Category Archives: Cigarette smoking

No joking on smoking: My top ten tips for giving up smoking this Stoptober

Although most of my academic research is on behavioural addiction, I have published quite a few papers on more traditional addictions such as alcohol addiction and nicotine addiction (see ‘Further reading’ below). In 2012, I had to watch my mother fight a losing battle with smoking-related lung cancer and chronic obstructive pulmonary disease. She died in September 2012 aged 66 years, and had chain-smoked most of her adult life. This followed the death of my father who also died of smoking-related heart disease, aged just 54.

In my previous blog I looked at ways to reduce alcohol intake as part of the ‘Go Sober For October‘ campaign. In today’s blog I provide my advice for giving up smoking as part of the annual ‘Stoptober’ campaign. In the UK smoking accounts for approximately one in four cancer deaths, and as I said, it’s something I’ve witnessed first-hand. I’m sure most people reading this are aware of the addictive nature of nicotine. As soon as nicotine is ingested via cigarettes, it can pass from lungs to brain within ten seconds and stimulates the release of the neurotransmitter dopamine. The release of dopamine into the body provides reinforcing mood modifying effects. Despite nicotine being a stimulant, many people use cigarettes for both tranquillising and euphoric effects.

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Most authorities accept that nicotine is one of the most addictive drugs on the planet and that smokers can become hooked quickly. One of the reasons my own parents were never able to give up was because of the prolonged withdrawal effects they experienced whenever they went more than a few hours without smoking. This would lead to intense cravings for a cigarette. Watching both my parents’ die of smoking-related diseases is enough incentive for me to never smoke a cigarette. Hopefully, others can find the incentives they need to help them give up permanently. Here are my top ten tips to help you (or someone you know and love) stop smoking:

  • (1) Develop the motivation to stop smoking: Many smokers say they would like to stop but don’t really want to. When you take stock, make sure you are clear as to why you want to give up. It may be to save money, to improve your health, to prevent yourself getting a smoking-related disease, or to protect your family from passive smoking. (It could of course be all of the above). Really wanting to give up is the best predictor of successful smoking cessation.
  • (2) Get all the emotional support you can: Another good predictor of whether someone will overcome their addiction to nicotine is having a good support network. You need people around you that will support your efforts to quit. Tell as many people that you know that you are trying to quit. It could be the difference between stopping and starting again.
  • (3) Avoid ‘cold turkey’: Although some people can stop through willpower alone, most people will need to reduce their nicotine intake slowly. The best way of doing this is to replace cigarettes with a safe form of nicotine such as those available from the pharmacy, or on prescription from the doctor.
  • (4) Get support from a professional: Even if you are using a safe form of nicotine from your pharmacist or doctor, cutting out cigarettes completely can be hard. Getting support from a trained NHS stop smoking adviser can double your chances of stopping smoking. To find your nearest free NHS stop smoking service (in the UK call 0300 123 1044) or visit the Smokefree website.
  • (5) Use non-nicotine cigarette shaped substitutes: Smoking is also a habitual behaviour where the feel of it in your hands may be as important as the nicotine it contains. The use of plastic cigarettes or e-cigarettes will help with the habitual behaviour associated with smoking but contain none of the addictive nicotine.
  • (6) Use relaxation techniques: When cravings strike, use relaxation exercises to help overcome the negative feelings. At the very least take deep breaths. There are dozens of relaxation exercises online. Practice makes perfect.
  • (7) Treat yourself: One of the immediate benefits of stopping smoking will be the amount of money you save. At the start of the cessation process, treat yourself to rewards with the money you save.
  • (8) Focus on the positive: Giving up smoking is one of the hardest things that anyone can do. Write down lists of all the positive things that will be gained by stopping smoking. Constantly remind yourself of what the long-term advantages will be that will outweigh the short-term benefits of smoking a cigarette. In short, focus on the gains of stopping rather than what you will miss about cigarettes.
  • (9) Know the triggers for your smoking: Knowing the situations in which you tend to smoke can help in overcoming the urges. Lighting up a cigarette can sometimes be the result of a classically-conditioned response (e.g. having a cigarette after every meal). These often occur unconsciously so you need to break the automatic response and de-condition the smoking. You need to replace the unhealthy activity with a more positive one and re-condition your behaviour.
  • (10) Fill the void: One of the most difficult things when cigarette craving and withdrawal symptoms strike is not having an activity to fill the void. Some things (like engaging in physical activity) may help you in forgetting about the urge to smoke. Plan out alternative activities and distraction tasks to help fill the hole when the urge to smoke strikes (e.g. chew gum, eat something healthy like a carrot stick, call a friend, occupy your hands, do a word puzzle, etc.). However, avoid filling the void with other potentially addictive substances (e.g. alcohol) or activities (e.g. gambling).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (1994). An exploratory study of gambling cross addictions. Journal of Gambling Studies, 10, 371-384.

Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Griffiths, M.D. (2012). First person: Highly-addictive drug killed both of my parents. Nottingham Post, October 1, p.13.

Griffiths, M.D., Parke, J. & Wood, R.T.A. (2002). Excessive gambling and substance abuse: Is there a relationship? Journal of Substance Use, 7, 187-190.

Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2010). Gambling, alcohol consumption, cigarette smoking and health: findings from the 2007 British Gambling Prevalence Survey. Addiction Research and Theory, 18, 208-223.

Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2011). Internet gambling, health. Smoking and alcohol use: Findings from the 2007 British Gambling Prevalence Survey. International Journal of Mental Health and Addiction, 9, 1-11.

Resnick, S. & Griffiths, M.D. (2010). Service quality in alcohol treatment: A qualitative study. International Journal of Mental Health and Addiction, 8, 453-470.

Resnick, S. & Griffiths, M.D. (2011). Service quality in alcohol treatment: A research note. International Journal of Health Care Quality Assurance, 24, 149-163.

Resnick, S. & Griffiths, M.D. (2012). Alcohol treatment: A qualitative comparison of public and private treatment centres. International Journal of Mental Health and Addiction, 10, 185-196.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Umeh, K. & Griffiths, M.D. (2001). Adolescent smoking: Behavioural risk factors and health beliefs. Education and Health, 19, 69-71.

“Turn and face the strange”: A personal goodbye to David Bowie

“There is a well known cliché that you should never meet your heroes but if David Bowie or Paul McCartney fancy coming round to my house for dinner I’m pretty sure I wouldn’t be lost for words”.

This was the last sentence I wrote in my blog on the psychology of being starstruck less than a month ago. I, like millions of others, was deeply shocked to learn of Bowie’s death from liver cancer earlier this week (January 10) two days after his 69th birthday.

I first remember hearing David Bowie on a 1975 edition of Top of the Pop(when the re-release of ‘Space Oddity’ reached No.1 in the British singles chart). Although I heard the occasional Bowie song over the next few years (‘Golden Years’, ‘Sound and Vision’ and ‘Boys Keep Swinging’ being some of the songs I taped off the radio during the weekly chart rundown) it wasn’t until ‘Ashes To Ashes’ reached the UK No. 1 spot in the week of my 14th birthday (late August 1980) that I became a Bowie convert.

I still vividly remember buying my first Bowie album – a vinyl copy of his first greatest hits LP (Changesonebowie) on the same day that I bought the third album by The Police (Zenyatta Mondatta) and the latest issue of Smash Hits (that had Gary Numan on the cover with a free yellow flexidisc of the track ‘My Face’ by John Foxx). It was Saturday October 4th, 1980. Ever since that day I’ve been collecting David Bowie music and now have every single song that he has ever commercially released along with hundreds of bootlegs of unreleased songs and live recordings.

