Addiction

What Is Drug Addiction?

What Causes Drug Addiction?

Who Is at Risk of Addiction?

What Are Some Addictive Drugs?

What Is an Addictive Disorder?

What Are the Signs of a Drug Addiction?

What Are the Signs of an Addictive Disorder?

How Is an Addiction Diagnosed and Treated?

Resources

Addiction (a-DIK-shun) refers to the use of a substance, such as alcohol or another drug, to the point where a person develops a physical or psychological need for it. The term also may be used to describe a harmful habit that is out of control, such as gambling or spending too much time on the Internet.

KEYWORDS

for searching the Internet and other reference sources

Chemical dependence

Substance abuse

Tobacco addiction

Without Drugs = Withdrawal

When long-term or heavy drug use suddenly stops, people may soon experience a number of unpleasant symptoms.

These symptoms vary, depending on the substance involved. Some common symptoms are:

• Alcohol and sedatives: shaking hands, upset stomach, vomiting, anxiety, sweating, rapid heartbeat, restlessness, trouble sleeping, seizures, and hallucinations.
• Amphetamines and cocaine: bad mood, tiredness, vivid nightmares, increased appetite, and sleeping too much or too little.
• Caffeine: tiredness, sleepiness, depression, anxiety, upset stomach, vomiting, and headache.
• Heroin and morphine: bad mood, upset stomach, vomiting, muscle aches, runny nose or eyes, sweating, diarrhea, yawning, fever, and trouble sleeping.
• Nicotine: bad mood, depression, trouble sleeping, crankiness, anger, anxiety, short attention span, restlessness, slower heartbeat, increased appetite, and weight gain.

When friends first told Josh that his drinking and drug use were out of control, he ignored them. He liked to party, he said, but he could stop anytime he wanted. He did not stop, though, no matter how much his grades fell and his soccer game suffered. He still did not stop even after he was kicked off the soccer team and lost many of his friends. Eventually, Josh had to admit that his use of alcohol and drugs had gotten out of hand. He had developed an addiction, he now said, and he needed help to fight it.

What Is Drug Addiction?

We often say that people who have an addiction are “hooked” on a substance or behavior. It is an apt choice of words, since addicts often feel as if they are dangling like a trout from a fishing hook and that they cannot break free. Fortunately, this is not true. Treatment can help people with an addiction overcome their bad habits and regain control of their lives.

Physical dependence

People with an addiction to alcohol or another drug develop a dependence on it, which is a strong need to use the substance no matter how bad the consequences may be. Sometimes the need is physical. One sign of physical dependence is called tolerance. When someone develops tolerance for a certain substance, it means that over time he or she starts to need more and more of it to get drunk or feel high. If someone keeps using the same amount of the substance, after a while he or she may notice that it does not have the same effect anymore.

Another sign of physical dependence is withdrawal, which means that people who are hooked on a substance can have physical symptoms and feel sick if they stop using it. The symptoms are so unpleasant that people may be driven to start drinking or using drugs again just so they can feel better. This is one effect that keeps people coming back for more of a substance, even after they realize that they have a serious problem.

Psychological dependence

Some people feel as if they have lost control of their drinking or drug use, yet they do not show signs of tolerance or withdrawal. While these people may not be physically hooked on a substance, they can still have a strong psychological dependence on it. Like people with a physical dependence, they may feel an intense craving and find themselves drinking or using drugs in larger amounts or more often than they intend.

The Tiniest Addicts

What could be sadder than a tiny baby in the throes of drug withdrawal? This tragic scene is played out when babies of drug-abusing mothers are born with an addiction. Babies born addicted to heroin, for example, sneeze, hiccup, twitch, and cry. They also may have such symptoms as restlessness, shakiness, trouble sleeping and eating, a stuffy nose, vomiting, diarrhea, a high-pitched cry, fever, irregular breathing, and seizures*. These symptoms usually start within a few days after birth, and some can last for 3 months or more.

* seizures

can occur when the electrical patterns of the brain are interrupted by powerful, rapid bursts of electrical energy, which may cause a person to fall down, make jerky movements, or stare blankly into space.

People who are dependent on alcohol or other drugs, either physically or psychologically, often spend much of their time finding ways of getting the substance, using it, hiding it, and recovering from its ill effects. Friendships, school, work, sports, and other activities all may suffer as a result. As the problems pile up, people may want desperately to give up the substance, yet they find it very hard to do so despite repeated efforts to kick the habit. Often, users will not see the connection between drug use and life problems. They think that the issues in their lives justify their drug and alcohol use and deny that their substance abuse is a real problem.

What Causes Drug Addiction?

Addiction usually begins with a conscious choice to drink or use drugs. People often turn to alcohol or other drugs to avoid things that bother them. For teenagers, this may mean pressure from friends, stress at home, or problems at school. Teenagers also may think that drinking or using drugs will help them fit in, let them overcome their shyness at parties, or make them look older or “cooler.” Some just like the feeling of being high. In the long run, though, they end up feeling worse. The more they drink and use drugs, the more problems arise, and the harder it is to stop. By this point, however, people may feel as if they no longer have a choice, because the urge to use alcohol or drugs has become so powerful.

To understand how alcohol and drugs can gain such a strong hold on people, it helps to grasp how these substances act inside the body. Once a substance is taken in through drinking, smoking, injecting, or inhaling, it travels through the bloodstream to the brain, which has its own built-in reward system. When people do things that are important for survival, such as eating, special nerve cells in the brain release chemicals that make people feel pleasure. In this way, the brain is programmed so that people want to repeat these actions that make them feel good.

Substances that are addictive affect the brain’s reward system. Instead of teaching people to repeat survival behaviors, though, they “teach” them to take more drugs. The way this happens varies from substance to substance. Some drugs, such as heroin* or LSD*, mimic the effects of a natural brain chemical. Others, such as PCP*, block the sending of messages between nerve cells. Still others, such as cocaine*, interfere with the molecules that carry brain chemicals back to the nerve cells that released them. Finally, some drugs cause brain chemicals to be released in larger

* heroin

is a narcotic, an addictive painkiller that produces a high, or a euphoric effect. Euphoria (yoo-FOR-ee-a) is an abnormal, exaggerated feeling of well-being.

* LSD

short for lysergic acid diethylamide (ly-SER-jik A-sid dye-thel-AM-eyed), is a hallucinogen, a drug that distorts a person’s view of reality and causes hallucinations.

* PCP

short for phencyclidine (fen-SY-kle-deen), is a hallucinogen, a drug that distorts a person’s view of reality.

* cocaine

(ko-KAYN) is a stimulant, a drug that produces a temporary feeling of alertness, energy, and euphoria.

amounts than normal. Methamphetamine, a type of amphetamine* also known as “speed,” is one example. At first, drug use may seem fun, because it leads to feelings of pleasure or relaxation. Over time, though, drug use gradually changes the brain so that people need to take drugs just to feel normal.

* amphetamines

(in-HAY-lunts) are substances that a person can sniff, or inhale, to get high.

Addiction is believed to change the brain’s pleasure circuits and pathways. A complex cascade of signals within the brain creates the craving that characterizes addiction. Thus, an addiction to a substance may be both psychological and physiological, as the body creates demands that are out of the person’s control.

Who Is at Risk of Addiction?

Addicts come in all shapes and sizes. The homeless man sleeping on the street may have an addiction, but so may the captain of the high school soccer team. Any person who abuses alcohol or other drugs is at risk of becoming addicted. For some people, however, the risk is especially high. For one thing, problems with drinking and drug use, just like heart disease or cancer, often run in families. Children whose parents are addicted to alcohol, for example, may be more likely than other people to have an alcohol or drug problem themselves.

People who have certain mental disorders also have a higher than average risk of addiction. This is not surprising, since it is thought that many mental disorders are caused in part by an imbalance in the same kinds of brain chemicals that drugs affect. People who suffer from depression, for example, may find that a certain drug lifts their mood for a while. The “self-medication” theory of addiction says that people learn to respond to a particular mood by taking a drug, in a misplaced effort to relieve their mental pain.

What Are Some Addictive Drugs?

People can become addicted to a wide range of substances, including alcohol, amphetamines, cocaine, heroin, inhalants*, LSD, marijuana*,

* inhalants

(am-FET-ameenz) are stimulants, drugs that produce a temporary feeling of alertness, energy, and euphoria.

* marijuana

(mar-a-WA-na) is a mixture of dried, shredded flowers and leaves from the hemp plant that a person can smoke or eat to get high.

morphine*, tobacco, PCP, and sedatives*, just to name a few commonly abused drugs.

* morphine

(MOR-feen) is a narcotic, an addictive painkiller that produces a high.

* sedatives

(SAID-uh-tivs) are drugs that produce a calming effect or sleepiness.

People who use cocaine often feel smart and powerful. Actually, a brain impaired by cocaine use is less active than a healthy brain. These positron emission tomography (PET) scans show areas of high brain activity in red and yellow. Note that brain activity is reduced in the cocaine user, especially in the frontal lobes (arrows) where ideas, thoughts, plans, and memories are created. Photo Researchers, Inc.

Marijuana addiction

Some people believe that marijuana use is relatively safe, because it does not lead to addiction. However, regular marijuana users may become psychologically dependent on the drug. Some longtime, heavy users also can experience mild signs of physical dependence, including tolerance and withdrawal. Some studies suggest that marijuana affects the brain’s reward system in much the same way as other addictive drugs.

Alcohol addiction

Alcoholism (AL-ko-hall-i-zm) is the common name for an addiction to alcohol. Some people with alcoholism develop a tolerance that lets them drink large amounts of alcohol without seeming drunk or passing out. Others have nasty withdrawal symptoms if they stop drinking. Delirium tremens (de-LEER-ee-um TRE-munz) is the name given to the most severe withdrawal symptoms seen in people who have alcoholism. These symptoms include confusion, disordered thoughts, and hallucinations*.

* hallucinations

(ha-loo-si-NAY-shuns) are sensory perceptions that have no cause in the out-side world. A person with hallucinations may see and hear things that are not really there.

Tobacco addiction

Cigarette smoking is a very tough habit to overcome. This is because tobacco contains nicotine, a highly addictive substance that is added to tobacco when it is made into cigarettes. Smokers can build up a tolerance for nicotine, as shown by the fact that most smokers work up to smoking at least a pack a day by the age of 25. They also go through withdrawal when they are unable to smoke, which explains why many smokers rush to light up as soon as they leave a place where smoking is not allowed.

