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278 J.H. Robinson and W S. Pritchard The physiologic, pharmacologic and behavioral effects of smoking and nicotine are fun- damentally different from those of addicting drugs such as heroin and cocaine. To conclude otherwise may actually do a disservice to those attempting to quit by providing a crutch suggesting it may be too difficult to even try. It could actually encourage experimenting with illicit drugs by suggesting they are no different than cigarettes. Finally, equating smoking and nicotine with heroin and cocaine endangers our credibility as scientists with the average layman who can readily distinguish the effects of smoking or coffee drinking from the tragedies of cocaine and heroin addiction. References I. Robinson JH, Pritchard WS. The role of nicotine in tobacco use. Psychophannacology. 1992; 105: 397-407. 2. USDHHS. The health consequences of smoking: Nicotine addiction. A report of the Surgeon General. Washington, DC. US Government Printing Office, 1988. 3. USDHEW. Smoking and Health. Report of the advisory committee to the Surgeon General of the Public Health Service. Washington, DC. US Government Printing Office, 1964. 4. West R. Nicotine addiction: a re-analysis of the arguments. Psychopharmacology. 1992; 108: 408-410, 5. Hughes J. Smoking is a drug dependence: a reply to Robinson and Pritchard. Psychopharmacology. 1993: 113: 282-283. 6. Stolerman IP, Jarvis MJ. The scientific case that nicotine is addictive. Psychopharmacology, In press. 7. American Psychiatric Association: Diagnostic and statistical manual of mental disorders, Fourth Edition. Washington, DC. American Psychiatric Association, 1994. 8. Bewley S., Bewley TH. Drug dependence with oestrogen replacement therapy. Lancet. 1992, 339: 290-291. 9. Griffiths RR, Woodson PP. Reinforcing effects of caffeine in humans. J Pharmacol Exp Ther. 1988. 246:21-29. 10. Cemey L, Cemey K. Can carrots be addictive? An extraordinary form of drug dependence Br J Addict. 1992, 87:1195-1197. ~

276 J. H. Robinson and W S. Pritchard those that produced "hallucinations or disturbances in motor function or thinking or behavior or perception or mood" (WHO, Technical Report Series, No. 618, 1978, p 8). In 1984, NIDA defined "psychoactive" (addicting) substances as those that produced "a distortion of the perception of time, space and the location of objects within space" along with disruptions in "physical coordination or psychomotor functioning" (DHHS Publication No. (ADM)85-1374, 1984, pp. 19-20). It was not until the publication of the 1988 Surgeon General's Report (2) that the criterion of intoxication, previously a critical component of the definition of a 'psychoactive drug', was dropped. The reason for this is obvious. Smokers simply do not smoke to become intoxicated. We would also point out that the concept of intoxication as a principal feature of addict- ing drugs is valid even today, but is ignored when it comes to smoking and nicotine. The American Psychiatric Association has recently published the fourth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 7). In DSM-IV, 11 classes of substances that produce disorders are discussed, and behavioral intoxication plays a critical role in these substance disorders. In fact, pick any of the substance disorders listed in DSM-IV and you will find it produces some form of behavioral intoxication -- every substance except nicotine of course. Nicotine intoxication is dismissed with the statement, "This category does not apply to nicotine" (p. 183). We therefore find it somewhat surprising that our critics deny that intoxication has been and still is a principal feature of addicting drugs (4-6). In contrast to the distinct and scientifically testable definitions we review, the nicotine-ad- diction proponents offer vague definitions and analogies in response. The most persistent argument they offer centers on the 'highly controlled or compulsive use' of tobacco products. We are told that smokers have lost control of their ability to decide to stop smoking and that they experience powerful urges, uncontrollable cravings and irresistible desires when they attempt to stop smoking that they are apparently powerless to fight. Much of the evidence to support these claims relies on smokers' assertions that they would like to quit, but cannot (4). Yet, how do we measure someone's desire to quit? What constitutes a loss of control or an irresistible urge? In the United States, over 40 million smokers have quit smoking without any help. The smoker's ability to think or reason clearly is not diminished when making the decision to quit or continue smoking. In short, this is not a behavior that the smoker has lost control over. 51936 0385