My collection of Bowie books is ever growing and I have dozens of Bowie DVDs (both his music and films in which he has appeared). In short, I’m a hardcore fan – and always will be. Like many other fans, I’ve spent all this week listening to his final studio LP (Blackstar) and poring over the lyrics knowing that he wrote all these songs knowing that he had terminal cancer. The first line of ‘Lazarus’ appears particularly poignant in this regard (Look up here, I’m in heaven/I’ve got scars that can’t be seen/I’ve got drama, can’t be stolen/Everybody knows me now/Look up here, man, I’m in danger/I’ve got nothing left to lose”).

Anyone who’s been a regular reader of my blog will know that when I get a chance to mention how important he has been in my life, I do so (and do so in writing). I mentioned him in my articles on the psychology of musical preferences, on the psychology of a record-collecting completist, on record collecting as an addiction, and on the psychology of pandrogyny. I’ve also mentioned him (somewhat predictably) in my articles on the psychology of Iggy Pop, and the psychology of Lou Reed (two more of my musical heroes).

I’ve also been sneaking the titles of his songs into the titles of my blog articles ever since I started my blog including ‘Space Oddity’ (in my article on exophilia), ‘Holy Holy’ (in my article on Jerusalem Syndrome), ‘Ashes To Ashes’ (in my article on ‘cremainlining‘), ‘Under Pressure’ (in my article on inflatable rubber suit fetishism), and ‘Changes’ (in my article on transformation fetishes).

When I started writing this article I did wonder whether to do ‘the psychology of David Bowie’ but there is so much that I could potentially write about that it would take more than a 1000-word blog to do any justice to one of the most psychologically fascinating personalities of the last 50 years (Strange Fascination by David Buckley being one of the many good biographies written about him).

Trying to get at the underlying psychology of someone that changed personas (‘the chameleon of pop’) so many times during his career is a thankless task. However, his desire for fame started early and he was determined to do it any way he could whether it was by being a musician, a singer, an actor, a mime artist, an artist, or an entrepreneur (arguably he has been them all at one time or another). Being behind a mask or creating a persona (or “alternative egos” as Bowie called them) was something that got Bowie to where he wanted to be and I’m sure that with each new character he became, the personality grew out of it.

As an academic that studies addiction for a living, Bowie would be a perfect case study. Arguably it could be argued that he went from one addiction to another throughout his life, and based on what I have read in biographies a case could be made for Bowie being addicted (at one time or another) from cocaine and nicotine through to sex, work, and the Internet.

Bowie also had a personal interest in mental health and various mental disorders ran through his family (most notably his half-brother Terry Burns who was diagnosed as a schizophrenic and committed suicide in January 1985 by jumping in front of a moving train. A number of his aunts were also prone to clinical depression and schizophrenia). Bowie first tackled his “sad [mental] inheritance” in ‘All The Madmen’ (on his 1971 The Man Who Sold The World LP) and was arguably at his most candid on the 1993 hit single ‘Jump They Say’ that dealt with is brother’s mental illness and suicide.

Like John Lennon, I’ve always found Bowie’s views on almost anything of interest and he was clearly well read and articulate. He described himself as spiritual and recent stories over the last few days have claimed he almost became a Buddhist monk. Whether that’s true is debatable but he was certainly interested in Buddhism and its tenets. Now that I am carrying out research into mindfulness with two friends and colleagues who are also Buddhist monks (Edo Shonin and William Van Gordon), I have begun to read more on the topic. One of the things that Buddhism claims is that identity isn’t fixed and nowhere is that more true than in the case of David Bowie. Perhaps the chorus one of his greatest songs – ‘Changes’ from his 1971 Hunky Dory LP says it all:

Ch-ch-ch-ch-changes/Turn and face the strange/Ch-ch-changes/Don’t want to be a richer man/Ch-ch-ch-ch-changes/Turn and face the strange/Ch-ch-changes/Just gonna have to be a different man/Time may change me/But I can’t trace time”

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK 

Further reading

Buckley, D. (2005). Strange Fascination: David Bowie – The Definitive Story. London: Virgin Books.

Cann, K. (2010). Any Day Now: David Bowie The London Years (1947-1974). Adelita.

Goddard, S. (2015). Ziggyology. London: Ebury Press.

Hewitt, P. (2013). David Bowie Album By Album. London: Carlton Books Ltd.

Leigh, W. (2014). Bowie: The Biography. London: Gallery.

Pegg, N. (2011). The Complete David Bowie. London: Titan Books.

Seabrook, T.J. (2008). Bowie In Berlin: A New Career In A New Town. London: Jawbone.

Spitz, M. (2009). Bowie: A Biography. Crown Archetype.

Trynka, P. (2011). Starman: David Bowie – The Definitive Biography. London: Little Brown & Company.

Target practice: The psychology of New Year’s resolutions and how to keep them

(Please note: This blog is a slightly extended and fully referenced version of an article that was first published in The Conversation).

Academic research by Dr. John Norcross and his colleagues has shown that up to 50% of adults make New Year’s resolutions (NYRs) and the most common resolutions are wanting to lose weight, doing more exercise, quitting smoking, and saving money. It’s a time that individuals want to re-invent themselves but less than 10% actually manage to keep the NYRs after a few months.

We’ve all made NYRs that we begin with the best of intentions but within a few weeks are back to our old ways. As a Professor of Behavioural Addiction I know how easy people can fall into bad habits, and why on trying to give up those habits is easy to relapse. NYRs usually come in the form of lifestyle changes and changing behaviour that has become routine and habitual (even if they are not problematic) can be very hard to break.

The main reason that people don’t stick to their NYRs is that they set too many and/or they are unrealistic to achieve. There has also been some research by Dr. Janet Polivy and Dr. Peter Herman into ‘false hope syndrome’ (FHS) that is applicable to NYRs. FHS is characterized by an individual’s unrealistic expectations about the likely speed, amount, ease, and consequences of changing their behaviour.

For some people, it takes something radical for them to change their ways. It took a medical diagnosis to make me give up alcohol and caffeine, and it took pregnancy for my partner to give up cigarette smoking. To change your day-to-day behaviour you also have to change your thinking. But there are tried and tested ways that can help individuals stick to their NYRs and here are my personal favourites:

Be realistic You need to begin by making NYRs that you can keep and that are practical. If you want to reduce your alcohol intake because you tend to drink alcohol every day, don’t immediately go teetotal. Try to cut out alcohol every other day or have a drink once every three days. Also, breaking up the longer-term goal into more manageable short-term goals can also be beneficial and more rewarding. The same principle can be applied to exercise or eating more healthily.

Do one thing at a time One of the easiest ways routes to failure is to have too many NYRs. If you want to be fitter and healthier, do just one thing at a time. Give up drinking. Give up smoking. Join a gym. Eat more healthily. But don’t do them all at once. Chose just one and do your best to stick to it. Once you have got one thing under your control, you can begin a second resolution.

Be SMART Anyone working in a jobs that includes objective-setting will know that any goal should be SMART (i.e., specific, measurable, achievable, realist and time-bound). NYRs should be no different. Cutting down alcohol drinking is an admirable goal but it’s not SMART. Drinking no more than two units of alcohol every other day for one month is a SMART resolution. Connecting the NYR to a specific aspirational goal can also be motivating (e.g., dropping a dress size or losing two inches off your waistline in time for the next summer holiday).

Tell someone your resolution(s) Letting family and friends around you know that you have a NYR that you really want to keep will act as both a safety barrier and a face-saver. If you really want to cut down smoking or drinking, real friends will not put temptation in your way and can help you in monitoring your day-to-day behaviour. Never be afraid to ask for help and support from those around you.

