Why is Cigarette Smoking So Addicting? An Overview of Smoking as a Chemical and Process Addiction

Why is Cigarette Smoking So Addicting? An Overview of Smoking as a Chemical and Process Addiction

Tobacco is a potent drug that exerts strong control over its regular users. Typically, the need to use and reuse tobacco occurs gradually. What begins as an innocuous pastime or a simple pleasure eventually becomes a compelling and insistent demand. Many who are caught in tobacco addiction eventually come to terms with the intensity of their dependence, and they seek help. Others continue to use and remain in denial. Even though the ill effects of tobacco use are widely publicized through the media, over 55 million Americans continue to smoke.

Persons who have never used tobacco, either in a smoked or smokeless form, cannot understand the compulsive persistency and force that fuels nicotine addiction. Consider the laryngectomized patient who, having already suffered severe consequences from engaging in his addiction, continues to smoke through a tracheostomy opening in his neck, or take notice of the emphysematous patient who, at rest, can hardly take a breath, yet continues to smoke (and he faces the added risk of his lit cigarette's close proximity to his oxygen bottle!).

Amazingly, 50% (or more) of patients who are recovering from surgery for a smoking related disease (e.g., lung cancer, cardiovascular disease) continue to smoke while they are hospitalized or resume smoking shortly after they are discharged.( 2)

In all societies where tobacco is used, intake becomes disproportionately excessive and out of control. Virtually all smokers adopt a predictable usage pattern, whereby the initial cigarette of the day is smoked soon after waking. Other cigarettes automatically follow, as the brain's need for a bolus of nicotine returns.( 3) Throughout the day, smokers unconsciously learn how to titrate their nicotine intake by altering their puffing and inhaling behaviors. Thus, they maintain a predictable nicotine-containing blood level, which satisfies their body's dependency needs.

Smoking is seldom a take-it-or-leave-it activity. Most smokers cannot choose to use tobacco one day and leave It alone the next. (However, a few rare individuals, called "chippers," have managed to maintain an occasional cigarette smoking status. Only about 10.6% of current smokers use 5 or fewer cigarettes per day.( 1)) Typically, smokers must ingest 20-30 cigarettes daily to keep peace with their brain. Most smokers admit that they would like to quit, but are unable to do so. Moreover, about 70 to 80% of smokers who do quit are likely to relapse within the first 3 months of cessation.( 3) Nicotine craving can also surface many months or even years after quitting. One of our women patients who had been abstinent from smoking for 7 years resumed her addiction after she started to date a man who smoked. She stated, "The urge to begin smoking again was irresistible! It was as if I had never quit smoking at all. Almost immediately, I started smoking at my previous level, using the same brand of cigarettes, and automatically falling back into the same set of comfortable smoking rituals."

The purpose of this paper is to review the addictive nature of cigarette smoking and the pharmacologic, psychological, and sociocultural parameters of tobacco usage. The question to be addressed is: "Why is cigarette smoking so addicting?" Emphasis is also placed upon the value of developing strong support systems while recovering from nicotine addiction.

Tobacco Smoking: A Prototypical Addiction

Prior to 1960, smoking was considered to be a "dirty and offensive, but relatively harmless personal habit." The choice to smoke was perceived as being totally voluntary. Often, heavy smokers were viewed as "weak people" who lacked the willpower and fortitude to give up cigarette usage.( 4) Some claimed that smokers were immoral individuals who had a significant character defect.( 1) In a Biblical sense, they were defiling their bodies -- the temples of the Holy Spirit. Today, most Americans have a more enlightened understanding of cigarette smoking and realize that nicotine is an addictive substance the regular intake of which predictably leads to compulsive usage.

Generally, addiction can be defined as a "slavish physical and/or emotional dependence on a harmful, habit-forming substance and/or behavior."( 5) These unhealthy, excessive attachments can be to specific persons, places, things, or actions. According to Nakken, an addiction is an out of control and aimless searching for wholeness, happiness, and peace, through a relationship with an external object or event.( 6) Nakken also believes that addiction can be conceptualized as "a pathological love and trust relationship with an object or an event."( 6) An addiction exists whenever the discontinuance of a mood-altering substance or behavior results in distress sufficient enough to interfere with the routines of normal daily living (e.g., eating, sleeping, communicating, or working).( 7) Chemical (drug) dependency is often placed into a "disease concept" (i.e.,. "in recognition that a chemical dependency is a chronic, progressive, and potentially fatal biogenetic and psychosocial disease (illness), characterized by tolerance and physical dependence, manifested by loss of control, as well as diverse personality changes and social consequences").( 8)

