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I I I I I I I A 1 I I I I I I I I I Ar,ADEMIC Is Nicotine Use an Addiction? 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 pharmacologic and behavioural processes that determine tobaoco addiction are similar to those that determine addiction to drugs such as heroin and oo- caine, i.e. nicotine is addicting in the same sense as heroin or co- caine. To psychologists, this is an interesting ciaim and to smokers it is a very serious claim and this paper will examine it in detail. The addiction label Originally, the term •addiation' was used for any strong indi- nation towards any kind of conduct, good or bad (Warburton, 1985). Only in the twentieth century have cer- tain natterns of drug use been labei{ed as 'addicxions'. Today, 'addiction' is often used to imply an undesirabfe, and usually an il{egal, use of drugs. Simifariy, the noun 'addict' has lost its denotative meaning of people engaged in certain habits and has become a stigmatising label, implying some- one with a disease. UrW th. end of the nineteenth century, alooholics and drug users were viewed as being morally depraved, but, by the end of the century they were seen as diseased (Berridge & Edwards, 1987). Disease, defined as deviation from the nor- mal, had been developed for medirat conditions, IiCe typhoid. The disease concept of drug use implies that the 'addid' has some 'physiobgicai addiction mechanism'. Thus, there is no control but the person is at the mercy of physiofogical 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 ot the wir, a type of mental disease. In this way, the concept of addiciion has linked notions of moral, psychological and physiological pattalogy. Attempts are now being made to appiy this complex concept to nicotine use. Nicadine use as an "addiction" The Surgeon General (1988) has produced a list of criteria for defining niootirte use as an 'addiciion'. These criteria de- pend on argument by analogy. Argument by analogy may be used to suggest a corkiusion, but cannot estaWish it. The force of argument by analogy depends upon the resem- blrnce of the defining properties of X and Y. It only needs Y to possess sortte property that X does not, for the analogy to be unsound and the conclusion fadacious, no matter how many propeRies X and Y have in common. © 1989 The British Psyc,fiobgical Society ' The rst: Bul/edn of the 8rib'sh sychologi:sl ` $ociety (1989 , 4, 166-170. 166 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 compulsive use. (a) Psychoactive effeets This criterion is a novel one in the substance use field. The Surgeon General supports its inclusion by saying that 'To distinguish drug dependenca from habitual behaviours not invoiving drugs, it must be demonstrated that a drug with psyc~toactive (mood aftering) effecss in the brain enters the blood stream" (USDHHS, 1988: 7-8). This criterion is trivial. Firstly, entering the blood stream does not define psydhoactivity. Psychoactive drugs, IiCe anti- depressants, atter 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 psychoactivel Nicotine does enter the brain and does modrfy mood (Warburton, Revelf & Waiters, 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 the opiates. k is true that both heroin, cocaine and nicotine are psyc~hoacsive 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. Hefoin, 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, Revea & Walters, 1988). As Pomerieau and Pomerieau (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 physiolcigical response that is an exaggerated or inappropriately applied version of a mechanism for conserving resources in situations where ZN-D struggle is useless ... with deleterious health and social con- n sequences-. *P6 Pomerkau and Pomerieau (1984) concluded, 'For example, = in contrast to drugs of abuse, nicotine from smoking is not ~ only compatible with work but actually facilitates perfor- O mance of certain kinds of tasks'. Thus, in txms of the ~ psychoactive criterion, nicotine has a behavioural mode of W action which is quite different from heroin and cocaine. -11 It is also worth pointing out that repeated cocaine use re- F10"- suRs in psychological changes incfuding depression, irritability, an inability to experience pleasure, lack of energy. April 1989 The Psychofogist

