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Chapter 4

She stops to scrub her hands on the way back indoors after her mid-morning cigarette. As she washes, she explains that she doesn't want to smell like a smoker.

She puts her cigarette lighter back in her purse and we settle back into our chairs in her office. I ask how she knew it was time to smoke a few minutes before.

"I wanted a cigarette," she says. "I felt like it for about a half an hour before I told you, twenty minutes maybe. How do you know when you get thirsty? It's a part of your life if you're an addict, as I am. It's just a part of your life. You don't even think about it."

What does it mean to think of herself as an addict?

"I'm not proud of it at all. Many times, I wish I weren't an addict. Any addiction rules your life. It rules my life. If I can't have a cigarette, I start getting irritable, cranky, and unmanageable." She growls, but cutely. "It's like a bad hair day."

So, I ask, do you structure your day around smoking?

"I have one before I come to work, one once I get to work, one at 10 or 10:30. I eat lunch and I have one after I eat. I have one anywhere from 2:30 to 3:30, somewhere around in there.

"Here's the thing," she continues. "I go back to the fact that it's an addiction. Every person who is addicted has times when they're embarrassed or disgusted with their addiction. There were times when I was embarrassed to be a smoker, because of who I was around. I'd think, oh, God, if they find out I smoke, then they won't like me anymore, because smoking is disgusting. Which it is. They won't want to hang out with ashtrays. They won't like that smell.

"I get disgusted with myself because I find that so far I haven't been strong enough to beat the damn thing. But mostly I'm embarrassed because I feel like it's a weakness." She pauses, considering what she has just said. Then she reiterates, with emphasis: "It's a weakness."

And does she ever have the "I can't believe I ate the whole thing" feeling?

"I guess I've just kinda gotten used to that. I've smoked when I was out with friends at night, and then the next day I've said, 'I can't believe I smoked so much last night!' But it's never been that I was amazed at the amount; I was amazed that I was so unaware of it."

It is different, she knows, for some people.

"I have a couple of friends who are social smokers. They smoke mostly if they go out, they smoke once or twice a day or once or twice a week. I wish I could do that, and I can't. Once I quit, I can't ever let that happen again."

So that's something you learned from quitting? I ask. You learned that once you quit, you can't even let yourself smoke one or two cigarettes socially?

She shakes her head. "I tried that, a long time ago. It's like being an alcoholic. Stay away from that first drink. All the others don't matter. It's that first one."

Myths and Mysteries
of Addiction

When a row of tobacco executives held up their right hands and testified to a U.S. Congressional committee that nicotine is not addictive, many people were displeased, but few were surprised. It wasn't new news. Dog bites man. Ho hum.

But when, in 1997, a tobacco company conceded that tobacco is addictive and that the company had known it all along, it was news indeed. Man bites dog, and the ensuing reports even made the cover of Time magazine. Never mind that millions of people, among them millions of smokers, already believed that nicotine is addictive. The news was that the tobacco industry was beginning to admit what many of the rest of us already knew. By early 1998, tobacco company executives stated that they knew it, too.

Oscar Delgado knew. An ex-smoker, he participated in the second 1996 presidential debate. He had one question to ask a candidate. As America watched, Delgado rose from the back of his section and addressed the candidate. "About 30 years ago, I was a pack-plus-a-day man, okay?" Delgado addressed his question to former Senator Bob Dole, who would later lose the election.

"You mentioned in a statement . . . some time ago that you didn't think nicotine was addictive," Delgado commented. "Would you care to . . . hold to that statement, or do you wish to recant, or explain yourself?"

"Oh, that's very easy," Dole replied, citing his voting record. Then returning to the question, Dole mused, "Are they addictive? Maybe they're—they probably are addictive. I don't know. I'm not a doctor." It was, he said, a "technical question."

His comment was pondered by many analysts, among them a psychiatrist writing for the Wall Street Journal the following summer. She provided the answer that, she claims, one pundit wished Dole had said: "Clumsy me," she parodied the response Dole should have given, "I got all tangled up in a technical matter—the nature of addiction—when all that I meant was . . ."

