SMOICTNG. NICOTINE AND ADDICTION
How to define "addiction"
It is well known that a satisfactory definition of
"addiction" (ie one
that takes into account all factors that could
reasonably be supposed to
be associated with the problem, and that has
received widespread
acceptance in both academic and regulatory
circles) probably does not
exist. Unfortunately, this state of affairs may
lead to a certain degree
of complacency, based upon the conviction that if
it is not possible to
agree on a definition of addiction, then, by
definition, it should not be
possible to agree that tobacco smoking is or is
not addictive. A much
more pragmatic approach is to consider the
individual components that have
tended to be utilised in the formation of the wide
variety of definitions
that currently exist, and to investigate the
relevance of these particular
components to tobacco smoking behaviour. Such an
approach precludes
falling into two of the many traps that might
await the unwary: that of
supposing that the problem does not exist because
it cannot be adequately
defined, or that of guessing as to what the most
likely definition might
be.
The most widely cited definitions of drug
addiction are given below.
Their acceptance -is generally based more on the
apparent influence of the
scientist or the body that has issued it than the
quality of the
definition per se.
- Definitions that do not include physical
dependence or withdrawal:
United States Narcotic Rehabilitation Act (1966):
An addict is "any individual who uses any narcotic
drug so as to
endanger the public morals, health, safety or
welfare, or who is so
far addicted to the use of such narcotic drugs as
to have lost the
power of self-control with reference to
addiction".
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- Definitions that include physical dependence as
a possible
characteristic:
Maurer & Vogel (1962):
"Drug addiction may be defined as a state in which
a person has lost
the power of self-control with reference to a drug
and abuses the drug
to such an extent that the person or society is
harmed ....... In
addition, one or more of the following related but
distinct phenomena
are always present: (a) tolerance; (b) physical
dependence with
resulting abstinence illness when the drug is with
held; (c)
habituation or emotional dependence".
- Those including physical dependence as a crucial
component:
World Health Organisation Expert Committee on
Addiction-Producing
Drugs (1957):
"Drug addiction is a state of periodic or chronic
intoxication
produced by the repeated consumption of a drug
(natural or synthetic).
Its characteristics include: M an overpowering
desire or need
(compulsion) to continue taking the drug and to
obtain it by any
means; (ii) a tendency to increase the dose; (iii)
a psychic
(psychological) and generally a physical
dependence on the effects of
the drug; and (iv) detrimental effect on the
individual and on
society".
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The WHO Expert Committee on Addiction-Producing
Drugs (1964)
commented:
"The definition of addiction gained some
acceptance, but confusion in
the use of the terms addiction and habituation and
misuse of the
former continued. Further, the list of drugs
abused increased in
number and diversity. These difficulties have
become increasingly
apparent and various attempts have been made to
find a term that could
be applied to drug abuse generally. The component
in common appears
to be dependence, whether psychic or physical or
both. Hence, use of
the term 'drug dependence', with a modifying phase
linking it to a
particular drug type in order to differentiate one
class of drugs from
another, had been given most careful
consideration. The Expert
Committee recommends substitution of the term
'drug dependence' for
the terms 'drug addiction' and 'drug habituation'.
National Institute on Drug Abuse (1979):
"An addicting substance is one that has: (1)
pharmacological
properties leading to compulsive use; (2) a
capability of producing
organ and/or behavioural toxicity; and (3) a use
pattern associated
with adverse social consequences. In addition,
this term is generally
applied when the ingestion of such substances is
viewed by a large
segment of the society as undesirable".
Definitions of Dependence:
WHO (1969):
"A state, psychic and sometimes also physical,
resulting from the
interaction between a living organism and a drug,
characterised by
behavioural and other responses, that always
include a compulsion to
take the drug on a continuous or periodic basis in
order to experience
its psychic effects, and sometimes to avoid the
discomfort of its
absence. Tolerance may or may not. be present".
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The American Psychiatric Association: in their "
Diagnostic and
Statistical Manual of Mental Disorders (1980)"
give a specific
definition of dependence on tobacco:
"A. Continuous use of tobacco for at least one
month.
B. At least one of the following:
(1) serious attempts to stop or significantly
reduce the amount
of tobacco use on a permanent basis have been
unsuccessful.
(2) attempts to stop smoking have led to tobacco
withdrawal.
(3) the individual continues to use tobacco
despite a serious
physical disorder (eg respiratory or
cardiovascular disease)
that he or she knows is exacerbated by tobacco
use".
"Since tobacco use rarely causes any identifiable
state of
intoxication as does alcohol there is no
impairment in social or
occupational functioning as an immediate and
direct consequence
of tobacco use".
Although probably each of the above definitions
can be criticised for
failing to be 'complete' or to take into account
all possible factors,
when taken together, a number or important
concepts emerge. These
include:
- physical dependence
- psychological dependence
- tolerance
- withdrawal syndrome
- relapse
- craving (compulsive use)
- danger to individual (organ and/or behavioural
toxicity)
- danger to society / adverse social consequences
- loss of self-control.
These concepts, and their relationship to smoking
behaviour and nicotine,
will be dealt with in the following sections.
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2. The role of nicotine as a iDrimarv
vharmacologj~pAl
reinforcer in cigarette smoking
A major question that should be answered at the
outset is whether one is
concerned with tobacco dependence or with nicotine
dependence. The two do
not necessarily lead to the same implications or
to the same answer on the
question of whether cigarette smoking is an
addictive process. For
example, the components of tobacco smoke other
than nicotine may play a
critical role in determining the extent to which
smoking has adverse
individual and social consequences. The most
pragmatic stance is to
assume that tobacco dependence is the critical
subject. Of course, this
is not to suggest that nicotine is not the most
important component of
tobacco smoke as far as addiction is concerned.
The evidence that
nicotine is critical in smoking behaviour, and
that nicotine may be
considered to possess 'abuse liability', is
discussed below.
In order to determine whether nicotine is the
primary reinforcer in
cigarette smoking, the following have to be
demonstrated:
a) People smoke to obtain nicotine
b) People regulate intake of nicotine to specific
levels
c) Nicotine can be used as a reward to reinforce
behaviour.
Demonstration of the second point would imply that
smokers have a specific
requirement for a given amount of nicotine, and
have a mechanism in the
body that is sensitive to nicotine, thus enabling
them to titrate the
dose.
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a) Do iDeolDle -ke to obtain nicotine?
It is not the purpose of the present paper to
exhaustively review the
evidence on this subject. Haweverg support for a
positive response
may be derived from the following kinds of study:
- Preferred cigarette brand.:
In general, nicotine-free brands have not been
liked by smokers.
Most smokers select or prefer brands giving them a
machine-smoking delivery of 1.0mg nicotine.
Goldfarb, Jarvik
and Glick (1970) found that ratings of
satisfaction and perceived
strength correlated highly with the nicotine (and
not the tar)
content of the cigarettes.
- Inhalation:
Inhalation of cigarette smoke is an ideal means by
which nicotine
can be obtained rapidly, and the dose of nicotine
received
titrated efficiently, by smokers.
- Smoking pattern:
Hid-mrning levels of plasma nicotine are
consistent within
subjects across days.
- Reinforcing effects of nicotine:
These are discussed in more detail below.
b) Do --kers reaulate their nicotine intake?
Evidence from the following types of study
suggests strongly that
smokers do regulate their intake of nicotine to an
'optimum' level:
- Cigarette consumption (no. of cigarettes)
increases if less nicotine
is available
- Nicotine preload (oral or by injection) reduces
consumption
- Administration of nicotine antagonists increases
consumption
- Smoke generation studies (no. of puffs,
interpuff interval, puff
U_J
duration and puff volume) show
- Smoke manipulation studies. ON
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c) Is nicotine reinforcing?
Evidence that nicotine is reinforcing can come
from both animal and
human studies.
Animal studies
The 'self-administration paradigm' has been widely
used as a procedure
to directly assess the reinforcing efficacy of
drugs, and thereby to
quantify their 'abuse liability'. In
self-administration studies,
animals (usually monkeys, sometimes rats) are
taught to perform a task
(usually to press a lever in a cage) with a drug
as the reward for
performing correctly. If an animal will work to
obtain a drug
'reward', then the drug is supposed to have high
'abuse liability'.
Drugs that are generally regarded to be
'addictive' are able to serve
as rewards (reinforcers) in such paradigms, eg
opioids, psychomotor
stimulants, tranquilizers.
Initial work on nicotine in self-administration
studies did not
provide particularly outstanding results. The
consensus from these
studies was that nicotine is a less robust
reinforcer than drugs
considered to have high abuse potential, and that
the range of
environmental conditions under which nicotine
serves as a reinforcer
is much more restricted. However, under the
appropriate study
conditions there is no doubt that nicotine is
reinforcing. Such
studies raise the interesting possibility that the
nature of the
control of smoking behaviour by nicotine is
modified in response to
changing environmental conditions. [Without
wishing to confuse the
issue, there are also situations in which nicotine
can be seen to be
aversive, ie animals will stop responding if
responding results in a
nicotine injection, or they will work to postpone
an injection). C:__
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In a series of studies, Yanagita and his
colleagues have attempted to
induce monkeys to work for cigarette smoke, rather
than for a nicotine
injection. Ihey succeeded in persuading ten out of
fourteen monkeys
to suck on a pipe delivering cigarette smoke; two
monkeys continued
this behaviour'for approximately five years.
However, compared to
studies using intravenous nicotine as a
reinforcer, this was not
considered to be very successful.
Human studies:
Human subjects will also work to receive
intravenous nicotine
injections, in studies designed to parallel the
animal studies. As
with animals, nicotine could also be shown to be
aversive under
certain circum tances. These circumstances depend
upon: (a) history
of the subject, (b) temporal aspects of access to
nicotine, and (c)
nicotine dose.
These studies,which are cited as evidence that
nicotine has 'abuse
potential', are for a very large majority of
scientist ; (particularly
pharmacologists and psychologists) the major
reason for supposing that
nicotine is addictive. The next section will
consider additional
evidence for or against the addictive potential of
nicotine.
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3. Is nicotine "addictive"?
In this section the individual components that
have been used as building
blocks in the various definitions of addiction
that have been proposed,
are disamsed with reference to nicotine.
1) Physical dependence
The concept of dependence carries the implication
that the body has
beccme accumstomed to a substance, and requires it
to function
'ncrmally'. Body chemistry etc is altered, which
suggests a genuine
physiological 'need' for the substance. The
existence of physical
dependence is an inference made from the
observation of a stereotyped
withdrawal syndrome that occurs when a
chronically-administered drug
is discontinued. (The nicotine withdrawal syndrome
is discussed
belcw).
2) Psvchological demndence
The concept of 'abuse liability', as discussed in
the previous
section, is important here. The important factors
are whether a drug
is reinforcing, whether people will spontaneously
self-administer the
substance, and whether high ratings on a
euphoria/liking scale are
observed. Published data (Henningford, 1984)
exists to suggest that
nicotine is rated positively on euphoria/liking
scales. Of course,
this alone is not sufficient to determine whether
a person is or could
beccme psychologically dependent on a drug. Ihis
depends to a large
extent on the use to which people put the drug .
For example, in the
ca of nicotine, if a smoker is dependent on
smoking to maintain his
concentration and performance to an optimum level,
and if, without
this, he begins to deteriorate, then he may be
said to be
psychologically dependent on the drug. Similarly,
psychologi 1
ca
dependence may be inferred if a smoker depends on
smoking to help
alleviate his symptoms of stress, or to help him
cope in times of
stress. Url
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3) Tolerance
The concept of tolerance involves the notion that,
as the use of a
given s~stance increases, progressively higher
doses are required to
maintain its effects; and that, therefore, if the
same dose only is
administered, then the effects initially observed
will rapidly
attenuate and then disappear. Tolerance has been
strongly linked to
the development of physical dependencet but the
exact relationships
between the two phenomena are undetermined.
Tolerance can be of three different kinds:
i) metabolic or dispositional tolerance (ie the
drug is metabolised
more rapidly); (ii) tissue or pharmacodynamic
tolerance (changes in
the availability of the receptors that are
activated by the drug at
its final site of action in the body), and (iii)
behavioural tolerance
(the waT in which the subject using the drug
changes his behaviour to
adapt to the effects produced by the drug).
The possibility of dispositional tolerance to
nicotine has not been
thoroughly investigated due to the fairly recent
development of
sensiti-ie measurement techniques. However, at
least one stXXfy has
given reason to believe that dispositional
tolerance is not important
in nicotine tolerance. Pharmacodynamic tolerance
has been recognised
as a more important form of tolerance for most
drug dependencies.
Tolerance to the peripheral effects of nicotine
has been determined in
smokers. After the initial few exposures, smokers
rarely experience
the sweating, tremor, nausea, vomiting, abdominal
pain, diarrhorea,
palpitation, fatigue and headaches that are
commonly reported in naive
smokers. However, no sophisticated studies have
been performed to see
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whether (either in animals or, where possible, in
humans) tolerance
develops to the effects of nicotine that are
likely to contribute to
its reinforcing effects: the positive effects on
performance,
concentration and stress. This, clearly, is an
important point that
should be investigated.
The exact mechanisms by which tolerance develops
to the effects of
nicotine on the behaviour of laboratory rats
(usually simple tests of
motor behaviour, or lever-pressing) are not well
understood. However,
several recent studies on the effects of chronic
nicotine treatment on
nicotine receptors have indicated that an increase
in the number of
receptors occurs. An up-regulation of binding in
response to a
receptor agonist such as nicotine is unusual:
down-regulation normally
occurs. The functional significance of this result
in relation to
tolerance development is poorly understood.
4) The nicotine withdrawal syMvome
Shiffman (1979) concluded that "... the presence
of an abstinence
syndrome is crucial to the definition of drug
dependence". Until a
few years ago, the existence or not of a nicotine
(or tobacco)
withdrawal syndrome was a matter of controversy.
However, as more
attempts have been make to characterise the
syndrome, for the .-ast
majority of scientists and regulatory bodiest its
existence is no
longer seriously in doubt. It is acknowledged that
the syndrome is
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extremely variable in terms of which symptoms are
observed, with what
frequency and over what time-course. In general,
the onset of
withdrawal is -rapid (as little as 2 hours after
the last dosc) Am
tends to level off in severity after 5-10 days. An
additional form of
evidence that withdrawal occurs from nicotine is
that smokers who
change to low-delivery cigarettes often report
withdrawal symptoms.
The reduction in dose of other
'dependence-producing substances'
characteristically induces withdrawal.
The classic symptoms are as follows:
- Decreased heart-rate and diastolic blood
pressure
- Decreased excretion of certain body chemicals
(adrenalin and
neradrenaline) and other metabolic changes
- Decreased peak -frequency in the EOG
Increased low frequency activity in the EBG
Increased EEG sleep-like activity
Decreased latency to rapid eye-movement sleep and
increased REM
sleep time
Increased amplitude and decrea ed latency to evoke
responses ie
bypersensitivity to low intensity stimuli
(-All of this is largely indicative of decreased
EE)G arousal, but
this is by no means uniform!)
- Increased weight gain
- Diminished performance on psychomotor tasks
- Subjective changes in physical symptoms,
arousal, and mood.
Ccumn are: nausea, headache, constipation,
diarrhoea, increased
appetite, drowsiness, insomnia, inability to
concentrate,
inc eased irritabilityo agression and anxiety.
- Cmving fo r tobacco.
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5) Relaipse
Relapse in smokers is a matter of some
controversy. There are those
who maintain that the relapse rate is as strong
for smokers as for
heroin addicts. However, if one looks at figures
showing the
percentage of smokers who give up successfully,
this is rising
considerably. The reason for relapse should also
be taken into
account; although craving for tobacco and other
'withdrawal symptoms'
play a major role, these symptoms are not as
urgent as they are in the
cases of addiction to hard drugs, and therefore
common sense alone
would indicate that withdrawal symptoms alone
would result in less
compelling rea ons for relapse in the case of
smokers. It has been
suggested, instead, that the loss of the
psychological benefits
accrued by smokers due to the positive effects of
nicotine on
cognitive performance etc. are more realistic
reasons for relapse.
6) craving
Craving for tobacco is considered to be a major
withdrawal symptom and
a major reason why smokers relapse. The rather
tenuous concept of
craving is believed to be related to the
'compulsion' to smoke
experienced by some smokers and is used in some
definitions of
addiction.
7) Loss of Control
Loss of control over substance intake is widely
held to be a major
component of addictive behaviour. It is widely
observed in alcoholics
in particular, for whom one drink invariably leads
to more, to the
point of intoxication. It is less conceivable in
smokers. Smokers
maintain a regular pattern of smoking over a
period of years, and to
that extent appear capable of controlling their
intake quite
adequately.
