Tobacco Documents Online

• SOCIAL ISSUES ADDICTION STATJS The U.S. Surgeon General's Report, "The Health Consequences of Smoking: Nicotine Addiction," was released in May 1988.1 This report was narrowly focused on what it described as the "pharmacologic basis of tobacco addiction." Although it conceded that "[p]sychological and social factors are also important influences on tobacco use," the Surgeon General argued that a detailed review of these important factors was "beyond the scope" of the report. The report reached three major "conclusion": Tobacco products, including cigarettes, are "addicting." ~. -'.:e basis for this "addiction" is the drug nicotine L:, tobacco. s. The processes which determine tobacco "addiction" are similar to those which determine addiction to other drugs such as heroin and cocaine. • Other sources often relied on by anti-smoking groups to support a cigarette addiction claim are the diagnostic manual used by the American Psychiatric Association (APA). For example, the third edition of the APA's Diagnostic and Statistical Manual (DSM-III) published in 1980, included the terms "tobacco dependence" and "tobacco withdrawal."2 A revised manual known as DSM-III-R was published in 1987.3 In DSM-III- R, the terms "tobacco dependence" and "tobacco withdrawal" were changed to "nicotine dependence" and "nicotine withdrawal." The anti-smoking movement has attempted to use the claim of addiction -- and a related claim that cigarettes are a "gateway" to illicit drug use -- in their efforts to restrict or ban sales and marketing practices, including: vending machines and open displays, advertising and sport promotion, sampling and couponing. SUMMA_RY ARGUMENTS ZND Q 1. The Addiction Claim In The 1988 U.S. Surgeon ~ General's Report Is An Extreme Position That Has Been ~p Strongly Criticized By Experts From The U.S. And Other ~ Countries. dIO • ~ According to Dr. David Warburton (Department of © Psychology, University of Reading, U.K.), the 1988 Surgeon ~

• General's Report used an "argument by analogy" to establish criteria that could define tobacco use as an "addiction." Dr. Warburton, although a contributor to the 1988 Surgeon General's Report, was highly critical of its conclusions. [T]he Surgeon-General has ignored the discrepancies in his enthusiasm to find criteria to compare nicotine use with heroin and cocaine use-.4 Of course, nicotine use can be called an 'addiction'; someone, like the Surgeon General just has to say that it is . . . . However, the most important measure for a scientific claim is experimental verification, not political pronouncements, however masterful.5 • In a detailed review of the literature on smoking and n:.cotine, 0r. Warburton conclude that smoking is significantly different from addictive drug use. ("1]icotine does not act on the reward pathways in the brain or on the neurochemical systems that have been associated with euphoria. It has proved very difficult to get animals to self-administer nicotine, and smokers have shown that they do not actually experience any marked euphoriant effects. Thus, whatever the nature of the mechanism by which nicotine maintains use, it is not the same as that activated by other substances which are habitually used.6 Professor Albert Hirsch, head of the Department of Pulmonary Medicine at the University of Paris, expressed additional criticisms of the 1988 Surgeon General's Report. Although Dr. Hirsch is a vocal critic of the tobacco industry, he noted that tobacco "cannot be compared to drugs, especially hard drugs like heroin or other narcotics." He characterized such comparisons as an attempt "to fight an evil with misstatements or distortions of the truth."7 Within the United States, strong criticisms have been raised concerning the Surgeon General's addiction claim. In U.S. Congressional testimony concerning the Report, a noted clinical psychologist, Dr. Theodore Blau, described the nicotine addiction claim as "misleading and potentially harmful."8 2. By Calling Smokers Addicts, Anti-Smokers Hope To Eventually Eliminate Smoking As A Social Custom. The social and political underpinning of the addiction claim was admitted by Dr. Morris A. Lipton, one of several scientists who was involved in developing the United States ~ government's official position on smoking and addiction in the early 1980's He gave the following reason for the government's use of the addiction label: "It was selected because it's sort of a dirty word."9 Thus, it should be

