Research paperA qualitative study of smokers’ views on brain-based explanations of tobacco dependence
Introduction
Public portrayals and perceptions of cigarette smoking have changed dramatically in recent decades. There has been a shift from the idea that smoking is a habit to the idea that it is an addiction, and more recently, an addiction located in the brain. This paper examines the attitudes of smokers toward brain-based understanding of addiction to smoking, and the ways they interpret its relevance for their everyday practice of smoking.
Neuroscience research has provided strong evidence demonstrating the addictive nature of tobacco smoking. This research has focused mainly on the role of nicotine, and has revealed that nicotine produces behavioural reinforcement by binding to nicotinic acetylcholine receptors in the brain, thereby influencing dopamine release in the brain's mesocorticolimbic reward circuit (Benowitz, 2010, De Biasi and Dani, 2011). The brain's stress system is also affected by chronic nicotine administration in ways that may contribute to the withdrawal symptoms such as anxiety and irritability that many smokers experience on cessation (Bruijnzeel, 2012). At the molecular and cellular levels, plastic changes in the brain, such as changes in synaptic connectivity and the regulation of gene expression, occur with repeated nicotine use and are associated with the development of the clinical signs of addiction: craving, withdrawal, and tolerance (Govind et al., 2009, Govind et al., 2012, Peng et al., 1994).
The general news media regularly report on neuroscientific research, often uncritically, but it is difficult to evaluate the extent to which the public have been exposed to or accept these findings. Articles have appeared in the mainstream media with titles such as “Nicotine takes control of brain” (Fewster, 2002, June 11) and “Quitting is a brain game” (Author not attributed, 2011). The public have also been exposed to brain-based explanations of smoking via advertisements for smoking cessation medications. An Australian campaign by Pfizer is headed with the phrase “Break the hold nicotine has over your brain” (Pfizer, 2015). Additionally, influential institutions in the USA have begun to define addiction as a “brain disease” or “brain disorder.” For example the National Institute of Drug Abuse (NIDA) describe addiction as a “chronic, relapsing brain disorder” (National Institute on Drug Abuse, 2007) and the American Association for Addiction Medicine define it as “a primary, chronic disease of brain reward, motivation, memory and related circuitry”(American Society for Addiction Medicine, 2015). An emphasis on how drugs affect the brain is evident in much of NIDA's public education material, including that on smoking (National Institute on Drug Abuse, 2006).
The veracity of the “brain disease model” has been critiqued at length in the academic literature (Courtwright, 2010, Hall et al., 2015, Kalant, 2010, Russell and Davies, 2009). Our goal here is not to address the “reality” of the claim, but to anticipate its potential social implications, specifically its effects on smokers’ understandings of their own smoking behaviour. A number of claims have been made about how an emphasis on the role of the brain could influence the way addicted individuals understand their addiction and the best ways to quit. Proponents believe that it will reduce the stigma associated with addiction, thereby increasing treatment seeking, and also that it will lead to the development of more efficacious and technological treatments (Dackis and O’Brien, 2005, Gardner et al., 2009, Leshner, 1997). Others however, express concern that the brain disease model of addiction could reduce feelings of individual responsibility for tobacco smoking or other substance use and undermine addicted individuals’ beliefs in their ability to stop using or their willingness to try. In the case of smoking, critics are concerned that quitting self-efficacy will be reduced if smokers are told that they require medical treatment due to a biological “need” to smoke (Caron, Karkazis, Raffin, Swan, & Koenig, 2005) and hence that medicalization of smoking may reduce unassisted quit attempts (Chapman & MacKenzie, 2010). Conversely, some believe that new smoking cessation treatments will be viewed as “magic bullets”, with smokers becoming overly optimistic about the potential for medical treatments to “cure” their addiction to smoking (Dingel, Karkazis, & Koenig, 2011).
These can be seen as examples of a wider concern about the influence of “brain talk” on subjectivity and identity. Nikolas Rose believes that neuroscientific discourses of human behaviour are creating “neurochemical selves” (Rose, 2003). That is, individuals are coming to understand their identity and behaviour as mediated by chemical occurrences in their brain. Sociological accounts of addiction have problematised such an emphasis on biology. They have noted the power relations inherent in reductive biomedical accounts of addiction, and prefer to describe drug use as a rational response by social actors (Weinberg, 2011). But as Weinberg has noted, in doing so, some sociological work on addiction has downplayed the sense of “viscerally felt compulsion” that is evident in the accounts of those who describe themselves as addicted to drugs (Weinberg, 2002). Weinberg recommends a post-humanist, empirical approach to addiction that acknowledges the “local practice” of addiction as an embodied experience (Weinberg, 2002, Weinberg, 2013).
There is little empirical research examining the psychological or behavioural impact of neurobiological understandings of nicotine addiction on smokers. A survey study by Hughes (2009) found that many smokers believed that an inability to quit smoking was due to addiction, but only a small proportion believed that biological factors were to blame. Hughes also found that smokers’ causal beliefs were not strongly related to treatment preferences. He recommended that qualitative research be conducted in order to explore in more depth smokers’ understanding of the causal determinants of addiction and their treatment preferences. Research from the genetics field has looked at the impact of genetic understandings of tobacco addiction on smokers’ sense of control and treatment preferences (Cappella et al., 2005, Park et al., 2011, Wright et al., 2003), however mixed findings and variations in study design mean that no clear conclusions can yet be drawn from this data. Moreover, it remains to be seen if people will respond to genetic and neuroscience information in similar ways, given important differences between the two (Green, 2006).
This paper will report exploratory qualitative research examining how smokers interpret and apply information about the brain and addiction to their own lived experiences as smokers. The aims are to:
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Explore the extent to which smokers believe their brain is involved in their smoking behaviour;
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Document the ways that smokers incorporate neurobiological explanations of addiction into their mental models of smoking; and
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Assess the ways in which brain-based understandings of addiction might influence smokers’ sense of self-efficacy and their treatment preferences.
Section snippets
Method
The data reported here are drawn from the initial qualitative component of a mixed-methods study examining neurobiological understandings of smoking and addiction. For this qualitative stage of the research, semi-structured interviews were conducted with 29 participants who smoked daily. Participants were recruited from a large metropolitan city in Australia. Because this was an exploratory study, purposive sampling was used in order to recruit a diverse range of participants in relation to
Participants
We recruited 29 participants who were evenly distributed in relation to gender (M = 15, F = 14). Most participants were in the middle age ranges, with fifteen participants aged 26–54, nine younger participants (18–24 years olds) and five participants older than 55. Eleven had completed a university degree, ten had completed a trade certificate or diploma, four had completed secondary school and four had not finished secondary school. With regard to heaviness of smoking: seven participants were
Discussion
The primary aim of this research was to explore how smokers engaged with ideas about the neural basis of nicotine addiction. Many of our participants had some awareness that smoking tobacco affected their brain. However, few were aware of the detailed neurobiological mechanisms associated with addiction to smoking, and some were misinformed. This is consistent with other literature on nicotine replacement therapy that has found that smokers do not have a good understanding of how nicotine works
Acknowledgments
We would like to acknowledge the participants who provided their time and thoughts for this research. This work was supported by an Australian Research Council Discovery Grant (Grant ID: DP120100732) awarded to W.H. K.M. was supported by an Australian Postgraduate Award and a UQ Advantage top up scholarship. W.H. was supported by a National Health and Medical Research Council Australia Fellowship (Grant ID: 569738). B.P., C.G. and A.C. were all supported by National Health and Medical Research
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