How Addictive is Cigarette Smoking?

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Are cigarettes likelier to cause addiction than heroin? Are they more addictive than cocaine? The answers depend on how one defines "addiction."

The word "addict" traces to "addictus," the past participle of the Latin verb "addicere." "Addicere" combines the prefix "ad-," meaning "to or toward," and the verb "dicere." The standard meaning of "dicere" was "to say" (as exemplified in the words "dictate" and "dictionary," for instance), but its other senses were "to allot" and "to adjudge or give over." Thus, "addicere" meant "to give (oneself) over to"--i.e., "to give in or surrender to."[*]

Centuries ago, "to be addicted" meant to be devoted (to give oneself up) to a practice. Shakespeare wrote in Othello: "Each man to what sports and revels his addiction leads him." "The unhappy woman has ever been more addicted to the rites of her pagan ancestors than those of Holy Church," wrote the English statesman and poet Edward G. Bulwer-Lytton (1803-1873). In those days--long before 20th century theorists defined addiction in terms of the physiologic signs of discontinuance of the use of certain drugs--addictions were recognized not as bodily conditions, but rather as habitual behaviors with certain characteristics.

The headlines of some newspaper and magazine articles about potentially addictive behaviors other than drug taking clarify that in ordinary usage the word "addicted" continues to convey the meaning of "addicere." Acceptance of basing recognition of addiction on this meaning, rather than on physical symptoms of withdrawal, has been growing. For example, in a 1997 edition of The Washington Post, Dr. Alan I. Leshner, director of the National Institute on Drug Abuse, stated in an editorial:

At bottom, one becomes addicted (devoted in a way that disrupts one's life) not to objects--drugs or television sets, for example--but rather to behaviors, like snorting drugs or watching telecasts. The expression "drug addiction" should be considered shorthand for "drug taking addiction."

EVALUATING ADDICTIVENESS

So I rephrase and combine this article's introductory questions: Is smoking cigarettes more addictive than shooting heroin into oneself or snorting (or smoking) cocaine? The 1998 Surgeon General's report Health Consequences of Smoking: Nicotine Addiction likened the pharmacologic and behavioral processes responsible for "tobacco addiction" to those responsible for addiction to heroin and cocaine. The Surgeon General acknowledged "tobacco addiction" not only on the basis of compulsive use but also because smokers often develop:

(a) a withdrawal syndrome from not smoking, and (b) tolerance-in this case, the necessity of increasing nicotine intake to maintain one's response to the drug. The report did not, however, deal comparatively with the addictiveness of tobacco, heroin, and cocaine.

A psychiatrist who has done so is Yale University lecturer Sally Satel, M.D. In a 1996 Wall Street Journal (WSJ) editorial, she stated:

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.

Satel did not state the criteria she had used to judge the addictiveness of cigarette smoking relative to that of heroin use. Her implication that heroin addicts are likelier to lie, cheat, or steal to get heroin than are cigarette smokers to get cigarettes may well be correct--at least for American heroin addicts. If it is correct, however, the difference may be completely unrelated to differences in physiologic effects between shooting heroin and smoking cigarettes: In the United States, heroin addicts face sociolegal obstacles much more formidable than those that persons addicted exclusively to cigarette smoking face. And the more formidable such obstacles are, the likelier that an individual who decides to use a drug nonmedically will lie, cheat, and/or steal to get the drug. First, heroin addiction puts heroin addicts in danger of prosecution and coercion by courts to join treatment programs; by comparison, the legal risks of addiction to cigarette smoking are negligible. Second, a typical day's supply of heroin for an individual is much costlier than a typical day's supply of cigarettes. Third, heroin is available only through the black market, whereas anyone aged at least 18 years can easily and lawfully obtain tobacco.

Banning cigarettes would generate a cigarette black market and result in the inflation of cigarette prices; it would thus increase lying, cheating, and stealing among cigarette smokers. While many persons smoke less or quit smoking altogether when the sales tax on cigarettes increases, many others---even many for whom an extra weekly expenditure of a few dollars would be considerable---continue to smoke, unabatedly. After an 80-cent rise in the price of a pack of Pall Malls, a smoker with a physical disability told The New York Times in February 1999: "The President says he plans to raise the price of cigarettes another 55 cents. He does that, I'm going to make a gang, a wheelchair gang, and we're going to go out and steal money for cigarettes."

Data from the most recent National Household Survey on Drag Abuse (NHSDA) suggest that most heroin users are not heroin addicts. In a 1998 edition of The New York Times, Satel herself conveyed information suggesting that heroin use is not as addictive as many persons suppose: "Two decades ago Lee Robins, a professor of psychiatry at Washington University in St. Louis, in a classic study of returning Vietnam veterans, found that only 14 percent of men who were addicted to heroin in Vietnam resumed regular use back home. The culture surrounding heroin use, the price and fear of arrest helped keep the rest off the needle."

