Tobacco Documents Online

61 TECHNICAL REVIEW ON CIGARETTE SMOKING AS AN ADDICTION: REPORT ON THE TASK FORCE ON SMOKING 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 18 years of age. Despite teenagers' dis- claimers 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 cigarettet: consumed by smokers averages 30 per day. Each inhaled puff of cigarette smoke delivers a dose of drug to the brain resulting in 50-70,000 such doses 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 :10 prrcent (17 inilliom) :tttrmptcd to quit smoking. Unfortunately, the long-term prol ability of success on any given rluit 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 nn,i to t.wo years. Fut•thermore• the proba- bility of relapse over time to cigarette smoking shuws remarkable similarity to " y ,.r--in tf:an cigarettes. ,Icehol and heroin use. It is of interest to : Mth heroin and cigarettes report that they woc oF ADDICTION AND AN ADDICTING SUBSTAI s.r." r-•••dtng to consider whether current evidence all ~tr.r•a <<!rir•tte smoking as an addiction, we must define •.re•.e vr,.. addtiction is a state characterized by the rep ,W s a„ .!. .•r.at ts toxic and leads to undesirable social cons a.N..raw+ •^.cb•.nasses other terms often used to describe nonme .ref s v,..... habituation, and dependence. An addicting sub a.a ss. • pharmacotogical properties leading to compulsive frrs •t ~nq ?rRan and/or behavioral toxicity; and (3) a ...rwsa .rn .,.:•.rse social consequences. In addition, this to+sar. -f..n ,.•• :nzestton of such substances is viewed by a ls ia ~v•r .. ~nj•eu•able. ,M1 M 'u... ~l••:. t,.en two general approaches to obtaining data a%.rar -..o ,n be viewed as an addicting substance: (1) +r.r+aaa sw aanc Y~:r se, and (2) studies of nicotine alone, sin 40r.Par.: wt>n. .uzRest that it is the most likely component in • a. ..r.:.c,.e „e A variety of behavioral studies of the ac 40'•+ +a*a •: r.•a ut ui animals. One of the methods used in cne addiction potential of drugs is the drug is a good correspondence between drugs tha +l.oratory animals and those that atre common . 1'iii t-nor:ttily holds iru<• f~~r 'lritl;s within II s.i-n•,av,tor stunulant class. Furthermore, drugs wh •+'.•ances are not self-administered by animals.

observed with alcohol and heroin use. It is of interest to note that indi- 'w/ruls who use both heroin and cigarettes report that they would find it easier MjSve up heroin than cigarettes. pQF1NITION OF ADDICTION AND AN ADDICTING SUBSTANCE Before proceeding to consider whether current evidence allows the cate- Me{sstlon of cigarette smoking as an addiction, we must define this term. In be pro.dest sense, addiction is a state characterized by the repeated ingestion :aj a substance that is toxic and leads to undesirable social consequences. This -tidynitlon e^compasses other terms often used to describe nonmedical drug use, #a! as abuse, habituation, and dependence. An addicting substance is one t1W has: (L) pharmacological properties leading to compulsive use; (2) a capa- b6ty of producing organ and/or behavioral toxicity; and (3) a use pattern asseeiated with adverse social consequences. In addition, this term is generally ilplf.d when the ingestion of such substances is viewed by a large segment of So society as undesirable. There have been two general approaches to obtaining data to determine lb.ther tobacco can be viewed as an addicting substance: (1) the study of WCfrstte smoking eer se, and (2) studies of nicotine alone, since its phanna- Mo6feal actions suggest that it is the most likely component in tobacco leading r 1ts repetitive use. A variety of behavioral studies of the action of nicotine 6M been carried out in animals. One of the methods used in the animal labora- 11" to determine the addiction potential of drugs is the drug self-administration Protedure. There is a good correspondence between drugs that are sel.f- 6611lnistered by laboratory animals and those that are common Irugs of addic- I~q in humans. This genernlity hu61:; ttve Gu• ih'iiyts wilhin thr ol,inid, sr,ta- Oat. and psychomotor stimulant class. Furthermore, drugs which are not M"etive substances are not self-administered by animals.

