Week 2 Lecture Slides on Smoking and Alcohol PDF

Lecture 2 – Smoking and alcohol What we’re going to cover • Health effects on individuals • Rates and trends • Consequences (burden) at a population level • Broad efforts to change behaviour • Addiction Smoking • Between the 1930s and 1950s smoking was ‘doctor recommended’. • The negative eff...

Lecture 2 – Smoking and alcohol What we’re going to cover • Health effects on individuals • Rates and trends • Consequences (burden) at a population level • Broad efforts to change behaviour • Addiction Smoking • Between the 1930s and 1950s smoking was ‘doctor recommended’. • The negative effects of smoking were first reported in 1954 when Doll and Hill reported that smoking cigarettes was related to lung cancer. The health effects of smoking • Since Doll and Hill’s original work, smoking has been implicated in a host of other diseases including heart disease and cancer pretty much anywhere in the body. Øe.g., throat, stomach, bowel, liver, pancreas, bladder, cervix. • Tobacco smoke contains >70 chemicals that can cause cancer. • Smoking is the number one risk factor for lung cancer – in the US it is linked to 80-90% of lung cancer deaths. Smoking is also linked to… • • • • • Shortness of breath Asthma + more severe asthma symptoms Higher blood pressure Greater risk of respiratory tract infections Sleep disturbance – smokers report less total sleep time, longer sleep onset latency, increased difficulty falling asleep and maintaining sleep, and waking up earlier than desired compared to non-smokers. (e.g., see McNamara et al., 2013; Murin & Bilello, 2005; Polosa & Thomson, 2013; Primatesta et al., 2001) Mental health effects • Depression • Anxiety • Stress • Quality of life • Affect – Bidirectional relationships? ØRigorous research designs needed to unpack this. Steuber and Danner (2006) • 14,634 adolescents from a national longitudinal study. • Two waves of data collection – 1 year apart. • Divided sample into 4 groups: ØNevers didn’t smoke at Time 1 or Time 2. ØStarters didn’t smoke at Time 1 but did at Time 2. ØQuitters smoked at Time 1 but not Time 2. ØMaintainers smoked at Time 1 and Time 2. Results • Overall, starters, quitters, and maintainers were 1.5, 1.4, and 2.0 times more likely to be depressed at Time 2, respectively, than those who had never smoked. • There was a decrease in depression among females who quit smoking, and an increase in depression among those who started. Males Females Meta analysis of longitudinal studies – Taylor et al. (2014) • Synthesised 26 longitudinal studies that assessed mental health before smoking cessation and at least six weeks after cessation or baseline in healthy and clinical populations. • Follow-up mental health scores were measured between 7 weeks and 9 years after baseline. • Compared changes in anxiety, depression, mixed anxiety and depression, stress, quality of life, and positive affect between baseline and follow-up in quitters compared with continuing smokers. Anxiety -.37 Depression -.25 -.31 Smoking (continuing vs quitting) Mixed anxiety and depression -.27 .22 .40 Note: Numbers represent standardized mean differences between continuers and quitters. Stress Quality of life Positive affect • The effect sizes… ØWere equal to, or larger than, those of antidepressant treatment for mood and anxiety disorders and were as large for those with psychiatric disorders as those without. ØSuggests that smokers who may normally be prescribed antidepressants may gain at least as much benefit from quitting smoking as they would from the antidepressants. • However, remember that… ØObservational data can never prove causality. ØThe gold standard for establishing cause and effect are randomised controlled trials. ØBut, in this context such studies have considerable ethical and practical difficulties… Why? • Difficult to randomly assign one group of people to quit smoking and another group to not quit smoking because you can’t tell people to keep smoking! • Adherence to quitting smoking or not quitting smoking wouldn’t be absolute in your trial groups anyway. ØMost people in interventions tend not to actually quit and some people not in interventions will quit! ØSo intention to treat analyses, where you analyse people on the basis of the condition they were assigned to, would become problematic. • So, almost all we know about the harms of smoking and the benefits of cessation is derived from observational studies. Possible explanations for Taylor et al.’s (2014) findings 1. A common factor explains both improved mental health and cessation. - e.g., positive life events, like having a baby. But there was no evidence of this, and outcomes were assessed over up to 9 years so unlikely this was the case over the full period. 2. Improving mental health causes cessation. - In most studies included everyone attempted to quit, therefore the decision was not contingent on improved mental health. 