NATIONAL INSTITUTE ON DRUG ABUSE
TECHNICAL REVIEW ON CIGARETTE
SHO)MM AS AN ADDICTION
Thursday and Friday, August 2.3 and 24, 1979
FINAL REPORT I
Moderators:
Norman A. KrasceCor, Ph.D.
Pierre E. Renault, H.D.
Hacro Systems, Inc. September 18, 1979
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INTRODUCTION
This report summari2es the Technical Review on Cigarette Smoking as an
Addiction that took place on Thursday and Friday, August 23 and 24, 1979.
This task force meeting was sponsored by the National Institute on Drug Abuse
(NIDA), Division of Research, to evaluate the scientific evidence that exists for
and against cigarette smoking as an addiction and fo arrive at a consensus on
this question based on the available scientific evidence.
Macro Systems, Ina., -assisted NIDA in the conduct of the meeting. This
summary report was written by Dr. Charles R. Schuster of the-University of
Chicago. The Appendix presents the agenda for the meeiiiag and a list of the
participants with institutional affiliations. addresses, and telephone numbers.
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TECHNICAL REVIEW ON CIGARETTE SMOKING AS AN ADDICTION:
-REPORT ON THE TASK FORCE ON SMOKING
I. STATEMENT OF THE PROBLEM
Cigarette smoking is the single most important environmental factor con-
tributing to -early death and disability in the United States. In 1978, 33 per-
cent of the population, age 17 and over, were current cigarette smokers.
Induction into smoking begins in the great majority of individuals before 21
years of age and in over half, before IS years of age. Despite teenagers' dis-
that their cigarette smoking can be voluntarily curtailed, the onset of
smoking at this age results in a high probability of sustained lifelong use. Of
teenagers who smoke more than one or two casual cigarettes, 85 percent escalate
to a lifestyle of regular smoking. It is estimated that only 2 percent of smokers
consume cigarettes on 'an occasional basis. In general, the number of cigarettes
consumed by smokers aver-ages 30 per day. Each inhaled puff of cigarette
smoke delivers a dose of drug to the brain resulting in 50-70,000 such doses i
per person every year. There is no other form of drug-taking that occurs
with such regularity and frequency.
Despite widespread public acknowledgement of the health consequences of
smoking and the documented statements made by the great majority of smokers
that they would like to quit, a very large number have been unsuccessful in
their attempts. More specifically, of the 33 percent of Americans. age 17 and
over, who are smokers, three out of four express a desire to quit. Indeed,
over 60 percent of these current smokers claim to have made at least one serious
attempt. During 1978 alone, over 30 percent (17 milli-on) attempted to quit
smoking. Unfortunately, the long-term probability of success on any given quit
attempt is only 20-25 percent. Even those who seek professional help and are
successful in completing an organized smoking cessation program show a 60-80
percent return to smoking within one to two years. Furthermore. the proba-
bility of relapse over Lime to cigarette smoking shows remarkable similarity to
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that observed with 'alcohol and heroin use. It is of interest to note that indi-
viduals who use both heroin and cigarettes report that they would find it easier
to give up heroin than cigarettes.
2. ,.DEFINITION OF ADDICTION AND AN ADDICTING SUBSTANCE
Before proceeding to consider whether current evidence allows the cate-
gorization of cigarette smoking as an addictioa, we must define -this term. In
its bmadts-t sea5e, addiction is a state characterized by the repeated ingestion
bf a substance that is toxic and leads to undesirable social consequences. -This
definition encompasses other terms often used to describe no=edical.drug use,
such as abuse, habituation, and dependence. An addicting substance is one
that has: .(1) pharmacological properties leading to compulsive use; (2) a capa-
rbility of producing organ and/or behavioral tonicity; and (3). a use pattern
iassociated with adverse social consequences. Jn addition., this term is generally
applied when the ingestion of such substances is viewed by a large segment of
the society as undesirable.
3. r@ii@-I@L"_S'TU'DIES
There have been two general approaches. to obtaining data to determine
whether tobacco can be viewed as an addicting substance: (1) the study of
cigarette smoking per se, and (2) studies of nicotine alone, since its pharma-
cological actions suggest that it is the most likely component in tobacco leading
to its repetitive use. A variety of behavioral studies of the action of nicotine
have been carried out in animals. One of the methods used in the animal labora-
torY to determine the addiction potential of drugs is the drug self-administration
procedure. There is a good correspondence between drugs that are self-
administered by laboratory animals and those that are common drugs of addic-
tion in humans. This generality holds true for drugs within the opioid, seda-
tive, and psychomotor stimulant class. Furthermore, drugs which are not
addictive substances are not self-administered by animals.
