Where There’s Smoke, There’s Ire

The Wall Street Journal, July 16, 1996

By Sally Satel

“Clumsy me, I got all tangled up in a technical matter — the nature of addiction — when all I meant was . . .” These are the words one pundit wished Bob Dole had used to extricate himself from the tobacco mess. On the technical matter of addiction, Mr. Dole isn’t alone in his confusion. Here are some answers that may help clear the air:

What does it mean to be addicted? The standard medical authorities use the term “dependence” rather than “addiction.” Dependence is defined as the persistent, time-consuming, compulsive use of a substance in the face of harmful consequences, with the tendency to relapse after withdrawal. Most dependent users develop a tolerance — they need increasing doses to achieve a desired effect — and experience withdrawal symptoms when the drug wears off.

P> Can smokers become dependent on nicotine? Yes. Regular smokers often develop tolerance, even over the space of a day. That’s why many smokers find the first cigarette of the day the most enjoyable. When smokers quit, they often experience withdrawal symptoms (insomnia, irritability, headache, mild depression and craving for a cigarette), which put them at high risk for relapse.

Mr. Dole was right when he said that nicotine isn’t always addictive. Some people can smoke cigarettes in take-it-or-leave-it manner. But it is a well-established epidemiological fact that the majority of smokers who start as teenagers or young adults go on to become dependent. Cigarette smoking is a stylized habit that serves psychological functions — suppression of anxiety, social lubrication. These benefits are reasons why intermittent smokers often desire a cigarette. But it is primarily the urge to suppress the symptoms of nicotine withdrawal that makes regular smokers feel they need one.

Is addiction biological? Yes. When someone who uses a substance repeatedly explains that he does so largely to stave off withdrawal symptoms and that he no longer feels much of a high when using it, it’s likely that his brain has undergone some drug-induced changes. The changes generally disappear over time but can be permanent in cases of heavy use of alcohol or illicit drugs.

Nicotine does have the capacity to trick the brain into “thinking” that it needs a cigarette by subtly altering the physiology of its “reward centers.” But it is different in that it has no effect on parts of the brain needed to negotiate the workplace, home and community.

Biology is not destiny. While smokers often struggle unsuccessfully to kick the habit, nearly all who do quit do so on their own. Many people have been able to overcome addiction even to powerful drugs like cocaine on their own. To be sure, treatment, external pressure or legal sanctions for illicit use can help initiate the recovery process and ensure a greater likelihood for success among those unable or unwilling to stop themselves.

Is it true that cigarettes are more addictive than heroin? This is ridiculous. When cigarettes are temporarily unavailable, smokers — as lousy as they may feel without a cigarette — don’t initiate a crazed effort to find their next “fix.” In contrast, people addicted to heroin commonly lie, cheat or steal to get money to buy more, so distressing are the symptoms of heroin withdrawal. In the case of cocaine, the rush is so stimulating and the “crash” after a binge so wrenching that addicts will often do virtually anything to get more cocaine. Even alcoholics sometimes resort to desperate measures.

Alcohol and illegal drugs can render users unable to cope with ordinary life. It’s a vicious circle for many users, who turned to alcohol or drugs because they had trouble coping and the substance promised to numb their pain. By contrast, even the heaviest smokers don’t forsake their families and jobs to pursue a nicotine habit. Cigarettes may shorten one’s life, as sociologist James Q. Wilson has said, but they don’t debase it.

Treatment for nicotine addiction is pharmacological (nicotine gum, patches or nasal spray) or behavioral (learning techniques to overcome craving). Treatment for hard-core addiction to alcohol or illicit drugs, by contrast, generally involves repairing the psychological or spiritual deficits that underlie the addiction.

But why is it so hard to stop smoking? The answer is social as much as physiological. Cigarettes are easily and legally available, and the would-be quitter is constantly bombarded by visual cues — from advertising billboards to smokers puffing on the sidewalk — that trigger cravings. Moreover, the immediate deleterious consequences of smoking are minimal, the long-term health effects uncertain for any individual. True, the distress of withdrawal has weakened many a smoker’s resolve to quit. But it’s nothing like the agony of heroin or even alcohol withdrawal.

So while cigarettes are a major public health problem, they are not a social pathogen. Heavy smokers, unlike hard-core heroin, cocaine, marijuana and alcohol users, are able to attend to their responsibilities as employee, parent, spouse and citizen. Before we tar our politicians for not understanding the nature of addiction, let’s get the facts straight ourselves.