Time to kick the habit as smoking alters the brain
New research shows smoking has deep psychological effects and may even cause schizophrenia. Is Big Tobacco doomed?
At St Patrick's University Hospital, the Dublin mental hospital founded by author Jonathan Swift, consultant psychiatrist Séamus Ó Ceallaigh had often noticed that the patients he treated for psychotic mental illnesses were heavy smokers. Like many doctors, he assumed the habit eased their distress.
"Someone who is experiencing psychosis, like people with schizophrenia, would describe smoking as having a calming or smoothing effect," said Ó Ceallaigh, director of the hospital's psychosis recovery programme.
"People are using cigarettes to cope with their symptoms. Giving up smoking is difficult for anyone, but it is especially difficult if they are experiencing an acute episode of mental illness."
That's why inpatients at St Patrick's are allowed to smoke in covered outdoor areas. Psychiatric hospitals received an exemption clause from the ban on smoking in the workplace that was introduced in 2004 and put Ireland at the forefront of Europe's war on tobacco.
But new research may have thrown a spanner in the works for the hospitals' policies on tobacco use: smoking itself may be one of the causes of schizophrenia and other psychotic disorders.
Scientists at King's College London reviewed data from 61 previous studies involving 288,000 people and concluded in a study, published in The Lancet Psychiatry journal this month, that 57pc of people diagnosed with schizophrenia for the first time were smokers. The study also showed that daily smokers became psychotic around a year earlier than non-smokers.
One reason provided by the researchers for this is a possible link between smoking and excess dopamine, a brain chemical that plays a role in transmitting nerve signals. Dopamine is thought to play an important role in the development of schizophrenia, a disorder whose symptoms include hearing voices and paranoia.
While more research is needed to determine for sure that tobacco is the real villain behind psychosis, the latest findings are yet another nail in the coffin of a vice that is the single most preventable cause of death. Small wonder the fashion for smoking is going up in smoke.
Just 19.5pc of Irish adults indulge in the habit, one of the lowest rates in the European Union, according to 2014 figures from the Health Service Executive's National Tobacco Control Office. In 1998, a third of Irish adults smoked, a proportion that slid to 29pc in 2004, when Ireland became the first country to prohibit smoking in public places. (The world's first ban was imposed in Nazi Germany in the mid-1930s by Adolf Hitler, who believed smoking posed a hazard to the bodily purity of the Aryan race.)
The middle classes are especially steering clear of tobacco: just 13.8pc of people who belong to the highest socio-economic groups smoke, compared to 24.1pc of those who live in the poorest communities, according to the HSE.
"As the prevalence of smoking decreases, the remaining smokers are mainly disadvantaged people," said Professor Luke Clancy, director general of the Tobacco-Free Research Institute and a key player in the 2004 ban. "The people who give up are the more educated and better off - they can read all the ads, access the services and get the support they need."
It is a truly dismal era to be a smoker from any class. Those who were first lured into tobacco's tight grip as a teenager after puffing on a friend's cigarette behind the school bike shed now find themselves huddling together in pub doorways from the rain, decrying the nanny state and demonised as outcasts by an increasingly health conscious Irish society. It's a far cry from the image cast by the cigarette-toting and ruggedly handsome Marlboro Man who rode off into the sunset.
Publicans got creative in the wake of the workplace ban, trying to bring smokers back in from the cold and shore up their declining profits by offering beer gardens and other smoking areas as comfortable as bar interiors. But the government, spearheaded by James Reilly, the Minister for Children, is closing in on the nicotine habit in his bid to turn Ireland into the world's first "tobacco-free zone".
The Government, which aims to have a smoking rate of just 5pc by 2025, is getting ready to ban smoking in cars where children are present and the measure is expected to come into force within six months. Its main battleground is overcoming legal challenges from the tobacco companies to put into effect its legislation of logo-free packaging for cigarette packs. If Ireland succeeds, a health warning and graphic image of the dangers of smoking will be the largest thing on a pack of fags, Big Tobacco's final tool to recruit young smokers.
Teenagers, the traditional target for tobacco companies eager to clinch lifetime customers, are not responding to Big Tobacco's call in the way they used to. Just 7.9pc of people aged between 15 and 17 smoke, compared to 27.3pc of those aged between 25 and 34, the HSE says.