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8) Danger to the individual
This is often cited as a major component of
addictive behaviour or
dependence: focusing in the adverse consequences
of use of the
substance. In the case of tobacco, the medical
profession would be
strong proponents of the view that use is
detrimental to the health of
the individual in physiological (if not in social
and psychological)
terms.
9) Danger to Societv
Although it cannot be said that smoking is
dangerous to society in the
same way that heroin addiction is dangerous (eg
causing crime,
homelessness etc) there are those who would
maintain that the
phenomenon of environmental tobacco smoke
constitutes a health danger
to other members of society.
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4.
Suunary
1. A major reason why smokers smoke is to obtain
nicotine.
2. Nicotine has positive reinforcing effects,
undoubtedly due to its
ability to improve cognitive performance and
regulate arousal.
3. Taking the various components that have been
used as building-blocks
in various definitions of addiction, nicotine is
considered by certain
scientists to be addictive on the following
grounds:
- production of physical dependence
- production of psychological dependence
- tolerance (NB only to certain effects of
nicotine)
- presence of a withdrawal syndrome
- presence of craving for tobacco when deprived
- relapse can occur, often as a result of
'withdrawal' symptoms
- smokers smoke in spite of suggested danger to
themselves in health
terms.
Other factors that have been taken into
consideration are:
- nicotine is a positive reinforcer (ie is
self-administered) in many
situations; in general drugs that are not abused
are not positive
reinforcers, and all drugs that are abused are
positive reinforcers.
- nicotine has positive effects on mood and
performance, and is
frequently rated in the direction of euphoric.
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5. Alternatives to the Addiction Theory
The preceding sections consider the reasons for
the current scientific
body of opinion that nicotine may be an addictive,
or dependence-producing
compound. However, there are a number of factors
that do not fit in with
such a theory, and a number of alternatives to the
'addiction' model of
smoking.
Considerations aaainst the addiction model
1) 'Dependence' is a condition that exists in many
forms and many
degrees; everyone is to some degree 'dependent'
for general quality of
life on a range of objects and products.
'Dependence' as a concept
begins to be viewed as a problem and therefore
abnormal when a
particular set of socially accepted norms are
exceeded eg persistent
excessive and lengthy alcohol use at lunch-times.
'Dependence' as a
concept is heavily linked to the social
acceptability of a drug at a
given time.
2) Tobacco use does not cause an identifiable
state of behavioural
intoxication. In this it differs from almost every
supposed 'drug of
abuse'.
3) Prolonged use of tobacco does not lead to any
form of 'behavioural
toxicity': distinct personality changes and
decline in social
functioning are not observed, as is the case for
drugs of abuse.
4) Tolerance is a critical concept in drug
dependence. Tolerance
normally develops to the effects of
dependence-producing drugs to such
as extent that the user is forced to augment his
intake to maintain
the same drug effect. Ibis does not happen with
cigarette smoking;
smokers reach a stable consumption and, in
general, this remains
consistent.
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6) Increases in consumption can, however, be
linked to the occurrence of
stressful events. This would suggest that smokers
use tobacco to
allow them to cope more efficiently with life
events, rather than that
they smoke simply to avoid withdrawal symptoms, as
would be suggested
by a simple addiction model.
6) Many smokers are able to stop smoking easily,
without professional
help, and without the observation of a 'withdrawal
syndrome'.
7) Those smokers who do report the occurrence of a
'withdrawal syndrome'
may simply be experiencing the simple behavioural
response to the
deprivation of a reinforcer. Such
frustration-induced effects are
reliably observed in laboratory animals who have
been deprived of a
reinforcer such as food, water etc.
8) Many smokers have a smoking pattern that is not
consistent with the
necessity to maintain a relatively constant level
of nicotine in the
body to alleviate withdrawal symptoms, such as
would be predicted by
an addiction model. Some smokers smoke only at
work, others smoke
only socially.
9) There are sex and socioeconomic differences in
use of tobacco and in
smoking cessation success; this would not be
predicted by an addiction
model.
10) Although Henningfield (1984) claimed that
tobacco and nicotine rated
positively on euphoria/liking scales, Warburton
has shown that a
re-plotting of individual graphs for individual
drugs on the same
scale and as a percentage of placebo, results in
nicotine and tobacco
being at the very bottom of the scale of drugs:
well below alcohol,
valium and ma ijuana.
