Smoking and health

Dr Sarah Jackson
Principal Research Fellow
UCL Tobacco and Alcohol Research Group
s.e.jackson@ucl.ac.uk @DrSarahEJackson
Outline

• Smoking and smoking cessation trends

• Health effects of smoking and benefits of stopping
• Why people smoke and find it hard to stop
• Stopping smoking

2
Outline

• Smoking and smoking cessation trends

• Health effects of smoking and benefits of stopping
• Why people smoke and find it hard to stop
• Stopping smoking

3
Cigarette smoking in the UK

4
Cigarette smoking in the UK by age group

5
Cigarette smoking in the UK by occupational group

6
Outline

• Smoking trends
• Health effects of smoking and benefits of stopping
• Why people smoke and find it hard to stop
• Stopping smoking

7
Diseases at least partially caused by smoking

• Aortic aneurism (causing rupture of the main blood supply from the heart)
• Back pain
• Buerger’s disease (leading to amputations)
• Cancer of the bladder
• Cancer of the cervix
• Cancer of the lung, trachea and bronchus1
• Cancer of the mouth
• Cancer of the oesophagus
• Cancer of the pancreas
• Cancer of the stomach

8
1
Major cause of death
Diseases at least partially caused by smoking

• Chronic obstructive pulmonary disease (COPD) (Bronchitis and emphysema)

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Major cause of death
1
Diseases at least partially caused by smoking

• Chronic obstructive pulmonary disease (COPD) (Bronchitis and emphysema)

• Death of baby during childbirth
• Dementia
• Diabetes
• Early menopause (stopping periods)
• Fetal growth stunting (delaying development of the baby in the womb)
• Gum disease (leading to tooth loss)
• Heart disease (leading to angina, heart attack and heart failure)

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Major cause of death
1
Diseases at least partially caused by smoking

• Impotence (inability to get an erection)

• Infertility
• Leukaemia (cancer of the blood cells)
• Miscarriage
• Osteoporosis (leading to broken bones)
• Peripheral vascular disease (leading to amputation)
• Pneumonia
• Skin wrinkles
• Stroke
• Ulcer of the stomach and duodenum

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Diseases made worse by smoking

• Asthma
• Crohn’s disease (inflamed bowel)
• Graves’ disease (overactive thyroid gland)
• Multiple Sclerosis

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Effect on mortality

Source: Doll et al (2004) BMJ

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Effect on mortality

Source: Doll et al (2004) BMJ

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Effect on mortality

Source: Doll et al (2004) BMJ Source: Pirie et al (2012) Lancet

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Benefits of cessation

16
Doll et al (2004) BMJ
Benefits of cessation

17
Doll et al (2004) BMJ
Outline

• Smoking trends
• Health effects of smoking and benefits of stopping
• Why people smoke and find it hard to stop
• Stopping smoking

18
Addiction to cigarettes

• Cigarettes deliver nicotine rapidly to the brain via the pulmonary circulation in
a form that is convenient and palatable
• Nicotine delivered in this way is highly addictive
• The primary mechanism is ‘operant learning’
– Smoking is rewarded (‘positive reinforcement’)
– Abstinence is punished (‘negative reinforcement’)

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Addiction to cigarettes

• Cigarettes deliver nicotine rapidly to the brain via the pulmonary circulation in
a form that is convenient and palatable
• Nicotine delivered in this way is highly addictive
• The primary mechanism is ‘operant learning’
– Smoking is rewarded (‘positive reinforcement’)
– Abstinence is punished (‘negative reinforcement’)

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Positive reinforcement

• Nicotine binds to nicotinic

acetylcholine receptors in the
Ventral Tegmental Area

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Positive reinforcement

• This increases NMDA-initiated burst

firing of the mesolimbic dopamine
pathway

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Positive reinforcement

• This increases release of dopamine in the

Nucleus Accumbens

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Positive reinforcement

• The dopamine release ‘teaches’ the smoker to repeat the action of puffing on
a cigarette just like feeding a dog teaches it to sit up and beg

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Negative reinforcement

• Prolonged exposure to nicotine results in neural adaptation

• Nicotine is rapidly removed from the body by metabolism and excretion with
a half life of about 120 minutes
• Even short periods of abstinence lead to ‘withdrawal symptoms’
• Smoking a cigarette alleviates these symptoms
• This ‘teaches’ the smoker to smoke when symptoms of this kind occur

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Negative reinforcement

Withdrawal Puff on a Withdrawal More

discomfort, cigarette relief puffs
craving

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Nicotine withdrawal symptoms

Symptom Duration
Irritability/aggression < 4 weeks
Depression < 4 weeks
Restlessness < 4 weeks
Poor concentration < 2 weeks
Increased appetite/weight gain >10 weeks
Light-headedness <48 hours
Night-time awakenings < 1 week
Constipation >2 weeks
Coughs/colds/mouth ulcers >2 weeks
Urges to smoke >2 weeks

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The double ‘whammy’

• Smoking is rewarded and abstinence is punished

• Both of these processes tap into ancient motivational systems that evolved
millions of years before humankind
• When a smoker ‘decides’ to try to stop, he or she is fighting these processes

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Addiction to cigarettes

I really want to
stop smoking: it’s
costing me money
and it will probably
kill me

Just
smoke
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Outline

• Smoking trends
• Health effects of smoking and benefits of stopping
• Why people smoke and find it hard to stop
• Stopping smoking

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The secret to stopping smoking

• Keep rolling the dice

• Load the dice in your favour

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 Motivating quit attempts

• Increase cost
• Smokefree legislation
• Health practitioner advice on quitting
• Advertising bans
• Mass media campaigns

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 The secret to stopping smoking

• Keep rolling the dice

• Load the dice in your favour

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 When the urge is stronger than resolve and
cigarettes are available, a lapse will occur
Urge to smoke

Time

Resolve Strength of urge

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 Our job is to keep these lines apart!