That wasn't the answer Dole gave, although it does consider the technical nature of the question of addiction. Behavioral scientists, psychopharmacologists, clinicians, and others studied this issue for decades, trying out this definition and that, before settling into what are now useful, if contested, terms.

The Elusive "Addictive Personality"

In Stephen Vincent Benet's epic John Brown's Body, the fictional belle Sally Dupré was like a forbidden fruit to young Clay Wingate, who fancied her. A soldier in the Civil War, Clay knew that if he so much as kissed her once before going off to fight, his heart would be unalterably turned toward her. "Your mouth is generous and bitter and sweet," Clay mused. "If I kissed your mouth, I would have to be yours forever." To a degree, this image depicts the fear of many people about addiction. They blame not the substance itself, but rather themselves for being addiction prone. They decide, with grim acceptance, that there must be something wrong with their personality.


50% younger adult U.S. smokers who are nicotine dependent (addicted)
87% older adult U.S. smokers who are nicotine dependent
three-fourths U.S. smokers who say they are addicted
78% U.S. smokers who say they could quit if they decided to
two-thirds U.S. smokers who say they wish they could quit
four-fifths U.S. smokers who say they wish they had never started

A common cultural belief holds that some people are drawn like magnets to abusable substances and potentially compulsive behaviors. One drink, and they're alcoholic. One smoke, and they're addicted to nicotine. Whatever the substance, compulsion, vice, or temptation, it is supposedly the nature of their personality or their chemistry to be drawn toward it, to embrace it, and to be unable to abandon it. Believers in this notion apply the concept to an array of human behaviors. Those with this weakness, some believe, have an "addictive personality." It is their nature to be addicted easily and permanently.

Scientifically, however, this notion is unsupportable. At its core is a misapplication of several established, replicated research findings, including the following:

Despite heroic efforts and the expenditure of many research dollars, science has never been able to establish the existence of an addictive personality style that predisposes people to a variety of addictions and compulsions. Convincing the general public that this phenomenon does not exist may be difficult, since we have become accustomed to hearing about "chocoholics" and "foodaholics," and since the concept of an addictive personality offers a simplistic, intuitive explanation. In reality, the notion of the addictive personality remains unproven, undemonstrated, and most likely incorrect.

Has Science Ever Defined Addiction?

Well, yes and no.

Facts exist independent of who is citing them or whether the person is using them correctly; it is the way they are cited that frames their interpretation and results in misapplied meanings. Few areas of substance abuse debate are as riddled with ambiguous meanings and syntactical nuances as is the word addiction.

Some tobacco-financed researchers and industry supporters have asserted that one reason for not believing that nicotine is addictive is their claim that science has no adequate, consistent definition of the term addiction. This claim surfaces in such diverse places as peer-reviewed scientific journal articles, newspaper columns, litigation, and testimony before Congress. To the contrary, scientists with no financial ties to the tobacco industry have argued that the question is not one of defining addiction, but rather one of defining the properties of nicotine itself. Whether or not we use the word addiction, does nicotine have traits in common with substances that we commonly identify as addictive?

Some scientists defined addiction to their satisfaction several decades ago, but the word was appropriated into other contexts and stripped of its precise meaning. The term was first applied to chronic use of opiates, including morphine and heroin. Originally, addiction was identified primarily by compulsive use, physical dependence, tolerance, and damage to the user and society. Readministration of the substance was found to relieve abstinence-related withdrawal symptoms, leading to the concept of physical dependence as a "central defining characteristic of addiction," as explained by pharmacologist Caroline Cohen, writing with colleagues Wallace Pickworth and Jack Henningfield.

When the term drug addiction became associated with pejorative images, the World Health Organization recommended using the term drug dependence. As Cohen explained, drug dependence is a "psychic and sometimes also physical" state marked by a compulsion to use a given substance continuously or periodically to experience its effects and sometimes to avoid the discomfort brought on by its absence. This state may or may not include tolerance. People can develop both tolerance to drugs and physical dependence on drugs that are not abused. Similarly, patients in experimental settings do not seek out some drugs despite having developed tolerance and physical dependence.

