The Health
Cdnsequences
Of Smoking

NICOTINE ADDICTION

a report of the
Surgeon General

1988

US. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health &vke
Cmlen for Disease Control
Cenlw for Healfh Plomofkn and Educatkn
Offke on Smoldng and Health
Rockvllk, Maryland 20857

For sale by the Superintendent of Documents, U.S. Government Printing Office
            Washingtoa, D.C. 20402


The Honorable James Wright
Speaker of the House
of Representatives
Washington, D.C.  20515

Dear Hf. Speaker:

I am pleased to transmit to the Congress the 1987 Surgeon General's Report on
the health consequences of smoking, as mandated by Section B(a) of the Public
Health Cigarette Smoking Act of 1969.  The Act requires the Secretary of
Health and Human Services to transmit a" annual report to Congress on the
health consequences of smoking and such recommendations for legislation as the
Secretary may deem appropriate.

This report, entitled The Health Consequences of Smoking: Nicotine Addiction,
examines the scientific evidence that cigarettes and other forms of tobacco
are addicting.  The issue of tobacco addiction has been addressed in previous
Surgeon General's Reports and in the medical literature beginning in the early
1900s.  Because of the recent expansion of research in this area, a thorough
review of this topic is warranted.  Despite the significant health risks of
tobacco use outlined in previous reports, many smokers have great difficulty
in quitting.  This report concludes that such difficulty is in large part due
to the addicting properties of nicotine, which is present in all forms of
tobacco.

The report further concludes that the processes that determine tobacco
addiction are similar to those that determine addiction to other drugs such as
heroin and cocaine.  Through such understanding, health-care providers may be
better able to assist tobacco users in quitting.

Private health organizations, health-care providers, community groups. and
government agencies should initiate or strengthen programs to inform the
public of the addicting nature of tobacco use.  A warning label on the
addicting nature of tobacco use should be rotated with other health warnings
now required on cigarette and smokeless tobacco packages and advertisements.
Preventing the initiation of tobacco use must be a priority because of the
difficulty in overcoming "icocine addiction once it is firmly established.
Because most cases of nicotine addiction begin during childhood and
adolescence, school curricula on the prevention of drug use should also
include tobacco.

Cigarette smoking, the chief avoidable cause of premature death in this
country, is responsible for mare than 300,000 premature deaths each year. The
disease impact of smoking justifies placing the problem of tobacco use at the
top of the public health agenda.  The conclusions of this report provide
another compelling reason for strengthening our efforts to reduce tobacco use
in our society.

                         Sincerely,
          f$&--- `4.y
                         Otis R. Bane", Y.D.
                         %YPZt*ry

Enclosure


The Honorable George Bush
President of the Senate
Washington, D.C. 20515

Deer Hr. Presfdent:

I am pleased to transmit t" the Congress the 1987 Surgeon General's Report an
the health consequences of smoking, as mandated by Section g(a) of. the Public
Health Cigarette Smoking Act of 1969.  The Act requires the Secretary of
Health and Human Services to transmit an annual report t" Congress on the
health consequences of smoking end such recommendations for legislation as the
Secretary may deem appropriate.

This report, entitled The Health Consequences of Smoking: Nicotine Addiction,
examines the scientific evidence that cirarettes and other forma of tobacco
are addicting.  The issue of tobacco addrction has been addressed in previous
Surgeon General's Reports end in the medical literature beginning in the early
1900s.  Because of the recent expansion of research in this area, a thorough
revi.& of this topic is warranted.  Despite the significant health risks of
tobacco "se outlined in previous reports, many smokers have great difficulty
in quitting.  This report concludes that such difficulty is in large part due
t" the addicting properties of nicotine, which is present i" all forms of
tobacco.

The report further concludes that the processes that determine tobacco
addiction are similar to those that determine addiction to other drugs such as
heroin and cocaine.  Through such understanding, health-care providers may be
better able to assist tobacco users in quitting,

Private health organizations, health-care providers, community groups. and
government agencies should initiate or strengthen programs to inform the
public of the addicting nature of tobacco use.  A vaming label on the
addicting "ature of tobacco use should be rotated vith other health warnings
now required on cigarette and swkelesa tobacco packages and advertisements.
Preventing the initiation of tobacco use must be a priority because of the
difficulty in overcoming "icotfne addiction once it is firmly established.
Because m"st cases of nicotine addiction begin during childhood and
adolescence, school curricula on the prevention of drug use should also
include tobacco.

Cigarette smoking, the chief avoidable cause of premature death in this
country, is responsible for more than 300,000 premature deaths each year. The
disease impact of smoking justifies placing the problem of tobacco use at the
top of the public health agenda.  The conclusions of this report provide
another compelling Peas"" for strengthening "UT efforts to reduce tobacco use
in our society.

Sincerely,

C&=5---&
Otis R. Boven, H.D.
Secretary


FOREWORD

This 20th Report of the Surgeon General on the health conse-
quences of tobacco use provides an additional important piece of
evidence concerning the serious health risks associated with using
tobacco.

The subject of this Report, nicotine addiction, was first mentioned
in the 1964 Report of the Advisory Committee to the Surgeon
General, which referred to tobacco use as "habituating." In the
landmark 1979 Report of the Surgeon General, by which time
considerably more research had been conducted, smoking was called
"the prototypical substance-abuse dependency." Scientists in the
field of drug addiction now agree that nicotine, the principal
pharmacologic agent that is common to all forms of t.obacco, is a
powerfully addicting drug.

Recognizing tobacco use as an addiction is critical both for treating
the tobacco user and for understanding why people continue to use
tobacco despite the known health risks. Nicotine is a psychoactive
drug with actions that reinforce the use of tobacco. Effort,s to reduce
tobacco use in our society must address all the major influences that
encourage continued use, including social, psychological, and phar-
macologic factors.

After carefully examining the available evidence, this Report
concludes that:

o Cigarettes and other forms of t,obacco are addicting.
o Nicotine is the drug in tobacco that causes addiction.
o The pharmacologic and behavioral processes that determine
   tobacco addiction are similar to those that determine addiction
  to drugs such as heroin and cocaine.
We must recognize both the potential for behavioral and pharma-
cologic treatment of the addicted tobacco user and the problems of
withdrawal. Tobacco use is a disorder which can be remedied
through medical attention; therefore, it should be approached by
health care providers just as other substance-use disorders are
approached: with knowledge, understanding, and persistence. Each
health care provider should use every available c!inical opportunity
to encourage or assist smokers to quit and to help former smokers to
maintain abstinence.


To maintain momentum toward a smoke-free society, we also must
take steps to prevent young people from beginning to smoke. First,
we must insure that every child in every school in this country is
educated as to the health risks and the addictive nature of tobacco
use. Most jurisdictions require that school curricula include preven-
tion of drug use; therefore, education on the prevention of tobacco
use should be included in this effort. Second, warning labels
regarding the addictive nature of t,obacco use should be required for
all tobacco packages and advertisements. Young people in particular
may not be aware of the risk of tobacco addiction. Finally, parents
and other role models should discourage smoking and other forms of
tobacco use among young people. Parents who quit set an example
for their children.

Smoking continues to be the chief preventable cause of premature
death in this country. Nicotine has addictive properties which help
to sustain widespread tobacco use. It is gratifying to see the decline
in reported smoking prevalence and cigarette consumption in the
United States during the past 25 years. However, we cannot expect
to see a sustained decline in rates of smoking-related cancers,
cardiovascular disease, and pulmonary disease without sustained
public health efforts against tobacco use.

The Public Health Service is committed to preventing tobacco use
among youth and to promoting cessation among existing smokers.
We hope that this Report will assist the health care community,
voluntary health agencies, and our Nation's schools in working with
us to reduce tobacco use in our society.

Robert E. Windom, M.D.
Assistant Secretary for Health

ii


PREFACE

This Report of the Surgeon General is the U.S. Public Health
Service's 20th Report on the health consequences of tobacco use and
the 7th issued during my tenure as Surgeon General. Eighteen
Reports have been released previously as part of the health
consequences of smoking series; a report on the health consequences
of using smokeless tobacco was released in 1986.

Previous Rep0rt.s have reviewed the medical and scientific evi-
dence establishing the health effects of cigarette smoking and other
forms of tobacco use. Tens of thousands of studies have documented
that smoking causes lung cancer, other cancers, chronic obstructive
lung disease, heart disease, complications of pregnancy, and several
other adverse health effects.

Epidemiologic studies have shown that cigarette smoking is
responsible for more than 300,000 deaths each year in the United
States. As I stated in the Preface to the 1982 Surgeon General's
Report, smoking is the chief avoidable cause of death in our society.

From 1964 through 1979, each Surgeon General's Report ad-
dressed the major health effects of smoking. The 1979 Report
provided the most comprehensive review of these effects. Following
the 1979 Report, each subsequent Report has focused on specific
populations (women in 1980, workers in 19851, specific diseases
(cancer in 1982, cardiovascular disease in 1983, chronic obstructive
lung disease in 19841, and specific topics (low-tar. low-nicotine
cigarettes in 1981, involuntary smoking in 1986).

This Report explores in great detail another specific topic: nicotine
addiction. Careful examination of the data makes it clear that
cigarettes and other forms of tobacco are addicting. An extensive
body of research has shown that nicotine is the drug in tobacco that
causes addiction. Moreover, the processes that determine tobacco
addiction are similar to those that determine addiction to drugs such
as heroin and cocaine.

Actions of Nicotine

All tobacco products contain substantial amounts of nicotine.
Nicotine is absorbed readily from tobacco smoke in the lungs and
from smokeless tobacco in the mouth or nose. Levels of nicotine in

. . .
111


the blood are similar in magnitude in people using different forms of
tobacco. Once in the blood stream, nicotine is rapidly distributed
throughout the body.

Nicotine is a powerful pharmacologic agent that acts in a variety
of ways at different sites in the body. After reaching the blood
stream, nicotine ent,ers the brain, interacts with specific receptors in
brain tissue. and initiates metabolic and electrical activity in the
brain. In addition, nicotine causes skeletal muscle relaxation and
has cardiovascular and endocrine (i.e., hormonal) effects.

Human and animal studies have shown that nicotine is the agent
in tobacco that leads to addiction. The diversity and strength of its
actions on the body are consistent with its role in causing addiction.

Tobacco Use as an Addiction

Standard definitions of drug addiction have been adopted by
various organizations including the World Health Organization and
the American Psychiatric Association. Although these definitions
are not identical, they have in common several criteria for establish-
ing a drug as addicting.

