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ACADEMIC rAt,,t1.y Is Nicotine Use an Addiction? 1?0 David M. Warburton The Report of the US Surgeon General of the United States was released on 16 May 1988, with the title of 'Nicotine Addiction' (USDHHS, 1988). ' The major conclusions of the Report (p.9) are: 1. Cigarettes and other forms of tobacco are addicting. 2. Nicotine is the drug In tobacco that causes addiction. 3. The pharmacoiogic and behavioural processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and co- caine, i.e. nicotine Is addicting In the same sense as heroin or co- caine. To psychoiogists, this is an Interesting claim and to smokers it is a very serious claim and this paper will examine it In detail. The addiction label Originaliy, the term 'addiction' was used for any strong incli- nation towards any kind of conduct, good or bad (Warburton, 1985). Only in the twentieth century have cer- tain patterns of drug use been labelled as 'addictions'.' Today, 'addiction' is often used to imply an undesirable, and usually an illegal, use of drugs. Simiiarly, the noun 'addict' has lost its denotative meaning of people engaged in certain habits and has become a stigmatising tabei, implying some- one with a disease. Until the and of the nineteenth century, alcoholics and drug users were viewed as being morally depraved, but, by the and of the century. they were seen as diseased (Berridge & Edwards, 1987). Disease, defined as deviation from the nor- mal, had been developed for medical conditions, like typhoid. The disease concept of drug use implies that the 'addct' has some 'physiokogical addiction mechanism'. Thus, there is no control but the person is at the mercy of physiological craving. Relapse is a symptom of the re- emerging disease. However, the disease concept has been extended so that drug use is not just a physical disease, but Is a 'disease of the will', a type of mental disease. In this way, the concept of addiction has linked notions of moral, psychological and physiological pathology. Attempts are now being made to apply this complex concept to nicotine use. Nicotine use as an "addiction" The Surgeon General (1988) has produced a list of criteria for defining nicotine use as an 'addiction'. These criteria de- pend on argument by analogy. Argument by analogy may be used to suggest a conciusion, but cannot establish it. The' force of argument by analogy depends upon the resem- btance of the defining properties of X and Y. It only needs Y to possess some property that X does not, for the analogy to be unsound and the conclusion fallacious, no matter how many properties X and Y have In common. 0 1989 The British Psychological Society The Psychologist: Bu!letin of the British Psychologica! Society (1989~), 4, 166-170. Part of the argument of this paper is that the Surgeon- General has ignored the discrepancies in his enthusiasm to find criteria to compare nicotine use with heroin and cocaine use. Primary criteria The Surgeon-General's primary criteria are (a) psychoactive effects; (b) drug-reinforced behaviour; and (c) highly control- led or compuisive use. (a) Psychoactive effects This criterion is a novel one in the substance use field. The Surgeon General supports its inclusion by saying that 'To distinguish drug dependence from habitual behaviours not involving drugs, it must be demonstrated that a drug with psychoactive (mood ahering) effects in the brain enters the blood stream' (USDHHS, 1988: 7-8). This criterion is trivial. Firstly, entering the blood stream does not define psychoactivity. Psychoactive drugs, ike anti- depressants, alter mood only if they enter the brain and act on neurochemical systems in the brain that are responsible for mood control. If they do not enter the brain, then they cannot be psychoactivei Nicotine does enter the brain and does modify mood (Warburton, Revell & Walters, 1988). But does psychoactivity make nicotine or any other substance addictive? An important issue for the Surgeon General's argument is whether the actions of nicotine are like those of cocaine and thd opiates. It is true that both heroin, cocaine and nicotine are psychoactive but they are very different in their effects. In comparison with the psychoactive effects of heroin or co- caine, nicotine's psychoactive effects are extremely difficult to measure. Heroin, as well as inducing euphoria, impairs performance and cocaine impairs judgement (Goodman & Gilman, 1985). In contrast, nicotine improves performance, renders the user more alert and increases efficiency of per- formance and reduces anxiety (Warburton, Revell & Walters, 1988). As Pomerieau and Pomerleau (1984) said: 'Nicotine has a