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Is Nicotine Addictive? It Depends on Whose Criteria You Use
Experts say the definition of addiction is evolving
Philip J. Hilts
Aug 2, 1994
New York Times: Science
WASHINGTON - When heavily dependent users of cocaine are asked to
compare the urge to take cocaine with the urge to smoke
cigarettes, about 45 percent say the urge to smoke is as strong
or stronger than that for cocaine.

Among heroin' addicts, about 3 percent rank the urge to smoke as
equal to or stronger than the urge to take heroin. Among those
addicted to alcohol, about 50 percent say the urge to smoke is at
least as strong as the urge to drink.

Yet seven chief executives of tobacco companies testified under
oath before a Congressional subcommittee in April that nicotine
was not addictive. Experts in addiction disagree with that
assessment, hut they say that the definition of addiction is
evolving, and that they can see how such a statement might be
made.

Hearings on SmokIng

This week, the Food and Drug Administration is holding hearings
to consider whether cigarettes fit in the array of addictive
drugs and whether the Government should regulate them.

The standard definition of addiction comes from the American
Psychiatric Association and the World Health Organization, which
list nine criteria for determining addiction.  The two groups,
which prefer the term drug dependence, base their definition on
research done since the 1960's, which has determined that
multiple traits must be considered in determining whether a
substance is addictive. Thus although cigarettes do not offer as
intense an effect as drugs like heroin and cocaine, they rank
higher in a number of other factors. They not only create
dependence among users but also elicit a high degree of
tolerance, the need for more and more of drug to satisfy a
craving. When all the factors are added up, the consensus among
scientists is that nicotine is strongly addictive.

In smoking, it is not the nicotine addiction that is most
harmful, but other toxic chemicals produced by burning tobacco,
which cause most of the 400,000 deaths each year that are
attributed to smoking.

Dr. Lynn T. Koslowski, an addiction expert at Pennsylvania State
University, said addiction could generally be defined as "the
repeated use of a psychoactive drug which is difficult to stop."
He added that there might be many explanations for why it was
hard to stop, including withdrawal that was too disturbing, or a
high that was too enticing.

A diagnosis of mild dependence on a psychoactive drug is
determined by meeting three of the nine criteria.  Five items
show moderate dependence and seven items indicate a strong
dependence. (Not all nine items apply to each drug. For example,
time and effort spent acquiring a drug are a significant feature
of heroin addiction, but have no meaning in nicotine addiction.)

ADDICTION CRITERIA

* Taking the drug more often or in larger amounts than intended.

* Unsuccessful attempts to quit; persistent desire, craving.

* Excessive time spent in drug seeking. 

* Feeling intoxicated at inappropriate times, or feeling
  withdrawal symptoms from a drug at such times.

* Giving up other things for it.

* Continued use, despite knowledge of harm to oneself and others.

* Marked tolerance in which the amount needed to satisfy       
  increases at first before leveling off.

* Characteristic withdrawal symptoms for particular drugs.

* Taking the drug to relieve or avoid withdrawal.

Before applying a test of the nine criteria, the expert first
determines if the symptoms have persisted for at least a month or
have occurred repeatedly over a longer period of time. 

Asked about the tobacco executives' testimony on addiction, Dr.
Kozlowski said, "In a way, I can see how they could say that. It
has to do with a mistaken image of what addiction is, and I have
many well-educated, intelligent people say something like that to
me. People often think of a person taking one injection of heroin
and becoming hopelessly addicted for the rest of their lives.
That is wrong."

In addition, he said, when people tend to think of the high that
heroin produces, one that is about as intense as cocaine and
alcohol, they cannot believe cigarettes are in the same category.
And they are not. Even though in large doses nicotine can cause a
strong high and hallucinations, the doses used in cigarettes
produce only a very mild high.    

But researchers now know, says Dr. Jack Henningfield, chief of
clinical pharmacology at the Addiction Research Center of the
Government's National Institute on Drug Abuse, that many
qualities are related to a drug's addictiveness, and the level of
intoxication it produces may be one of the least important.

If one merely asks how much pleasure the drugs produce, as
researchers used to do and tobacco companies still do, then
heroin or cocaine and nicotine do not seem to be in the same
category. Dr. Kozlowki said, "It's not that cigarettes are
without pleasure, but the pleasure is not in the same ball park
with heroin."