The central element among all forms of drug addiction is that the
user's behavior is largely controlled by a psychoactive substance (i.e.,
a substance that produces transient alterations in mood that are
primarily mediated by effects in the brain). There is often compul-
sive use of the drug despite damage to the individual or to society,
and drug-seeking behavior can take precedence over other important
priorities. The drug is "reinforcing"-that is, the pharmacologic
activity of the drug is sufficiently rewarding to maintain self-
administration. "Tolerance" is another aspect of drug addiction
whereby a given dose of a drug produces less effect or increasing
doses are required to achieve a specified intensity of response.
Physical dependence on the drug can also occur, and is characterized
by a withdrawal syndrome that usually accompanies drug absti-
nence. After cessation of drug use, there is a strong tendency to
relapse.

This Report demonstrates in detail that tobacco use and nicotine
in particular meet all these criteria. The evidence for these findings
is derived from animal studies as well as human observations.
Leading national and international organizations, including the
World Health Organization and the American Psychiatric Associa-
tion, have recognized chronic tobacco use as a drug addiction.

Some people may have difficulty in accepting the notion that
tobacco is addicting because it is a legal product. The word
"addiction" is strongly associated with illegal drugs such as cocaine
and heroin. However, as this Report shows, the processes that


determine tobacco addiction are similar to those that determine
addiction to other drugs, including illegal drugs.

In addition, some smokers may not believe that tobacco is
addicting because of a reluctance to admit that one's behavior is
largely controlled by a drug. On the other hand, most smokers admit
that they would like to quit but have been unable to do so. Smokers
who have repeatedly failed in their attempts to quit probably realize
that smoking is more than just a simple habit.

Many smokers have quit on their own ("spontaneous remission")
and some smokers smoke only occasionally. However, spontaneous
remission and occasional use also occur with the illicit drugs of
addiction, and in no way disqualify a drug from being classified as
addicting. Most narcotics users, for example, never progress beyond
occasional use, and of those who do, approximately 30 percent
spontaneously remit. Moreover, it seems plausible that spontaneous
remitters are largely those who have either learned to deliver
effective treatments to themselves or for whom environmental
circumstances have fortuitously changed in such a way as to support
drug cessation and abstinence.

Treatment

Like other addictions, tobacco use can be effectively treated. A
wide variety of behavioral interventions have been used for many
years, including aversion procedures (e.g., satiation, rapid smoking),
relaxation training, coping skills training, stimulus control, and
nicotine fading. In recognition of the important role that nicotine
plays in maintaining tobacco use, nicotine replacement therapy is
now available. Nicotine polacrilex gum has been shown in controlled
trials to relieve withdrawal symptoms. In addition, some (but not all)
studies have shown that nicotine gum, as an adjunct to behavioral
interventions, increases smoking abstinence rates. In recent years,
multicomponent interventions have been applied successfully to the
treatment of tobacco addiction.

Public Health Strategies

The conclusion that cigarettes and other forms of tobacco are
addicting has important implications for health professionals, educa-
tors, and policy-makers. In treating the tobacco user, health profes-
sionals must address the tenacious hold that nicotine has on the
body. More effective interventions must be developed to counteract
both the psychological and pharmacologic addictions that accompa-
ny tobacco use. More research is needed to evaluate how best to treat
those with the strongest dependence on the drug. Treatment of
tobacco addiction should be more widely available and should be

V


considered at least as favorably by third-party payors as treatment of
alcoholism and illicit drug addiction.

The challenge to health professionals is complicated by the array
of new nicotine delivery systems that are being developed and
introduced in the marketplace. Some of these products are produced
by tobacco manufacturers; others may be marketed as devices to aid
in smoking cessation. These new products may be more toxic and
more addicting than the products currently on the market. New
nicotine delivery systems should be evaluated for their toxic and
addictive effects; products intended for use in smoking cessation also
should be evaluated for efficacy.

Public information campaigns should be developed to increase
community awareness of the addictive nature of tobacco use. A
health warning on addiction should be rotated with the other
warnings now required on cigarette and smokeless tobacco packages
and advertisements. Prevention of tobacco use should be included
along with prevention of illicit drug use in comprehensive school
health education curricula. Many children and adolescents who are
experimenting with cigarettes and other forms of tobacco state that
they do not intend to use tobacco in later years. They are unaware of,
or underestimate, the strength of tobacco addiction. Because this
addiction almost always begins during childhood or adolescence,
children need to be warned as early as possible, and repeatedly
warned through their teenage years, about the dangers of exposing
themselves to nicotine.

This Report shows conclusively that cigarettes and other forms of
tobacco are addicting in the same sense as are drugs such as heroin
and cocaine. Most adults view illegal drugs with scorn and express
disapproval (if not outrage) at their sale and use. This Nation has
mobilized enormous resources to wage a war on drugs - illicit drugs.
We should also give priority to the one addiction that is killing more
than 300,000 Americans each year.

We as citizens, in concert with our elected officials, civic leaders,
and public health officers, should establish appropriate public
policies for how tobacco products are sold and distributed in our
society. With the evidence that tobacco is addicting, is it appropriate
for tobacco products to be sold through vending machines, which are
easily accessible to children? Is it appropriate for free samples of
tobacco products to be sent through the mail or distributed on public
property, where verification of age is difficult if not impossible?
Should the sale of tobacco be treated less seriously than the sale of
alcoholic beverages, for which a specific license is required (and
revoked for repeated sales to minors)?

In the face of overwhelming evidence that tobacco is addicting,
policy-makers should address these questions without delay. To

vi


achieve our goal of a smoke-free society, we must give this problem
the serious attention it deserves.

C. Everett Koop, M.D., Sc.D.
Surgeon General

vii


ACKNOWLEDGMENTS

This Report was prepared by the Department of Health and
Human Services under the general editorship of the Office on
Smoking and Health, Ronald M. Davis, M.D., Director. The Manag-
ing Editors were Thomas E. Novotny, M.D., and William R. Lynn,
Office on Smoking and Health.

Scientific editors were Neal L. Benowitz, M.D., Professor of
Medicine, Chief, Division of Clinical Pharmacology and Experimen-
tal Therapeutics, San Francisco General Hospital, University of
California, San Francisco, California; Neil E. Grunberg, Ph.D.,
Department of Medical Psychology, Uniformed Services University
of the Health Sciences, Bethesda, Maryland; Jack E. Henningfield,
Ph.D., Chief, Biology of Dependence and Abuse Potential Assessment
Laboratory, Addiction Research Center, National Institute on Drug
Abuse, Baltimore, Maryland; and Harry A. Lando, Ph.D., Professor,
Department of Psychology, Iowa State University, Ames, Iowa.

The following individuals prepared draft chapters or portions of
the Report.

David B. Abrams, Ph.D., Assistant Professor of Psychiatry and
Human Behavior, Brown University Program in Medicine, The
Miriam Hospital, Center for Health Promotion, Providence, Rhode
Island

Timothy B. Baker, Ph.D., Department of Psychology, University of
Wisconsin, Madison, Wisconsin

Neal L. Benowitz, M.D., Professor of Medicine, Chief, Division of
Clinical Pharmacology and Experimental Therapeutics, San Fran-
cisco General Hospital, University of California, San Francisco,
California

Thomas H. Brandon, M.S., Department of Psychology, University of
Wisconsin, Madison, Wisconsin

Richard F. Catalano, Ph.D., Research Assistant Professor, Center for
Social Welfare Research, School of Social Work, University of
Washington, Seattle, Washington

Larry D. Chait, Ph.D., Research Associate (Assistant Professor),
Department of Psychiatry, University of Chicago, Chicago, Illinois
Paul B.S. Clarke, Ph.D., Department of Pharmacology and Thera-
peutics, McGill University, Montreal, Quebec, Canada

ix


Richard R. Clayton, Ph.D., Professor, Department of Sociology,
University of Kentucky, Lexington, Kentucky
Allan C. Collins, Ph.D., Institute for Behavioral Genetics, School of
Pharmacy, University of Colorado, Boulder, Colorado
Thomas M. Cooper, D.D.S., Professor, Department of Community
Dentistry, University of Kentucky, Lexington, Kentucky
Lori A. Crane, M.P.H., Division of Cancer Control, Jonsson Compre-
hensive Cancer Center, University of California, Los Angeles,
California

Susan Curry, Ph.D., Center for Health Studies, Group Health
Cooperative of Puget Sound, Seattle, Washington
D. Layten Davis, Ph.D., Director, Tobacco and Health Research
Institute, University of Kentucky, Lexington, Kentucky
Ronald M. Davis, M.D., Director, Office on Smoking and Health,
Center for Health Promotion and Education, Centers for Disease
Control, Rockville, Maryland

Edward F. Domino, M.D., Professor, Department of Pharmacology,
University of Michigan, Ann Arbor, Michigan
John L. Egle, Jr., Ph.D., Department of Pharmacology/Toxicology,
Medical College of Virginia, Virginia Commonwealth University,
Richmond, Virginia

Joan Ershler, Ph.D., Research Associate, Mt. Sinai Medical Center,
Milwaukee, Wisconsin

Raymond Fleming, Ph.D., Assistant Professor, University of Wiscon-
sin-Milwaukee, Mt. Sinai Medical Center, Milwaukee, Wisconsin
Kathleen A. Fletcher, Ph.D., M.P.H., Consultant, The University of
Texas Health Science Center, Houston, Texas
Paul J. Fudala, Ph.D., Addiction Research Center, National Institute
on Drug Abuse, Baltimore, Maryland
C. Gary Gairola, Ph.D., University of Kentucky, Tobacco and Health
Research Institute, Lexington, Kentucky
David Gilbert, Ph.D., Department of Psychology, Southern Illinois
University, Carbondale, Illinois

Lewayne D. Gilchrist, Ph.D., Research Associate Professor, School of
Social Work, University of Washington, Seattle, Washington
Donna M. Goldberg, M.A., Annapolis, Maryland
Steven R. Goldberg, Ph.D., Preclinical Pharmacology Research
Branch, Addiction Research Center, National Institute on Drug
Abuse, Baltimore, Maryland

John Grabowski, Ph.D., Department of Psychiatry and Behavioral
Science, The University of Texas Health Science Center, Houston,
Texas

Neil E. Grunberg, Ph.D., Department of Medical Psychology, Uni-
formed Services University of the Health Sciences, Bethesda,
Maryland

X


Dorothy K. Hatsukami, Ph.D., Department of Psychiatry, University
of Minnesota, Minneapolis, Minnesota
J. David Hawkins, Ph.D., Professor, Center for Social Welfare
Research, School of Social Work, University of Washington,
Seattle, Washington