3. Smoking cessation causes the improvement in mental health. - Most plausible, supported by biological evidence that smoking effects neurological functioning and that this can return to the same level as nonsmokers approximately 3 weeks after quitting (Mamede et al., 2007). The broader consequences (burden) of smoking… • Worldwide, smoking is responsible for an estimated 15% of all deaths (Institute for Health Metrics and Evaluation, 2019). • It is the leading preventable cause of death worldwide (CDC, 2022). • Life expectancy for smokers is at least 10 years shorter than for nonsmokers (Jha et al., 2013). • In Australia, the total annual tangible and intangible costs of smoking is estimated at $136.9 billion (National Drug Research Institute, 2019). Source: https://ourworldindata.org/smoking Second-hand smoke According to the World Health Organization: • Second-hand smoke kills over 1 million people every year. • It causes heart disease, cancer, and many other diseases and disabilities. • Among newborns exposed either in utero or after birth there is: ØAn increased risk of premature birth and low birth weight. ØDouble the risk of Sudden Infant Death Syndrome. Prevalence Percentage of adults (18+) who smoke daily in Australia Source: AIHW https://www.aihw.gov.au/reports/ australias-health/tobacco-smoking How much are things really getting better? • There are currently around 19 million adults in Australia. • If 12% of them smoke, that’s about 2.28 million smokers. • In 2011, there were around 16 million adults in Australia. • If approximately 16% of them smoked (according to the graph), that’s about 2.56 million smokers. Who Smokes? Percentage of Australians that smoke daily by age and gender Source: AIHW https://www.aihw.gov.au/reports/aust ralias-health/tobacco-smoking Trends by socioeconomic status in Australia Source: Greenhalgh et al (2021) - https://www.tobaccoinaustralia.org.au/chapter-1-prevalence/1-7-trends-in-theprevalence-of-smoking-by-socioec Why do health psychologists care about these specifics? • Because they can tell us where the biggest challenges/problems are, and therefore: ØThe populations it might be most fruitful to focus on in interventions. ØWhere we might get the best ‘bang for our buck’. Rates of smoking in Indigenous Australian populations According to the Department of Health and Aged Care (2020): • Aboriginal and Torres Strait Islander peoples are almost 3 times more likely to smoke compared to Non-Indigenous Australians. • 37% of Aboriginal and Torres Strait Islander peoples smoke daily. • i.e., a higher percentage than among people of the lowest socioeconomic status. Longitudinal data from the ABS and AIHW indicate: • No change to the gap between the smoking prevalence among the Aboriginal and Torres Strait Islander adult population and the non-Indigenous adult population during the last approximately 20 years. • Has remained at around 30 percentage points. Age standardized smoking rates among Indigenous Australian adults and Non-Indigenous Australian adults (aged 15+) Source: AIHW: https://www.indigenoushpf.gov.au/measures/2-15-tobacco-use#references Comparative smoking trends for Indigenous Australian adults living in remote vs non-remote areas Source: AIHW: https://www.indigenoushpf.gov.au/measures/2-15-tobacco-use#references Impact on the burden of disease According to the AIHW (2016): • Indigenous Australians experience a burden of disease (measured in DALYs) that is 2.3 times the rate of Non-Indigenous Australians. • Smoking is the risk factor most responsible for the gap in disease burden between Indigenous and Non-Indigenous Australians. ØIt estimated to be responsible for 23% of the health gap. What have we tried/are we trying to do about it? • The WHO Framework Convention on Tobacco Control (FCTC) and its guidelines seek to provide the foundation for countries to implement and manage tobacco control. • To help make this a reality, WHO introduced the MPOWER measures. • These are intended to assist in the country-level implementation of effective interventions to reduce the demand for tobacco, contained in the WHO Framework Convention on Tobacco Control. • The MPOWER measures have 6 key foci… 1. Monitoring tobacco use • Countries are required to regularly collect and share national data on the magnitude, patterns, determinants, and consequences of tobacco use and exposure. • Continual monitoring of the tobacco epidemic, and of the interventions to control it, can enable interventions to be more effectively managed and improved. • WHO works with countries to help them gather data, ensure the data is high quality, and make use of it to advocate for effective policies. • There is now high-quality global data on smoking rates + data suggests that tobacco use is declining significantly in over 30 countries. 