Change your behaviour with others – Trying to change habitual behaviour on your own can be difficult. For instance, if you and your partner both smoke, drink and/or eat unhealthily, it is really hard for one partner to change their behaviour if the other is still engaged in the same old bad habits. By having the same NYR (e.g., going on a diet), the chances of success will improve if you are both in it together.

Behavioural change isn’t limited to the New Year Changing your behaviour (or some aspect of it) doesn’t have to be restricted to the start of the New Year. It can be anytime.

Accept lapses as part of the process – It is inevitable that when trying to give up something (alcohol, cigarettes, junk food) that there will be lapses. You shouldn’t feel guilty about giving in to your cravings but accept that it is part of the learning process in enabling behavioural change. Bad habits can take years to become engrained and there are no quick fixes in making major lifestyle changes. These may be clichés but we learn by our mistakes and every day is a new day and you can start each day afresh. Right here. Right now.

Finally, some of you reading this might think all of this sounds like too much hard work and that it’s not worth making NYRs to begin with. However, research by John Norcross and colleagues has also shown that individuals who make NYRs are ten times more likely to achieve their goals than those that don’t make explicit NYRs. Food for thought (rather than thought for food)!

Dr Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Koestner, R. (2008). Reaching one’s personal goals: A motivational perspective focused on autonomy. Canadian Psychology/Psychologie Canadienne, 49(1), 60-67.

Marlatt, G. A., & Kaplan, B. E. (1972). Self-initiated attempts to change behavior: A study of New Year’s resolutions. Psychological Reports, 30(1), 123-131.

Norcross, J. C. (2006). Integrating self-help into psychotherapy: 16 practical suggestions. Professional Psychology: Research and Practice, 37(6), 683-693.

Norcross, J. C., & Mrykalo, M. S. (2002). Auld Lang Syne: Success predictors, change Processes, and self-reported outcomes of New Year’s resolvers and nonresolvers. Journal of Clinical Psychology, 58, 397-405.

Norcross, J. C., Ratzin, A. C., & Payne, D. (1989). Ringing in the New Year: The change processes and reported outcomes of resolutions. Addictive Behaviors, 14(2), 205-212.

Norcross, J. C., & Vangarelli, D. J. (1989). The resolution solution: longitudinal examination of New Year’s change attempts. Journal of Substance Abuse, 1(2), 127-134.

Polivy, J. (2001). The false hope syndrome: Unrealistic expectations of self-change. International Journal of Obesity and Related Metabolic Disorders, 25, S80-84.

Polivy, J., & Herman, C. P. (2000). The False-Hope Syndrome Unfulfilled Expectations of Self-Change. Current Directions in Psychological Science, 9(4), 128-131.

Polivy, J., & Herman, C. P. (2002). If at first you don’t succeed: False hopes of self-change. American Psychologist, 57(9), 677-689.

Relatively stressed: How to cope with family-related tensions this Christmas

As much as we all want Christmas to revolve around perfect presents, tasty food and drink, no work, and leisure time to be spent with close family and friends, it can be a psychologically tense and stressful time even among the most happy and well-adjusted families.

Not only is there the crowded shopping, the writing of copious Christmas cards, the wrapping of presents, and the travelling, but there is often the extra burden of obligatory extended family staying and/or visiting. Patience can be pushed to the outer limit throughout the festive period. Trying to satisfy multiple family members all of who have different needs is difficult at best.

Additionally, family reunions have the potential to bring about a range of deep- rooted emotions including jealousy, resentment, competitiveness, and (sibling) rivalry. Expectations may not be met. Instead of joy and happiness we may feel stressed, hurt and/or exhausted. So how do you cope with the family-related stresses and strains during the festive period? Here are my top ten tips.

  • Keep expectations of time spent with family hopeful but realistic – You may not be able to change your family’s dynamics, but at least be aware of how your family can affect your psychological mood state. Some relatives may use the Christmas family reunion to play out family dynamics or re-enact old sibling rivalries. Knowing the problems you might expect from particular family members makes them easier to deal with should they arise. If possible, find ways to shorten or eliminate the family experiences that put you in a bad, anxious or depressed mood.
  • Make your family time count – Instead of watching television or DVDs for hours on end, do something together as a family. Go for a walk after the Christmas dinner, play a karaoke video game, play a board game or a parlour game like charades. Basically, do anything where you have to interact with each other. Even making the Christmas dinner could be a communal activity where each adult and child has a specific job.
  • Drink alcohol in moderationAlcohol can be a double-edged sword so be mindful when drinking with family members. Alcohol’s disinhibiting effect can help facilitate friendly family interaction but drinking too much during family gatherings can sometimes lead to saying things that we later regret.
  • Don’t take everything personally – The ability to step back from a stressful situation caused by a family member is a skill to be cultivated. Remember that any family member is an individual with moods and desires that are separate from their relationship with you. If something really irritates or stresses you, think about what triggered the feeling, then try to let it go and don’t take it personally.
  • Take time out every day – Stress at Christmas time can sometimes arise just because there is a house full of people with little opportunity for “me” time. Try to find time in the day to do something on your own. Go for a brisk walk, pop to the newsagents, have a long bath, tidy up the kitchen while listening to a soccer match or the Ashes, or put your headphones on and listen to your favourite music. Do anything that gives you that much needed little ‘time out’ for the day.
  • Be organized – Sounds easy but good organization can often be the key to a hassle-free day. Starting out each day with some kind of ‘game plan’ can help alleviate the typical stress that arises from the Christmas family politics.
  • Be assertive – Again, easier said than done but learning the power of how to be politely assertive and just saying ‘no’ when faced with family obligations over Christmas can pay big stress-free dividends. Learn how to set boundaries with family so you can experience the true joy of the festive season.
  • Beware the vicious circle – Children, as well as adults, can feel stressed during Christmas. Children often pick up on signs of your anxiety and they themselves can become stressed. This can lead to you feeling even more stressed. In short, a vicious circle where stress and anxiety feeds off each other. Try to hide the stress you feel, especially from children, as this may decrease the length of time you feel anxious.
  • Be grateful for what you have in life – No matter how stressful your family may be over the festive period, it is always good to be grateful for the things you have in your life. As one psychologist noted in his blog: “If you are reading this online, then you are alive, have access to the internet, and have at least some free time to surf the net”.
  • Remember that relationships are the most important thing we have – All of us need to remember that the Christmas feelings of joy and happiness come not from the gifts, decorations, food and drink, but from our relationships with other people. Christmas is about relationships – not only the relationship you have your family and friends, but also the relationship you have with yourself. If we make our close relationships the top priority, then the rest of the Christmas should fall naturally into place.

Dr Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Cured meets: Treating addictive behaviours

Addiction is a highly prevalent problem within today’s society and there is a lot of time and many spent in trying to prevent and treat the behaviour. There has also been a move towards getting addicts motivated to want to change their behaviour. The most influential model worldwide is probably the ‘stages of change’ model by Dr. James Prochaska and Dr, Carlo Di Clemente that identifies an individual’s ‘readiness for change’ and tries to get a person to a position where they are highly motivated to change their behaviour. The individual stages of this model are:

  • Precontemplation – This is where the person unaware of the consequences of his or her own behaviour and no change in behaviour is foreseeable.
  • Contemplation – This is where the person aware problem exists and is contemplating change.
  • Preparation – This is where the person has decided to change in the near future (e.g., New Year resolution).
  • Action – This is where the person effects change (e.g., gets rid of all association items related to the behaviour).
  • Maintenance – This is where the person consolidates behaviour change over time.
  • Relapse – This where the person reverts to a former behaviour pattern (e.g., contemplation, preparation).