• readily apparent that the term addiction was intended to have an emotional impact, and it has been applied to smoking with little regard for its scientific meaning. • 3. The Dramatic Physical, Psychological And Societal Effect Of Drug Addiction Are In Sharp Contrast With the Simple Pleasures Of Cigarette Smoking. Despite This Obvious Fact, Some Researchers Have Attempted To Broaden The Definition Of Addiction So That It Includes Smoking. Broadening the definition of addiction relegates addiction to little more t'.:an a description of any frequently occurring behavior. That seems to be why the word addiction is sometimes used to describe distance running or jogging, watching television, sexual activity, even shopping. In the ~;nited States, form Surgeon General C. Everett Koop also contributed to the misuse cf the term when he said in 1982 :hat video games are "addicting."1o Even as early as 1974, Reginald Smart of Canada's Addiction Research Founciation noted that terms such as addiction and dependence "Cover too much and attempt to bring :nder single rubrics types of drug use that are extremely :isparate. "li Similarly, Dr. David Warburton, of Britain's Reading ~niversity, observed: We all are 'dependent' for our ordinary happiness, gratification, emotional well-being and general quality of life on a whole range of people and object.12 Even coffee drinkers who regularly enjoy as few as three cups each day have been described as having a form of "dependence. "13 In short, the terms "addiction" and "dependence" become almost scientifically meaningless when they are used merely as description of any valued behavior or pleasurable habit. 4. The Addiction Claim Is Strongly Challenged By Reports That Smokers Have The Ability To Quit Smoking When They Make A Decision To Do So. Even the 1988 Surgeon General's Report noted that over 41 million people in the United States have quit smoking -- the vast majority without any outside assistance.14 In 1989, the Surgeon general made this point even more dramatically, noting that: "Nearly half of all living adults who ever smoked have quit."15 In the "Forward" to the 1990 • Surgeon General's Report, this point was reiterated by Dr. James 0. Mason (Assistant Secretary for Health, Public Health Service) and Dr. William L. Roper (Director, Centers for Disease Control).1s

• • Moreover, the efforts involved in quitting smoking are often highly exaggerated. Although some people describe unpleasant feeling when they quit smoking, these feelings are variable, generally not long-lasting and mild. They appear to be quite similar to the sort of feelings people often have when they stop doing any enjoyable activity. Whatever experiences some people have when they quit smoking appear to be "highly idiosyncratic."17 Therefore, they cannot be cloaked with any scientific validity. Furthermore, reports of smokers' desires to quit smoking, and their difficulties in carrying out decision to quit, may be misleading. Some smokers may say they want to quit simply to pleas someone else, such as their spouse or employer. Yet, they may enjoy smoking and have no true motivation to stop. Accordingly, what smokers say about "_heir intentions and attempts to give up smoking often should '-e viewwith a certain amount of skepticism.ls :t is clear from common experience and the quit statistics that smokers are able to refrain from smoking, or ~o quit smoking altogether, when they choose to do so. In testimony before the U.S. House of Representatives, a former president of the American Psychological Association, Dr. ':'heodore Blau, stated: It has been reported that many smokers are able to refrain from smoking for relatively long periods of time for practical, safety or religious reasons and to do so without apparent discomfort. Some examples are coal miners who may not smoke at the pitface, Orthodox Jews who give up smoking at sundown on Friday and cease smoking until sundown on Saturday, and so forth. Such behavior does not fit conventional view of addiction.19 Alan Marsh, U.K. Office of Population Censuses and Surveys, argued that the high rates of quitting smoking cannot be explained by the addiction or dependence theory of smoking. [T]he dependence view of smoking contributes nothing to an explanation of why one in five of those smoking ten years ago no longer do so. It is not open to us to believe that the power of nicotine to produce dependence has mysteriously lessened.20 5. The Inclusion of Tobacco Use In The APA's Diagnostic Manuals (DSM-III and DSM-III-R) Does Not Demonstrate That Smoking Is An Addiction. • The APA's inclusion of a smoking-related "withdrawal" diagnosis does not establish that addiction occurs in smokers. DSM-III-R states, for example, that any so-called