Cohen clarified: "Addictive agents have one common attribute: the creation of a behavioral response repertoire often referred to as 'psychic dependence.'" While some would claim that "psychic" dependence differs from physical dependence, this view denies the fact that psychological dependence has a physiological basis.

When it became fashionable to label as addictive such diverse activities as compulsive gambling, overeating, and frequent sex, the word addiction lost its moorings. Nonetheless, the term still can be applied to any drug use that involves "drug-seeking behaviors," compulsive use of the substance, denial of the consequences of using the substance, and relapse after cessation.

The scientific and medical communities have moved away from the term addiction and shifted instead toward the term dependence as a way to describe serious substance-use disorders, including addiction to nicotine. Dependence is a precise term with specific published criteria and implications. To meet criteria for dependence on a substance, someone must have experienced at least three of these symptoms:

These criteria, published in the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association and thus used for formal diagnosis, have become the basis for identifying and researching numerous substances of abuse, including hallucinogens, amphetamines, opiates, alcohol, and tobacco. Although they are codified, they are by no means universally accepted by the scientific community or applied in research paradigms. Some researchers choose to define addiction and dependence much more simply: the inability to stop a drug-reinforced behavior when one wants to stop.

The concepts of dependence and its less severe cousin abuse provide a useful heuristic for understanding what constitutes nicotine addiction. Although they have become a gold standard of sorts, they are not the final word. For example, The National Household Survey on Drug Abuse included four key questions to determine nicotine dependence, as part of a much larger survey about overall substance use:

These questions were not a comprehensive measure of nicotine addiction and did not measure all symptoms of nicotine withdrawal. Thus they probably underestimated the proportion of smokers who would qualify as dependent. A 1989 committee reporting to the Royal Society and to Health and Welfare Canada defined drug addiction as this: "a strongly established pattern of behaviour characterized by (1) the repeated self-administration of a drug in amounts which reliably produce reinforcing psycho-active effects, and (2) great difficulty in achieving voluntary long-term cessation of such use, even when the user is strongly motivated to stop."

Cohen and her colleagues added to this definition of dependence their summary of compelling research evidence that smoking is "a highly controlled or compulsive behavior." The control in smoking comes from the precision with which smokers obtain nicotine to maintain consistent blood levels. They cited as proof the consistent patterns of cigarette smoking; the gradual increase of cigarette intake over time until a stable level is achieved; and the findings that more than three-fourths of current smokers say they would like to quit, and two-thirds have made at least one serious attempt.

Additional evidence of nicotine's addictive nature is that it is considered rewarding by smokers, even to the point of being what Cohen and her colleagues called a "potent euphoriant."

Addiction or Habit?

Calling smoking merely a "habit" troubles many scientists who study the effects of nicotine and tobacco. "One of my linguistic pet peeves is the use of the word 'habit' in reference to smoking and tobacco use," wrote Ronald Davis, former director of the U.S. Office on Smoking and Health, now editor of the journal Tobacco Control. He decried the repeated use by the tobacco industry of the 1964 Surgeon General's report to justify their claims that nicotine is merely a habit. The 1964 document concluded: "The tobacco habit should be characterized as an habituation rather than an addiction." However, Davis noted, "[T]he industry invariably skips over the preceding paragraph," in which the report stated that habitual use was "reinforced and perpetuated" by nicotine's action on the central nervous system.

The 1964 report did not label nicotine as addictive, referring to it instead as a substance used habitually, like coffee. Those insisting that tobacco isn't strictly addictive latched onto this distinction. A smoker's morning cigarette, they said, was no different than a morning cup of coffee. It must have been disconcerting for them to read reports in respected medical journals in the mid-1990s that caffeine can also be addictive. Quitting caffeine use when one routinely has even a small amount per day can result in abstinence symptoms that often include a nasty headache that can last for days. However, this physical dependence usually is not accompanied by compulsive drug-seeking behavior.

Unlike the 1964 report, the 1988 Surgeon General's report (subtitled Nicotine Addiction) was devoted almost entirely to nicotine's addictive qualities. With the benefit of hindsight, the latter report explained the nuances of terminology and classification that had resulted in the 1964 report, and stated that the terms drug addiction and drug dependence are equivalent.