I I I I I I I I I I I I I I I I I I I and social isolation. A particularly sinister consequence is the oxurrc -ice of a paranoid psychosis, attention and mem- ory pcoblems (American Psychiatric Association, 1987). There is no evidence of any psychological cF-anges after a I'rfetime 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 crudal study was done by Nemeth-Coslett and Griffiths (1986). Naloxone is an opiate antagonist and reduces heroin use by blocking its behaviou- ral actions. However, naloxone has no reliabie 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 (Griffiths, Bge- low & Liebson, 1976; Mello, Mendelson, Sellers & Kuehnle, 1979), amphetamine (Schuster, Lucchesi & Emley, 1979) and heroin (Mello, Mendelson, Sellers & 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 benefRs that were sought by the smoker, e.g. relief of anxiety or help for concentration (O'Connor & Stravynski, 1982). (b) Drug-reinforced behavlour Drug-reinforced behaviour means 'the pharmacological ac- tivity of the drug is sufficiently rewarding to maintain self-administration' (USDHHS, 1988: iv). With drugs such as heroin and cocaine, rats and monkeys can be readily trained to press a lever to obtain an injeaion (Deneau, Yanagita and Seevers, 1969). This is not so with nicotine. Extensive research has shown that d is extremely difficult to train mon- keys to 4ever-press for nicotate and the pattern of administration beara, no relation to human smoking. (The training schedule of reinfoncoment was technically a 5-min fixed interval, 7-min fixed time schedule). As Goldberg and Henningfield (1988) oonciuded: "... nicotine can act as an effective reinforcer for humans and experimental aninais, 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 effea tive than food for training animals to lever press and 'R is certainy not as powerful as heroin and cocaine. In additian, the Report states that 'addicting drugs often pro- vide ... benefit or otherwise useful effects; these effects may also corttn'bute to the compufsive nature of drug us." (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 Ike food and sex. (c) Highty-controlhd or compuQsivs uss Compuisive use has been a component of many previous definitions (Warburton, 1985). In the Surgeon C»n.ra!'s Re- port, it is stated that, "t-lighly oontroded or compulsive use indicates that drug-seeking and drug-taking behavior is driven by strong, often irresistible urgas" (USDHHS, 1988: 7). This degree d'computsion" 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 apparentty experi- erxdng 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: 'the rationa{e for labeiling them as addicts is not convincing'. The PsycWbgist ACADEMIC Secondary crtterta Seoondary criteria of the Surgeon General involve: (a) stere- . otypic patterns of use; (b) rewrrent drug cravings; (c) relapse following abstinence; and (d) use despite harmful ef- f ects. (a) Stereotypic patterns of use Stereotypic behaviour or narrowing of behavioural repertoire occupies a prominent position in the formulation of the abo- hoi dependence syndrome. The concept is based on the fact that some people develop a stereotyped, repetitfve pattern of daily drinking (Royal College of Psychiatrisb, 1979; Orford, 1985). The consumption of ordinary drinkers varies from day to day, in response to a variety of internal o~exter- nal cues. With stereotyped use, alcohol consumption comes more and more under the control of withdrawal sympbms, so that drug use will become more regular. Heavy drinkers can descxtbe their schedule of drinking within fairly narrow limib. Stereotyped use implies less flexible use, less an aa tivity with a sociat meaning, and more something done for ds own sake. Heroin is clearly under the control of withdrawal symptoms, while nicotine use, in Rs most common form, re- tains its social character and is very clearly under situational control, Idce stress (Ashton & Stepney, 1982; Warburton, 1987). This Iatter point will be eniphasised in a lafer section. (b) Craving The Surgeon General defines craving as urges to ir.se a drug which may be recurrent and persistent (USOHHS, 1988). A committee of the World Health Organization met to discuss the use of ft term "craving" in alcohol research. They concluded that "... a term such as 'craving' with its everyday connotations should not be used in the sa.rttifie literature to describe (certain kinds of alcoholic drinking be- havimrr) d confusion is to be avoided' (WHO, 1955: 63). More recsrttfy, Hughes (1987) commertted that the construet of craving is intertwined wRh several aspects of the disease model, such as physieai dependence and Ioos of control. In his view, there is no agreemertt on whether craving is a physiobgical, subjective or behavioural state, and it has so many connotations that d may no longer be able to be used objectively. Thus he condudes, "tn summary, I beliave that, at present, the variety of meanings for the constnx:t of crav- ing precludes its utiky' (Hughes, 1987: 38). In their discussion of craving. Kozbrvski and WiNcinson (1987) point out that tobaoao researcters (Shiffman, 1987; West, 1987) and alcohol resaarcfwrs (StockweN, 1987) may be talking about different phenomena when they use the word "craving". He beiieves that Wesf (1987) and Shtffman (1987) are referring to a mild effecx in which 'craving• is nearly the same as "missing" or 'thiMang about" smoking, compared with severe physicai withdrawal symptoms afhr alcohol. Kozlowski and Wikinson ask, 'Are desires for aloo- hoi, tobaoco and other drugs different? If yes, in what