pharmacological profile that accords ideally with its use as a'coping response' in diverse situations. Other drugs, like alcohol or heroin, typically do not Improve perfor- mance; rather, they may induce a physiological response that is an exaggerated or inappropriately applied version of it mechanism for conserving resources in situations where struggle is useless ... with deleterious health and social con- sequences'. Pomerleau and Pomerleau (1984) concluded, 'For example, in contrast to drugs of abuse, nicotine from smoking is not only compatible with work but actually facilitates perfor- mance of certain kinds of tasks'. Thus, in terms of the psychoactive crherion, nicotine has a behavioural mode of action which is quite different from heroin and cocaine. r.d.Tv It is also worth pointing out that repeated cocaine use re- suits C;7 in psychological changes including depression. irritabiiity, an inability to experience pieasure, iadc of energy, 166 April 1989 The Psychologist

and xocial isolation. A particularly sinister consequence is the occurrence of a paranoid psychosis, attention and mem- ory • pcoblems (American Psychiatric Association. 1987). There is no evidence of any psychological changes after a I:ietime use of nicotine. Of course, it might be argued that, while there is a different profile of action, there is still some common 'addictive mech- anism' that maintains smoking. A crucial study was done by Nemeth-Coslett and Gr'dtiths (1986). Naloxone is an opiate antagonist and reduces heroin use by blocking its behaviou- ral actions. However, naloxone has no reliable effects on smoking behaviour. It could be argued that if nicotine was acting on the same neural mechanisms as heroin, cocaine or other habitually used drugs, that these substances would substitute for nico- tine and reduce smoking, in the same way as morphine will substitute for heroin. On the contrary, alcohol (Grilfiths, Bige- low & Liebson, 1976; Mello, Mendelson, Sellers 3 Kuehnle, 1979), amphetamine (Schuster, Lucchesi b. Emley, 1979) and heroin (Mello, Mendelson, Sellers 3 Kuehnle, 1980) In- crease smoking and do not reduce it. There Is no pharmacological substitution for nicotine use. However, smoking has been modified by substituting behavioural methods of achieving the benefits that were sought by the smoker, e.g. relief of anxiety or help for concentration (O'Connor & Stravynski, 1982). (b) Drug-relnforced behaviour Drug-reinforced behaviour means 'Ihe pharmacological ac- tivity of the drug is sufficiently rewarding to maintain seH-administration' (USDHHS, 1988: iv). With drugs such as heroin and cocaine, rats and monkeys can be readily trained to press a lover to obtain an injection (Deneau, Yanagita and Seevers, 1969). This is not so with nicotine. Extensive research has shown that it is extremely difficult to train mon- keys to' lever-press for nicotine and the pattern of administration bears no relation to human smoking. (The training schedule of reinforcement was technically a 5-min fixed interval, 7-min fixed time schedule). As Goldberg and j~npjngtje (1988) concluded: '... nicotine can act as an e ed"ivetenforcer for humans and experimental animals, but it does so under a more limited range of conditions than do other reinforcers such as IV cocaine injection or food presentation' (p.233). In other words, nicotine is less effec- t'rve than food for training animals to lever press and it is certainly not as powerful as heroin and cocaine. In addition, the Report states that 'addicting drugs often pro- vide ... benefit or otherwise useful effects; these effects may also contribute to the compulsive nature of drug use' (USDHHS. 1988: 250). In other words, it is claimed that if something is beneficial, it can be addictingl If so, we are all addicted to things like food and sex. (c) Hlghly-controlled or compulslve use Compulsive use has been a component of many previous definitions (Warburton, 1985). In the Surgeon General's Re- port, it is stated that 'Highly controlled or compulsive use indicates that drug-seeking and drug-taking behavior is driven by strong, often irresistible urges' (USDHHS, 1988: 7). This degree of 'compufsion' hardly seems to apply to nicotine. Many smokers have patterns of smoking behaviour by which they smoke at work but not at home, and vice versa. Many refrain from smoking for relatively long periods, for practical or religious reasons, without apparently experi- encing any hardship, e.g. coal miners who cannot smoke at the pit face and orthodox Jews who do not smoke on the Sabbath. As Ashton and Stepney (1982) state about these smokers: '1he rationale for labelling them as addicts is not conv'utcing'. ACADEMIC