2. Protecting people from tobacco smoke • Aims to help countries know exactly what to do to protect their people from second-hand smoke. • Argues that any country, regardless of incomelevel, can implement effective smoke-free legislation. • Provides recommendations for how to make cities, campuses etc. smoke free. • 62 countries have strong laws in place that make all public places completely smoke-free. 3. Quitting tobacco • Under the framework, countries are mandated to treat tobacco use and dependence. • WHO provides capacity building and training packages to help governments establish/strengthen their tobacco cessation systems, including: ØIntegrating brief tobacco interventions into their primary care systems. ØDeveloping national toll-free quit lines. Ø‘mCessation’ projects (i.e., mobile phone-based smoking support). • In 2007, only 15% of the world's population were covered by at least one comprehensive tobacco control measure, in 2019 it was 65%. 4. Warning about the dangers of tobacco It advocates for: • Large and clear warnings on the front and back of the packaging that describe specific illnesses caused by tobacco. • The use of graphic images demonstrating the harm of tobacco use. • Disseminating anti-tobacco messaging through the media. • Over half the world’s population are now exposed to large and effective graphic health warnings. 5. Enforcing tobacco advertising, promotion, and sponsorship bans • A total ban on direct and indirect advertising, promotion, and sponsorship. • Bans must be complete and apply to all marketing categories. Otherwise, the industry redirects resources to nonregulated marketing channels. • 48 countries covered by a comprehensive ban. 6. Raising taxes on tobacco • Significantly increasing tobacco excise taxes and prices is the single most effective and cost-effective measure for reducing tobacco use, particularly among youth and low-income groups. WHO advocates for: • Tobacco taxes that decrease affordability by accounting for the impact of inflation and economic growth. • Using tax structures that do not differentiate based on tobacco product characteristics, therefore reducing consumers’ incentive to downshift their consumption to cheaper brands. • Evidence suggests that a 10% price increase = 5% less tobacco use. Source: AIHW; https://www.aihw.g ov.au/reports/austr alias-health/healthpromotion New Zealand’s ‘tobacco-free generation’ policy • From 2022 all sales of tobacco to anyone born after 2008 banned. • Effectively, anyone 14 years or younger is banned from purchasing cigarettes, for their entire lifetimes. • It will raise the minimum age to buy cigarettes every year beginning in 2023: ØIn 2023, no one aged 15 or younger can buy cigarettes, in 2024 no one aged 16 or younger will be able to etc. • Other major tobacco controls will also be introduced, including significantly restricting where cigarettes can be sold. Vaping • Vaping is the inhaling of an aerosol (or vapour) created by an electronic cigarette (e-cigarette) or other vaping device. • The aerosol is made up of chemicals and small particles. • Vaping devices heat up a liquid (e-juice) to turn it into a mist (vapour), which is then inhaled. • The concerns about vaping mainly centre around the chemicals that are found in the e-juices, and the vapours that they generate. ØThese include very fine particles, heavy metals, volatile organic compounds, and poly-cyclic aromatic hydrocarbons. Health effects • Not yet clear if vaping causes heart disease. However, has been shown to increase blood pressure, heartrate, and the stiffness of arteries (e.g., see Peruzzi et al., 2020) – risk factors for heart disease. • Similar for cancers – lab studies have shown that vapours from e-cigarettes can damage human DNA, which is a pathway to developing cancer, and some of the chemicals in the e-juices have been linked to cancer in other contexts (e.g., see Bracken-Clarke et al., 2021) Health effects • Increasing evidence for links to chronic respiratory disease. • E.g., Xie et al. (2020) followed 21,618 participants over 5 years and found that, compared with people who never used e-cigarettes, those who vaped were approximately: Ø70% more likely to develop emphysema. Ø60% more likely to develop chronic obstructive pulmonary disease. Ø30% more likely to develop asthma. Health effects • Increasing evidence for links to acute lung disease and lung injury. • E.g., EVALI – Electronic Cigarette or Vaping Product Use-Associated Lung Injury (e.g., see Corcoran et al., 2020; Gordon & Fine, 2020). Vaping prevalence According to Tobacco in Australia data: • In 2019, approximately 11% of the general population aged 14 and over reported having ever used e-cigarettes. • The highest prevalence rates were among 18-24 year olds – 26.1% reported having ever used e-cigarettes. The most