Smoking addiction in chronic obstructive pulmonary disease

Abstract

The aim of this review is to extend professional understanding of the various mechanisms that make smoking cessation difficult for patients with chronic obstructive pulmonary disease (COPD). Smoking in people with COPD is a major challenge for health care today. In spite of significant advances in knowledge about the processes of nicotine addiction, current interventions to support smoking cessation in patients with COPD are less successful than hoped for. A wealth of literature has confirmed that nicotine addiction is a powerful force and that smoking is not simply an unhealthy lifestyle or destructive behavior. However, research based on this realization is still in its infancy. To increase understanding and to develop ways of enhancing smoking cessation in patients with COPD, we review and synthesize knowledge found in neurobiology and phenomenology. We use neurobiology to explain the neurochemical changes that take place in addiction in order to substantiate phenomenological perspectives of smoking in patients with COPD. We relate the smoking experience to the concept of “affordances”—in this context “smoking affordances”—to analyze how smoking affects action possibilities in individuals with COPD. Combining these perspectives helps to illuminate the manifold and unique issues related to smoking addiction in patients with COPD.

Introduction

Chronic obstructive pulmonary disease (COPD) causes premature death and is expected to become the third leading cause of mortality worldwide by the year 2030. ¹ Quitting smoking is the most effective action that people with COPD can undertake to reduce the progression of the disease. ² However, interventions to help smoking cessation for people with COPD have shown disappointing results, with an optimal long time abstinence rate of 25% expected. ² This calls for a concerted effort to improve treatment approaches. New approaches should not only address how smoking is entangled with every aspect of daily life ^3,4 they should also acknowledge that tobacco consumption changes the neurobiology of the brain. ⁵

The difficulties that people with COPD encounter in quitting smoking and refraining from smoking are puzzling to others, particularly the fact that people continue to smoke after their health has become seriously threatened. ⁶ To professionals and lay people alike this contradiction is perplexing; occasionally this manifests itself through inconsiderate behavior and rudeness to the patient. ⁷ It is tacitly assumed that it is the responsibility of the smoker to take notice of anti-smoking advice, to understand the real consequences of smoking, and to respond in a rational manner by ceasing to smoke. ⁸ This, however, is easier said than done and may create tensions in the way that COPD patients who smoke interact with other people. ^9,10

Merleau-Ponty’s phenomenology provides a philosophical framework that can be used to convey an understanding of how nicotine addiction alters the freedom and the functioning of the individual with COPD. ¹¹ For Merleau-Ponty, the body is the perceptual nexus that unites the individual with the environment. The active body uncovers qualities and possibilities inherent in the world. Qualities do not become real qualities and possibilities are not real possibilities until the individual attaches meanings and ambiances to them. ¹¹ Possibilities for action depend largely on the synergy of the individual’s body shape, capacities, and limitations. ¹² Normally the body functions in a near-automatic manner to saturate goals and intentions. As a result, people adjust to the demands of everyday situations almost effortlessly. ¹¹ When the bodily balance gets disturbed and no longer functions in a healthy way—as happens equally with COPD and nicotine addiction—the usual fluency of the active body is damaged. This draws people’s attention toward issues that no longer function correctly. ¹² Changes in embodiment can be seen in the alteration of spatiality—how the world appears to people (felt space) and the space they constantly attune themselves to (lived space)—and temporality, the perception of time which emerges in the succession of the past, the present, and the future. ^11,13

We seek to integrate mainstream knowledge across the spectrum of neurobiological mechanisms, physical perturbations, and the lived experience of smoking. This is synthesized through the lens of affordances, understood in this instance as the way in which people perceive and create possibilities for (non)smoking actions in their daily lives. Accordingly, we proceed as follows:

Articulate aspects of nicotine addiction by means of neurobiological mechanisms.

Present an account of the subjective experience and phenomenology of smoking addiction in patients with COPD. Throughout this article, smoking refers not only to cigarettes but also to other kinds of tobacco consumption.

Introduce the concept “affordances”—in this case “smoking affordances”—to offer new perspectives on smoking in COPD patients.

