Smoking is a choice, not a compulsion
By Christopher Russell
The official view of nicotine addiction states that while initial smoking is voluntary, nicotine gradually changes the normal processes of neurotransmission within the brain’s reward system which make it increasingly difficult for smokers to control when and how much they smoke. As people continue to smoke, they are believed to eventually pass a ‘tipping point’, as if a switch has been flipped in their brains, at which “to smoke or not to smoke is not a question of free will of the individual, because nicotine makes people to depend on her, thereby reducing their capacity for making free choices.” (Ochoa, 1994: 196–197). In other words, smokers are no longer merely smokers; they are now nicotine addicts whose smoking is physically compelled, no longer under their willful control. This medical explanation for why some people continue to smoke despite their stated desire to quit is endorsed by several authoritative health bodies including the World Health Organisation, American Medical Association, and the American Psychiatric Association, provides justification for tobacco control measures and the provision of medical treatment to quitting smokers, and is largely accepted by smokers and the general public as an unquestioned, scientifically-proven truth of nicotine addiction.
It may be surprising to some readers then to learn that the argument that certain smokers are physically unable to stop smoking is actually consistently and critically undermined by a large body of empirical evidence and logical argument. On the contrary, what we can show is that some people find quitting smoking to be easy, a bit hard, quite hard, or extremely difficult, and that people keep smoking and quit smoking because they choose to for their own reasons, not because they are caused to. Though an extensive review of research is not possible here, this article describes what I consider to be among the strongest arguments for viewing smoking always as a choice, not as a physically compelled act.
Nicotine withdrawal severity does not distinguish those who do quit from those who don’t quit
The medical explanation is built on the assumption that nicotine withdrawal severity, as a measure of dependence, should predict who is most able, less able, and unable to stop smoking, and promises that medical research will soon find a more effective treatment for reducing nicotine withdrawal severity. However, no conclusive evidence of a relationship between withdrawal syndrome severity and quit outcome has yet been observed.
In a review of fifteen prospective studies of the strength of severity of withdrawal symptoms as predictors of quit outcome, Patten and Martin (1996) found that only six studies reported a relationship between withdrawal severity and quit outcome with the remaining nine reporting only weak relationships between withdrawal symptom intensity and frequency and short- and long-term relapse. In some studies, quitters reporting moderately severe symptoms lapsed to smoking within hours whereas people who reported severe withdrawal distress were are able to forego smoking for days and even weeks. Furthermore, most research has found that withdrawal symptoms largely resolve within two to three weeks following cessation and most affective symptoms resolve within three to four weeks yet the tendency to relapse to smoking persists for several years following cessation, long after withdrawal symptoms should have abated. Such incongruence between the temporal courses of withdrawal emergence and relapse potential suggests they are only weakly related.
Furthermore, in opposition to claims that NRT produces smoking cessation by alleviating the severity of the nicotine withdrawal syndrome, the extent to which NRTs suppress withdrawal symptoms has not been found to correspond well with their ability to produce abstinence. I’ve chosen two of many studies which found this poor correspondence. In Jorenby and colleagues (1995) study, though a forty-four milligram transdermal nicotine patch further reduced participants’ craving for nicotine than a twenty-two milligram patch, this reduction was not related to success in maintaining abstinence as smoking cessation did not differ significantly between the two patch groups at either eight weeks or twenty-six weeks following the quit date.
Alternatively, in a study by the Transdermal Nicotine Study Group (1991), though a twenty-one milligram transdermal nicotine patch produced a better abstinence rate at six months post-quit than a fourteen milligram patch and placebo treatment, abstinence rates across groups did not associate with changes in self-reported withdrawal symptom severity. This lack of a consistent association between withdrawal severity and quit outcome raises questions about the mechanisms of action and the psychosocial aspects of NRT.
Belief in the addictiveness of nicotine as a better predictor of quit success
There is better evidence that withdrawal symptoms are temporary rather than enduring obstacles, the effects of which are mediated by cognitive factors such as self-control ability, belief in the addictiveness of nicotine, and perceived self-efficacy. The belief that nicotine is addictive seems to increase the salience of withdrawal symptoms, thereby adding to their unpleasantness and increasing the chances of relapsing. In making symptoms more salient, a belief in the addictiveness of nicotine may lead quitters to overestimate the strength of these symptoms, therefore believing that they at greater risk of lapsing back to smoking than is actually posed by pure pharmacology. However, there is also evidence for the inverse hypothesis; frequent failure to stop smoking leads the smoker explain these failures as due to the fact that he is physically addicted and is incapable of stopping.
The main reason given by smokers for their failure to stop smoking is that they see themselves as addicted, and many smokers are very willing to describe themselves as “addicts” on the back of cessation failures. From a functional perspective, attributing smoking to a physical disease is attractive because the “addict” label allows smokers to claim diminished responsibility for their behaviour, diminished free will to control their behaviour, and so, justification for discontinuing their efforts to quit without assistance. Therefore, regardless of its legitimacy, disseminating the message that some smokers have lost the ability to control their smoking should be counter-productive to the goal of persuading our populations to quit smoking.