Differentiating habits and addictions: the evidence that nicotine is not'addictive 275 tinctions were made between the effects of habituating substances like nicotine in cigarette smoke or caffeine in coffee and addicting drugs such as heroin, cocaine and alcohol. Smoking and coffee drinking were classified as habits, based on the critical attribute that differentiated all addicting drugs: Behavioral intoxication ojthe user. In response, the nicoti- ne-addiction proponents argue that the concept of 'habituation vs. addiction' is no longer 'recognized' or that these definitions are 'outdated'. Stolerman and Jarvis (6) have suggested that it is time to confine the term habituation "to the archives of history". Equating vastly differing behaviors under one nebulous term should be unacceptable to all of us as scientists. In contrast, by labeling nicotine and caffeine as habituating we quickly highlight important features that separate these compounds from addicting drugs such as alcohol, heroin and cocaine. This suggests that instead of being confined to the archives, perhaps it is time to re-esta- blish the concept of habituation, or perhaps develop a new term, as a construct that adds significant meaning to the discussion of addicting drugs. Intoxication A critical issue in the debate centers on our argument that, through the decades, behavior- al intoxication has been a defining feature of addicting drugs. We use the term 'behavioral intoxication' as described in DSM-IV (7) to mean disturbances of perception, attention, wakefulness, thinking, judgment and interpersonal relations that drastically alter the person's behavior, lifestyle and value system. These disruptions limit the addict's ability to think or reason clearly, work or drive safely or even to perform the simplest of manual tasks normally. Anyone who has experience with a friend or relative with a drug or alcohol problem knows exactly what we are describing, and consequently why intoxication is important to defining an addicting drug. The addiction proponents respond to this by simply dismissing or ignoring our view, stating that intoxication is not a defining attribute of addicting drugs. However, the published literature seems to be clearly on our side with regard to this issue. As stated earlier, the 1964 Surgeon General's Report (3), quoting the WHO definitions of addiction and habituation, used the clearly defined feature of intoxication to distinguish nicotine and caffeine from addicting drugs. In 1978, WHO defined "psychotropic" (dependence producing or addicting) drugs as

Effects of Nicotine on 273 Biological Systems II Advances in Pharmacological Sciences © Birkhauser Verlag Basel DIFFERENTIATING HABITS AND ADDICTIONS: THE EVIDENCE THAT NICOTINE IS NOT 'ADDICTIVE' John H. Robinson and Walter S. Pritchard Psychophysiology Laboratory, R.J. Reynolds Tobacco Company, P.O. Box 2959, Winston-Salem, NC 27102 Summary: We review the data supporting our position that nicotine and smoking are more accurately labeled as habit than addiction. The case is presented that a meaningful definition of addiction should allow researchers to distinguish the pharmacologic and behavioral effects of substances like nicotine and caffeine from those of addicting drugs such as heroin and cocaine. A key attribute that has differentiated habits from addictions through the decades, and is still valid today, is that addicting drugs result in behavioral intoxication of the user. The pleasurable sensory experience, as well as the positive emotional and cognitive effects that smokers report, are discussed as an alternative explanation as to why people smoke. The opportunity to contribute to this volume on the topic of nicotine 'addiction' is very timely. Recent events in the United States have again focused national attention on the debate concerning whether tobacco products and the nicotine contained in tobacco products are 'addictive'. Media coverage of U.S. Congressional and Food and Drug Administration hearings has served to promote emotional issues surrounding the debate, while doing little to add to the scientific discussion. This manuscript will demonstrate that the same data used by the nicotine-addiction proponents to support their view that nicotine is addictive, also readily support another view that clearly distinguishes the physiologic, pharmacologic and behavioral effects of substances like nicotine and caffeine from addicting drugs such as alcohol, heroin and cocaine. In order to achieve an open dialogue in this debate, we ask that the reader put aside the emotional issues involved with smoking and nicotine, including the health risks that have principally been ascribed to the 'tar' fraction of smoke, and focus on a critical and objective evaluation of the data that will be presented.