People can stay in one stage for a long time and it is also possible for unassisted change such “maturing out” or “spontaneous remission”. Various techniques can be used to help people prepare for readiness include motivational techniques, behavioural self-training, skills training, stress management training, anger management training, relaxation training, aerobic exercise, relapse prevention, and lifestyle modification. The goal of treatment can be either abstinence or simply to cut down.

The intervention and treatment options for the treatment of addiction include, but are not limited to counselling/psychotherapies, behavioural therapies, cognitive-behavioural therapies, self-help therapies, pharmacotherapies, residential therapies, minimal interventions and combinations of these (i.e., multi-modal treatment packages). The most important of these are outlined below.

Pharmacotherapy: Pharmacological interventions basically consist of addicts being given a drug to help overcome their addiction. These are mainly given to those people with chemical addictions (e.g., nicotine, alcohol, heroin, etc.) but are increasingly being used for those with behavioural addictions (e.g., gambling, sex, work, exercise, etc.). For instance, some drugs produce an unpleasant reaction when used in combination with the drug of dependence, replacing the positive effects of the drug of dependence with a negative reaction. For instance, alcoholics are sometimes prescribed disulfiram (more commonly known as Antabuse), that when combined with alcohol may produce nausea and vomiting. Other common therapies include methadone and the use of opioid antagonists (such as nalaxone or naltrexene) for heroin addiction. The methadone prevents withdrawal symptoms, block the effects of heroin use, and decreases craving. The main criticism of all these treatments is that although the symptoms may be being treated, the underlying reasons for the addictions may be being ignored. On a more pragmatic level, what happens when the drug is taken away? Often, the addicts return to their addiction if this is the only method of treatment used.

Behavioural therapy: Behavioural therapies are based on the view that addiction is a learned maladaptive behaviour and can therefore be ‘unlearned’. These have mainly been based on the classical conditioning paradigm and include aversion therapy, in vivo desensitisation, imaginal desensitisation, systematic desensitisation, relaxation therapy, covert sensitisation, and satiation therapy. All of these therapies focus on cue exposure, and relapse triggers (like the sight and smell of alcohol/drugs, walking through a neighbourhood where casinos are abundant, pay day, arguments, pressure, etc.). The theory is that through repeated exposure to ‘relapse triggers’ in the absence of the addiction, the addict learns to stay addiction free in high-risk situations. It could be argued that if the addiction is caused by some underlying psychological problem, (rather than a learned maladaptive behaviour), then behavioural therapy would at best only eliminate the behaviour but not the problem. This therefore means that the addictive behaviour may well have been curtailed but the problem is still there so the person will perhaps engage in a different addictive behaviour instead.

Cognitive-behavioural therapy: A more recent development in the treatment of addictive behaviours is the use of cognitive-behavioural therapies (CBT). There are many different CBT approaches that have been used in the treatment of addictive behaviours including rational emotive therapy, motivational interviewing, and relapse prevention. The techniques assume that addiction is a means of coping with difficult situations, dysphoric mood, and peer pressure. Treatment aims to help addicts recognise high-risk situations and either avoid or cope with them without use of the addictive behaviour. In relapse prevention, the therapist helps to identify situations that present a risk for relapse (both intrapersonal and interpersonal). Relapse prevention provides the addict with techniques to learn how to cope with temptation (positive self statements, decision review, and distraction activities), coupled with the use of covert modelling (i.e., practicing coping skills in one’s imagination). It also provides skills for coping with lapses (by redefining what is happening), and utilizes graded practice (a desensitization technique where addicts encounter real life situations slowly). Overall, CBT approaches are better researched than the other psychological methods in addiction but are probably no more effective (Luty, 2003).

Psychotherapy: Psychotherapy can include everything from Freudian psychoanalysis and transactional analysis, to more recent innovations like drama therapy, family therapy and minimalist intervention strategies. The therapy can take place as an individual, as a couple, as a family, as a group and is basically viewed as a ‘talking cure’ consisting of regular sessions with a psychotherapist over a period of time. Most psychotherapies view maladaptive behaviour as the symptom of other underlying problems. Psychotherapy often is very eclectic by trying to meet the needs of the individual and helping the addict develop coping strategies. If the problem is resolved, the addiction should disappear. In some ways, this is the therapeutic opposite of pharmacotherapy and behavioural therapy (which treats the symptoms rather than the underlying cause). There has been little evaluation of its effectiveness although most addicts go through at least some form of counselling during the treatment process.

Self-help therapy: The most popular self-help therapy worldwide is the Minnesota Model 12-Step Programme (e.g., Alcoholics Anonymous, Gamblers Anonymous, Narcotics Anonymous, Overeaters Anonymous, Sexaholics Anonymous, etc.). This treatment programme uses a group therapy technique and uses only ex-addicts as helpers. Addicts attending 12-Step groups involves them accepting personal responsibility and views the behaviour as an addiction that cannot be cured but merely arrested. To some it becomes a way of life both spiritually and socially and compared with almost all other treatments it is especially cost-effective (even if other treatments have greater success rates) as the organization makes no financial demands on members or the community. For the therapy to work, the 12-Step Programme asserts that the addict must come to them voluntarily and must really want to stop engaging in their addictive behaviour. Further to this, they are only allowed to join once they have reached “rock bottom”. To date there has been little systematic study of 12-Step groups but drop out rates are very high (typically 80-90%). There are a number of problems preventing evaluation, particularly anonymity, sample bias, and what the criterion for success is. The empirical evidence suggests that self-help support groups’ complement formal treatment options and can support standardized psychosocial interventions.

When examining all the literature on the treatment of addiction, there are a number of key conclusions that can be drawn. These include that: (i) treatment must be readily available, (ii) no single treatment is appropriate for all individuals., (iii) it is better for an addict to be treated than not to be treated, (iv) it does not seem to matter which treatment an addict engages in as no single treatment has been shown to be demonstrably better than any other, (v) a variety of treatments simultaneously appear to be beneficial to the addict, (vi) individual needs of the addict have to be met (i.e., the treatment should be fitted to the addict including being gender-specific and culture-specific), (vi) clients with co-existing addiction disorders should receive services that are integrated, (vii) remaining in treatment for an adequate period of time is critical for treatment effectiveness, (viii) medications are an important element of treatment for many patients, especially when combined with counselling and other behavioural therapies, (ix) recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment, (x) there is a direct association between the length of time spent in treatment and positive outcomes, and (xi) the duration of treatment interventions is determined by individual needs, and there are no pre-set limits to the duration of treatment.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (1996). Pathological gambling and its treatment. British Journal of Clinical Psychology, 35, 477-479.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

Griffiths, M.D. & H.F. MacDonald (1999). Counselling in the treatment of pathological gambling: An overview. British Journal of Guidance and Counselling, 27, 179-190.

Hayer, T. & Griffiths, M.D. (2015). The prevention and treatment of problem gambling in adolescence. In T.P. Gullotta & G. Adams (Eds). Handbook of Adolescent Behavioral Problems: Evidence-based Approaches to Prevention and Treatment (Second Edition) (pp. 539-558). New York: Kluwer.

King, D.L., Delfabbro, P.H., Griffiths, M.D. & Gradisar, M. (2012). Cognitive-behavioural approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.

Luty, J. (2003). What works in drug addiction? Advances in Psychiatric Treatment, 9, 280–288.

National Institute on Drug Abuse (1999). Principles of drug addiction treatment: A research-based guide. NIDA.

Potenza, M. & Griffiths, M.D. (2004). Prevention efforts and the role of the clinician. In J.E. Grant & M. N. Potenza (Eds.), Pathological Gambling: A Clinical Guide To Treatment (pp. 145-157). Washington DC: American Psychiatric Publishing Inc.