Addictive behavior is characterized by an overwhelming involvement with the abusive substance (or process), while attempting to remain functional; it includes not only the desire to experience the drug's effects but also the ritual, atmosphere, and mind set accompanying the drug usage.( 9-10) It undergoes continuous development from a definite, though often unclear, beginning, toward an end point. A chemical addiction is a compulsive substance intake, where loss of control is experienced in terms of usage, frequency, amount, duration, dosage, and resulting behaviors; where usage continues even when its adverse consequences are known, and where a high relapse potential exists. The individual comes to trust and rely on this destructive substance or process and feels powerless to overcome it.

Cigarette smoking typically exemplifies the characteristics that describe an addiction. The cigarette becomes a tyrant, "demanding" (and receiving) the primary attention and allegiance of its users, who give up their autonomy and personal power, and cede their will to this compelling and slavish practice.

Tobacco Smoking: A Multifaceted, Addictive Behavior

Addictions are often categorized as being either ingestive or process in nature.( 11) In ingestive addictions, artificially refined or produced mood-altering substances (specific foods, drugs, gases, alcohol, or tobacco) are taken into the body excessively and compulsively. In process addictions, a person becomes "hooked" on a set of actions or interactions; a neutral behavior becomes overused to the point where it loses its original value, meaning, and purpose. It is no longer a means to an end, but an end in itself. The behavior becomes the "high"; the addictive process takes on a life of its own. Examples of processes that can become addictive include gambling, working, exercising sexual behaviors, spending money, eating, or avoiding food intake (bulimia/anorexia).

Cigarette usage can also become highly addictive. It is precisely this combination -- an ingestive act that is fused with a behavioral process -- that makes smoking so difficult to give up.( 12) In ingestive and process addictions, the substances and behaviors that are used to deal with stress must be taken into the body and re-performed more and more frequently to achieve some sense of normalcy. Smokers habitually and intensely build their lives around an object (the cigarette); they routinely ingest a highly addictive substance (nicotine); and they frequently perform a ritualistic event (the smoking act). A nicotine addict who feels stressed or deprived will instinctively seek relief through cigarette smoking.

In essence, smoking is an extremely multifaceted, addictive behavior that involves pharmacological, environmental, cognitive, and affective factors. It has both similarities to and differences from other addictions.( 13) Cigarette smoking, a special form of addiction with its own unique features, is incredibly resistant to long-term modification.( 14)

The Addictive Smoking Chain

Physiological dependence on nicotine, defined as a "true" chemical addiction by the U.S. Surgeon General,( 1) can be conceptualized as the central, connecting link in a three-linked chain.( 12) The two additional links, psychological dependence and influential sociocultural factors, interconnect with this common core and with each other, as well. According to the Surgeon General, "cigarette smoking is not a random or capricious behavior that simply occurs at the will or pleasure of those who smoke. Rather, smoking is the result of behavioral and pharmacologic factors that lead to highly controlled or compulsive use of cigarettes."( 1)

To most effectively explain the addictive nature and dynamics of smoking, nicotine addiction will be addressed first.

Physiological Dependence on Nicotine

The central element of all forms of chemical dependency is that the user's behavior is largely controlled by a psychoactive chemical that is, a substance that produces transient alterations in mood that are primarily mediated by effects in the brain.( 1) Nicotine is now understood to be a strongly addictive, mood-altering drug, with properties that clearly reinforce the continued use of tobacco products. As an ingestive disorder, compulsive nicotine intake causes physiological tolerance, tissue dependence, psychic dependence, and relatively well-defined physical withdrawal symptoms.

Generally, smoking can be characterized as a "nicotine-seeking behavior." As Russell states, "If it were not for the nicotine in tobacco smoke, people would be little more inclined to smoke cigarettes than they are to blow bubbles or light sparklers.( 15) Nicotine can simultaneously act on various parts of the brain as a stimulant (euphoriant), a depressant, or a tranquilizer, depending on the dosage.