Jack E. Henningfield, Ph.D., Chief, Biology of Dependence and
Abuse Potential Assessment Laboratory, Addiction Research Cen-
ter, National Institute on Drug Abuse, Baltimore, Maryland.
Ronald I. Herning, Ph.D., Addiction Research Center, National
Institute on Drug Abuse, Baltimore, Maryland
Matthew Owen Howard, M.S., M.S.W., Research Assistant, Center
for Social Welfare Research, School of Social Work, University of
Washington, Seattle, Washington

John R. Hughes, M.D., Departments of Psychiatry, Psychology, and
Family Practice, University of Vermont, Burlington, Vermont
Edgar T. Iwamoto, Ph.D., Department of Pharmacology, College of
Medicine, University of Kentucky, Lexington, Kentucky
Murray E. Jarvik, M.D., Ph.D., The Neuropsychiatric Institute and
Hospital, School of Medicine, University of California, Los An-
geles, Veterans' Administration Medical Center, Brentwood Divi-
sion, Los Angeles, California

Robert C. Klesges, Ph.D., Associate Professor, Center for Applied
Psychological Research, Department of Psychology, Memphis
State University, Memphis, Tennessee
Lynn T. Kozlowski, Ph.D., Head, Behavioral Research on Tobacco
Use, Addiction Research Foundation, Professor of Psychology and
of Preventive Medicine and Biostatistics, University of Toronto,
Toronto, Ontario, Canada

Howard Leventhal, Ph.D., Professor and Chairman, Department of
Psychology, University of Wisconsin, Madison, Wisconsin
Edythe D. London, Ph.D., Chief, Neuropharmacology Laboratory,
Addiction Research Center, National Institute on Drug Abuse,
Baltimore, Maryland

Scott E. Lukas, Ph.D., Assistant Professor of Psychiatry (Pharmacol-
ogy), Harvard Medical School, Department of Psychiatry, Alcohol
and Drug Abuse Research Center, McLean Hospital, Belmont,
Massachusetts

Alfred C. Marcus, Ph.D., Associate Director, Division of Cancer
Control, Jonsson Comprehensive Cancer Center, University of
California, Los Angeles, California
Andrew W. Meyers, Ph.D., Professor, Center for Applied Psychologi-
cal Research, Department of Psychology, Memphis State Universi-
ty, Memphis, Tennessee

Thomas E. Novotny, M.D., Medical Epidemiologist, Office on Smok-
ing and Health, Center for Health Promotion and Education,
Centers for Disease Control, Rockville, Maryland

xi


Carol Tracy Orleans, Ph.D., Senior Investigator, Behavioral Medi-
cine and Director of Smoking Cessation Services, Division of
Cancer Control, Fox Chase Cancer Center, Philadelphia, Pennsyl-
vania

John P. Pierce, MSc., Ph.D., Chief, Epidemiology Branch, Office on
Smoking and Health, Center for Health Promotion and Education,
Centers for Disease Control, Rockville, Maryland
Ovide F. Pomerleau, Ph.D., Behavioral Medicine Program, Universi-
ty of Michigan, Department of Psychiatry, Ann Arbor, Michigan
Amelie G. Ramirez, M.P.H., Faculty Associate, The University of
Texas Health Science Center, Assistant Professor, Baylor College
of Medicine, Houston, Texas

Jed E. Rose, Ph.D., Veterans' Administration Medical Center,
Wadsworth and Brentwood Divisions, Los Angeles, California
J.A. Rosecrans, Ph.D., Department of Pharmacology, Medical Col-
lege of Virginia, Virginia Commonwealth University, Richmond,
Virginia

David P.L. Sachs, M.D., Director, Smoking Cessation Research
Institute, Palo Alto, California

Mary Anne Salmon, Ph.D., Research Associate, Health Services
Research Center, University of North Carolina, Chapel Hill, North
Carolina

Nina G. Schneider, Ph.D., Associate Research Psychologist, Depart-
ment of Psychiatry and Biobehavioral Sciences, UCLA School of
Medicine, Research Psychologist, Psychopharmacology Unit, Vet-
erans' Administration Medical Center, Brentwood Division, Los
Angeles, California

V.J. Schoenbach, Ph.D., Associate Professor, Department of Epide-
miology, Research Associate, Health Services Research Center,
University of North Carolina, Chapel Hill, North Carolina
Saul Shiffman, Ph.D., Associate Professor, Department of Psycholo-
gy, University of Pittsburgh, Pittsburgh, Pennsylvania
Victor J. Strecher, Ph.D., Research Associate, Health Services
Research Center, Assistant Professor, Department of Health
Education, University of North Carolina, Chapel Hill, North
Carolina

David M. Warburton, Professor, Department of Psychology, Univer-
sity of Reading, Whiteknights, Reading, United Kingdom
Elizabeth A. Wells, Ph.D., Post-Doctoral Fellow, Center for Social
Welfare Research, University of Washington, Seattle, Washington
Thomas Ashby Wills, Ph.D., Assistant Professor of Psychology,
Assistant Professor of Epidemiology and Social Medicine, Depart-
ment of Epidemiology and Social Medicine, Ferkauf Graduate
School of Psychology and Albert Einstein College of Medicine,
Bronx, New York

xii


Phillip P. Woodson, Dr.sc.nat., Addiction Research Center, National
Institute on Drug Abuse, Baltimore, Maryland

The editors acknowledge with gratitude the following distin-
guished scientists, physicians, and others who lent their support in
the development of this Report by coordinating manuscript prepara-
tion, contributing critical reviews of the manuscript, or assisting in
other ways.

Leo G. Abood, Ph.D., Department of Pharmacology, University of
Rochester Medical Center, Rochester, New York
John S. Baer, Ph.D., Department of Psychology, University of
Washington, Seattle, Washington
Timothy B. Baker, Ph.D., Department of Psychology, University of
Wisconsin, Madison, Wisconsin

Claudia R. Baquet, M.D., M.P.H., Chief, Special Populations Studies
Branch, Division of Cancer Prevention and Control, National
Cancer Institute, Bethesda, Maryland
Glen Bennett, M.P.H., Field Studies Advisor, Office of Prevention,
Education, and Control, National Heart, Lung, and Blood Insti-
tute, Bethesda, Maryland

George E. Bigelow, Ph.D., Associate Professor of Behavioral Biology,
Director, Behavioral Pharmacology Research Unit, Department of
Psychiatry and Behavioral Sciences, The Johns Hopkins Universi-
ty School of Medicine, Baltimore, Maryland
Clarice Brown, M.S., Data Analyst, Office of Prevention, Education,
and Control, National Heart, Lung, and Blood Institute, Bethesda,
Maryland

David M. Burns, M.D., Associate Professor of Medicine, Division of
Pulmonary and Critical Care Medicine, University of California
Medical Center, San Diego, California
Donald R. Cherek, Ph.D., Department of Psychiatry and Behavioral
Sciences, Mental Sciences Institute, The University of Texas
Health Science Center, Houston, Texas
Paul B.S. Clarke, Ph.D., Department of Pharmacology and Thera-
peutics, McGill University, Montreal, Quebec, Canada
Ro Nemeth-Coslett, Ph.D., Psychologist, Prevention Research
Branch, Division of Clinical Research, National Institute on Drug
Abuse, Rockville, Maryland

Thomas J. Crowley, M.D., University of Colorado Health Sciences
Center, Denver, Colorado

Joseph W. Cullen, Ph.D., Deputy Director, Division of Cancer
Prevention and Control, National Cancer Institute, Bethesda,
Maryland

K. Michael Cummings, Ph.D., M.P.H., Research Scientist, Depart-
ment of Cancer Control and Epidemiology, Roswell Park Memorial
Institute, Buffalo, New York

. .
x111


Susan Curry, Ph.D., Center for Health Studies, Group Health
Cooperative of Puget Sound, Seattle, Washington
Vincent T. DeVita, Jr., M.D., Director, National Cancer Institute,
National Institutes of Health, Bethesda, Maryland
Sir Richard Doll, University of Oxford, Oxford, England
Manning Feinleib, M.D., Dr.P.H., Director, National Center for
Health Statistics, Centers for Disease Control, Hyattsville, Mary-
land

William H. Foege, M.D., Executive Director, The Carter Center of
Emory University, Atlanta, Georgia
Richard R. Frecker, M.D., Ph.D., Head, Biomedical Research,
Department of Pharmacology, Addiction Research Foundation,
Toronto, Ontario, Canada

K.H. Ginzel, Ph.D., Professor, Department of Pharmacology and
Interdisciplinary Toxicology, University of Arkansas for Medical
Sciences, Little Rock, Arkansas
Russell E. Glasgow, Ph.D., Oregon Research Institute, Eugene,
Oregon

Nancy P. Gordon, Sc.D., Behavioral Scientist, Division of Research,
Kaiser Permanente Medical Group, Oakland, California
Roland R. Griffiths, The Johns Hopkins University School of
Medicine, Baltimore, Maryland

Ellen R. Gritz, Ph.D., Director, Division of Cancer Control, Jonsson
Comprehensive Cancer Center, University of California, Los
Angeles, California

Sharon M. Hall, Ph.D., Professor, Department of Psychiatry, Center
for Social and Behavioral Sciences, University of California, San
Francisco, California

Louis S. Harris, Ph.D., Senior Science Advisor, National Institute on
Drug Abuse, Alcohol, Drug Abuse, and Mental Health Administra-
tion, Rockville, Maryland

Ronald I. Herning, Ph.D., Addiction Research Center, National
Institute on Drug Abuse, Baltimore, Maryland
Dietrich Hoffmann, Ph.D., Associate Director, Naylor Dana Insti-
tute, Valhalla, New York

Leo Hollister, M.D., Medical Director, Harris County Psychiatry
Center, Houston, Texas

Enid Hunkeler, Senior Investigator, Kaiser Permanente Medical
Care Program, Oakland, California
Peyton Jacob III, Ph.D., Division of Clinical Pharmacology, San
Francisco General Hospital, University of California, San Francis-
co, California

Jerome Jaffe, M.D., Director, Addiction Research Center, National
Institute on Drug Abuse, Baltimore, Maryland
Murray E. Jarvik, M.D., Ph.D., The Neuropsychiatric Institute and
Hospital, School of Medicine, University of California, Los An-

xiv


geles, and Veterans' Administration Medical Center West LOS
Angeles, Brentwood Division, Los Angeles, California
Martin Jarvis, M.Phil., Senior Lecturer, Addiction Research Unit,
Institute of Psychiatry, London, England
Chris-Ellen Johanson, Ph.D., Department of Psychiatry, Pritzker
School of Medicine, University of Chicago Drug Abuse Research
Center, Chicago, Illinois