62 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 psychomotor 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 existence of these aversive effects of nicotine may account in part for changes in human cigarette smoking after variations in nicotine content or treatment with nicotine or nicotine antagonists. Effects of pharmocological treatment with nicotine antagonists can alter smoking behavior in humans and suppress nicotinf 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, and the ways in which pharmacological treatments can alter smoking behavior or self-administra 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 obtain 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. HUMAN STUDIES AllhouKh it is still nut uncyniv,1r:iI1V rlwn• Ihal nir„lino is Ihr „nly nKenl . 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 pt•imary role still ,twaits ndemonstration that the cigarette withdrawal syndrome is similar to the nicotine withdrawal syndrome. However, there have 63 unpUcating nicotine's role in the subjective frequency. For instance, subjects have been -r with greatly diminished nicotine) and they f r-r;,vment of smoking. Some subjects seem to er t.;.v... but tt is possible that they are able to extra ty ,war~ : t ~.•.r m.+nner of smoking (e, g. , increased inhalation ~. t..,..- -.•nt :nvolves delivering nicotine to subjects via ar M.,... r. . -•.:es tnhal3tion. Subjects of these experiments *L.. •-re- of satisfaction that they get from their cu .. •-•rn :n sme instances they do report some satisfacti /.. r,.r evtdence implicating the role of nicotine in cigarettt r.+•<n..r .-,n studies that have directly measured cigarette s.trs .. •+- have shown: (1) increases or descrear aw.. ,. ,r• associated with compensatory changes in s 1~ _. .ar•,:n -u%.:rtne blood levels within certain limits; (2) m akvw. .. ..:.,n ,t nicotine either upwards or downwards is als sw .rs..eu•,r•r ,:h:.nqes in smoking which tend to maintain nic t•*m. ..+z n.rt.un tunits; (3) pretreatment with nicotine (intra• trnrti+ =: -.- .• ;:mpensatory decreases in smoking; and (4) pr( • 411111N"*A" w"+t nist produces elevation in smoking. -?•r'P_NDENCE AND TOLERANCE ,-:asstc drugs of abuse such as the opioids an :ut dependence are important characteristics c MIGN. w' •aa'°rt•ate rne user's tendency to continue its use. T~ .••• ph.irmacol,>r'i :ai effects of drugs and may 1 ...:(-u „l h1i;hrt J,.•.,., „f Ih,• ,hr,it;. whirh in ttt 4''0'"• t- a, or untowar l effects on the user. ' ' -n tcm n~tr: tc,l f1,r Ihc cff,•ct: uf ,tm,kinK o( many of the components of cigarettes.

"verat studies implicating nicotine's role in the subjective aspects of smok- N weU as the frequency. For instance, subjects have been given cigarettes t nicotine (or with greatly diminished nicotine) and they fail to report customary enjoyment of smoking. Some subjects seem to enjoy the low- ci`arettes, but it is possible that they are able to extract more nicotine gWging their manner of smoking (e.g., increased inhalation). Another of experiment involves delivering nicotine to subjects via another route of tration besides inhalation. Subjects of these experiments do not experi- 40pe Hft usual degree of satisfaction that they get from their customary ciga- , although in some instances they do report some satisfaction from the lurther evidence implicating the role of nicotine in cigarette smoking is by human studies that have directly measured cigarette smoking vlor These studies have shown: (1) increases or descreases in nicotine w cigarettes are associated with compensatory changes in smoking which JMsd to mamtain nicotine blood levels within certain limits; (2) manipulation of WU.ry excretion of nicotine either upwards or downwards is also associated tisL tampensatory changes in smoking which tend to maintain nicotine blood bVels rnthut certain limits; (3) pretreatment with nicotine (intravenously or Mflly) produces compensatory decreases in smoking; and (4) pretreatment with SdtoGUe antagonist produces elevation in smoking. As with other classic drugs of abuse such as the opioids and sedatives, MKtaace and physical dependence are important characteristics of a drug because Ot)L may exacerbate the user's tendency to continue its use. Tolerance, for Ualaoet, reduces the pharmacolnrticil offecrs of drugs and may lead to more 6quenl a,hninisu•nl.iun of hi/;her (I-sc.+ ,f Ihf. drIiIf, wbirh in [tn•n may pru li.ice St7ater risks of toxicity or untoward effects on the user. Tolerance has been demonsl.r:itcd f r ihc cIY•cts -,f ,nwkinl; cignrrites rd also to the effects of many of the components of cigarettes. Nausea and