Secondary criteria Secondary criteria of the Surgeon General involve: (a) stere- otypic patterns of use; (b) recurrent drug ciavings; (c) relapse following abstinence; and (d) use despite harmful ef- fects. (a) Stereotyplc patterns of use Stereotypic behaviour or narrowing of behavioural repertoire occupies a prominent position In the formulation of the abo- hol dependence syndrome. The concept is based on the fact that some people develop a stereotyped, repetitive pattern of daily drinking (Royal College of Psychiatrists, 1979; Orford, 1985). The consumption of ordinary drinkers varies from day to day, in response to a variety of internal or exter- nal cues:-With stereotyped use, alcohol consumption comes more and more under the control of withdrawal symptoms, so that drug use will become more tegular. Heavy drinkers can describe their schedule of drinking within fairly narrow limits. Stereotyped use implies less flexible use, less an ac- tivity with a social meaning, and more something done for its own sake. Heroin is clearly under the control of withdrawal symptoms, while nicotine use, in its most common form, re- tains its social character and is very clearly under situational control, like stress (Ashton 8 Stepney, 1982; Warburton, 1987). This latter point will be emphasised in a later section. (b) Craving The Surgeon General defines craving as urges to use a drug which may be recurrent and persistent (USDHHS, 1988). A committee of the World Health Organization met to discuss the use of the term 'craving' in alcohol research. They concluded that "... a term such as 'craving' with its everyday connotations should not be used in the scientific literature to describe (certain kinds of alcoholic drinking be- haviour) if confusion is to be avoided' (WHO. 1955: 63). More recently, Hughes (1987) commented that the construct of craving is intertwined with several aspects of the disease modei, such as physical dependence and loss of control. In his view, there is no agreement on whether craving is a physiological, subjective or behavioural stale, and it has so many connotations that it may no longer be able to be used objectively. Thus he concludes, 'In summary, I believe that, at present, the variety of meanings for the construct of crav- ing precludes its utiAy' (Hughes, 1987: 38). In their discussion of craving. Kozlowski and Wilkinson (1987) point out that tobacco researchers (Shiffman, 1987; West, 1987) and alcohol researchers (Stockwell, 1987) may be talking about different phenomena when they use the word 'craving'. He believes that West (1987) and Shitiman (1987) are referring to a mild effect in which 'craving' is nearly the same as 'missing' or "thinking about' smoking, compared with severe physical withdrawal symptoms after alcohol. Kozlowski and Wilkinson ask, 'Are desires for alco- hol, tobacco and other drugs different? If yes, in what ways do they diHer? Is it simply that the desires are the same but the physiological correlates are different? We think that these questions need to be answered" (p.490). In other words, the evidence is not available to say 'craving for nico- tine' is the same as "craving for heroin" or 'craving for cocaine" and so this criterion is invalid. (c) Relapse Many definitions of addiction have cited difficulty in abstain- ing as a criterion. Evidence for smoking relapse rates being the same as that of heroin, comes from comparisons of the retapse rates for ex•smokers with the rates reported for ex- heroin users and ex-alooholics (Hunt. Barnett 8 Branch, 1971). The curves are analogous but we cannot infer similar mechanisms. As Jaffe and Jarvik (1978) commented, re- lapse to heroin occurs in the context of immediate high risk and strong social disapprovai, and the considerable effort of April 19P9 167 The Psychologist

ACADEMIC obtafning R. Relapse to smoking occurs in an environment in which the cigarettes are ubiquitous and there is no immedi- a!e'risk to health or social status. They conclude 'While we may continue to wonder what drives the exopiate addict to relapse, given the multiple motives for smoking that have been postulated and the number of cigarettes a heavy smoker may have consumed over a 10-year period, we may find it remarkable that relapse is not universal' (Jaffe & Jarvik, 1978: 1674-1675). Another important point is that Hunt of ars conclusion is based on the results of clinic studies with seN-selected sub- jects who had actively sought help. Schachter (1982) noted that the view that smoking Is hard to give up has been mouldad largely by that seN-selected hard-core •group of people who ... go to therapists for help, thereby becoming the only easily available subjects for studies of recidivism'. People who stop by themselves and continue to abstain do not go to therapists. SUrveys of non-therapeutic populations indicate that long- term abstinence from smoking is a common event and the abstinence rates are considerably higher than those re- ported In the therapeutic literature. An estimated 29,000,000 Americans quit smoking between 1965 and 1975, with 70 per cent to 80 per cent quitting on their own (Center for Disease Control and National Cancer Institute. 