Our aim is to facilitate understanding and respect for the situation of people who smoke and, in particular, for those smokers who are patients with COPD. Making the multiple dimensions of smoking addiction clearly visible, biological as well as phenomenological, personal, social, and contextual may inspire nurses and other health care professionals to develop a better understanding of smoking addiction and help them to envisage more effective approaches to smoking cessation in people with COPD.

Smoking addiction—neurochemical changes and explanations

An abundance of research has proved the addictive nature of smoking, by both describing the addictive behavior of smoking and confirming the addiction by means of functional brain image studies. ^14,15 The diagnostic criteria for (nicotine) dependence have been indexed and fulfill the criteria defined by the American Psychiatric Association (DSM-IV-TR). ¹⁶ In addition, the International Classification of Diseases (ICD-10) from the World Health Organization ¹⁷ defines nicotine addiction as a relapsing brain disorder characterized by loss of control over smoking and its negative impact on daily functioning. Typical symptoms of dependence are increased tolerance to nicotine, smoking more cigarettes than intended, persistent smoking despite clear evidence and recognition of harmful effects. ¹⁷ Neurochemical changes play an influential role in clarifying substance abuse in general and addiction to nicotine in particular. ¹⁸ This underscores the need to consider how the brain responds to smoking.

Nicotine-activated changes in brain function

Cigarettes have multiple ingredients; however, nicotine appears to be the key reinforcing element of smoking addiction, which basically prohibits people from controlling their urge to smoke. ¹⁹ When smoke is inhaled from a cigarette, nicotine is refined and transported to the lungs, where it enters the pulmonary venous circulation and subsequently the arterial blood circulation. From there, nicotine is transported to the brain. This process happens almost instantaneously; nicotine has passed the blood–brain barrier within 10 seconds of inhaling the cigarette smoke. ⁵ The half-time of the blood nicotine level is around 2 hours, and with recurrent smoking during the day, the effects of nicotine do not fluctuate significantly. ¹⁵

Nicotine activates nicotinic acetylcholine receptors in the brain, which in turn modulate the release of several neurotransmitters. The most important neurotransmitter, critical for addiction to smoking, is dopamine. ^14,20 Other neurotransmitters that are released by nicotine activation include norepinephrine, acetylcholine, glutamate, serotonin, endorphins, and γ-aminobutyric acid. ²¹ The triggering of the nicotinic acetylcholinergic receptors also indirectly stimulates the mesolimbic reward system, mainly located in the ventral tegmental area and the nucleus accumbens. ²² This stimulation produces elevated dopamine levels within the reward system.

The neurotransmitters, most importantly dopamine, work in a reinforcing way by generating a pleasant “feel” of smoking. These rewarding effects encompass increased arousal, less fatigue, a light rush, a comfortable feeling of ease, and stress relief. Further, there may be gratifying effects due to mood modulation, performance enhancement, pain relief, and weight loss. ^15,21,23 When the positive rewarding effects wear off, people experience aversive effects that mediate a fresh craving to smoke. When the nicotine craving is once more satisfied, this again produces relief. ¹⁵ Typical symptoms of withdrawal are fatigue, drowsiness, negative mood states, anxiety, and irritability along with difficulties in staying focused, headache, and increased hunger. ²² Other commonly occurring withdrawal symptoms are gastrointestinal problems and difficulties in sleeping. ^19,22