Reese T. Jones, Ph.D., Department of Psychiatry, University of
California School of Medicine, San Francisco, California
Kenneth J. Kellar, Ph.D., Department of Pharmacology, Georgetown
University Medical Center, Washington, D.C.
Lynn T. Kozlowski, Ph.D., Head, Behavioral Research on Tobacco
Use, Addiction Research Foundation, Toronto, Ontario, Canada
Richard J. Lamb, Ph.D., Addiction Research Center, National
Institute on Drug Abuse, Baltimore, Maryland
Charles L. LeMaistre, M.D., President, University of Texas Systems
Cancer Center, Houston, Texas

Claude Lenfant, M.D., Director, National Heart, Lung, and Blood
Institute, National Institutes of Health, Bethesda, Maryland
Howard Leventhal, Ph.D., Professor of Psychology, University of
Wisconsin, Madison, Wisconsin

Edward Lichtenstein, Ph.D., Oregon Research Institute, Eugene,
Oregon

Donald Ian Macdonald, M.D., Administrator, Alcohol, Drug Abuse,
and Mental Health Administration, Rockville, Maryland
G. Alan Marlatt, Ph.D., Professor of Psychology, University of
Washington, Seattle, Washington
William R. Martin, M.D., Chairman, Department of Pharmacology,
University of Kentucky College of Medicine, Lexington, Kentucky
James 0. Mason, M.D., Dr.P.H., Director, Centers for Disease
Control, Atlanta, Georgia

J. Michael McGinnis, M.D., Deputy Assistant Secretary (Disease
Prevention and Health Promotion), Washington, D.C.
A. Thomas McLellan, Ph.D., Substance Abuse Treatment Research
Center, Philadelphia Veterans' Administration Medical Center
and The University of Pennsylvania, Philadelphia, Pennsylvania
Nancy K. Mello, Ph.D., Alcohol and Drug Abuse Research Center,
McClean Hospital, Belmont, Massachusetts
Gregory J. Morosco, Ph.D., M.P.H., Smoking Education Program
Coordinator, National Heart, Lung, and Blood Institute, Bethesda,
Maryland

Joseph P. Mulholland, Ph.D., Bureau of Economics, Federal Trade
Commission, Washington, D.C.

Herbert W. Nickens, M.D., M.A., Director, Office of Minority Health,
Public Health Service, Washington, D.C.

xv


Richard Peto, M.A., M.Sc., Imperial Cancer Research Fund, Cancer
Studies Unit, Nuffield Department of Clinical Medicine, Radcliffe
Infirmary, University of Oxford, Oxford, England
Roy W. Pickens, Ph.D., Director, Division of Clinical Research,
National Institute on Drug Abuse, Rockville, Maryland
John P. Pierce, MSc., Ph.D., Chief, Epidemiology Branch, Office on
Smoking and Health, Center for Health Promotion and Education,
Centers for Disease Control, Rockville, Maryland
John M. Pinney, Executive Director, Institute for the Study of
Smoking Behavior and Policy, John F. Kennedy School of Govern-
ment, Harvard University, Cambridge, Massachusetts
Michael R. Polen, M.A., Research Associate, Division of Research,
Kaiser-Permanente Medical Group, Oakland, California
William Pollin, M.D., Former Director, National Institute on Drug
Abuse, Bethesda, Maryland

David C. Ramsey, M.P.H., Health Educator, Division of Health
Education, Center for Health Promotion and Education, Centers
for Disease Control, Atlanta, Georgia
Everett R. Rhoades, M.D., Assistant Surgeon General and Director,
Indian Health Service, Rockville, Maryland
M.A.H. Russell, F.R.C.P., Addiction Research Unit, Institute of
Psychiatry, University of London, London, England
Charles R. Schuster, Ph.D., Director, National Institute on Drug
Abuse, Rockville, Maryland

Burt Sharpe, M.D., Hennepin County Medical Center, Department of
Medicine, Minneapolis, Minnesota
Donald R. Shopland, Public Health Advisor, Smoking, Tobacco, and
Cancer Program, National Cancer Institute, Bethesda, Maryland
Jerome E. Singer, Ph.D., Medical Psychology, Uniformed Services
University of the Health Sciences, Bethesda, Maryland
Maxine L. Stitzer, Ph.D., Associate Professor, Behavioral Biology,
The Johns Hopkins School of Medicine, Behavioral Pharmacology
Research, Francis Scott Key Medical Center, Baltimore, Maryland
David N. Sundwall, M.D., Assistant Surgeon General and Adminis-
trator, Health Resources and Services Administration, Rockville,
Maryland

Dennis D. Tolsma, M.P.H., Director, Center for Health Promotion
and Education, Centers for Disease Control, Atlanta, Georgia
Frederick L. Trowbridge, M.D., Director, Division of Nutrition,
Center for Health Promotion and Education, Centers for Disease
Control, Atlanta, Georgia

Frank J. Vocci, Jr., Ph.D., Acting Chief, Drug Abuse Staff, Center for
Drug Evaluation and Research, Food and Drug Administration,
Washington, DC

Ronald W. Wilson, M.A., National Center for Health Statistics,
Centers for Disease Control, Hyattsville, Maryland

xvi


Roy A. Wise, Ph.D., Department of Psychology, Concordia Universi-
ty, Montreal, Quebec, Canada
Faye Wright, Center for Applied Psychological Research, Depart-
ment of Psychology, Memphis State University, Memphis, Tennes-
see

Ernst L. Wynder, M.D., President, American Health Foundation,
New York, New York

James B. Wyngaarden, M.D., Director, National Institutes of Health,
Bethesda, Maryland

Tomoji Yanagita, M.D., Ph.D., Preclinical Research Laboratories,
Central Institute for Experimental Animals, Kawasaki, Japan
Frank E. Young, M.D., Commissioner, Food and Drug Administra-
tion, Rockville, Maryland

The editors also acknowledge the contributions of the following
staff members and others who assisted in the preparation of this
Report.

Margaret Anglin. Secretary, Office on Smoking and Health, Rock-
ville, Maryland

Charles Appiah, Project Clerk. Smoking and Health Project,. The
Circle, Inc., McLean, Virginia

John L. Bagrosky, Associate Director for Program Operations, Office
on Smoking and Health, Rockville, Maryland
Sonia Balakirsky, Secretary, Office on Smoking and Health, Rock-
ville, Maryland

Carol Bean, Associate Project Director, Smoking and Health Project,
The Circle, Inc., McLean, Virginia
Tamara Blair, Production Coordinator, Information Management
Department, ATLIS Federal Services, Inc., Rockville, Maryland
Catherine E. Burckhardt, Editorial Assistant, Office on Smoking and
Health, Rockville, Maryland

Gayle Christman, Word Processing Specialist, Smoking and Health
Project, The Circle, Inc., McLean, Virginia
Carol K. Cummings, Secretary, Office on Smoking and Health,
Rockville, Maryland

Stephanie D. DeVoe, Programmer, Information Systems Depart-
ment, ATLIS Federal Services, Inc., Rockville, Maryland
Michael C. Fiore, M.D., M.P.H., Medical Epidemiologist, Office on
Smoking and Health, Rockville, Maryland
David Fry, Editor, Smoking and Health Project, The Circle, Inc.,
McLean, Virginia

Lynn Funkhauser, Word Processing Specialist, Smoking and Health
Project, The Circle, Inc., McLean, Virginia
Mary Gardner, Senior Editor, Smoking and Health Project, The
Circle, Inc., McLean, Virginia

xvii


Amy Garson, M.P.H. student, Office on Smoking and Health,
Rockville: Maryland

-4rnetta G. Glover, Secretary, Office on Smoking and Health,
Rockville, Maryland

William Groskopf, Library Acquisitions Specialist, Information
Management Department, ATLIS Federal Services, Inc., Rock-
ville, Maryland

Evridiki Hatziandreu, M.D., M.P.H., Epidemic Intelligence Service
Officer, Office on Smoking and Health, Rockville, Maryland
Susan A. Hawk, Ed.M., M.S., Chief, Technical Information Center,
Office on Smoking and Health, Rockville, Maryland
Patricia E. Healy, Technical Information Specialist, Office on
Smoking and Health, Rockville, Maryland
Terri L. Henry, Clerk-Typist, Office on Smoking and Health.
Rockville, Maryland

Timothy K. Hensley, Technical Publications Writer, Office on
Smoking and Health, Rockville, Maryland
Shirley K. Hickman, Data Entry Operator, Information Manage-
ment Department, ATLIS Federal Services, Inc., Rockville, Mary-
land

Robert S. Hutchings, Associate Director for Information and Pro-
gram Development, Office on Smoking and Health, Rockville,
Maryland

Karen Jacob, Senior Editor, Smoking and Health Project, The Circle,
Inc., McLean, Virginia

Sheila Jones, Word Processing Specialist, Smoking and Health
Project, The Circle, Inc., McLean, Virginia
Rick Keir, Senior Editor, Smoking and Health Project, The Circle,
Inc., McLean, Virginia

Julie Kurz, Graphics Specialist, Information Management Depart-
ment, ATLIS Federal Services, Inc., Rockville, Maryland
Diana Lord, Research Assistant, Department of Medical Psychology,
Uniformed Services University of the Health Sciences, Bethesda,
Maryland

Gerri E. Mast, Secretary, Center for Health Promotion and Educa-
tion, Centers for Disease Control, Atlanta, Georgia
Judy J. Mast, Secretary, Center for Health Promotion and Educa-
tion, Centers for Disease Control, Atlanta, Georgia
Dixie McGough, Program Manager, Information Management De-
partment, ATLIS Federal Services, Inc., Rockville, Maryland
Paul G. McGovern, Ph.D., Postdoctoral Research Associate, Smoking
Research Group, Department of Psychology, Iowa State Universi-
ty, Ames, Iowa

Dan McLaughlin, Editorial Assistant, Smoking and Health Project,
The Circle, Inc., McLean, Virginia

. . .
xv111


Nancy Miltenberger, Editor. Smoking and Health Project, The
Circle, Inc., McLean, Virginia

Cathie O'Donnell, Senior Editor, Smoking and Health Project, The
Circle, Inc., McLean, Virginia

Ruth C. Palmer, Secretary, Office on Smoking and Health, Rockville,
Maryland

Russell D. Peek, Library Acquisitions Specialist, Information Man-
agement Department, ATLIS Federal Services, Inc., Rockville,
Mar.yland