Prochaska, J.O. and DiClemente, C.C. (1984). The transtheoretical approach: Crossing the traditional boundaries of therapy. Melbourne, Florida: Krieger Publishing Company

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

United Nations Office on Drugs and Crime/World Health Organization (2008). Principles of Drug Dependence Treatment: Discussion paper. UN/WHO.

The weighting game: Gambling with the nation’s health (revisited)

A couple of weeks ago I wrote a blog on why problem gambling should be considered a health issue. Earlier this week, I came across an interesting study carried out by jackpot.co.uk who surveyed 2,131 online gamblers (58% males and 42% female) about their health. After the self-reported data had been collected, the gamblers were classed into one of nine categories based on the casino game type that the gambler played most often (i.e., slot machines, video poker, blackjack, roulette, dice/craps, baccarat, poker, pai gow, and ‘other’). The data were then tabulated so that all the health variables (including obesity) corresponded to the gambler’s preferred casino game.

I was interested in the findings not only because I am a Professor of Gambling Studies, but also because I was a member of the Department of Health’s Expert Working Group on Sedentary Behaviour, Screen Time and Obesity’ (a reference to our final report to the British government can be found in the ‘Further Reading’ section below). The study took an objective measurement of physical condition by asking each gambler their height (centimetres) and their weight (kilograms) to calculate each person’s Body Mass Index (BMI) by dividing the gamblers’ weight by height (metres) and dividing by height again (for example, someone who weighs 80kg and is 180cm tall, the BMI is 24.1 as this is 80/1.80)/1.80). The survey then asked s few general health and lifestyle questions (similar to ones that we have used in the last few British Gambling Prevalence Surveys:

  • Do you normally drink more than the recommended limit for weekly alcohol consumption (21 units of alcohol for men and 14 for women)? (Yes/No)
  • Do you smoke regularly? (Yes/No)
  • Do you normally engage in at least 30 minutes of physical activity, 5 times per week? (Yes/No)

Overall, the survey found that British casino gamblers as a group were no less healthy than the rest of the British population, with an average Body Mass index (BMI) of 27 (which is the same as the UK national average). However, the survey also reported that the average BMIs, health, and lifestyle choices (such as smoking cigarettes, engaging in exercise, and drinking alcohol varied considerably depending on the casino games that the respondents played. Here are some of the main findings:

  • Slots players were the least healthy. They took less exercise and had an average BMI of 31, pushing them into the category of obese (which is linked to increased chance of developing illnesses such as Type 2 diabetes and reduced life expectancy)
  • Roulette, blackjack, video poker and craps/dice players were not far behind slots players, each having BMI levels higher than the national average.
  • Those that played poker, baccarat and Pai Gow had an average BMI of 25 or under (well within the normal range recommended by the World Health Organisation.
  • Whilst drinking levels might be reasonably high among poker players, they were very exercise conscious, with 58% engaging in physical activity for at least 30 minutes, five times a week. For slots players the figure was 27% meeting this government recommended target.
  • Overall slots players drink the most, with 24.1% drinking over the recommended weekly limit. Poker players are not far behind on 23%. Female slots players were the biggest drinking subgroup, closely followed by male poker players.
  • Slots players also smoked more, with 24% being regular smokers (compared to the UK national average of 20%). Blackjack and roulette players smoked slightly more than average, on 21% and 22% respectively, while poker players smoked slightly less than average, on 19.5%.

None of these results is overly surprising as there are many studies (including my own) showing comorbidity between gambling and other potentially addictive behaviours. However, very few academic studies have ever looked at these health variables by game type. Although this was not an academic study, the results will likely be of interest to those in the gambling studies field.

The survey also examined the most common platform on which the gamblers played casino games. The most common was the desktop computer (65%), followed by mobiles and tablets (20%) and land-based casinos (14%). This is not surprising given the survey was completed by online gamblers. Interestingly, desktop use was linked to higher levels of obesity, drinking and smoking. This is something that I would expect given that online gambling is the most sedentary of these activities.

There are (of course) some limitations with the data collected particularly as it comprised a self-selected sample of online gamblers that played via jackpot.co.uk websites. We have no idea as to whether the sample is representative of all online gamblers but as I noted above, it is no surprise that online gamblers preferred playing casino games online compared to offline (i.e., land-based casinos). The data were also self-report and are therefore open to any number of individual biases including recall biases and social desirability biases. Also, we have no geographical breakdown of the sample as the internet (by definition) is global. However, the sample size is good in comparison to many published studies on gambling and the sample included individuals that were actually gamblers (as opposed to university undergraduates or members of the general public). According to Sam Marsden (editor of jackpot.co.uk and author of the report):

“There’s an undeniable link connecting passive games like slots and video poker to unhealthy, sedentary lifestyles. On the other hand, games that require concentration, strategy and some physical stamina like poker and blackjack seem to fare much better in the health stakes. It seems it’s less a case of ‘you are what you eat’ and more ‘you are what you play’.”  

Although such a conclusion could be argued to be PR spin on the findings, the results suggest that more rigorous studies could be carried out in the area including secondary analyses of the robust datasets that already exist including the British Gambling Prevalence Surveys, the English Health Surveys, and the Scottish health Surveys.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Biddle, S., Cavill, N., Ekelund, U., Gorely, T., Griffiths, M.D., Jago, R., et al. (2010). Sedentary Behaviour and Obesity: Review of the Current Scientific Evidence. London: Department of Health/Department For Children, Schools and Families (126pp).

Griffiths, M.D. (2001). Gambling – An emerging area of concern for health psychologists. Journal of Health Psychology, 6, 477-479.

Griffiths, M.D. (2004). Betting your life on it: Problem gambling has clear health related consequences. British Medical Journal, 329, 1055-1056.

Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association (ISBN 1-905545-11-8).

Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2010). Gambling, alcohol consumption, cigarette smoking and health: findings from the 2007 British Gambling Prevalence Survey. Addiction Research and Theory, 18, 208-223.

Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2011). Internet gambling, health. Smoking and alcohol use: Findings from the 2007 British Gambling Prevalence Survey. International Journal of Mental Health and Addiction, 9, 1-11.

Marsden, S. (2014). Booze, bets, and BMI. Jackpot.co.uk, October 6. Located at: http://www.jackpot.co.uk/online-casino-articles/booze-bets-bmi

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

Wardle, H., Griffiths, M.D., Orford, J., Moody, A. & Volberg, R. (2012). Gambling in Britain: A time of change? Health implications from the British Gambling Prevalence Survey 2010. International Journal of Mental Health and Addiction, 10, 273-277.

Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.

Wardle, H., Seabury, C., Ahmed, H., Payne, C., Byron, C., Corbett, J. & Sutton, R. (2014). Gambling behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012. London: NatCen.

Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M. D., Constantine, R., & Pigott, S. (2007). The British Gambling Prevalence Survey 2007. London: National Centre for Social Research.

The teen screen scene: How does media and advertising influence youth addiction?

When we are looking for factors that change behaviour we can look inside the individual for personal characteristics that make people vulnerable to addiction and we can look outside the individual for features of the environment that encourage addictive behaviours. Addiction is a multi-faceted behaviour that is strongly influenced by contextual factors that cannot be encompassed by any single theoretical perspective.

