In 2019 there were still nearly 7 million adult smokers in the UK. In England, there were more than 500,000 hospital admissions estimated to be attributable to smoking. Although fewer people are now smoking, it is still a significant health risk. What may be putting people at higher risk of smoking, and what can be done to reduce this? Are emotional health problems a factor?

Samaritans describe emotional health as how we think and feel. It is about our sense of wellbeing, coping with life events, and how we acknowledge both our own and others emotions.     

The Link Between Emotional Health Issues and Smoking

Examples of emotional health issues, such as feeling stressed or anxious, play a large role in smoking behaviours. A systematic review of published research found that individuals with high levels of anxiety were twice as likely to be smokers, and higher anxiety was related to earlier smoking.

A similar link has also been found in individuals who are stressed. Research suggests that stress can increase the risk of smoking, and is associated with a higher level of relapse. One study found that following stress, participants were less able to resist smoking, smoked more intensely (increased puffs, shorter inter-puff interval, and greater peak puff velocity), and perceived greater satisfaction and reward from smoking. 

This suggests that treatments for smoking may be more beneficial if they target emotional health issues such as stress. A similar result was found in another study, which found that treatments that lowered stress reactivity were more effective for helping people stop smoking.

A review of socioeconomic status and smoking suggested that lack of support, lack of motivation and a higher amount of life stress makes adhering to treatment difficult for people who are disadvantaged. While Office for National Statistics data in 2019 suggested that the proportion of current smokers was significantly higher among unemployed people (26.8%) compared with those who were employed (14.5%).

It is clear that emotional health issues such as feeling stressed or anxious play a role in smoking behaviours. Smoking cessation treatments should therefore aim to reduce these emotional health issues. Here are some examples of possible ways of achieving this.

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) aims to help with emotional health issues. This form of therapy primarily focuses on identifying and changing maladaptive thought and behaviour patterns. It includes problem solving and coping skills rooted in relapse prevention theory, along with cognitive restructuring for maladaptive thoughts. CBT has been described as, ‘one of the most well-established and efficacious interventions for smoking cessation.’

Mindfulness-based treatments

Another form of therapy that has been found beneficial here is mindfulness-based treatments (MBTs). This may involve using mindfulness- and acceptance-based strategies, such as noticing and accepting negative emotions (letting these emotions be exactly as they are, without reacting to them).

One study found that mindfulness-based therapy reduces stress, and suggested this may underlie its effectiveness as a smoking cessation treatment. Mindfulness was shown in this study to even be more effective than CBT as a smoking therapy. This could be due to the larger impact mindfulness had on reducing stress compared with CBT.

Acceptance and Commitment Therapy

There is also evidence that Acceptance and Commitment Therapy(ACT) can help reduce stress and, in turn, help people stop smoking. ACT uses aspects of mindfulness-based therapies, and takes the approach of helping individuals stop attempting to control or avoid unpleasant sensations or emotions and instead allow the things that are deeply important to them to guide their behaviour. The goal of ACT is not to lessen unpleasant sensations, emotions, and thoughts, but rather to increase willingness and openness to experience them.

One study carried out a comparison of an ACT intervention and CBT, the current standard in behavioural intervention for smoking cessation. The study found that the ACT intervention appeared both feasible and acceptable to participants, who had higher odds of abstinence compared with CBT at the longest-term follow-up point.

These findings suggest that looking at interventions to help people accept their emotional health problems, and learn to manage and cope with them, have more effective outcomes when it comes to stopping smoking compared to the current standard of CBT, which uses more distraction methods.

Conclusions

• Emotional health issues appear to increase the risks of smoking. In particular, feeling anxious or stressed increases the risk of smoking and smoking relapse. This suggests that initiatives to reduce smoking will be more effective if they consider and seek to address the underlying emotional health issues an individual might have.
• Societal sources of stress and anxiety (such as unemployment, precarious employment and poor housing) are clearly major factors and need to be addressed. 
• At an individual level, research suggests that the current standard treatment of CBT has value and that therapies such as Acceptance and Commitment Therapy (ACT) and mindfulness may be even more effective - perhaps due in part to the larger impact they have on reducing stress levels and supporting emotional health.

Beth Thomas March 2021