With time, the brain gets accustomed to some of the changes curbed by nicotine and neuroadaptation happens within the circuits of memory, motivation, and learning. ²⁰ This “new” homeostasis requires the regular delivery of nicotine to prevent withdrawal symptoms from occurring. As a result, people alter their daily actions to include opportunities for sating habitual smoking routines. ^14,15 However, nicotine addiction becomes even more complex. The primer physiological effect of nicotine on the nervous system is relatively modest when compared with many other drugs—one does not get extremely high from smoking. Yet smoking is considered one of the most difficult drug addictions to disrupt. ^18,19 This may be explained by the dual reinforcement theory which considers both the primary effect of nicotine and the potent effects of non-nicotine stimuli, for example, the sight of a cigarette or places and situations where the person is accustomed to smoke. ^18,20 The individual associations that people make to reward the effects of nicotine and its withdrawal symptoms may yield powerful cues that result in an increased urge to smoke. ²⁰ For example, it is common to feel nervous during withdrawal or abstinence. If a person experiences similar nervousness for other reasons, for example, when attending a job interview or waiting for results from a lung function test, this may generate neural firing within the circuits of the reward system and a subsequent need to smoke. This turns on the reward system and induces states of needing nicotine. ^14,20 Hence, smoking addiction becomes amplified by connection to various mood states, the circumstances when smoking takes place, and the environment. This includes habits such as smoking when drinking coffee and/or reading the newspaper, smoking in the company of certain people, smoking when feeling blue, smoking to relieve stress, or when having difficulties concentrating. Addiction, then, entails oversensitivity to smoking-related cues. ¹⁵

Further supporting the notion of non-nicotine cuing mechanisms, sensorimotor brain structures related to the action observation network (AON) may be triggered in current and former smokers. This system is activated by inert stimuli, such as pictures related to smoking, or items in the environment that open possibilities for smoking or planning events that, in one way or another, are related to smoking. ^24,25 The threshold of realizing smoking may thus diminish with activation of AON. ²⁵ Evidence from the dual reinforcement theory and activation of AON explains how conditioned cuing may gradually sanction behavior and induce a longing to smoke even during periods of nicotine saturation and desensitization of nicotinic cholinergic brain receptors. ¹⁵ People who cease smoking are, therefore, vulnerable to relapse for a long time, even for years, due to the non-nicotine effects related to smoking. ^14,21,25 Those who succeed in giving up smoking have almost certainly developed some kind of inhibitors that hinder smoking from being realized in action. ²⁶ This cognitive “red light stop” has been researched by functional brain image studies (i.e. functional magnetic resonance imaging). Results indicate that cognitive control, seen by increased activation of the prefrontal cortex when former smokers are presented with smoking stimuli, is important for preserving smoking abstinence when nicotine smoking-related cues are present in the environment. ²⁶ Thus, successful abstinence may be characterized by increased activation in the prefrontal cortical brain regions in former smokers when they are exposed to smoking cues, for example, in pictures. ²⁶

Given the potential effects of nicotine and non-nicotine cues, people who have become dependent on nicotine cannot just stop smoking in spite of their subjective desire to do so. This is partly explained by a change in their brain chemistry. Most withdrawal symptoms after smoking cessation climax within 48 hours and the primer physiological dependence gradually fades away over a period of 6 months. ¹⁹ However, the potent reinforcing effects of non-nicotine stimuli should be well thought out in smoking cessation because these reinforcing effects explain the persistent longing to smoke, even after years of abstinence, and the high incidence of relapse. ² Nicotine replacement therapy and most medications for nicotine addiction are aimed at controlling primer withdrawal symptoms. ^18,26,27 They neither replace the positive and pleasant effects of smoking nor do they turn off the cue-related circuits. ¹⁵ Influences of non-nicotine stimuli have been demonstrated in research where cigarettes without nicotine diminish withdrawal symptoms in smokers who have temporarily been deprived from smoking, whereas the intravenous supply of nicotine had no effect at all. ²⁸

It is clear that people do not merely smoke to obtain nicotine and refrain from withdrawal symptoms; habits related to smoking and non-nicotine cues also have dominant effects in the brain. This supports the need to combine knowledge of brain function with identification of the specific issues that trigger and maintain the urge to smoke in patients with COPD.

