Peele, S. (2010), The fluid concept of smoking addiction. In: Phillips, Carl V., & Bergen, Paul L. (Eds.), Tobacco Harm Reduction 2010: A Yearbook of Recent Research and Analysis. TobaccoHarmReduction.org.
The Fluid Concept of Smoking Addiction
Editors’ Note: The relevance of this chapter may not be immediately apparent, so it is worth making explicit. Once the harm from nicotine use is reduced to close to zero, it is difficult for anti-tobacco/nicotine activists to justify their animosity and demands for eliminating it despite people’s desire to consume it. A typical first response is “but it is still addictive,” neatly damning the consumption pattern while implicitly denying, without having to try to defend the point, that people consume nicotine because it is beneficial to them. A standard response is, “addiction is still a lot better than lung cancer.” While this is undoubtedly true, anyone who really thinks through the claim about addiction sees that there is a far more comprehensive and deeper response, along the lines of, “what is this ‘addiction’ of which you speak, and what is so bad about it that it justifies interfering with public health, individual choice, free markets, etc.?” This response may produce sputtering rage, but it seldom produces an answer to either half of the question.
Peele’s summary of history of the addiction concept as applied to tobacco use explains why. It has not been agreed what addiction means and whether this applies to tobacco, let alone whether a particular definition implies a condition that is inherently so bad as to warrant massive policy action to avoid it. A case can be made that some particular definition applies to tobacco/nicotine use and Peele indicates that he has long felt that smoking fell into contemporary definitions of addiction. But more important, Peele illustrates, based on the historical plasticity and political construction of the term, that merely calling something “addictive” actually tells us very little about it.
The History of the Addiction Concept
As I have described elsewhere (Peele, 1985; 1990), although addiction is generally viewed as an irreducible scientific and biological syndrome, the concept of addiction has evolved and continues to do so. Through antiquity and into the late nineteenth and early twentieth centuries, addiction referred to the strength of people’s habits in many different areas. “Addicted to” was equivalent to “had a passion for.” At the beginning of the twentieth century, a medical conception of addiction was consolidated, particularly in the United States, and an addiction syndrome was outlined for narcotics, particularly heroin. In this conception, use of narcotics – unlike use of any other drug – inevitably created a deepening and irreversible physical condition marked by the impossibility of cessation without traumatic withdrawal.
This notion was a departure from many centuries in which narcotics use was widespread, yet they were not regarded as causing a special state different from that resulting from the use of other substances or, indeed, non-drug activities. Once this modern version of the addiction concept grew, it was only late in the twentieth century that the idea of addiction was broadened, in some ways coming to resemble its pre-modern medical definition. Through the 1950s, World Health Organization pharmacologists presented a clear-cut description of addiction that they assumed was linked only to narcotics. But in order to respond to the growing use of a range of illicit substances, in 1964 the World Health Organization (WHO) Expert Committee on Addiction Producing Drugs changed its name by replacing “Addiction” with “Dependence.” At that time, these pharmacologists identified two kinds of drug dependence, physical and psychic, where the latter “is the most powerful of all factors involved in chronic intoxication with psychotropic drugs . . . even in the case of most intense craving and perpetuation of compulsive abuse” (see Peele, 1985, p. 20).
In the 1980s, as cocaine use became more popular, attention shifted from the classical withdrawal syndrome that marked narcotics use to intensive bursts of drug intoxication typical with cocaine. Although cocaine became the illicit substance of greatest public health concern, it was not classified as being capable of producing physical dependence. This drove pharmacologists to focus on the experiential effects that compel continued drug use in theorizing about addiction, to wit: “[That] cocaine produces no gross physiological withdrawal symptoms...demonstrate[s] that subjective experiences or symptoms other than physiological discomfort are crucial in addiction to cocaine and to other substances of abuse.... [I]nvestigators are now exploring how psychological symptoms in drug withdrawal, particularly unpleasant mood states and craving for drug euphoria, maintain chronic drug addiction” (Gavin, 1991, p. 1580). A similar expansion of the addiction concept occurred with marijuana in the 1990s.