From Use to Misuse to Abuse to Addiction

Alcohol or drug use by teenagers typically moves through four stages as it goes from occasional use to full-blown addiction. The stages are:

• Occasional use: Teenagers at this stage typically use beer, marijuana, or inhalants on weekends with their friends. There are few obvious changes in behavior during the week.
• Regular misuse: Teenagers at this stage actively seek the high they get from drinking or using drugs. They may try stimulants (for example, amphetamines or cocaine) or hallucinogens (for example, LSD or PCP), and they may use drugs four or five times per week, even when they are alone. Grades start to slip, activities fall by the wayside, and old friends are replaced with new ones who also use alcohol or drugs.
• Frequent abuse: Teenagers at this stage can have mood swings that go from extreme highs to such lows that suicide becomes a concern. Many start to sell drugs to support their habit. As the drug use continues, lying, fighting, stealing, and school failure become problems.
• Full-blown addiction: Teenagers at this stage may need alcohol or drugs every day to fend off withdrawal. They will use whatever drug is handy and do whatever it takes to get high. Drug use is all they think about, and they may feel as if they have lost control. Guilt, shame, and depression are common emotions, and overdoses and medical problems may occur.

Caffeine addiction

Among the most widely used mind-altering chemicals in the world is caffeine (ka-FEEN), a substance found in coffee, tea, colas, and many nonprescription medicines. It is no accident that coffee, a potent source of caffeine, is the favorite wake-up drink in so many homes. People often use caffeine for the temporary surge of energy it produces, much like the “buzz” that comes from some other drugs. Owing to tolerance, however, it eventually takes more and more caffeine to get this feeling. When daily coffee drinkers stop using caffeine, they may have withdrawal symptoms, such as headaches, fatigue, and irritability.

What Is an Addictive Disorder?

People also may develop harmful behavior patterns that share many of the same traits as dependence on alcohol or other drugs. Such behaviors sometimes are referred to as addictions too. Among the types of behavior that can be taken to an unhealthy extreme are gambling, sexual activity, and Internet use. When people say they have an addiction to gambling, for example, they mean that they have trouble controlling their desire to gamble, even when they experience harmful consequences, such as losing a lot of money.

Experts disagree about whether this kind of out-of-control behavior should be termed an addiction. Many doctors prefer to call it an impulse control disorder. People with an impulse control disorder are unable to curb their urge to do something that is harmful to themselves or others, even though they may try to resist and feel guilty for failing to do so. In everyday conversation, though, people often refer to excessive gambling, sexual behavior, and Internet use as addictions, since people with these problems act much like people who are addicted to alcohol or other drugs. Rather than responding to outside chemicals, however, such people may be responding in part to natural chemicals released inside the brain. Exciting activities, such as gambling and sexual behavior, can trigger the release of brain chemicals that have an arousing effect. This is similar to the effect that people get from taking cocaine or amphetamines.

Gambling addiction

Gambling addiction, also sometimes called pathological (pa-tha-LAH-ji-kal) gambling, refers to out-of-control gambling with harmful consequences. Like people addicted to substances, gambling addicts may need to risk ever-increasing amounts of money to feel the same excitement they got from gambling a small amount at first. They also may become restless or cranky if they try to cut down or stop gambling, which makes it hard for them to quit. The continued gambling causes trouble at home, school, or work. Yet gambling addicts use their habit as a way of escaping problems or feeling better, much the way someone else might use alcohol or drugs. They may find that much of their time is spent thinking about their next bet or scheming to get more money. They also may start lying to friends and family to hide how much they are gambling, or they may need to borrow money to cover their losses. As things get worse, they may even turn to stealing. Despite the problems, such people find it nearly impossible to stop gambling.

Sexual addiction

Sexual feelings and desires are a normal, healthy part of life, but some people take these natural feelings to an unhealthy extreme, to the point where they are unable to control their sexual thoughts or behavior. Some people might spend hour after hour looking at pornography*, while others might have casual sex with partner after partner. In either case, there can be serious negative consequences. People who spend too much time looking at sexual pictures or videos may lose friends or drop out of other activities. Those who have numerous sex partners risk an unwanted pregnancy or a sexually transmitted disease (an infection, such as herpes or HIV, that can be passed from person to person by sexual contact).

* pornography

is the depiction of sexual activity, in writing or in pictures or videos, that is meant to cause sexual excitement.

Internet addiction

A new problem in the computer age is seen among people who are unable to control their on-line behavior. Some people feel driven to “surf” websites or play computer games for hours on end, to the point where they lose interest in off-line activities. Others spend so much time “chatting” with on-line buddies that they have no time for real-world friends. Still others who already have trouble controlling their desire to gamble or look at pornography spend a lot of time at websites that cater to their frequent, strong cravings.

What Are the Signs of a Drug Addiction?

It is not always easy to tell when someone is suffering from an alcohol or drug addiction, since the person may go to great lengths to hide the problem. Nonetheless, there are usually signs that something is terribly wrong. Typical warning signs in young people include:

• getting drunk or high on a regular basis
• having to use more alcohol or drugs to get the same effect
• wanting to quit but being unable to do so
• lying about or hiding the alcohol or drug use
• avoiding friends in order to get drunk or high
• giving up other activities, such as homework or sports
• pressuring others to drink or use drugs
• taking risks, including having unsafe sex
• driving under the influence of alcohol or drugs
• getting into trouble with the law
• being kicked out of school for a reason related to alcohol or drugs
• thinking that the only way to have fun is to drink or use drugs
• being unable to remember actions the night before while drunk or high
• feeling run-down, hopeless, or depressed.

Twelve 12-Step Groups

Since its founding in Akron, Ohio, in 1935, Alcoholics Anonymous has mushroomed to nearly 2 million members in more than 99,000 groups worldwide. Not surprisingly, dozens of other self-help groups have since tried to copy this successful model. They include:

• Chemically Dependent Anonymous, P.O. Box 4425, Annapolis, MD 21403. Telephone 800-CDA-HOPE. http://www.cdaweb.org
• Cocaine Anonymous, 3740 Overland Avenue, Suite C, Los Angeles, CA 90034-6337. Telephone 310-559-5833. http://www.ca.org
• Crystal Meth Anonymous, 8205 Santa Monica Blvd., PMB=114, West Hollywood, CA 90046-5977. Telephone 213-488-4455. http://www.crystalmeth.org
• Debtors Anonymous, P.O. Box 920888, Needham, MA 02492-0009. Telephone 781-453-2743. http://www.debtorsanonymous.org
• Emotions Anonymous, P.O. Box 4245, St. Paul, MN 55104-0245. Telephone 651-647-9712. http://www.emotionsanonymous.org
• Food Addicts in Recovery Anonymous, 6 Pleasant Street, Suite 402, Malden, MA 02148. Telephone 781-321-9118. http://www.foodaddicts.org
• Gamblers Anonymous, P.O. Box 17173, Los Angeles, CA 90017. Telephone 213-386-8789. http://www.gamblersanonymous.org
• Marijuana Anonymous, P.O. Box 2912, Van Nuys, CA 91404. Telephone 800-766-6779. http://www.marijuana-anonymous.org
• Narcotics Anonymous, P.O. Box 9999, Van Nuys, CA 91409 Telephone 818-773-9999. http://www.na.org
• Nicotine Anonymous, 419 Main Street, PMB370, Huntington Beach, CA 92648. Telephone 866-536-4359. http://www.nicotine-anonymous.org
• Overeaters Anonymous, 6075 Zenith Court Northeast, Rio Rancho, NM 87124. Telephone 505-891-2664. http://www.overeatersanonymous.org
• Sexaholics Anonymous, P.O. Box 111910, Nashville, TN 37222. Telephone 615-331-6230. http://www.sa.org.

What Are the Signs of an Addictive Disorder?

People with an addictive disorder may act much like those with alcohol or drug addiction. Typical warning signs include:

• taking part in the behavior more often or intensely than intended
• having to increase the behavior to get the same effect
• wanting to quit but being unable to do so
• feeling restless or cranky if the behavior stops
• continuing the behavior despite knowing that it causes real problems
• giving up other activities, such as homework or sports
• thinking about or planning for the behavior all the time
• spending a lot of time on the behavior and its aftereffects.

How Is an Addiction Diagnosed and Treated?

An addiction is a tough problem to beat, but it can be done. The first step is to seek professional help. To make a diagnosis, a physician or mental health professional, such as a psychologist, social worker, or counselor, will ask the person about past and present alcohol and drug use. If possible, the doctor or mental health professional also will talk to the person’s family or friends. In addition, he or she will perform a full medical checkup and may order tests to check for diseases that are more common among addicts. For example, a person who injects drugs might be tested for HIV infection, which can be contracted by sharing needles with an infected person.

Once a diagnosis has been made, there are several treatment options. Medications can help control drug cravings and relieve withdrawal symptoms. These are not the same kinds of drugs that are involved in the addiction but rather medications that help lessen the addiction problem. Talk therapy can help people with addictions understand their own behavior, develop higher self-esteem, and cope better with stress. For most people, a combination of medication and talk therapy works best. Talk therapy can be done one-on-one with a therapist or in a group.

Many people do quite well being treated at a clinic while living at home, but others may need to spend a short time in a hospital. This is especially true if they have other mental disorders, are not motivated to change, have friends who still use alcohol or drugs, or have failed in past treatment efforts. Peer group self-help programs, such as Alcoholics Anonymous or Narcotics Anonymous, have become cornerstones of treatment for addiction problems.

Medications

Some medications block the effects of addictive drugs and relieve withdrawal symptoms. For example, methadone (METH-adon) is a medication used to treat heroin withdrawal, while naltrexone (nal-TREK-zone) blocks the effects of heroin and related drugs. Other medications discourage the use of addictive drugs. For example, disulfiram (dy-SUL-fi-ram) works against alcohol use by causing severe nausea and other unpleasant symptoms when a person drinks alcohol.

Talk therapy

Several kinds of talk therapy (psychotherapy) are used to treat addiction. Cognitive (COG-ni-tiv) therapy targets the faulty thinking patterns that lead to alcohol and drug use. For example, people who think that alcohol protects them from pain may be helped to recognize the pain alcohol has caused them (such as loss of friends, work, self-esteem). People who use drinking as the only way to cope with problems may be helped to identify other ways to cope with problems. They are then helped to reconsider their old beliefs that alcohol is the only way to cope, and that drinking protects them from pain. By discovering that old beliefs are false, it is possible for them to decide what beliefs are more accurate. In this way, with time and effort, thinking patterns and false beliefs can change. Behavioral (bee-HAV-yor-al) therapy takes aim at negative forms of behavior, often by using a system of rewards and punishments to replace harmful behaviors with more positive ones. A teenager, for example, might get movie tickets for having a drug-free urine sample or lose the privilege of driving the car as a result of a setback. Behavioral therapy may also focus on identifying behaviors that keep a drug or alcohol problem in place (such as going to bars for recreation or spending time with friends who drink) and choosing behaviors that help beat the problem (going to the gym instead of a bar). Family therapy works on problems at home that may play a role in alcohol or drug abuse, such as conflict between family members. Family members may be taught to communicate better, or to solve problems more effectively.

