Tobacco Documents Online

Bulletin of Thc British Psychological Socieh• (1W), 38, 285-288 Printed in Great Britain C 1985 The British Psychological Society Addiction, dependence and habitual substance use David 11L Rarburton For over six months noa, I have been haunted bv the word addiction It started when someone asked me at a party. 'You are a psychologist. You do worik on smoking. Do you think that smoking is addic- tive?' I said 'Pto. not in the sense that addiction is usuallv used'. and said something about smoking not being in the same sort of activrtv as heroin taking I didn't think much more about the conversation until I read in Nevvs and Notes of the Britcsh Medical lournal of 16 yune 1984 that: In the United States smoAerrs with lung cancer eontinue their efforts to sue the tobacco eompanies: in its Mav'Jurie newsletter the Association for Non- smof.ers' R ght reports that Rose Cipolloni's lawyers are claimine that the companies .. manufactured addictive cigarettes which made health a•arnings meaninglest Did this mean that the word addiction could be applied to cigarette smoking after all and that I had been mistaken in mv answer? Later. I noticed a newspaper headline which read 'The Dangers of Addiction' (Guardiar;. 14 August 1yFa1 1 started to read it eagerl% and discovered that it was an article on the widespread use of computers h% children to solve mathematical proh- lem• to the detriment of thcir arithmetic abihn If We ascume that this headline w•as not one of the famed Guardian misprints. the n what did this sort of addiction mean" I was ven puzzled A(eu months after this on the PAi programme of BBC Radio 4. there was a discussion on soap opera• and the inten•iewer asked 'Do people become addicted to soap operas?' The person's ansvve: wat 'Of course. thev dr'. There was mn hesitation hy thc interview•ee. E; no". I Kas confused about the ust of vvord> li):e'addret'.'addicted', and'addiction' and so I headed for the maior dictionaries for help. Addiction In common usage in the United States, addiction i~ taken to mean hahitua' behaviour. For example. tS chctcr < A'gu /nrernationa.' Pictronan (3rd ed. ) d,ftnet addiction as 'the compulstve uncontrolled u.e of habit Orming drug~' and the addict as'ont uhd hahimal-v use~ and ha~ an uncontrollablt craving for an addtctive drug' In this definition, an addtcti e compound is seemmel) onh one that can generate uncontrollable craving ln contras; the Conci-cc Os(o-d Drcnonan defines an addict as a person addicted to a habit. esp one dependent on a (specified) drug'. In the Vtebster definition. there is no mention of dependence, while the British English definition has no mention of uncontrollable craving. Obviousl}. there is not a simple consensus in the English speaking World. In desperation. I looked up the derivation of the words addict, addicted and addtction. The Shorter Oxford Dicuonan gices the etvmolog) of addict as: from the Lat.in w'ord. addreru.<-assigned bv decree, made over. the past participle of addicere. to appoint. allot. Addict in Roman Lau meant to deliver over formalh b% judicial sentence to. and from that. figuraticeh. to devote or apply habitualh to a practice. As exam- ples, it cites: 1. The dav he addicts ... to studv. 2. Iie cannot addict his mind to . business. 3. To addict themselves to Sack. 4, To addict themselves to vice. . . profitable From addict has come the past participle 'addreted' used in the sense of devoted to. Maria.... and he will smile upon her, which will now bc so uncuitable to her dtcptKUUon. being addicted to a mclancholh as she is. that it cannot but turn him into a notable eontempt 7arlfrl: A'rgh:. 11. v 211. ., hut Mr Satteena voas not ven addtcted to praver> so hr marched up to bed Ashford Hc br virerns. and addicted te virginiut Greenc The noun addiction has come trom Roman Lav< referrinc to 'a formal givtne over ht sentence of court: hence. a dedication to a master' and so devotion. Houever. addtction. as well as meaninc devotion. can also mean a bent or an inclination. Herald. It it Othello s pleasure. our nohle and vaham general that. upon certain tidmgs nou arrived. imp:,rtinf thc mere perdition of the 'Iurkish flee!. evM man put himself into triumph. sotnc to dance. somc to make honftres. each man to ahat sport and re,els hts addiction leads him Orhelle II ii 6 Thus vve can see that addiction in ordinan' usage can refer to vvurk and business, sport and revels. melancholv and stud}. Sacl, and vice, prayers and virginitN. Certainh. it is a cen broad concept which has been applied to a wide variet% of behavioural phenomena. Besides the evercdav use of the uord addiction. it is reasonable to ask if there is a scientific definition of 'addiction' A search of the literature reteals man% possible medical deftnition~. One set of these includes physical dependence as an essential charac- teristic. For example. the Naiional Clearinghouse 28; 1