Urge to smoke

Time

Resolve Strength of urge

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Medication
25

20
↑ % abstinent >6m

15

10

0
Varenicline Single form Dual form NRT for Varenicline
NRT NRT* 'reduce to for 'reduce
quit' to quit'

Data from RCTs; Cochrane reviews (NRT 2013; Varenicline 2016); Wu 2015
doi:10.3390/ijerph120910235; *Estimated by combining effect sizes; All comparisons are
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active medication versus placebo in context of behavioural support
Psychological support

16
14
↑ % abstinent >6m

12
10
8
6
4
2
0

Data from RCTs; Cochrane reviews (2008, 2009, 2013, 2016); Indirect estimates compared
with nothing; Insufficient data on smartphone apps; Mixed data on websites
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E-cigarettes & cessation

• Divergent claims on how far use of e-cigarettes contribute to or detract from

smoking cessation
• On the one hand
• RCTs suggest that when used in a quit attempt they improve the chances of
success of that quit attempt1
• Several large comparative observational studies yield similar findings2

1
Cochrane Database Syst Rev. 2020:CD010216; Hajek, P., et al. (2019). New England Journal of Medicine 380(7): 629-637.
2
Jackson, S., Kotz, D., West, R., and Brown, J. (2019) Addiction, doi: 10.1111/add.12623; McNeill, Brose et al, PHE, 2018
 E-cigarettes & cessation

• Divergent claims on how far use of e-cigarettes contribute to or detract from

smoking cessation
• But on the other hand
• Others find past use of e-cigarettes is associated with a reduced likelihood of
quitting in the future1
– unable to control for important confounders such as dependence,
inadequately assessed reasons or motives for using e-cigarette, or used
an unsuitable comparison group2

1
Kalkhoran & Glantz. 2016 Feb;4(2):116-28.
2
Abrams et al, Annu Rev Public Health, 2018.
 E-cigarette use
60 Current use in past-year smokers 60 Use in a quit attempt
50 50

40 40
Percent

30 30

20 20

10 10

0 0
0 7 0 8 0 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 0 7 0 8 0 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7
20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20

N=51867 adults who smoke or who stopped in the past year N=18561 adults who smoked and tried to stop in the past year

40
 Quit success and attempts
60
Success
60 Quit attempts
50 50

40 40
Percent

30 30

20 20

10 10

0 0
0 7 0 8 0 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 0 7 0 8 0 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7
20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20

N=18561 adults who smoked and tried to stop in the past year N=51867 adults who smoke or who stopped in the past year

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Use of other support in a quit attempt
60

50

40 NRT OTC
Beh'l support
30
Zyban
Champix
20
NRT Rx
10 No support

0
0 07 008 009 010 011 012 013 014 015 016 017
2 2 2 2 2 2 2 2 2 2 2

N=18561 adults who smoked and tried to stop in the past year

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• Success rate of quit attempts increased
0.058% (0.038 to 0.078; P<0.001) for every
1% increase in the prevalence of e-cigarette
use during a recent quit attempt
• No clear evidence for association between e-
cigarette use and:
– quit attempts (β 0.025; 95% confidence
interval −0.035 to 0.085; P=0.41)
– use of NRT bought over the counter (β
0.006; −0.088 to 0.077; P=0.89)
– overall use of prescription treatment (β
−0.070; −0.152 to 0.013; P=0.10)
– use of behavioural support (β −0.013;
−0.102 to 0.077; P=0.78)
Interpretation

• Leads to a population estimate of approx. 54,000 medium-term additional ex-

smokers attributed to e-cigarette use in 2015
– These real-world results are consistent with RCTs suggesting e-cigarette
use in quit attempts among most effective method for stopping
– And little evidence of undermining use of other support
Key messages
1. Smoking prevalence is declining in England – currently around 15% of
adults
2. After early adulthood smoking brings on old age and death an average
of 5-6 hours earlier for each day of smoking
3. The main causes of death from smoking are lung cancer, heart disease
and COPD
4. The primary driver of smoking is nicotine’s effect as a positive and
negative reinforcer, acting on NAch receptors in the midbrain
5. Successful stopping involves repeatedly trying and each time using the
best available method
6. Varenicline or dual form NRT or e-cigarettes together with support from
a trained professional provide the best chances of success
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 Reading

West R (2017) Tobacco smoking: Health impact, prevalence, correlates and

interventions Psychology & Health. 2017 Aug 3; 32(8): 1018–1036.

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