The biomedicalisation of smoking cessation: A mixed methods study of lay perspectives on nicotine addiction Kylie Morphett BA (Hons), BPsych (Hons) A thesis submitted for the degree of Doctor of Philosophy at The University of Queensland in 2016 School of Medicine i Abstract Biomedical models of addiction are becoming increasingly prevalent in public discourse about cigarette smoking, however there is some concern that smoking is becoming overly medicalised. Neuroscience research has revealed that nicotine use is associated with long- lasting changes in the brain, and these findings are being presented in the media and in advertising campaigns for smoking cessation pharmacotherapies. The “brain disease model of addiction”, which posits that chronic drug use leads to long-term changes in brain networks that make it very difficult to quit, is increasingly being applied to tobacco dependence. This is controversial in the tobacco control field, where population-based strategies have been successful in reducing the prevalence of smoking. Proponents of a biomedical model of tobacco dependence believe that it will lead to increased treatment seeking, more efficacious treatments, and a reduction in stigma. Critics of a biomedical model of nicotine addiction have expressed concerns that it will reduce individual responsibility for smoking, increase stigma, and undermine individuals’ beliefs in their ability to quit. While these competing views on the impacts of biomedical models of addiction have been debated in the academic literature, it is unknown to what extent members of the public endorse a biomedical model of tobacco dependence, and have incorporated it into their everyday understandings of smoking. This research examined the influence of biomedical discourses of smoking on lay beliefs of Australian smokers and non-smokers about tobacco dependence and its treatment. It also explored daily smokers’ attitudes to the labelling of nicotine addiction as a “brain disease.” A mixed methods approach was used to ascertain the extent to which biomedical understandings of smoking have been incorporated into lay discourse on smoking and quitting; how Australian smokers understand nicotine addiction and the role of the brain; and how endorsement of the brain disease model of addiction may be related to smokers’ attitudes towards smoking cessation and preferences for quitting methods. The thesis is comprised of three studies. Firstly, a secondary analysis of data from interviews with 55 members of the general public, including never smokers, ex-smokers and current smokers. The data was analysed to ascertain public attitudes on the best methods for quitting smoking. Results revealed that while cessation medications were frequently described as a helpful means to quit, the role of willpower, choice, and motivation were seen as central. ii Medications were often described as a “second line of defence”, or as aids to be used alongside counselling or behavioural strategies. A second qualitative study involved in-depth interviews with 29 daily smokers about their views on smoking cessation and their understanding of the role of the brain in smoking. The results revealed positive attitudes to quitting without assistance. Cessation medications were not perceived as magic bullets, and willpower and personal responsibility were emphasised. While many smokers were aware that smoking affected their brain, few agreed it was a brain disease. Participants expressed concerns that biomedical understandings of smoking could increase the stigma of smoking, diminish personal responsibility for cessation, and deter smokers from seeking treatment. These qualitative results informed the design of a quantitative survey completed by 1538 Australian smokers. This survey examined endorsement of neurobiological explanations of smoking, and their relationship to self-efficacy and treatment preferences. Approximately one third of participants agreed that smoking was a brain disease and more than half agreed that smoking changes the chemistry of the brain. Endorsement of the brain disease label, and agreement that smoking changes the chemistry of the brain, were associated with greater intention to use cessation medications. However the effect sizes were small, suggesting that beliefs about smoking and the brain may have modest real world impact. Contrary to the claim that promotion of brain-based explanations of smoking will increase feelings of fatalism, this survey shows that agreement with the claim that smoking is a brain disease was associated with higher self-efficacy. A medical, or chronic disease, model that emphasises the role of neurochemistry in tobacco dependence, while becoming more dominant in academic discourse, was not accepted by most