Mary B. Pfeiffer, M.L.S., Librarian, Addiction Research Center,
National Institute on Drug Abuse, Baltimore, Maryland
Margaret E. Pickerel, Public Information and Publications Special-
ist, Office on Smoking and Health, Rockville, Maryland
Renate Phillips, Desktop Publishing/Graphic Artist, Smoking and
Health Project, The Circle, Inc., McLean, Virginia
Karen Sherman, Production Assistant, Information Management
Department, ATLIS Federal Services, Inc., Rockville, Maryland
Linda R. Spiegelman. Administrative Officer, Office on Smoking and
Health, Rockville, Maryland

Tamara Shipp, Publications Assistant, Smoking and Health Project,
The Circle, Inc., McLean, Virginia
Evelyn L. Swarr, Systems Management Projects Supervisor, Infor-
mation Systems Department, ATLIS Federal Services, Inc., Rock-
ville, Maryland

Patricia Y. Thomas, Secretary, Addiction Research Center, National
Institute on Drug Abuse, Baltimore, Maryland
Daniel R. Tisch, Project Director, Smoking and Health Project, The
Circle, Inc., McLean, Virginia

Louise G. Wiseman, Technical Information Specialist, Office on
Smoking and Health, Rockville, Maryland

xix


TABLE OF CONTENTS

Foreword ................................................................. i


Preface .................................................................. iii

Acknowledgments .................................................... ix

I. Introduction, Overview, Summary, and
  Conclusions . . . . . . . . . . . . . . . . . . ..**............................... 1

II. Nicotine: Pharmacokinetics, Metabolism, and Phar-
macodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

III. Nicotine: Sites and Mechanisms of Actions.. ........ .75


IV. Tobacco Use as Drug Dependence ..................... 145

V. Tobacco Use Compared to Other Drug
  Dependencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

VI. Effects of Nicotine That May Promote Tobacco
  Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377

$11. Treatment of Tobacco Dependence.. . . . . . . . . . . . . . . . . . . .459

Appendix A: Trends in Tobacco Use in the United
       States . . . . . , . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . .561

Appendix B: Toxicity of Nicotine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . 619

xxi


CHAPTER I

INTRODUCTION, OVERVIEW,
SUMMARY, AND CONCLUSIONS


CONTENTS

Introduction ............................................................ 5
Development and Organization of this Report ......... 5

Overview ................................................................ 6

Major Conclusions .................................................... 9

                                               .__-
Brief History Relevant to this Report .......................... 9

Chapter Conclusions ............................................... .13
  Chapter II:  Nicotine: Pharmacokinetics, Metabo-
         lism, and Pharmacodynamics ........... .13
  Chapter III: Nicotine: Sites and Mechanisms of
          Actions  ........................................ ,14
  Chapter IV: Tobacco Use as Drug Dependence.. ... .14
  Chapter V:  Tobacco Use Compared to Other Drug
         Dependencies ................................. .15
Chapter VI: Effects of Nicotine That May Promote
           Tobacco Use .................................. .15
Chapter VII: Treatment of Tobacco Dependence .... .15
  Appendix A: Trends in Tobacco Use in the United
           States .......................................... .16
  Appendix B: Toxicity of Nicotine  ....................... .16

References ............................................................ .18

3


Introduction
Development and Organization of this Report
This Report was developed by the Office on Smoking and Health,
Center for Health Promotion and Education, Centers for Disease
Control, Public Health Service of the U.S. Department of Health and
Human Services as part of the Department's responsibility, under
Public Law 91-222, to report new and current information on
smoking and health to the United States Congress.
The scientific content of this Report reflects the contributions of
more than 50 scientists representing a wide variety of relevant
disciplines. These experts, known for their understanding of and
work in specific content areas, prepared manuscripts for incorpora-
tion into this Report. The Office on Smoking and Health and its
consultants edited and consolidated the individual manuscripts into
appropriate chapters. These draft chapters were subjected to an
extensive outside peer review (see Acknowledgments for individuals
and their affiliations) whereby each chapter was reviewed by up to
11 experts. Based on the comments of these reviewers, the chapters
were revised and the entire volume was assembled. This revised
edition of the Report was resubjected to review by 20 distinguished
scientists inside and outside the Federal Government, both in this
country and abroad. Parallel to this review, the entire Report was
also submitted for review to 12 institutes and agencies within the
U.S. Public Health Service. The comments from the senior scientific
reviewers and the agencies were used to prepare the final volume of
this Report.
This Report contains a Foreword by the Assistant Secretary for
Health, a Preface by the Surgeon General of the U.S. Public Health
Service, and the following chapters and appendices:

  Chapter I.  Introduction. Overview, Summary, and Conclu-
           sions
Chapter II. Nicotine: Pharmacokinetics, Metabolism, and
        Pharmacodynamics
Chapter III. Nicotine: Sites and Mechanisms of Actions
Chapter IV. Tobacco Use as Drug Dependence
Chapter V. Tobacco Use Compared to Other Drug
         Dependencies
Chapter VI. Effects of Nicotine That May Promote Tobacco
          Use
Chapter VII. Treatment of Tobacco Dependence
Appendix A. Trends in Tobacco Use in the United States
Appendix B. Toxicity of Nicotine


Overview

This Report of the Surgeon General on tobacco and health focuses
on the pharmacologic basis of tobacco addiction. Previous Surgeon
General's Reports have reviewed the medical and scientific evidence
establishing that cigarette smoking and tobacco use in other forms
are deleterious to health. Several reports emphasized particular
diseases (e.g., 1982 Report on cancer (US DHHS 1982), 1983 Report
on cardiovascular disease (US DHHS 1983a), 1984 Report on chronic
obstructive lung disease (US DHHS 1984a)); some reports concentrat-
ed on specific populations (e.g., 1980 Report on women (US DHHS
1980)); and some reports dealt with particular aspects of smoking
(e.g., 1986 Report on involuntary smoking (US DHHS 1986a)). These
reports have been important because so many individuals engage in
a behavior that causes morbidity and premature mortality.

The present Report addresses a central issue of the tobacco and
health problem: Why do people smoke and in other ways consume
tobacco products? Specifically, this Report reviews the pharmacolog-
ic basis of the disease-producing and life-threatening behavior of
tobacco use. Psychological and social factors are also important
influences on tobacco use, but a detailed review of these factors is
beyond the scope of this Report. Reviews of this literature include
previous reports of the Surgeon General (US DHEW 1979; US DHHS
1980, 1982, 1983a, 1984a), research monographs from the National
Institute on Drug Abuse (NTDA) (Jarvik et al. 1977; Krasnegor 1978,
1979a,b,c; Grabowski and Bell 1983), and articles by scientists who
study tobacco use and nicotine (Russell 1971, 1976; Gritz 1980;
Henningfield 1984).

This Report reviews evidence that tobacco use is addicting and
that nicotine is the active pharmacologic agent of tobacco that causes
this addictive behavior. Previous Surgeon General's Reports have
focused on evidence that cigarette smoking and tobacco use are
health hazards. Now that those relationships are well-documented
and well-known, this Report addresses addictive properties of
cigarette smoking and tobacco use in order to help develop more
effective prevention and cessation programs.

This Report topic is particularly timely because of recent advances
and extensive data gathered in the 1980s relevant to the issue of
tobacco addiction. Since the early 1900s scientific literature and
historical anecdotes have provided evidence that tobacco use is a
form of drug addiction. In the 1970s however, research efforts
increased considerably on various aspects of tobacco addiction,
including nicotine pharmacokinetics, pharmacodynamics, self-ad-
ministration, withdrawal, dependence, and tolerance. In addition,
advances in the neurosciences have begun to reveal effects of
nicotine in the brain and body that may help to explain why tobacco
use is reinforcing and difficult to give up. These issues are addressed

6


in this Report. Finally, recent developments in the use of nicotine
replacement in smoking cessation emphasize the importance of
pharmacologic aspects of cigarette smoking.

Concepts of drug addiction or drug dependence are discussed in
detail in Chapters IV and V. It is useful to begin this Report with a
brief summary of main points about drug dependence that provide
the foundation for the findings of the Report.

The terms "drug addiction" and "drug dependence" are scientifi-
cally equivalent: both terms refer to the behavior of repetitively
ingesting mood-altering substances by individuals. The term "drug
dependence" has been increasingly adopted in the scientific and
medical literature as a more technical term, whereas the term "drug
addiction" continues to be used by NIDA and other organizations
when it is important to provide information at a more general level.
Throughout this Report, both terms are used and they are used
synonymously.

The main conclusions of the Report are based upon concepts of
drug dependence that have been developed by expert committees of
the World Health Organization, as well as in publications of NIDA
and the American Psychiatric Association. These concepts were used
to develop a set of criteria to determine whether tobacco-delivered
nicotine is addicting. The criteria for drug dependence include
primary and additional indices and are summarized below.

CRITERIA FOR DRUG DEPENDENCE

Primary Criteria
. Highly controlled or compulsive use
. Psychoactive effects
. Drug-reinforced behavior

Additional Criteria

. Addictive behavior often involves:
  -stereotypic patterns of use
  -use despite harmful effects
  -relapse following abstinence
  -recurrent drug cravings
. Dependence-producing drugs often produce:
  -tolerance
  -physical dependence
  -pleasant (euphoriantl ef'fects

The primary crit.eria listed above are sufficient to define drug
dependence. Highly controlled or compulsive use indicates that drug-


seeking and drug-taking behavior is driven by strong, often irresisti-
ble urges. It can persist despite a desire to quit or even repeated
attempts to quit. Such behavior is also referred to as "habitual"
behavior. To distinguish drug dependence from habitual behaviors
not involving drugs, it must be demonstrated that a drug with
psychoactive (mood-altering) effects in the brain enters the blood
stream. Furthermore, drug dependence is defined by the occurrence
of drug-motivated behavior; therefore, the psychoactive chemical
must be capable of functioning as a reinforcer that can directly
strengthen behavior leading to further drug ingestion.

