Tobacco Documents Online

~s:PE]IDERC::EON CTCJ3Z2TE S~G - A itEV'I1CW BEPOETE0. RD.1532 RESTL~C'J:ED 15.12.1977 ~E= A. Kay Comer ISSUED BY: Z.E. Thornton FROG. ]~F: 13.01.O5 DT~T1LTJK~ZON: Dr. S.J. G~ae~ D=. Z.W. H=$hes K.M. G:Lbb, Esq. K.S. Wade, l~q. E.G. NLchoZls, Ksq. Haz'r E. Kictarshs~uJ Dr. F. Seehofec Mr. ,A.J. lr.rusz3q~ki Dr. C..1.P. cLe Siqueira Dr. D.G. Felt.on Library Cop7 lio. 1, 2, 3, 4 Irt " " 6, 7 111 tl 8 " " 9, 10, 11 " " 12, 13 " " 14 " " 15 " " 16 " " 17 " " 18 " " 19, 20 (:OPT NO. ,mmm~ cr~ BAT Co LTD - MINNESOTA TOBACCO LITIGATION

CONTENTS ~e 2. t e e ,,. 7. 8. 9. 10. 11. 12. sumu~¥ INTRDDUCTEON DEFINITIONS OF ADDICTION, HABITUATION AND DEPENDEHCE EV%DENCE FOR THE ROLE OF NICOTINE AS A DETERMINANT OF CIGARETTE SHOKING 2.1 H/erotical 2.2 Evidence from ExperJ~nents UsinK Animal8 2.3 Evidence from ExperLmenrs on Humans: The Effects of Nicotine nnd of ~ed Delive~ of Smoke Constituents on Smoking Behaviour 2.4 Comparison of CiKarette, Pipe and ClEar Smoklns THE EFFECTS OF SMORIHG AND NICOTINE IN HUMAN SUBJECTS 3.1 Physiolosical Effects 3.2 PsycholoKical Effects 3.3 Effects on Performance DIFFERENCES BETWEEN SMOKERS AND NON-SMOKERS AND BETWEEN SMOKERS OF DIFFERING CIGAKETTE CONSUMPTZON PhysioloEical Differences 4.2 rsychoZoEical Differences Social Differences SMOKING MOT3~VJ~TON 5.1 PharmaeoEoKica~ Theories of Smoking Motlvanion 5.2 Behaviourel/Psychological Theories of SmokinS Mo~ivetiom 5.3 Mixed Theories of Smokinj Motivation ~NITIATION OF SMOKING BEHAVIOUR CESS&T$ON OF SMOKING BEHAVIOUR TOLERANCE TO NICOTINE &HD b'ITHDRAHAL SYMPTOMS THE CONNECTION OF SMOKIBG WITH THE USE OF DRUGS COMP&R~SON OF SMOKIHG WKTH THE USE OF DRUG8 USE OF THE TERMS "ADDICTIOH", '~ABZTUATIO~' AND "DEPENDENCE" IN THE COHTEXT OF TOBACCO S~K)K~lfG COHCLUSIOHS REFERENCES I 2 3 11 12 14 17 37 41 41 47 53 56 57 63 71 7~ 74 75 84 96 101 126 135 139 150 159 162 t.n CO CO BAT Co LTD - MINNESOTA TOBACCO LITIGATION __

AJ~ / CAL / 4 6J Group Research & Development Centre, Brlt~sh-Amer£can Tobacco Co. Ltd., SOUTHAMPTON. l$th December 1977 DEPENDE3gCE ON CT~ SMOKZNG - A REVIEW (Keport Ho. RD.1532 Keecricted) Dependence on c£Karette 8mokln8 is reviewed with reference to the definitions of "addictlon", "habltuatlon" and "dependence". Evidence for the importance of u~coc£ne in 8mokiz~ behavlour is dLscussed and a number of the affects of ~kinK and nicotine are considered. Differences betweeu 8moke~s and non-smokers are rev~eved and a Var£eCy of smoic~n4~ motlvmClon theoc~es ~re pressured tosether w~th information on the phanomenA of smoking initiation and cessation. The counection of mnolc~n4K with the use of druKs ks expZored and comparisons 8remde between the use of tobacco and druKs such as oplaces and marijusna. It is concluded thJt the majority of smokers are to some extent dependent on s~k~ but that behaviourel, 8oc£aI and psycholosical factors may be as important as those of a pharmacologlcal nature. BAT Co LTD - MINNESOTA TOBACCO LITIGATION

