Differences in happiness between smokers, ex-smokers and never smokers: cross-sectional findings from a national household survey
Introduction
Smoking kills more than half of all those who do not stop (Doll et al., 2004). A major barrier to trying to stop is enjoyment of smoking (Fidler and West, 2011, Lader, 2007). It is widely believed that smokers use tobacco to help regulate their mood and self-medicate (Carmody, 1992, McNeill et al., 1987, Parrott, 1995) and in the short term, stopping smoking commonly leads to an increase in mood disturbance and depressive symptoms (West et al., 2006). Indeed, research suggests a reciprocal and dynamic relationship between anhedonia and smoking such that smokers experiencing anhedonia and low positive affect evidence stronger cravings and have difficulty in maintaining abstinence (Ameringer and Leventhal, 2010). However, the relationship between smoking and smoking cessation and mental well-being in the long term is more complex (Fergusson et al., 2003, West and Jarvis, 2005). Cross-sectional studies show a clear association between smoking and psychiatric symptoms of all kinds (Breslau and Johnson, 2000, Glassman et al., 1990) but this could be due to common aetiology (Kendler et al., 1993) or smokers self-medicating in the belief that smoking helps with symptoms when it does not (Breslau et al., 1998). Although longitudinal studies suggest that the onset of psychiatric illnesses precedes smoking uptake (Johnson et al., 2000, Kelly and McCreadie, 1999, Klungsoyr et al., 2006), there is also growing evidence that starting to smoke may increase the risk of subsequent psychiatric morbidity (Boden et al., 2010, Kang and Lee, 2010, Steuber and Danner, 2006) and that long-term cessation is associated with a decrease in stress and anxiety and no worsening of depressed mood (Bolam et al., 2011, Hajek et al., 2010, West and Hajek, 1997).
Whilst a substantial amount of research has focused on psychological health and negative affect (e.g., Kassel et al., 2003), much less is known about the effect of smoking on global measures of subjective well-being – what is often referred to as ‘happiness’ (Veenhoven, 2003). This is important, as psychological health and happiness are potentially different. Indeed, the related concepts of negative and positive affect are considered largely independent dimensions (Watson et al., 1988). Therefore, findings may not straightforwardly translate from one to the other. The lack of research in this area is likely due to the difficulty in providing an invariant and universal definition of happiness, separating it from conceptually similar yet distinct aspects of subjective well-being, such as positive affect and quality of life (Veenhoven, 2000, Diener et al., 2003) and, hence, in operationalising this construct (Haybron, 2003). Thus, many questions about the association of smoking and happiness remain to be answered to complement existing findings on psychiatric symptoms and morbidity.
Following the growing popularity of the positive psychology movement (Seligman et al., 2005), happiness has become a focus of attention recently because there is increasing evidence that it affects not only mental but also physical health (Pressman and Cohen, 2005). Moreover, the little research that exists in relation to smoking has focused mainly on current smoking rather than cessation. This shows that smokers report worse mood than non-smokers acutely over the course of a day (Adan and Sanchez-Turet, 2000) and lower happiness levels for life in general (Koivumaa-Honkanen et al., 2003), irrespective of their background (Grant et al., 2009). These findings are supported by studies of the psychobiological processes underpinning positive affect. Smokers tend to have higher levels of the biomarker cortisol than non-smokers (Pickworth and Fant, 1998) and lower levels of cortisol are consistently associated with greater self-reported well-being and happiness (Steptoe et al., 2009).
Given the dearth of evidence, it is important to gain a better understanding of the association between happiness and smoking status and in particular whether smoking decreases happiness and stopping increases it and over which time course. This is important as the short-lived anhedonic effects of smoking cessation may lead smokers to infer that stopping smoking will lead to a permanent decrease in life enjoyment, which may undermine quit attempts. Indeed, research suggests that people are bad at ‘affective forecasting’ and normally overestimate medium-to-long term negative emotional reactions (Gilbert et al., 1998). However, if it is the case that smoking adversely affected happiness and that stopping would improve it, this may increase smokers’ motivation to stop and remove this potential barrier to cessation.
We have previously investigated the association between smoking cessation and happiness, finding that ex-smokers report that they feel happier now then when they were smoking and that this effect was only apparent among those who had stopped for a year or more (Shahab and West, 2009). However, this study was limited by potential recall bias as it simply asked ex-smokers whether they felt happier now compared with when they were smoking and did not include any appropriate control groups (i.e., current or never smokers). Here we examined self-reported happiness cross-sectionally in a representative population sample including smokers, ex-smokers and current smokers. As no universally agreed measures of happiness exist, we chose to assess this concept using two global constructs, life enjoyment and life satisfaction, which are considered important conceptual referents that capture happiness (e.g., Shin and Johnson, 1978, Rojas, 2005). Specifically, this study aimed to answer the following questions:
- (1)
Does self-reported happiness vary as a function of smoking status and duration of abstinence?
- (2)
What, if any, smoking characteristics are associated with self-reported happiness?
Section snippets
Procedure
The study was part of the Smoking Toolkit Study, a series of cross-sectional household-based surveys carried out in England which follows an established random location quota sampling method. The sample representativeness has been validated against other national datasets and details of the methodology are provided elsewhere (Fidler et al., 2011). Grouped output areas (containing 300 households) stratified by ACORN characteristics (http://www.caci.co.uk/acorn/acornmap.asp) and region were
Results
As previously shown (Fidler et al., 2011) the sample was of a representative regional and socio-demographic composition (Table 1). On average, never smokers were older than current smokers and recent ex-smokers but younger than established ex-smokers (F(3, 6922) = 126.3, p < 0.001) and more likely to be female compared with established ex-smokers and current smokers (χ2(3) = 31.1, p < 0.001). Never smokers and established ex-smokers were more likely to come from higher social groups than recent
Discussion
This study found a clear association between smoking status and happiness levels. Smokers reported substantially lower life enjoyment and satisfaction than either never smokers or ex-smokers who had stopped for a year or more, but there were no differences between established ex-smokers and never smokers, even after adjusting for confounders.
As this analysis was cross-sectional, it is not possible to establish the direction of the association between smoking cessation and happiness. The result
Role of funding source
This study is funded by the Department of Health, Cancer Research UK, Pfizer, GlaxoSmithKline and Johnson and Johnson, who had no involvement in the design of the study, collection, analysis or interpretation of the data, the writing of the report, or the decision to submit the paper for publication. Both authors are funded by Cancer Research UK but work independently from all funders listed.
Contributors
Lion Shahab undertook the analyses, ran the literature review, and prepared the first draft of the manuscript. Robert West conceived the study, contributed to the analysis and interpretation of the results and commented on the initial draft of the paper. Both authors had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. Both authors have seen and approved the final version of the paper.
Conflict of interest
Lion Shahab has received an honorarium for a talk and travel expenses from a pharmaceutical company making smoking cessation products. Robert West undertakes research and consultancy for the following developers and manufacturers of smoking cessation treatments; Pfizer, J&J, McNeil, GSK, Nabi, Novartis and Sanofi-Aventis. He also has a share in the patent of a novel nicotine delivery device.
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