Tolerance is the need to ingest increasingly larger doses of a drug to obtain a given physiologic effect. Nicotine tolerance occurs when progressively greater numbers of cigarettes are required, in order to produce a specific reaction or subjective sensation.( 7) Highly dependent smokers need a bolus of nicotine about every 20 to 30 minutes, throughout their waking hours.( 6, 16) Dependence occurs when the body becomes accustomed to the presence of the given chemical and is altered in such a way that it needs that substance in order to function normally. To feel stabilized, heavy smokers need to maintain a high level of nicotine in their brain. These individuals will unconsciously regulate their puff rate until this requirement is met. Withdrawal refers to the body's sense of physical discomfort and traumatic readjustment when the intake of an addictive substance is discontinued. According to Pomerleau, smoking can be defined "as negatively-reinforced behavior -- an escape-avoidance response to the aversive consequences of nicotine withdrawal."( 16) In fact, for habitual smokers, much of the pleasure of smoking appears to stem from the relief experienced as nicotine quells withdrawal symptoms.( 12) (The neuro-chemical aspects of physiological addiction to nicotine are covered in greater detail in an accompanying paper).

Psychological Dependence on Nicotine

Smoking and other addictions appear to be practiced in an attempt to meet specific internal human needs. According to Maslow,( 17) all human beings have an ascending order of five major, prioritized needs, based on physiology, safety (security), love (belongingness), self-esteem, and self-actualization. When these basic needs remain unmet, an unconscious effort is made to fill the empty space -- the so-called "hole in the soul," which exists as a result of their absence. The vacancy will be filled -- either positively, through personal spiritual growth and a healthy connection to one's Higher Power (as classically described in Twelve Step recovery programs) or negatively, through the use of nicotine, alcohol, drugs, gambling, obsessive sex, excessive food, etc.( 5)

The reasons why people begin to smoke and why they escalate their smoking behaviors are not always related. Initially, cigarettes may be smoked for experimental, social, or recreational purposes. However, after one has become habituated -- often as a result of peer influences -- a potent, new set of learned and reinforced psychological and social needs is activated. In a process addiction, certain repetitive actions and interactions become highly stylized and perfected over a prolonged period of time. (A pack-a-day smoker repeats the stimulus-response-reward inhalation cycle about 73,000 times a year! No other drug of abuse is used as often as nicotine.)( 18) Each smoker develops numerous smoking rituals (approximately 25 distinct and separate sub-acts,) each of which has psychological satisfactions and payoffs of its own. Conscious and unconscious cues may trigger both the physiological drive to smoke and the psychological need to perform smoking-related behaviors.( 18)

Some individuals use nicotine as a tranquilizer; they believe that smoking keeps them on an even emotional keel and reduces their feelings of anger, fear, and frustration. Stress has been identified as a risk factor for the initiation of smoking among adolescents.( 5) Smokers commonly report that smoking helps them to regulate their dysphoric moods or negative affect, and those who experience excessive stressors tend to increase their cigarette consumption.( 1) One young housewife reported that when she tried to stop smoking she became a "bitch," and her family, distressed by her contrary behavior, encouraged her to return to cigarette usage. Eventually, however, she realized that she was using her anger and moodiness as an excuse to resume smoking. Consequently, she was able to move past this self-imposed barrier.

Although cigarette usage does not improve general learning, some individuals report that smoking helps them to think and perform more effectively, as they undertake certain cognitive tasks; that is, those requiring sustained or selective attention.

People use a wide range of other excuses and rationalizations to justify their return to smoking. Many smokers, especially women, use cigarette smoking as a way to control their weight. In general, cigarette smokers weigh less than nonsmokers. Many smokers who quit smoking gain weight.( 1)

Because the act of smoking is paired with so many enjoyable events, smokers are continually being reminded to smoke. Many daily routines trigger the desire for a cigarette. As Krogh explains it, "People are tied to smoking as Gulliver was tied to the ground by the Lilliputians -- through hundreds of individual threads.( 18) Examples of pleasurable activities that are linked to smoking include talking on the telephone, relaxing after dinner or after sex, coffee drinking, consuming alcohol, or driving.