r for Drug Abuse Ir,formation in the 1970s. equated addiction with physical dependence on a drug and this is the most common. older definition of addic- hun. For example: Addiction occurs onh ahen. opiates arc used to alleviate -ithdrau'al drstress. after thi, dr,tress has been properlt uiderstood or mtcrprcted. that i• to sa}. after it has tMen repre>ented to rh: indntdua! rn terms of linguistic symbols and cultural habits whtct. hat•e grown up around the opiate habtt. If the individual fails to conceive of his distress as with- draw•al dtstress brought about bt the absence of opiates he cannr.l become addicted ... Lmdesmitb (tQa7) This 'addiction' d:finition hN Lindesmith (194') requires that there is physctal dependence. but atx, it specifies that there is some recognition b} the individual of the connection between use and withdrawal symptoms. Tttus. without this aw•are- ness, the term addiction cannot be used. Some defmitiors, however- have not made physical dependen:e or withdrawal symptoms a requirement at all. For example. Chapman (1962) proposed: Drug addiction is the repetitive and compulsive use of some natural or ~w~rrthctic substance to the detriment of self or societn. In the United Stntec Narcotic Rehabilitation Act of 196b, as is quoted in Rappolt (1972). an addict is am individual who habituath uses an% narcotic drut so as to endanger the pubhc moral, health- safen or wclfare. ot whu is so ta, addicted to the use of sac}. narcotic druer, as to have lost thc powcr of sclt-contro: w'ith reference to addiction In these terms. an addict is either a person whc- uses drugs and so creates moral, health or safer. prohlems. or he ma% onh hc a user with no contro! over their use. or both. Physical dependence or withdraKal symptorx is not a necessar_. symptom at all in this sort of defrnition. AfarrN definitions have not made physical depen- dence or withdrawal scmprom• a crucial require- ment hut do inciudc it as one of the ser eral possible characteristics. like loss of self-control and harm. The definition of Maurer & Vogel (1962) is one example of this sort of definition firur addiction mat txdeffined a, a state in whtch a person ha• kKt the poucr of cell-contro' .+nh redcr- cnc< to a drug ani abuse< the drur tn such an cxtcni that the per.nn o- soncts is harmed ._ In addition one or more of thc fofloµtnl: related but dtcunc: ptrenomen:• arc alaarI prescnt, (a) tolerancL: (bt ph%srcal dcpenderxe with resulting abstinence ilines> when thc druc i, withhcld. tc) habituation or emotrorr atdependenc< In these latter definitions. an essential chara.ter- isnc crf addretiorn is loss of self-control over usc and the extent of the hann for the user or socretn and not ph* vsical dependence. However- the statements ah- out 'p(wer of self-control' and 'harm' are so safuc as to be almost meanineiess A rather different definition of addiction was proposed h% the World Health Organization Expert Committee on Addiction-Producing Drugs in 1950 and revised in 1957. Their 1957 definition stated: Drug addiction is a statc of periodic or ehronic intoxicatton produced b) the repeated consumption of a drug fnatura: or synthetic) It• eharaneristrc include (it an oterpoaering desire or need )ccmn pulsron) to continue taking the drug and to obtain it b) an} means: (ii I a tendenc) to increase the dose: (iii) a psychic (ps}chological) and gencralf} a phYsical dependence or. the effects of the drug. and (b) detrimental effect on the individual and on societ% It is clear that the WHO definition departs signifrcanth from those of Lindesmith. Maurer & Vbgel, and Chapman. In the WHO defrnition. the essential aspects are an overpowering desire. a tendenc% to increase the dose and a detrimental effect on both the individual and on societn. Physical dependence is not a requirement for addiction. onl% a possibilin. Tolerance is not essential and onl% a 'tendenc%' is required Clear specification of state- ments such as 'oterpowering desire' and 'tendenct to increase the dose' were not made. Similarlt. 