Australian smokers. Concerns about negative consequences of describing smoking in this way, and wariness about the motives behind public health anti-smoking campaigns, were reasons behind this rejection. Consistent with existing literature on lay understandings of health and illness, alternatives discourses that describe it as a matter of willpower, choice, and a habit, remain strongly rooted in public dialogue about smoking. This means that smokers are unlikely to see the terminology of smoking as a “brain disease” positively. However, smokers were interested in information about the effects of smoking on the brain, and further research should investigate constructive ways of presenting this information in health promotion material and iii clinical interactions. Biomedical explanations of smoking should acknowledge the agency of individuals and the complexity of addiction to cigarettes in order to be believable and acceptable to smokers. iv Declaration by author This thesis is composed of my original work, and contains no material previously published or written by another person except where due reference has been made in the text. I have clearly stated the contribution by others to jointly-authored works that I have included in my thesis. I have clearly stated the contribution of others to my thesis as a whole, including statistical assistance, survey design, data analysis, significant technical procedures, professional editorial advice, and any other original research work used or reported in my thesis. The content of my thesis is the result of work I have carried out since the commencement of my research higher degree candidature and does not include a substantial part of work that has been submitted to qualify for the award of any other degree or diploma in any university or other tertiary institution. I have clearly stated which parts of my thesis, if any, have been submitted to qualify for another award. I acknowledge that an electronic copy of my thesis must be lodged with the University Library and, subject to the policy and procedures of The University of Queensland, the thesis be made available for research and study in accordance with the Copyright Act 1968 unless a period of embargo has been approved by the Dean of the Graduate School. I acknowledge that copyright of all material contained in my thesis resides with the copyright holder(s) of that material. Where appropriate I have obtained copyright permission from the copyright holder to reproduce material in this thesis. v Publications during candidature Peer-reviewed papers Morphett, K., Lucke, J., Gartner, C. E., Carter, A., Meurk, C., & Hall, W. (2013). Public attitudes toward the treatment of nicotine addiction. Nicotine and Tobacco Research.15(9), 1617-1622. Meurk, C., Hall, W., Morphett, K., Carter, A., & Lucke, J. (2013). What does 'acceptance' mean? Public reflections on the idea that addiction is a brain disease. BioSocieties, 8(4), 491-506. Meurk, C., Partridge, B., Carter, A., Hall, W., Morphett, K., & Lucke, J. (2014). Public attitudes in Australia towards the claim that addiction is a (brain) disease. Drug and Alcohol Review, 33(3), 272-279. Morphett, K., Partridge, B., Gartner, C., Carter, A., & Hall, W. (2015). Why Don’t Smokers Want Help to Quit? A Qualitative Study of Smokers’ Attitudes towards Assisted vs. Unassisted Quitting. International Journal of Environmental Research and Public Health, 12(6), 6591. Morphett, K., Carter, A., Hall, W., & Gartner, C. (2016). A qualitative study of smokers views on brain-based explanations of tobacco dependence. International Journal of Drug Policy, 29, 41-48. Meurk, C., Morphett, K., Carter, A., Weier, M., Lucke, J., & Hall, W. (2016) Scepticism and hope in a complex predicament: people with addictions deliberate about neuroscience. International Journal of Drug Policy. doi: 10.1016/j.drugpo.2016.03.004 Open-Peer Commentary vi Morphett, K., & Meurk, C. (2013). The “Brain Disease” Concept in Addiction: A Cause for Ambivalence, Not Concern. AJOB Neuroscience, 4(3), 48-50. Conference abstracts Morphett, K., Lucke, J., Gartner, C., Carter, A., Meurk, C., Hall, W., (2013). Public attitudes towards the treatment of nicotine addiction. Society for Research on Nicotine and Tobacco (SRNT), Westin Waterfront Hotel, Boston, USA. 16 March 2013, [poster presentation – presenting author]. Morphett, K., Smokers Understandings of Nicotine Addiction: A Qualitative Study. Neuroethics Down Under. University of Queensland Centre for Clinical Research, Herston, 4 October 2013 [oral presentation – presenting author]. Morphett K., Gartner, C., Carter, A., Lucke, J, Partridge, B., Hall, W. Is smoking a brain disease? The attitudes of smokers towards a neurobiological conceptualisation of nicotine dependence. Symposium