiovascular System Effects of Smoking on the Respiratory System Smoking . Maryland 20857 Research on Smoking Behavior ACKNOWLEDGEMENT This monograph is derived from papers presented at a conference on smoking behavior convened at the. Development Smoking and Cancer Experimental Tobacco Carcinogenesis Discussant for Section on Consequences Consequences: Session Overview IV. BEHAVIORAL CHANGE Smoking: