Koop Focuses on Addiction and Nicotine

A coming report by U.S. Surgeon General C. Everett Koop that will label tobacco as one of the most addictive of drugs will constitute perhaps the most sweeping indictment of smoking in more than 20 years, experts familiar with it say.

The report, to be released Monday, is expected to lead to even greater ostracism of smokers, these experts believe, but will probably not result in tobacco prohibition.

Using a wide range of studies--some previously publicized and some new--the Koop report, the annual statement on the subject by the nation’s top health officer, builds such a thorough case for equating the addictive potential of nicotine with cocaine and heroin, researchers who have seen it say, that some believe the volume may end up being a major reference work and one joked that the same point could have been made in about half the length of the book Koop will release.

Key Studies Noted

Among resources on which the report draws at least in part, according to experts who either conducted the research or contributed directly to the Koop report, are these studies:

--In one series of experiments between 1981 and 1982 at the federal government’s Addiction Research Center in Baltimore, Dr. Steven Goldberg induced monkeys to inject themselves with nicotine and cocaine. The research found that the animals were equally desperate in their attempts to get at supplies of both drugs.

--In another study completed in about 1985 at the University of Vermont College of Medicine, Dr. John Hughes found that withdrawal symptoms--central to any definition of addiction--are in many ways stronger and more long-lasting in smokers than in hard-core junkies. Hughes found that tobacco addicts suffer from withdrawal for from two to six weeks--in contrast to a matter of a few days for many narcotics addicts.

--In still other research, at the Addiction Research Foundation in Toronto, more than 700 people who checked themselves in for treatment of hard drug habits were asked a series of questions last year comparing their cravings for tobacco with those for narcotics. A third of the subjects said it was “much harder” to kick tobacco addiction than heroin, alcohol or cocaine and another 24% said it was “a little” more difficult. A third said the drug craving for nicotine was stronger than alcohol or other drugs of abuse and 29% said nicotine and other drugs were equal.

Raw Addictive Potential

Charles Schuster, a former University of Chicago cocaine abuse researcher who now heads the government’s National Institute on Drug Abuse, said the research projects together have confirmed that, in terms of raw addictive potential, there is no difference between tobacco and traditionally illicit drugs.

“I think that, although the addictive properties of tobacco have been recognized, only in the last few years has there been clear-cut experimental evidence (from which the addictive properties) have become well substantiated,” Schuster said. “It is possible to show that smokers who receive nicotine intravenously show the same type of subjective behavior effects as they would if they’d received other addictive drugs.

“Studies of nicotine simply fail to discriminate between it and many of the other drugs of abuse. I would put them in the same category.

“One of the biggest problems that we have about this is that we have a system in the United States whereby tobacco has been well advertised and glamorized and it’s very difficult to talk about tobacco dependence independent of these kinds of social factors. Thank God we have not had similar advertisement about cocaine or heroin or other drugs.”

Substitution Therapy

Dr. Murray Jarvik, a UCLA psychopharmacology researcher who is a co-author of one of the chapters in the report, said nicotine has proven as frustrating for treatment scientists as other common addictions. Like heroin, Jarvik said, only substitution therapy--in which nicotine chewing gum is substituted for smoking--has been significantly successful, drawing an inevitable comparison to heroin, for which substitution of the synthetic narcotic methadone is a common therapy.

But Jarvik said the physical severity of withdrawal from tobacco is not as potentially catastrophic as it may be from the other commonly misused drugs. “They’re all different,” Jarvik said. “The only thing they’ve got in common is there is a strong dependence.

“I think (withdrawal) is the hallmark of addiction or dependence. But in a sense, addiction is a buzzword. It isn’t very clearly defined.

“You can go to an Alcoholics Anonymous meeting and they’re all smoking. In that sense, it seems to be a more difficult habit to break. But is it physiological or psychological? I don’t know.”

“I think the public has perhaps appreciated nicotine’s dependence potential for a lot longer than the scientific community,” said Dr. Jerome Jaffe, head of the Addiction Research Center. “There were people who knew they were hooked on nicotine at a time when the majority of scientists were unwilling to even think about that in a serious way,” Jaffe said.

