Quit Smoking. Mental Health. Marketing. Are They Connected?

“What the #$@% do you want,” I yelled across the shop. The tech standing next me asked, “What’s wrong with you today?” Even though I tried to reply, anxiety was overcoming my very being. It had been a few weeks without smoking. My skills for coping were exhausted and I left without saying a word. This story may sound dramatic, but scenes such as this with smokers attempting quitting occurs all the time. I know because that was my story. I have been successful as a non smoker on and off in my life. The longest was two years. This time I tried the transdermal patch, but once again overcome with stress and inability to cope I self medicated.

Countless smoking cures exist in the market place. Each has a promise to either help with nicotine cravings, withdrawal symptoms or make bold statements like “Stop smoking or your money back.” Though some cure alls are marketed with credibility, snake oil has been around awhile too. The personal sacrifices – financial investment, time investment, and at times suffering can be exorbitant to the unsuccessful quitter.

In the eighties it was gum, the nineties the transdermal patch, and today we have antidepressants, whose side effect is a decrease in smoking. Other advertised methods include herbal therapy, root extracts such as Lobeline, acupuncture therapy, and hypnosis therapy. Oddly, almost all insurance companies do not cover smoke cessation as a psychological cause for therapy. There are many broad advertised claims and it is a lucrative market place.

When one travels the road of seeking help usually they receive simple explanations like you just don’t want to quit enough. Explaining failed attempts to the hot line of the transdermal patch you receive another simple reply “you must not have followed the directions.” Talking it over with a primary care physician the feeling of helplessness and lack of control is communicated. But, the smoker is told the more times you try the closer to success you become.

A closer look at the transdermal patch it is discovered that “one year sustained non-smoking rates were nearly three times higher for patients using the patch, 22% vs. 9% contrasting those using a placebo (Dr. Sachs, M.D. director of Palo Alto Center for Pulmonary Disease Prevention). In the book Smoking Cessation: The unfiltered Truth written by Dr. Sachs, it is concluded “The single most important finding from this study is that 25% of those who use the active 16-hour patch refrained from smoking for an entire year, or 7-1/2 months after they had stopped using their nicotine patch, compared of those who have been treated with the placebo patch. When you look at the few other studies that present either six-months or one year results, our results are almost twice as high as those.”

Additional studies are available, though they report no significant differences compared with the previous study. Predicting Smoking Cessation: Who Will Quit With and Without the Patch, only 30% remained abstinent after six months. Nicotine Patch Therapy for Smoking Cessation With Physician Advice and Nurse Follow-up: One-Year Outcome and Percentage of Nicotine Replacement, a report to the AMA states, “By one year, the smoking cessation rate fell to 28% of smokers receiving nicotine patches and 14% of those receiving placebo patches.”

Next, the time of recidivism becomes a key element with the unsuccessful quitter. That critical moment when the decision is made to begin smoking again is paramount. Although most smokers will tell you something like “yeah, I just started smoking again,” actually something triggered the relapse. In order for relapse to occur three things must happen: 1) the new ex-smoker must be presented with a potential relapse crisis situation , 2) the relapse crisis situation must trigger an intensive cigarette craving , and 3) the craving must overwhelm the ex-smoker’s ability to cope.

Looking closer, recent studies indicate smoking may only be the symptom and not the health problem when looking at the issue of smoking. Each pack of cigarettes displays a Surgeon General’s Warning of some kind. The smoker is aware of the consequences. But, is it a choice?

Today there is evidence that smoking is not only more difficult for those with a history of depression, but also likely to exacerbate the related disorder(s). In the American Journal of Psychiatry, Alexander H. Glassman, M.D. states, “This may be why so many people with depression smoke like chimneys.” Continuing further in the article he says, “Smokers with a history of depression who want to give up cigarettes should consider taking an antidepressant to reduce the risk of provoking depression – especially if nicotine patches and psychotherapy fail to work.

We see this evidenced this century with the introduction of Zyban. Wellbutrin a well known antidepressant was receiving documentation from prescribing members of the medical field that patients were “stopping smoking or at least diminishing its use.” Capitalizing on this the maker of Wellbutrin introduced Zyban, another form of Wellbutrin, as a smoke cessation product. Here is evidence of a marketable connection between depression and smoke cessation.

Studies since 1978 have linked smoking to depressive symptoms or a psychiatric concept called “negative affect.” The significance of “negative affect” is reported by the American Journal of Psychiatry. Wall-Manning and de Hamel showed that smokers rated higher on symptom measures of both anxiety and depression than did non-smokers. Pomerleau et al demonstrated that smokers who identified “negative affect” as a reason for smoking were more than likely to fail in their attempts to quit. Shiffman found that “negative affect” was the most common antecedent of a smoking relapse. It is reported that 60% of smokers who failed multiple times at smoke cessation have had a present or previous history of depression or strong tendency for this disorder.