ways do thay differ? Is it simpiy that the desires are ft same but the physblogical correlates are different? We think that thesm questions, need to- be answered' (p.490). In oih.r words. ft evidence is not avaifabie to say "craving for nioo- tine" is ft same as "craving for henairt" or "craving for cocaine" and so this criterion is invaiid. (c) R.IaPs. Many definitions of addiction have cited difficulty in abstain, ing as a criterion. Evid.nca for smoking relapse rates beirq the same as that of heroin, comes from comparisons of the, relapse rates for ex-smokers with th. rates reported for ex- heroin users and ex-aboholics (Hunt, Bamett & Branch, 1971). The curves are analogous but we cannot atfer similar mechanisms. As Jaff* and Jarvic (1978) oommented, re- lapse to heroin oaoJrs in the context of immediate high risk and strong social disapproval, and the considerable effort of April 1989 167

I I I I I I I A I I I I I I I I I I MVML/G1vuv ob2aining if. Relapse to smoking occurs in an environment in whidh the agaretfes are ubiquitous and there is no immedi- ate risk to health or social status. They conclude 'Whik we may continue to wonder what drives the ex-opiate 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 at a/'s conclusfon is based on the results of clinic studies with self-selected sub- jects who had actively sought help. Schachter (1982) noted that the view that smoking is hard to give up "has been moulded largely by that self-selected hard-core group of people who ... go to therapists for help, thereby becoming the only easily available subjeds 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 hgher 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 generaity-accepted view that nicotine is as hard to give up as alcohol and heroin is due to a reliance on dinical studies, with setf-seiected populations. ft has ignored the benefits of niootine-use and the different social controls on nicotine use and heroin use. (d) Uae despfte harmful effects This criterion refers to 'use may persist despite adverse physical, psychological, or social consequenoes' (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, whne 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, othenNise everything wdh the possibiity of risk could be defined as an addiction. Starr (1969) compared smoking with some voluntary acti- vities which have asaocxated risks, Ike ftying and ski-ing. As a simplifying assumption, risk of harm was equated with the probability of fatallties per person-hour of exposure to the aCtivity. For smoking. Starr used an estimate of risk which was based on the US Govemmerrt estimated rates of fatality from heart disease and lung cancer for smokers. Benefd was calculated from the amount of money spent on the ac- tivRy by the participant. On the basis of dteae estimates, the subjectiw acceptability of risk was the same for smoking as ft was for flying and ski-ing. It suggests that similar dacision procasses we operating for smoking as for aciivities which involve stated risk and thst nicotine usens do not adopt an excess risk over otlw risk-associated activities. Harmful consequences is also interpreted to mean harm to sociaty. Heroin use has led to serious consequences for so- d.ty, ;e.g. theft, prostitution and spread of disease, but it cannot be claimed that nicotine use has had these sorts of cartsequences. As the American Psychiatric Association (1987) commented about nicotine: "... there is no impairment in social or occupatioiortal functioning as an immediate and direct consequence of its uae' (p.182). Tertiary criteria As tertiary criteria, the Surgeon General includes: (a) pleas- art (euphorianrt) effeota; (b) tolerance and (c) physical dependence. (a) Pleasant (euphoriant) effects 'Euphoriant effecis' refers to the pleasurable effects ot a substance. Heroin and cocaine users report a strong pleasuraf:.e 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. Certainiy, the effect of nicotine is not at all like the intense, sexual thrill that cocaine and heroin users describe, rather smokers report miid effects which are analogous to those produced by coffee and chocolate, rather than those of heroin and cocaine (Warburton, 1988). (b) Tolerance The Diagnostic and Statistical Manual III-R (American Psy- chiatric Association, 1987) defines tolerance as the 'need for markedly increased amounts of the substance (at /east a 50 per cent increase) in order to achieve the desired effect'. Certainiy, heroin and alcohol users increase the amount that they take, but this does not occur with cigarette smoking. Although 'olerance' occurs quite rapidly to some effects of cigarette smoking, e.g. nausea, diainess, there is no evi- dence that tolerance develops to the 'psychological' effects of smoking, such as stresg,.reduction and improved concen- tration (Warburton, 1989). Smokers rapidly arrive at their preferred number of cigarettas per day and this number re- mains stable for