Self-help groups

Self-help groups can be very helpful to people who are trying to deal with an addiction and to their family members. Many are 12-step groups, patterned on the 12 steps that are the guiding principles of Alcoholics Anonymous. Those who attend group meetings receive personal support from other people who are fighting the same addiction and winning.

See also

Alcoholism

Hallucination

Substance Abuse

Therapy

Tobacco Addiction

Resources

Book

McLaughlin, Miriam Smith, and Sandra Peyser Hazouri. Addiction: The “High” That Brings You Down. Springfield, N.J.: Enslow Publishers, 1997.

Organizations

Alcoholics Anonymous, P.O. Box 459, New York, NY 10163. This oldest and largest 12-step group offers information about its program and referrals to local meetings. Telephone 212-870-3400 http://www.alcoholics-anonymous.org

National Council on Alcoholism and Drug Dependence, 20 Exchange Place, Suite 2902, New York, NY 10005. This national organization provides information about alcohol and drug addiction and referrals to local support groups. Telephone 800-NCA-CALL http://www.ncadd.org

National Clearinghouse for Alcohol and Drug Information, P.O. Box 2345, Rockville, MD 20847-2345. This government clearinghouse is the world’s largest resource for current information and materials on substance abuse and addiction. Telephone 800-729-6686 http://www.health.org

National Institute on Alcohol Abuse and Alcoholism, 6000 Executive Boulevard, Bethesda, MD 20892-7003. This government institute provides in-depth information on alcohol abuse and addiction. Telephone 301-443-3860 http://www.niaaa.nih.gov

National Institute on Drug Abuse, 6001 Executive Boulevard, Room 5213, Bethesda, MD 20892-9651. This government institute provides detailed information about drug abuse and addiction. Telephone 301-443-1124 http://www.drugabuse.gov

Nemours Center for Children’s Health Media, A. I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803. This organization is dedicated to issues of children’s health. Their website has valuable information for children, teens, and parents on addiction and related topics. http://www.kidshealth.org

ADDICTION

Addiction (chemical dependency) is caused by three substances: alcohol, narcotics, and tobacco (nicotine). In the period from 1870 to 1920, alcohol had a far greater impact on literary creativity than did narcotics or tobacco. The understanding of the nature of addiction—particularly addiction to alcohol—changed significantly from the Civil War period to the passage of the Eighteenth Amendment (Prohibition) to the Constitution in 1919. Throughout most of the nineteenth century, habitual drunkenness, for example, was judged, especially by temperance societies (which actually advocated abstinence or teetotalism) and by many Protestant clergy, to be a choice and a vice. The emerging opinion of many in the medical establishment and among liberal reformers, however, was that addiction to moodaltering substances was a treatable disease.

ALCOHOL

The three principal reform movements of the nineteenth century were abolition, woman suffrage, and temperance. The first reform was achieved by the Civil War, the latter two through constitutional amendments. These movements were linked by activists who were, in many instances, deeply involved in all three causes.

Whereas the moralists' uncompromising condemnation of habitual drunkenness largely prevailed in the popular literature of the nineteenth century, by the 1870s the medical (disease) model of the affliction began to gain a sympathetic audience. That alcoholism (a usage dating from 1849) was a treatable illness had a certain appeal not only for the medical establishment but also for public officials because the attempts to cure the inebriate by simply eliminating the availability of liquor were not working. In spite of efforts by temperance advocates to ban or even physically destroy the saloon (e.g., Carry Nation's "hatchetation"), the statistics of alcohol consumption from 1870 to 1919 remained relatively stable, between 1.72 and 2.60 U.S. gallons of absolute alcohol a year per capita of the drinking-age population (the high for America was 7.10 gallons in 1830; the low, 0.90 in 1920, the first year of Prohibition) (Rorabaugh, p. 232; Lender and Martin, pp. 205–206). Because a large part of the population (especially women) did not drink, however, the consumption of spirits by those who did was heavy indeed.

The belief in the nineteenth century that alcoholism could be cured or at least treated and arrested achieved practical application primarily through two methods: self-help groups and the inebriate asylum. Self-help organizations such as the Washingtonian Temperance Society, started in Baltimore in 1840, were followed by similar societies leading ultimately to the founding of Alcoholics Anonymous in 1935. Most of these groups consisted of meetings of drunkards who had taken a pledge to stop drinking. They supported their sobriety by confessing to each other stories about their drunken behavior. The asylum movement aimed to establish treatment centers that would replace the more expensive hospitals and insane asylums. The first such center was the New York State Inebriate Asylum in Binghamton, an institution that existed from 1864 to 1879. The self-help groups were more successful in helping alcoholics maintain sobriety than were the asylums, but in the nineteenth century neither lasted much past the original enthusiasm of their founders.

That African Americans had the strength to war against alcoholism and slavery at the same time is a testament to human endurance. A popular African American temperance pledge of the time was "Being mercifully redeemed from human slavery, we do pledge ourselves never to be brought into the slavery of the bottle" (Warner, p. 257). Frederick Douglass seemed at moments to be as concerned about the one as the other. Perhaps the most significant temperance novel of the period by an African American is Sowing and Reaping: A Temperance Story (1876–1877) by Frances E. W. Harper. Harper, like Douglass, devoted much of her long life to the abolition first of slavery and then of alcohol.

"Stories," says Edmund O'Reilly, in his analysis of recovery narratives, "may be the best means we have for comprehending alcoholism, since only stories can begin to contain alcoholism's bewildering, intractable, contradictory, protean nature" (Reynolds and Rosenthal, p. 180). This conclusion is supported by the fact that almost all the major—and many of the minor—American writers from Edgar Allan Poe to Jack London recognized the narrative power of drinking behavior and included the theme of alcohol abuse in their work. Drinking was the subject matter in poems and plays as well as in stories, but with the notable exceptions of Walt Whitman and Emily Dickinson, the quality seldom rises above doggerel or preaching.

Regional literature, particularly humorous tales, is another matter. The yarns and satires of the Old Southwest and the West, for instance, document the reality that boozing and fighting were simply facts of life. But the drunk—like the prostitute—was almost always a stereotype, there to make a joke, not to make the case for sobriety or chastity. Mark Twain is an exception. Twain in fact took temperance—by which he meant moderation—very seriously, but in his stories drunkenness, not drinking, is the problem. Another exception is Owen Wister, whose The Virginian: A Horseman of the Plains (1902) depicts what was to become the classic western saloon scene: whiskey, cards, and guns. In a celebrated passage the Virginian, after Trampas the villain said, "Your bet, you son-of-a—," responded: "When you call me that, smile" (p. 23).

The theme of alcoholism as an often intractable problem that cannot be cured by willpower alone finds its most complex expression in the works of Harriet Beecher Stowe, William Dean Howells, Stephen Crane, and London. The long, rich career of Stowe (1811–1896) is a case in point. Nicholas O. Warner, in his analysis of drinking in Stowe's fiction, traces her characterization of drunkenness as a moral failing and a sin in her early work to her finally arriving at the conviction in the later work that uncontrolled drinking is a disease leading to the tragedy of alcoholism. By the time Stowe wrote about the alcoholic Bolton in My Wife and I (1871) and in We and Our Neighbors (1873), however, she had developed a character, sensitive if flawed, who is a victim of a compulsion beyond his will. Bolton desperately attempts to control his drinking but discovers that because of his nature this is impossible: fate displaces weakness, a situation his wife understands and accepts.

The philosopher and psychologist William James (1842–1910) explored the subject of addiction in depth. In The Principles of Psychology (1890) he dealt with the pathological aspects of addiction, and in The Varieties of Religious Experience (1902) he treated the spiritual and mystical effects of the use of alcohol and drugs. The following is from Varieties.

The sway of alcohol over mankind is unquestionably due to its power to stimulate the mystical faculties of human nature, usually crushed to earth by the cold facts and dry criticisms of the sober hour. Sobriety diminishes, discriminates, and says no; drunkenness expands, unites, and says yes. It is in fact the great exciter of the Yes function in man. It brings its votary from the chill periphery of things to the radiant core. It makes him for the moment one with truth. . . . The drunken consciousness is one bit of the mystic consciousness, and our total opinion of it must find its place in our opinion of that larger whole.

William James, The Varieties of Religious Experience, in Writings 1902–1910 (New York: Library of America, 1987), pp. 348–349.

If Stowe's depiction of the alcoholic Bolton leans toward the sentimental, this cannot be said of Howells (1837–1920), that master of realism who chronicled through his voluminous writings the complexities of middle-class life. As John W. Crowley points out, from Hicks in The Lady of the Aroostook (1879), Bartley Hubbard in A Modern Instance (1882), and Berthold Lindau in A Hazard of New Fortunes (1890) to Alan Lynde in The Landlord at Lion's Head(1897), alcoholism is (variously) characterized as moral decay or a disease of the will. The vulnerable individual is driven to drink by the vicissitudes and disorders of modern life. Howells takes a hard look at drunken behavior, but for all that he delineates his characters' failings with more nuance and understanding than Stowe. In the final analysis both authors combine the moral model of addiction with the medical model. They both knew that each model by itself would result merely in stock figures: the unredeemable, the wretch, the clown, the hopeless victim—in short, in types of little literary or moral seriousness.

Stowe's and Howells's worlds are those of the middle and upper-middle class: immoderate drinking and drunkenness were not to be displayed in public, embarrassment was privatized, and tragedy was familial. This was not the world of Crane, London, and Wister, a world in which the tavern and the saloon displayed public drinking at its worst and best. The saloon of the time could be the friendly tavern seen in Crane's (1871–1900) George's Mother ("a little glass-fronted saloon that blinked jovially at the crowds" [p. 216]), and then again it was described as an elegant or even a palatial establishment. Theodore Dreiser (1871–1945), in Sister Carrie (1900), describes Hurstwood's "resort," Fitzgerald and Moy's, as "a gorgeous saloon . . . ornamented with a blaze of incandescent lights, held in handsome chandeliers. . . . The long bar was a blaze of lights, polished wood-work and cut glassware, and many fancy bottles. It was a truly swell saloon" (p. 41). This was preeminently a man's world, the conviviality unconcealed.

