Tobacco Documents Online

FOREWORD This 20th Report of the Surgeon General on the health conse- quences of tobacco use provides an additional important piece of evidence concerning the serious health risks associated with using tobacco. The subject of this Report, nicotine addiction, was first mentioned in the 1964 Report of the Advisory Committee to the Surgeon General, which referred to tobacco use as "habituating." In the landmark 1979 Report of the Surgeon General, by which time considerably more research had been conducted, smoking was called "the prototypical substance-abuse dependenoy." Scientists in the field of drug addiction now agree that nicotine, the principal pharmacologic agent that is common to all forms of tobacco, is a powerfully addictifig drug. Recognizing tobacco use as an addiction is critical both for treating the tobacco user and for understanding why people continue to use tobacco despite the known.health risks. Nicotine is a psychoactive drug with actions that reinforce the use of tobacco. Efforts to reduce tobacco use in our society must address all the major influences that encourage continued use, including social, psychological, and phar- macologic factors. After carefully examining the available evidence, this Report concludes that: a Cigarettes and other forms of tobacco are addicting. a Nicotine is the drug in tobacco that causes addiction. a The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. We must recognize both the potential for behavioral and pharma- cologic treatment of the addicted tobacco user and the problems of withdrawal. Tobacco use is a disorder which can be remedied through medical attention; therefore, it should be approached by health care providers just as other substance-use disorders are approached: with knowledge, understanding, and persistence• Each health care provider should use every available clinical opportunity to encourage or assist smokers to quit and to help former smokers to maintain abstinence. i

To maintain momentum toward a smoke-free society, we also must take steps to prevent young people from beginning to smoke. First, we must insure that every child in every school in this country is educated as to the health risks and the addictive nature of tobacco use. Most jurisdictions require that school curricula include preven- tion of drug use; therefore, education on the prevention of tobacco use should be included in this effort. Second, warning labels regarding the addictive nature of tobacco use should be required for all tobacco packages and advertisements. Young people in particular may not be aware of the risk of tobacco addiction. Finally, parents and other role models should discourage smoking and other forms of tobacco use among young people. Parents who quit set an example for their children. Smoking continues to be the chief preventable cause of premature death in this country. Nicotine has addictive properties which help to sustain widespread tobacco use. It is gratifying to see the decline in reported smoking prevalence and cigarette consumption in the United States during the past 25 years. However, we cannot expect to see a sustained decline in rates of smoking-related cancers, cardiovascular disease, and pulmonary disease without sustained public health efforts against tobacco use. The Public Health Service is committed to preventing tobacco use among youth and to promoting cessation among existing smokers. We hope that this Report will assist the health care community, voluntary health agencies, and our Nation's schools in working with us to reduce tobacco use in our society. Robert E. Wlndom, M.D. Assistant Secretary for Health ii

@ PREFACE This Report of the Surgeon General is the U.S. Public Health Service's 20th Report on the health consequences of tobacco use and the 7th issued during my tenure as Surgeon General. Eighteen Reports have been released previously as part of the health consequences of smoking series; a rePOrt on the health consequences of using smokeless tobacco was released in 1986. Previous Reports have reviewed the medical and scientific evi- dence establishing the health effects of cigarette smoking and other forms of tobacco use. Tens of thousands of studies have documented that smoking causes lung cancer, other cancers, chronic obstructive lung disease, heart disease, complications of pregnancy, and several other adverse health effects. Epidemiologic studies have shown that cigarette smoking is responsible for more than 300,000 deaths each year in the United States. As I stated in the Preface to the 1982 Surgeon General's Report, smoking is the chief avoidable cause of death in our society. From 1964 through 1979, eacl~ Surgeon General's Report ad- dressed the major health effects of smoking. The 1979 Report provided the most comprehensive review of these effects. Following the 1979 Report, each subsequent Report has focused On specific populations (women in 1980, workers in 1985.), specific diseases (cancer in 1982, cardiovascular disease in 1983, chronic obstructive lung disease in 1984), and specific topics (low-tar, low-nicotine cigarettes in 1981, involuntary smoking in 1986). This Report explores in great detail another specific topic: nicotine addiction, Careful examination of the data makes it clear that cigarettes and other forms of tobacco are addicting. An extensive body of research has shown that nicotine is the drug in tobacco that causes addiction. Moreover, the processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. Actions of Nicotine All tobacco products contain substantial amounts of nicotine. Nicotine is absorbed readily from tobacco smoke in the lungs and from smokeless tobacco in the mouth or nose. Levels of nicotine in iii