As the 1964 WHO Report and the definition of cocaine addiction indicate, throughout the second half of the twentieth century and into the present, experts have labored to separate addiction into physical and psychological components, and just as often found this distinction unsupportable. This is illustrated in the development of the American Psychiatric Association (APA, 2000; originally published in 1994) manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). DSM-IV-TR divided substance use disorders into two categories – abuse and dependence. DSM’s use of dependence to replace addiction includes what were previously regarded as both psychic and physical dependence symptoms such as a failed effort to halt or cut back use, along with tolerance and withdrawal.
In February 2010, the APA offered a draft version of DSM-V for comment (the final version of the document was scheduled for publication in May, 2013). The sections concerning addiction and substance abuse had two especially interesting elements. In the first place, the APA proposed returning to the usage "addiction," re-replacing dependence. This change was based on the idea that reliance on any powerful substance – including most medications – results in tolerance and withdrawal phenomena, but that such dependence was not the concern of a psychiatric manual. Second, DSM-V proposed to create an entirely new "behavioral addiction category" into which it (as of February 2010) placed a single activity – pathological gambling.
If any further proof were needed that the meaning and application of the addiction concept evolves, these changes surely erase them. After more than a century of medical usage, modern medicine and psychiatry are still trying to decide whether or not the term should be used, and what it includes. This of course indicates that the meaning of addiction is still up for grabs.
Neurobiological Model of Nicotine Addiction
Fitting nicotine (tobacco) within the addiction paradigm has occurred (as with cocaine) relatively recently. All of the conflicting trends of thinking about addiction manifest themselves in the case of nicotine because the designation of a substance as addictive inevitably entails social, legal, and political considerations. We have seen that both cocaine and marijuana were reclassified as addictive because public health professionals wanted to highlight the abuse of these substances. Tobacco only began to be listed as a dependence-producing substance in the 1980 DSM-III. When I asserted that smoking was addictive in my 1975 book, Love and Addiction, this was not customary usage. This shortsightedness occurred due to popular and scientific biases against the idea that a legal, non-intoxicating substance could be addictive.
This reluctance has now largely disappeared, and the history of the development of the nicotine-dependence (or addiction) model illustrates one phase of the modern evolution of the addiction concept. For several decades – really only a relatively short time – pharmacologists and addiction theorists have developed a neurobiological model of nicotine addiction. In brief, this view maintains, smokers become physically habituated (develop tolerance) to nicotine at a cellular level, so that any substantial depletion in cellular nicotine impels the smoker to consume nicotine (most notably by smoking), and the failure to do so produces traumatic withdrawal. From this perspective, every significant aspect of smokers’ use of tobacco – and much else of their behavior – over their lifetimes, is driven by this process, conceived as a physiological imperative.
The neurobiological model of addiction is static. It is built on the difficulty – often stated as the near impossibility – of quitting or moderation. The model does not attempt to explain how (or, more accurately, why) people cease addictions – even though such cessation is more typical than not with every type drug. The neurobiological model really has nothing to say about why smokers quit (as a majority do), for example due to the pleading of a spouse or a child. In the terms of the model, cessation is unexpected, unexplained, unpredictable, and simply falls beyond its purview or boundaries.
The History of Nicotine Dependence (Addiction) Concept
1. 1964 Surgeon General’s Report, Smoking and Health. The treatment of the addictiveness of cigarettes in the original 1964 Surgeon General’s Smoking and Health (SGR64; U.S. Department of Health, Education, and Welfare, 1964) can only be understood with reference to the history of the addiction concept. That is, WHO pharmacologists had not yet recognized parallels among addicting drugs and so labeled “non-narcotic substances” as “habituating,” as did the 1964 SGR, which concluded that tobacco is not addictive but only “habituating,” as follows (p. 351): Smoking and Health claims that the main factors promoting smoking for the individual are experiential: smoking “will relax and sedate us when we are tense and excited” (p. 350). Furthermore, “Heavy cigarette smokers who inhale often describe the act as a pleasant sensory experience which constitutes for them one of the prime drives to continue to smoke.” In summary, “The habitual use of tobacco is related primarily to psychological and social drives, reinforced and perpetuated by the pharmacological actions of nicotine on the central nervous system, the latter being interpreted subjectively either as a stimulant or tranquilizing [sic] dependent upon the individual response” (p. 354, italics added).