There is evidence that smokers tend to share a number of distinctive personality traits, as compared to nonsmokers. For example, they may be risk-takers and sensation-seekers.( 18) Smokers are more likely than nonsmokers to think that what happens to them is controlled by outside forces -- other people or fate.( 19) They rate high on the "external control" scale. Smokers tend to be more rebellious, restless, defiant, impulsive, extroverted, and abrasively honest. Additonally, they have actively engage in more serious types of misconduct.( 18)

In seeking the transitory rewards that smoking offers them, tobacco addicts develop many of the classic, addiction-related signs of powerlessness and unmanageability: fantasizing; obsessing; becoming devious; failing at attempts to exercise control; analyzing excessively; rationalizing; suffering negative emotional or physical effects; encountering related legal problems; harming self or others; becoming unnecessarily busy; feeling depressed; shutting down emotionally; avoiding others; denying dysfunctional behaviors; manipulating others to support their dysfunctional actions; giving up outside interests; going against spiritual or moral values; or being adversely affected, socially and/or financially.( 11)

Addiction-prone persons tend to be influenced by both nature and nurture. Some individuals may have inherited certain vulnerabilities and predispositions toward addiction. Additionally, they may have encountered painful, early life experiences (parental abuse or neglect, inconsistent parenting, emotional deprivation, parental shaming, or chaotic family behaviors) that have negatively affected their self-respect, self-confidence, self-determination, self-discipline, and self-control.( 11) As they attempt to live with these deficits, they develop a growing illusion that they must, at all costs, maintain coercive control over self, others, and the environment in order to survive. When stress levels become unmanageably high and external control is untenable, the addiction-prone person tends to seek relief from an outside source -- a specific product or process. The resultant nicotine high, or "rush," offers almost instantaneous relief. This relief-seeking ritual is easily repeated, and future rewards are similarly anticipated.

The cigarette smoking addiction, like all others, is cyclical. When escape from physiologic or psychic pain is sought and temporarily found through an external source, the addictive cycle is activated. As tension builds, the person engages in smoking to seek relief. A sense of release is almost immediately experienced, but guilt and shame quickly follow, along with the resolve to exercise self-control and total abstinence in the future. As life stresses and tensions occur and escalate, relief is again needed and the addictive cycle is repeated.

There are few "pure" addictions.( 20) When individuals are physiologically and psychologically dependent on one chemical substance or behavior, they tend to be concurrently dependent on others. All addictions are believed to be interrelated. Additionally, they are often multiple or interchangeable (traded), and they do not remain static. Addictive behaviors impact on one another in complex ways. When one compulsion appears to be under control, another may erupt (i.e., those who are giving up cigarettes may begin to drink coffee or alcohol, or consume inordinate amounts of chocolate or sugar). About 90% of recovering alcoholics are cigarette smokers. Many of these dual users have reported that they increased their cigarette consumption when they quit drinking. Conversely, alcohol drinking is a powerful trigger for cigarette smoking relapse; that is, a "printing dose" of alcohol can stimulate craving for both alcohol and cigarettes? Smoking drug users and alcoholics frequently admit that giving up tobacco usage is more difficult to accomplish than quitting drug or alcohol use.

Those who give up one addiction but adopt another have altered not their habit patterns, only their focus of attention. Still engaging in "drug-seeking," they have merely substituted one substance or behavior for another.( 5)

Sociocultural Factors That Influence Tobacco Use

Tobacco use is learned and typically initiated during adolescence, when the need to achieve acceptance through peer conformity is particularly strong.( 10, 15) These belongingness pressures are compounded by the influence of mass media messages, portray smokers as being highly attractive, sophisticated, and socially energetic.( 5, 21) The desire to feel more grown-up and the drive to become self-defined and individuated often cause adolescents to rebel against strict parental control or to challenge cultural/religious expectations. Among adolescents, smoking can serve as a strong peer group bond. During these formative years, teenagers actively attempt to distance themselves from parental influences. Their rebellion may be acted out in a variety of ways, including engaging in tobacco use. The two major predictors of early cigarette usage are (a) experiencing peer pressure to smoke and (b) having one or th parents who smoke.( 10) The child of two smoking parents is twice as likely as the child of two nonsmokers to smoke.( 22) It is noteworthy to observe that adolescents are not only drawn to cigarette usage because of rebellion against parental control and a desire for individuation but conversely, they are also highly influenced to smoke by living with smoking parents!