'detrimental effects' is such a value-laden concept that agreement on its nature would be impossible. Indeed. it is doubtful whether am_ of these terms can easil) he specified In addition. it is obvious that the condition. 'psychic dependence'. if it existed. w'ould be difficult to determine. This has now been recogniaed b" % the WHO and th; 1Mh WHO report of the Expert Cammittee on Drug Dependence (196Q) stated. Evidence ecrncerning the preunee and degree of psychic dependence is dra~n mainh from case hisrnrr ies, suhtecuve statements and general obsen•attcv. In view of these flaw's in the deftnition. it is not surprising that the WHO Expert Committee on Addiction-Producing Drugs (1964) concluded- The defrmnor of addiction gained some aceeptance. but confusion tn the use of the terms addiction anc habituation and misuse of the former continued Further. thc hw of drue, abused increased in number and di.ersrn. These difficulties ha.c becomc in- ereasmplc apparent and .•anou, attempts ha%e beer, madr to find a term that could he applied to drvc ahus: gcncrafl' %. The eomponent in common ap(+ear• to be dependence. whether p•~chtc or pMstca'l or txltb Hencc, use of the term 'drug dependence'. with a m.ddt inF phracc hnking it to a particular drug t~pc rn ordcr tc differentiate one clas• of drue• fron. another. ha• heen gtten mosr careful constderatror. The Expert Committee recommend> substitution of the terrr 'drut dependence' for the term> 'drue addrttion' and 'drug habituatioc' This recommendat)on was endorsed bt the WHO Scientific Group later in that cear (Xti7-10 Scientifu Group. 19641. The term addiction wao- abandoned and the WHO Expert Committee on Addiction- Producing Drugs was renamed the WHO Expen Committee on Drug Dependence. I

r In spite of this reje:tion of the term. The National Institute on Drug Abuse produced their Technical RCP1eN' on Cigarette Smoking as an Addiction in 1979, in which a NIDA committee gave a definition Which was devised sltecificalh to include smoking. Unfortunatelt. it is susceptible to man} of the criticisms of addiction that have been mentioned before, Their wording of the definition w'as: An addicting substa.nce is one that haz(1) pharmacm logical properties leading to compulsive usc: (2) a capabihtc of producing organ an3~or behavioral toxic- iq: and (3) a use pattern associated with adverse social consequences In addition. this term is generall}apphed when the ingestion of such substances is vieued b) a large segment of the society as undesir ablc The definitions that hace been cited imph that 'addiction' is drug use that results in dependence, tolerance and the need to increase the dose. and compulsive use resulting from uncontrollable crav- ing in various combinations. However. Stepney (1981) has shown cotrvincinglt that certain non-drug habits. such as slim'ninz. athletics. hobbies and gambling. reveal manc of these sorts of features as Well. For example. he points out that the tolerance is not unique tcr drug use. For the confirmed athlete no speed is fast enough. for the stamp collector no specimen rare enough, for the anorexic no weight i• low enough. for the businessman no banik balance large enough. From this description. it is clear that there is no agreement about the ~9eftnition of the term 'addi.- tion' in the medical and psychological literature, it has often been defrned to fit the substances that the incestigators have be,_n interested in The broad definitions include r:r;an% sorts of habits Some definitions of addiction impl} physical dependence and some dct not. Sotoe in.olca tolerance and the need to increase the close and some do not TheN sometimes specif} eompulsite use with uncon- trollablt craving and sometimes they do not. The meanins of the word 'addiction' is thus confusing not onf. to ordinarn people but even to the scientift. eommunitt. Indeed. as Reginald Smart of the Addiction Research Foundation in Toronto. who listed some deftnitions of addiction that were mentioned abcne, concluded. 'In summar_n. there is no real agreement aho.tt concepts such as addiction and abuse' (Smart. 