Substance use and abuse

Friday, September 01, 2006

Theories of Substance Abuse; for Smoking Tobacco

Before looking at explanations for why people smoke, it is useful to know about some of the more general explanations that are offered for substance abuse. These can be summarised as -

The Moral Model

According to this model individuals are viewed as responsible for the initiation and development of problems as a result of substance misuse. Addictive behaviours such as drug taking, heavy drinking or gambling are seen as sinful or weak willed. Substance misusers need to exert willpower to refrain from drinking or taking drugs and treatment consists of mainly spiritual intervention.

The Medical/Disease Model

This model views addictive behaviour as a progressive, incurable disorder and the cause of the disease is firmly attributed to the genetic/biological make up of the individual. This medical/disease approach also implies the adoption of the sick role by the substance misusers and the individuals are expected to be treated as having a 'disease'. The treatment approach also implies that recovery from drug or alcohol misuse can only be sustained through the goal of total abstinence.

The Psychological Model

The psychological model includes the social learning, family interaction and personality approaches. The social learning theory model proposes that social behaviour is learnt through observation and modelling. It is stated that modelling by parents is an important factor in the initial pattern of consumption of social and illicit psychoactive substances, especially in those with poor social skills (Baer et al. 1987). The family interaction model emphasises the role of parental behaviour in the abuse of substances, especially in the case of alcoholism. The personality characteristics of the substance misuser have also been linked to substance misuse. Several factors, including lack of maturity, interpersonal and intrapersonal conflicts, low self-esteem, underlying depression and anxiety, inability to cope with anger, etc., have been suggested to be the cause of drug and alcohol problems. The term 'addictive personality' has been ascribed to those individuals who have become dependent on drugs or alcohol. (Rassool, 1998)

The Sociocultural Model

Sociocultural explanations of the use and misuse of psychoactive substances emphasise the role of culture, beliefs, values and attitudes held by a community or minority groups in the way individuals will abstain from or take drugs. Cultural attitudes towards the use of psychoactive drugs may also play an important part in shaping individual behaviour. Sociological factors such as unemployment, social deprivation, poor environment, etc., may have important effects on whether individuals start misuse drugs and whether they continue (Peck & Plant 1986). Other social factors such as age, sex, religion, ethnicity, socio-economic class and family background directly influence whether an individual will use psychoactive substances in that way.

Explanations for why people smoke tobacco -

Biological theories of smoking

Nicotine, the main active ingredient in tobacco smoke, is a substance which if taken in large quantities can be toxic. However, delivered in small amounts via cigarette smoke it has a range of psychophysiological effects including tranquillization, weight loss, decreased irritability, increased alertness and improved cognitive functioning (Rose, 1996). The apparent conflict between the stimulant physiological effect of nicotine and reports of relaxation has been called the 'nicotine paradox' (Nesbitt, 1973). One explanation for this paradox is that smoking appears relaxing because the smokers are often in a state of mild nicotine withdrawal which is relieved by the cigarette which returns the nicotine level in the body to 'normal' (Hughes, 1991; Foulds and Ghodse, 1995).

Over time the smoker seems to develop a physical dependence on nicotine. In the USA several tobacco companies have publicly admitted that smoking is addictive. In 1997 the smallest of the big five US tobacco companies (the Liggett Group) admitted that it had raised the nicotine content in cigarettes to increase their addictiveness (Porter, 1997). The USA Department of Health and Human Services (1988) reported that 'the pharmacologic and behavioural processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine'.

The experimental work of Schachter et al (1984) developed the nicotine regulation model of smoking. According to this model there is a physiological regulatory mechanism which monitors the level of nicotine in the brain. When this falls below a certain level the individual feels the need for another cigarette.

Admittedly, not all people smoke or exhibit a desire to smoke. This raises the suggestion that perhaps there is a genetic component. A number of twin studies from different continents have produced evidence of strong genetic link in the risk of smoking. Heath and Madden (1995) reviewed the evidence from national twin studies in Scandinavia and Australia. In their predictive model genetic factors increased both the likelihood of becoming a regular smoker ('initiation') and of these smokers becoming long-term smokers ('persistence'). In a large follow-up survey of the smoking practices of male twin pairs from the US Vietnam Era Twin Registry, True et al. (1997) found that genetic factors accounted for 50% of the risk of smoking and environmental factors accounted for a further 30%. In addition, genetic factors accounted for 70% of the risk variance of becoming a ereas environmental factors were not important.

Psychological theories of smoking

Probably the most frequently used model of smoking is that based on learning theory. Basically, it argues that people become smokers because of the positive reinforcement they obtain. Initially, smoking is physically unpleasant but this is overruled because of the social reinforcement from peers. The pleasant associations of smoking then generalize to a range of other settings. In addition, the smoker learns to discriminate between those situations in which smoking is rewarded and those in which it is punished. He or she also develops responses to a number of conditioned stimuli (both internal and external) which elicit smoking. Smoking can be conceptualized as an escape/avoidance response to certain aversive states (Pomerlau, 1979). The smoker will light up a cigarette to escape or avoid an uncomfortable situation.