Many social factors that contribute to the initiation of smoking also perpetuate nicotine addiction.( 23) As young adults move away from their extended family support system, peer influences assume greater importance. Adult smokers are likely to have a number of smoking friends. The maintenance of tobacco addiction is enhanced when an individual has a smoking spouse or cohabitant.( 23) One study showed that 68% of young women smokers had boyfriends or husbands who smoked, as compared with 41% of nonsmoking women who had smoking boyfriends or husbands.( 24) Other studies reported that nearly 90% of teenage smokers had one or more close friends who smoked -- as compared to 33% of nonsmoking teens who had smoking close friends.( 22)

In considering a person's smoking practices, it appears that "birds of a feather flock together." Socioeconomic status and occupation are related to smoking behaviors. For example, white-collar (professional, technical) male workers are reported to have the lowest smoking rates, whereas blue-collar male workers laborers, craftsmen) are shown to have the highest smoking rates.( 23) Upwardly mobile (relative to the parent's socioeconomic level) men are less likely to smoke; downwardly mobile men are more likely to be heavy smokers. However, among women, white- collar female employees have a higher incidence of smoking, than do blue-collar female workers.

When helping a smoker to quit, the smoking cessation facilitator needs to consider the smoking behaviors and attitudes of family members and significant others. Often, the environment of those who wish to quit smoking is not conducive to cessation success. Smoking has a strong social-facilitative effect that is also tied to one's life-style, friendships, and habit patterns. Those "would-be quitters" who live among smokers may have to change their surrounding in order to reduce negative pressures and receive positive support. Many recovering smokers have expressed the feeling that some close friends or relatives do not really want them to succeed. Peer or family-oriented discord often serves as a trigger for drug relapse.( 26) Additionally, relapse frequently occurs as a result of peer pressure; for example, cigarettes are offered to the recovering person by the non-abstinent friend.( 1) A variety of studies indicate that social pressure is a factor in about 15 to 40% of relapse episodes among alcohol and opioid users. Living with a smoker and being exposed to smoking peers contribute to about a 30% relapse rate among cigarette quitters.( 27)

Ferguson( 22) observes that smoking often serves as a potent bonding ritual and a means of shared communication. When two people smoke together, they share a highly valued experience that acts as a uniting ceremony. This type of emotional and ritualistic fusion cannot be given up easily.

The social dimension of the smoking process must be taken into consideration when planning smoking cessation activities. Social support is an extremely important factor in any effort to change personal behaviors. Early in the cessation process, non-judgmental and empathetic friends and family members can be enlisted to actively support recovering smokers. Those who are going through this difficult transitional period need to seek out a number of patient and understanding individuals on whom they can depend. Horwitz et al.( 25) showed that tobacco abstainers reported significantly more support from spouses, parents, family, and friends than did relapsers. The "buddy system" can also become a powerful positive reinforcer. Two (or more) individuals who have a similar problem can provide a great deal of mutual assistance and encouragement.

Healthy competition among recovering friends may also become a potent smoking cessation motivator. No one wants to be the person who fails while others succeed.

Ferguson recommends that persons who wish to quit smoking ask others for smoking cessation support in the following manner:( 22)

- Give me praise for any/all positive health efforts and progress I make.

- Reassure me that my efforts to quit smoking will be successful.

- Ask me regularly about how I am progressing.

- Assure me that the longer I can go without smoking, the easier it will be for me.

- Please do not smoke in my presence.

- Please do not offer me cigarettes.

With the increasing militancy now demonstrated by nonsmokers and with the additional legal restrictions presently being placed upon the smoking public, those who continue as hard-core smokers will undoubtedly begin to close their ranks. As these individuals feel more threatened and psychologically cornered, they may seek to enlist greater support from their smoking friends. As they flight to maintain their addiction, they may view both those who have quit smoking and those who have never smoked as the "common enemy." Health care professionals who are involved in the smoking cessation movement need to approach these persons with compassion and understanding. Yet they must also move forward in active commitment to the Surgeon General's goal of establishing a smoke-free society by the year 2000.( 28)

SUMMARY

Cigarette smoking is a genuine and multifaceted addiction that is both ingestive and process in nature. The addictive smoking chain can be visualized as having three interconnecting links: The central link, nicotine (physiological) addiction, is joined to two additional links, psychological (cognitive and effective) dependence and sociocultural (environmental) factors. It is precisely this dynamic combination of related factors that makes cigarettes smoking so incredibly resistant to long-term extinction. This paper helps to answer the question, "Why is cigarette smoking so addicting?" Additionally, it suggests the use of active support systems during nicotine addiction recovery.

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PNG Publications.

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By Arden G. Christen and Joan A. Christen

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