After all these years working in the emergency department I have learned one thing: beware the patient that tells you they think they are about to die. They are probably right.

The powerful physical effects that can be produced by placebos is now well documented. So powerful, that there may even be an emerging problem with placebo addicts flooding into the health system.
But all levity aside, what is less known, less examined, and probably just as significant,  are the effects of the nocebo (meaning “I will harm”).
New Scientist has an interesting article on the effects of  the nocebo, where negative expectations, and the power of suggestion can produce measurable negative effects.

Take Sam Shoeman, who was diagnosed with end-stage liver cancer in the 1970s and given just months to live. Shoeman duly died in the allotted time frame – yet the autopsy revealed that his doctors had got it wrong. The tumour was tiny and had not spread. “He didn’t die from cancer, but from believing he was dying of cancer,” says Meador. “If everyone treats you as if you are dying, you buy into it. Everything in your whole being becomes about dying.”

He didn’t die from cancer but from believing he was dying of cancer
Cases such as Shoeman’s may be extreme examples of a far more widespread phenomenon. Many patients who suffer harmful side effects, for instance, may do so only because they have been told to expect them. What’s more, people who believe they have a high risk of certain diseases are more likely to get them than people with the same risk factors who believe they have a low risk.
:: New Scientist::

One study of women found a fourfold increase in death from coronary symptoms amongst those who believed they were going to have a heart attack compared to others with the same risk factors.
In Many clinical trials, those in the control group being administered pharmacologically inert substances  will actually develop the negative side effects of the real therapies.

And in a retrospective study of 15 trials involving thousands of patients prescribed either beta blockers or a control, it was found that both groups reported comparable levels of side effects, including fatigue, depressive symptoms and sexual dysfunction. A similar number had to withdraw from the studies because of them.

Nocebo effect on smokers.

Which raises an interesting possibility.
In Australia, as in many other countries, all our cigarette packets now carry a mandatory ‘Smoking Kills’ warning including explicit, graphic pictures of smoking related illness. The warnings must cover 30% of the front and 90% of the back of the cigarette package.
This is combined with frequent runs of graphic advertising campaigns,  intended to be both powerful and disturbing.

Without doubt these programs have been effective. Today, Australia ranks with Sweden, Canada and the USA as having achieved the largest falls in daily smoking prevalence of any nation. And there is a strong push for increased use of these ‘shock’ tactics due to this very success.
There is absolutely no doubt regarding the terrible suffering that smoking inflicts on people. And the positive impact that these campaigns has had on countless lives as well as the massive savings to the health system are indisputable.

But could constant exposure to all this negative psychological  imprinting be producing a  nocebo effect, and actually  increasing the incidence of smoking related illness and even the death rate amongst those who have been unable to give up smoking?
Unable or unwilling to give up, do many smokers actually develop a belief that they are going to suffer lung cancer, or heart disease, or stroke? What effect would such belief have on their health?
Or do they just become de-sensitised to the whole thing?

13 Responses to “is the nocebo effect killing our smokers?”

  1. Well, smoking IS a major risk factor for avoidable disease and disability and for premature death. Making it known has helped a lot a people to quit and thus avoid disease, disability and premature death. Let’s not forget the basics…. .

  2. I had an intuition about the damaging effect of this anti-tobacco campaign, and since I was’nt able to quit, I devised ways to avoid getting exposed to this abuse. Too bad that I see so many people missing the point of all this. It is not a question of whether it helped some people quit smoking. You can also make them quit by pointing a gun to their head. Or putting them in jail. There are many legal products that can be hazardous to one’s health or well being. Were sufficient evidence was available, they shoul be made illegal. That process will ensure that in a court of law, all arguments will be presented. At this point, when it comes to smoking, only one side is allowed to speak. I have been a smoler for 40 years and learned how to avoid the most dangerous products, low quality, filled with chemicals and so on. I do believe that a high quality, natural tobacco product, when used in moderation poses no more risk than eating a hamburger, probably even much less. To be told that if you smoke you WILL die of cancer or other smoking related didease is a lie that discredits a health care professional in my opinion.

  3. This is something which has seriously bothered me since the warning labels came in in the UK a few years back. Smokers know that it is bad for them but I think that reminding smokers of this EVERY SINGLE TIME the have a cigarette and placing extremely graphic images on the packs is going to have an extremely negative effect.