Moreover, it is discernible from statistics on patterns of cocaine use that resisting cocaine is ordinarily not as difficult for cocaine users as Satel has implied. According to the aforementioned NHSDA, Americans who used cocaine occasionally (i.e., on 11 or fewer days) in 1997-1998 (approximately 2.4 million) outnumbered--by a factor of four--Americans who used it frequently (i.e., on at least 51 days). It is presumable that those who use cocaine often-the minority of cocaine users in the U.S.-- are much likelier to use it addictively than are those who use it occasionally. Thus, cocaine addicts may take extraordinary steps to obtain cocaine, but most cocaine users in the U.S. are not cocaine addicts. (Similarly, many persons addicted to imbibing resort to extremes to obtain alcoholic beverages, but most Americans who consume alcoholic beverages are not alcoholics.)

The summary of the NHSDA findings states: "Of the 23.1 million persons who used an illicit drug in the past year ... 4.1 million were dependent on an illicit drug." This statement suggests that less than 20 percent of Americans who use illegal drugs are addicted to using them. But most of the those respondents in the 1991-1992 NHSDA who said they had smoked cigarettes in the previous 30 days stated that they had: (a) smoked cigarettes daily for at least two weeks, (b) tried unsuccessfully to cut down on cigarettes, (c) felt dependent, and (d) felt sick when they'd refrained from smoking. None of these signs of addiction were reported by most of those respondents who stated that they had used alcohol, cocaine, or marijuana in the previous 30 days.

In 1994, researchers examined data from the National Comorbidity Survey and made the estimates about prevalence indicated below.

alcohol dependence anytime among consumers of alcoholic beverages: 15.4 percent

heroin dependence anytime among heroin users: 16.7 percent

dependence anytime on any drug other than alcohol and tobacco among drug users: 14.7 percent

In contrast, the researchers estimated the prevalence of tobacco dependence anytime among tobacco users at 31.9 percent. Indeed, they estimated the prevalence of tobacco dependence anytime among all Americans at 24.1 percent. Moreover, according to national surveys cited in the above-mentioned Surgeon General's report, 75-85 percent of cigarette smokers in the U.S. would like to quit smoking for good and have tried unsuccessfully to do so.

Satel's WSJ piece blurs the issue of addictiveness with the issue of socially disruptive eventualities from specific addictions. In research interviews, persons who use more than one drug addictively tend to rate tobacco as their top drug need and as the drug most difficult to stop using. Being "drug-free" is typically a requirement for participation in inpatient treatment programs for drug addicts. But cigarettes are not among the forbidden drugs in such programs. If they were, few drug addicts would be considered eligible for participation in them.

According to a 1994 edition of The New York Times, Dr. Jack E. Henningfield of the National Institute of Drug Abuse and Dr. Neal L. Benowitz of the University of California at San Francisco independently ranked alcohol, caffeine, cocaine, heroin, marijuana, and nicotine in terms of each of five categories:

withdrawal symptoms;

"reinforcement"--the likelihood that using the substance will result in its repeated use in preference to other substances;

tolerance--the necessity of increasing use of the drug to maintain one's response to it;

intoxication; and

dependence--e.g., relative difficulty of discontinuing use of the drug.

Neither scientist ranked nicotine as first among the six drugs in any of the above-mentioned categories except that of dependence--in which category both Henningfield and Benowitz ranked nicotine as first. And dependence of the kind they have defined is basically addiction of the "addicere" sort. This rank apparently holds across cultures.

THE BOTTOM LINE

Inherently, other drugs may have more "reinforcement" power than nicotine has; for example, they may please users more than nicotine pleases cigarette smokers. But addictive cigarette smokers smoke cigarettes more often than "drug addicts" use the drugs they favor. I consider cigarette smoking the most addictive form of drug taking.

ACSH SCIENTIFIC ADVISOR WILLIAM M. LONDON, ED.D., M.P.H., IS A WALDEN UNIVERSITY FACULTY MENTOR

How Fast Can One Become Addicted to Cigarette Smoking?

In a 1998 study published recently in the British Medical Association journal Tobacco Control, scientists with the University of Massachusetts surveyed smoking habits among 681 youngsters, 95 of whom said they'd started smoking cigarettes occasionally (at least one per month) during the study. The researchers found that 63 percent of these 95 subjects had at least one of eight symptoms of addiction, and that these symptoms had arisen shortly after their first smoke. They further found that 25 percent of the symptomatic smokers had developed a symptom of addiction within two weeks of their first smoke. Sixty-two percent of the symptomatic subjects had said that they'd developed such a symptom before they'd started smoking daily or that the symptoms had set off their smoking daily.--JR

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By William M. London

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