Drug addiction is a state of periodic or chronic intoxication produced by the repeated consumption of a drug.
Drug habituation (habit) is a condition resulting from the repeated consumption of a drug.
1) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means;
1) a desire (but not a compulsion) to continue taking the drug for the sense of improved well-being which it engenders;
2) a tendency to increase the dose;
2) little or no tendency to increase the dose;
3) a psychic (psychological) and generally a physical dependence on the effects of the drug;
3) some degree of psychic dependence on the effect of the drug, but absence of physical dependence and hence of an abstinence syndrome [withdrawal]:
4) detrimental effect on the individual and on society.
4) detrimental effects, if any, primarily to the individual.
Smoking and Health claims that the main factors promoting smoking for the individual are experiential: smoking “will relax and sedate us when we are tense and excited” (p. 350). Furthermore, “Heavy cigarette smokers who inhale often describe the act as a pleasant sensory experience which constitutes for them one of the prime drives to continue to smoke.” In summary, “The habitual use of tobacco is related primarily to psychological and social drives, reinforced and perpetuated by the pharmacological actions of nicotine on the central nervous system, the latter being interpreted subjectively either as a stimulant or tranquilizing [sic] dependent upon the individual response” (p. 354, italics added).
As a result, the SGR64 section entitled “Tobacco Habit Characterized as Habituation” (p. 351) contrasts cigarettes to physically addicting drugs for which “Proof of physical dependence requires demonstration of a characteristic and reproducible abstinence syndrome upon withdrawal of a drug or chemical which occurs spontaneously, inevitably, and is not under control of the subject” (p. 352, italics added). SGR64 concludes, “The tobacco habit should be characterized as an habituation rather than an addiction, in conformity with accepted World Health Organization definitions, since once established ... psychic but not physical dependence is developed.... No characteristic abstinence syndrome is developed upon withdrawal” (p. 354, italics added).
Given that people had been consuming tobacco for centuries, and smoking cigarettes for a century or more, why hadn’t people noticed that smoking causes withdrawal? In part, what defines withdrawal had changed and the redefining of withdrawal increased the likelihood it was observed with smoking. The SGR64 assertion that smoking does not lead to withdrawal is especially notable since the publication making this claim was written to highlight the dangers of smoking. However, this omission did not mean that SGR64 did not recognize the difficulty in quitting smoking:
Psychogenic dependence is the common denominator of all drug habits and the primary drive which leads to initiation and relapse to chronic drug use or abuse. Although a pharmacologic drive is necessary it does not need to be a strong one or to produce profound subjective effects in order that habituation to the use of the crude material becomes a pattern of life. Besides tobacco, the use of caffeine in coffee, tea, and cocoa is the best example in the American culture. . . . Thus correctly designating the chronic use of tobacco as habituation rather than addiction carries with it no implication that the habit may be broken easily. (p. 351; italics added)
Note that SGR64 placed tobacco in the same dependence-producing category as caffeine. SGR64 further noted, “Discontinuation of smoking, although possessing the difficulties attendant upon extinction of any conditioned reflex, is accomplished best by reinforcing factors which interrupt the psychogenic drives. Nicotine substitutes or supplementary medications have not been proven to be of major benefit in breaking the habit” (p. 354, italics added). This assertion is an example of how views of addiction impact treatment – i.e., since cigarette habituation was regarded as behavioral and setting-related, nicotine replacement per se was not considered an effective treatment.
