Circulation: BATCo No ls/Public Affairs Managers
Scientific Research Group
Enclosed are some views on the Surgeon-General's
20th report: "Nicotine
Addiction" published earlier this week. Please do
not hesitate to contact
me for any further information that is required.
kc-
Dr Sharon Boyse
Corporate R&D Department
Millbank
cc Mr N R Cannar
Mr R L 0 Ely
20 th May 1988
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The 20th Report of --he Surgeon-General makes the
following conclusions:
- Cigarettes and zther forms of tobacco are
addicting.
- Nicotine is the drug in tobacco that causes
addiction.
- The pharmacolog:c and behavioural processes that
determine tobacco
addiction are similar to those that determine
addiction to drugs such
as heroin and c:caine.
The Surgeon-General uses the following criteria
for drug dependence (or
addiction):
Primary criteria
Highly controlied or compulsive use
Psychoactive --ftects
Drug-reinforced behaviour
Additional critcria
Addictive behaiiour often involves:
sterotypic pa::--erns of use
use despite hE--mful effects
relapse folloving abstinence
recurrent drug cravings
Dependence - ;roducing drugs often produce
tolerance
physical depenience
pleasant (euphcriant) effects.
1. It is well-knou-n that there has been
considerable conflict among
scientists in de-i-eloping a satisfactory
definition of
addiction/depend.--nce and the criteria that can
be considered as
representative cf addiction. Even bodies such as
the World Health
Organisation, the American Psychiatric Association
etc. have
recognised this eifficulty, and have produced
definitions that have
not been universally accepted.
The Surge on-General has produced his own list of
criteria that he
considers to be important. This is open to exactly
the same
criticisms as earlier definitions and need not be
viewed as
definitive. In fact, more importantly, the
Surgeon-General's
definition of addiction differs in various
important ways from
previous definitions (see below). Unfortunately,
the changes made
have made it muc_~ easier to compare nicotine with
addicting drugs than
was previously passible; nicotine could not
convincingly be
incorporated int-- traditional definitions. So,
for example, we find
that the Surgeon--~,eneral:
M has relegated certain criteria of addiction to
the bottom of his LZ4
league table. Unfortunately, these happen to be
the criteria C30
that have a2lways been agreed to be critical to
any definition of C)
addiction: talerance, physical dependence, and
euphoria. These Ul
also happe= tto be the criteria for which
conviincing evidence on Uj
nicotine has never been forthcoming (see below).
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(ii) These important criteria now, take second
place to some rather
vague, new criteria e.g. 'psychoactive effects'
and
,drug-reinforced behaviour'; reasons why it is
rather strange to
consider these criteria as primary are discussed
in detail below.
2. The simplest way of considering the
Surgeon-General's argument and the
reasons why his theory that nicotine is addictive
is not acceptable,
is to consider each of his criteria in turn, and
the evidence for
nicotine's relevance to each of these criteria.
Even with the ,
Surgeon-General's new definition it is apparent
that nicotine does not
fit comfortably into his scheme.
Hijthlv-controlled or compulsive use
Compulsive use has been a component of many
previous definitions.
Compulsive use, as elaborated by the WHO (1957)
is: "... an
overpowering desire or need (compulsion) to
continue taking the
drug and to obtain it by any means". This degree
of 'compulsion'
hardly seems to apply to tobacco; many smokers
have interesting
patterns of smoking behaviour by which they smoke
at work but not
at home, and vice versa. This is hardly
characteristic of
'Compulsion'.
Psychoactive effects
Any drug that affects mood or behaviour in any way
is generally
classified as a psychoactive drug. This does not
mean that any
psychoactive drug is addictive. For example,
caffeine is
classified as a psychoactive drug, and by this
line of reasoning
coffee would be addictive. Antidepressants are a
major class of
psychoactive drug because they alter mood, but
there has never
been any suggestion that they are addictive.
Nicotine's
psychoactive effects are extremely difficult to
measure and by no
means as apparent as the psychoactive effects of
heroin,
amphetamine, alcohol, valium etc.
This criterion has never appeared in any major
definition of
addiction/dependence in this simple form.
As support for the inclusion of this criterion,
the
Surgeon-General says that, "to distinguish drug
dependence from
habitual behaviours not involving drugs, it must
be demonstrated
that a drug with psychoactive (mood-altering)
effects in the
brain enters the blood stream". However, this
distinction is
inherently illogical for the following reason:
psychoactive drugs
are able to alter mood and behaviour because they
mimic the
effects of natural I y-occur i ng chemicals in the
brain that are
responsible for normal behaviour not involving
drugs. On the
basis of what happens in the brain under normal
circumstances, it
is not possible to qualitatively distinguish
between 'normal' and
drug-induced behaviour. The difference is, in
fact, usually a
quantitative one (more of a particular chemical
present;
increased activity of particular brain cells). L-4
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3. DruR-reinforced behaviour
This criteria is included on the basis of studies
carried out in
animals. Some evidence shows that the behaviour of
laboratory
rats (e.g. pressing a lever in a box) is
'reinforced' by nicotine
i.e. rats will press a lever as a result of which
they obtain a
nicotine injection. However, this finding has to
be put into
perspective: it is well-known that laboratory rats
will also
press a lever to obtain food, water, milk,
saccharin, chocolate
... 'Addiction' is not a necessary corollary.
Also. early
studies in this field suggest that is extremely
difficult to find
the correct circumstances under which rats can be
induced to
lever-press for nicotine. With drugs such as
heroin, rats will
work extremely hard for the compound under any
circumstances e.g.
they will press a lever thousands of times to
obtain one
injection. This is not so with nicotine.