Most people quit smoking without assistance, medical or otherwise.
What we can and cannot show about the nature of nicotine addiction today is summed up by Akers (1991), a sociologist:
“The problem is that there is no independent way to confirm that the “addict” cannot help himself and therefore the label is often used as a tautological explanation of the addiction. The habit is called an addiction because it is not under control but there is no way to distinguish a habit that is uncontrollable from one which is simply not controlled”.
As an identifiable pharmacological substrate which compels smoking is yet to be found, the only evidence we have that people can’t stop is people say they can’t stop or are observed as not stopping. We cannot observe that people cannot stop; only that people do not stop. Conversely, the best evidence we have that people can stop is that they often do stop in large numbers, and more often without medical intervention or a painful withdrawal experience. Indeed, despite the staunch promotion of nicotine replacement products as the best hope for those trying to quit and in opposition to media messages that quitting is more likely with the use of nicotine replacement products, population studies consistently show that unassisted cessation is by far the most effective quitting method, leading the second most effective method – nicotine replacement therapy – by a large distance (see Chapman, 2010). For example, in 1986, the American Cancer Society reported that “over 90% of the estimated 37 million people have stopped smoking in the US since the Surgeon General’s first report linking smoking to cancer (in 1964) have done so unaided” (i.e. without the help of a formal treatment method). During a similar time frame, a report by the United States Department of Health, Education and Welfare also estimated that 95% of those who have quit smoking have done so on their own (USDHEW, 1977) This suggests that, for these 90-95% of Americans, quitting smoking was a matter of changing their minds about smoking however this change of mind came about, not through pharmaceutical intervention. It is somewhat puzzling then that unassisted quitting is rarely advised to smokers and no public education campaigns to my knowledge carry statistics for unassisted cessation or promote unassisted cessation as an effective strategy.
Lastly, in contrast to the popular belief that smokers typically plan their quit attempt in advance and that such advance planning leads to longer cessation, West and Sohal (2006) found that 48.6% cent of smokers put their most recent quit attempt into effect immediately after the decision to quit was made and, compared to those who planned their quit attempt in advance, those who quit on the spot were 2.6 times more likely to still be not smoking six months later. More recently, Ferguson and colleagues (2009) similarly found that the odds of a “spontaneous” quit attempt lasting for 6 months or longer were twice that of quit attempts planned in advance. These favourable findings for spontaneous as opposed to planned, assisted quitting fit with many smokers’ stories of giving up because they just felt like it; they had just had enough; a friend was dying of lung cancer; they themselves had a brush with death; or they had just found out that they were to become a parent or grandparent, among many other reasons for quitting on the spot. Successful, unplanned quitting happens seems to happen because a sudden switch in motivation changes our view of smoking from something positive to something which threatens an important part of our life.
The main point here is that quitting smoking appears to not depend on treating a physical addiction to nicotine, but on us becoming addicted to other ways of living and seeing smoking as something which interferes with these more valued ways of living. Simply, it appears that people smoke when it makes sense to smoke and stop smoking when smoking stops making sense.
Why brain pharmacology cannot explain why people smoke
Pharmacological processes of nicotine merely provide an on-line explanation of what happens to people’s brains and bodies when nicotine is consumed (i.e. the causes); they do not provide retrospective explanation for why people use nicotine (i.e. the reasons). There is good evidence that nicotine can make quitting hard; there is no evidence that a nicotine-induced pharmacological substrate compels people to put cigarettes in their mouths. Essentially, asking what happens when a person smokes is to ask about the involuntary neuroadaptation and gene expression which are caused; to ask why he smoked is to ask about the plethora of intra- and inter-individual reasons for voluntarily putting a cigarette to mouth and lighting. These are two very different sets of phenomena which require different levels of explanation.
The fact that millions of people say they are addicted is not evidence that they are addicted; the vast majority of people who say at one point “I can’t stop smoking” then do stop smoking! Unfortunately, physicians and tobacco control bodies tend to take these “I’m addicted!” claims as if they were literally true, solid pieces of evidence of an actual physical disease! But no other true physical disease is diagnosed solely on what people say they can and cannot do. We would certainly be suspicious if our physician diagnosed us as having diabetes without conducting any physical tests. We wouldn’t allow it; we would demand that tests be conducted before accepting the diagnosis and starting a course of treatment. But this is not how we currently ‘diagnose’ nicotine addiction and not how doctors decide to prescribe a course of nicotine replacement products; these decisions are made on the basis of how people talk about their smoking, not on what can objectively be observe in their brains and bodies.