the blood are similar in magnitude in people using different forms of tobacco. Once in the blood stream, nicotine is rapidly distributed throughout the body. Nicotine is a powerful pharmacologic agent that acts in a variety of ways at different sites in the body. After reaching the blood stream, nicotine enters the brain, interacts with specific receptors in brain tissue, and initiates metabolic and electrical activity in the brain. In addition, nicotine causes skeletal muscle relaxation and has cardiovascular and endocrine (i.e., hormonal) effects. Human and animal studies have shown that nicotine is the agent in tobacco that leads to addiction. The diversity and strength of its actions on the body are consistent with its role in causing addiction. Tobacco Use as an Addiction Standard definitions of drug addiction have been adopted by various organizations including the World Health Organization and the American Psychiatric As,~ociation. Although these definitions are not identical, they have in common several criteria for establish- ing a drug as addicting. The central element among all forms of drug addiction is that the user's behavior is largely controlled by a psychoactive substance (i.e., a substance that produces transient alterations in mood that are primarily mediated by effects in the brain). There is often compul- sive use of the drug despite damage to the individual or to society, and drug-seeking behavior can take precedence over other important priorities. The drug is "reinforcing" - that is, the pharmacologic activity of the drug is sufficiently rewarding to maintain self- administration. "Tolerance" is another aspect of drug addiction whereby a given dose of a drug produces less effect or increasing doses are required to achieve a specified intensity of response. Physical dependence on the drug can also occur, and is characterized by a withdrawal syndrome that usually accompanies drug absti- nence. After cessation of drug use, there is a strong tendency to relapse. This Report demonstrates in detail that tobacco use and nicotine in particular meet all these criteria. The evidence for these findings is derived from animal studies as well as human observations. Leading national and international organizations, including the World Health Organization and the American Psychiatric Associa- tion, have recognized chronic tobacco use as a drug addiction. Some people may have difficulty in accepting the notion that tobacco is addicting because it is a legal product. The word "addiction" is strongly associated with illegal drugs such as cocaine and heroin. However, as this Report shows, the processes that Q

determine tobacco addiction are similar to those that determine addiction to other drugs, including illegal drugs. In addition, some smokers may not believe that tobacco is addicting because of a reluctance to admit that one's behavior is largely controlled by a drug. On the other hand, most smokers admit that they would like to quit but have been unable to do so. Smokers who have repeatedly failed in their attempts to quit probably realize that smoking is more than just a simple habit. Many smokers have quit on their own ("spontaneous remission") and some smokers smoke only occasionally. However, spontaneous remission and occasional use also occur with the illicit drugs of addiction, and in no way disqualify a drug from being classified as addicting. Most narcotics users, for example, never progress beyond occasional use, and of those who do, approximately 30 percent spontaneously remit. Moreover, it seems plausible that spontaneous remitters are largely those who have either learned to deliver effective treatments to themselves or for whom environmental circumstances have fortuitously changed in such a way as to support drug cessation and abstinence. Treatment Like other addictions, tobacco use can be effectively treated. A wide variety of behavioral interventions have been used for many years, including aversion procedures (e.g., satiation, rapid smokingl, relaxation training, coping skills training, stimulus control, and nicotine fading. In recognition of the important role that nicotine plays in r~aintaining tobacco use, nicotine replacement therapy is now available. Nicotine polacrilex gum has been shown in controlled trials to relieve withdrawal symptoms. In addition, some (but not all/ studies have shown that nicotine gum, as an adjunct to behavioral interventions, increases smoking abstinence rates. ]n recent years, multicomponent interventions have been applied successfully to the treatment of tobacco addiction. Public Health Strategies The conclusion that cigarettes and other forms of tobacco are addicting has important implications for health professionals, educa- tors, and policy-makers. In treating the tobacco user, health profes- sionals must address the tenacious hold that nicotine has on the body. More effective interventions must be developed to counteract both the psychological and pharmacologic addictions that accompa- ny tobacco use. More research is needed to evaluate how best to treat those with the strongest dependence on the drug. Treatment of tobacco addiction should be more widely available and should be

