f,'AY 2
NOTES ON THE 1988 SURGEON GENLkAL'S REPORT
ON NICOTINE ADDICTION
GBG 5.20.88
Overall comment
The initial impression of the report is strong
because of the
Sugeon General's image, but its substance is less
convincing and
way contain fatal flaws.
The Surgeon General (SG) has redefined the
criteria for
addiction, borrowing selectively from the
controversial and
often discordant definitions of the WHO and the
American
Psychiatric Association, and adding a few ideas of
his own. For
all his labors, the SC still has to stretch points
a long way in
order to fit nicotine into the mold.
As a result the report trivializes the concept of
addiction in
two ways. It implies that heroin, cocaine and hard
drugs are in
fact as mild as smoking, and Vy opening wide the
definition it
leads people to conclude that many common
substances - sugar,
coffee, aspirin... - come to be defined as
addictive. It is
likely that a substantial fraction of the public
will perceive
this inconsistency and will come to doubt, albeit
subconsciously, the SG's credibility. This is an
error of
overconfidence and overreaching that_could most
likely diminish
the efficacy of the report.
The report makes repeated reference to its
"scientific" nature
as a badge of objective endorsment. In fact its
self-styled
definition of addiction is anything but
scientific. This effort
- and also the definitions of the WHO and the
American
Psychiatric Association - are semantic gropings at
defining a
rather subjective concept loaded vith value
judgment, cultural,
ethical and professional perceptions. rn this
sense the
definition ends up to be commonly accepted and
validated only
if it reflects public perception. So far the
public perception
of addiction has been in association with
behavioral extremes,
and certainly not with cigarette smoking. As a
consequence the
SG report ought to be perceived a forcible attempt
to change
some trivial form of individual behavior, and will
raise the
question of -fiat kind of behavioral agenda does
the SC have for
Americans. Until the SC sticks to objectively
defineable
diseases and generally accepted concepts he may be
doing what he
is expected to do, buL the redefining of
behavioral standards to L,-4
suit his agenda MAY be open to question.
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The SC may be an excellent pediatric surgeon, but
simply because
he once successfully separated Siamese twins does
that make him
the beha,-ioral arbiter or America? If it is not
his personal
agenda, what are the real motivations of the
Department and of
the other self-styled defenders of public health?
How much
influence and power do they buy by pounding on an
issue that
they have suceeded in making appear &a fair game?
Ali these questions come in sharper focus as one
goes through
the substance of the report. The chapter that
deals more
directly with the alleged addictive properties of
smoking and
nicotine does so on the basis of scientific
evidence either
gathered in self-injection animal studies of
dubious relevance
to smokers, or on the basis of studies with hard
drugs, whose
results are inductively compared with nicotine. In
other terms
the report builds a case against nicotine largely
by editorial
association with hard drugs, rather than on
independent
scientific evidence. The reason is that such
evidence does not
exist and cannot be produced.
The report could not have ignored the positive
behavioral
effects of smoking and nicotine without being
accused of
dereliction and bias. The chapter on thi-s subject
gives a
surprisingly extensive review of the literature,
even though
there is a constant effort to downgrade and
belittle the
significance of such effects and the validity of
the attending
scientific research. With all this bias, the
chapter unwittingly
makes a strong point to illustrate the good and
simple reasons
why some people smoke, and why the habit cannot be
given the
negative connotations that the commornly accepted
definition of
addiction implies. Likewise, the last chapter on
the toxicity of
nicotine struggles mightily to paint a dark
picture, but the
facts reported speak of its relative safety to any
objective
reader. At smoker's doses, nicotine appears no
less safe than
physiologic neurotransmitters endogenously
produced, such as
dopamine, AC44.~Ilcholine, and GABA. Just as those
substances, it
becomes 6aversiv ~) and acutely toxic once certain
thresholds are
exceeded.
The credibility of the report will be undermined
in the long
run, because its gross exaggeration is untuitive
to most people.
At best it could have made a case against the
abuse of smoking,
a concept that everyone might agree on. but then,
defining abuse
would be equally difficult. Do we put restrictions
on the sale
of food because some people are compulsive eaters?
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Specific comment
p.i. There is a blank unsupported statement that
the
pharmacological and behavioral processes or heroin
and cocaine
are similar to those of nicotine.
p.iii, It states that tens of thousands of studies
certify to
the dangers of smoking. This is an implicit
admission that the
studies are not very good, or else there would
not'be a need for
such numbers if the case against smoking were all
that clear.
p.iv, Some of the addiction criteria obviously
inappropriate for
nicotine are : 1) a user's behavior is larxely
controlled by a
psychoactive substance. 2) there is a compulsive
use of the drug
despite damage to self and society.* 3) drug
seeking behavior
takes precedence over other important priorities.
4) Greater
doses of the drug (tolerance) are increasingly
necessary to
achieve the same effects.
p.iv, The report admits that the evidence comes
from animal
studies. It fails to mention that such studies are
largely
irrelevant to man.
V.vi, Takes a jab at the RJR artificial cigarette.
%
p.7, One of the criteria for defining addiction is
that a
substance is "pleasurable". That has definitive
overtones of
prohibitionism.
p.168, States that the machine yield of a brand or
the number of
cigarettes smoked per day have Little relationship
to nicotine
intake.
p.190, . bottom. States that in self-injecting
animals the
response rates are much lower for nicotine than
for cocaine. It
fails to mention that there may be a thousand fold
difference.
p.192, top. States that nicotine usage is
determined by
environmental stimuli, such as stress. It
implicitly admits that
smoking is not self triggered - as a true
addiction is - but is
a response to external stressors.--Z
p.287, The list of physical dependence criteria
are certainly
not met by smoking or nicotine.
Chapter V, Addiction. Talks mostly of hard drugs
and stuggles to
establish a parallel for nicotine.
%'
Chapter Benefits. Struggles to downplay the
obvious
behavioral existential benefits of smoking. Also
at p.
~nd 468
92.
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