1974- p. 311 If there is ne consensus on the definition of addtction. hou can the word he used as a health warninl: on cigarette packs or on ad%ertisernents" As pscchologists. we should abandon the u!.e of the term Which has so mam tague connotations. It is significant that the American Psvchiatric Association (I9SUI in then Diagnostic and StarisncaJ Manual qf Menta? Drs- orders do not use the term 'addtctron' for an% substance use dtsordet and instead thc't use th~ concept of dependence. e.g. tobacco dependence. The question is whether the concept of dependence is a better concept thar, addiction. Dependence The WHO definition of drug dependence (WHO. 1969) Which was used to replace addiction was: A state. psrchic and sometimes also physical, resulting from the interactioqhetaecn a living organism and a drug. charactensed by beha•iural and other responses that alwas include a compulsion to take the drug on a continuous or periodic basis in order to experience its ps~chic effects. and sometimeo- to avoid the diuomfori of its absence. Tolerance mac or may not he present. Unfortunatel}. this definition is as unsatisfactor} as that of addiction because it still involves vague concepts such as 'overpowering desire'. 'psychic dependence'. 'depri.'atton s_cmptoms* and 'tendenc) to increase dose'. It is so broad as to be almost meaningless. The onh sort of substance use that could be excluded might be a chemical from which the user derived no benefit after continued use. Certainh coffee drinking is included. and man} forms of chronic medication, like hormone therap} and pain killers. would fit as well. The definition would even encompass eating as a form of chemical dependence. The American Psvchiatric Association (1980) in their Dragnosttc and Statutica( Manuat of Menral Drsorders include problem use as one of their diagnostic criteria. Thus, for tobacco dependence the definition is- A Continuous use of tobacco for a least one month. B At least one of the following (I) serious attempt to stop or signiftcantl) reduce the amount of tobacco use on a permanent basis have been unsuccessful. (21 attempts to stop smoking ha%c led to tuhacce u'ithdrawal. (3) the individual continues to usc tobacco despite a seriou, physical disorder (e.g resptraton or cardio- vascular diseasc I that he or she knows re exacerbated b, tobacco usc. The American Psychiatric Association note specift- calh With respect to impairment that Smcc tobacco use rareh causes an} identifiable statc of tntosrcation as does alshol. there is no impairment in social or occupational functiontne as an immediate and direct consequence ottobacco use The main criteria for Which thee recognize depen- dence is tal when the person is ill and this illness is agera.ated bN continuing to use tobacco. and (b) that w hen people. w•ho wish to give up for whatever reason. cannot do it. Thit definition does not imohe cague concepts stich as `overpowering de- sire'. 'p<cchrc dependence'. 'depritation s}mptoms' and 'tendencN to increase dose'. It mereh arsues for a diagnosis of dependence when there are proiSfenu associated w•ith substance use. This definitictn recot:nizes that depende nce is a condttion that exists in mam furms and man} decrees. and it is not onh With extreme use that problems can o:cur, Depandence has mam aspects to it. rather than am one ket diagnostic feature. We 287

I are all 'dependent' for our ordinar% happiness. gratification. emotional well-being and general qual- it% of life on a whale range of people and objects. V1'e are in this sens^ clearlc dependent on things like our famil_% and friends, our job. our motor car. our favourite armchair and the television set. R'e experience 'withdra..'aI svmptoms' if we are dep- ri.•ed of them. It is consistent with this view that some people find that their quaht' N of life is improved b% the use of chemical suhstances. like a glass of beer. a cup of coffee and a cigarette and some degree of substance dependence on alcohol. coffee and cigarettes. If the word is used in this a a} - dependence must be considered a normal condition. Among normal drinkers and smokers there will be a wide range of sent.ed need tor alcohol. eoflee and cigarettes. in terms both of smoking and drinking occasions and the amount consumed. Thus e%ervone who smokes or drinks is at least in some minor degree dependent -in cigarettes. coffee and alcohol. The} suffer 'depri•:ation' symptoms if the} did not have their evening glass of sherry or their after-meal cigarette and coff,!e. The crucial issue is not the dependence but the consequences that ma) result from habitual