On this blog I tend to talk about opiate addiction more than any other kind, mostly because opiate-addicted patients are the ones I most often see and treat. Of course, we can still learn from other kinds of addiction — in fact, if we really want to look at a powerful model for the disease of addiction, we need to look back at the gold standard: smoking.
There is very little actual advantage to smoking a cigarette, not in the way that there is for other drugs. It does not give you a lasting or euphoric high; it is not a great way to party or relax after hard week at work; it does not have nearly the psychoactive effect of any other typically abused drug. It can be a social activity, but more and more restaurants, hotels, and even public parks and bars have been banning smoking in recent years; smoking is becoming less and less feasible as a means of social connection, like alcohol is. The nicotine itself, apart from its addictive effects, provides a minimal amount of relaxation or stimulation (depending on how it is smoked) that literally lasts only for seconds.
So why do people smoke, and why do they continue to smoke after it becomes costly, inconvenient, and even life-threatening? The answer, of course, is because of nicotine’s addictive effect on the brain’s reward system. People become so addicted to this short-lived effect that they find it necessary to reproduce it hundreds of times per day. A one-pack-per-day smoker is smoking 20 cigarettes each day, perhaps taking between 10 to 15 puffs per cigarette. That equals 200 to 300 hits per day. The effect on the brain of a single hit of nicotine lasts about 4 seconds. 250 hits per day gives 1000 seconds, or slightly less than 17 minutes of nicotine-stimulated brain activity per day. If someone smokes their one pack a day over a typical 16 hours of being awake, each day they are providing nicotine to the brain for only 2% of their waking hours.
Now think about the cost that society and individuals pay for this addiction in years of life lost due to cancers, chronic lung disease, premature heart disease, etc. On average, smokers die 13 to 14 years earlier than nonsmokers. (You can check out some of the tobacco statistics here.)
Smokers are exactly like anyone addicted to any other drug. They aren’t weak, and they aren’t bad people. To non-addicts, it looks like they are constantly, continuously making an irrational choice, but that’s not the case. Their brains have simply become so dependent on those little bursts of nicotine that it is incapable of putting any long-term health or financial consequences before getting the next hit. The very fact that it’s not so obviously harmful, and that it generally takes years to start showing negative health consequences, allows smoking to escape a great deal of the stigma of other addictive drugs. While it’s true that no addict should be stigmatized for their illness, that also doesn’t mean that smoking should get a pass, or be considered ‘not a problem’, when it can be just as powerful a controlling force in an addict’s life as a stronger opiate.
Cigarette smoking is less extravagantly destructive than heroin or methamphetamine, but it follows the same pattern of all other addiction. These are all different forms of a single disease. Our current scientific advances in the treatment of addiction notwithstanding, the best way of dealing with addictions is still with education and prevention, so that they never start in the first place.