The experience of addiction to smoking in COPD

Central to exploring the experience of nicotine addiction in patients with COPD from a phenomenological perspective is the notion of how people face their bodily infidelity: What is it like to live with the need to smoke and being simultaneously challenged with COPD? What do the restrictions of COPD feel like? How do people detect signs of disease progression? What is it like to smoke and yet feel breathing difficulties? What effects does COPD/smoking have on personal relations? What happens to felt space, lived space, future anticipations and temporality in the midst of losing control over one’s own actions (agency)? (cf. p. 97). ¹³

The spatial and temporal dynamics related to the live-world change for people with COPD during the course of the disease. Restricted spatiality decreases worldly interchange and is strongly associated with physical capabilities encompassing breathing difficulties and external contextual factors such as the need for aids (e.g. oxygen concentrators) as well as difficulties in managing activities once taken for granted such as eating and personal hygiene. ³ Further, spatiality may be decreased when people limit their contacts with others to prevent undesirable situations from occurring such as coughing up lung secretions in front of others (p. 609). ³ People like to behave in a socially acceptable way and so may isolate themselves if they cannot live up to their own expectations. ^29,30 COPD and nicotine addiction work differently on the temporality of experience. Within many areas of life, the person with COPD needs to be on guard before acting; time slows down. Even the simplest tasks of daily living require detailed planning. Utmost caution is needed to avoid exhaustion and exacerbation of breathing difficulties which is a profoundly feared situation. ²⁹ Paradoxically, in the craving for nicotine, the reorganization of temporal dimensions is characterized by an impulsive “act now” to achieve immediate satisfaction of one’s needs. ^11,31 The impulsive urge to smoke may override any reflection on the future that looks beyond the immediate “wished for” and craved effects of smoking.

An addictive opaqueness is present when the ability to control smoking has vanished while the costs of smoking can be distinguished by the individual:

I’ve been so ill at times; it makes you want to stop more. I mean I know it is a sin to light a cigarette. I know when I am sitting having a smoke it is not right. I know that. I mean there is no one that has to tell me that because I am suffering for smoking I am paying the price (p. 822). ³²

To acknowledge that one has only oneself to blame for having developed COPD may be a painful experience. ^10,33 In the initial stages of COPD, this feeling of self-blame may also prevent people from seeking professional help. ^34,35 People may make many excuses to smoke just one more cigarette. Then, afterward, they may deeply regret smoking and even make promises to themselves that “this will be the last one,” ³⁶ only to reach for another cigarette as soon as the craving returns. When such a situation transpires again and again, it progressively intrudes on normal bodily cadence and predictability, creating a vicious circle that gradually breaks people down and undermines their belief in the possibility of quitting. ³⁷ Despite objective knowledge of the adverse consequences people may go so far as to argue for the “benefits of cigarette smoking” and, in a self-indulgent way, start to smoke just because somebody told them not to. ^38,39 Others may lack incentives to stop smoking because the lung disease is already established (p. 299) ³⁶ and may put great effort into finding contributory factors for the development of COPD other than smoking such as pollution or the work environment. ^9,10,39 The various excuses mobilized to assist in relieving unbearable feelings can be regarded as having self-protective properties. ^31,37 In many instances, smokers with COPD are confronted with negative attitudes because their disease is “self-inflicted.” ¹⁰ In this way, smoking may cause isolation from other people who show little understanding of the power of nicotine addiction. This may in turn contribute to further withdrawal from other people, leading COPD patients into the realm where the cigarette is perceived as a “dear friend.” ⁷ The activity of smoking can acquire value, leading to feelings of security and well-being, less sense of loneliness and relief from anxiety. Even though the effects of smoking are short-lived, this provides instant satisfaction and a bizarre—but stable—axis in life. ⁷ Being more open to the outside world and seeking help may seem dangerous as it increases the risk of stigma and raises demands that people may not have the energy or capacity to confront.

A prominent, but paradoxical, aspect in the experience of smokers with COPD is the subjective desire to quit and to maintain the highest degree of health possible. This subjective perspective, however, is not equal to the tendency of the person addicted to nicotine to ignore the consequences of smoking. Consequently, when both these situations exist, care and support strategies may become complex. It is important to investigate the smoking-related cues to which people are exposed, that is, how people with COPD act, seek, and respond to smoking opportunities—or smoking affordances—in their daily life.