    Also in this time I’ve observed public attitudes towards smokers decline heavily, I’ve even had somebody try to physically attack me for standing outside near a wall smoking.

    Apart from this many of the warnings are simply propaganda such as the one about smoke containing cyanide, yes smoke does contain cyanide but at a very low level, lower than many foods.

    I’m fine with banning smoking in restaurants etc but the restrictions go way too far when you’re not aloud to smoke in your own company vehicle (even when you’re alone) and I’d like to see smokers treated like human beings again.

  4. Brilliant hypothesis!!! I am a smoker and I live in
    constant fear that I am going to get either lung cancer or throat
    cancer. After many patch aided attempts, I have been unable to
    quit. When I hear that someone has quit, I grill them about how
    they stopped and get a little jealous. I really do believe that my
    constant worrying from daily barrages from people and the media are
    having a negative effect on my psyche and my health.

  5. Aha, another easily seized excuse. It wasnt the cigarettes that killed me, it was the nasty government with their terrible pictures. So what will happen when all the cigarettes go in plain packaging, will people not die? And what about all those people who smoked in WW1 and WW2 when smoking was sexy and fun, did they all live long, healthy and happy lives because they believed they would? What about passive smokers and children, do they develop illnesses purely because they are told they will?

    Being told you are terminally ill and about to die in 3 months is very different from being told you may shorten your life span and develop cardiovascular disease in your 60′s when you are 20. The resulting psychological effects of depression and withdrawal that create the self fulfilling prophecy are simply not the same.

    Im married to a smoker who has tried many times to quit. Our first child died from SIDS – much more common in families of those who smoke – and certainly not due to the nocebo effect as 5 day olds cant read.

    Cigarette smoking can increase your risk of developing serious illnesses, that is a fact. If you chose to smoke, be honest, its because you enjoy it and youre willing to take the risk or you believe it wont happen to you (in 24 years Ive lost count of how many patients told me their grandma smoked a pipe and lived to be a hundred and forty three). Thats fine, its your choice.

    Actually i think photographs of oozing arteries on McDonalds and other fast food packaging is a good idea, though making the doorway only 2 feet wide might be more effective.

    Without doubt, some people who smoke are also very fit. Now. They may live to be 143 and remain fit and well, but they will be in the minority, and not because everyone else saw a nasty picture, but because they have won the genetic lottery of life.

  6. I’m so glad people are starting to look into this. I find it phenomenal that while science clearly accepts hypochondria as a real illness (which basically causes people to physically become sick because they believe they will) that there is no “opposite effect” phenomenon (meaning that if a person’s default belief is that they are healthy, they are. Clearly the mind has a lot more to do with things than Big Pharma would like to admit.

    Personally I love tobacco. I don’t like additive chemicals, which I why I smoke American Spirits. I haven’t taken a Western Med in about eight years. I never get sick. Serious. My immune system has strengthened to an amazing level. I run half-marathons. I look at the roots under my inner stressors, and work on myself to remedy them. I work with medicinal plants in the Amazon, plus tobacco, and my body is okay with moderate amounts of beer. I don’t like hormones and antibiotics and all that crap. That’s MY body.

    Everyone’s body is different, and will speak clearly if the individual will let it. I don’t think tobacco is a matching plant for everyone, but for some, with the right mentality (including an APPRECIATION for tobacco, rather than a love/hate relationship), balanced with a health-focused lifestyle, I feel that to make blanket statements about what is right or wrong for each person’s body is inaccurate. People can figure out where their “too much” point is (if you’re coughing and wheezing, it’s likely overkill.) I know much more about my own body than anyone else, and if they decide to add that ‘smoking kills’ label on the cigarettes here, I will transfer them to a pretty pack so my mind doesn’t weaken my body.

  7. Long have I pondered whether there is a reverse placebo effect associated with the so-called health warnings that wowsers have forced upon smokers. It is only recently that I came upon the term “nocebo” and now have a name for my long held suspicion. The campaign against smokers is nothing more than discrimination and minority bashing. The argument that smokers place a strain on our health system is totally ludicrous. I’m sure that if all the smokers in this country had never smoked they would still sicken and eventually die, albeit a couple of years later than if they hadn’t smoked. Those making claims that smokers are taxing our health system must be trying to say that if we don’t smoke we’ll never get ill and we’ll be immortal, because that’s the only way a non-smoker can claim that they’re less of a burden on the health system. In fact, if non-smokers do live longer, then it is they who’re likely to more heavily tax the health care system.