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11) The so-called 'withdraal syndrome' from
nicotine is extremely
variable in incidence and severity, but in no
cases have they been
reported to be incapacitating, such as is the case
for 'hard' drugs
such as heroin.
12) Even for widely accepted
'dependence-producing' drugs such as heroin
and alcohol, use of the drug does not
automatically lead to
dependence. The majority of people are able to use
alcohol without
any evidence of dependence, and patients receiving
heroin for
therapeutic purposes rarely become dependent.
A number of different theories have been proposed
as alternative to an
addiction model:
1) Genetic theories
Genetic theories propose that recruitment to
smoking, persistence in
smoking and consumption levels are governed by
genetic dispositions.
Burch (1976) has argued that certain genes
predispose to smoking.
There are some data suggestive of inheritance of
the smoking habit;
however, some conflicting results exist. Eysenck
has long been a
proponent of the idea of a genetic basis for
personality traits.
Since he has related certain personality traits
(eg extraversion and
neuroticism) to smoking, he believes that the true
genetic link may be
with personality, rather than directly with
smoking.
2) Psychoanalytic theories
Psychoanalytic theories about smoking are based on
the Freudian
concept of orality, and range from simple models
based on phallic
analogies, to the more general 'oral frustration'
theory. However,
Psychoanalytic theories are (almost by definition)
difficult to test,
and where this is possible they have failed to
survive strict
experimental scrutiny.
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3) Aousal modulation theories
Of all the alternatives to addiction models, this
type of explanation
is more readily acceptable, and an example of it
is that put forward
by DELvid Warburton.
This theory suggests that smoking is an activity
that has the function
of controlling arousal ie the smoker smokes to
increase arousal when
bored or fatigued, and to reduce arousal when
tense. When the smoker
is neither fatigued nor tense, he continues to
smoke partly through
habit and partly because it has become a positive
reinforcer.
There is more positive support for this theory
than for any of the
others. Nicotine has both stimulant and depressant
effects in both
physiological and psychological test systems.
Nicotine facilitates
performance in a variety of tests of attention and
vigilance in
humans. However, it must be noted that nicotine
addiction theorists
regard the positive effects of nicotine as a
subjective
rationalisation for the feeling of relief produced
by the arrival of
nicotine at depleted CNS sites. Whether or not me
accepts the
'reality' of the positive effects on performance,
the data do not
necessarily provide an alternative to an addiction
model, but can be
incorporated into it.
4) Social learning theories
Social learning theories suggest that smoking is a
habit that is
initially acquired under conditions of social
reinforcement eg peer
pressure. Eventually, smoking becomes ritualised
and incorporated
into many everyday activities and situations.
Although little
emphasis is placed on the pharmacological
determinates of smoking,
they can be incorporated into the theory.
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Conclusions
The question of whether nicotine (and therefore
smoking) is addictive is
complicated by (a) the difficulty in producing a
satisfactory definition
of 'addiction' or 'dependence', and (b) changing
social norms and social
acceptability as far as smoking is concerned. Many
scientists, from the
data presented in the early part of this paper,
would suppose that
nicotine has all the qualities that qualify it for
classification as a
drug of dependence, or a drug of abuse. Indeed, in
the pharmacological
literature nicotine is now al st always considered
under the heading of
drug of -hu e. Public opinion and social
acceptability is being altered
by the increasingly frequent suggestions in the
media that smokers are
essentially drug addicts who find it impossible to
give up nicotine.
However, as discussed in the previous section,
there are a good many
reasons that can be cited to challenge the present
scientific dogma that
nicotine is a dependence-producing compound. A
simple addiction model
cannot cope with many of these criticisms. A
sensible strategy would be
to compare nicotine with caffeine (and therefore
smoking with coffee
drinking). The two compounds have similar
pharmacological properties, and
although the public may talk about being "addicted
to" caffeine or to
their cup of tea, caffeine consumption is still a
socially acceptable
habit - this, in spite of the fact that caffeine
"dependency" was
classified by the American Psychiatric Association
some time before
nicotine "dependency" was discovered.
CD
---,j
BATCo document for Province of British Columbia 27
October 1999