The last pleasure?

Working in drug and alcohol research for over 10 years, I am still shocked that one of the few daily comforts many people have is something that actively sickens and makes them poorer with every use. Yet, in times of crisis, in times of pain, and amongst poverty, smoking is afforded tacit approval. It remains one of the last socially permissive taboos that health professionals afford those with hard lives (e.g. Soar et al., 2020; Walsh et al., 2018). There are many reasons for this; smoking is often neglected and given less priority amongst competing needs, the harms from smoking are distal and can be sidelined, and that smoking worsens mental illness and maintains poverty is not widely understood. 

Access to pleasure is scarce at the current time. In some way or another we are all feeling it. Being able to go for a run, a bike ride, even order some food online, are all small things can bring pleasure amongst circumstances which are distressing and when the future feels uncertain. For so many of the poorest in the UK, even simple pleasures will be limited. This is where smoking fills the void. A long, silent, draw on a cigarette by the backdoor will be one of few pleasures available to so very many people. Amongst the distress and the alarming headlines, taking a moment to smoke a cigarette, to remove oneself from an unhappy reality and to calm the nerves will be a welcome break. 

Smoking has gradually declined in high income countries (Jha & Peto, 2014), and in the UK, across all social gradients (NHS Digital, 2019), but those on the lowest incomes and with competing health and social needs are still more likely to smoke. It is not unrealistic to suggest that over the next decade smoking will be a behavioural marker for social inequality. Why smoking is so stubbornly pervasive amongst the poorest communities is not hard to understand. Environment plays a key role: tobacco outlet density is higher in the poorest areas (Shortt et al., 2015), as is the sale of cheaper illicit tobacco (Stead et al., 2013). Intergenerational smoking, a behaviour passed down from mum and dad, common amongst brothers, sisters and friends, is tied with affection. Quitting can be perceived as an outward rejection of one's cultural identity (Thirlway, 2020).

But it's more than just being around it. Smoking is perceived as a relief from psychological and physical pain, sought after because – like all stimulants – it is a mood lifter, offering stimulation amongst little else. During long days, smoking also helps time pass and is symbolic of different parts of the day, marking the passing hours with a cigarette becomes important. Then, so too, time of the day becomes a trigger for craving and the cycle continues. 

However, any relief and pleasure derived from the nicotine hit will be short lived as nicotine withdrawal comes on quickly and rapidly, reinforcing the need to smoke more and drag harder. A little-known fact, is that smokers often need higher doses of other medications (e.g., Goff et al., 1992). The toxic effect of tobacco on the blood system reduces uptake and efficacy of drugs, resulting in the need to take a higher dose of prescribed medication. This constant need for relief is expensive, an average packet of cigarettes nearing £10, taking money away from other pleasures. Feeling terrible for longer will lead to a greater number of years as a smoker and this reduces one's chance of quitting. Being in a position of poverty for long periods of time will exacerbate low mood, further limiting choices. Thus, smoking is not just associated with poverty, it plays an active role in maintaining it. It is certainly no more or less harmful the richer or poorer the smoker. 

Therefore, it should be of concern to all of us, that smoking is still very much afforded tacit approval, at least amongst the most disadvantaged – 'the last pleasure'. This is an erroneous perception that contradicts the evidence. Indeed, review evidence shows that when adults with a mental illness quit smoking they can reduce their medications and report positive subjective well-being within weeks, this improves if maintained (Taylor et al., 2014). More still, quitting is no less desired amongst the poorest groups within England and quit attempts are as frequent in those in social housing as those who are not… it is success that is low (Jackson et al., 2019).  

Public Health England have recognised there may be a link between tobacco related vulnerabilities and Covid-19, and because smoking increases the risk of respiratory disease, cessation is in the public health spotlight. #Quitforcovid is trending on social media. This is a welcome public health initiative, but its long-term impact will only be as great as the people it reaches. Stop smoking services have faced a decade of financial cuts. Pharmacies, which are a source for over the counter nicotine replacement therapies, are reportedly overwhelmed. Vape shops have unfortunately been deemed non-essential, so can only supply online. The latter is particularly worrying as we now have over 3 million vapers in the UK, and vaping has become most popular method for quitting. However, in some cruel irony, tobacco in all its forms remains widely available. The sentiment to end smoking must be matched by the availability of the help. 

Tobacco researchers will be looking with interest on how Covid-19 has influenced the general downward trend in smoking prevalence rates in the UK, and if it has promoted quitting which demographic groups have responded most. The fear is that those with difficult lives, who can really benefit from quitting, will be talked out of it or simply cannot get access to the products they need. 

- Dr Sharon Cox is a Senior Research Fellow at London South Bank University

References 

Goff, D. C., Henderson, D. C., & Amico, E. (1992). Cigarette smoking in schizophrenia: relationship to psychopathology and medication side effects. The American journal of psychiatry.

Jackson, S. E., Smith, C., Cheeseman, H., West, R., & Brown, J. (2019). Finding smoking hot‐spots: a cross‐sectional survey of smoking patterns by housing tenure in England. Addiction, 114(5), 889-895.

Jha, P., & Peto, R. (2014). Global effects of smoking, of quitting, and of taxing tobacco. New England Journal of Medicine, 370(1), 60-68.

Shortt, N. K., Tisch, C., Pearce, J., Mitchell, R., Richardson, E. A., Hill, S., & Collin, J. (2015). A cross-sectional analysis of the relationship between tobacco and alcohol outlet density and neighbourhood deprivation. BMC public health, 15(1), 1014.

Soar, K., Dawkins, L., Robson, D., & Cox, S. Smoking amongst adults experiencing homelessness: a systematic review of prevalence rates, interventions and the barriers and facilitators to quitting and staying quit. Journal of Smoking Cessation, 1-15.

Stead, M., Jones, L., Docherty, G., Gough, B., Antoniak, M., & McNeill, A. (2013). 'No‐one actually goes to a shop and buys them do they?': attitudes and behaviours regarding illicit tobacco in a multiply disadvantaged community in E ngland. Addiction, 108(12), 2212-2219.

Taylor, G., McNeill, A., Girling, A., Farley, A., Lindson-Hawley, N., & Aveyard, P. (2014). Change in mental health after smoking cessation: systematic review and meta-analysis. Bmj, 348, g1151.

Thirlway, F. (2020). Explaining the social gradient in smoking and cessation: the peril and promise of social mobility. Sociology of Health & Illness, 42(3), 565-578.

Walsh, H., Duaso, M., & McNeill, A. (2018). Missed opportunities: a qualitative study of views and experiences of smoking cessation amongst adults in substance misuse treatment. Addiction Research & Theory, 26(6), 507-513.