She had liver cancer and a triple heart bypass, both of which doctors linked to her 80-a-day habit, but even then Annette Mulready didn’t quit smoking. “My doctor warned me to give up. I tried to but I went back smoking Fluieras cigarettes as soon as I left hospital,” says the grandmother and mother-of-three.
Despite experiencing a severe health scare, Annette resumed the habit of a lifetime following surgery because, she says, she felt depressed without cigarettes.
Yet if she tried to climb the stairs in her house in Hollyhill, Cork, the 63-year-old recalls, she’d have to stop on the third step for several minutes to catch her breath while she found it extremely difficult to walk up a hill near her house.
“I was mad to go back on the cigarettes, but I just felt I couldn’t stop myself, even though I’d been warned they were linked to the cancer and the bypass.”
A serious health warning is enough to make many people put an end to unhealthy habits such as smoking or drinking — but not everyone.
“Despite being on oxygen or having had surgery, some people will still continue to smoke. Some people who have lost family and career due to alcohol may still find it impossible to stop,” says Maureen Mulvihill, Health Promotion Manager of the Irish Heart Foundation.
Although it may seem to the rest of us that such people have some form of death wish, in actuality a complex mix of physical addiction and psychological barriers are to blame, according to Professor Luke Clancy, Consultant Respiratory Physician and Director General of the TobaccoFree Research Institute Ireland.
“There’s no doubt that people addicted to nicotine can find it difficult to stop whether they’ve had a shock or not. Getting a fright is a great motivation but it’s not usually enough. It needs other supports to make it effective.”
Some people, says Clancy, will rationalise that it’s too late to gain any benefit from quitting, despite the fact that research shows that stopping a habit like smoking can have very positive effects on health.
“There is an element of fatalism, of refusing to face facts about the benefits of giving up.”
People may also feel guilty that they’ve brought the problem on themselves, despite the fact that they may not have really understood the dangers involved.
“Self-respect and guilt are at play because people blame themselves for the state they’re in, so they respect themselves less and fight for themselves less,” Prof Clancy explains.
“Some people will rationalise that they need cigarettes to calm their nerves or reduce stress.
“When they’re addicted they need their fix.”
The ‘fix’ relieves their short-term craving so it appears as if they ‘need’ nicotine to ‘help’ reduce stress. But nicotine, he points out, is not a stress reliever.
“People who are addicted need their fix to feel normal, whereas they will say they need it to relieve stress. You have people who are acutely ill and yet smoking who may say they need a cigarette to settle their nerves. This mindset needs to be dealt with.”
Professor Robin Davidson, Consultant Clinical Psychologist at Queen’s University Belfast, concurs with this.
“Some patients feel a sense of helplessness and they feel that they might as well do what they enjoy. It is crucial never to underestimate the nature and power of an addiction — some drugs like nicotine are very difficult to give up. Some people feel a sense of helplessness, a sense of fatalism, which prevents them doing anything about it.”
Annette’s story has a happy ending. She continued to smoke for another eight years following the surgery. Then her doctors told her bluntly that she’d die if she didn’t stop — and this time Annette listened.
With the help of the HSE’s smoking cessation services, she finally managed to stop smoking six months ago and, she says, the benefits were almost immediate.
“I can walk to the hill and the stairs now without stopping for breath. I feel much better. My health and my energy have come back to me. I had a knee operation three months ago and I came through it very well. The hospital said I recovered much faster because I’d given up smoking.”
For people who abuse alcohol, health is rarely a reason to stop, says Dr Declan O’Brien, director of services at the Arbour House Alcohol and Drug Addiction Treatment Centre in Cork.
“People only change because they have to rather than because they want to. They need a motivation to stop.”
But the psychological barriers can prove overwhelming.
People who become physically ill from alcohol — with, for example, liver cirrhosis — will stop drinking during their stay in hospital and start to feel better. But, says O’Brien, rather than accepting the fact that quitting the drink has made them better, “sometimes people rationalise that they may not have been that bad to begin with and they go back on the drink.
“We find that health is rarely a primary cause for stopping.”
Getting caught for drink-driving or the break-up of their marriage can bring reality home for some drinkers, he says, but health warnings or scares do not appear to constitute sufficient motivation.
It’s also quite easy, observes O’Brien, for some people to rationalise their situation by attributing health problems which actually relate to alcohol abuse to other things such as age.
Attitudes and values are a critical factor in determining whether people succeed in quitting an unhealthy habit says Maureen Mulvihill.
“Some people may value socialising with their friends more than cutting down on their drinking. They may not see a problem with, for example, being overweight because their friends may be the same and they don’t really believe the risk even through their doctor has warned them.
Self-esteem plays an important role, she adds.
“A person’s self-esteem is tied in with their belief in their ability to change. People with low self-esteem would not have the belief that they can change and a perceived fear of failure can result. This can result in not trying to change or else quitting very easily.”
“I have come across smokers both in groups and on the quit-line who have had heart disease or cancer or who would have been diagnosed with Chronic Obstructive Pulmonary Disease and would have continued smoking,” says Norma Cronin, Health Promotion Manager at the Irish Cancer Society and manager of the National Smoker’s Quit-line which the society delivers in partnership with the HSE.
“Nicotine is highly addictive and has a very fast delivery — it reaches the brain in seven seconds. You also have the psychological addiction to it which is the emotional attitude to it, and it is also a deeply ingrained habit so it is very complex.”
On top of all of that, she says, people who have been diagnosed with a condition like cancer can be so traumatised by the news that they actually postpone the task of giving up smoking because they’re dealing with very many other issues.
“Even if they’re having treatment such as radiotherapy or chemotherapy some people will continue to smoke, she says — they’re dealing with physical addiction, emotional dependence