-2- ]~T~ODU~ION Since interest was first shown in the reasons for smok~ tobacco there has been conslderable confusion about the use of the terms "add£ctic~", "habituation" and "dependence". The purpose o£ this report is to try and cSar££y the position v~th reKatd to cigarette smoking and also to discuss some of the theories and experiment&l results obc~[ned on the effects of nicotine and smoking and on smoking motivation. The report is divided into a number of sections, ~ach representing • different aspect of factors Invo1~td in clsa~ttt• 8moklnS. An attempt has been made to structu=• the sections in such • may that they can be read independently. This involves • certain amount o£ unavoidable repetition and some publications are discussed 4, more than one section. Zt is hoped that • £L~rly r~presentat£ve selection of the work on smok£~ is presented here, although it is obvio~ly not possible to discuss •lZ the avaiZabZe publications. Some emphasis is placed on the work of Dr. H.A.B. ]bJsseL1 o£ the Addiction l~se~rch Unit, Znstitute o~ Psychiatry, at the Haudslay Bospt:al, London. Re has pubZished a Zarse nmsber of papers on i vide m~rie~y o£ aspects of smok/~S, sad his work is discussed in relation to that 0£ other authors. BAT Co LTD - MINNESOTA TOBACCO LITIGATION c~

-3- D~NITIONS OF ADDICTIONv H&BZTUATZON ld~D DF~PENDENCE The inCmnCion in ChUm emotion is Co present jose of the definitions chac have bmen published, as It~h£s ~11 form the basis for discussion of them and chair relevance co smoking, in subsequent sections. The de£iuiCions of the ceres addiccion mad habltuacion which are most often quoted wars SivRn by the World Health Orlanisacion in 1957 (224). Addiction is said co be "a scmcm of periodic oc chronic inco~4cac4ou produced by repeated consmnption o£ • drug". Xts char&cter£scics include: An overpowering desire or need (compuXs£on) Co continue Caking the drug and Co obtain iC by any moans. 2. A tendency Co £ncruse Cha dose. 3. A psychic (psycholos£cal) sad jmmrsIly • physical depeudmnce on the effaces of the drug. 4. kcrlmmntal effects co the ind£vidual mad Co sociecy. Hab£CuaCion is • "condition" reaulClng from repeated adm~nlscraCion of • drug. Its characteristics include: (a) A desire (but noC compulsion) co continue Caking the drug £or the s•nse og ~ell-being ic engenders. (b) Little or no tendency to incrmmse the dose. (c) Some deKrme of psychic dependence on the mf£ect 0£ the drug may be present buC physical dependence and hence am &bsCiwence syndrome are absent. (d) DecrLmmnc~/ e£f•ccs, if any, et pr/marily to the /Jldividual. The "official" 'de£inicion o£ addiction given by the Drug Addiction Co~iCCee o£ the National Rasemrch Cmmcll (U.S.A.) (21~) is similar to thaC o£ the World Health OrKmaisacion buC stresses ehAC the development C3~ BAT Co LTD - MINN~C~TA TOBACCO LITIGATION

-4- of the means to continue adminlstratlon of the drug becomes an importRnt motive for the addlctts ~st@nce. StunSo (201) suKKested in 1961, that the @rld Health Orsanlsatlon ddinition did not sufficiently elphasise the i~evitabiltty of abstinence symptoms ehen an addictive drug i8 withdrawn. ~e defined drus addiction as: "a physical and psych4c dependance on a drub and the need to ~ake it in proKressively Lncreasin~ doses or at shorter intervals because of the development of tolerance and because, othezwiee severe abstinence Symptoms Ere e~perie~ced". As Lateen and Silva•re (124) have iudlcated, there are at ~aast £our di£Eeranc v~s of usJ~=K the term "addiction". The phaz:~colosist defines it at s cellular level as involvlnS an altered physioloKical state, with tolerance development. This state is produced by repeated administration of a drug and administration must be continued to maintain the altered state and prevent the development og the abstinence s3mdr~n. Beha~ioural scientists define addictiou as a be~tvi0ural pattern of compulsive drus use. There is an ovarwhelm/~s ~avolvement vith aspects of use mad supply o£ the druK a~d a h~Kh tendency to relapse agter withdzmml. Set,el•Keats delineate addicCion on the bas£s of the ham Chat the usa of certa£n drujs does to society in Sen.•tel. To the layman an addict£on £s any poverful habit thmC is difficult to break, vhethar it applies to drugs or activities. Any deflation of addiction mast. thera£ore, if it is to be readily understandable, indicate Ln which sense ~ha word 48 bein8 used. In 1964 the World Health OTKa~Loaeion sussasted ~hat the word "dependence" be 8ubst£tuted For both addiction and habituation. The -mmm~ C~ BAT Co LTD - MINNESOTA TOBACCO LITIGATION