A confusion of outcomes with intentions
While I do not dispute that tobacco smoking is associated with the onset of several bodily diseases, the act of smoking itself is not symptomatic of a disease. That people die from smoking says nothing about whether they were able to stop smoking at any point; it only says that they didn’t stop. That bad things happen as a result of smoking also does not make the decision to smoke a pathological decision, just as injury or death due to climbing mountains at the peak of winter does not mean that the decision to go mountain climbing, with all the foreknowledge of the potential risks, was a pathological decision. We must remember that people do risky things every day, many of which have the potential to kill on the spot, but the outcome of doing these behaviors says nothing about why these behaviors were instigated.
What medications do and do not do for smokers
Of course, I do not deny that the uses of medications like bupropion make it easier to forego smoking by blocking parts of the brain which can increase the pleasure obtainable through smoking. I would encourage people to use these medications if they find it helps them to not abstain from smoking. However, reducing the difficulty of quitting should not be confused with restoring the individual’s ability to quit as if this ability was at any point lost. Medications can help people quit smoking and great strides are being made to manufacture medications which make the process of quitting more tolerable. However, these medications are not necessary for controlling smoking in the way heart medicines, radiation therapy, and insulin are necessary to stave off the mortal threats of heart diseases, cancers, and diabetes respectively. These groups of people unfortunately do not have agency over their conditions in the way smokers have over their smoking.
No medication has yet been shown to restore a smoker’s free will to reject cigarettes. Additionally, manufacturing medications has long been considered by addiction researchers such as Bruce Alexander, Stanton Peele, and John Davies to be focusing on the thin edge of the wedge; too much focus on the uses of medication, they would argue, restricts the need for drug users and treatment providers to consider a broad social analysis of why tens of millions of people start or continue to light up each day.
Conclusion
The evidence in several domains combine to suggest that the nature of nicotine addiction is not well explained by nicotine pharmacology alone, but rather, that the evidence depicts smoking as primarily a reasoned choice influenced only peripherally by the pharmacologic effects of nicotine on the brain and body. Even when accounting for the presence of severe nicotine withdrawal symptoms and intense negative emotional experience associated with smoking abstinence, a relapse to smoking is not something that is done to people, but rather, something people do. There is good evidence that smokers often fail to control their smoking but no scientific evidence that they ever lose the ability to control their smoking.
Although the medical explanation receives unwavering support from authoritative health bodies around the world, particularly in the United States, continual reformulation is required to keep it from being undermined by the facts of nicotine addiction. The view that smokers continue to smoke through choice is vehemently denied by these health bodies, deeming this explanation to be judgmental and unsympathetic, and its dissemination to be irresponsible, ill-conceived, and dangerous to those smokers who want to quit. On the contrary, this position is not harsh, judgmental, or ideological; it is based on what available evidence suggests smokers are capable of.
Current arguments about the nature of smoking were intended only to encourage those who argue for the medical model to present evidence and theory which stand up to or resolve the caveats described here. I do not contest that nicotine replacement products can make the abstinence period more physically tolerable but I would always emphasize smoking, abstinence and relapse are chosen outcomes, each of which do occur with and without the use of nicotine replacement products.
To conclude, smokers will smoke for as long as smoking makes sense to them; when smoking stops making sense, people stop smoking. The issue for the tobacco industry and health bodies then is to advertise smoking in ways which respectively reinforce the sense and senselessness in continuing to smoke.
References:
Akers, R. L. (1991). Addiction; the troublesome concept. The Journal of Drug Issues, 21(4). 777-793.
Chapman, S. & McKenzie, R. (2010). The global research neglect of unassisted smoking cessation: Causes and consequences. PLoS Medicine, 7(2), 1-6.
Ferguson, S. G., Shiffman, S., Gitchell, J. G., Sembower, M. A., & West, R. (2009). Unplanned quit attempts – Results from a U.S. sample of smokers and ex-smokers. Nicotine & Tobacco Research, 11(7), 827-832.
Jorenby, D. E., Smith, S. S., Fiore, M. C., Hurt, R. D., Offord, K. P., Croghan, I. T., et al. (1995). Varying nicotine patch dose and type of smoking cessation counselling. Journal of American Medical Association, 274, 1347–1352.
Transdermal Nicotine Study Group. (1991). Transdermal nicotine for smoking cessation. Six-month results from two multicenter controlled clinical trials. Journal of the American Medical Association, 266, 3133–3138.
Ochoa, E. L. M., Li, L., & McNamee, M. G. (1990). Desensitization of central cholinergic mechanisms and neuroadaptation to nicotine. Molecular Neurobiology, 4, 251–287.
Patten, C. A., & Martin, J. E. (1996). Does nicotine withdrawal affect smoking cessation? Clinical and theoretical issues. Annals of Behavioral Medicine, 18, 190–200.
U.S. Department of Health, Education and Welfare. (1979). Smoking and health: A report of the surgeon general. Washington, DC: Author.
West, R. J., & Sohal, T. (2006). “Catastrophic” pathways to smoking cessation: findings from national survey. BMJ, 332(7539), 458–460.