65 dizziness is common among novice smokers, but disappears with experience. Metabolic tolerance can be demonstrated in smokers to various components of cigarette smoke (e.g., nicotine, "tar", benzypyrene, carbon monoxide, other compounds) as well as to a wide variety of drugs such as barbiturates and chiorpromazine. Receptor tolerance can be demonstrated to some extent to cet= tain components of tobacco smoke. For instance, nicotine given intravenously has been shown to have a greater physiological effect upon nonsmokers than oti 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 metabolities. 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 increase in craving for smoking which decreases with time. Despite this reported increase in craving, the extent to which physical dependence on tobacco or nicotine influences the frequency of smoking remains to be determined. Human experiments indicate that, following a period of deprivation, irritability 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 they play in the maintan:tnce of smoking rrm:tins Io I- rsl,inr,vl. It would seem clear from the evidence presented that tobacco smoking pro- duces pharmacological effects which often lead to compulsive use. As stated 1,,..,, , r viin1tton of addictitm, it is necessary 0,00,,, .:,.-. nroduces organ and/or behavioral to. ..••cts of smoking are mild in compariso ., .., t- .c,,unces, the multiple deleterious healtl ,. ~ r,:wj sortaltty and disability and their atte b6 d ll h F ti th t tI esta . ew ques s e on a : f„r •« .• ~ ~• «..... ~.:, . wtde range of organ toxicity. r•utton of the group after reviewing the :ne toxicity, and the adverse social cons , s.n..r,r anould be considered a form of addictic s. •.. .. •^... an addicting substance. _ r concluded that cigarette smoking is ~;,ucatx,n of this conclusion is that cigare in hght of the range of policy consi •.+ .= r.erdered germane to the classic forms ot •- •.- n t, the narocitics, sedatives, stimulants. r.,t ctgarette smoking is considered an a: :t shouid be viewed as a disease. S •ta' -1rlstlrtttnr rt' 0ter metttods and' conc, +• ~'+.:n to oe applied to the smoking problem. " •••lrch efforts should be focused on th hum.ins. Rcsc:irch programs st +'~,t Pn+rmacologtcal variables which influ .-•rnjt;on of cigarette smoking behavior " ` -' - n and mauttenance of cigarette smokin ~" ' +• .;tentwn to other components of smoke

I 65 a 0 I poty t,~ our defintt:on of addiction, it is necessary to demonstrate that an aq aub.rance produces organ and/or behavioral toxicity. Although the IU+Oartaral •ffects of smoking are mild in comparison to those produced by @16dactIng substances, the multiple deleterious health effects of cigarette M4, tt.ciu;hng mortality and disability and their attendant social conse- p.a, ve now well established. Few question that the regular use of = M.da to a wide range of organ toxicity. ""CLi'SIOVS ~ nf etgarettes, an addicting substance. nro uwe, the toxicity, and the adverse social consequences, that cigarette MAavtor should be considered a form of addiction, and tobacco in the 11 ..s the epinion of the group after reviewing the evidence regarding the Oft_SCATIOtiS REGARDING CIGARETTE SMOKING AS AN ADDICTION (1) Tt•e_group concluded that cigarette smoking is an addiction. The iec.A.zt tmplication of this conclusion is that cigarette smoking should now be rs-exammed in light of the range of policy considerations which are 0rsentiv considered germane to the classic forms of drug addiction such r add:cuon to the narocitics, sedatives, stimulants, or alcohol. r.iSY Gr:en that cigarette smoking is considered an addiction it could be tended that it should be viewed as a disease. Such a categorization .Mo.1d allow the application of the methods and conceptual formulations of Pub:1e health to be applied to the smoking problem. ~~ apecial attention to other components of smoke that may modulate its ph t!M utitiation and maintenance of cigarette smoking should be explored WRAut and elanination of cigarette smoking behavior. The role of nicotine bMn7oral and pharmacological variables which influence both the mainte- rct ni_t:chavior_in hwnans. Rr.sc:irch progr:~ms shoubt clucidate the t3t 9asic research efforts should be focused on the analysis of cigarette i