Additional criteria are often used to help characterize drug
dependence. Several are associated with the drug-taking behavior
itself': (1) the behavior may develop into regular temporal and
physical patterns of use (repetitive and stereotypic); (2) drug use may
persist despite adverse physical, psychological, or social conse-
quences; (3) quitting episodes are often followed by resumption of
drug use (relapse); (4) urges (cravings) to use the drug may be
recurrent and persistent, especially during drug abstinence. Similar-
ly, several common effects of dependence-producing drugs can
strengthen their control over behavior and increase the likelihood of
harm by contributing to the regularity and overall level of drug
intake: (1) diminished responsiveness (tolerance) to the effects of a
drug occurs, and may be accompanied by increased intake over time;
(2) abstinence-associated withdrawal reactions (due to physical
dependence) can motivate further drug intake; (3) effects that are
considered pleasant (euphoriant) to the drug user can be provided by
the drug itself. Dependence-producing drugs can also produce effects
that individuals find useful. For example, many addicting drugs
have therapeutic uses in medical treatments of various disorders.
Most medically approved drugs that are addicting, however, are
generally only available by prescription. Effects of a drug considered
by the individual to be useful can promote initiation of drug use,
strengthen the addiction, and contribute to relapse following cessa-
tion of use.

Tobacco and nicotine are considered in the Report in light of the
above criteria. In brief, the organization of the Report is as follows:
review of evidence that tobacco use is accompanied by orderly
patterns of uptake of nicotine in the body and brain resulting in the
development of tolerance (Chapter II); review of how effects of
nicotine in the brain and the rest of the body are chemically
mediated (Chapter 1111; review of the evidence that tobacco is
addicting and that nicotine is an addicting drug (Chapter IV);
comparison of tobacco use with other addictions and of nicotine with
other addicting drugs (Chapter VI: review of possible effects of
nicotine that may promote the use of tobacco and present impedi-
ments to quitting smoking (Chapter VII; review of strategies for

8


helping people to achieve and maintain tobacco abstinence (Chapter
VII). In addition, appendices are included that summarize informa-
tion regarding trends in tobacco use (Appendix A) and information
regarding the toxicity of nicotine itself (Appendix BI. A summary of
the main findings of the Report follows.

Major Conclusions

   1.  Cigarettes and other forms of tobacco are addicting.

2.  Nicotine is the drug in tobacco that causes addiction.

3.  The pharmacologic and behavioral processes that
  determine tobacco addiction are similar to those that
determine addiction to drugs such as heroin and
  cocaine.

Brief History Relevant to this Report

Tobacco products have been used for centuries. The tobacco plant
was native to the New World. The oldest cited evidence of tobacco
use appears on a Mayan stone carving dated from 600 to 900 A.D.
There are reports of tobacco smoking in Christopher Columbus'
diary in 1492; reports of tobacco smoking appear in the logs of other
European explorers of the New World in the 16th century. Since the
colonial period, tobacco has been an integral part of the American
economy (Robert 19491.

Tobacco use permeated the New World and quickly spread
throughout the rest of the world during the 16th and 17th centuries.
As use of tobacco products spread, so did controversy over the effects
of these products. Throughout history, while some persons extolled
the virtues of tobacco (including numerous alleged medicinal uses),
others condemned its use. George Washington is attributed with
exhorting the home front during the Revolutionary War, "If you
can't send money, send tobacco." In contrast, Dr. Benjamin Rush
condemned tobacco use in his 1798 book Essa,vs. The controversy
continued into the 19th century with no convincing scientific or
medical evidence to support either position (Robert 1949).

In 1856-57 the British medical journal Lancet published opinions
of 50 physicians on tobacco use. Many opponents attributed in-
creased crime, nervous paralysis, loss of intellectual abilities, and
visual impairment to tobacco use-all of these claims lacked
convincing evidence. In restating the main arguments of the tobacco
proponents, the Lancet editors wrote that tobacco use "...must have
some good or at least pleasurable effects; that, if its evil effects were

9


so dreadful as stated the human race would have ceased to exist"
(Lancet 1857).

While the health-promoting and health-damaging effects of tobac-
co products were being debated throughout the 17th and 18th
centuries, scientists were trying to determine the chief active
ingredient in tobacco. In the early 1800s the oily essence of tobacco
was discovered by Cerioli and by Vauquelin. This active substance
was named "Nicotianine," after Jean Nicot, who sent tobacco seeds
from Portugal to the French court at the end of the 16th century. In
1828, Posselt and Reimann at the University of Heidelberg isolated
the pure form of Nicotianine and renamed it, "Nikotin." The
chemical's empirical formula, C10H,4N2, was determined in the
184Os, and "nicotine" was synthesized in the 1890s (Robert 1949).

Since the late 1800s research on the pharmacologic actions of
nicotine has contributed substantially to basic information about the
nervous system (Kharkevich 1980; Volle 1980). The classic work by
Langley and Dickinson (18891 on nicotine's effects in autonomic
ganglia led to the postulates that chemicals transmit information
between neurons and that there are receptors on cells that respond
functionally to stimulation by specific chemicals. As early as the
1920s and 1930s some investigators were concluding that nicotine
was responsible for the compulsive use of tobacco products (Arm-
strong-Jones 1927; Dorsey 1936; Lewin 1931). Johnston (1942)
concluded that, "smoking tobacco is essentially a means of adminis-
tering nicotine, just as smoking opium is a means of administering
morphine."

Throughout the 20th century, research has continued to investi-
gate the role of nicotine in tobacco use. The 1964 Report of the
Surgeon General's Advisory Committee on Smoking and Health (US
PHS 19641 held that: "The habitual use of tobacco is related
primarily to psychological and social drives, reinforced and perpetu-
ated by the pharmacologic actions of nicotine on the central nervous
system. Nicotine-free tobacco or other plant materials do not satisfy
the needs of those who acquire the tobacco habit." The 1964 Report,
relying upon a distinction (that is no longer made) between
"habituating" and "addicting" drugs. asserted that tobacco was
habituating and not addicting. The distinction in 1964 between
habituating drugs iincluding cocaine and amphetamines) and addict-
ing drugs (including opiates and barbiturates) was based on: (1)
whether the drug produced clear physical dependence; (2) whether
damage was mainly to the individual user (habituating drugs) or to
society (addicting drugs); and (3) the strength of the habitual
behavior that developed. There was no question at the time of the
1964 Report that nicotine was the critical pharmacologic agent for
tobacco use, but its role was then considered to be more similar to
cocaine and amphetamines than to opiates and barbiturates. Later

10


in 1964 the World Health Organization dropped this semantic
distinction between habituating and addicting drugs because it was
recognized that habitual use could be as strongly developed for
cocaine as for morphine. that social damage generally accompanied
personal damage, and that behavioral characteristics of drug use
could be similar for the so-called habituating and addicting drugs. In
an effort to shift the focus to dependent patterns of behavior and
away from moral and social issues associated with the term
addiction, the term dependence was recommended.

It is now clear that even by the earlier distinction in nomencla-
ture, cigarettes and other forms of tobacco are addicting and actions
of nicotine provide the pharmacologic basis of tobacco addiction. The
term "dependence producing" may also be used to describe cigarettes
and other forms of tobacco use, analogous to actions of other drugs
(e.g., opiates, cocaine). Since 1964, considerable additional evidence
has been compiled that substantiates these conclusions. The present
Report reviews this information and the relevant literature.

Previous Surgeon General's Reports provided current reviews of
the health consequences of cigarette smoking particularly relevant
to public health. For example, despite the accumulating evidence, in
the early 1960s there was little recognition by the public of the
health hazards of smoking. Each Report examined specific informa-
tion considered to be important for public dissemination. A brief
review of topics addressed in these reports provides the background
for the present Report.

In the late 195Os, the U.S. Public Health Service, the National
Cancer Institute, the National Heart Institute, the American Cancer
Society, and the American Heart Association appointed a study
group to examine the available evidence on smoking and health.
This study group concluded that excessive cigarette smoking is a
causative factor in lung cancer.

In 1962, Surgeon General Luther Terry established an advisory
committee on smoking and health. This committee released its
Report on January 11, 1964, concluding that cigarette smoking is a
cause of lung cancer in men and a suspected cause of lung cancer in
women, and increased the risk of dying from pulmonary emphysema.
The next Report was issued in 1967 (US PHS 1968a) and stated that
"the case for cigarette smoking as the principal cause of lung cancer
is overwhelming." Further, the 1967 Report concluded that: "There
is an increasing convergence of many types of evidence . . . which
strongly suggests that cigarette smoking can cause death from
coronary heart disease." The 1967 Report also concluded that
"Cigarette smoking is the most important of the causes of chronic
non-neoplastic bronchopulmonary disease in the United States."

The 1968 and 1969 Reports (US PHS 1968b, 1969) strengthened
the conclusions reached in 1967. The 1971 Report provided a detailed

11


review of the evidence to date regarding health consequences of
smoking (US DHEW 1971). The subsequent reports (1972 to 1976)
continued to review the increasing evidence associating cigarette
smoking with many health hazards. The 1972 Report also discussed
involuntary or passive smoking (US DHEW 1972). The 1973 Report
included some data on the health hazards of smoking pipes and
cigars (US PHS 1973). The 1975 Report updated information on the
health effects of involuntary or passive smoking (US DHEW 1975).
The combined 1977-78 Report discussed smoking-related problems
unique to women (US DHEW 1978).
At the time of its release, the 1979 Report was the most
comprehensive review by a Surgeon General's Report of the health
consequences of smoking, smoking behavior, and smoking control. In
addition to providing a thorough review of the health consequences
of smoking, the 1979 Report discussed the health consequences of
using forms of tobacco other than cigarettes (pipes, cigars, and
smokeless tobacco). Moreover, the 1979 Report expanded the scope of
the previous reports and examined behavioral, pharmacologic, and
social factors influencing the initiation, maintenance, and cessation
of cigarette smoking. Relevant to the topic of the present Report, the
1979 Report concluded that "it is no exaggeration to say that
smoking is the prototypical substance-abuse dependency and that
improved knowledge of this process holds great promise for preven-
tion of risk." Since the release of the 1979 Report, each subsequent
Report has focused on a specific population or setting (women in
1980 (US DHHS 19801, the workplace in 1985 (US DHHS 1985)), a
specific topic (health effects of low-tar and low-nicotine cigarettes in
1981 (US DHHS 19811, involuntary smoking in 1986 (US DHHS
1986a)), or a specific disease (cancer in 1982 (US DHHS 19821,
cardiovascular diseases in 1983 (US DHHS 1983aL chronic obstruc-
tive lung disease in 1984 (US DHHS 1984al).
In addition to the previous Surgeon General's Reports, several
other developments and publications provide relevant background
for the present Report. For example, numerous monographs pre-
pared in the 1970s by the National Institute on Drug Abuse (NIDA)
considered tobacco use as a form of drug dependence. In 1980, the
American Psychiatric Association, in its Diagnostic and Statistical
Manual of Mental Disorders, included tobacco dependence as a
substance abuse disorder and tobacco withdrawal as an organic
mental disorder (APA 1980). The 1987 revised edition of this manual
tAPA 1987), in recognition of the role of nicotine, changed "tobacco
withdrawal" to "nicotine withdrawal." In 1982, the Director of NIDA
testified to Congress that the position of NIDA was that tobacco use
could lead to dependence and that nicotine was a prototypic
dependence-producing drug. In a 1983 publication, "Why People
Smoke Cigarettes," the U.S. Public Health Service supported this


position of NIDA regarding tobacco and nicotine (US DHHS 1983133.
In the 1984 NIDA Triennial Report to Congress, nicotine was labeled
a prototypic dependence-producing drug and the role of nicotine in
tobacco use was considered to be analogous to the roles of morphine,
cocaine, and ethanol, in the use of opium, coca-derived products, and
alcoholic beverages, respectively (US DHHS 1984b3. In 1986, a
consensus conference of the National Institutes of Health and the
Report of the Advisory Committee to the Surgeon General on the
health consequences of using smokeless tobacco concluded that
smokeless tobacco can be addicting and that nicotine is a depen-
dence-producing (i.e., addicting) drug (US DHHS 1986b).