• "withdrawal" could simply reflect frustration due to giving up a pleasurable habit, or the "loss of a reinforcer."21 DSM-III-R also notes the absence of intoxication associated with smoking, in contrast with the use of addictive drugs. Since nicotine, unlike alcohol, rarely causes any clinically significant state of intoxication, there is no impairment in social or occupational functioning as an i.ediate and direct consequence of its use.22 S Clearly, one cannot say the same about the use of alcohol, cocaine, ::eroin or cannabis. Inclusion of tobacco in DSM-III and DSM-III-R may have teen influenced by a variety of social and political considerations.23 There may also have been a financial Lntluence because the manuals are used as a basis for ~nsurance reimbursement. 7~SM-iII's criteria for "tobacco dependence" are arguably largely Meaningless because they can be used to classify almost any smoker as "tobacco dependent." In one survey of the U.S. general population, 90 percent of the smokers were reported to fulfill the DSM-III criteria for "tobacco dependence." Based on these results, the government- supported researchers suggested that the DSM-III criteria for "tobacco dependence" are "overinclusive."24 The dubious significance of the diagnosis of "nicotine withdrawal" in DSM-III-R is perhaps most strikingly clear in the manual's own admission that no one knows whether this diagnosis has anything to do with quitting smoking. DSM-III-R states: Whether severe Nicotine Withdrawal decreases the ability to stop smoking or remain abstinent from smoking is unknown.25 6. The Claim That Cigarettes Are A "Gateway" To Illicit Drug Use Is Questionable On Intuitive Grounds, As Well As By The Weakness Of The Data used By Those Making This Claim. Although it has sometimes been reported that smoking may precede illicit drug use, the mere fact of this order of events cannot be considered to mean a cause-and-effect relationship. After all, even if a hard drug user first smoked cigarettes, he also undoubtedly first did a large variety of other things, such as drink milk or soft drinks, • eat ice cream, ride a bicycle and so on. The intuitive point should be obvious: Just because one activity chronologically precedes another does not mean that the activities are casually related.

r In terms of the available data, even studies claiming an - association between smoking and hard drug use report that the relationship, if any, is quite weak and of dubious predictive value. For example, Dr. John O'Donnell, a researcher writing in a United States government publication, noted: Whatever the nature of the association, it is small, and would not suggest that cigarette use would be a useful predictor of later drug use.26 A similar conclusion was reached in a study of U.S. adults which attempted to assess the relationship between use of marijuana, alcohol and tobacco. Evidence for this relationship was described as "tenuous."27 I U.S. Department of Health and Human Services, The Health and aseuuence S moxinQ e ua on. A Reoort of the SurQeon General. publication No. DHHS (CDC) 88-8406 Washington D C U S 2 , , . ., . . Government Printing Office, 1988. American Psychiatric Association, DiaQnostic and Statistical Manual of Mental Disorder. t3rd ed. - rev.), Washington D.C. American Psychiatric • 3 , , Association, 1980 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorder. (3rd ed. - rev.), Washington D.C. American Psychiatric 4 , , Association, 1987. Warburton, D.M., Is Nicotine Use An Addiction?," the PsvcholoQist: Bulletin of the British PsvcholoQical Society 4: 166-170 (at 166) 1989 5 , . Ibid. at 169. 6 Warburton, D.M., "The Puzzle of Nicotine Use." In: 111g psvchonharmacoloev of Addiction M. Lader (ed.). New York Oaford 7 , University Press, Chapter 3, 27-49 (at 44-45), 1988. Hirsch, A., Interview on French Radio Network, Europe 1, May 18, 1988. 8 Bleu, TH.., Statement, Re: "Health Consequences of Smoking: Nicotine Addiction." In: Hearing Before the Subcommittee on Health and the Environment of the Committee on Energy and Commerce, United States House of Representatives One Hundredth Congress, Second Session, 319- 332 (at 319), July 29,1988. Z) ® 9 Christensen, R., "Cigarettes Addictive, Panel Says, "The News and .A Observer. Raleigh, North Carolina, Wednesday, September 3, 1980, 1 and ~ 5B (at 5B). ~ • 10 Mattiace, P., "Surgeon General Says Video Games May Harm Children IND cl~ , "The Associated Press, November 9, 1982, A.M. cycle. ~ ~

