Kylie Morphett. Smokers understandings of nicotine addiction: A qualitative study.

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1 Kylie Morphett Smokers understandings of nicotine addiction: A qualitative study.

2 Why smoking? High prevalence Smoking is the largest preventable cause of disease in Australia Tobacco causes many serious health problems: half of smokers die of smoking related disease. Economic cost = $31.5 B in 2004/2005. Capture rate among lifetime users 32% vs 23% for heroin, 15% for alcohol & cocaine Medicalisation of smoking cessation increasing availability of pharmacological cessation aids.

3 Nicotine and the brain Acute effects: nicotine binds to nicotinic acetylcholine receptors in the brain s reward circuit. Dopamine released from the nucleus accumbens. Benowitz, N. (2010). Nicotine Addiction. NEJM. 362 (64) Memory (hippocampus) Emotion (amygdala) Decision-making (prefrontal cortex) Long term effects Upregulation Desensitisation. Dysregulation of brain s stress system

4 Media Portrayals Source: Courier Mail, 2002 Headline: Smokers' addiction all in the brain Published in the scientific journal Neuron, the research shows nicotine stimulates pleasure in the brain's reward centre and also has the unique ability to "turn off" the "switch" that subdues good feelings. The new evidence helps explain how one cigarette quickly teaches the brain cells of a first-time smoker to crave nicotine. And for the thousands who try to quit smoking each year and fail, the findings show why breaking the habit is so hard.

5 Media portrayals Source: The Advertiser, 2007 Headline: Science pinpoints smoking addiction SMOKERS have been warned not to rely on medical research to deliver them from addiction after U.S. scientists pinpointed the brain part responsive to the drug. Quit SA manager David Edwards said the discovery, by U.S. scientists, could help to develop a quit-smoking drug.

6 Advertising Can t quit smoking? It s not you. It s your brain.

7 The impact of neuroscience explanations of addiction Julie Netherland (2011) interviewed opioid users being treated with buprenorphine. Heavy exposure to medical model however didn t describe addiction in scientific terms. Emphasised external and lifestyle factors that influenced their drug use. Hammer et al (2012) - interviewed those seeking treatment for nicotine or alcohol dependence. Approx half participants talked about role of brain in explanations Those at treatment centres that emphasised neuroscience more likely to talk about the brain.

8 Qualitative interviews with smokers 30 interviews with daily smokers from Brisbane area. Themes of interview: Smoking history and thoughts about own smoking, Understanding of addiction, including thoughts about control and responsibility Views on treatment methods Response to short PowerPoint presentation on the neurobiology of smoking Attitude toward the idea that nicotine addiction is a brain disease

9 Participant demographics n=29 Gender Male n=15 Female n=15 Age (yrs) n= n= n=6 60+ n=1 Highest level of education No formal qualification n=4 Secondary school n=4 Diploma/trade n=10 University n=11 Cigarettes per day 1-10 n= n= n=3 31+ n=4 (missing data =1)

10 1. Awareness of the role of the brain Most had a vague/general awareness that tobacco influenced the brain. A smaller number had no awareness I think yes because I always assume drugs messes your head, whereas smoking was purely like physical, you know like lungs and heart and throat and stuff. Like obviously your appearance it ages you. But when you compare it to how it affects your brain. I always like that's a drugs thing. You know but that's with it's a nicotine thing, yes. (female, 24, 1-10 cigarettes per day) Very few had an accurate or sophisticated understanding of the way nicotine works in the brain.

11 2. Does neuroscience information influence smokers perceptions of their smoking? Increased motivation to quit Neuroscience of nicotine addiction scary The brain as a special organ Maybe we should start scaring the shit out of people and telling them that it is very insidious and it does interact with the brain and make you do things differently and think things differently. It's a lot more terrifying than having lung cancer and I know that sounds terrible but it just is. It's my brain and we all sort of associate it with our essence, it's us, you know, yeah. (female, 32, 1-10 CPD)

12 2. Does neuroscience information influence smokers perceptions of their smoking? Brain-based information as helpful for developing quit strategies It s because you know more about yourself. I think now that you know how it works, definitely you can train yourself. (male, 18, 1-10 CPD) Brain changes are reversible So yeah it's a bit scary. But you can retrain the brain so you can rewire and it's malleable so yeah. (female, 40, 31+ CPD)