"The culture has changed so it's less cool for teenagers to smoke than it was," said Dr Pat Doorley, chairman of the policy group on tobacco at the Royal College of Physicians of Ireland. "The opportunities for smoking have fallen because so many indoor areas are non-smoking."
It is outdoor smoking bans that may prove one of the final frontiers for anti-smoking advocates and the government. The HSE has already banned smoking from hospital grounds, prompting some patients and even pregnant women to grab a quick fag in their dressing gowns far from the hospital entrance.
Parks and playgrounds are next in line. Local authorities can only receive capital funding for new facilities if they are smoke-free. On July 1, Waterford city and county councils prohibited smoking in their parks, alongside a hodgepodge of bans on other habits it deemed anti-social, such as swearing and barbecues. Most local authorities either have implemented, or intend to implement, smoke-free policies in parks.
"For us, it's about giving the message to society, and children in particular, that smoking is not normal behaviour," said Doorley, speaking from beside a newly smoke-free beach in Nice. In France, where there was traditionally more tobacco smoke than air in cafés, seaside resorts are outlawing smoking on beaches.
"I was in Vancouver recently and it was hard to see people smoking anywhere at all because beaches and parks are all smoke-free. These measures don't have to be heavily policed because the majority of smokers are law abiding."
But tobacco companies are unlikely to take any crackdowns on smoking lying down. Japan Tobacco began a legal action against the State in April over laws to bring in plain packaging on cigarette boxes.
Clancy said JTI will "probably lose the plain packaging case but that won't matter because it will have tied up the tobacco control unit by getting it to spend all its time fighting that case.
"The Government tried to send the case to Europe but the Commercial Court has decided it's too premature to go to Europe so it should be tried here. They could spend the next two years in litigation."
JTI Ireland, which supplies stores with brands such as Benson & Hedges and Camel, has said the introduction of plain packaging would be contrary to EU harmonisation objectives and an obstacle to trade between member states and to competition. Forest Éireann, a smokers' group, claims standardised packaging would fuel cigarette smuggling.
"Multinationals actually wrote to every TD in the Dáil before the plain packaging law was passed and warned them not to pass it. They have decided to challenge every intervention we bring about," Clancy said.
In addition to this measure, the professor is keen for even higher taxes on cigarettes, more smoking cessation services being made available to the public, and more hard-hitting campaigns such as the harrowing television commercial featuring Gerry Collins, who died from tobacco-related lung cancer last year shortly after filming the series of ads for the HSE's QUIT campaign. In the films, Collins appears to deliver his message from beyond the grave, saying: "I'm dying. I'm dying from cancer as a result of smoking. I wish I'd stopped smoking sooner." Collins never lived to see the broadcasts, but the HSE has credited the campaign with encouraging thousands of people to kick the habit. There were 70,000 fewer smokers last year than in 2013, the biggest annual drop in five years.
Smoking kills one in two lifelong users of tobacco, as the Collins campaign drives home. Each year, at least 5,200 people in Ireland die from diseases caused by tobacco use and it accounts for about 19pc of all deaths, according to the Irish Cancer Society.
But, compared to other drugs, nicotine is the hardest to kick. It can take an average of 30 years for a dependent smoker to quit tobacco, more than seven times longer than it takes to stop using cocaine, according to research by Gene Heyman, an American addiction academic.
If Ireland is to stub out the nicotine habit for good within the next decade, it will have to step up its crusade, Doorley said.
"We need a faster rate of progress," he said. "It's a very insidious addiction."
Big tobacco's new battlegrounds
With smoking falling out of favour in the western world, tobacco companies are striving to compensate by expanding into emerging markets such as the Balkans and into electronic cigarettes.
Vaping, or inhaling a vapour through an e-cigarettes, could yet prove a salvation for the €712bn tobacco industry in developed economies, and companies such as Reynolds American have their own e-cigarette brands. Teenage use of e-cigarettes in the US tripled in 2014 alone, making them more common than conventional cigarettes.
The traditional industry received one of its biggest ever blows last month, when a Quebec court ordered three tobacco companies to pay out a combined €11bn to smokers. The same day, a ban on both outdoor and indoor smoking came into effect in Beijing, capital of the world's heaviest smoking country.