recent data from the ABS (2022) suggests that: • 2.2% of Australians currently use e-cigarettes. Percentage of U.S. High School Students currently using tobacco products From King et al. (2020) New England Journal of Medicine. Are we heading towards a new health crisis? • Systematic reviews suggest that evidence for the efficacy of ecigarettes to help people quit smoking is limited (e.g., Dib et al., 2017; Weaver et al., 2018). Drinking The health effects of drinking According to the World Health Organization (2018), alcohol is: • Linked to over 200 different health conditions, such as heart disease, cancer, liver cirrhosis, and tuberculosis. • Linked to a range of secondary risk factors such as increased rates of sexual assault, violence, unprotected sex, and traffic accidents. Cancer risk Pandeya et al. (2015) • Estimated that 3208 cancer cases (2.8% of all cancer cases) occurring in Australian adults in 2010 were attributable to alcohol consumption. • Greatest numbers were for colon and female breast cancers. • Estimated that the incidence of alcohol-associated cancer-types could have been reduced by 4.3% if no Australian consumed >2 drinks per day. ØTogether, smoking and alcohol have a synergistic effect on cancer risk: the combined effects of use are significantly greater than the sum of individual risks (Winstanley et al., 2011). Mental health effects • Seem to be quite complex. ØDirection and nature of the relationships between alcohol consumption and mental health outcomes unclear/debated. ØMay not be linear. Gemes et al. (2019) • 5087 participants who provided information on alcohol consumption and completed measures of hazardous drinking and depression at 3 waves: Ø1998-2000 Ø2001-2003 Ø2010 • Analysed the association between alcohol consumption and depression while controlling for previous alcohol consumption and depressive symptoms and other confounders (e.g., education, stressful life events). Results • Non-drinkers had a higher depression risk than ‘light drinkers’ (≤7 drinks per week). • People who drank 7–14 drinks per week had depression risk similar to that of people who drank ≤7 drinks per week. • Drinking 2-3 times per week was associated with the lowest risk of depression. • Hazardous drinking was associated with a higher risk of depression than non-hazardous drinking. J-shaped relationship between alcohol consumption and depression (see also Alati et al., 2005). Possible explanations • Non-drinkers are less socially active and have weaker social support than drinkers. This could be a confound – we know that greater social support/more group memberships is linked to reduced rates of depression. ØAnd non-drinkers may deliberately avoid social occasions involving alcohol, especially if they have previously quit. • Biological mechanisms – a small amount of alcohol can decrease inflammation and improve functioning of the gut microbiome, which are both linked to reduced risk of depression. Global burden Lancet GBD study (2018): • Globally, alcohol use was the seventh leading risk factor for both deaths and DALYs in 2016, accounting for 2.2% of age-standardised female deaths and 6.8% of age-standardised male deaths. • For people aged 15-49, the 3 leading causes of attributable deaths were tuberculosis (1.4% of total deaths), road injuries (1.2% of total deaths), and self-harm (1.1% of total deaths). • For people aged 50+, cancers accounted for the largest proportion of total alcohol-attributable deaths (27.1% of total female deaths and 18.9% of total male deaths). In Australia… According to the Australian Institute of Health and Welfare: • Approximately 6,000 people die from alcohol-induced or related deaths per year. • Alcohol is consistently the most commonly recorded drug for drugrelated hospitalisations and accounts for the highest rate of ambulance attendances nationally. Global Burden of Disease study estimates • Smoking accounted for 6% of total DALYs globally in 2015 (GBD Tobacco, 2017). • Alcohol use accounted for 1.6% of total DALYs globally in 2016 among females and 6% among males (GBD Alcohol, 2018). i.e., ØOf all the Disability Adjusted Life Years lost, 6% because of smoking. ØOf all the Disability Adjusted Life Years lost by females, 1.6% because of drinking. ØOf all the Disability Adjusted Life Years lost by males, 6% because of drinking. Benefits of cutting down • Reduced risk of physical and mental health problems. • Weight loss and more energy. • Financial benefits. • Better relationships – heavy alcohol consumption makes you more likely to argue and alienate your friends and reduces your sex drive. What about an occasional glass of red? There is some evidence that alcohol (in moderation!) can have health benefits: • Ronksley et al. (2011) reviewed 84 studies of alcohol consumption and cardiovascular disease (i.e., assessed impact of alcohol consumption