Crane's grim view of drinking is illustrated in Maggie, A Girl of the Streets: A Story of New York (1893) and in George's Mother (1896). In Maggie he tells the story of the corruption of a naive woman by Pete, a bartender who presides over a saloon and who in the end becomes its best customer, arriving "at that stage of drunkenness where affection is felt for the universe" (p. 73). Crane's most powerful study of drinking, however, is George's Mother (1896). Crane's father, the Reverend Jonathan Townley Crane, author of The Arts of Intoxication (1870), and his mother were both well-known temperance workers, and Crane makes good use of this background in his novella. A famous print of the time, The Drunkard's Progress (1846), describes the nine steps of the downfall of the alcoholic from "a glass with a friend" through "a confirmed drunkard" to the last step, "death by suicide" (Monteiro, pp. 48–49). As George Monteiro argues, the nine stages roughly correspond to the rise and fall of George Kelcey, the alcoholic son in George's Mother. The stark realism of the destructive bickering between an evangelical mother and her aimless, boozing son here is as painful to observe as is the witnessing of a pathologist's dissection. In his chilling story George's Mother, Crane creates a world where life seems scarcely worth living.

John Barleycorn (1913), London's (1876–1916) "alcoholic reminiscences," is in the tradition of addiction memoirs beginning with Thomas De Quincey's Confessions of an English Opium Eater (1822). London's memoir is perhaps the most powerful and the most important literary work about addiction published in this period. It is also a curious narrative that is almost perfectly ambivalent. London attempts to explain his temptation to drink and at the same time to warn his readers against the persuasions of John Barleycorn. Furthermore, he states that he supports both Prohibition and woman suffrage, the latter because women are far more likely to vote for the Prohibition Amendment than are men and must therefore be enfranchised. These declarations, though a minor part of the book, had much to do with making it a best-seller, as reformers sent copies of it to their huge membership.

The odd characteristic of John Barleycorn is that throughout his memoir London claims that he is not an alcoholic, yet his descriptions of his drinking, from his getting drunk at the age of five to his conclusion that "I survived . . . because I did not have the chemistry of a dipsomaniac" (p. 1107) reveal what clinicians would define as chronic physical alcohol dependence and denial of that dependence. London believed that he drank because he craved male companionship even though he detested the taste of liquor and did not especially care for the way it made him feel. Yet because he craved friendship he drank and drank—and drank. And he did so because his alter egos John Barleycorn and the White Logic compelled him. The former is the "friend" that leads him to drink in spite of himself, the latter the "philosopher" that rationalizes temptation. What distinguishes London's account from temperance novels and makes it such a powerful, sustained confession is his modern psychological insight and social awareness.

It is this modernity that signaled the fundamental change in the medical, the literary, and finally the public perception of the nature of alcoholic addiction. This change—that the substance was not so much the problem as was the abuse of it—eroded the moral power of the temperance movement: no longer could the inebriate be portrayed simply as weak and contemptible. In short, from Stowe to London's John Barleycorn the sympathetic ministrations of the psychologist began gradually to displace the puritanical thunder of Jeremiah.

NARCOTICS

Narcotics—opiates (opium, morphine, heroin, codeine, laudanum), cannabis (hemp, hashish, marijuana), and cocaine—were in widespread use in nineteenth-century America. Indeed, opium in one form or another was popular among all classes in Western society at least from the seventeenth century. David Musto, in his study of narcotics in America, points out that a rapid rise in the importation of raw opium and its derivative morphine began in the 1870s. Opiates were widely prescribed by physicians and were also included in many patent medicines. "The unregulated patent medicine craze in the United States hit its peak in the late nineteenth-century—a time when the opiate content of these medicines was probably also at its highest" (Musto, p. 3). A glance at the Sears Roebuck catalog for 1897 explains in part why. It offered laudanum, among other nostrums ("Directions on each bottle for old and young") at $3 for a dozen four-ounce bottles ("our goods go into every city, town and hamlet in every state").

There is some dispute regarding the extent of drug addiction in America at the turn of the century, but it appears that it peaked in 1900 at about 250,000 addicts. The Chinese were often blamed for the problem, yet it was in fact found among all groups—not least among women. Crane begins his "Opium's Varied Dreams," an 1896 article he published in the New York Sun, "Opium smoking in this country is believed to be more particularly a pastime of the Chinese, but in truth the greater number of the smokers are white men and white women," and he claimed that there were "25,000 opium-smokers in the city of New York alone" (p. 853). The increasingly widespread use of narcotics led to a series of reforms, beginning with the Pure Food and Drug Act of 1906 and the Harrison Act of 1914. The latter was designed not to prohibit the sale of drugs but to control them—a major difference from the attacks on alcohol—since opiates in particular had legitimate medical uses.

A word is needed about absinthe, a blend of 72 percent alcohol and herbals, including wormwood. Called La Fée Verte or the Green Fairy by nineteenth-century French artists, absinthe allegedly caused hallucinations, convulsions, and "brain-rot" (absinthism), though London, for one, was not impressed. "The trouble with [absinthe]," he writes in John Barleycorn, "was that I had to take such inordinate quantities in order to feel the slightest effect" (p. 1083). The drink gained a mythical status among the avant-garde: as with opium earlier, absinthe was thought to enhance the artistic imagination, and French artists and poets in particular consumed large quantities of it. Absinthe's perceived dangers, however, led to its banning in America in 1912 and in France in 1915. Though it frequently appeared in works of the European fin de siècle, it had little literary influence in America.

The drug that appears most prominently in the literature of this time is morphine, in large part because of its consumption by middle- and upper-class respectable women as an analgesic and as a treatment for neurasthenia, a popular affliction characterized by neurotic symptoms of fatigue and ennui. Just as the sensitive, world-weary male had his alcoholism, so the female had her morphinism, though the latter addiction was much easier to conceal than the former.

Although the use of drugs in America by the general population was at the time widespread, it had not yet significantly entered the literary or artistic imagination. London mentions his "adventures" in "Hasheesh Land" in John Barleycorn (p. 1092), but as with absinthe, narcotics for him were not part of the White Logic. The tales of Oscar Wilde, Robert Louis Stevenson, Sir Arthur Conan Doyle, and Sax Rohmerinvolving opium and cocaine were widely read, but not until Nelson Algren's The Man with the Golden Arm (1949) and William S. Burroughs's Naked Lunch (1959) do narcotics become a major subject for serious American writers.

TOBACCO

Drouet, in Sister Carrie, enjoyed dining at Rector's, where, amid a profusion of lights and in the company of actors and professional people, he had a splendid meal followed by liquor and a cigar. The experience would not have been complete without the cigar, and one is reminded that smoking has more than nicotine to recommend it. Nicotine, a stimulant like cocaine, is the addictive substance in tobacco, but the act of smoking is also habituating. This psychological-aesthetic experience, when integrated with the chemical substance, forms a powerful double hold on the user.

The population of the United States doubled between 1880 and 1910, and tobacco availability in all forms grew accordingly. Snuff and especially chewing tobacco were popular, and the spittoon (more elegantly, the cuspidor) was a fixture in most public buildings. Pipes, often beautifully designed, were marketed along with an array of tools for cigar smokers. Added to these attractions was the fact that tobacco products were remarkably cheap (cigarettes, for example, sold in 1876 for ninety-six cents per one thousand). The almost universal use of tobacco drew the critical attention of two powerful reformers, the Women's Christian Temperance Union (calling it "demon weed") and Theodore Roosevelt's trustbusters. The net result was that broken up, the tobacco companies became increasingly competitive largely by vastly expanding their advertising—as a child Jack London collected cigarette-card advertisements—and consumption accelerated.

Also, tobacco was thought to be a necessity. No less an authority than General John J. Pershing, the American commander in World War I, demanded tobacco for his troops, arguing that cigarettes were more necessary for them than food.

One notable genre where literature and tobacco merged was the verse anthology. These collections, filled with praise of the "divine weed," characterized the pipe in particular as a valued—and sometimes the only—friend. A representative volume is Joseph Knight's compilation Pipe and Pouch: The Smoker's Own Book of Poetry (1894), which went through many printings, including a leather-bound edition with its own pouch. The poems are the kind that would appeal more to J. Alfred Prufrock than to Prince Hamlet: sentimental, comforting, at times therapeutic. A verse letter by James Russell Lowell is included, thanking Charles Eliot Norton for a box of cigars ("Tobacco, sacred herb . . . Baffles old Time . . . And makes him turn his hourglass slowly" [p. 34]). Ella Wheeler Wilcox, whose first published work was a volume of temperance poems, contributed:

I like cigars

Beneath the stars,

Upon the waters blue.

To laugh and float

While rocks the boat

Upon the waves,—Don't you?

(P. 121)

In addition, the imagist poet Amy Lowell made a practice of smoking cigars in public.

Tobacco, then, as an addiction, a habit, and a pleasure was accepted by many—by men and increasingly by women—as a fact of life. Its health problems were by no means unknown, but such concerns at this time were defeated by the glamour and seduction that were beginning to come into play in advertising, popular songs, and film.

CONCLUSION

In the initial year of Prohibition, two novels were published that signified that social change was on the way: Sinclair Lewis's Main Street (1920) and F. Scott Fitzgerald's This Side of Paradise (1920). The revolt against the village and the rejection of social proprieties were modernist departures from the literary tradition that drew to a close as the First World War began. Both authors were enormously popular and much admired—and alcoholic. How relevant alcoholism was to their art is problematic, but an aspect of their celebrity was the defiance of decorum by their publicly drunken behavior that fifty years earlier would have doomed their careers as later it did their lives.

Chemical dependency or altered states of consciousness, those morally neutral terms that replaced the old, prescriptive labels for addiction, were becoming existential conditions for which a cure was not necessarily desired and of which the altered state was the reality consciously sought. It is profoundly ironic that at that moment when modernism announced the new sensibility, Prohibition went into effect.

See alsoHealth and Medicine; Reform; Temperance

BIBLIOGRAPHY

Primary Works

Crane, Stephen. Prose and Poetry. New York: Library of America, 1984.

Crowley, John W., ed. Drunkard's Progress: Narratives of Addiction, Despair, and Recovery. Baltimore: Johns Hopkins University Press, 1999.