years. Indeed, many smokers in recent years have switched from high nfootine cigarettes to low ni- cotine cigarettes with only partiai compensation (Stephen, Frost, Thompson, & Wald, 1988). In other words, smokers have reduced their nioatine intake over the years which would arQue against the tolerance criterion being applied to (c) Physlcal dependence The existend of physical dependence is an inference 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 smoking abstinence differ widely from one individual to another and are not pres- ent at ap in 25 per cent of people giving up smoking (Shiffman, 1979). The Diagnostic and Statisticai Manual III-R (American Psychiatric Association, 1987) observes that; for nicotine: 'tn any given case, R is difffCuk to distfnguish a withdrawal effect from the emergenc:e of psychological traits that were suppressed, controlled or altered by the effects of nicotine or from a behavioral reaotion (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 h'ke to consider the consequen- ces of defining nicotlirie use as an addicxion for the person who wishes to quit niootine 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 therapiat may call smoking an addiction in order to less- en the client's guitt. 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". I 1SO April 1989 The °sychobgist

I I I I I I I ~ I I I I I I I I I I I Equating nicotine with heroin and cocaine makes things worse. Many smokers are reluctant to quit because they fear tf:d blow of failure to their setf-esteem (Sutton & Eiser, 1984). They will be even more reluctant 'rf they think that quitting 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 tobaoco and nicotine. The problem is that put- ting tobaoco, a legal product, in the same category with heroin and cocaine trivialises the illicit drug problem. Thus, statements that equate smoking with heroin use and cocaine 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 like 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- rioration in the frequent user. Misleading comparisons of smoking with other substances may unintentionally enoour- age hard drug use and its horrifying evils. In fact, the Surgeon General's argument, that nicotine is like heroin and cocxine, can be turned upside down to argue that his findings offer reasons for legalising cocaine and her- oin sales. After all, one possibility why nobody turns to prostitution and theft to support nicotine use is because na cotine is legal. Consequentiy, legafising heroin and cocaine would reduce drug-related crime. This argument may seem perverse, but Time (30 May, 1988) and Newswoefr (30 May, 1988) dis~ the debate about 'decriminalising" drugs IiCe heroin, comine and marijuana. According to Tm., 30 May 1988 (the same issue that presented the conclusions 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 regulated, e.g. forbidden to seY to anyone under 21 years oldi Some supporters of legalisation would support only the sale of marijuana. but the Mayor of Washington, Marion Barry, mght add cocaine. Professor Alan Dershowitz (Harvard Law School) would allow the distribution of free heroin in the inner cities to those with a medicat certifica2e. Economist Mikon Friedman (University of Chimqo 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 Th. Surgeon Generars Report concludes that nicotine is ad- dictive on the basis of ten criteria. Thes" criteria do not fit nicotine use very wall, except in a sup.rfiaal sense: The Report also argues that the pharmacological and beha- vioural processes of nicotine use are similar to thosa 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 oorttrary to the intentions of the Sur- geon General. Of course, nicotine use can be called an "addiction"; some- one, Ike the Surgeon General, just has to say that it is. As Lewis Carroll wrote: "When I use a word,' Humpty Dumpty said in rather a r r .......m....... ACADEMIC scomtul tone, "it means just what I choose it to mean - neither more nor less.* "The question is,' said Alice, 'whether yot• can make words mean so many different things.' 'The question is,' said Humpty Dumpty, "which is to be master - that's all.' However, the most important measure for a scientific claim is experimental verification, not political pronouncements, however masterful. References Ashton, H. & St.pn.y, R. (1982). Smoking, Psychology and Phar- maoo/ogy. London: Tavistock Ameriean Psychiatric Assooiatbn. (1987). Diagnosoc and Staes- ricar Afanuai of Menral Disorolsrs. (Third Edition-Fievisecq. Washing- ton: American Psyctuatnc Asaocpation. Benidg., V. & Edwards, G. (1987). Opfum and Ehs People: Cpiaea use n Nmereenrh-csnaxy England New Haven, Corm.: Yale University Press. C.ntar for Disss. Control and National CancK Instttuta. (1976). Adult Uss of Tobacco. (Contract No. CDC 21-74-520). Washington OC: Center for Diseas. Controi and Nationaa Caneer Institute. 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