• 12 13 1 4 15 . 16 17 18 19 20 Smart, R.G., "Addiction, Dependency, Abuse, or Use: Which Are We Studying with Epidemtology?" In: Drug Use. EoidemioloQical and SocioloQical ADi)roachesE. Josephson and E.E. Carroll (eds.). Washington, D,C., Hemisphere Publishing Corporation, Chapter 2, 23-42 (at 32), 1974. Warburton, D.M.. Addiction. Dependence and Habitual Substance Use," Bulletin of The Brltizh PwcholoQical Society 38: at 285-288 (at 287-288), 1985. Hughes, J.R., Higgins. S.T., Bickel, W.K., Hunt, W.K., Fenwick, J.W., Gulliver, S.B. and Mireault, G.C.. "Caffeine Self-Administration, Withdrawal, And Adverse Effects Among Coffee Drinkers, "Arch Gen Psvchiatrv 48: 6 1 1-6 17, 1991 l.' S. Department of Health and Human Services, The Health and onseauence moxinQ S a aa on. A Report of the SurQeon General. Publication No. DHHS (DCD) 88-8406, Washington, D.C., U.S. Government Printing Office. at 466, 1988.. U.S. Department of Health and Human Services, ReducinQ the Health ons_e auence moxine S ProQress. A Rep o General. Publication No. DHHS (DCD) 89-841 1. Washington, D.C., U.S. Government Printing Office. at 1 1, 1989. eeon U.S. Department of Health and Human Services, The Health Benefits of Sm_oking Cessation. A Rej)ort nf the Surgeon eneral Publication No pl-iHS (DCD) 90-8 146 WashinQton r tre r:,,i,ernment Pr; rr;,.o D nttnQ Q at i. 1990, . Murray, A.L. and Lawrence. P.S., "Sequelae to Smoking Cessation: A Review, "Clinical Psychology Review 4 (2): 143-157 (at 143), 1984. Kozlowski, L.T., Herman, C.P. and Frecker, R.C., "What Researcher Make of What Cigarette Smokers Say: Filtering Smokers' Hot Air," The Lancet I (18 170 ): 699-700, 1980. Blau, T.H., Statement, Re: "Comprehensive Smoking Prevention Education Act." In: Hearings Before the Subcommittee on Health and the Environment of the Committee on Energy and Commerce, United States House of Representatives, Ninety-Seventh Congress, Second Session, 486-488 (at 487), March 5, 11, and 12, 1982. Marsh, A., "Smoking: Habit or Choice?, "Population Trends, 37:14-20 (at 15), 1984. 21 American Psychiatric Association, DiaQnostic and Statistical Manual of . Mental Disorders, (3rd ed. - rev.), Washington, D.C., American Psychiatric Association, at 150, 1987..

0 22 Ibid. at 182. 23 McReynolds, W.T., "DSM-III and the Future of Applied Social Science, Professional Psychology 10 (1): 123-132, 1979. 24 Hughes, J.R., Gust, S.W, and Pechacek, T.F., Prevalence of Tobacco Dependence and Withdrawal," American lournal of Psychiatry 142 (2): 205-208 (at 205), 1987. 25 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. (3rd ed. - rev.), Washington D.C American , ., Psychiatric Association, at 151. 1987. 26 O Donnell. J.A.. 'Cigarette Smoking as a Precursor of Illicit Drug Use." In: CiQarette SmokinQ as a Deoendence Process N.A. Krasnegor (ed ) . . National Institute on Drug Abuse Research Monograph 23, Publication No. DHEW (ADM) 79-800, Washington, D.C., U.S. Government Printing Office. Chapter 4, 30-43 (at 42), 1979. 27 Dull. R T. And Williams, F P., Marihuana, Alcohol ad Tobacco: Reassessment of a Presumed Relationship,'iournal of DruQ Education 1 1 (2): 129-1 39 (at 135). 1981. 0