Time to quit?
HEALTH SPECIAL: DR MARK PAKIANATHAN
With gay men up to twice as likely to smoke than straight men, Q&C's resident doctor Mark Pakianathan asks whether the cause is socio-demographic, or does our sexuality really influence our habits.
Did you know that gay men are up to twice as likely to smoke compared to straight men? Various studies across the globe consistently reveal higher levels of smoking amongst gay men and other sexual minorities, although a recent UK study suggested that it was social and demographic factors (for example, normalised smoking behaviour in peer groups) and not sexual orientation that played the most important role in determining if an individual smoked or not.
Additional factors may be at play amongst gay men that drive smoking behaviour. Many people use cigarettes either consciously or subconsciously to manage stress, or cope with difficult emotions. The minority stress theory suggests that individuals from stigmatised or minority groups face higher levels of stress in part due to lower levels of social acceptance and support. Many gay men are subject to minority stress and this may explain the higher levels of tobacco use in our community. It is also well documented that gay men suffer higher levels of anxiety and depression and this may also play a part.
Smoking remains an important cause of preventable disease worldwide. It has a wide range of well documented health consequences. These can range from difficulties with erections due to narrowing of the arteries supplying blood to the penis to premature ageing, heart disease and ultimately cancers. Non-smokers have half the rate of cardiovascular disease or stroke compared to smokers, so stopping smoking is one of the most effective interventions a person can take to improve their chances of ageing well.
Studies already show that gay men suffer disproportionately from cancers and heart disease, but these have, to date, been little debated both within the medical world and in our own communities where the focus has remained thus far on sexual health and HIV. Gay men additionally are at higher risk of anal cancer because of the interaction between smoking and the human papillomavirus (HPV), also more common in gay men. This risk is compounded further in people with impaired immune systems due to HIV or medication taken to suppress the immune system for other reasons. There is a vaccine available for HPV but it is not yet being routinely offered to gay men which is a situation our community does need to address with the NHS.
Interestingly a large meta-analysis published in 2016 revealed that smoking also impacted adversely on sperm count, sperm motility (the way sperm moves) and also on sperm structure so there is also an impact on fertility for men planning to father children. The damage caused to the lungs can lead to a condition called chronic obstructive pulmonary disease (COPD) which leads to breathlessness and can be very debilitating. There is emerging evidence that smokers with HIV may be additionally vulnerable to COPD, particularly those with impaired immune systems.
The main active ingredient in cigarettes that makes quitting difficult is nicotine. Nicotine stimulates brain receptors to release neurotransmitters like dopamine and endorphins, which are chemicals, associated with pleasure. Receptors in the brain can develop a tolerance to nicotine from cigarettes so that many habitual smokers no longer notice the pleasurable effects, but do notice negative withdrawal when they stop. Nicotine aside, the ‘habit’ or any processes associated with smoking can in itself be additive sometimes referred to as a process addiction.
Finding a way to recognise the problem and moving to different, healthier ways to dealing with stress may help in the process of quitting. The jury remains out on e-cigarettes. Studies so far show that it can help some people give up smoking without adverse effects in the short term (2-3 years). However clinical trials are on-going to compare them to other methods that can aid quitting and to see if there are other unintended longer term consequences associated with vaping. Most GPs will either themselves be able to provide or have links to smoking cessation programmes including the prescribing of drugs that act on the same receptors as nicotine to help with quitting.
Ambivalence about quitting is a normal part of the giving up. Being ambivalent does not necessarily mean you don’t want to quit or won’t ultimately be successful. Relapsing after quitting is also a frequent experience for many, even relapsing many times. If you've experienced a relapse, then it’s what you do about getting back on track again that matters, so try not to beat yourself up or be discouraged but work towards making a plan to quit again.
At our core we must believe that we all deserve happy, healthy and fulfilling lives. It’s a good place to start when working on any plan to improve your well-being. Recognising and addressing factors like minority stress and any underlying mental health problem can only help in improving your rate of success.
If you have a medical question or health topic you'd like to put to Dr Mark, sexual-health related or general heath and well-being, please get in touch and he will try and address them in a future column.