But now, he said, there are more questions to ask. "If the
question is How hard is it to stop? then nicotine
a very impressive drug," he said. "Its urges are very similar to
heroin."

Among the properties of a psychoactive drug - how much craving it
can cause, how severe is the withdrawal, how intense a high it
brings - each addicting drug has its own profile.

Heroin has a painful. powerful withdrawal, as does alcohol. But
cocaine has little or no withdrawal. On the other hand, cocaine
is more habit-forming in some respects, it is more reinforcing in
the scientific terminology, meaning that animals and humans will
seek to use it frequently in short periods of time, even over
food and water.

Drugs rank differently on the scale of how difficult they are to
quit as well, with nicotine rated by most experts as the most
difficult to quit.

Moreover, it is not merely the drug that determines addiction,
says Dr. john R. Hughes, an addiction expert at the University of
Vermont.  It is also the person, and the circumstances in the
person's life.  A user may be able to resist dependence at one
time and not at another.

A central property of addiction is the user's control over the
substance.  With all drugs. including heroin, many are occasional
users. The addictive property of the substance can be measured by
how many users maintain a casual habit and how many are
persistent, regular users.

According to large Government surveys of alcohol users, only
about 15 percent are regular. dependent drinkers. Among cocaine
users, about 8 percent become dependent.  For cigarettes, the
percentage is reversed. About 90 percent of smokers are
persistent daily users, and 55 percent become dependent by
official American Psychiatric Association criteria, according to
a study by Dr. Naomi Breslau of the Henry Ford Health Sciences
Center in Detroit.  Only 10 percent are occasional users.

Surveys also indicate that two-thirds to four-fifths of smokers
want to quit but cannot, even after a number of attempts.  Dr.
John Robinson, a psychologist who works for the R. J. Reynolds
Tobacco Company, contests the consensus view of nicotine as
addictive. Using the current standard definition of addiction, he
said at a recent meeting on nicotine addiction, he could not
distinguish "crack smoking from coffee drinking, glue sniffing
from jogging. heroin from carrots and cocaine from colas."


It is not that Dr. Robinson and other scientists supported by
tobacco companies disagree with the main points made by
mainstream scientists. but that they define addiction
differently.   Dr. Robinson says intoxication that is
psychologically debilitating is the major defining trait of an
addicting substance. It is a feature that was part of standard
definitions of the 1950's, and is still linked to popular ideas
about addiction, but which experts now say is too simplistic and
has been left behind as scientific evidence accumulates.
.HOW EXPERTS RATE PROBLEM SUBSTANCES

Dr. Jack E. Henningfield of the National Institute on Drug Abuse
and Dr. Neal L. Benowitz of the University of California at San
Francisco ranked six substances based on five problem areas.

Withdrawal: Presence and severity of characteristic withdrawal
symptoms.

Reinforcement: A measure of the substance's ability, in human
and animal tests, to get users to take it again and again, and in
preference to other substances.

Tolerance: How much of the substance is needed to satisfy
increasing cravings for it, and the level of stable need that is
eventually reached.

Dependence: How difficult it is for the user to quit, the relapse
rate, the percentage of people who eventually become dependent,
the rating users give their own need for the substance and
the degree to which the substance will be used in the face of
evidence that it causes harm.

Intoxication: Though not usually counted as a measure of
addiction in itself, the level of intoxication is associated with
addiction and increases the personal and socIal damage a
substance may do.
.COMPARATIVE DATA CHARTS

1 = Most serious  6 = Least serious

HENNINGFIELD RATINGS

Substance   Withdrawal Reinforcement Tolerance Dependence Intoxication

Nicotine        3           4           2           1           5
Heroin          2           2           1           2           2
Cocaine         4           1           4           3           3
Alcohol         1           3           3           4           1
Caffeine        5           6           5           5           6
Marijuana       6           5           6           6           4

BENOWITZ RATINGS

Substance   Withdrawal Reinforcement Tolerance Dependence Intoxication

Nicotine       3*           4           4           1           6
Heroin          2           2           2           2           2
Cocaine        3*           1           1           3           3
Alcohol         1           3           4           4           1
Caffeine        4           5           3           5           5
Marijuana       5           6           5           6           4

*equal ratings