Dreiser, Theodore. Sister Carrie; Jennie Gerhardt; Twelve Men. New York: Library of America, 1987.

Knight, Joseph, ed. Pipe and Pouch: The Smoker's Own Book of Poetry. Boston: H. M. Caldwell, 1894.

London, Jack. Novels and Social Writings. New York: Library of America, 1982.

Wister, Owen. The Virginian: A Horseman of the Plains. 1902. Edited by Philip Durham. Boston: Houghton Mifflin, 1968.

Secondary Works

Conrad, Barnaby, III. Absinthe: History in a Bottle. San Francisco: Chronicle Books, 1988.

Courtwright, David T. Dark Paradise: Opiate Addiction in America before 1940. Cambridge, Mass.: Harvard University Press, 1982.

Crowley, John W. The White Logic: Alcoholism and Gender in Modernist Fiction. Amherst: University of Massachusetts Press, 1994.

Crowley, John W., and William L. White. Drunkard's Refuge: The Lessons of the New York State Inebriate Asylum. Amherst: University of Massachusetts Press, 2004.

Gilman, Sander L., and Zhou Xun, eds. Smoke: A Global History of Smoking. London: Reaktion, 2004.

Klein, Richard. Cigarettes Are Sublime. Durham, N.C.: Duke University Press, 1993.

Kluger, Richard. Ashes to Ashes: America's Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris. New York: Knopf, 1996.

Lender, Mark Edward, and James Kirby Martin. Drinking in America: A History. Rev. and expanded ed. New York: Free Press, 1987.

McCrady, Barbara S., and Elizabeth E. Epstein, eds. Addictions: A Comprehensive Guidebook. New York: Oxford University Press, 1999.

Monteiro, George. Stephen Crane's Blue Badge of Courage. Baton Rouge: Louisiana State University Press, 2000.

Musto, David F. The American Disease: Origins of Narcotic Control. Expanded ed. New York: Oxford University Press, 1987.

O'Reilly, Edmund B. Sobering Tales: Narratives of Alcoholism and Recovery. Amherst: University of Massachusetts Press, 1997.

Reynolds, David S., and Debra J. Rosenthal, eds. The Serpent in the Cup: Temperance in American Literature. Amherst: University of Massachusetts Press, 1997.

Rorabaugh, W. J. The Alcoholic Republic: An American Tradition. New York: Oxford University Press, 1979.

Roth, Marty. Drunk the Night Before: An Anatomy of Intoxication. Minneapolis: University of Minnesota Press, 2005.

Vaillant, George E. The Natural History of Alcoholism. Cambridge, Mass.: Harvard University Press, 1983.

Warner, Nicholas O. Spirits in America: Intoxication in Nineteenth-Century American Literature. Norman: University of Oklahoma Press, 1997.

Roger Forseth

Addiction

Definition

Addiction is a persistent, compulsive dependence on a behavior or substance. The term has been partially replaced by the word dependence for substance abuse. Addiction has been extended, however, to include mood-altering behaviors or activities. Some researchers speak of two types of addictions: substance addictions (for example, alcoholism, drug abuse, and smoking ); and process addictions (for example, gambling, spending, shopping, eating, and sexual activity). There is a growing recognition that many addicts, such as polydrug abusers, are addicted to more than one substance or process.

Description

Addiction is one of the most costly public health problems in the United States. It is a progressive syndrome, which means that it increases in severity over time unless it is treated. Substance abuse is characterized by frequent relapse, or return to the abused substance. Substance abusers often make repeated attempts to quit before they are successful.

The economic cost of substance abuse in the United States exceeds $414 billion, with health care costs attributed to substance abuse estimated at more than $114 billion.

By eighth grade, 52% of adolescents have consumed alcohol, 41% have smoked tobacco, and 20% have smoked marijuana. Compared to females, males are almost four times as likely to be heavy drinkers, nearly one and a half more likely to smoke a pack or more of cigarettes daily, and twice as likely to smoke marijuana weekly. However, among adolescents these gender differences are not as pronounced and girls are almost as likely to abuse substances such as alcohol and cigarettes. Although frequent use of tobacco, cocaine and heavy drinking appears to remain stable in the 1990s, marijuana use has increased.

An estimated four million Americans over the age of 12 used prescription pain relievers, sedatives, and stimulants for "nonmedical" reasons during one month.

In the United States, 25% of the population regularly uses tobacco. Tobacco use reportedly kills 2.5 times as many people each year as alcohol and drug abuse combined. According to data from the World Health Organization, there were 1.1 billion smokers worldwide and 10,000 tobacco-related deaths per day. Furthermore, in the United States, 43% of children aged 2-11 years are exposed to environmental tobacco smoke, which has been implicated in sudden infant death syndrome, low birth weight, asthma, middle ear disease, pneumonia, cough, and upper respiratory infection.

Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating, affect more than five million American women and men. Fifteen percent of young women have substantially disordered attitudes toward eating and eating behaviors. More than 1,000 women die each year from anorexia nervosa.

A Harvard study found that an estimated 15.4 million Americans suffered from a gambling addiction. More than one-half (7.9 million) were adolescents.

Causes and symptoms

Addiction to substances results from the interaction of several factors:

Drug chemistry

Some substances are more addictive than others, either because they produce a rapid and intense change in mood; or because they produce painful withdrawal symptoms when stopped suddenly.

Genetic factor

Some people appear to be more vulnerable to addiction because their body chemistry increases their sensitivity to drugs. Some forms of substance abuse and dependence seem to run in families; and this may be the result of a genetic predisposition, environmental influences, or a combination of both.

KEY TERMS

Addictive personality— A concept that was formerly used to explain addiction as the result of pre-existing character defects in individuals.

Process addiction— Addiction to certain mood-altering behaviors, such as eating disorders, gambling, sexual activity, overwork, and shopping.

Tolerance— A condition in which an addict needs higher doses of a substance to achieve the same effect previously achieved with a lower dose.

Withdrawal— The unpleasant, sometimes life-threatening physiological changes that occur, due to the discontinuation of use of some drugs after prolonged, regular use.

Brain structure and function

Using drugs repeatedly over time changes brain structure and function in fundamental and long-lasting ways. Addiction comes about through an array of changes in the brain and the strengthening of new memory connections. Evidence suggests that those long-lasting brain changes are responsible for the distortions of cognitive and emotional functioning that characterize addicts, particularly the compulsion to use drugs. Although the causes of addiction remain the subject of ongoing debate and research, many experts now consider addiction to be a brain disease: a condition caused by persistent changes in brain structure and function. However, having this brain disease does not absolve the addict of responsibility for his or her behavior, but it does explain why many addicts cannot stop using drugs by sheer force of will alone.

Scientists may have come closer to solving the brain's specific involvement in addiction in 2004. Psychiatrists say they have found the craving center of the brain that triggers relapse in addicts. The anterior cingulated cortex in the frontal lobe of the brain is the area responsible for long-term craving in addicts. Knowing the area of the brain from which long-term cravings come may help scientists pinpoint therapies.

Social learning

Social learning is considered the most important single factor in addiction. It includes patterns of use in the addict's family or subculture, peer pressure, and advertising or media influence.

Availability

Inexpensive or readily available tobacco, alcohol, or drugs produce marked increases in rates of addiction.

Individual development

Before the 1980s, the so-called addictive personality was used to explain the development of addiction. The addictive personality was described as escapist, impulsive, dependent, devious, manipulative, and self-centered. Many doctors now believe that these character traits develop in addicts as a result of the addiction, rather than the traits being a cause of the addiction.

Diagnosis

In addition to a preoccupation with using and acquiring the abused substance, the diagnosis of addiction is based on five criteria:

• loss of willpower
• harmful consequences
• unmanageable lifestyle
• tolerance or escalation of use
• withdrawal symptoms upon quitting

Treatment

Treatment requires both medical and social approaches. Substance addicts may need hospital treatment to manage withdrawal symptoms. Individual or group psychotherapy is often helpful, but only after substance use has stopped. Anti-addiction medications, such as methadone and naltrexone, are also commonly used. A new treatment option has been developed that allows family physicians to treat heroine addiction from their offices rather than sending patients to methadone clinics. The drug is called buprenorphine (Suboxone).

Researchers continue to work to identify workable pharmacological treatments for various addictions. In 2004, clinical trials were testing a number of drugs currently in use for other diseases and conditions to see if they could be used to treat addiction. This would speed up their approval by the U.S. Food and Drug Administration (FDA). For example, cocaine withdrawal is eased by boosting dopamine levels in the brain, so scientists are studying drugs that boost dopamine, such as Ritalin, which is used to treat attention-deficit hyperactivity disorder, and amantadine, a drug used for flu and Parkinson's diease.

The most frequently recommended social form of outpatient treatment is the twelve-step program. Such programs are also frequently combined with psychotherapy. According to a recent study reported by the American Psychological Association (APA), anyone, regardless of his or her religious beliefs or lack of religious beliefs, can benefit from participation in 12-step programs such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). The number of visits to 12-step self-help groups exceeds the number of visits to all mental health professionals combined. There are twelve-step groups for all major substance and process addictions.

The Twelve Steps are:

• Admit powerlessness over the addiction.
• Believe that a Power greater than oneself could restore sanity.
• Make a decision to turn your will and your life over to the care of God, as you understand him.
• Make a searching and fearless moral inventory of self.
• Admit to God, yourself, and another human being the exact nature of your wrongs.
• Become willing to have God remove all these defects from your character.
• Humbly ask God to remove shortcomings.
• Make a list of all persons harmed by your wrongs and become willing to make amends to them all.

• Make direct amends to such people, whenever possible except when to do so would injure them or others.
• Continue to take personal inventory and promptly admit any future wrongdoings.
• Seek to improve contact with a God of the individual's understanding through meditation and prayer.
• Carry the message of spiritual awakening to others and practice these principles in all your affairs.

Prognosis

The prognosis for recovery from any addiction depends on the substance or process, the individual's circumstances, and underlying personality structure. Polydrug users have the worst prognosis for recovery.

Prevention

The most effective form of prevention appears to be a stable family that models responsible attitudes toward mood-altering substances and behaviors. Prevention education programs are also widely used to inform the public of the harmfulness of substance abuse.

Resources

BOOKS

Robert Wood Johnson Foundation. Substance Abuse: The Nation's #1 Problem. Princeton, N.J., 2001.

PERIODICALS

Kalivas, Peter. "Drug Addiction: To the Cortex … and Beyond." The American Journal of Psychiatry 158, no. 3 (March 2001).