The debate about whether or not nicotine is addictive has centered on several assertions, as reiterated by R. J. Reynolds researchers John Robinson and Walter Pritchard, who have participated in scientific forums. Robinson and Pritchard argued:

Just how accurate are the tobacco industry's claims? Many scientists and policymakers are skeptical of arguments emanating from researchers on the payrolls of the tobacco industry, even if the arguments have validity and serve to nudge science toward a clearer definition of addiction. The 1988 Surgeon General's report compared nicotine addiction to that of the "hard" drugs, including the opiate heroin. It concluded that tobacco does have many addictive properties in common with other drugs of abuse. As a toxic substance, it often makes first-time users queasy, if not actually nauseated. With continued exposure, users develop a tolerance and can use increasingly larger quantities. When smokers are deprived of nicotine, they may experience measurable, unpleasant withdrawal symptoms. These characteristics, true of many hard drugs, are also well documented for nicotine use.

A small percentage of tobacco users continue to use nicotine at a low level for many years without developing tolerance or dependence. Their personalities, lifestyles, and metabolism of nicotine resemble those of smokers who are nicotine dependent. These low users are not naïve smokers, since they consume many thousands of cigarettes over the years that they smoke. However, they are anomalous smokers. They follow a daily use pattern that remains minimal, and they experience virtually no abstinence effects when they quit using tobacco.

Is the existence of such smokers, as described by Saul Shiffman in 1989, a valid argument against characterizing nicotine as an addictive substance? If nicotine were addictive, according to those arguing against that idea, shouldn't it be addictive for all users? That argument actually works against its proponents; the term chippers, which is often used to describe these low-use smokers, originated with the scientific and medical research on opiate use. The existence of chippers among opiate users does not call the addictiveness of opiates into question.

But staking the determination of nicotine's addictiveness on the slippery definition of addiction seems to beg the question. The imprecision of one term does not change the nature of the substance. No one has claimed that tobacco produces the same "high" as cocaine or the same intoxication as marijuana, at least in the doses commonly used by cigarette smokers. A more fundamental question is whether nicotine fits the profile of drugs known to be addictive, or carries a high risk for leading to chronic use. Thus, the questions addressed by the medical and mental health community are these: Do people become tolerant to higher and higher amounts of nicotine delivered over the course of the day? Do regular users of nicotine experience abstinence effects when they go without nicotine? If the answer is an overwhelming yes, it may indicate a physical dependence. Perhaps it matters little that common usage refers to people being "addicted" to Twinkies, or even that many tobacco-related behaviors can be labeled as habitual.

The nature of addiction is that each substance with a potential for abuse, including nicotine, has a unique profile of use. Each substance requires separate, specific examination. Why should the effects of inhaling nicotine have to be virtually identical to the effects of injecting heroin for the similarities to be worth noting? The commonalities provide evidence that both substances can be used deleteriously; the differences merely illuminate the complex nature of human addiction.

Nicotine in the Brain

From the first cigarette, smoking changes the brain. The brain's billions of nerve cells communicate through the electrical and chemical activity of substances called neurotransmitters. Nerve impulses travel as electrical signals and are transformed into chemical signals. Neurologist Richard Restak described neurotransmitters as being like ferry boats "steaming across a channel toward the 'loading dock,' the receptor on the membrane of the receiver cell."

The receptor cells, or Restak's "loading dock" cells, can increase in number and in activity. When a person uses a large amount of a certain substance (such as nicotine), the number of receptors for this substance increases. Restak described it metaphorically as "the basis for the withdrawal response in addiction when the receptors, deprived of their usual supply of addicting substance, 'cry out' like deserted lovers for the missing chemical." Without the chemical for a long enough period of time, the receptors are "down regulated." The circuits of the brain adapt to the presence of nicotine, whose structure mimics the structure of a naturally occurring brain chemical called acetylcholine, a substance that releases another substance called dopamine.