-5- de, in, clans given here are taken from a report of the Expert Ccm~Ctee on Drug Dependence. which was published in 1974 (226). '~: Any substance Chat. when cak4m into the living or~mism, may modify one or more of ice functions." "Drug dependence: A scare, psychic or sometimes aXso phys£cal, result£nS from the interaction between • 1£~n8 orrju~em and • drug, cha~mcterised by behmvloural and ocher responses that always include 8 compulsion co cake the drug cm a continuous or periodic buls in order co avoid the dLscc~forc of its absence. Tolerance may or amy not be present. A l~erson may be dependent on more r.ban one drug." '?sychic depender•: A condiclon /:: which • d~'uK produces • feeling of szcisfacc£on and • psychic drive Chat requires • periodic or continuous admln~sCreCion of the drug co produce pZeasu=e or avoid d£scomforC." '~?hys£c&1 dependance: An adeptly• scare chaC man, rests Itself by LuceuJe physical dlscurbances whm~ the mdmiu~scrac£on of the drug is suspended. These disturbances i.e. ohm u~chdrawmZ or abstinence syndrome, are made up of specific arrays of symptoms and glens of • psychic or physical naL~re that are characteristic for each drug cype." "Dependence-producing drug: A dz~K having the capacity to interact with • living orKanlsa £o produce • mCm£e of psychic mr physical dependence or both. Such • d~ may be used medically or nou-modlcally v~Chout necessarily produc4~a~ much • sC&Ce. The chErmcterlsC4cm of the stare of drug dependance, once developed, will vary with the type of dru~ involved o" The Amaz~can Psychiac~c AnsocLaCion 1968 ad£cion of the Diagnostic and $cac£sCical Manual of Manta1 D~sordets (DS~Z) (4) subsCLcucad BAT Co LTD - MINNESOTA TOBACCO LITIGATION C.,,':, Cr'2~

~m "dcug dependence" for "drug addiction" ~th a s~n~lar de££nitlon to that used by the World Health Ocganisacion. Drug dependence gas catelor£sed under '~ersouallcy disorders Rnd certa£n other n~aTsych4atr£c mmntal disorders". Freedman (68), commmntinS on Chls, points out Chat drugs r which are med£cally prescribed mud the £nCmkm of which conforms to medlczl need, art not included. Yor s psychiatric d4s4nosis co be made, the therapist needs evidence of t~b£tuml use or a clear sum of need in the patient. The presence of an abstinence syndrome is noC t~e only evidence for dia4snos4s. Freedman also t~dicmCed chat aZchouKh the calm "drug dependence" is am £mprovmmnt c~ar "addiction", chert are s~ill mnb£guities. "Drug use is so £nextr£cmbly e part: of modern soc£ety that one £s o£cen re£e~£u8 Co social de£1nltion8, related to e parCiculax culture and slcuation". Russell (168) has also cc~enced on the de£inttions o£ dependence Kiven by the World Health O:gm~Lsec£ou. He states chac physical dependance is 8chorally held to involve the presence of phys4oloiic41 adaptive changes. These include: (i) tolerance to effects of the d~ primarily due to changes aC syc~pses and also in some casts Zo increased capacity to netabolise and excrete the drug, as a result of euzyum ~:duct4cm, mainly in the 1:1.vet; (ii) wichdr~l sympc~ resulting Jr'ore rebound overa~t4vi~7 at 8yu~pses when the ~mt~k8 o~ the drug ts reduced or discont4nuad. Psychic dmpendance is bal£eved Co have no mzch underlying physioloK~cAl mechanimns. Russell objects Co the a4scinct4on heCumm phys£caZ and psycholoK4ce1 dependence since stz~ng dependence may occur 4n the absence o£ t demozmCrmble Ir~Chdrmmel rTndrome m~l., u psychologiui p:ocessas are mediated by physiological mvemcs in the brL~u, them Ch£s BAT Co LTD - MINNESOTA TOBACCO LITIGATION "-O

