Feature

Why a few tips won’t go far

Recent anti-smoking campaigns ignore the psychological nature of smoking, say Catherine Sykes and David Marks

What do you get if you mix an old Health Education Authority leaflet with a bit of gloss, some colour and widespread publicity? Answer: the recent NHS ‘Don’t give up giving up’ smoking cessation campaign.

This campaign is based on the Stopping Smoking Made Easier leaflet published in 1992, a simplified application of the well-known health psychology model of health behaviour change.¹ But remove the gloss and all that remains is several snippets of advice on smoking cessation. Are we wrong to have doubts about some of the advice offered? Can you really imagine that dry cleaning your clothes, getting your teeth polished and asking family and friends to sponsor your quit attempt will be helpful to smokers, especially those from lower socio-economic backgrounds? It certainly does not fit with our experience of the many smokers with whom we have worked. Doing something else or avoiding situations where you smoke is inappropriate advice. What are you supposed to do if – like many smokers – you smoke after a meal? Avoid eating?

The advice then moves on to the ‘staying stopped’ stage, where smokers are advised to stay positive, keep busy, relax and deal with stress – and not let people pressure them to restart. But no techniques to implement this advice are offered. A recent randomised control trial of the Stopping Smoking Made Easier leaflet, compared with a psychological therapy, showed that after a year 23 of 116 participants (20 per cent) receiving therapy were abstinent and a further 10 (9 per cent) had cut down by at least a quarter. But only six (6 per cent) of 104 participants in the Stopping Smoking Made Easier group were abstinent and none had reduced consumption.²

The better publicised and resourced Don’t give up giving up campaign may be more effective than the Stopping Smoking Made Easier leaflet. Yet from our investigations we are not confident that there will be a big difference. When we telephoned the helpline as health professionals, it took six weeks to receive the package and it arrived with a note stating that certain items were out of stock would be forwarded when available. A conversation with a smoker who telephoned the helpline was recorded. When asked what the pack contained and if it was any different to ‘Ready Steady Stop’, the adviser claimed she did not know as she had never seen the (NHS) pack. It then took 3 weeks to receive the pack.

The 10 minute counselling session proved to be better and full marks should be given for the motivation that was offered to the smoker. The actual techniques for quitting were basically the same as the advice given in the Don’t give up giving up package: set a date, when you feel an urge to smoke keep active, take a hot shower (!), drink water, eat carrots, try to relax or go the gym. There was the added advice to call a counsellor during the first days of quitting when a urge for a cigarette was strong – but who can really just pick up a phone and call a counsellor when they feel like smoking?

The white paper Smoking Kills hints at the psychological nature of smoking.³ The Don’t give up giving up TV adverts mention that the psychological nature of smoking is probably as bad as the addictive side. But simply emphasising the ‘stages of change’ model does not go nearly far enough in dealing with the psychological nature of smoking – and there is no clear strategy on how to tackle this. Psychological dependency, especially in the context of stressful events, is the major cause of continuing the habit in spite of having all the necessary advice, health information and motivation to make the change. Stressing the need for willpower to cope with the psychological addiction to nicotine will leave smokers demoralised and with even lower self-esteem if they do not succeed. Many smokers have used willpower to try to quit. They are aware of all the little tips to stop smoking. But they need more.

The major recommendation in this campaign is nicotine replacement therapy (NRT). NRT is certainly unable to treat smokers’ psychological dependency on smoking. The use of NRT has been shown to only have an efficacy of 2-6 per cent in family practice settings and 7-16 per cent in self-referred smokers.⁴

Despite all this, the NHS should be congratulated for its efforts in this recent campaign. It definitely has some positive aspects, such as the use of different media, widespread dissemination of the message and the availability of the package in Braille, audio cassette and several languages. The first smoking cessation policy is a step in the right direction. Yet the techniques and recommendations offered to smokers could be improved. The present campaign sees smoking as a physical problem to be treated – and this is disempowering.⁵

Interventions are needed which target smokers for whom addiction, need and reinforcement play a key role in maintaining their dependency.6 We believe that more research is needed to test the efficacy of psychological therapy in conjunction with NRT. Failing to offer smokers techniques that tackle the psychological nature of smoking is ignoring the reasons why many smokers continue to smoke.