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NCTOH: Addiction is addiction is addiction
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This is a series of special reports from the National Conference on Tobacco or Health in Phoenix, AZ.
Erik Augustson, PhD, MPH for the National Cancer Institute said that tobacco dependence is a complex issue and there is no accepted definition but that the process is influenced by a variety of factors:
- Compulsive use despite adverse consequences.
- The drug reinforces behavior.
- There is a predictable pattern of withdrawal.
- Relapse--quitting is hard.
In the past 20 years, not much progress has been made in the prevalence of smoking. There is no other drug where dependence rates are as high as they are for smoking, 20%. There is also a health disparity issue since the individuals that are more likely to smoke have less education, more likely to be below the poverty level or unemployed and higher rates with some ethnic groups.
Dr. Augustson said that there are high rates of nicotine use and dependence and the rate of prevalence has leveled off and we should be asking why is it so difficult to quit? He doesn't believe it is because of the drug since nicotine is eliminated from the body fairly quickly with a half life of about an hour. Withdrawal symptoms are manageable and the severity of withdrawals is not a predictor of relapse, yet cravings, which are a physical response, can last several months but are context dependent. For example, since you can't smoke in a church, there is little effort to avoid smoking in that situation but go to your favorite bar, and the cue is strong to smoke.
The product is part of the reason because it has been manufactured to promote addiction and dependence. The delivery system is the same as crack cocaine:
- The brain gets a big spike of nicotine fast, in less than 10 seconds.
- There is rapid absorption of the drug.
- There is a short half life, so the smoker needs to smoke about one an hour or about 20 a day (there is a reason why a pack has 20 cigarettes).
- The behavior is easy to modify, the smoker can smoke more or less cigarettes, more or less of the cigarette.
- He states that the problem with nicotine replacement products is that they are not cigarette-the dose of nicotine is low and response time is slow.
A simplistic view of conditioning with nicotine as the reinforcer is that individuals smoke to enjoy the positive feelings and to avoid the negative feelings of withdrawal. But the problem is more complex than this, addiction includes learning the behavior and environment factors. The reason why it is so difficult to quit is a complex interaction between:
- Environmental and social aspects: media, peers, SES, culture.
- Biological issues: genetics, drug induced brain changes, stress response.
- Behavioral and psychological: learning (classical and operant conditioning), use of other substances, mental illness and coping with stress.
.A smoker will usually have a strong history of both classical and operant conditioning since every puff of smoke is a reinforcer. With 10 puffs per cigarette, an average smoker over 20 years with have 1.5 million learning opportunities. This will have a direct effect on the reward circuit of the brain. Common reinforcing effects are:
- Decrease in fatigue.
- Modulates stress.
- Mood management.
- Decrease in appetite.
- Avoid withdrawal.
Social and environmental factors that help a smoker quit:
- Support from family, friends and co-workers, both positive reinforcement and avoidance of punishment ( such as saying "You're so cranky, go have a cigarette")
- Smoking restrictions at home, work and in the public, which changes the context where you can and can't smoke
- Combination therapy of both the patch and oral nicotine such as the gum or the lozenge. The patch gives a steady dose of nicotine and the oral nicotine is from a more immediate response.
