Challenging the Received Wisdom on Tobacco Addiction

What does it take to get hooked on nicotine?

--Smokers who smoke five or fewer cigarettes per day can still become addicted to tobacco.

--Tobacco addiction can also be present in non-daily smokers.

--Nicotine withdrawal symptoms do not necessarily begin within 24 hours.

These and other controversial assertions come from Joseph R DiFranza, a physician with the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. Dr. DiFranza recently authored a provocative examination of smoking truisms in an article for the online publication Harm Reduction Journal.

In an attack on what he calls the Threshold Model of Addiction, DiFranza defines the model as follows:

In brief, the threshold model maintains that until tobacco consumption is maintained above a threshold of 5-10 cigarettes per day (cpd) for a prolonged period, smokers are free of all symptoms of tobacco addiction. It holds that declining blood nicotine levels trigger withdrawal symptoms so quickly that addicted smokers must protect their nicotine levels by smoking at least 5 cpd. The threshold model states that until addiction is established with moderate daily smoking, smoking is motivated and maintained by peer pressure, pleasure seeking and the social rewards of smoking.

DiFranza breaks this prevailing paradigm into a half-dozen hypotheses, offering his opinion on the state of scientific evidence that, in his view, refutes every one of them:

--Hypothesis 1. Tobacco addiction cannot occur in nondaily smokers, or even in daily smokers who regularly consume fewer than 5 cpd.

DiFranza’s response:   “Although it is difficult to prove a negative, this hypothesis would be supported if study after study demonstrated that all surveyed subthreshold smokers (individuals who smoke < 5 cpd) have no symptoms of addiction…. Since no studies have demonstrated a complete lack of addiction symptoms in any representative population of subthreshold smokers, the peer reviewed literature soundly refutes the hypothesis that tobacco addiction requires as a prerequisite the daily consumption of 5-10 cigarettes. The threshold model and the DSM are wrong. “

--Hypothesis 2. Tobacco addiction requires prolonged daily use as a prerequisite.

Response: “Many subjects developed symptoms quite soon after the onset of intermittent tobacco use. These findings have been replicated in several longitudinal studies, in cross-sectional studies showing symptoms of addiction in nondaily smokers, and by case histories showing the same.”

Hypothesis 3. Nicotine withdrawal symptoms begin within 24 hours in all smokers.

“The standard subject in all early smoking studies was an adult who had been a heavy daily smoker for decades. Such individuals do experience nicotine withdrawal soon after their last cigarette. A problem arises when this observation is inappropriately generalized by applying it to all smokers, including children, novices and nondaily smokers.”

Hypothesis 4. Addicted smokers must maintain nicotine above a threshold blood concentration to avoid withdrawal.

“Since a person must smoke at least 5 cpd to maintain a minimum nicotine level throughout the day, another approach to testing this hypothesis would be to determine if all smokers that experience withdrawal symptoms smoke at least 5 cpd. This test has been completed over a dozen times, and always with the same result. Withdrawal symptoms have been reported in smokers of fewer than 5 cpd in every study that has examined this issue.”

Hypothesis 5. Psychosocial factors maintain smoking over the several years it may take to reach threshold levels of smoking.

“There must be thousands of studies that demonstrate that social factors such as socioeconomic status, smoking by family and friends, cigarette advertising, the availability of cigarettes, smoking depictions in movies, and attitudes and beliefs are predictive of which youth will try smoking. However, if such factors sustain tobacco use until tobacco addiction develops, they should predict which smokers will advance to addiction in prospective studies. But this has not been shown. None of more than 40 psychosocial risk factors for the onset of smoking was able to predict the progression to tobacco addiction. The author is aware of no studies that establish that peer pressure of other social factors sustain adolescent or young adult smoking over the 4 or 5 years it may take for smokers to reach threshold levels of smoking. “

Hypothesis 6. Increasing tolerance to the pleasurable effects of smoking drives the escalation in tobacco use up to the threshold of addiction.

“The author is not aware of any studies that demonstrate that smokers must smoke more cigarettes over time to obtain the same amount of pleasure (for example smoking 10 cpd to obtain the same pleasure initially obtained from smoking 1 cpd. Indeed, our data indicate that the pleasure obtained from smoking each cigarette actually increases in proportion to the degree of addiction, with pleasure ratings correlating strongly with addiction severity. While this is only one study, it directly contradicts the hypothesis that non-addicted novice smokers obtain much more pleasure from each cigarette than do addicted heavy smokers.”

Photo Credit: http://nikotin.floridadmat.com/

Tobacco Settlement Turned Upside Down

“Tobacco bonds” link state budgets to cigarette sales.

Bob Sullivan of MSNBC reports that ten years after a group of states wrestled Big Tobacco to its knees in a $200 billion settlement, the creation of “tobacco bonds” by Wall Street has allowed investors and state governments to borrow against their future tobacco settlement payments. The result? Money that was to be paid out over the next thirty years for smoking cessation programs is being redirected into infrastructure projects and shoring up municipal credit.

“A review of 660 leading bond funds covered by the investment research firm Morningstar Inc., conducted at msnbc.com’s request, showed that more than 260 are invested in tobacco bonds,” Sullivan writes on his blog, The Red Tape Chronicles.

What, you may well ask, are tobacco bonds, and where did they come from? “Perhaps from you,” Sullivan writes. “When Wall Street talked 25 states into borrowing against future tobacco payments—a process known as ‘securitization’—it sold bonds to individual investors and mutual funds that buy municipal bonds.”

The irony of that approach, says Sullivan, is that “because these states have essentially borrowed against future payments from the tobacco industry, they are now dependent on the continued vitality of cigarette sales. If Big Tobacco stumbles, states will be on the hook for these massive, billion-dollar loans.” As a lawyer involved in litigation over the tobacco settlement put it to Sullivan: “Now [the states] have an incentive not to put tobacco out of business.” More than that, any significant failure by the tobacco industry to make its payments would be “catastrophic both to state budgets and individual investors.”

It wasn’t supposed to be this way. But the settlement from the lawsuit designed to blow up Big Tobacco was just too attractive to investment bankers. Sullivan notes that Oppenheimer’s Rochester family of bond funds includes funds with up to 20 per cent of assets held in tobacco bonds. The lure to the states was that, rather than waiting for the money, they could opt for an attractive lump sum payment up front. And many states did just that.

The problem, according to a tobacco policy researcher quoted on Sullivan’s blog, is that “the states have this horribly naive view that they will outsmart Wall Street. Wall Street always gets the better deal.” Many states have settled for a payout of 50 cents on the dollar, plus additional insurance fees against the risk of tobacco companies going out of business.

Eric Lindblom, a director of the Campaign for Tobacco-Free Kids, told Sullivan: “There is a horrible failure of the states to invest even a minuscule amount of the funds for tobacco control. It’s a real tragedy for our country.”

Roughly 3 per cent of tobacco settlement money has been paid out for smoking cessation efforts over the decade since the settlement, Sullivan writes.

Photo Credit: www.treasury.state.la.us

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