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Several studies have demonstrated that intravenous nicotine can maintain
self-administration behavior in rats and monekys, but the environmental condi-
tions under which this occurs appear more limited than with drugs such as
opioids or psychcmotor stimulants. Nicotine appears to be a substance which
has the pharmacological, properties necessary to lead to its repeated ingestion.
Doses of nicotine which are otherwise self-administered may even function as
punishers to suppress behavior under certain environmental conditions. The
wastence of these aversive effects of nicotine may account in part for changes
in hum@an cigarette -smoking after variations-in nicotine content or treatment with
nicotine or nicotine antagonists. Effects of pharmacological treatment with
nicotine antagonists can alter smoking behavior in humans and suppress nicotine
self-administration in animals. Clearly, further studies are needed to determine
the range of conditions over which nicotine will maintain or suppress behavior,
the critical factors controlling these properties of nicotine, add the ways in
which pharmacological treatments can alter smoking behavior or self-administration
of nicotine.
There has also been limited research on actual cigarette smoking in animals.
The majority of monkeys given free access to cigarettes will smoke, but in a
rather sporadic fashion. Certain animals, however, will regularly smoke and
,)b nicotine blood levels comparable to those obtained by-human cigarette
smokers.
These studies of smoking behavior and nicotine self-administration in ani-
mals support the view that nicotine is the primary constituent in cigarettes that
maintains their compulsive use.
4. IMIAN STUDIES
Although it is still not unequivocally clear that nicotine is the only agent
responsible for the development of physical dependence on tobacco or the main-
tenance of smoking behavior, it is' certainly the leading contender. Proof of
nicotine's primary role still awaits a de-non that the cigarette withdrawal
syndrome is similar to the nicotine ivith draw al syndrome. However, there have
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been several studies implicating nicotine's role In the subjective aspects or smok-
ing as well as the frequency. For instance, subjects have been given cigarettes
%without nicotine (or with greatly diminished nicotine) and they fail to report
their customary enjoyment of smoking. Some subjects seem to enjoy the low-
nicotine cigarettes, but it is possible that they are able to extrnct more nicotine
by changing their manner of smoking (e.g. , increased inhalation). Another
type of experiment involves delivering nicotine to subjects via another route of
administration besides inhalation. Subjects of these experiments do not experi-
ence the usual degree:of satisfaction that they get from their customary ciga-
rettes, although in some instances they d6o report some satisfaction- from the
nicotine.
Further evidence implicating the role of nicotine in cigarette smoking is
proVided by h=an studies that have directly measured cigarette Smo
behavior. These studies have shown: (1) increases or descreases in nicotine
dose in cigarettes are associated with compensatory changes in smoking %-.h;ch
tend to maintain nicotine blood levels within certain limits; (2) manipulation of
urinary excretion of nicotine either upwards or downwards is also associated
with compensatory changes in smoking which tend to maintain nicotine blood
levels within certain limits-, (3) pretreatment. With nicotine (intravenously or
orally) produces compensatory decreases in smoking; and (4) pretreatment WiLh
a nicotihe - antagonist produces elevation it; smoking.
S. -,I@PHYSICAL DE'PEINMEN C'E' A MD TOLERANCE
As with other classic dru-s of abuse such as the opioids and sedatives.
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tolerance and physical dependence are important characteristics of a drug because
they may exacerbate the user's tendency to continue its use. Tolerance. fzr
instance, reduces the pharmacological effects of drugs and may lead to more
frequent administration of higher doses of the drug, which in turn maY produce
greater risks or to.%icity or untoward effects on the user.
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Tolerance has been demonstrated for the effects of smokin- ci-arettes
'in
alse) to the effects of many of the components of cigarettes. Nausea and
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dizziness is common among novice smokers, but disappears. with experience.
Metabolic tolerance can be demons tra ted in smokers to various components of
cigarette smoke (e.g., nicotine, "Ear", benzypyrene, carbon monoxide. other
compounds) as well as to a wide variety of drugs such as barbiturates and
chlorpromazine. Receptor tolerance can be demonstrated to some extent to cer-
tain components of tobacco smoke. For instance, nicotine given intravenously
has been shown. to have a greater physiological effect upon nonsmokers than on
smokers. Similarly.. tolerance to behavior, such as activity level, has been
demonstrated in a wide variety of animal studies. Behavioral tolerance to nico-
tine also has been demonstrated in animals; i.e., animals learn to Compensate
for decrements in performance while under the influence of the drug.