1976). Thus, the generally-accepted view that nicotine is as hard to give up as alcohol and heroin is due to a reliance on clinical studies, with seN-seleded populations. It has ignored the benefits of niootine-use and the different social controls on nicotine use and heroin use. (d) Use despite harmful effects This criteran refers to 'use may persist despite adverse physical, psychological, or social consequences' (USDHHS. 1988: 8). People take part in many activities at the risk of harm to themselves. These days, sex carries the risk of dis- ease, while sunbathing can result in fatal skin cancer. Thus, for this criterion to have any force for nicotine, it must be demonstrated that users adopt an excess risk over other ac- tivities with associated risk, otherwise everything with the possbfity of risk could be defined as an addiction. Starr (1969) compared smoking with some voluntary acti- vities which have associated risks. like flying and ski-ing. As a simplifying assumption, risk of harm was equated with the probability of fatalities per person-hour of exposure to the activily. For smoking, Starr used an estimate of risk which was based on the US Government estimated rates of fatality from. heart disease and lung cancer for smokers. Benefit was calculated from the amount of money spent on the ac- tiviry by the participant. On the basis of these estimates, the subjective acceptability of risk was the same for smoking as it was for flying and ski-ing. It suggests that similar decision processes are operating for smoking as for ad'rvhies which involve stated risk and that nicotine users do not adopt an excess risk over other risk-associated activities. Harmful consequences is also interpreted to mean harm to society. Heroin use has led to serious consequences for so- ciety, e.g. theft, prostitution and spread of disease, but it cannot be daimed that nicotine use has had these sorts of consequences. As the American Psychiatric Association (1987) commented about nicotine: '... there is no impairment in social or occupalioional functioning as an immediate and direct consequence of its use' (p.182). Tertiary criteria As tertiary criteria, the Surgeon General includes: (a) pleas- ant (euphoriant) eNects; (b) tolerance and (c) physical dependence. (a) Pleasant (euphorlant) effects 'Euphoriant elfeds' refers to the pleasurable effects of a substance. Heroin and cocaine users report a strong pleasurable thrill which some users describe in sexual terms (Lindesmith. 1970). Anyone who has experienced both alcohol and nicotine would agree that the pleasure from these two substances is not comparable. Certainly. the effect of nicotine is not at all like the intense, sexual thrill that cocaine and heroin users describe, rather smokers report mild effects which are analogous to those produced by coffee and chocolate, rather than those of heroin and cocaine (Warburton, 1988). (b) Tolerance Thetiagntstic and Statistical Manual 111-R (American Psy- chiatric Association, 1987) defines tolerance as the 'need for markedly increased amounts of the substance (at least a 50 per cent increase) in order to achieve the desired eflect'. Certainly, heroin and alcohol users increase the amount that they take, but this does not occur with cigarette smoking. Although 'lolerance' occurs quite rapidly to some effects of cigarette smoking, e.g. nausea, dizziness, there is no evi- dence that tolerance develops to the 'psychological' effects of smoking, such as stress reduction and improved concen- tration (Warburton, 1989). Smokers rapidly arrive at their preferred number of cigarettes per day and this number re- mains stable for years. Indeed, many smokers in recent years have switched from high nicotine cigarettes to low ni- cotine cigarettes with only partial compensation (Stephen, Frost. Thompson. & Wald, 1988). In other words, smokers have reduced their nicotine intake over the years which would argue against the tolerance criterion being applied to nicotine. (c) Physical dependence .09 Aw 7 %-,4iA The existence of physical dependence is anin(erencre made from the abstinence syndrome that occurs when a chroni- cally-administered drug is discontinued. Certainly, there are marked, stereotyped symptoms that occur after giving up heroin and alcohol (American Psychiatric Association. 