274 J. H. Robinson and W S. Pritchard This manuscript will briefly summarize our previously published challenge (I) to the con- clusions in the 1988 Surgeon General's Report (2) that tobacco products, and the nicotine con- tained within tobacco products, are as addictive as heroin and cocaine. In our previous manuscript, we argued from the viewpoint presented in the 1964 Surgeon General's Report (3) that smoking and nicotine are more accurately labeled as habit than addiction, since the effects of nicotine, like caffeine, are fundamentally different from those of addicting drugs. As expected, our position has generated a significant amount of discussion (4-6) and we welcome this opportunity to continue to discuss the meaning of addiction, why intoxication is critically important to defining an addicting drug, and an alternative explanation as to why people smoke. The Meaning of Addiction The determination of whether any substance should be labeled as 'addictive' obviously depends on one's definition. Unfortunately, no universally accepted definition of addiction currently exists. Instead, researchers and policy makers choose the important elements of their particular definition from a wide range of components (3-7). One common 'definition' offered by the nicotine-addiction proponents seems to be a very simplistic one - any behavior which some people may find difficult to stop. If one accepts this simplistic definition, then smoking would indeed be labeled an 'addiction'. Unfortunately, adopting this definition leads to a wide variety of substances and activities being labeled as addictions, including estrogen-replacement therapy (8), caffeine in coffee (9), and even carrots (10). Part of our responsibility as scientists is to explore, differentiate, and dissect the underly- ing 'reasons why'. As behavioral scientists, we find it unfortunate that a definition that should serve as a foundation for conducting meaningful scientific studies apparently cannot distin- guish the pharmacological and behavioral effects of crack smoking from coffee drinking, and cocaine from colas. Instead of adopting a language that recognizes obvious differences in this wide array of behaviors, the addiction proponents choose to anchor all pleasurable, repetitive behaviors at one end of the scale by labeling everything an addiction. This has not always been true, however. When a scientifically meaningful definition of addiction did exist, important dis- 51936 0383

Differentiating habits and addictions: the evidence that nicotine is not'addictive' 277 In response to this, the addiction proponents say that even those smokers who quit may require several serious attempts before they are successful. This is not surprising. Most smokers who quit report that they were successful when they finally became truly motivated to quit, when the pluses for them no longer outweighed the minuses. We would like to be very clear on one point. Our argument that behaviors like smoking and coffee drinking are more accurately labeled as habits than addictions does not suggest that everyone would easily be able to quit. Successfully changing a well-ingrained, pleasurable behavior can be extremely difficult. One need only look at those who continually fight to lose weight, only to regain it and start the process over again, to verify that pleasurable behaviors, behaviors we say we want to change, may be very difficult to modify. Why People Smoke If smokers are not addicted, why then do they continue to engage in a behavior that has such well-publicized risks associated with it? The simple answer is smokers obviously enjoy smoking. The work of Dr. Rose, Professors Battig, Adlkofer (this volume) and that at other labs, including our own, indicates that while a significant portion of this pleasure is associated with the sensory aspects of smoking, the 'taste', the smell, the 'feel' of the smoke, we also recognize that nicotine can produce mild pharmacological effects that are important to some smokers. Professors llindmarch and Warburton (this volume) indicate that smoking and nicotine can result in positive emotional, cognitive and performance benefits to the smoker. Drs. Levin, Joseph and Newhouse (this volume) discuss the positive effects nicotine can have on learning and memory. - In short, smoking is a pleasurable activity that seems to result in specific personal benefits to the smoker that probably serve to reinforce the habit. It should not be surprising, therefore, that some people report difficulty in quitting; but difficulty quitting does not serve as evidence that nicotine is an addicting drug on a par with alcohol, heroin and cocaine. Drug addiction is the result of a complex interaction of behavioral and pharmacological variables. It cannot be defined or characterized by any single activity or effect. Simply stated, the determination of whether or not a substance is addictive should be related to the total behavioral effects of that substance. With this in mind, we argue in direct opposition to the 1988 Surgeon General's Report.