Where there's smoke, there's desire

On April 14, 1994, Representative Henry Waxman, chair of the Committee on Energy and Commerce, presided over the Subcommittee on Health and the Environment's Hearing on the Regulation of Tobacco Products. For the first time ever, the chief executive officers of the nation's tobacco companies were testifying together before the U.S. Congress. At that hearing, seven tobacco companies' CEOs, one right after the other, swore under oath, “I believe that nicotine is not addictive.”¹ I actually burst out laughing while watching the evening news when I saw this 7-man executive club raise their collective right hands and, without hesitation, make this claim before a Congressional committee. Where was Representative Joe Wilson and his “You lie!” shout-out during Obama's health care speech in 2009 when we really needed him? I would be a hypocrite if I didn't tell you now that at the time of the Congressional hearing, I smoked more than a pack of cigarettes a day. I knew something the tobacco CEOs apparently didn't – I was addicted to nicotine.

I volunteer at a local food kitchen, and the other day, while a fellow volunteer and were chatting, we saw that two of the people waiting in line for food had stepped outside to have a cigarette. My friend said, with undisguised disgust, “Would you look at that. They're here for free food and they're out there smoking. How much is a pack of cigarettes these days? Six dollars? Seven dollars? They'd rather smoke than feed their kids?”

Sometimes, there's nothing more annoying than a righteous nonsmoker. I know that I'm not going to gain much sympathy from anyone by saying that I think that smokers are misunderstood. However, I believe that we, as clinicians, need to rethink our approach to talking with our patients who smoke. There isn't a smoker alive who doesn't know the negative consequences of smoking. Smoking is far more than just a bad habit; if it were just a habit, it would be a lot easier to quit. We need to look at smoking for what it truly is – a powerful addiction. The patient is an addict, and the drug is nicotine.

Perhaps reviewing the medical definition of addiction will help us to see if it applies to smoking. This definition is based on the of American Psychiatric Association (DSM-IV) and the World Health Organization (ICD-10) criteria.² The following is a list of 7 questions, some with several parts. I've modified the questions slightly to make them specific to smoking. If an individual answers “yes” to at least 3 of these questions, then he/she meets the medical definition of addiction. Imagine the grip an addiction has on individuals who answer “yes” to all 7 questions!

1. Tolerance. Has your use of cigarettes increased over time?

2. Withdrawal. When you stop smoking, have you ever experienced physical or emotional withdrawal?

3. Difficulty controlling your use. Do you sometimes smoke more or for a longer time than you would like?

4. Negative consequences. Have you continued to smoke even though there have been negative consequences to your mood, health, job, or family?

5. Neglecting or postponing activities. Have you ever put off or reduced social, recreational, work, or household activities because of your smoking?

6. Spending significant time or emotional energy. Have you spent a significant amount of time concealing your smoking or planning on when to smoke? Have you spent a lot of time thinking about smoking? Have you ever concealed or minimized your smoking? Have you ever thought of schemes to avoid getting caught smoking?

7. Desire to cut down. Have you sometimes thought about cutting down or controlling your smoking? Have you ever made unsuccessful attempts to cut down or control your smoking?

In the early 1990s, Fiore introduced the concept of the fifth vital sign; that is, considering a patient's smoking status along with blood pressure, pulse, temperature, and respiratory rate.³ This approach provides an important opportunity to gain information at each patient visit about the patient's tobacco status and an opportunity to promote smoking cessation. Quitting smoking is certainly one of the most beneficial lifestyle changes patients can make. Of course, using the “addiction model” may not be appropriate for all patients. Yet, thinking about smoking within the context of serious addiction demonstrates not only the gravity of the problem but also the importance of having greater understanding and compassion for how very difficult it is to quit an addiction.

For the record, after several unsuccessful attempts, I quit smoking approximately 17 years ago. Every once in awhile, I still have dreams that I am smoking; I panic, realizing that I have to start the quit process all over again. Yet, upon awakening, although much relieved, if I had known it was just a dream, I would have smoked the whole darn thing. Other ex-smokers always nod their heads and laugh when I tell them that experience. They've been there, too.

REFERENCES

1. Inside the tobacco deal. FRONTLINE online.

2. The definition of addiction. ADDICTIONSandRECOVERY.org.

3. Fiore MC, Jorenby DE, Schensky AE, et al. Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke. Mayo Clin Proc. 1995;70:209-213.