1987). However, the reported changes after smokirig abstinence differ widely from one individual to another and are not pres- ent at all in 25 per cent of people giving up smoking (Shi(fman, 1979). The Diagnostic and 'atistical Manual 111-R (American Psychiatric Association, 1987) observes that, for nicotine: 'In any given case, it is difficult to distinguish a withdrawal effect from the emergence of psychological traits that were suppressed, controlled or altered by the effects of nicotine or from a behavioral reaction (e.g. frustration) to the loss of a reinforcer' (p.150), i.e. the loss of something that they enjoy. Smoking cessation In this next section. I would like to consider the consequen- ces of defining nicotine use as an addiction for the person who wishes to quit nicotine use. The Surgeon General's Re- port said that recognising smokers as nicotine addicts should make it easier for them to quit. The problem is that ex-smokers find themselves in a double-bind. The therapist may call smoking an addiction in ordei to tess- en the client's guill. The client can accept this view, for an addiction is an illness from which you suffer and the clinician is responsible for the cure. However, it is a contradiction in terms to tell a person that they are addicted, and at the same time tell them that they are responsible for getting bet- ter. Addiction, in terms of the Surgeon General's criteria. implies compulsive use, something that cannot be controlled and yet the smoker is then told 'Control yourself'. April 1989 The Psychologisl

~. Equpting nicotine with heroin and cocaine makes things worse. Many smokers are reluctant to quit because they fear 4 the biow,of failure to their self-esteem (Sutton & Eiser, 1984).` Thfiy will be even more reluctant if they think that quitti:ig is going to be as bad as the layperson's view of heroin withdrawaL Teenage experimentation The report also has consequences for the teenager who may be considering experimenting with drugs. In the Sur- geon General's view, steps should be taken to 'protect children' from tobacco and nicotine. The problem is that put- ting tobacco, a legal product, In the same category with heroin and cocaine triviaiises the illicit drug problem. Thus, statements that equate smoking with heroin use and codaine use could promote hard drug experimentation with all its risks. Teenagers see the normality of friends and relatives who smoke and think that, if heroin and cocaine use are only Bke smoking, then there Is no harm in trying these drugs. Nothing could be further from the truth. Heroin use in our society leads to gross physical, social and moral dete- rioratlon in the frequent user. Misleading comparisons of smoking with other substances may unintentionally encour- age hard drug use and its horrifying evils. In fact, the Surgeon General's argument, that nicotine is like heroin and cocaine, can be turned upside down to argue that his findings offer reasons for iegalising cocaine and her- oin sales. After all, one possibility why nobody turns to prostitution and theft to support nicotine use is because ni- cotine is legal. Consequently, legalising heroin and cocaine would reduce drug-related crime. This argument may seem perverse, but Time (30 May. 1988) and Newsweek (30 May, 1988) discussed the debate about 'decriminalising' drugs like heroin, cocaine and marijuana. According to Time, 30 May 1988 (the same (ssue that presented the condusions of the Surgeon General) one common proposal is to handle the sale of these drugs in a manner similar to the sale of alcohol. The substances could be sold only by licensed dealers, who would be taxed and heavily reguiated, e.g. forbidden to sell to anyone under 21 years oid!1Some supporters of legalisation would support only the sale of marijuana, but the Mayor of Washington. Marion Barry, might add cocaine. Professor Alan Dershowitz (Harvard Law School) would allow the distribution of free heroin in the inner cities to those with a medical certificate. Economist Milton Friedman (University of Chicago and theorist of Monetarism) advocates the sale of any drug at the local chemist shop. Why not, if heroin and cocaine are similar to nicotine? Summary The Surgeon General's Report concludes that nicotine is ad- dictive on the basis of ten criteria. These criteria do not fit nicotine use very well. except in a superficial sense. The Report also argues that the pharmacological and beha- vioural processes of nicotine use are similar to those that determine use of heroin and cocaine. However, many as- pects of nicotine use, in its most common form of cigarette smoking, contradict his argument by analogy that nicotine use Is the same as heroin use or cocaine use. In terms of smoking cessation and teenage experimentation, equating nicotine use with heroin use and cocaine use may have consequences contrary to the intentions of the Sur- geon General. Of oourse, nicotine use can be called an "addiction"; some- one, like the Surgeon Generai, just has to say that it is. As Lewis Carroll wrote: 'When I use a word; Humpty Dumpty said in rather a r+t.rucwnt, scornful tone, it means just what I choose it to mean - neither more nor less." -The queslion is,' said Alice. 