The media (television, radio, newspapers, etc.) are an important channel for portraying information and channelling communication. Knowledge about how the mass media work may influence both the promotion of potentially addictive behaviour (as in advertising), and for the promotion of health education (such as promoting abstinence or moderation). Much of the research done on advertising is done by the companies themselves and thus remains confidential. The media, especially television and film, often portray addictions (e.g., heroin addiction in the film Trainspotting, marijuana use in the TV show Weeds, gambling addiction in the TV show Sunshine, etc.). Because of this constant portrayal of various addictions, television and film dramas often create controversy because of claims that they glorify addictive behaviour. The popularity of media drama depicting various addictions requires an examination of their themes and the potential impact on the public.

A 2005 study in the Journal of the Royal Society of Medicine by Dr. H. Gunasekera and colleagues analysed the portrayal of sex and drug use in the most popular movies of the last 20 years using the Internet Movie Database list of the top 200 movies of all time. The researchers excluded a number of films including those released or set prior to the HIV era (pre-1983), animated films, films not about humans, and family films aimed at children. The top 200 films following the exclusions were reviewed by one of two teams of two observers using a data extraction sheet tested for inter-rater reliability. Sexual activity, sexually transmitted disease (STD) prevention, birth control measures, drug use and any consequences discussed or depicted were recorded.

The study reported that there were 53 sex episodes in 28 (32%) of the 87 movies reviewed. There was only one suggestion of condom use, which was the only reference to any form of birth control. There were no depictions of important consequences of unprotected sex such as unwanted pregnancies, HIV or other STDs. Movies with cannabis (8%) and other non-injected illicit drugs (7%) were less common than those with alcohol intoxication (32%) and tobacco use (68%) but tended to portray their use positively and without negative consequences. There were no episodes of injected drug use. The researchers concluded that sex depictions in popular movies of the last two decades lacked safe sex messages. Drug use, though infrequent, tended to be depicted positively. They also concluded that the social norm being presented in films was of great concern given the HIV and illicit drug pandemics.

Drug use in this context could be argued to illustrate a form of observational learning akin to advertisement through product placement. A similar 2002 study by Dr. D. Roberts and colleagues examined drug use within popular music videos. Whilst depictions of illicit drugs or drug use were relatively rare in pop videos, when they did appear they were depicted on a purely neutral level, as common elements of everyday activity.

The makers of such drama argue that presenting such material reflects the fact that addictions are everywhere and cut across political, ethnic, and religious lines. Addiction is certainly an issue that impacts all communities. However, it is important to consider possible impacts that it might have on society. Empirical research suggests that the mass media can potentially influence behaviours. For example, research indicates that the more adolescents are exposed to movies with smoking the more likely they are to start smoking. Furthermore, research has shown that the likeability of film actors and actresses who smoke (both on-screen and off-screen) relates to their adolescent fans’ decisions to smoke. Perhaps unsurprisingly, films tend to stigmatise drinking and smoking less than other forms of drug taking. However, the media transmit numerous positive messages about drug use and other potential addictions, and it is plausible that such favourable portrayals lead to more use by those that watch them. Anecdotally, some things may be changing. For instance, there appears to be more emphasis on the media’s portrayal of alcohol as socially desirable and positive as opposed to smoking that is increasingly being regarded as anti-social and dangerous.

Back in 1993, the British Psychological Society (1993) called for a ban on the advertising of all tobacco products. This call was backed up by the UK government’s own research which suggested a relationship between advertising and sales. Also, in four countries that had banned advertising (New Zealand, Canada, Finland and Norway) there was been a significant drop in tobacco consumption.

However, public policy is not always driven by research findings, and the powerful commercial lobby for tobacco has considerable influence. In her reply to the British Psychological Society, the Secretary of State for Health (at the time) rejected a ban saying that the evidence was unclear on this issue and efforts should be concentrated elsewhere. This debate highlights how issues of addictive behaviours cannot be discussed just within the context of health. There are also political, economic, social and moral contexts to consider as well. The British government and European Community made commitments to ban tobacco advertising though they found it difficult to bring it in as quickly as they hoped. It is now rare to see smoking advertised anywhere in the UK but there is a new trend in television drama and films to set the action in a time or location where smoking is part of the way of life (for example the US television programme Mad Men).

Just as the British Government have banned cigarette advertising and banned smoking in public places, they have also deregulated gambling through the introduction of the 2005 Gambling Act. This Act came into effect on September 1st 2007 and allowed all forms of gambling to be advertised in the mass media for the first time. This has led to a large number of nightly television adverts for betting shops, online poker, and online bingo. Whether this large increase in gambling advertising will impact on gambling participation and gambling addiction remains to be seen. There have been very few studies that have examined gambling advertising and those that have been done are usually small scale and lack representativeness.

In an article I wrote in 2010 looking at these issues, I reached a number of conclusions that I don’t think have changed in the past few years since I wrote that article. My conclusions were:

  • Glamorisation versus reality is complicated: The issue of glamorisation versus reality is of course complicated. Although the drama producers hope to accurately depict various addictions, they still need to keep ratings up. Clearly, positive portrayals are more likely to increase ratings and programmes might favour acceptance of drug use over depictions of potential harms.
  • Research on the role of media effects is inconclusive: More research on how the media influence drug use is needed in order to evaluate the impact of such drama. With media and addiction, it is important to walk with caution, as the line between reality and glamorisation is easy to cross. More research is needed that investigates direct, indirect, and interactive effects of media portrayals on addictive behaviour.
  • Relationship between advertising and addictive behaviour is mostly correlational: The literature examining the relationship between advertising on the uptake of addictive behaviour is not clear cut and mostly correlational in nature hence it is not possible to make causal connections.
  • There could be different media effects for different addictions: Although there appears to be some relationship between tobacco advertising and tobacco uptake, this does not necessarily hold for all addictive behaviours. For instance, some academics claim that econometric studies of alcohol advertising expenditures come to the conclusion that advertising has little or no effect on market wide alcohol demand.
  • Research done to date may not be suitable: Survey research studies have failed to measure the magnitude of the effect of advertising on youth intentions or behaviour in a manner that is suitable for policy analysis. As a consequence, policy makers may introduce and/or change policy that is ineffective or not needed on the basis of research that was unsuitable in answering a particular question.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Cape, G. S. (2003). Addiction, stigma, and movies. Acta Psychiatrica Scandinavica, 107, 163-169.

Dalton, M.A., Sargent, J.D., Beach, M.L., Titus-Ernstoff, L., Gibson, J.J., Aherns, M.B., & Heatherton, T.F. (2003). Effect of viewing smoking in movies on adolescent smoking initiation: A cohort study. Lancet, 362, 281-285.

Distefan, J. M., E. A. Gilpin, et al. (1999). Do movie stars encourage adolescents to start smoking? Evidence from California. Preventive Medicine, 28, 1-11.

Griffiths, M.D. (2005). Does advertising of gambling increase gambling addiction? International Journal of Mental Health and Addiction, 3 (2), 15-25.

Griffiths, M.D. (2010). Media and advertising influences on adolescent risk behaviour. Education and Health, 28(1), 2-5.

Gunasekera, H. Chapman, S. Campbell, S. (2005). Sex and drugs in popular movies: An analysis of the top 200 Films. Journal of the Royal Society of Medicine, 98, 464-470.

Nelson, J.P. (2001). Alcohol advertising and advertising bans: A survey of research methods, results, and policy implications. In M.R. Baye & J.P. Nelson (Eds.), Advances in Applied Microeconomics, Volume 10: Advertising and Differentiated Products (Chapter 11). Amsterdam: Elsevier Science.

Roberts, D.F., Christenson, P.G. Henriksen, L. & Bandy, E. (2002). Substance Use in Popular Music Videos. Office Of National Drug Control Policy. Located at: http://www.mediacampaign.org/pdf/mediascope.pdf

Wilde, G.J.S. (1993). Effects of mass media communications on health and safety habits: An overview of issues and evidence. Addiction, 88, 983-996.