-7- is alSO m £m~£rectly, a physical effect. .Accordlug to R~ssell it is scme~u~t 8~bStrax-y how hiKh a deKree o£ depe~dsnce is required before a dependance disorder is texmad an addiction. Pa~n (157) suggested Chat "drug dependence iwises when as a result of giv/~g up • dTug, forces - physiological, biochmn~c~l, social or 8nviromental - are set up which predispose to continued dru8 use". Russell (168) has criticlsed this daf~Ltion and has stated rJ~st: "dependence on a drug, object or activity requires the crucial featmre of negative a££act in the absence of that drug, object or ac~i~,Ity. The deKree o£ dependence is equated vir3h the smmant o£ neSative a~fect which may range fz~n mild discomfort to ~trm distress, or may be equated with the amount of di£ficulty or e££ort required to do w~thout the drug, object or acti~ty". Thls is =eiated to the P~m~ory o£ T~k/~s who listed the phenomenoLogicalIy oriented criterla £or psycholoKical addiction (206). He said chat the absence 0£ the addicting substance is always noted and awareness of absence ~eKuls~ly t~sttsaCes incense ~$ative a~ftct £or which there is also avatuss and this increases with the time o£ deprivatiou. The addict expects that only the add~ctin8 substance can reduce this neKative af£ect (or emotion) and produce positi~ L~£eCtS. and these expectat£on.s, s~e invariably con~iz=s~/. Both (94) distinguished be~woen "habit" which reflects ropetiti~e. behav~our with no a~fectima c~c~nt, and "dapsndonce" in ~hlch the~e is en increasing desire or need for the e~£ects produced. Runt and l~atarsu~o (96) also discussed hab4t, addiction and dependence. Their de~in£tion of "habit" is- "learned behsm~c~r - a fixed bed~viour pttcer~ cmerLaarned to the point of becoaJ:~ s~t~atic and ms~ked by dsc::easi~ awareness and increasing dependence on sacond8~7 rather than BAT Co LTD - MINNESOTA TOBACCO LITIGATION c'~

-S- prinary re~uforce~ent". They reserve "addiction" for situations in vhich tolerance occurs and dosase must be increased to avoid withdrawal symptoms, lephylioal dependence" is said to be related to 8dd£c~on w~th the body develop~ dependence on e drug, but little tolerance is developed, the dose is not incrused and wt~adrmwal sympcams are mTng~nal or m~ss~. Hunt and Hatarazzo ad~t that the tetm~noloKy is 8ommdamt confusing mad di££erentiatlon between habit, dependence and addiction is dif£icult. They also define a term s'awlre~tsJu; "consciousness of u4~c is Ko£ns on, or the ability .to a~ke verbal report on the precedgmK or attendant stylus situation. It i8 minimal or missing with the performane~ of repetitive, stereotyped behsvio~ and present with some intene£~y in the phenomenon of craving and with the v£thdrm~tl symptoms comou to edd~cfiive dz~Ks." They alms su&Kest that psychic and physical dependence as defined by the World Health O=Kan,~sav£on can be :elated to their own re=ms '~bAbit" sad "m~rm~ess". Co svold confuslon between pu:ely physical processes and psych4c processes vith a physiological b~sis (of. R~ss'ell 4168)). ¥~slly in this section it amy be useful to give smae of the de£~tions presented in varLous lay. and mndiul dicciona~ies. The Concise Oz~o:d Diccionm~ (~7) defines addict as= "(verb) Devote. apply habit~ally or cmepu~sively: hence add£ctLon (noun) (romp) condition of d~ ezcess£vely and beLuK unable to cease dot so without adverse effects; add4cC~ve (8djecCi~n), causing addiction and depem~ence. Addict (noun) ~ereon 8ddicCad to a habit, sap. one dependent on a (specified) druS". B1ak4stons Gould ~edlcal Dictloumry (26) defines "habit" as: "a beh~v~our pattern f~zmd by repettc£on". Heroines for '~mb~ttion" include: "1. A condition of Sole=trice to the effects of a dru4J or a poison acquired by its continued use; ~ by a cra~K £or BAT Co LTD - MINNESOTA TOBACCO LITIGATION c.,m Oo c.,r't