    The systematic social alienation conducted against smokers probably has more to do with health issues than smoking itself. How healthy can someone be who’s stressed and worried by health warnings and then to top this off has the indignity of being legally discriminated against and being treated as a total social pariah? The resultant lowered state of self-esteem generated by systematic smoker bashing has much more to do with any poor health experienced by smokers than smoking itself. Then to compound the issue the government levies enormous taxes from smokers, trying to give the public the impression it’s being directed into the health care system when the actual figure is only around 5 percent. As the majority of smokers tend to be at the lower end of the socio-economic spectrum, this high level of taxation puts even further strain on their mental health. The smoker who tries to quit and can’t achieve this is made to feel as if they are weak by the smoker bashers, further compounding the deleterious effects upon the smoker’s mental health by the lowering of their self-esteem. The legal discrimination against smokers can in no way be seen to have a beneficial effect upon the smoker.

    The whole campaign against smokers is a result of nothing more than totally inadequate, small-minded, non-critical, linear, Newtonian thinking. I charge that our governments, the AMA and the Anti Cancer Council have much more to answer for in relation to the deleterious effects upon smoker’s health than cigarettes actually do. The anti-smoking campaign is nothing more than a surreptitious, systematic attack upon the mental health and well-being of the socio-economically disadvantaged to satisfy nothing more than political and financial agendas.

  8. I have struggled with smoking for years. You see, when I give up, I feel I am missing a good friend. This feeling stays no matter how long I give up for. It’s also really hard giving up.

    I am now a happy smoker of 8-10 daily. It is such an enjoyable part of life for me I am happy to take the risk.

    Studies show that inactivity confers the same level of cardiovascular risk as smoking. So instead of giving up smoking, I run hard, (15:30 3 km run up big hills) do regular indoor rockclimbing and work out with weights. I can outrun and outclimb and outlift most nonsmokers my age. I also have lots of fruit and vegetables and nuts and dark chocolate.

    I have noticed that a lot of people don’t believe they can exercise until they give up. Perhaps that explains the much increased mortality from smokers today compared to 50 years ago. The feeling one cannot exercise until one quits is a major nocebo effect.

    We talk about harm reduction with heroin. We should discuss it with smoking; but often it seems that anti-smoking is a fundamentalist religion and this is not allowed. It’s like talking to a Christian fundamentalist about contraception for teenagers.

    What would happen if we put nasty fat filled artery pictures on McDonalds fries packets?

  9. I as a smoker have become desensitized to the health warnings, even though I have just watch my husband die of COPD after 3 long years.
    Our hospital has recently introduced a smoke-free workplace, and it has actually become a chore to go and have a smoke – and boring to boot. It has stopped a lot of the social interaction that went on when you ‘went for a smoke’
    You now feel like a criminal standing in the black square – especially since the camera went up! You also begin to realize how stupid it looks to see a group of adults puffing away.
    The downside is that the minute you leave work you try to catch up on the lost smokes – and I have actually smoked more since the smoke ban went on at work.
    Damned if you do … or don’t.

  10. I’m a great believer in this. Like the widows who pass away not long after their husbands (“die of lonliness”) or even the people who think that generic medicines dont work. I think it’s got a lot more to do with psychology than physiology.

  11. Yes, you’re probably right there. It’s like affirmations – you read it, see it, say it and you start to believe it could be, or is so. Also why we sometimes let those negative friends go.

    Yet another thought provoking piece, thanks

  12. In my experience, my patients seem similar to Jen’s (and I don’t live in New Jersey). The patients who keep smoking are the ones who also drive too fast and eat at McDo’s daily and…. think they will live to be 100.

    It’s only once they start believing that it has caused their current illness (and my COPDers all say things like, well, I worked at that place with the dust for four months back in the 60′s… no, I think my smoking has nothing to do with it) and will eventually kill them, that the majority figure out how to quit.

    So risk/benefit ratio over the nocebo? Hmm, I’d still go with the scare tactics.

  13. I dunno. Most smokers that I know (myself formerly included) know that smoking is harmful, but believe themselves impervious. When I speak to patients about the dangers of smoking and the benefits of quitting, I often talk about my own experience quitting, including the fact that I didn’t think it affected me, yet I feel so much healthier since quitting. Most of them reply with something along the lines of “I don’t have any real health problems because of it, and really it helps me stay calm.”

    Maybe that’s just New Jersey.

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