considered at least as favorably by third-party payor8 as treatment o? alcoholism and illicit drug addiction. The challenge to health professionals is complicated by the array of new nicotine delivery systems that are being developed and introduced in the marketplace. Some of these products are produced by tobacco manufacturers; others may be marketed as devices to aid in smoking cessation. These new products may be more toxic and more addicting than the products currently on the market. New nicotine delivery systems should be evaluated for their toxic and addictive effects; products intended for use in smoking cessation also should be evaluated for efficacy. Public information campaigns should be developed to increase community'awareness of the addictive nature of tobacco use. A health Warning on addiction should be rotated with the other warnings now required on cigarette and smokeless tobacco packages and advertisements. Prevention of tobacco use should be included along with prevention of illicit drug use in comprehensive school health education curricula. Many children and adolescents who are experimenting with cigarettes and other forms of tobacco state that they do not intend to use tobacco in later years. They are unaware of, or underestimate, the strength of tobacco addiction. Because this addiction almost always begins during childhood or adolescence, children need to be warned as early as possible, and repeatedly warned through their teenage years, about the dangers of exposing themselves to nicotine. This Report shows conclusively that cigarettes and other forms of tobacco are addicting in the same sense as are drugs such as heroin and cocaine. Most adults view illegal drugs with scorn and express disapproval (if not outrage) at their sale and use. This Nation has mobilized enormous resources to wage a war on drugs -- illicit drugs. We should also give priority to the one addiction that is killing more than 300,000 Americans each year. We as citizens, in concert with our elected officials, civic leaders, and public health officers, should establish appropriate public policies for how tobacco products are sold and distributed in our society. With the evidence that tobacco is addicting, is it appropriate for tobacco products to be sold through vending machines, which are easily accessible to children? Is it appropriate for free samples of tobacco products to be sent through the mail or distributed on public property, where verification of age is difficult if not impossible? Should the sale of tobacco be treated less seriously than the sale of alcoholic beverages, for which a specific license is required (and revoked for repeated sales to minors)? In the face of overwhelming evidence that tobacco is addicting, policy-makers should address these questions without delay. To e Q vi •

achieve our goal of a smoke-free society, we must give this problem the serious attention it deserves. C. Everett Keep, M.D., So.D. Surgeon General vii

ACKNOWLEDGMENTS This Report was prepared by the Department of Health and Human Services under the general editorship of the Office on Smoking and Health, Ronald M. Davis, M.D., Director. The Manag- ing Editors were Thomas E. Novotny, M.D., and William R. Lynn, Office on Smoking and Health. Scientific editors were Neal L. Benowitz, M.D,, Professor "of Medicine, Chief, Division of Clinical Pharmacology and Experimen- tal Therapeutics, San Francisco General Hospital, University of California, San Francisco, California; Nell E. Grunborg, Ph.D., Department of Medical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Jack E. Henningfield, Ph.D., Chief, Biology of Dependence and Abuse Potential Assessment, Laboratory, Addiction Research Center, National Institute on Drug Abuse, Baltimore, Maryland; and Harry A. Lando, Ph.D., Professor, Department of Psychology, Iowa State University, Ames, Iowa. The following individuals prepared draft chapters or portions of the Report. David B. Abrams, Ph.D., Assistant Professor of Psychiatry and Human Behavior, Brown University Program in Medicine, The Miriam Hospital, Center for Health Promotion, Providence, Rhode Island Timothy B. Baker, Ph.D., Department of Psychology, University of Wisconsin, Madison, Wisconsin Neal L. Benowi~z, M.D., Professor of Medicine, Chief, Division of Clinical Pharmacology and Experimental Therapeutics, San Fran- cisco General Hospital, University of California, San Francisco, California Thomas H, Brandon, M.S., Department of Psychology, University of Wisconsin, Madison, Wisconsin Richard F. Catalano, Ph.D., Research Assistant Professor, Center for Social Welfare Research, School of Social Work, University of Washington, Seattle, Washington Larry D. Chait, Ph.D., Research Associate (Assistant Professor), Department of Psychiatry, University of Chicago, Chicago, Illinois Paul B.S. Clarke, Ph.D., Department of Pharmacology and Thera- peutics, MeGill University, Montreal, Quebec, Canada ix