(4) Research on psychosocial influences should not be deemphasized, bu4 projects should be sought which try to evaluate psychosocial and pharma codynamic influences within the same context. (5) Basic research efforts should be focused on the analysis of nicotine self-administration in laboratory animals. The range of conditions neces sary for the establishment, maintenance, and elimination of nicotine se) ~ administration should be studied. (6) Research efforts should be directed toward establishing an adequate~ animal modell of cigarette smoking behavior. (7) Research should be undertaken to establish valid low-cost, and pf~ erably noninvasive measures of cigarette smoking to be used as outcome measures in clinical treatment research. Examples of such measures mcl urinary nicotine or expired-air CO levels. (8) Physiological and psychological changes that occur during repeated administration (tolerance and physical dependence) and upon smoking cesi? sation (withdrawal) should be characterized in detail. The contribution these changes to the clinical phenomenon of relapse to smoking should established. * ;%,> ,,..:r.I.... Well, thank you, Dr. Pollin. A,: j .:•,! ~?:+nd it• you need to leave to go to a tt+. r', i% Fh:,t is right. Vr~ •~.! V•+A.. When is the latest you need to t* !°•:.•. I have at least 20 to 25 minutes, 1V . tir . v i)o you have any questions? z. N • x~.~,c>n. I have only one question. n~.%.•here you talk about adding " w„Fvrous, are you suggesting that tc a.r bt;. rft• r:Idditional labels that we may chc -0iwra-vt -: ~-, -•• word "addictive"? ' l ~+r i•, f.ltihe National Advisory Council, i w.ts 4uhgesting the addition of the w 400 s»-nt tatxrl. I would conclude from the natt now& anat tnw would think it would be important 'UM of any campaign emphasizing i . trt•ttt•ti. ret~->;! •r t•.0 t;Wrxlu. Is that your personal concl• ti# •.. It is. ti%"xlu. Is it the administration's p, A, Ur. Brandt indicated today, the i%4,r of stronger health warnings. T n n1;t%. most optimally achieve that a 1MMP's- ;.: n ,• r'., kwixnu. 'I'hank you. fx+;k%t..V Ur. Pollin, let me ask you thi: * .JM6M'W& •-jr ' rts•rt testimony, and you have cot This report has summarized the Technical Review on Cigarette Smoking an Addiction. Additional information about the meeting may be obtained from Dr. Pierre Renault, NIDA Division of Research. ~~ ~•. tnat tobacco is an addicting sub: !lf~nazs,i s. t drug. why has tobacco escaped be: ~' ~f1.:f a~,(lvtltnl•eS~~ i'`==--• i:mn sure that there is a com 1• e : mnr,r i . ~ p equlppea at tnls point to al n,tw led to indeed a ver diff , y , '•'-t,acco as compared with other s hwe ~ , ~ %7, ci u1JL111gU1Jileu c)acl 1hO N •ou believe that requirii ~ .o be ~,-tnK tffi an eectve method of 40"4* '"o•VP that these types of warnings rtL;tlrettes? rx•l,c•Vce that knowledge of healtl- r! ar. ... oft •~~~~~. ts cieariy not a simple ~'~°~ (•tther know it or don't know th A I the r easons that lead to bel :rndations and multiple levels ol tht i d :a• assemonstrated by "'t ` K h,ch ih .s peraps one of the +truments that man has dev~ ~ML "4, +ti4-M tlresentation of inessages. t)r-sentation of health conse( -=ivtdual because it represent `'O"ch has become so well know 0360'7594

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