Kelly, Timothy. "Addiction: A Booming $800 Billion Industry." The World and I (July 1, 2000).

Leshner, Alan. "Addiction is a Brain Disease." Issues in Science and Technology 17, no. 3 (April 1, 2001).

"A New Office-based Treatment for Prescription Drug and Heroin Addiction." Biotech Week (August 4, 2004): 219.

"Research Brief: Source of Addiction Identified." GP (July 19, 2004): 4.

"Scientists May Use Existing Drugs to Stop Addiction." Life Science Weekly (Sepember 21, 2004): 1184.

ORGANIZATIONS

Al-Anon Family Groups. Box 182, Madison Square Station, New York, NY 10159. 〈http://www.Al-AnonAlateen.org〉.

Alcoholics Anonymous World Services, Inc. Box 459, Grand Central Station, New York, NY 10163. 〈http://www.alcoholics-anonymous.org〉.

American Anorexia Bulimina Association. 〈http://www.aabainc.org〉.

American Psychiatric Association. 〈http://www.pscyh.org〉.

Center for On-Line Addiction. 〈http://www.netaddiction.com〉.

eGambling: Electronic Joural of Gambling Issues. 〈http://www.camh.net/egambling/main.html〉.

National Alliance on Alcoholism and Drug Dependence, Inc. 12 West 21st St., New York, NY 10010. (212) 206-6770.

National Center on Addiction and Substance Abuse at Columbia University. 〈http://www.casacolumbia.org〉.

National Clearinghouse for Alcohol and Drug Information. 〈http://www.health.org〉.

National Institute on Alcohol Abuse and Alcoholism (NIAAA). 6000 Executive Boulevard, Bethesda, Maryland 20892-7003. 〈http://www.niaaa.nih.gov〉.

Addiction

Addictions

Chemical addictions

The nonchemical addictions

The addict

Treatment of addiction

Resources

Addiction is a compulsion to engage in unhealthy or detrimental behavior. Human beings can become addicted to many forms of behaviors such as gambling, overeating, sex, or reckless behavior, but the term addiction is most commonly used to refer to a physiological state of dependence caused by the habitual use of drugs, alcohol, or other substances. Addiction is characterized by uncontrolled craving, increased tolerance, and withdrawal symptoms when deprived of access to the addictive substance. Addictions afflict millions of people in the United States each year.

The term addiction has been partially replaced by the term dependence for substance abuse. Addiction has been extended, however, to include mood-altering behaviors or activities. Some researchers speak of two types of addictions: substance addictions such as alcoholism, drug abuse, and smoking; and process addictions such as gambling, spending, shopping, eating, and sexual activity. Many addicts are addicted to more than one substance or process.

Addiction results from an incessant need to combat the negative side effects of a substance or situation by returning to that substance or situation for the initial enhancing effect. The desire for drugs such as heroin, cocaine, or alcohol all result from a need to suppress the low that follows the high. Other forms of addiction occur where seemingly harmless behaviors such as eating, running, or working become the focus of the addict’s life.

Addiction and addictive substances have long been a part of human culture. The use of alcoholic beverages, such as beer, was recorded by the ancient Egyptians. The Romans and other early civilizations fermented, drank, and traded in wine. The infamous opium dens of the Far East offered crude opium. The discovery of America was accompanied by the discovery of tobacco, grown by the indigenous population.

Addiction today, especially addiction to illegal drugs, takes a heavy toll on modern society. Illegal drugs are easy enough to obtain, but they have a high price. In order to get money to feed their addiction, some addicts resort to theft or prostitution. Aside from criminal damage, addiction disrupts families and other social institutions in the form of divorce, abuse (mental and physical), and neglect.

Addictions

There are two classifications for addiction: chemical (substance) and nonchemical (process). While dependency on substances that are ingested or injected is more commonly discussed, there are a number of non-chemical addictions that can lead to equally devastating lifestyles.

Chemical addictions

Chemical addiction is the general description for an addiction to a substance that must be injected or ingested. Alcohol, opiates, and cocaine are the most common of these chemicals. Though each of them is addictive, they have different effects on the body.

Addiction to alcohol, for example, may be the result of heavy drinking coupled with a malfunctioning type of cell in the liver of the alcoholic. Many adults can drink large quantities of alcoholic beverages and suffer only a hangover—headache and nausea. The malfunctioning liver in the alcoholic, however, does not detoxify the byproducts of alcohol ingestion rapidly. The resultant accumulation of a chemical called acetaldehyde causes several symptoms, including pain, which can be relieved by the intake of more alcohol. The consumption of ever-increasing amounts of alcohol with greater frequency can lead to organ failure and death if the alcoholic is left untreated.

Opium, produced by a species of poppy, is an ancient addictive substance that is still produced for its cash value. Although raw opium is not the form most addicts encounter, purified, powdered opium has been used in many forms for hundreds of years. Tincture of opium, or laudanum, was introduced in about the year 1500. Paregoric, a familiar household remedy today, dates from the early 1700s.

Heroin, a derivative of opium, has become a common addictive drug. Heroin is a powder dissolved in water and injected into the user’s vein, giving an immediate sensation of warmth and relaxation. Physical or mental pain is relieved, and the user enters a deeply relaxed state for a few hours. The powder can also be inhaled for a milder effect. Heroin is extremely addictive and with only a few doses the user is hooked. Morphine, a refinement of opium, was discovered in the early 1800s. It was first used as an effective analgesic, or painkiller, and it is still used for that purpose. Its fast action makes it a drug of choice to ease the pain of wounded soldiers during wartime. Morphine has one-fifth the addictive power of heroin.

Cocaine in its various forms is another class of addictive compounds. In fact, it is the most addictive of these drugs; some people need only a single exposure to the drug to become addicted. Cocaine is processed from the cocaplant and is used in the form of a white powder. It can be inhaled, ingested, injected, or mixed with marijuana and smoked. It is also further processed into a solid crystalline substance marketed as crack. Unlike the opiates, which bring on a warm feeling and immobility, cocaine makes its users energetic. This strong stimulation and period of hyper-activity (usually no more than half an hour) is quickly followed by a period of intense depression, fatigue, and paranoia. In order to relieve these harsh side effects, the user will typically retreat to taking more cocaine or using another drug, for example alcohol or heroin. Suicide is a common occurrence among cocaine addicts.

Any of these chemical substances can become the object of intense addiction. Addicts of the opiates and cocaine must have increasingly frequent doses to maintain their desired physiological effects. Soon the addict has difficulty focusing on anything else, making it nearly impossible to hold a job or maintain a normal lifestyle. These drugs are of economic importance not only because of their high cost, but also because of the crimes committed to obtain the cash necessary to buy the drugs. The drug enforcement resources dedicated to policing those crimes and the rehabilitation programs provided to the drug addicts are costly.

Some experts consider drinking large amounts of coffee or cola beverages evidence of an addiction to caffeine. In fact, these substances do provide a short-term mood lift to the user. The first cup of coffee in the morning, the midmorning coffee break, the cola at lunch, and the dinner coffee are habitual. Withdrawal from caffeine, which is a stimulant, can cause certain mood changes and a longing for additional caffeine.

Tobacco use is also addictive (due to the nicotine found in tobacco). Cigarette smoking, for example, is one of the most difficult habits to stop. Withdrawal symptoms are more pronounced in the smoker than in the coffee drinker. Reforming smokers are subject to swift mood swings and intense cravings for a cigarette. A long-time smoker may never overcome the desire for cigarettes.

Withdrawal symptoms are caused by psychological, physical, and chemical reactions in the body. As the amount of addictive chemical in the blood begins to fall, the urge to acquire the next dose is strong. The hard drugs such as heroin and cocaine produce intense withdrawal symptoms that, if not eased by another dose of the addictive substance or an appropriate medication, can leave the user in painful helplessness. Strong muscle contractions, nausea, vomiting, sweating, and pain increase in strength until it becomes extremely difficult for the user to stay away from the drug.

The nonchemical addictions

Addictions can involve substances or actions not including addictive chemicals. Some of these addictions are difficult to define and may seem harmless enough, but they can destroy the lives of those who cannot escape them.

Gambling is one such form of addiction, affecting 6 to 10% of the U.S. population in any given year, according to some experts. Gamblers begin as most others do, by placing small bets on horses or engaging in low-stakes card games or craps. Their successes are a form of ego enhancement, so they strive to repeat them. Their bets become larger, more frequent, and more irrational. Gamblers have been known to lose their jobs, homes, and families as a result of their activities. Their pattern is to place ever-larger bets to make up for their losses. Gamblers are difficult to treat because they refuse to recognize that they have an abnormal condition. After all, nearly everyone gambles in some form: on the lottery, horses, home poker games, or sporting events. Once a compulsive gambler is convinced that his or her problem is serious, an addiction program may be successful in treating the condition.

Food addiction can be a difficult condition to diagnose. Food addicts find comfort in eating. The physical sensations that accompany eating can become addictive, although an addict may not taste the food. Food addicts may indulge in binge eating— consuming prodigious quantities of food in one sitting, or they may consume smaller quantities of food over a longer period of time, but eat constantly during that time.

A food addict can become grossly overweight, leading to extremely low self-esteem, which becomes more pronounced as he or she gains weight. The addict then seeks comfort by eating more food, setting up a cycle that probably will lead to a premature death if not interrupted.

The opposite of addiction to eating is addiction to not eating. This addiction often starts as an attempt to lose weight and ends in malnutrition. Two common forms of this type of addiction, anorexia and bulimia, are typically associated with young females, although males and females of all ages may develop this disorder. Anorexia is a condition in which food is almost completely rejected. These addicts literally starve their bodies, consuming as little food as possible. Bulimia on the other hand, involves consuming large amounts of food uncontrollably until satisfied and then purging the food they took in as soon after eating as possible. Some experts claim that nearly 100 people each year in the United States die of malnutrition resulting from anorexia or bulimia. Others believe the number is much larger because the deaths are not recorded as anorexia or bulimia, but as heart failure or kidney failure, either of which can result from malnutrition.

Anorexia and bulimia are difficult to treat. In the minds of victims, they are bloated and obese even though they may be on the brink of starvation, and so they often resist treatment. Hospitalization may be required even before the official diagnosis is made. Treatment includes a long, slow process of psychiatric counseling.

The sex addict also is difficult to diagnose because normal sexual behavior is not well defined. Generally, any sex act between two consenting adults is condoned if neither suffers harm. Frequency of sexual activity is not used as a deciding factor in diagnosis. More likely the sex addict is diagnosed by his or her attitude toward sex partners.