But what is negative affect? Affect is the feelings or emotions we experience and usually as component of cognition. To be negative means it causes overwhelming distress and requires implementation of a coping skill and/or administration of stress release mechanism. It can be as simple as scratching your head to taking a drink or using drugs. Important in understanding drug addictions from the psychological perspective the cognitive-behavioral discipline of learning becomes apparent.

Further research points strongly to anxiety and depression as a reason for failed attempts, though in actuality only statistics and accountability are provided for successful attempts, not failed attempts, are provided within smoke cessation research – clinics, follow-up and interviews. The Center for Epidemiological Studies Depression Scale (CES-D) is one method that can be used for screening. An observation by Anda et al., who reviewed 3,000 cases of participants of a study by the Center for Disease Control, concluded “Individual with the most severe depressive symptom scores were most likely to smoke cigarettes, and the smokers with the highest depression scores were significantly less likely to be successful in smoking cessation.”

Additional support for depression as a cause for failure is available to all primary care physicians. In the article, Cigarette Smoking: Implications for Psychiatric Illness, which used the National Health and Nutrition Epidemiological Survey and the St. Louis ECA Study, Alexander H. Glassman, M.D. suggests, “a stronger effect for depression on smoking in women than in men.” Further along he concludes, “However, on a number of occasions we and others have seen severe, extended depressions that developed following cessation disappear within hours of resumption of cigarette smoking.” Why?

Today, medical science can offer a multitude of solutions for many ailments. Although report after report indicate less than one fifth are successful with one year cessation using the transdermal patch, follow-up surveys indicate only 7-11% remain non-smokers after two years. Only one other significant study indicates similar results, Predictors of Smoking Abstinence Following a Single-Session Restructuring Intervention with Self-Hypnosis having similar results, one out of five.

Today’s drug interventions are still under time consuming research. Society is becoming less tolerant of the smoker and for good cause. However, where does that leave the smoker, knowing it is an unhealthy addiction and failed attempt after attempt. Most likely the possibility of the aid of anti-depressants, therapy, and groups are never introduced into the equation. Insurance companies do not cover this most likely due to expense and the high rate of recidivism. There is no assurance of success, since there are not any studies.

Giving up smoking is a complex process. To be successful the individual has to cope with nicotine withdrawal, understand her/his behavior patterns, develop a strong support system and accept both the physiological changes and possible mental health implications that are presented. Although many have succeeded at smoke cessation, statistics point out that only 10% stop smoking with over a two year success rate. When considering a percentage of those are in fact on their second attempt, third or more, the starkness of the plight to be a non smoker bears a new light. Finally, regarding smoke cessation, a U.S. Department Health and Human Sources Report, states, “The majority of new non-smokers did so “cold turkey.” So, I wonder, is making the choice of becoming a non-smoker, acting on that decision, and failing, a market issue or a health issue?

This article may cause a view of generality that smokers are depressed, but that simply is not true. Nor is that the purpose of the article. The purpose is to point out the struggle to become a non-smoker is not a wishful thought in many cases. Scare tactics of showing pictures of infected lungs do get the point across of the benefits of being a non smoker, but what about the how? What about the tolerance that may be needed during the process. What about the mental health warning signals? Sure, “you can do it” and “don’t give up” are encouraging, yet are there cases where more may be needed? Some can take the absolutist view saying wrong is wrong, but does that solve a health issue that is actually worldwide?

Opinion | Smoking Pros and Cons Plus Current News & Research Debby Bruck a homeopathic practitioner discusses where smoking is headed - marketing, public policy, health, and social attitudes.

Smoking and Teenagers Adriana Evans discusses why teens begin to smoke and how to say no.

My Diary of Quitting Smoking with the Nicotine Solutions Course Mistyhorison2003 give an account of her quest to become a non-smoker. Diary entries follow her on this quest.

Big Tobacco versus Big Alcohol: a modern double standard Hubber Jason R. Manning takes a look at the differences and similarities of alcohol and tobacco. His focus is on which is worse.

The Radioactive Polonium In Cigarettes Smoke Hubpage contributor melpor introduces us to the Polonium 210. His article opens with "For fifty years the tobacco industry have known that cigarettes contain a dangerous isotope called Polonium 210. Knowing this fact the industry could have easily removed it but they did nothing and allow it to remain in the cigarettes exposing millions of smokers to this deadly radioactive material."

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