Richard R. Clayton, Ph.D., Professor, Department of Sociology, University of Kentucky, Lexington, Kentucky Allan C. Collins, Ph.D., Institute for Behavioral Genetics, School of Pharmacy, University of Colorado, Boulder, Colorado Thomas M. Cooper, D.D.S., Professor, Department of Community Dentistry, University of Kentucky, Lexington, Kentucky Lori A. Crane, M.P,H., Division of Cancer Control, Jonsson Compre- hensive Cancer Center, University of California, Los Angeles, California D. Layten Davis, Ph.D., Director, Tobacco and Health Research Institute, University of Kentucky, Lexington, Kentucky Ronald M. Davis, M.D., Director, Office on Smoking and Health, Center for Health Promotion and Education, Centers for Disease Control, Reckville, Maryland Edward F. Domino, M.D., Prol'essor, Department of Pharmacology, University of Michigan, Ann Arbor, Michigan John L. Egle, Jr., Ph.D., Department of Pharmaoclogy/Toxioclogy, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia Joan Ershler, Ph.D., Research Associate, Mr. Sinai Medical Center, Milwaukee, Wisconsin Raymond Fleming, Ph.D., Assistant Professor, University of Wiscon- sin-Milwaukee, Mt. Sinai Medical Center, Milwaukee, Wisconsin Kathleen A. Fletcher, Ph.D., M.P.H., Consultant, The University of Texas ttealth Science Center, Houston, Texas Paul J. Fudala, Ph.D., Addiction Research Center, National Institute on Drug Abuse, Baltimore, Maryland C. Gary Gairola, Ph.D., University of Kentucky, Tobacco and Health Research Institute, Lexington, Kentucky David Gilbert, Ph.D., Department of Psychology, Southern Illinois University, Carbondale, Illinois Lewayne D. Gilchrist, Ph.D., Research Associate Professor, School of Social Work, University of Washington, Seattle, Washington Donna M. Goldberg, M.A., Annapolis, Maryland Steven R. Goldberg, Ph.D., Preclinical Pharmacology Research Branch, Addiction Research Center, National Institute on Drug Abuse, Baltimore, Maryland John Grabowski, Ph.D., Department of Psychiatry and Behavioral Science, The University of Texas Health Science Center, Houston, Texas Dorothy K. Hatsukami, Ph.D., Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota J. David Hawkins, Ph.D., Professor, Center for Social Welfare Research, School of Social Work, University of Washington, Seattle, Washington x •

Jack E. Henningfield, Ph.D., Chief, Biology of Dependence and Abuse Potential Assessment Laboratory, Addiction Research Cen- ter, National Institute on Drug Abuse, Baltimore, Maryland. Ronald I. Herning, Ph.D., Addiction Research Center, National Institute on Drug Abuse, Baltimore, Maryland Matthew Owen Howard, M.S., M.S.W., Research Assistant, Center for Social Welfare Research, School of Social Work, University of Washington, Seattle, Washington John R. Hughes, M.D., Departments of Psychiatry, Psychology, and Family Practice, University of Vermont, Burlington, Vermont Edgar T. Iwamoto, Ph.D., Department of Pharmacology, College of Medicine, University of Kentucky, Lexington, Kentucky Murray E.. Jarvik, M.D., Ph.D., The Neuropsychiatric Institute and Hospital, School of Medicine, University of California, Los An- geles, Veterans' Administration Medical Center, Brentwood Divi- sion, Los Angeles, California Robert C. Klesges, Ph.D., Associate Professor, Center for Applied Psychological Research, Department of Psychology, Memphis State University, Memphis, Tennessee Lynn T. Kozlowski, Ph.D., Head, Behavioral Research on Tobacco Use, Addiction Research Foundation, Professor of Psychology and of Preventive Medicine and Biestatistics, University of Toronto, Toront:o, ()ntario, Canada Howard Levanthal, Ph.D., Professor and Chairman, Department of Psychology, University of Wisconsin, Madison, Wisconsin Edythe D. London, Ph.D., Chief, Neuropharmacology Laboratory, Addiction Research Center, National Institute on Drug Abuse, Baltimore, Maryland Scott E. Lukas, Ph.D., Assistant Professor of Psychiatry (Pharmacol- ogy), Harvard Medical School, Department of Psychiatry, Alcohol and Drug Abuse Research Center, McLean Hospital, Belmont, Massachusetts Alfred C. Marcus, Ph.D., Associate Director, Division of Cancer Control, Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California Andrew W. Meyers, Ph.D., Professor, Center for Applied Psychologi- cal Research, Department of Psychology, Memphis State Universi- ty, Memphis, Tennessee Thomas E. Novotny, M.D., Medical Epidemiologist, Office on Smok- ing and Health, Center for Health Promotion and Education, Centers for Disease Control, Rockvine, Maryland C. Tracy Orleans, Research Associate, Health Services Research Center, University of North Carolina at Chapel Hill, President, Smoking and Health Consultants, Inc., Princeton, New Jersey xi