Will, K. E., B. E. Porter, et al. (2005). Is television a healthy and safety hazard? A cross-sectional analysis of at-risk behavior on primetime television. Journal of Applied Social Psychology, 35, 198-22

Stats entertainment (Part 2): A 2013 review of my personal blog

My last blog of 2013 was not written by me but was prepared by the WordPress.com stats helper. I thought a few of you might be interested in the kind of person that reads my blogs. I also wanted to wish all my readers a happy new year and thank you for taking the time to read my posts.

Here’s an excerpt:

The Louvre Museum has 8.5 million visitors per year. This blog was viewed about 860,000 times in 2013. If it were an exhibit at the Louvre Museum, it would take about 37 days for that many people to see it.

Click here to see the complete report.

What a drag: A brief look at cigarette smoking and nicotine dependence

Cigarette smoking among adults (i.e., those aged 18 years and over) has been a highly prevalent behaviour in Great Britain for decades but overall rates have significantly declined in recent times. Figures show that the highest recorded level of nicotine smoking among British males was in 1948 when four-fifths smoked (82%) although at that time only two-thirds smoked manufactured cigarettes (as the rest smoked pipes and/or cigars). The highest recorded level of nicotine smoking among British females was in the mid-1960s (45%) slightly higher than the prevalence rate of 41% in 1948.

A 2003 study by Dr. M. Jarvis in the journal Addiction reported that since 2000 the overall adult smoking rates in Great Britain had been declining by around 0.4% per year. More recently, the British prevalence rates of smoking remained constant at 21% between 2007 and 2009 (according to a 2013 report by Action on Smoking and Health [ASH]). According to the 2013 Office for National Statistics report, the most recent prevalence rate is 20% (21% of men and 19% of women). This equates to around 10 million British adult cigarette smokers. Smoking prevalence rates are highest in young adults. More specifically, in the 20-24 year age group, the prevalence rate of nicotine smoking is 30% in males and 28% in females. Only 1% of children are nicotine smokers at the age of 11 years. By the age of 15 years, 11% of children are regular smokers. As the 2013 ASH report noted:

“Since the mid 1970s cigarette consumption has fallen among both men and women. The overall reported number of cigarettes smoked per male and female smoker has changed little since the mid 1980s, averaging 13 cigarettes per smoker per day. As in previous years, men smoked slightly more per day on average than women and there was an association between consumption and socio-economic group. In 2011, smokers in manual occupations smoked an average of 14 cigarettes a day compared with 11 a day for those in managerial or professional groups… In 2011, 63% of smokers said they would like to stop smoking altogether. Other ways of measuring dependence include how difficult people would find it to go for a whole day without smoking and how soon they smoke after waking… In 2011, 60% of smokers said they would find it hard to go for a whole day without smoking. Eighty-one per cent of heavier smokers (20 or more a day) said they would find it difficult, compared to 32% of those smoking fewer than 10 cigarettes per day”.

Like drug addictions more generally, nicotine addiction is a complex combination of influences including genetic, pharmacological, psychological, social and environmental factors. In 2010, the US Surgeon General asserted that “there is no established consensus on criteria for diagnosing nicotine addiction” but that there are a number of symptoms can be viewed as addiction indicators such as:

  • Drug use that is highly controlled or compulsive with psychoactive effects
  • Stereotypical patterns of use
  • Continued use despite harmful effects
  • Relapse following abstinence accompanied by recurrent cravings.

A 2000 report by the Royal College of Physicians also noted that nicotine fulfils criteria for defining an addiction and states that:

“It is reasonable to conclude that nicotine delivered through tobacco smoke should be regarded as an addictive drug, and tobacco use as the means of self-administration…Cigarettes are highly efficient nicotine delivery devices and are as addictive as drugs such as heroin or cocaine.”

One of the key characteristics of drug addiction or dependence on a substance is the degree of compulsion experienced by the user. Since 1992, the British General Lifestyle Survey (which typically surveys around 15,000 adults from over 9000 households annually) has asked three questions relevant to nicotine dependence and addiction. The first is whether the person would like to stop smoking, the second is whether person would find it easy or difficult not to smoke for a whole day, and the third is how soon after waking up they smoke their first cigarette. Since 1992, there has been almost no change in any of the three measures.

The latest 2013 survey reported that 63% of smokers said they would like to stop smoking altogether and 60% felt it would be difficult for them to go a day without smoking. Four-fifths (81%) of heavy smokers (i.e., those smoking 20 or more cigarettes a day) said they would find it difficult to give up smoking compared to one-third (32%) of lighter smokers (i.e., those smoking less than 10 cigarettes a day). The average number of cigarettes smoked per day is 13, and 14% smoke a cigarette within five minutes of getting up in the morning, a figure that rises to 35% among heavy smokers who smoke more than 20 cigarettes a day. Research consistently shows that approximately two-thirds of smokers want to quit the behaviour yet the majority are unable to do so, which is also suggestive of a genuine addiction. Those that do try to quit smoking typically experience a wide range of withdrawal symptoms including craving for nicotine, irritability, anxiety, difficulty concentrating, restlessness, sleep disturbances, decreased heart rate, and increased appetite or weight gain.

Outside of Great Britain, tobacco and other drug use prevalence have been examined extensively among youth and adults. For example, by the Monitoring the Future research group in the U.S. (http://monitoringthefuture.org). They reported that daily (20 or more days in last 30 days) cigarette smoking varied from 11.4% among 18 year olds to 17% among 50 year olds. One may infer that daily cigarette smoking is addictive use, though several studies measure tobacco (nicotine) addiction specifically. Tobacco addiction (dependence) among older teenagers has been found to vary between 6% and 8%. Studies have found a prevalence rates of between 1.7% to 9.6% for tobacco addiction among college students.

In a 2004 issue of the Archives of General Psychiatry, Dr. Jon Grant and colleagues found a prevalence of 12.8% for tobacco addiction among a U.S. national sample of adults. A few years later in a 2009 issue of the American Journal of Public Health, Dr. R.D. Goodwin and colleagues found a prevalence of 21.6% and 17.8% for tobacco addiction among a U.S. national sample of male and female adults, respectively. It appears that daily smoking demonstrates about the same level of prevalence as direct measures of dependence, particularly among adults.

In a 2011 study that I carried out with Dr. Steve Sussman and Nadra Lisha, we estimated that past year nicotine dependence prevalence in the general adult population of the U.S. as being approximately 15%. A different summary of research on the epidemiology of drug dependence has shown that of all people who initiate cigarette use, almost one-third become addicted smokers (32%), a figure that is much higher addiction rate than for users of heroin (23%), cocaine (17%), alcohol (15%) or cannabis (9%).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Action on Smoking and Health (2012). Nicotine and addiction. London: Action on Smoking and Health.

Action on Smoking and Health (2013). Smoking statistics: Who smokes and how much. London: Action on Smoking and Health.

Benowitz, N. (2010). Nicotine addiction. New England Journal of Medicine, 362, 2295–2303,

Carpenter C.M., Wayne, G.F., & Connolly, G.N. (2007). The role of sensory perception in the development and targeting of tobacco products. Addiction, 102, 136-147.

Goodwin, R.D., Keyes, K.M., & Hasin, D.S. (2009). Changes in cigarette use and nicotine dependence in the United States: Evidence from the 2001-2002 wave of the National Epidemiologic Survey of Alcoholism and Related Conditions. American Journal of Public Health, 99, 1471-1477.