He said a key obstacle to judgment of whether nicotine is a truly addictive drug--capable of instilling a helpless dependency equivalent to that of heroin--has long been over differences in withdrawal syndromes associated with tobacco and drugs.

But in recent years, he said, experts have gravitated to the view that drug dependence does not necessarily rely only on the lethal nature of withdrawal but on a complex of behaviors--including craving and the influence of the drug on behavior--by whose standards tobacco is unquestionably truly addictive.

“What has been happening in the scientific community is a more sophisticated appreciating of the factors that go into generating drug dependence,” Jaffe said, “and some more tempered appreciation of the importance of withdrawal.

“I think the tough thing for the public to recognize is the phenomenon called drug dependence. It varies with different drugs but the core issue is to what degree the drug gains control over behavior. Depending on how you conceptualize the notion of drug dependence, tobacco certainly meets the criteria.”

Television Appearance

The first indication of the content of the new document came in a television appearance more than a week ago by Dr. Ronald Davis, head of the federal Office for Smoking and Health, who revealed to a network interviewer that Koop’s report would list nicotine as a key element in the pharmacopoeia of addiction and drug abuse. The appearance by Davis quickly led to speculation that vending machine cigarette sales and sales to minors might eventually be outlawed.

The talk of prohibition prompted a preemptive strike from the Tobacco Institute, the cigarette industry’s principal trade association, which said that “anti-tobacco zeal has overtaken common sense and good judgment. To imply that the 55 million American tobacco smokers are drug abusers is to subvert and divert attention from the nation’s war on illicit drugs. It is a trivialization of the county’s urgent concern with hard drugs (that) verges on irresponsibility.”

But to medical experts on tobacco and drug abuse, the new focus on tobacco’s narcotics-like addiction potential was in keeping with a tradition, dating to 1964, in which the office Koop currently holds serves as the nation’s most effective bully pulpit on tobacco issues. In that year, then-Surgeon General Luther Terry issued the first major report linking smoking to lung cancer, setting in motion an evolution in research that has steadily linked tobacco to a widening variety of fatal and near-fatal health problems.

Greater Ostracism

Dr. John Pinney, executive director of the Institute for the Study of Smoking Behavior and Policy at Harvard University, said the focus on tobacco as an addiction signals a new phase in the evolution of public policy toward tobacco use, but he predicted that greater ostracism of smokers, combined with increased legal strictures on sales of tobacco products, use by young people and promotion and advertising will stop short of a national attempt to launch the equivalent of Prohibition.

“There are so many similarities between nicotine and cocaine that to separate them is a sort of an artificial thing,” Pinney said. “This country had a romance with the cigarette for the first half of the 20th Century. That romance is over. I think we’re in a transitional state and this (report) will influence things substantially.”

But Pinney said disillusionment with not just the 1920s-era attempt at outlawing alcoholic beverages but more recent failures in combating cultivation of marijuana will both work against a policy that eventually criminalizes tobacco entirely.

“I think (there) will be an impetus for new and overdue public policy sanctions, but this does not mean we can do away with tobacco,” Pinney said. “As a nation, we’ve shown such ingenuity in learning how to cultivate marijuana.”

Social Pressures

Schuster agreed that prohibition of tobacco is neither desirable nor possible. “We can better handle this kind of problem with education and the kinds of social pressures being exerted now,” Schuster said, alluding to increasing ostracism of smokers and social disdain for their activities. “Where we have to make a big difference between tobacco and other addictive drugs is that when one smokes tobacco, it does not alter your behavior or your ability to function so you become dangerous or obnoxious or an embarrassment to society.”

Dr. George Lundberg, editor of the Journal of the American Medical Assn., agreed that while smokers will undoubtedly find themselves even less welcome in society than they do now, total prohibition is unlikely.

“All adults and kids who are now truly addicted to nicotine through tobacco cigarettes or oral use will be given every serious opportunity to abstain and those who succeed will be praised,” Lundberg said. “But those who just can’t for whatever reason (quit) will be allowed to continue to practice their addiction in private in the presence of consenting adults.”