Part of the above explanation canbe highlighted by a study conducted by Murray et al (1988) asked young adults to indicate what factors were important reasons for smoking in different situations. In all situations relaxation and control of negative affect (emotional states)were considered the most important reasons. At home boredom was also considered important, perhaps reflecting these young people's frustration with family life. At work addiction was considered important, perhaps reflecting the extent to which it disrupted their work routine, while socially habit was rated important.

There may also be personality differences between smokers and non-smokers. According to Zuckerman (1979) individuals engage in sensation seeking so as to maintain a certain level of physiological arousal. Carton et al. (1994) found in a French sample that smokers scored higher on a measure of sensation seeking, in particular on disinhibition, experience seeking and boredom susceptibility subscales. They suggest that from a physiological perspective these sensation seekers have a low level of arousal and seek exciting, novel or intense stimulation to raise their level of cortical arousal. This argument is very similar to that of Eysenck et al (1960) who found that smokers scored higher on measures of extroversion. This personality dimension is also supposed to reflect a lower level of cortical arousal which could be raised by engaging in risky activities such as smoking.

Lastly, a variety of different types of studies have found that stress is associated with smoking. Schachter et al. (1984) found that among smokers, consumption was higher in experimental stressful laboratory situations. Lindenthal et al. (1972) found in a survey that people with higher selfreports of stress were more likely to be heavy smokers. In a study of nurses' smoking practices, Murray et al. (1983) found that those who reported the most stress were more likely to smoke. This relationship remained after controlling for the effect of family and friends' smoking practices.

Social theories of smoking

Smoking is a social activity, thus social factors may contribute to why some people become addicted to smoking. Even when the smoker smokes alone he or she society where cigarettes are widely available and promoted. A number of qualitative studies have considered the social meaning of smoking to highlight the point that there is more to smoking addiction than biological and psychological aspects. For example, Murray et al (1988) conducted detailed interviews with a sample of young adults from the English Midlands. These suggested that smoking had different meanings in different settings. For example, at work going for a cigarette provided an opportunity to escape from the everyday routine. As one young factory worker said:

'We would say we were going to the toilet and have a quick cigarette ... As long as they [management] didn't catch you. If they caught you, well, you'd be in hing. But it was alright. We used to go in about every hour, something like that.' (Murray et al., p. 49)

For these workers, to have a cigarette meant to have a break and conversely not to have a cigarette meant not to have a break. The cigarette was a marker, a means to regulating their work routine.

Outside work, smoking was perceived as a means of reaffirming social relationships. For those young people who went to the pub, the sharing of cigarettes was a means of initiating, maintaining and strengthening social ire cigarettes were frowned upon. One young man explained when he smoked:

'Only, basically, when somebody else has one. Say we're all out in a group, say, ig [sharing] the fags [cigarettes] and that. Say it's somebody else's turn, I'd wait for them to get one out. I wouldn't light one of my own. I'd wait for him to get his out and if it's my turn, I'd just wait about ten minutes and get mine out ... I can't handle that, people who just smoke on their own. It doesn't seem right.' (Murray et al 1988, p. 65)

In another series of studies, along similar lines, Graham (1976,1987) provided a detailed understanding of the meaning of smoking to working-class women. In one of her studies (Graham, 1987) she asked a group of low-income mothers to complete a 24-hour diary detailing their everyday activities. Like the young workers in the study by Murray et al. (1988), smoking was used as a means of organizing these women's daily routine. For example, one woman said:

'I smoke when I'm sitting down, having a cup of coffee. It's part and parcel of resting Definitely, because it doesn't bother me if I haven't got a cigarette when I'm working. If I'm busy, it doesn't bother me, but it's nice to sit down afterwards and have a cigarette.' (Graham, 1987, p. 52)

Further, for these women smoking was not just a means of resting after completing certain household tasks but also a means of coping when there was a sort of breakdown in normal household routines. This was especially apparent when the demands of childcare became excessive. Graham describes smoking as 'not simply a way of structuring caring: it is also part of the way smokers re-impose structure when it breaks down' (p. 54). She gives the example of one woman who said:

'If it's nice, I send them [children] out or ask them to play in the bedroom but normally I will sit in the kitchen and have a cup of coffee and a cigarette . . . The cup of coffee calms me best, then a cigarette and then it's just being on my own for a few minutes to sort of count to ten and start again.' (Graham, 1987, p. 54)

Graham (1987) argues that for these women smoking is an essential means of coping with everyday difficulties. It is also a link to an adult consumer society. Through smoking the women were reaffirming their adult identity.

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