'whether you can make words mean so many different things.' 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$,tarr, C. (1969). Social benerit versus technological risk. Sdence. tGS, 1232-1238. Stephan, A.. Froet, C., Thompson, S. & Ward, N.J. (1988). Esli- ma'ting the extent of compensatory smoking. In N.J. Wald a P. Froggatt (Eds), Smoking and the Low Tar Programme. pp.100-115. Oxford: Oxford University Press. Stockwert, T. (1987) Is there a better word than 'uavinp'? 8riash Journal o/ Addicrior% 82 44-4 S. Sutton, S.R. & Eleer, J.E. (1984). The effect of fear-arousing oom- munications on cigarette smoking: an expectancy-value approach. Social Sdence and Medicine, 7, 13-33. US Department of Health and Human Services (1988). Nieotine AaWcdon: A report of the Surpeon-GeneraL DHHS Pubication Number (CDC) 88-8406, US Department of Health and Human Ser- vices, Office of the Assistant Secretary for Heallh, RockviAe, MD: Office on Smoking and Health. Warburton, D.M. (1985). Addidion, dependence and habitual sub- stance use. Bulktwr of The Brirish Psyr:hological Sociey, 38. 285- 288. Warburton, D.M. (1987). The functions of smoking. In W.R. Martin. G.R. Van Loon, E.T. Iwamoto & D.L. Davis (Eds) Tobacco Snroke and Nicodne: A Nearoblolo91ca1 Approach. New York: Plenum Press. Warburton, D.M. (1988). The puzzle of nicotine use. In M. Lader (Ed) The PsychophannacoloQy of the Add7crbn, pp.27-49. Oxford: Oxford Univarsity Press. Warburton, D.M. (1989). Psychopharmacological aspects of nico- tine. In M.A.H. RusseA, i.P.Stolerman & S. Wonnacott (Eds), Nicoa tire: Actions and Medcal 1mpGcations. Oxford: Oxford University Press. Warburton, D.M., Revell, A. i Waitera, A.C. (1988). Nicotlne as a resource. In M.J. Rand & K Thurau (Eds), The Pharmacology of Smoking Oxford: IRL Press, 359-373. West, R. (1987). Use and misuse of craving. 8nroish Journal of Ad- dretlon, 82, 39-4 1. World Health Organisation (1955). The 'craving' for alcohol. Re- r R of the WHO Expert Committee on Mental Health and on Atco- L Ouarterly Joumal of Studies on Alcoho( 16, 33-66. Requests for reprints should be addressed to: Professor D.M. Warburton. Department of Psychology, University of Reading, Reading RG6 2AL BPS THE BRITISH PSYCHOLOGICAL BOOKS SOCIETY Now available: two new titles in the Problems In Practice series Managing Stress by oavid Fontana BPr,$ MewAers' pria £4.75 pb, £11.25 hb, normaAy f5.95r£14.95 . Aimed at pradishg professionals, this books helps peopie identify the areas of stress in themelves, to understand the reason for this stress, to plan their rrves so as to avoid unnecessary stress, and to develop strategies for coping with slress when it does arise. Facing Physical Violence by Glynis Breakwell BPS Members' price £4.75 pb, £11.25 hb, numalty c5.M1 4.95 Violent attacks agains'a pradlioners working in the caring professions, social and pubiic services is a problem of serious concern worldwide. Why do such attacks oocur? How do they occur? Whai skils are needed to avoid such situations and to cope with them when they do ocau? What orgariisalional changes might help praditioners? Facing Physical Violence provides clear and straightfonxard advice to professionals, including problem scenarios and case studies. St Andrews House 48 Princess Road East Leicester LE1 7DR UK INST(TUTE OF PSYCHIATRY (University of London) BETHLEM ROYAL HOSPITAL AND THE MAUDSLEY HOSPITAL Do Crespigny Park, Denmark Hill, London SE6 8AF Monday 24 to Wednesday 26 July 1989 THE PRESENT STATE EXAMINATION - A FAMILIARiSATtON COURSE A course based on teaching from videotaped interviews, suitable for persons already trained wishing to refresh their knowledge and those wishing to learn something of the instrument and to increase their knowledge of psychopathology. PRESENTER: DR PAUL E BEBBINGTON Course Fee: £150 (including lunch and refreshments) For further information, please contact: Nadine Morgan Conference Office INSTITUTE OF PSYCHIATRY De Crespigny Park London SE6 8AF Telephone: 01-703 5411 Extension 3170 April 1989 The Psychologist 170