4. Stereotvpic patterns of use
This means that a behaviour may develop into
regular temporal and
physical patterns of use. It is a characteristic
pattern of
human behaviour to adopt 'stereotypic' patterns of
doing things
i.e. meals tend to be taken at particular times,
tea and coffee
are taken at particular times, people sleep at
particular times.
There is no evidence that cigarette smoking is a
particularly
unique example of a stereotypic pattern of
behaviour; in fact, it
is frequently less stereotyped than food intake!
Use despite harmful effects
Whether or not cigarette smoking causes certain
diseases has
still to be established and further scientific and
medical
research is required. However, even if it should
be established
that it constitutes a health risk, humans
frequently indulge in
behaviour that may involve potentially harmful
consequences e.g.
flying, driving. The fact of participating in an
activity that
has a risk associated with it does not mean that
one is addicted
to it. In spite of regular warnings by health
officials that
certain behaviour (e.g. eating certain types of
food) mav entail
harmful consequences, these behaviours are
continued. In many
previous definitions of addiction 'harmful
consequences' has
tended to refer to harm to society. This may well
be the case
for drugs like heroin, when a breakdown in the
psychological
functioning of the individual may lead to serious
consequences
for society e.g. crime etc; however, it can hardly
be applied to
cigarette smoking.
6. Relapse following abstinence
Many definitions of addiction have cited. as a
preferred
criterion, difficulty in abstaining; however, with
cigarette
smoking this does not apply as millions of people
worldwide have
given up successfully. Once they have given up,
some people do
indeed begin smoking again. However, this does not
mean they are
'addicted'. It may mean that, for them, the
perceived benefits
of smoking (improved concentration etc. - see
David Warburton)
are great enough that they prefer to continue to
smoke. People
frequently give up certain behaviour or habits,
only to begin
again.
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7. Recurrent drug cravings
The Surgeon-General defines this in the following
way: urges
(cravings) to use a drug may be recurrent and
persistent.
'Craving' is a rather tenuous concept that no-one
has been able
to define satisfactorily. Again, it does not apply
solely to
drugs, and certainly not solely to 'addictive'
drugs. People can
'crave' for anything that they enjoy doing, once
they are
deprived of it or are not able to do it at a
particular time,
e.g. sex. Are all such behaviours 'addictive'?
Tolerance
Although 'tolerance' apparently occurs quite
rapidly to the
initial effects of cigarette smoking e.g. nausea,
dizziness,
there is little evidence that tolerance develops
to the
'psychological' effects of smoking (e.g. stress
relief, improved
concentration etc). The idea of tolerance of
necessity carries
with it the assumption that as you habituate to
the effects of a
substance, it is essential to take in more of it
to try and
regain the initial effect. This does not occur at
all with
cigarette smoking. Smokers rapidly arrive at their
preferred
number of cigarettes per day, which can vary
widely. This
pattern tends to remain stable for years and there
is little
evidence that people increase their level of
smoking as they get
older. In fact many smokers in recent years have
switched from
high tar (and therefore high nicotine) cigarettes,
to low tar
(and therefore low nicotine) cigarettes. This
argues totally
.st tolerance and dependence.
9. Physical devendence
The existence of physical dependence is an
inference made from
the observations of a stereotyped withdrawal or
abstinence
syndrome that occurs in the vast majority of users
when a
chronically-administered drug is discontinued.
Shiffman (1979)
concluded that "... the presence of an abstinence
syndrome is
crucial to the definition of drug dependence".
However, there is
considerable doubt as to whether any symptoms that
smokers may
experience when they stop smoking are a result of
true
withdrawal, or merely symptoms of frustration
encountered by many
people when they decide to give up something that
they enjoy.
Cigarette 'withdrawal' symptoms', such as they
are, differ widely
from one individual to another, are totally absent
in many people
that give up smoking, and are minor compared to
symptoms that
occur upon giving up drugs like heroin.
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10. Pleasant (euphoriant) effects
Euphoriant effects tend to go hand in hand with
behavioural
intoxication e.g. alcohol is a euphoriant, and by
and large
intoxication accompanies (or is a result of) the
euphoria. No
behavioural intoxication accompanies cigarette
smoking or intake
of nicotine. One of the major studies that has
been used to
suggest that nicotine is euphoriant is a study by
Henningfield
(1984). In this study nicotine -as compared to a
series of drugs
such as cocaine and heroin, and was reported to
produce similar
levels of ratings of euphoria by subjects.
However, this study
has been extensively criticised (e.g. by David
Warburton) because
the ratings of euphoria were so variable that in
some cases
subjects who took placebo (no drug) rated it as
euphoric! This
is apparent when one examines the data from the
study, but is not
stressed in its conclusions.
3. Conclusions
The Surgeon-General's report concludes that
nicotine, and therefore
tobacco products are addictive. However, this
conclusion is based
upon a novel definition of addiction that has many
flaws and contains
many new criteria which other eminent scientists
have not considered
to be appropriate to the question of addiction.
Furthermore, even if
one adopts the Surgeon-General's criteria, it is
still debatable
whether nicotine fits the criteria. Hany aspects
of the behaviour of
cigarette smoking which would argue against his
theory are not
considered in the report.
Dr S Boyse
Corporate R&D Department
BATCo (Millbank)
SB/LES
20 th Hay 1988
BATCo document for Province of BritiSh Columbia 29
October 1999