Molecules of dopamine are released by the brain when pleasurable events occur, such as the everyday enjoyment of petting a cat or eating pizza. Some drugs that alter mood, including nicotine, trigger dopamine in the same way that life's big and little pleasures do. Brain cells adapt to the unnatural presence of these substances by changing both the sensitivity of receptors and the number of receptors.

Quite a different series of events occurs when smokers attempt to quit. Without the customary dosage of nicotine, the brain triggers several reactions that are normally associated with negative experiences such as punishment. As the lower blood levels of nicotine result in reduced dopamine to the brain, smokers experience withdrawal (or abstinence) symptoms, including irritability, anxiety, frustration, and depression. All that is necessary for the negative feelings to flee is for the smoker to replenish the body's supply of nicotine.

Pharmacologists explain the addictive nature of drugs as a reflection of the ability of the substance to enhance the transmission of dopamine at specific sites in the brain. The neurotransmission-enhancing effects of some nonnicotine substances are so strong, for example, that they alone can explain the addictive properties of the substances.

Nicotine is known to evoke an increase in "dopaminergic overflow" in a portion of the brain where neurotransmission-enhancing effects occur. However, not all smokers smoke alike. British researcher Michael Russell, in a 1990 report, identified at least two distinct types of smokers, "peak seekers" and "trough maintainers." The peak seekers are those who smoke to achieve a substantial peak nicotine level after each cigarette. This most likely stimulates the nervous system's central nicotinic receptors. Trough maintainers, on the other hand, smoke more frequently to maintain a relatively constant nicotine level, which results in the same receptors being blockaded so that the "loading dock" cells are closed to incoming transmissions. Peak seekers' blood levels of nicotine dip and rise dramatically over the course of a day, perhaps resulting in repeated stimulation of a dopamine system. Trough maintainers' blood nicotine levels are fairly constant throughout the day. As Scottish scientist David J. K. Balfour explained: "It is possible . . . that [smokers] adjust the way in which they smoke so that [they achieve] the appropriate combination of nicotinic receptor stimulation and desensitization which they find most rewarding." Desensitization refers to a process of diminished responding to a repeated stimulus, akin to the common situation of growing used to something that initially triggered a response.

The stimulation and desensitization processes Balfour described seem to occur commonly in smokers and may be part of why nicotine is addictive. Some scientists speculate that the desensitization effect may be a component of the anxiety-relieving, or anxiolytic, effects documented in tobacco research and evident in so many smokers who turn to nicotine to relieve stress. If this is so, desensitization may involve a different neural mechanism than the one activated by prescription drugs such as Valium (diazepam).

Is Addiction a Disease?

It was not long ago that alcoholism was blamed on lack of character. And it was not long ago that smokers believed they could quit if only they had enough will power. Certainly, strength of character and strong will can boost attempts to overcome an addiction—or a habit, for that matter. Nevertheless, our present understanding of the biology of nicotine addiction offers both clarity and charity. In the last several decades, science has brought some humanity and compassion to our understanding of the conundrum of addiction by showing that human vulnerability to numerous drugs of abuse is widespread. Defining a substance as addictive and defining its overuse as a disorder or a disease have helped free users from the trap of labels. Some people argue that in using a disease model for understanding addictions, we have given substance users a convenient excuse for not changing behavior by hiding behind arguments that their problem is "genetic" or is out of their control. While this claim may be accurate in part, it does not take into account the benefits that may come from biologically based explanations of addiction.

Chipping Away

fewer than 6 number of cigarettes smoked per day by the typical tobacco chipper
none withdrawal symptoms experienced by chippers when they quit smoking
8.2% Australian smokers who are chippers
15% California smokers who are chippers
decades how long the typical tobacco chipper smokes
tens of thousands total cigarettes consumed over a chipper's lifetime of smoking
none cigarettes per day considered safe to smoke

The first addiction to be recognized as a disease was alcoholism. In view of that, some have asked whether nicotine addiction is also a disease. Addressing this question requires that we consider the definition of disease. Whether or not nicotine addiction can be termed a disease depends on the answers to several questions. Is nicotine use under the control of the tobacco user? If nicotine use is addictive, then the onus is outside the individual smoker, even though the initial trials with cigarettes were the smoker's choice. As clinical researcher Norman Miller explained: "The primary foundation for considering nicotine addiction to be a disease rests on the acceptance of the loss of control by the nicotine addict."