In the 1957 WHO report Addiction Producing Drugs, addiction was ascribed to psychologically debilitated people, and is thus highly pejorative. The image of the drug (heroin) addict was of an uncontrolled sociopath. That this did not describe most smokers also contributed to the SGR64’s determination that smoking was not addictive: “It [calling smoking habituation] does, however, carry an implication concerning the basic nature of the user and this distinction should be a clear one. It is generally accepted among psychiatrists that addiction to potent drugs is based upon serious personality defects from underlying psychologic or psychiatric disorders which may become manifest in other ways if the drugs are removed. [Yet e]ven the most energetic and emotional campaigner against smoking and nicotine would find little support for the view that all those who use tobacco, coffee, tea and cocoa are in need of mental care...." (pp. 351-352). Indeed, SGR64 concludes, “Medical perspective requires recognition of significant beneficial effects of smoking primarily in the area of mental health” (p. 356).
2. 1988 Surgeon General’s Report, Nicotine Addiction. In retrospect, that the Surgeon General a quarter century later issued a report to establish what it had specifically denied in the original SGR is a remarkable cultural phenomenon. Although SGR88 (U.S. Department of Health and Human Services, 1988) was presented as a research-based document, it has a strong cultural subtext. How societies choose to regard drugs, including defining them as addictive, is a cultural phenomenon that extends beyond specific drug effects (Peele, 1990). It was not new research discoveries that motivated SGR88, but a societal need to explain that regular smokers are addicted. Even so, SGR88 falls far short of the standard contemporary neurobiological model of nicotine addiction.
Although SGR88 contains a great deal of information to establish that smoking causes adjustments in the nervous system and that cessation causes withdrawal, in large part SGR88’s task was the redefinition of addiction, now called drug dependence (p. 7):
CRITERIA FOR DRUG DEPENDENCE
Highly controlled or compulsive use
Addictive behavior often involves
- stereotypic patterns of use
- use despite harmful effects
- relapse following abstinence
- recurrent drug cravings
Dependence-producing drugs often produce
- physical dependence
- pleasant (euphoriant) effects
By these criteria, smoking could have been labeled as addictive in 1964. In fact, a cultural shift had occurred in defining addiction. The key elements in this shift were:
- SGR64, which explicitly claimed that smoking was not addictive, was now seen as not having gone far enough.
- Public health professionals wanted more ammunition to discourage smoking.
- Although smoking rates had dropped substantially since SGR64, smoking remained a significant presence in American life – that is, simply acknowledging and propagating information about smoking harms did not eliminate smoking.
- Addiction was being redefined beyond narcotics, extending to cocaine.
- Greater realism prevailed about the variability in responses to effects of – and usage patterns with – powerful illicit substances.
- Legality of a substance was no longer seen to be critical to the definition or presence of addiction.
- Experiential effects of a substance were recognized to be quite powerful even if a drug was not conventionally intoxicating.
- Addiction was marked primarily by the simple phenomenological fact of people’s difficulty in quitting.
- Addiction was no longer limited to people regarded as having neurotic personalities.
The additional research in SGR88 demonstrating cellular nicotine regulation, nicotine withdrawal, and smoking relapse was not necessary for the purposes they were used. After all, SGR64 had already asserted what was well-known – many people smoked compulsively (consider the term “chain smoker”), quitting smoking was often difficult, and a large number of people continued smoking despite saying they wished to quit. These phenomena were sufficient to allow people to recognize smoking was addictive (by the new broader definitions) before 1988, as I did in 1975 (Peele, 1975). Everything else was additional frosting.
SGR64 had already clearly indicated that some people were able to quit while others did not, as well as identifying the experiential “rewards” people gained from smoking. Leading to SGR88, a greater awareness had emerged that smoking patterns often resembled patterns of use of what had traditionally been classified as addictive drugs, including spontaneous cessation and similar or parallel experiential benefits. These parallels were outlined in SGR88 in Chapter V, “Tobacco Use Compared to Other Drug Dependencies.” With this more realistic picture of addiction to other drugs available, it was easier to see how smoking fit the addictive paradigm.
According to SGR88, people were in large part motivated to continue using both narcotics and tobacco because they welcomed their experiential effects. Chapter VI outlined “Effects of Nicotine That May Promote Tobacco Dependence,” such as enhanced attentiveness and stress reduction. Additionally, SGR88 noted strong social and contextual impacts on smoking rates, including social class and stress. It discussed the impact of the availability of information on smoking’s negative consequences, such that about half of all smokers had quit, typically without treatment, and overall smoking rates had declined substantially in the U.S.