Other compulsions or addictions include exercise, especially running. Running releases certain hormones called endorphins in the brain, giving a feeling of euphoria or happiness. This is the high that runners often describe. They achieve it when they have run sufficiently to release endorphins and have felt their effects. So good is this feeling that the compulsive runner may practice his hobby in spite of bad weather, injury, or social obligation. Because running is considered a healthful hobby, it is difficult to convince an addict that he is overdoing it and must temper his activity.

Codependency could also be regarded as an addiction, although not of the classical kind. It is a form of psychological addiction to another human being. While the term codependency may sound like a mutual dependency, in reality, it is very one-sided. A person who is codependent gives up their rights, individuality, wants, and needs to another person. The other person’s likes and wants become their own desires and the codependent person begins to live vicariously through the other person, totally abandoning their own life. Codependency is often the reason that women remain in abusive relationships. Codependent people tend to trust people who are untrustworthy. Self-help groups and counseling is available for codependents and provide full recovery.

Another form of addiction is addiction to work. No other addiction is so willingly embraced than that of a workaholic. Traits of workaholics are often the same traits used to identify hard workers and loyal employees. So, when does working hard become working too hard? When work becomes an addiction, it can lead to harmful effects in other areas of life, such as family neglect or deteriorating health. The individual drowns himself/herself in work to the point of shunning all societal obligations. Their parental duties and responsibilities are often handed over to the other spouse. The children are neglected by the parent and consequently end up having a poor relationship with the workaholic parent. Identifying the reason for becoming a workaholic and getting help, such as counseling, are key for overcoming this addiction.

Internet addictions are a new illness in society. The Internet is an amazing information resource, especially for students, teachers, researchers, and physicians. People all over the globe use it to connect with individuals from other countries and cultures. However, when the computer world rivals the real world, it becomes an addiction. Some people choose to commune with the computer rather than with their spouses and children. They insulate themselves from intimate settings and relationships. Internet abuse has been cited as a contributing factor in the disintegration of many marriages and families and even in the collapse of many promising careers. Since it is a relatively new disorder, few self-help resources are available. Ironically, there are some on-line support groups designed to wean people from the Internet.

The addict

Because addictive behavior has such serious effects on the health and social well being of the addict and those around him or her, why would anyone start? One characteristic that marks addicts, whether to chemicals or non-chemical practices, is a low sense of self esteem. The addict may arise from any social or economic situation, and there is no way to discern among a group of people who will become an addict and who will not.

It has been a basic tenet that the individual who uses drugs heavily will become addicted. However, soldiers who served in the Vietnam War (1959–1975) reported heavy use of marijuana and heroin while they were in the combat zone, yet the vast majority gave up the habit upon returning home. There are reports, however, of people becoming addicted to a drug with exposure only once or a few times.

Some experts believe people are born with the predisposition to become addicted. Children of addicts have a greater probability of becoming addicts themselves than do children whose parents are not. Thus, the potential for addiction may be hereditary. On the other hand, a psychological problem may lead the individual into addiction. The need for instant gratification, a feeling of being socially ostracized, and an inability to cope with the downfalls of life have all been cited as possible springboards to addiction.

Treatment of addiction

Habitual use of an addictive substance can produces changes in body chemistry and any treatment must be geared to a gradual reduction in dosage.

KEY TERMS

Detoxification —The process of removing a poison or toxin from the body. The liver is the primary organ of detoxification in the body.

Endorphins —A group of natural substances in the brain that are activated with exercise. They bind to opiate receptors and ease pain by raising the pain threshold. Of the three types, alpha, beta, and gamma, beta is the most potent.

Opiate —Any derivative of opium (e.g., heroin).

Opium —A natural product of the opium poppy, Papaver somniferum. Incising the immature pods of the plant allows the milky exudate to seep out and be collected. Air-dried, this is crude opium.

Initially, only opium and its derivatives (morphine, heroin, codeine) were recognized as addictive, but many other drugs, whether therapeutic (for example, tranquilizers) or recreational (such as cocaine and alcohol), are now known to be addictive. Research points to a genetic predisposition to addiction; although environment and psychological make-up are other important factors and a solely genetic basis for addiction is too simplistic. Although physical addiction always has a psychological element, not all psychological dependence is accompanied by physical dependence.

Addiction of any form is difficult to treat. Many programs instituted to break the grip of addictive substances have had limited success. The cure depends upon the resolve of the addict, and he or she often struggles with the addiction even after treatment.

A careful medically controlled withdrawal program can reverse the chemical changes of habituation Trying to stop chemical intake without the benefit of medical help is a difficult task for the addict because of intense physical withdrawal symptoms. Pain, nausea, vomiting, sweating, and hallucinations must be endured for several days. Most addicts are not able to cope with these symptoms, and they will relieve them by indulging in their addiction.

The standard therapy for chemical addiction is medically supervised withdrawal, along with a 12-step program, which provides physical and emotional support during withdrawal and recovery. The addict is also educated about drug and alcohol addiction. Stopping (kicking) a habit, though, is difficult, and backsliding is frequent. Many former addicts have enough determination to avoid drugs for the remainder of their lives, but research shows that an equal number will take up the habit again.

See also Alcoholism; Amphetamines; Barbiturates.

Resources

BOOKS

Daley, Dennis C. Addiction and Mood Disorders: A Guide for Clients and Families. Oxford, UK, and New York: Oxford University Press, 2006.

Doweiko, Harold E. Concepts of Chemical Dependency. Pacific Grove, CA: Thomson-Brooks/Cole, 2006.

Frances, Richard J., Sheldon I. Miller, and Avram H. Mack, eds. Clinical Textbook of Addictive Disorders. New York: Guilford Press, 2005.

Freimuth, Marilyn. Hidden Addictions. Lanham, MD: Jason Aronson, 2005.

Kirke, Deirdre M. Teenagers and Substance Use: Social Networks and Peer Influence. Basingstoke, UK, and New York: Palgrave Macmillan, 2006.

Kuhn, C., S. Swartzwelder, and W. Wilson. Just Say Know. New York: W.W. Norton & Co., 2002.

OTHER

Substance Abuse and Mental Health Services (SAMSHA), an agency of the United States Department of Health and Human Services. <http://www.samhsa.gov/> (accessed November 27, 2006).

Larry Blaser

Addiction

For most of the twentieth century, cigarette smokers counted in the millions and smoking was regarded as a willful behavior. Health care practitioners did not view smoking as a drug addiction, nor was it considered a major cause of premature death. A drastic change in thinking occurred during that century, and smoking was viewed in a new light by the dawn of the twenty-first century.

An explosion of research on the effects of nicotine took place during the last quarter of the twentieth century that profoundly changed how the health care field viewed tobacco products. The leading force was an overwhelming scientific base, which proved the deadly and addictive effects of tobacco beyond deniability even by the tobacco industry itself. The United Nation's World Health Organization (WHO) led the development of a Framework Convention treaty to control tobacco use and tobacco-caused diseases. Two driving motivations of the WHO Framework Convention provoked this change: the recognition that nicotine was an addicting drug and that tobacco addiction would lead approximately one-half of the world's more than 1 billion tobacco users to premature death. The WHO views addiction to nicotine as a powerful biological force that needs to be countered by powerful social, medical, and public health forces.

Why is tobacco recognized as an addicting substance? How do tobacco products compare to other addicting substances in their addicting power? Could nicotine-addicted tobacco users reduce their risk of disease without giving up nicotine? These are some of the key questions being addressed by governments around the world, regulatory agencies such as the U.S. Food and Drug Administration, and the United Nations through the WHO.

History of Nicotine Science

Ludwig Reimann and Wilhelm Heinrich Posselt, chemists at the University of Heidelberg, first isolated nicotine from the tobacco plant in 1828. It was quickly discovered that nicotine was a potent and powerful chemical that could be absorbed through the skin, which made it an effective pesticide that is still used around the world. By the 1890s John Langley, a physiologist at the University of Cambridge, began a series of studies on nicotine that covered three decades and generated discoveries profoundly important to understanding nicotine actions as well as how the nervous system works. His research showed that nicotine produced strong effects on the nervous system that were transmitted through what he termed "receptive substances" on nerves, known simply as "receptors." His studies showed that the strength of the effect was closely related to the amount administered (the "dose"); that repeated dosing led to weaker effects ("tolerance"); and that the effects could be countered by other chemicals such as curare ("antagonists"). This pioneering research on nicotine helped lay the foundation for modern research techniques with other nerve acting agents including morphine, cocaine, and drugs used to treat various psychiatric disorders and muscle diseases.

Many observers of behavior (writers, psychologists, religious leaders) documented tobacco's power to lead some of its users to habitual behavior. Understanding tobacco as a truly addicting substance similar to morphine or cocaine, however, developed slowly, and understanding nicotine was a key finding in this discovery. Louis Lewin's classic analysis of addicting drugs, Phantastica (University of Berlin, 1924) concluded that "the decisive factor in the effects of tobacco, desired or undesired, is nicotine." Lewin's conclusions fueled decades of investigations that ultimately confirmed his conclusions that nicotine was a critical determinant not only in the effects of tobacco but of why people used tobacco and of the difficulty in giving up tobacco. His ideas were a source of motivation for considerable subsequent research and further theory although scientific confirmation of his theory was not established until the 1980s.

NICOTINE RESEARCH AND ADDICTION. The path to confirmation was complicated, however, by evolving concepts of what defined addicting drugs. During the 1940s and 1950s, WHO reports highlighted the personality disorders of some individuals vulnerable to addictions, and how tranquilizing agents (such as morphine) and intoxicants (such as alcohol) produced addiction. Easily observable and powerful withdrawal symptoms, such as the flu-like symptoms of morphine withdrawal and convulsions from alcohol withdrawal, were also assumed to be hallmarks of addicting drugs. Cocaine addiction did not fit these symptoms but it was recognized as addicting in part because the pure drug was sought by people who were exposed and who had no apparent medical need except that the drug itself seemed to fuel powerfully persistent use in some of those who were exposed.

By contrast, many if not most users of tobacco were upstanding citizens who did not have personality disorders; experience intoxication with nicotine (although it could occur in first-time users or in over-dose); or show readily apparent signs of withdrawal (the withdrawal syndrome was assumed to be psychological in nature until the studies of the 1970s and 1980s, which confirmed physical and psychological components). Finally, although few challenged Lewin's core conclusions, the absence of evidence that pure nicotine would substitute for tobacco or be sought by users left in doubt the conclusion that nicotine was truly addicting. Even the landmark 1964 report of the U.S. Surgeon General on smoking and health, which concluded that cigarette smoking caused cancer, stated that smoking was most appropriately categorized as a habitual behavior not as drug addiction.