Smoking affordances

The concept of affordances applies well to phenomenology. It offers a way to articulate the complex relationships between things, people, and the environment. The term affordances can be traced to the work of the psychologist Gibson. According to Gibson, affordances are action promises that are present in the environment and which are picked up by an individual: “The affordances of the environment are what it offers the [person], what it provides or furnishes, either for good or ill” (p. 127). ⁴⁰ Examples used by Gibson include the following: air affords breathing; water affords drinking; and food affords eating. ⁴⁰ Affordances are bound up with individual circumstances and extend physical capabilities. For instance, walking up stairs affords the possibility for a person to visit a friend who lives in a fourth floor apartment. However, for the person with COPD the stairs to the fourth floor may afford severe breathing difficulties. In this way, the physical capabilities of the person with COPD become closely entangled with his/her wishes and desires or experiences. Affordances always predict action in a scenario linked to the real expertise and ability of the person to which an affordance is presented. Therefore, affordances are reliant on culture, prior experience and learning. ⁴¹ For example, in order to use a computer, a person needs more than just to see it—he/she needs to learn to use it. A smoker has also gone through the process of learning to smoke. To explain, for a child, a cigarette may reveal an affordance of “a funny thing to break” but it is certainly not something that the child can light up, put into his/her mouth, and inhale smoke.

The patient with COPD who continues to smoke in spite of adverse consequences interacts with the world by making use of smoking affordances present in the environment, affordances “for ill,” as Gibson would say (p. 127). ⁴⁰ This undesirable use of affordances may be difficult to comprehend from the perspective of a non-smoker. Many smokers with COPD have difficulties quitting because, in some ambiguous way, smoking affords some kind of support, a feeling of mastery, and being in control of a situation. Participants in a study considered themselves “depending on their smoking to provide structure, routine and company throughout the day” (p. 824). ³² In another study, a participant stated, “[Smoking] gives me the support that I don’t get elsewhere” (p. 300). ³⁶

The clinical meaning of affordances, embodied experiences, and addiction to smoking in COPD

For people with COPD, smoking may be perceived as a way to conquer and control aspects of their lives by recognizing and anticipating the calming effect of nicotine. Smoking provides an inexplicable feeling of gratifying one’s own expectations. Therefore, the person may shift into predictable (smoking) patterns and locate smoking affordances wherever reachable. Using the concept of affordances helps pinpoint where (e.g. physically) and when (e.g. situation) the person has increased sensitivity to smoking affordances and in which way meanings are attached to specific situations and points in time. The covert multidimensional associations related with cigarette use are gradually manifested in everyday life through acts of adaptation and/or conflicts. An addicted smoker with COPD seems to be drawn, as to a magnet, toward objects in the environment that afford smoking. Cigarette packs and lighters are among the more obvious items that afford smoking. However, indirect items may also afford smoking. For a person who only smokes when talking on the telephone, the ring of the telephone affords smoking. Such a person may not even answer the phone without lighting up a cigarette beforehand and placing an ashtray beside the phone. If the phone stays quiet for too long they may make a phone call in order to be “permitted” to smoke. Likewise, other people may afford smoking. For example, if a patient stops smoking but the spouse continues, the spouse indirectly affords smoking, both through smoking actions that remain present in the patient’s close environment and probably also in displaying nonsupporting behavior.

For a smoker, items that afford smoking seem to be everywhere. Being a smoker and perceiving smoking affordances suggests certain constraints because smoking affordances are so all-encompassing that they narrow a person’s horizons and their interaction with the environment. When people mainly “choose” to see and act upon items relevant to the fulfillment of their (smoking) longings and desires, their targeted actions and functions are based upon a degree of ignorance caused by the smoking addiction. In this way, the functions of cigarette smoking become established by the choices and actions taken. These in their turn mirror what smoking affords for the individual.

Health care professionals may afford the possibility for a patient to obtain treatment for their smoking addiction. However, in practice, patients may disregard these attempts if the longing to quit smoking is in the back of their mind. Depending on the degree of immersion in the smoking addiction, a person may fail to take account of the affordances not supporting the addiction, unless those affordances are of equal strength and importance. This explains why support offered by health care professionals does not always afford being “seen”. Hence, people may disregard offers of support and treatment and then, later on, state that “I wish that someone had told me that before”—well someone did. This affordance, however, was in the background and therefore was not fully registered.