Grant, B.F., Hasin, D.S., Chou, P., Stinson, F.S., & Dawson, D.A. (2004a). Nicotine dependence and psychiatric disorders in the United States. Archives of General Psychiatry, 61, 1107-1115.

Information Centre for Health and Social Care (2011). Smoking drinking and drug use among young people in England in 2011. London: Information Centre for Health and Social Care.

Jarvis, M. (2003). Monitoring cigarette smoking prevalence in Britain in a timely fashion. Addiction, 98, 1569-1574.

Office for National Statistics (2012). The 2010 General Lifestyle Survey. London: Office for National Statistics.

Office for National Statistics (2013). The 2011 General Lifestyle Survey. London: Office for National Statistics.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Wald, N. & Nicolaides-Bouman, A. (1991). UK Smoking Statistics (2nd edition). Oxford: Oxford University Press.

Becoming less of a drag: The Stoptober campaign (revisited)

(The following blog is based on an article I published last year in the Nottingham Post on why I was actively supporting the Stoptober smoking campaign to get people to stop smoking for 28 days during October. I also published a blog last year outlining my 10 top tips for giving up smoking. Since that blog, my ten tips have been slightly changed and adapted in co-operation with the Department of Health running the Stoptober campaign. I make no apologies for repetition between today’s blog and that published last year, as my only aim is to help people give up smoking).

Although most of my academic research is on behavioural addiction, I have published quite a few papers on more traditional addictions such as alcohol and nicotine addiction (see ‘Further reading’ below). Last year I had to watch my mother fight a losing battle with smoking-related lung cancer and chronic obstructive pulmonary disease. She died in September 2012 aged 66 years, and had chain-smoked most of her adult life. This followed the death of my father who also died of smoking-related heart disease, aged just 54.

This October, the Department of Health (DoH) are re-launching the ‘Stoptober’ campaign for the second time, urging as many nicotine smokers as possible to give up smoking for 28 days from October 1. The DoH website claims that “people who stop smoking for 28 days are five times more likely to stay smoke free” compared to those that don’t give up for such a long period. Like last year, those that decide to try and stop for the month will be given a lot of encouragement during the campaign including access to the Smokefree Facebook page and the downloadable Stoptober app. People will also be sent daily emails providing additional encouragement.

In the UK smoking accounts for approximately one in four cancer deaths, and as I said, it’s something I’ve witnessed first-hand. I’m sure most people reading this are aware of the addictive nature of nicotine. As soon as nicotine is ingested via cigarettes, it can pass from lungs to brain within ten seconds and stimulates the release of the neurotransmitter dopamine. The release of dopamine into the body provides reinforcing mood modifying effects. Despite nicotine being a stimulant, many people use cigarettes for both tranquillising and euphoric effects. Most authorities accept that nicotine is one of the most addictive drugs on the planet and that smokers can become hooked quickly. One of the reasons my own parents were never able to give up was because of the prolonged withdrawal effects they experienced whenever they went more than a few hours without smoking. This would lead to intense cravings for a cigarette. Watching both my parents’ die of smoking-related diseases is enough incentive for me to never smoke a cigarette. Hopefully, others can find the incentives they need to help them give up permanently. Here are my top ten tips to help you (or someone you know and love) stop smoking:

  • (1) Develop the motivation to stop smoking: Many smokers say they would like to stop but don’t really want to. When you take stock, make sure you are clear as to why you want to give up. It may be to save money, to improve your health, to prevent yourself getting a smoking-related disease, or to protect your family from passive smoking. (It could of course be all of the above). Really wanting to give up is the best predictor of successful smoking cessation.
  • (2) Get all the emotional support you can: Another good predictor of whether someone will overcome their addiction to nicotine is having a good support network. You need people around you that will support your efforts to quit. Tell as many people that you know that you are trying to quit. It could be the difference between stopping and starting again.
  • (3) Avoid ‘cold turkey’: Although some people can stop through willpower alone, most people will need to reduce their nicotine intake slowly. The best way of doing this is to replace cigarettes with a safe form of nicotine such as those available from the pharmacy, or on prescription from the doctor.
  • (4) Get support from a professional: Even if you are using a safe form of nicotine from your pharmacist or doctor, cutting out cigarettes completely can be hard. Getting support from a trained NHS stop smoking adviser can double your chances of stopping smoking. To find your nearest free NHS stop smoking service (in the UK call 0800-1690169) or visit the smokefree website and click on the ‘ways to quit’ tab.
  • (5) Use non-nicotine cigarette shaped substitutes: Smoking is also a habitual behaviour where the feel of it in your hands may be as important as the nicotine it contains. The use of plastic cigarettes or e-cigarettes will help with the habitual behaviour associated with smoking but contain none of the addictive nicotine.
  • (6) Use relaxation techniques: When cravings strike, use relaxation exercises to help overcome the negative feelings. At the very least take deep breaths. There are dozens of relaxation exercises online. Practice makes perfect.
  • (7) Treat yourself: One of the immediate benefits of stopping smoking will be the amount of money you save. At the start of the cessation process, treat yourself to rewards with the money you save.
  • (8) Focus on the positive: Giving up smoking is one of the hardest things that anyone can do. Write down lists of all the positive things that will be gained by stopping smoking. Constantly remind yourself of what the long-term advantages will be that will outweigh the short-term benefits of smoking a cigarette. In short, focus on the gains of stopping rather than what you will miss about cigarettes.
  • (9) Know the triggers for your smoking: Knowing the situations in which you tend to smoke can help in overcoming the urges. Lighting up a cigarette can sometimes be the result of a classically-conditioned response (e.g. having a cigarette after every meal). These often occur unconsciously so you need to break the automatic response and de-condition the smoking. You need to replace the unhealthy activity with a more positive one and re-condition your behaviour.
  • (10) Fill the void: One of the most difficult things when cigarette craving and withdrawal symptoms strike is not having an activity to fill the void. Some things (like engaging in physical activity) may help you in forgetting about the urge to smoke. Plan out alternative activities and distraction tasks to help fill the hole when the urge to smoke strikes (e.g. chew gum, eat something healthy like a carrot stick, call a friend, occupy your hands, do a word puzzle, etc.). However, avoid filling the void with other potentially addictive substances (e.g. alcohol) or activities (e.g. gambling).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (1994). An exploratory study of gambling cross addictions. Journal of Gambling Studies, 10, 371-384.

Griffiths, M.D.  (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Griffiths, M.D. (2012). First person: Highly-addictive drug killed both of my parents. Nottingham Post, October 1, p.13.

Griffiths, M.D., Parke, J. & Wood, R.T.A. (2002). Excessive gambling and substance abuse: Is there a relationship? Journal of Substance Use, 7, 187-190.

Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2010). Gambling, alcohol consumption, cigarette smoking and health: findings from the 2007 British Gambling Prevalence Survey. Addiction Research and Theory, 18, 208-223.

Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2011). Internet gambling, health. Smoking and alcohol use: Findings from the 2007 British Gambling Prevalence Survey. International Journal of Mental Health and Addiction, 9, 1-11.

Resnick, S. & Griffiths, M.D. (2010). Service quality in alcohol treatment: A qualitative study. International Journal of Mental Health and Addiction, 8, 453-470.

Resnick, S. & Griffiths, M.D. (2011). Service quality in alcohol treatment: A research note. International Journal of Health Care Quality Assurance, 24, 149-163.

Resnick, S. & Griffiths, M.D. (2012). Alcohol treatment: A qualitative comparison of public and private treatment centres. International Journal of Mental Health and Addiction, 10, 185-196.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Umeh, K. & Griffiths, M.D. (2001). Adolescent smoking: Behavioural risk factors and health beliefs. Education and Health, 19, 69-71.