The present Report is the 20th such report issued by the Public
Health Service on the health consequences of tobacco use. The
deleterious effects of cigarette smoking are now well known.
Therefore, this Report focuses on pharmacologic information to help
understand why people smoke. Such information will assist health
professionals in developing effective strategies to prevent initiation
and to promote cessation. The literature reviewed in this Report
indicates that tobacco use is an addictive behavior. It is the purpose
of this Report to thoroughly review the relevant literature.

Chapter Conclusions

In addition to the three overall conclusions of this Report, there
are many other substantive conclusions. These points are listed
under the appropriate Chapter and Appendix headings.

Chapter II: Nicotine: Pharmacokinetics, Metabolism, and Phar-
macodynamics

1. All tobacco products contain substantial amounts of nicotine
and other alkaloids. Tobaccos from low-yield and high-yield
cigarettes contain similar amounts of nicotine.
2. Nicotine is absorbed readily from tobacco smoke in the lungs
and from smokeless tobacco in the mouth or nose. Levels of
nicotine in the blood are similar in magnitude in people using
different forms of tobacco. With regular use, levels of nicotine
accumulate in the body during the day and persist overnight.
Thus, daily tobacco users are exposed to the effects of nicotine
for 24 hr each day.

3. Nicotine that enters the blood is rapidly distributed to the
brain. As a result, effects of nicotine on the central nervous
system occur rapidly after a puff of cigarette smoke or after
absorption of nicotine from other routes of administration.
4. Acute and chronic tolerance develops to many effects of
nicotine. Such tolerance is consistent with reports that initial

13


use of tobacco products, such as in adolescents first beginning
to smoke. is usually accompanied by a number of unpleasant
symptoms which disappear following chronic tobacco use.

Chapter III: Nicotine: Sites and Mechanisms of Actions

1. Nicotine is a powerful pharmacologic agent that acts in the
brain and throughout the body. Actions include electrocortical
activation, skeletal muscle relaxation, and cardiovascular and
endocrine effects. The many biochemical and electrocortical
effects of nicotine may act in concert to reinforce tobacco use.
2. Nicotine acts on specific binding sites or receptors throughout
the nervous system. Nicotine readily crosses the blood-brain
barrier and accumulates in the brain shortly after it enters the
body. Once in the brain, it interacts with specific receptors and
alters brain energy metabolism in a pattern consistent with the
distribution of specific binding sites for the drug.

3. Nicotine and smoking exert effects on nearly all components of
the endocrine and neuroendocrine systems (including catechol-
amines, serotonin, corticosteroids, pituitary hormones). Some
of these endocrine effects are mediated by actions of nicotine
on  brain  neurotransmitter  systems (e.g., hypothalam-
ic-pituitary axis). In addition, nicotine has direct peripherally
mediated effects (e.g., on the adrenal medulla and the adrenal
cortex).

Chapter IV: Tobacco Use as Drug Dependence

1. Cigarettes and other forms of tobacco are addicting. Patterns of
tobacco use are regular and compulsive, and a withdrawal
syndrome usually accompanies tobacco abstinence.

2. Nicotine is the drug in tobacco that causes addiction. Specifi-
cally, nicotine is psychoactive ("mood altering") and can
provide pleasurable effects. Nicotine can serve as a reinforcer
to motivate tobacco-seeking and tobacco-using behavior. Toler-
ance develops to actions of nicotine such that repeated use
results in diminished effects and can be accompanied by
increased intake. Nicotine also causes physical dependence
characterized by a withdrawal syndrome that usually accompa-
nies nicotine abstinence.

3. The physical characteristics of nicotine delivery systems can
affect their toxicity and addictiveness. Therefore, new nicotine
delivery systems should be evaluated for their toxic and
addictive effects.

14


Chapter V: Tobacco Use Compared to Other Drug Dependen-
cies

1. The pharmacologic and behavioral processes that determine
tobacco addiction are similar to those that determine addiction
to drugs such as heroin and cocaine.
2. Environmental factors including drug-associated stimuli and
social pressure are important influences of initiation, patterns
of use, quitting, and relapse to use of opioids, alcohol, nicotine,
and other addicting drugs.

3. Many persons dependent upon opioids, alcohol, nicotine, or
other drugs are able to give up their drug use outside the
context of treatment programs; other persons, however, re-
quire the assistance of formal cessation programs to achieve
lasting drug abstinence.

4. Relapse to drug use often occurs among persons who have
achieved abstinence from opioids, alcohol, nicotine, or other
drugs.

5. Behavioral and pharmacologic intervention techniques with
demonstrated efficacy are available for the treatment of
addiction to opioids, alcohol, nicotine, and other drugs.

Chapter VI: Effects of Nicotine That May Promote Tobacco
Dependence

1. After smoking cigarettes or receiving nicotine, smokers per-
form better on some cognitive tasks (including sustained
attention and selective attention) than they do when deprived
of cigarettes or nicotine. However, smoking and nicotine do not
improve general learning.

2. Stress increases cigarette consumption among smokers. Fur-
ther, stress has been identified as a risk factor for initiation of
smoking in adolescence.

3. In general, cigarette smokers weigh less (approximately 7 lb
less on average) than nonsmokers. Many smokers who quit
smoking gain weight.

4. Food intake and probably metabolic factors are involved in the
inverse relationship between smoking and body weight. There
is evidence that nicotine plays an important role in the
relationship between smoking and body weight.

Chapter VII: Treatment of Tobacco Dependence

1. Tobacco dependence can be treated successfully.
2. Effective interventions include behavioral approaches alone
and behavioral approaches with adjunctive pharmacologic
treatment.

15


3. Behavioral interventions are most effective when they include
multiple components (procedures such as aversive smoking,
skills training, group support, and self-reward). Inclusion of too
many treatment procedures can lead to less successful out-
come.

4. Nicotine replacement can reduce tobacco withdrawal symp-
toms and may enhance the efficacy of behavioral treatment.

Appendix A: Trends in Tobacco Use in the United States

1. An estimated 32.7 percent of men and 28.3 percent of women
smoked cigarettes regularly in 1985. The overall prevalence of
smoking in the United States decreased from 36.7 percent in
1976 (52.4 million adults) to 30.4 percent in 1985 (51.1 million
adults).

2. In 1985, the mean reported number of cigarettes smoked per
day was 21.8 for male smokers and 18.1 for female smokers.
3. Smoking is more common in lower socioeconomic categories
(blue-collar workers or unemployed persons, less educated
persons, and lower income groups) than in higher socioeconom-
ic categories. For example, the prevalence of smoking in 1985
among persons without a high school diploma was 35.4 percent,
compared with 16.5 percent among persons with postgraduate
college education.

4. An estimated 18.7 percent of high school seniors reported daily
use of cigarettes in 1986. The prevalence of daily use of one or
more cigarettes among high school seniors declined between
1975 and 1986 by approximately 35 percent. Most of the decline
occurred between 1977 and 1981. Since 1976, the smoking
prevalence among females has consistently been slightly
higher than among males.

5. The use of cigars and pipes has declined 80 percent since 1964.
6. Smokeless tobacco use has increased substantially among
young men and has declined among older men since 1975. An
estimated 8.2 percent of 17- to 19-year-old men were users of
smokeless tobacco products in 1986.

Appendix B: Toxicity of Nicotine

1. At high exposure levels, nicotine is a potent and potentially
lethal poison. Human poisonings occur primarily as a result of
accidental ingestion or skin contact with nicotine-containing
insecticides or, in children, after ingestion of tobacco or tobacco
juices.

2. Mild nicotine intoxication occurs in first-time smokers, non-
smoking workers who harvest tobacco leaves, and people who

16


chew excessive amounts of nicotine polacrilex gum. Tolerance
to these effects develops rapidly.

3. Nicotine exposure in long-term tobacco users is substantial,
affecting many organ systems (Chapters II and III). Pharmace
logic actions of nicotine may contribute to the pathogenesis of
smoking-related diseases, although direct causation has not yet
been determined. Of particular concern are cardiovascular
disease, complications of hypertension, reproductive disorders,
cancer, and gastrointestinal disorders, including peptic ulcer
disease and gastroesophageal reflux.

4. The risks of short-term nicotine replacement therapy as an aid
to smoking cessation in healthy people are acceptable and
substantially outweighed by the risks of cigarette smoking.