In particular situations, actions undertaken by the patient may illuminate how, where, and when smoking affordances are acted upon. COPD patients are fragile and “afford” getting hurt in multiple ways by smoking, by the disease itself, and from belittling remarks made by others. Certain actions work toward avoiding such adverse effects, for example, keeping cigarette packs away from patients who attempt to quit smoking, avoiding those people who afford the wish of smoking, educating health care professionals about the harmful consequences of disrespectful attitudes toward patients who smoke and so on. These protective actions need to be incorporated into the everyday life of patients.

How can nonsmoking cues be strengthened in order to foster the wished for effects? For patients to respond to treatments in a desired way, it is of paramount importance to incorporate the functional specificity of use for each individual, to individualize, and refine the details of receptiveness to nonsmoking affordances. When health care professionals encourage COPD patients to stop smoking, they simultaneously challenge the person’s perceived security, valued company, daily cadence and predictability, and perceived physical comfort. Thus, health care professionals must concentrate on the most resilient affordances to help the smoker quit smoking. This usage must be well practiced, talked about, and supported in a synthesis of daily life situations. In a phenomenological way, a space must be opened for the incorporation of new meaningful nonsmoking skills into the habitual pattern of living. Approaches to enhance smoking cessation cannot, as revealed by affordances, be confined to isolated treatment of the patient. Rather they should be offered in the context of the patient’s unique circumstances, particularly with regard to family. Any approach should entail a clear strategy based on exploration of the individual’s smoking affordances. ⁴² This may convey adequate and unique action possibilities for each and every person: patients, their personal network, especially the family, as well as professionals. Patients should have primary involvement in developing appropriate approaches for themselves; they should not be forced into a standardized and prescribed approach to stop smoking.

Persons with COPD have a subjective feel of agency and voluntary control over their smoking actions. They may sense that it was their own choice to smoke and that the decision was taken consciously. Obviously it was their doing to light the cigarette and inhale the smoke. They also often claim full responsibility for the related consequences of smoking and acknowledge that the disease was self-inflicted. However, knowledge from the fields of neuroscience and phenomenology challenges the individual’s genuine agency by putting a question mark as to the degree to which smoking is performed as an act of free will. As argued throughout this article, continuing to smoke is predominantly affected by forces outside the person’s own deliberate choosing, see Box 1 for the main points and implications for health care. When the urge to smoke arises it should be understood in line with bodily states such as hunger and thirst. The craving for nicotine is more than an inner feeling that smoking is pleasant; the craving nurtures the experience of the lack of nicotine as of something really needed. ^37,43

Box 1: Main points and implications for health care

The person addicted to smoking is almost automatically drawn to smoking affordances in the environment and creates opportunities for continued smoking without conscious thought.

Cigarette smoking is affordance-laden, which makes it necessary to emphasize the role that smoking plays in the physical, emotional, and social experiences of each individual.

Health care professionals caring for people with COPD should avoid looking on addiction to smoking as a poor personal choice, given the changes that addiction creates on the neurobiological functioning of the brain.

Informing people of the profound neurobiological dependence as well as offering care and concern may help to relieve the sense of guilt and enhance a trusting relationship.

Exploring how COPD patients perceive smoking affordances may help to reveal the actual needs of patients, which in reality might be incongruent with prescriptions in standard intervention protocols.

Bringing understanding of affordances into regular health care may help disclose wider opportunities for patients, their relatives, and health care professionals.

Conclusion

Synthesizing knowledge from neurobiology and the phenomenology of embodiment and affordances provides new perspectives on smoking cessation in COPD patients. This suggests the development of new approaches to clinical practice. Embracing the phenomenon of smoking affordances helps us to understand how smoking addiction is embedded into the everyday life of the smoker. This knowledge may guide health care professionals to know when, where, and how to support COPD patients to become—and remain—abstinent from smoking. Informing people of the profound neurobiological dependence as well as offering care and concern may help to relieve the sense of guilt and enhance a trusting relationship between health care professionals, patients, and families. How to develop such practice, however, needs further investigation.