13 2. Does neuroscience information influence smokers perceptions of their smoking? Makes it seem more difficult to quit I would say harder to the average person or even me. Well I m average, but you d go in a way you d go oh crap, really? So it s something that I can t control, it s something that the brain s just automatically doing. So that s going to make it even harder, not am I just fighting this, I m actually fighting something that s chemically happening. (female, 40, 31+ CPD) Emphasising physiological processes makes nicotine addiction seem more real/serious I guess it does highlight it as a real addiction, the kind of level of addiction you usually associate with things like illegal narcotics. (male, 32, CPD)

14 2. Does neuroscience information influence smokers perceptions of their smoking? Won t make a difference Information not sufficient to change behaviour It's science. It may - I may understand what's happening, but it's not going to change the way I do things. I understand now that the nicotine isn't sorting out the receptors out in the brain, but for me it makes it no difference. I'm smoking 40 a day anyway. I understand how it's happening it's now, that's [laughs] the only thing that's changed. Because like I say, I'm an addict to smoking. (male, 48, 31+ CPD) Already knew information

15 2. Does neuroscience information influence smokers perceptions of their smoking? Ambivalence about nicotine addiction: not physiologically addicted but then there are different kinds of smokers and each one has a different kind of addiction, you know so I mean this would be really helpful to those who are addicted to cigarettes just because of the nicotine, but you wouldn t help the vast majority. (male, 24, CPD) Psychological addiction/addicted to the habit No. I don't consider myself addicted to nicotine Mildly addicted perhaps, but again I think my addiction s mostly habit based. If I don't have a cigarette it's actually not a feeling of physical need for one so much as a feeling of depriving myself of this habit or of this thing that I consider special. (female, 32, 1-10 CPD)

16 3. Attitudes towards biomedical treatment Reluctance to use smoking cessation medication amongst some participants Yeah, I have personally tried the nicotine patch, the Nicorette gums, yeah, but I mean it could be based on the individual smokers. Like for me, I m more hooked on the sensation of smoking rather than the nicotine, so even if I have the nicotine in me I still do not feel good. (male, 24, CPD) Cessation aids not seen as magic bullets. But at the end of the day, as I said even taking that little tablet, you ve still got to say right, I really want to do this and do a chart and probably say well, this is why I want to do it and visualise it, yeah. (female, 56, CPD)

17 4. Maintaining control and personal responsibility Participants frequently stated the importance of willpower, strength, mindset, commitment I think I could stop smoking if I wanted to. That's just basically showing me how it works. It's not made me think, I can't stop smoking because it's going to dampen all this, that and the other. I don't think so. It's willpower, if you've got the willpower. There's people been smoking 40, 50 years who have stopped. (male, 48, 31+ CPD)

18 5. Responses to addiction being a brain disease Most objected to the term Accuracy No, but as far as disease is concerned, like to me a disease is something that attacks your blood cells. Something that changes, that is out of your control. Smoking is within your control so how can it be a disease. You're self-inflicting it. (female, 40, 31+CPD) Insufficient explanation I don't think it's fully your brain. I think it's your daily life, your routine, your social group, it's everything else, I think, and then maybe partially a brain disease or whatever. (female, 21, 1-10 CPD) Scare-mongering

19 5. Responses to addiction being a brain disease Most smokers thought that smoking was unfairly stigmatised Many were concerned that label of brain disease would increase stigma in relation to smoking I mean as it is, I mean personally for me I do feel that as a smoker I m already bad enough, and then I mean if you just keep pushing a person further you reach a point then when the person thinks that okay I m screwed up I might as well not bother and continue being screwed up (male, 24, CPD) I don t know, but I wouldn t like anybody to think of me as a dirty, diseased person just because I smoke. (male, 42, CPD)

20 Implications What might be the positive and negative effects of promoting the BDMA in relation to smoking? 1. Variety of responses May lead to reduction in self-efficacy by emphasising the addictiveness of nicotine and the propensity for relapse For some, neuroscientific information is seen as useful and empowering BUT for many, it is not seen as particularly relevant, especially for those who do not perceive themselves as addicted to nicotine

21 Implications (cont.) 2. Emphasis on willpower and motivation Willpower and motivation are important to people. Where do these concepts fit into the brain disease model? It may be counterproductive to challenge the importance of willpower and motivation in lay explanations of smoking It may be beneficial to portray pharmacological cessation aids as an aid to willpower, rather than a replacement. 3. The term brain disease was not accepted by most smokers.

22 Acknowledgements Advisory team: Prof Wayne Hall, Dr Coral Gartner, Dr Adrian Carter This study is funded by an Australian Research Council Discovery Grant awarded to Wayne Hall, Coral Gartner, Jayne Lucke, Brad Partridge and Adrian Carter. A disease of the brain : How do neurobiological explanations of addiction influence the attitudes and behaviour of smokers?

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