Attributing the undesirable consequences of the addiction to "a disease concept" removes the weight of viewing smoking as a "moral dilemma" and thus facilitates the earliest steps toward cessation. Miller added: "[I]nsistence on correcting a weak character or treating an underlying psychiatric or emotional disorder will not initiate abstinence or prevent relapse to nicotine. Nicotine addicts are already filled with self-condemnation, and a further exaggeration of the guilt by making the addicts at fault for their smoking will further impede the addicts' accepting responsibility for treatment of the nicotine addiction and its consequences."

When Russell asked heroin users to rate drugs in terms of being "needed," they put cigarettes at the top of their list. They said that they perceived coping without cigarettes to be more difficult than coping without heroin. Russell concluded in a 1990 report that "cigarette withdrawal is no less difficult to achieve and sustain than is abstinence from heroin or alcohol." Additional evidence of nicotine's powerful pull is in the statistic that between 45 and 70 percent of smokers who survive a heart attack resume smoking again within a year. About half of all smokers who undergo lung cancer surgery take up smoking again.

Where the Argument Leads

Few scientists, and only a small percentage of smokers, doubt that nicotine is addictive, by some definition. Much is at stake in the addiction debate. The risk of the rhetoric is that the realities of tobacco use and the smoking experience will be lost in a terminology war. Discussions over the definition of addiction can become a smoke screen obscuring the more fundamental and burning question: What makes people smoke?

The question of addiction is at the heart of initiatives by the U.S. Food and Drug Administration (FDA) to exert more government controls over the manufacture and sale of cigarettes and other tobacco products. Former FDA commissioner David Kessler testified in unequivocal language that between 74 percent and 90 percent of all smokers were addicted. He summarized in 1994: "Accumulating evidence suggests that cigarette manufacturers may intend this result—that they may be controlling smokers' choice by controlling the levels of nicotine in their products in a manner that creates and sustains an addiction in the vast majority of smokers. . . . Whether it is a choice by cigarette companies to maintain addictive levels of nicotine in their cigarettes, rather than a choice by consumers to continue smoking, that in the end is driving the demand for cigarettes in this country."

Kessler recounted how the one-time "simple agricultural commodity" of tobacco eventually evolved into the production and marketing industry for a "nicotine delivery system." To the surprise of many who heard his testimony, he explained that by reconstituting tobacco stems, scraps, and dust, cigarette makers began controlling and manipulating nicotine levels to achieve maximum addictive potential. He showed charts of patents in which tobacco companies added nicotine to tobacco rods, filters, and wrappers. Other patents indicated control of nicotine levels by extraction and utilization of new chemicals. Kessler stated: "Patents not only describe a specific invention. They also speak to the industry's capabilities, to its research, and provide insight into what it may be attempting to achieve with its products."

He cited the industry's achievements:

"Since the technology apparently exists to reduce nicotine in cigarettes to insignificant levels," Kessler asked, "why . . . does the industry keep nicotine in cigarettes at all?" And, similarly, "With all the apparent advances in technology, why do the nicotine levels found in the vast majority of cigarettes remain at addictive levels?" If nicotine is merely a flavorant, producing a burning in the throat to which smokers become accustomed, "why not use a substitute ingredient with comparable flavor, but without the addictive potential?"

Why not, indeed.

So, Is Nicotine Addictive?

On this question, some argue that the jury is still out. Others argue that the jury has never been presented with an adequate case. Others believe that the verdict was sealed more than a decade ago.

Here is a suggestion for those who aren't yet convinced. This winter, some day when it's 20 degrees Fahrenheit outside and snowing, look outside an office building in which smoking is prohibited. Note the smokers huddled outside in the doorways, braced against the weather. Ask yourself: Are they out there just for the pleasurable sensation of smoking?

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Copyright 1998 National Academy Press