An explosion of research on the effects of nicotine took place during the 1970s and 1980s and continues to the 2000s. These studies confirmed that in compulsive users, the strength of the addiction and difficulty in quitting could be as strong for cigarettes as for heroin or cocaine. Studies of nicotine absorption revealed that the cigarette did for nicotine what crack did for cocaine, namely, provide a portable means of producing tiny but explosively fast spikes of drug in the brain that set off a cascade of biological effects that the smoker wanted to repeat. Other studies showed that there was a nicotine withdrawal syndrome that involved impairment of mental functioning, nicotine craving, and other symptoms. This work contributed to the development of objective standards by major health organizations, including the World Health Organization, for diagnosing the tobacco addiction–related disorders, which were technically termed "withdrawal" and "dependence." Basic research studies mapped the actions of nicotine in the brain and showed that nicotine could produce powerful changes in brain function. Similar to cocaine and morphine, nicotine produces the entire range of physical and behavioral effects characteristic of addicting drugs. These effects include activation of brain reward systems that create behavioral effects and physiological cravings that lead to chronic drug use, tolerance and physical dependence, and withdrawal upon discontinuation.

Research on nicotine showed that it was possible to become addicted to pure nicotine, which led to the development of nicotine-delivering medicines, such as chewing gum containing nicotine and nicotine patches, to relieve withdrawal symptoms and make it easier to quit smoking. Thus, the scientific understanding of nicotine and tobacco as well as the concept of addiction changed during this productive period, which culminated in the 1988 report of the U.S. Surgeon General, The Health Consequences of Smoking. This report concluded that cigarettes were addicting; nicotine was the drug that caused addiction; and the underlying processes were similar to those that determined addiction to other drugs such as heroin and cocaine. These conclusions had radical implications for public health efforts to prevent tobacco use, medical efforts to help people quit smoking, and regulatory efforts to control the sale, distribution, and advertising of tobacco products.

Cigarettes: The Most Addicting Form of Nicotine

All tobacco products deliver addicting levels of nicotine and can lead to addictive patterns of use. The risk of addiction, however, varies across tobacco products. Oral smokeless products such as snuff and chewing tobacco do not produce as rapid an effect on the brain as cigarette smoke inhalation. In similar fashion, although many cigar and pipe smokers become addicted, these tobacco products are generally taken up later in life, are less likely to be inhaled, and lead to somewhat muted effects. The overall risk of addiction from these products is lower when compared to cigarettes. Speed of delivery is most remarkable with cigarettes, which both require and reinforce smoke delivery to the lung with nicotine "hits" to the brain within seven seconds.

The modern cigarette is a technological, albeit addictive and deadly, marvel from the perspective of engineering and pharmacology. It delivers a chemical cocktail of substances and is designed to be maximally addicting through this combination of chemicals. Other design features increase the ease and acceptability of obtaining high daily doses of nicotine. The tobacco industry recognized and took advantage of its knowledge of the impact of cigarette designs and ingredients and their effects on smokers. By the 1950s it was actively engaged in its own highly confidential research on topics such as the effects of nicotine on the nervous system and hormone regulation, how to manipulate the nicotine dosing capacity of cigarettes, and how to increase nicotine absorption efficiency. Its knowledge and efforts, however, were not extensively revealed until the 1990s by investigations of government agencies and lawyers who were suing the tobacco industry. Documentation of these studies was then posted on the Internet and today is readily accessible worldwide. Among the tobacco industry's documents is the following conclusion about the fundamental nature of the cigarette from a 1972 report by a leading scientist at Philip Morris Tobacco Company, Dr. William Dunn:

The cigarette should be conceived not as a product but as a package. The product is nicotine. Think of a cigarette as a dispenser for a dose unit of nicotine. Smoke is beyond question the most optimized vehicle of nicotine and the cigarette the most optimized dispenser of smoke (Hurt and Robertson).

Scientific studies have made it clear that the cigarette has many characteristics that make it such a powerfully addicting form of nicotine. Compared to a cigar, because the cigarette is a small package of nicotine, it must be used often, putting the user on a nicotine "roller coaster" that must be constantly refueled by hundreds of daily tiny puffs. This contributes to powerfully conditioned behavior in the user that can become inextricably entwined with nearly every aspect of the user's life.

The modern cigarette is more than simply a package of nicotine. It is a highly engineered device that employs state-of-the-art drug delivery technology, engaging physicists who specialized in topics such as drug dosage controls and the physics of smoke particles and other aerosols, combustion technology, and a combination drug delivery system to provide an extraordinarily addictive form of nicotine. Physicists working with tobacco companies helped them to develop cigarettes in which the size of smoke particles was controlled to be of the optimal 0.5- to 1-micron median diameter to allow deeper penetration into the lung. Chemists helped to develop concoctions with substances such as menthol and propylene glycol to sooth the throat and reduce the irritant effects that might prevent deep inhalation. Pharmacologists helped to understand and develop the balance of ingredients and processing materials to provide more explosively addictive forms of nicotine that were devoid of the electrical charge that so-called ionized nicotine molecules carry in their naturally occurring state. This yielded a non-ionized form of nicotine more commonly called "free-base" nicotine, which was more efficiently carried from the cigarette to the bloodstream. There can be no doubt that the modern cigarette has been designed to be the most addicting form of nicotine delivery.

LOW-TAR OR "LIGHT" CIGARETTES. The conclusion of the 1964 Surgeon General's report—that cigarettes caused lung cancer and that cancer risk was roughly proportional to the amount of smoking—led the Surgeon General to advocate for reduced levels of tar from cigarettes. Although there was no conclusive evidence that nicotine caused cancer, lower levels of nicotine were also encouraged because of the then-suspected role of nicotine in other illnesses such as heart disease. This led to a system of testing cigarettes for tar and nicotine levels known as the Federal Trade Commission (FTC) method in the United States and the International Standards Organization (ISO) method in most other countries. The method involved testing cigarettes in smoking machines programmed to take relatively small and infrequent puffs comparable to the behavior of most smokers.

The tobacco companies quickly learned to modify their cigarettes to produce much lower levels of tar and nicotine delivery but to enable smokers to continue to obtain high levels of tar and nicotine when they smoked cigarettes. The technology was sophisticated and extensive, and included features such as burn accelerants to make the cigarettes burn faster in smoking machines and hidden air vent holes that diluted the smoke in the machines but could be unknowingly blocked by the smoker's lips or fingertips. The end result, as documented by the U.S. National Cancer Institute in a 2001 landmark report on "light" cigarettes, was that low tar or "light" cigarettes did not reduce disease risk. The report concluded that the problems involved two major findings: (1) the design of the cigarette enables smokers to easily get much higher doses of tar than implied by the FTC or ISO tests; and (2) the powerful biological drive of addiction led smokers to inhale more smoke if it was diluted with air or lower in tar and nicotine content.

Treating Nicotine Addiction to Reduce Cancer and Other Diseases

The understanding that nicotine addiction drives the process of tobacco use has been met by safer ways of satisfying and treating the addiction. For example, some people can be counseled to gradually reduce their dependence on nicotine and thus break the addiction over time, that is, typically a few months. Others can be treated with nicotine-delivering medicines (chewing gum, skin patch, inhaler). Most people who quit smoking using this method usually discontinue the medicine within two to three months of use of the medicines. By the 1990s medicines delivering nicotine were available in several forms including chewing gum, skin patch, nasal spray, and lozenge. Also by the 1990s medicines that did not contain nicotine were recognized as effective including clonidine, nortriptyline, and bupropion. The dawn of the twenty-first century witnessed yet new generations of medicines including vaccines intended to keep former smokers from going back to smoking by preventing nicotine from getting to the brain in those who tried to resume smoking.

Some people, however, appear unable to discontinue nicotine use. Finding safer ways other than smoking to feed their addiction may be lifesaving. Thus, although not advocated by the pharmaceutical companies that make nicotine-delivering medicines, many health professionals recommend that these smokers continue to use nicotine gum or patches as long as needed to remain abstinent from tobacco.

International public health organizations recognize that many people will be unable to give up their addictions completely and that tobacco products should be made as low in actual harmfulness as possible. The international Framework Convention for Tobacco Control includes articles that could lead to the genuine reduction of the toxicants in tobacco products through government regulation and thus to reduced disease risk in people who do continue to use tobacco. However, public perception that smoking regulated cigarettes might be less hazardous may discourage some smokers from quitting, ultimately leading to a net increase in tobacco-related disease and death. These efforts may take decades to implement and have not yet been proven effective. Therefore, for many years to come the most reliable way to reduce tobacco-caused death and disease will be to address the addiction with a nontobacco delivery system, and ultimately to achieve complete nicotine and tobacco abstinence.

See Also Chemistry of Tobacco and Tobacco Smoke; Chewing Tobacco; Cigarettes; Documents; "Light" and Filtered Cigarettes; Nicotine; Product Design; Psychology and Smoking Behavior; Quitting Medications; Snuff.

▌ JACK E. HENNINGFIELD
▌ PATRICIA B. SANTORA

BIBLIOGRAPHY

Hurt, R. D., and C. R. Robertson. "Prying Open the Door to the Tobacco Industry's Secrets about Nicotine: The Minnesota Tobacco Trial." Journal of the American Medical Association 280 (1998): 1173–1181.

Kessler, David A. A Question of Intent: A Great American Battle with a Deadly Industry. New York: Public Affairs, 2001.

Kluger, Richard. Ashes to Ashes: America's Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris. New York: Vintage, 1997.

Kozlowski, Lynn T., Jack E. Henningfield, and Janet Brigham. Cigarettes, Nicotine and Health: A Biobehavioral Approach. Thousand Oaks, Calif.: Sage Publications, 2001.

U.S. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Online. Available: <http://www.cdc.gov/mmwr>.

U.S. Department of Health and Human Services. The Health Consequences of Smoking: Nicotine Addiction: A Report of the Surgeon General. Washington, D.C.: Government Printing Office, 1988.

physiology the study of the functions and processes of the body.

snuff a form of powdered tobacco, usually flavored, either sniffed into the nose or "dipped," packed between cheek and gum. Snuff was popular in the eighteenth century but had faded to obscurity by the twentieth century.

menthol a form of alcohol imparting a mint flavor to some cigarettes.

tar a residue of tobacco smoke, composed of many chemical substances that are collectively known by this term.