There is also evidence of physical dependence to tobacco. Clear signs of
withdrawal appear when heavy smokers abruptly quit, although there appears to
be considerable variability in its manifestation. When a smoker stops smoking
suddenly, he/she frequently shows a decrease in heart rate, sometimes in blood
pressure, and a decrease in excreted epinephrine and norepinephrine and its
metaboUties. Other endocrinological changes may also occur. Furthermore,
there is a decrease in mean EEG frequency, an increase in appetite and weight,
and an impairment in performance on psychomotor tasks and in concentration.
Disturbances in arousal and sleep may occur; and anxiety, irritability. and
aggression increase. Finally, there is an in&rease. in craving for smokin- which
decreases with time. Despite this reported increase in cravm@@. the extent to
which physical dependence on tobacco or nicotine influences the frequency or
smoking remains to be determined. Human experiments indicate that, following
a period of deprivation. ir and the probability of smoking increase.
In summary, although experimental findings are limited, it is clear that
tolerance and physical dependence do occur with cigarette smoking, but the role
Zhey play in the mainten.ince of smoking remains to be explored.
6. CiGiiIETTE SMOKING AS AIN ADDICTION.
IC would seem Clear from the evidence presented that tobacco smoking pro-
duct.-s phar-m3coloo-ical errects whicli often lead to compulsive use. As stated
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previously in our definition of addiction, it is necessary to demonstrate that an
addicting substance produces organ and/or behavioral toxicity. Although the
acute behavioral effects of smoking are mild in comparison to those produced bY
most addicting substances, the multiple deleterious health effects of cigarette
smoking, including mortality and disability and their attendant social conse-
quences, are now weU established. Few question that the regular use of
tobacco leads to a wide range of organ toxicity.
7. i CONCLUSIONS
t
It was the opinion of the group after reviewing the evidence regarding the
compulsive use, the toxicity, and the adverse social consequences, that cigarette
smoking behavior should be CC) a form of addiction, and tobacco in the
form of cigarettes, an addicting substance.
8. -IMPT REGARDING CIGARETTE SMOKING AS AN ADDICTION
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(1) The zrour) corc!uded that ciLrarette smokinZ is an addiction. The
broadest implication of this conclusion is that cigarette smoking should now
be re-examined in light of the rangre of policy considerations %which are
presently considered germane to the classic forms of drug addiction such-
as addiction to-the narocitics. sedatives. stimulants. or alcohol.
(2) Given thit dEarette smokinT is considered an addiction. it could be
concended that it should be viewed as a disease. Such a categorization
would allow the application of the methods and conceptual formulations of
public health to be app Lied to the smoking problem.
(3) Basic research efforts should be rocused on the analysis or cigarette
smokinir behavior Ln huronns. Research pro-rams should elucidate the
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bthavioral and pharmacoloocal variables which influence both the maintc-
nance and elim in at ion of ci-arette smoking behavior. The role of nicotine
in the initiation and maintenance of cigarette smoking- should be explored
wiEh special aEtention to odier components of smoke that mny modulate its
efrects.
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(4) Research on psvchosocial influences should not be Reemphasized. but'
projects should be sought which try to evaluate psychosocial and pharma-
codvnamic influences within the same context.
(5) Basic research efforts should be focused on the analysis or nicotine
self-administration in laboratory animals. The range of conditions neces-
sary for the establishment. maintenance. and elimination of nicotine self-
administration should be studied.
(6) Research efforts should be directed toward establishing- an adequate
animal model of ci!Tarette smokinir behavior.
(7) Research should be undertaken to establish valid. low-cost. and oref-
erabLv noninvasive measures of cigarette smokinK to' be used as outcome
measures in clinical treatment research. Examples of such measures include
urinary nicotine or expired-air CO levels.
(8) Phvsiolotcal and psychologrical changes that occur durinK repeated
administr.ation. tolerance and physical dependence and u2on smoking ces-
sation (withdrawal) should be characteriz-ed in detail. The contribution or
these changes to the clinical pheromenor. of relapse to smoking should be
established.
This report has summarized the Technical Review on Cigarette Smokin- as
U t2,
an Addiction. Additional infcrnatlon about the meeting may be obtaLned from
Dr. Pierre Renault. NIDA Division of Research.
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