on incidence of, and mortality from, cardiovascular disease, coronary heart disease, and stroke). Ø Found that alcohol consumption at 2.5–14.9 g/day (about ≤1 drink a day) was consistently associated with a 14–25% reduction in the risk of the various cardiovascular outcomes outcomes compared with abstaining from alcohol. What are the mechanisms? • Hypertension (high blood pressure) is a major risk factor for cardiovascular disease, and there is an inverse relationship between light-to-moderate alcohol intake and blood pressure. • The reduced cardiovascular risk associated with moderate consumption of alcoholic drinks may, in part, be due to a reduction in blood pressure (Li & Forstermann, 2012). • Red wine often used in studies examining the impact of alcohol consumption and is known to have vasodilator effects – i.e., it opens (dilates) blood vessels allowing blood to flow more freely meaning the heart doesn’t have to pump as hard (e.g., Hashimoto et al., 2001). But… • Zhao et al. (2017) argued that potential errors in studies may have led to inaccurate conclusions: ØE.g., systematic misclassification of drinkers as abstainers, inadequate measurement, and selection bias across the life course. • In their meta-analysis, Zhao et al. (2017) found that low volume alcohol consumption was not associated with reduced heart disease mortality in studies of those aged 55 years or younger at baseline, in higher quality studies, or in studies that controlled for heart health. And in terms of blood pressure… • In a meta-analysis, Roerecke et al. (2017) found that reducing alcohol intake lowers blood pressure for those who drink more than two drinks a day, and that blood pressure benefits from reducing alcohol intake are greater the more people drink. • In a further meta-analysis, Roerecke et al. (2018) found that: ØMen who drank 1, 2, 3, 4, or 5+ drinks per day were all at greater risk of hypertension than abstainers. ØAmong women, there was no difference in hypertension risk between those who drank 1 drink per day compared to 0, but differences in risk between abstainers and those who drank 2, 3, 4, or 5+ drinks. Cancer Council Australia (2011) position statement: “The existing evidence does not justify the promotion of alcohol use to prevent coronary heart disease, as the previously reported role of alcohol in reducing heart disease risk in light-to-moderate drinkers appears to have been overestimated.” Alcohol guidelines (Department of Health) • Healthy men and women should drink no more than 10 standard drinks a week and no more than 4 standard drinks on any one day. • People under 18 and women who are pregnant or breastfeeding should drink no alcohol. • The less you drink, the lower your risk of harm from alcohol. What is a standard drink? According to the National Health and Medical Research Council: • A standard drink contains 10 grams of pure alcohol. • The type of drink makes no difference, 10 grams of alcohol is 10 grams of alcohol, whether it is in beer, wine, or spirits. • It doesn’t matter whether it is mixed with soft drink, fruit juice, water, or ice. Formula for Standard Drinks • A government standard formula is used to determine how many standard drinks are in alcoholic beverages: Volume of beverage (litres) X the percentage of alcohol volume X 0.789 (0.789 is the specific gravity of ethanol alcohol) ØE.g., for one stubbie (375ml) of heavy beer, with 5% alcohol: 0.375 X 5 X 0.789 = 1.5 standard drinks There are also online calculators available, e.g., https://yourroom.health.nsw.gov.au/games-and-tools/pages/standard-drink-calculator.aspx How much are we drinking? Guideline: Healthy men and women should drink no more than 10 standard drinks a week and no more than 4 standard drinks on any one day. According to ABS health survey data from 2020/21: • 25.8% of Australians aged 18+ exceeded the Australian Adult Alcohol Guideline. • Men were more likely to exceed the guideline than women (33.6% compared to 18.5%). Proportion of Australians exceeding the alcohol guideline by age Source: ABS National Health Survey 2020/21 - https://www.abs.gov.au/statistics/health/health-conditions-and-risks/alcohol-consumption/latest-release Proportion of Australians (18+) exceeding the alcohol guideline by socioeconomic status Source: ABS National Health Survey 2020/21 - https://www.abs.gov.au/statistics/health/health-conditions-and-risks/alcohol-consumption/latest-release Alcohol consumption among Indigenous Australian adults and Non-Indigenous Australian adults (15+) Source: AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19 - https://www.indigenoushpf.gov.au/measures/2-16-riskyalcohol-consumption Indigenous Australians aged 15+ who exceeded the lifetime alcohol risk guidelines, by remoteness and sex, 2018–19 Source: AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19 - https://www.indigenoushpf.gov.au/measures/2-16-riskyalcohol-consumption Alcohol drinking status among Australians aged 14+ over time Trends over time Source: AIHW (2020) What have we tried/are we trying to do about it? In 2010, the WHO published a global strategy to reduce the harmful use of alcohol. • Its vision is: “improved health and social outcomes for individuals, families and communities, with considerably reduced morbidity and mortality due to harmful use of alcohol and their ensuing social consequences.” • The strategy aims to: “give guidance for action at all levels; to set priority areas for global action; and to recommend a portfolio of policy options and measures that could be considered for implementation and adjusted as appropriate at the national level, taking into account national circumstances, such as religious and cultural contexts, national public health priorities, as well as resources, capacities and capabilities.” See: https://www.who.int/teams/mental-health-and-substance-use/alcohol-drugs-and-addictive-behaviours/alcohol/governance/global-alcohol-strategy Policy options and interventions available for national action grouped into 10 recommended target areas: 1. Leadership, awareness and commitment 2. Health services’ response 3. Community action 4. Drink-driving policies and countermeasures 5. Availability of alcohol 6. Marketing of alcoholic beverages 7. Pricing policies 8. Reducing the negative consequences of drinking and alcohol intoxication 9. Reducing the public health impact of illicit alcohol and informally produced alcohol 10. Monitoring and surveillance. Policy options and interventions available for national action grouped into 10 recommended target areas: 1. Leadership, awareness and commitment 2. Health services’ response 3. Community action 4. Drink-driving policies and countermeasures 5. Availability of alcohol 6. Marketing of alcoholic beverages 7. Pricing policies 8. Reducing the negative consequences of drinking and alcohol intoxication 9. Reducing the public health impact of illicit alcohol and informally produced alcohol 10. Monitoring and surveillance. Health services’ response • Health services should provide prevention and treatment interventions to individuals and families at risk of, or affected by, alcohol-use disorders and associated conditions. • Health services and health professionals should inform societies about the public health and social consequences of harmful use of alcohol, support communities in their efforts to reduce the harmful use of alcohol, and advocate for effective societal responses. • Health services should be sufficiently strengthened and funded in a way that is commensurate with the magnitude of the public health problems caused by harmful use of alcohol. Example policy options and interventions for nations • Increase the capacity of health and social welfare systems. • Support initiatives for screening and brief interventions for hazardous and harmful drinking in primary health care. • Provide culturally sensitive health and social services as appropriate. • Provide universal access to health, including through enhancing availability, accessibility, and affordability of treatment services for groups of low socioeconomic status. Drink-driving policies and countermeasures • Strong evidence-based interventions exist for reducing drink-driving. • Strategies to reduce harm associated with drink-driving should include: ØDeterrent measures that aim to reduce the likelihood that a person will drive under the influence of alcohol. ØMeasures that create a safer driving environment in order to reduce both the likelihood and severity of harm associated with alcoholinfluenced crashes. Example policy options and interventions for nations • Introduce and enforce an upper limit for blood alcohol concentration, with a reduced limit for professional drivers and young or novice drivers. • Graduated licensing for novice drivers with zero-tolerance for drinkdriving. • Provide alternative transport (including public transport) until after the closing time for drinking places. • Run public awareness and information campaigns in support of policy and to increase the general deterrence effect. • Run carefully planned, high-intensity, well-executed mass media campaigns targeted at specific situations (e.g., holiday seasons) or audiences (e.g., young people). Addiction What is an addiction? • It depends on your perspective… ØMoral models regard addiction as a result of weakness and a lack of moral fibre. ØBiomedical models regard addiction as a disease. ØSocial learning theories regard addictive behaviours as behaviours that are learned. • Questions about the causes of an addiction also have different answers depending on your theoretical perspective, and dominant theoretical perspectives have changed over time… The 17th century and the moral model of