substance use. Habitual substance use The terms 'addiction' and 'dependence' are ahat Christie & Bruun (1969) referred to as 'fat words': they bring under single headings types of behaviour that are extremell disparate. In all definitions of addiction and dependence that ha%c been dt>cussed. the one common factor is suhstancc use. Recenth. this kind of approach has been folloKed by the National Researcf. Council of the United Stateo- The% sponsored a•;eries of ineeting~ and reports on habitual suhstance use with the aim of finding common bioloFical, ps~chological and social pro- cesses. undericin¢ the habitual use of substances. including alcohol- food. tohacco. and p5pchoacti.e drues 7lte results of this research are published in Cnntntonalutcs in Substancc Abucr and Hahtrua: Behavior (Levison er al.. 19F+) Among the mos- important consideration< of am studies of substance use is the sort of use that will result in problemt• for tha individual and societt which is called substance abuse L'nfununatelt. the articles in thc' COVrrnonaltrieF in Suhsrance Abttac and Habitual Bcherior %olumc do not consider thc extent of use that vrill result in problems In order to reduce thc likelihood of 'prohlem•'. it will be necessar~ to undcrstand safe substance usr. As Orfurd (1985) has lx,inted out in his hc+u1.. T.ucssrrt Al+pctitrs. man substance: are uced ht the maioritt of people- as a plcasurablc and muderate form of indulgence without prohlems. Conclusion The terms 'addiction' and 'dependence' are Vague terms about which there is considerable disaeree- 2Sf ment. Their definitions have been used to encom- pass under single headings types of behaviour that are extremelc disparate. It is important for future research. public health policy and education that psychologists should not use terms like addiction and dependence if we cannot saN what the} mean preciseh. It is the fecommendation of this paper that psychologists would do better to consider substance use and not substance 'addiction' or substance 'dependence'. It we knoK more about safe substance use. then optimization of use should be possible and we will be in a better position to consider the issues of substance abuse in terms of the individual and societ}. References American Psychiatric Association (1980) DmgnosNc and Starutrcal Manual of Mental Dccordrn Washington. DC' American Psvehiatric Association Chapman. K. W. (1962). The general problcm. ]n R' C. Blter (ed.). Problerrz in Addiction. Alcoholism and Narcoucs. NeK York' Fordham t3niversin Press Christie. N. & Bruun. K (1969t. Alcohol Prohlems. The Conceptual Frameu'orA Proceedmgs of the 7iVlltth International Congress on Alcohol and Alcoholism. vol ? Rutgers. NJ: Hillhouse Press. Levison. P.K.. Gerstein. D. R, & Maloff. D R(19E3). Commonalute~ in Substancr Ahusr and Habitual Bchavtor Lexington. MA Lexington Books (D C Heath & Co.). Lindesmith. A(19-i7). Upiate Addiction. Evanston. IL: Principia Press Maurer. D- %i. & Vogel. V. H(196_'1. Narcotics and harcnac Addiction Sprtncfield. ILC C' Thoma, Orford. J-(19S>). Exccssn•r Apprnta A l's.% rhnlnF+ra: 1"+rsu o• dh+ Add+ctinns London W'ilec Rapp(.h R 7. ()9?:t Drug le_islation In I. M Sine6. L H, t.lultcr & H, La! (ed~). Drug Addtroor,. Clinica: ar+d Soraidrpa! Asperv. co! 2 Mt Ktuo. heu } orl. Futura Prec Smart. k G(1074). Addiction, depcndenc~c abuse. or u,c: Which are ue stud}'tng aith epidem+olog~ ° Ir. E Josephson & E. E Carroll (ed~t. DruF Csr 6p+denuoiogiral and SoctnloFica' Approorhes 41 ach- ington. DC'. Hemisphere Stepne~. R(1Qb11. Habit• and addictions Bullrnn qfThr Brurch PsrchaloF+c'a! Socirn, :+4. 3.',.--'_?9. W orld Health Organization. Expert Commtttee on Afcntal Health (19;7). .4dd+crion-Producrnl, 11rup Scccmt+ Repnrr of the WHO Ezprrr Contntirrec Geneva; WHO Technica! Report Senes. 11E. w orld Healtt. Organization. Expert Committee on Addic- tion Producing DruF~ (19fs1. Thirterrul: Rrp:,r of rh, ttl1ll Exl-rrr Comnutte+. Genc.a WHO iechnical kep~,rt Sc rics.'-7 ? Nsc,rld Hcaltb Organization. Scientific Group (19t11 E.ramarrt-n of Uenendrnee-ProducmF I/ruF, Gene%a 11'HO 7echnical Report Scne:. 2R" Mnrld Hca)tb Organization Expert Committee on Drug Dependence (19b4t. Sureend: Repa~ q` rhr Si'1-Tit Eipcr, Cnmmtttec Geneva' WHO Technical Report Scne• 41" Requests icrz reprtnts should be addressed to Darid M. Itarburton. Department of Psycholog . Reading Uni%er- sitl. Readtn€. Berks RG6 2AL