Although SGR88 labeled and defined nicotine as addictive, it did so in a way that actually contradicts the ways nicotine addiction is currently characterized by nicotine addiction experts, who claim that the process is irreversible and exclusively biological. As opposed to this “hard wired” model of addiction, note this formulation in Chapter VII of SGR88 (p. 465):
It is evident that smoking is maintained by both pharmacologic and psychological determinants. The relative contributions of these factors are virtually impossible to separate and are likely to vary dramatically not only among individual smokers, but perhaps also within individuals at different times and stages of their smoking histories.
3. Those Who Continue to Smoke (DHHS, 2002). Although smoking declined following SGR64 through the 1980s, many people nonetheless continued to smoke. In 2002 the DHHS released Smoking and Tobacco Control Monograph #15, entitled Those Who Continue to Smoke, to address why the prevalence of smoking had not declined further. Research in the volume explored whether remaining smokers were more addicted in strictly biological terms than quitters, whether they had different biological or personality profiles, or whether cigarettes had somehow become more chemically addictive. The basic hypothesis was expressed in the subtitle to Monograph 15, “Is Achieving Abstinence Harder?”
Despite great efforts, this research volume found, “Surprisingly, none of the papers presents compelling evidence that this is the case” (p. 2). On its last page (p. 143), the Monograph states, “In summary, these trends do not suggest that the population of smokers who remains is more addicted, more resistant to cessation messages, less likely to attempt cessation, or increasingly composed of those with limited activities or poor mental health.” These statements are made in the 2002 volume with a kind of surprise and regret, coming as they do from the perspective of the hardening of the neurobiological model that SRG88 had more tentatively advanced.
Ordinarily, a scientific theory is evaluated by its effectiveness – does it explain the world that we encounter, and is it useful for affecting outcomes? The neurobiological model on which the hypotheses underlying Monograph #15 were based does not succeed by these criteria. After two decades when this model has held sway, it has failed in the following ways we can identify:
- While scores of millions of people quit smoking due to concerns about cigarettes’ negative health effects, a sizable group continued smoking.
- This group of remaining smokers, contrary to the neurobiological model, is not more addicted: “trends in measured dependence do not support the view that U.S. tobacco control efforts have led to proportionately more quitting among less dependent smokers or left behind a population of proportionally more dependent smokers.” (p. 5)
- In particular, the neurobiological model would lead us to expect that older, long-term dependent smokers should be less likely to quit. The opposite is true: “Older adults represent a population in which the prevalence of smoking has declined to a very low level (10.6% in 2000) and thus comprises a group in which the most ‘hardening’ should have occurred, a group with the greatest potential recalcitrance to standard treatment approaches. However. . . population-targeted self-help and primary care treatments designed specifically for them produced rates quite as high, if not higher, than those same general approaches in younger populations.” (p. 5)
- Despite the acceptance of the neurobiological model, “there has been a decline rather than an increase over the last two decades in the fraction of smokers smoking 25 or more cigarettes per day, and the mean number of cigarettes smoked per day as reported by smokers has declined as well.” (p. 42)
Although the irreversible, neurobiological model of nicotine addiction is now considered ironclad, irrefutable, and destined by biology, this has never been the case, as demonstrated most clearly by key U.S. government reports that have contributed to the creation of the currently dominant model of nicotine addiction. This model – and the image of smoking that underlies it – appeared relatively recently, despite centuries of experience with tobacco. It achieved supremacy as the definition of addiction shifted, a different cultural view of tobacco came to prevail, and tobacco moved from the non-addictive category to the addictive one. However, the underlying epidemiology of tobacco use has not changed. People give up tobacco more or less as their needs dictate they should or must, like all harmful habits. All of this shows, of course, that addiction is politically and social defined, despite repeated but mistaken claims to have identified a purely biological, asocial basis for defining and recognizing addiction.
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