addictions • Alcohol held in high esteem during the 17th century – safer than water, nutritious, the innkeeper was a pillar of the community. • Animals’ behaviours seen as determined by biological drives but human behaviours a result of their own free will. • So, alcohol consumption considered acceptable but excessive consumption regarded as a result of free choice and personal responsibility. • Alcoholism therefore considered worthy of punishment not treatment. The 19th century and the first disease concept • Alcohol became regarded as a powerful and destructive substance. • Alcoholics were seen as victims. • Alcohol banned in the United States. • The first disease concept of addiction was the earliest form of a biomedical model of addiction and regarded alcoholism as an illness. ØThe focus of this approach was on the substance (i.e., alcohol), which was seen as an addictive substance that people were passively succumbing to the influence of. ØExcessive drinkers need treatment. The 20th century and the second disease concept • The US realised banning alcohol was more problematic than expected. • Governments realised they could financially benefit from alcohol sales. • The second disease concept of addiction no longer saw the substance as the problem, but instead those people who became addicted. • Regarded alcoholism as an illness and emphasised treatment for addicted individuals. • Addiction a discrete entity: you are either an addict or not. Problems with the disease model • Encourages treatment through lifelong abstinence – very rare and difficult to achieve. • Does not incorporate relapse into its model of treatment. ØThis ‘all or nothing’ perspective might actually promote relapse by encouraging individuals to set unreasonable goals. • The notion of ‘controlled drinking’ suggests that alcoholics can actually return to ‘normal’ drinking patterns – complete abstinence doesn’t necessarily need to be the treatment goal. The 1970s onwards: Social learning theory • The development of behaviourism and learning theory led to an increasing belief that behaviour is shaped by interactions with the environment and other people. • ‘Addiction’ replaced by the term ‘addictive behaviour’. • Addictive behaviours seen as acquired/learned behaviours. • Addictive behaviours lie along a continuum. • Suggests such behaviours are no different from other behaviours and can also be unlearned. • Total abstinence or a return to ‘normal’ behaviour patterns can be the goal of treatment. How are addictive behaviours learned according to social learning theory? 1. Classical conditioning 2. Operant conditioning 3. Observational learning/modelling 4. Cognitive factors 1. Classical conditioning • Behaviours can be acquired through the process of associative learning. • An unconditioned stimulus (US) can elicit an unconditioned response (UR) ØE.g., eating (US) salivating (UR) • If the unconditioned stimulus (US) is associated with a conditioned stimulus (CS) then eventually this will elicit a conditioned response (CR). ØE.g., if eating (US) is associated with hearing a bell (CS) then eventually hearing a bell will make the dog salivate (CR). A human example… Going to the pub (US) feeling relaxed (UR) • If the unconditioned stimulus (US) is associated with a conditioned stimulus (CS) then eventually this will elicit a conditioned response (CR). ØE.g., if going to the pub (US) is associated with having a drink (CS) then eventually having a drink will make the person feel relaxed (CR). 2. Operant conditioning • The probability of a behaviour occurring is increased if it is: ØPositively reinforced by the presence of a positive event. ØNegatively reinforced by the absence or removal of a negative event. • E.g., Smoking will be increased by feelings of social acceptance, confidence, and control (positive reinforcers) and the removal of withdrawal symptoms (a negative reinforcer). 3. Observational learning/modelling • Behaviours are learned through watching significant others carry them out. ØE.g., young people watching parents and peers smoking. 4. Cognitive factors • Self-image ØAdolescents in particular are often motivated to maintain a positive self-image and engage in strategic self-presentation. ØThey can be drawn to smoking as a way of enhancing their self-image if they think it’s going to make them seem fun or ‘cool’. • Problem solving behaviour • Learn to use it as a coping mechanism Questions? Reading Essential: Global burden of disease smoking collaborators (2017). Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: A systematic analysis from the Global Burden of Disease Study 2015. The Lancet, 389(10082), 1885-1906. Global burden of disease alcohol collaborators (2018). Alcohol use and burden for 195 countries and territories, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. The Lancet, 392(10152), 10151035.