17


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20


CHAPTER II

NICOTINE: PHARMACOKINETICS,
    METABOLISM, AND
   PHARMACODYNAMICS


CONTENTS

            ___
Introduction ........................................................... 25

                                        ~-~
Nicotine and Other Alkaloids in Various Tobacco Prod-
ucts ................................................................... 26

Pharmacokinetics and Metabolism of Nicotine ............ .29
  Absorption of Nicotine ..................................... .29
  Distribution of Nicotine in Body Tissues ............. ..3 1
  Elimination of Nicot.ine                    33
                         .......................................
    Pathways of Nicotine Metabolism ................  34
    Rate of Nicotine Metabolism ........................ .37
     Renal Excretion ....................................... .37
Nicotine and Cotinine Blood Levels During Tobacco
   Use .............................................................. 37
     Nicotine Levels ........................................... 37
     Cotinine Levels ........................................... 38
  Intake of Nicotine ............................................. 40
    Cigarette Smoking ...................................... .40
    Elimination Rate as a Determinant of Nicotine
     Intake by Cigarette Smoking .................... .40
    Biochemical Markers of Nicotine Intake ........ .41
Analytical Methods for Measuring Nicotine and
    Cotinine in Biological Fluids ............................ .42

Pharmacodynamics of Nicotine ................................. .43
  General Considerations ....................................... 43
Dose-Response .................................................. .44
  Tolerance ......................................................... 44

  Acute Sensitivity .............................................. .46
     Human Studies ........................................... 46
     Animal Studies ........................................... 46
    Mechanisms of Differences in Acute
     Sensitivity. .............................................. 47
  Tachyphylaxis (Acute Tolerance) ......................... .47
     Human Studies .......................................... .47
     Animal Studies ........................................... 49
    Mechanisms of Tachyphylaxis ...................... .49
  Chronic Tolerance ............................................. .50
     Human Studies. ......................................... .50

23


   Animal Studies ........................................... 51
  Mechanisms of Chronic Tolerance ................. .53
Pharmacodynamics of Nicotine and Cigarette Smok-
ing ............................................................... 55

Constituents of Tobacco Smoke Other Than Nicotine
With Potential Behavioral Effects .......................... .56
  Minor Tobacco Alkaloids .................................... .56
  "Tar" and Selected Constituents of Tobacco Smoke
   Which Contribute to Taste and Aroma .............. .58
  Carbon Monoxide ............................................... 59
Acetaldehyde and Other Smoke Constituents ......... .60

Summary and Conclusions ....................................... .60

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

24


introduction

Chemicals with behavioral and physiological activity are delivered
to tobacco users when they smoke a cigarette or use other tobacco
products. Whether these chemicals are absorbed in quantities that
are of biological significance and whether such absorption is related
to the behavior of the tobacco user are critical issues in understand-
ing their role in addictive tobacco use. The scientific study of the
absorption processes, distribution within the body, and elimination
from the body of drugs and chemicals is called pharmacokinetics.
The study of drug and other chemical actions on the body, over time,
is called pharmacodynamics.

Pharmacokinetic and pharmacodynamic studies can be done
separately or together. An example of the latter is when a drug is
administered and its concentrations in the blood and its behavioral
and physiological actions are measured over time. Such studies can
reveal relationships among the dose of a drug, levels in the blood,
and effects on body functions.

The pharmacokinetics and pharmacodynamics of some tobacco
smoke constituents, particularly nicotine and carbon monoxide, have
been extensively studied. These studies show an orderly relationship
between the use of tobacco and the absorption of nicotine. Similarly,
the effects on behavioral and physiological functions, although
complex, are orderly and related to the pharmacokinetics of nicotine.
These data will be reviewed in this Section. Research shows that
nicotine is well absorbed from tobacco; that it is distributed rapidly
and in biologically active concentrations to body organs, including
the brain; and that nicotine is the major cause of the predominant
behavioral effects of tobacco and some of its physiologic conse-
quences.

One effect of nicotine, development of tolerance to its own actions,
is similar to that produced by other addicting drugs. Tolerance refers
to decreasing responsiveness to a drug or chemical such that larger
doses are required to produce the same magnitude of effect.
Tolerance to many actions of nicotine occurs in animals and humans.
Evidence for tolerance to nicotine and mechanisms of tolerance
development will be reviewed in this Chapter (see also Chapter VI).

Although nicotine has long been considered as the primary
pharmacologic reason for tobacco use, and the source of a number of
the physiological effects of tobacco, thousands of other chemicals are
present in tobacco. Most of these are delivered in such small
quantities that they appear to have little OF no behavioral conse-
quence. However, a few chemicals do appear to have behavioral
effects and there is a potential for numerous chemical interactions
that conceivably could have behavioral consequences. This Chapter
will conclude with an examination of tobacco smoke constituents

25


other than nicotine that rnay contribute to behavioral effects of
cigarette smoking.

The toxicity of nicotine is discussed in detail in Appendix B.

Nicotine and Other Alkaloids in Various Tobacco Products

Nicotine is a tertiary amine composed of a pyridine and a
pgrrolidine ring (Figure 1). Nicotine may exist in two different three-
dimensionally structured shapes,  called stereoisomers. Tobacco
contains only (S)-nicotine (also called l-nicotine), which is the most
pharmacoloqicaliy active form. Tobacco smoke also contains the less
potent (Rj-nicotine (also called d-nicotine) in quantities up to 10
percent of the total nicotine present (Pool, Godin, Crooks 1985).
Presumably some racemization occurs during the combustion pro-
cess.

The nicotine yield of cigarettes, as determined by standardized
smoking machine tests, is available for most brands. However, the
amount of nicotine in cigarettes or other tobacco products is not
specified by manufacturers. Because tobacco is a plant product, there
are differences in the amount of nicotine among and within different
types and strains of tobacco, including variations in different parts of
the plant, as well as differences related to growing conditions. Table
1 shows concentrations of nicotine and other alkaloids in several
different tobacco leaves used in making commercial tobacco prod-
ucts. Witliin a tobacco plant, leaves harvested from higher stalk
positions have higher concentrations of nicotine than from lower
stalk positions; ribs and stems of the leaves have the least (Rath-
kamp, Tso, Hoffmann 19731. Combining different varieties of tobacco
and different parts of the plant is a way to change the nicotine
concentration of commercial tobacco.

In a study of amounts of nicotine in the tobacco of 15 American
cigarette brands of differing machine-determined yields (Benowitz,
Hall et al. 19831, tobacco contained on average 1.5 percent nicotine
by weight. Nicotine yield of the cigarettes, as defined by Federal
Trade Commission smoking machine tests, was correlated inversely
with nicotine concentrations in the tobacco. Thus. tobacco of lower-
yield cigarettes tended to have higher concentrations of nicotine
than did tobacco of higher-yield cigarettes. However, lower-yield
cigarettes also contained less tobacco per cigarette, so the total
amount of nicotine contained per cigarette, averaging 8.4 mg, was
similar in different brands. Thus, low-yield cigarettes are low yield
not because of lower concentrations of nicotine in the tobacco, but
because they contain less tobacco and have characteristics which
remove tar and nicotine by filtration or dilution of smoke with air.
Concentrations of nicotine in commercial tobacco products are
summarized in Table 2.

26


NICOTINE

NORNICOTINE

N'-NITROSONORNICOTINE

NICOTINE N-OXIDE
(OXYNlCOTINEl

ANATAGINE        ANABASINE

N'-METHYLANATABINE   N`-METHYLANABASINE

NIMTYRINE       NORNICOTYRINE

COTININE       6'.OXOANABASINE

ANABASEINE

2.3'.DIPYPIDYL

METANICOTINE

PSEUDCOXYNICOTINE

FIGURE L-Chemical structures of nicotine and minor
        tobacco alkaloids
sOL'K(`E IRIP IY*:i

Although the major alkaloid in t.obacco is nicotine, there are other
alkaloids in tobacco which may be of pharmacologic importance.
These include nornicotine, anabasine, myosmine, nicotyrine, and
anatabine (Figure 1). These substances make up 8 to 12 percent of
the total alkaloid content of tobacco products (Table 1) (Piade and
Hoffmann 1980). In some varieties of tobacco, nornicotine concentra-
tions exceed those of nicotine (Schmeltz and Hoffmann 1977).

Typical quantities of the minor alkaloids in the smoke of one
cigarette are: nornicotine (27 to 88 pg), cotinine (9 to 50 pg),
anabasine (3 to 12 pgl, anatabine (4 to 14 pg). myosmine (9 pg), and
2,3' dipyridyl (7 to 27 pg). N'-methylanabasine, nicotyrine, nornicoty-
rine, and nicotine-N'-oxide have also been identified in cigarette
smoke (Schmeltz and Hoffmann 1977). Puffing characteristics,
especially puff frequency, influence the delivery of the component
alkaloids (Bush, Griinwald, Davis 1972).

27


TABLE l.-Alkaloid content of various tobaccos (mg/kg,
      dry basis)

Dar-k commercial tobacco

Anstabme              360       3x0       570       600

Anabasine

140       150        99       150

cotlnlne                195       140        90        40

M\oam,ne               45        50        60        30

2.3 -Dlpwld~l             1w       110        30        10

TABLE 2.-Nicotine content of various tobacco products

Nornicotine and anabasine have pharmacologic activity qualita-
tively similar to that of nicotine, with potencies of 20 to 75 percent
compared with that of nicotine, depending on the test system and the
animal (Clark, Rand, Vanov 1965). In addition to direct activity,
some of the minor alkaloids may influence the effects of nicotine. For
example, nicotyrine inhibits the metabolism of nicotine in animals
(Stalhandske and Slanina 1982).

The pharmacology of the minor tobacco alkaloids is discussed in
more detail in the last section of this Chapter.

28


Pharmacokinetics and Metabolism of Nicotine

Absorption of Nicotine

Nicotine is distilled from burning tobacco and is carried proximal-
ly on tar droplets (mass median diameter 0.3 to 0.5 urn) and probably
also in the vapor phase (Eudy et al. 19851, which are inhaled.
Absorption of nicotine across biological membranes depends on pH
(Armitage and Turner 1970; Schievelbein et al. 1973). Nicotine is a
weak base with a pKa (index of ionic dissociation) of 8.0 (aqueous
solution, 25oC). This means that at pH 8.0, 50 percent of nicotine is
ionized and 50 percent is nonionized. In its ionized state, such as in
acidic environments, nicotine does not rapidly cross membranes.

The pH of tobacco smoke is important in determining absorption
of nicotine from different sites within the body. The pH of individual
puffs of cigarettes made of flue-cured tobacco, the predominant
tobacco in most American cigarettes, is acidic and decreases progres-
sively with sequential puffs from pH 6.0 to 5.5 (Brunnemann and
Hoffmann 1974). At these pHs, the nicotine is almost completely
ionized. As a consequence, there is little buccal absorption of nicotine
from cigarette smoke, even when it is held in the mouth (Gori,
Benowitz, Lynch 1986). The smoke from air-cured tobaccos, the
predominant tobacco in pipes, cigars, and in a few European
cigarettes, is alkaline with progressive puffs increasing its pH from
6.5 to 7.5 or higher (Brunneman and Hoffmann 1974). At alkaline
pH, nicotine is largely nonionized and readily crosses membranes.
Nicotine from products delivering smoke of alkaline pH is well
absorbed through the mouth (Armitage et al. 1978; Russell, Raw,
Jarvis 1980).

When tobacco smoke reaches the small airways and alveoli of the
lung, the nicotine is rapidly absorbed. The rapid absorption of
nicotine from cigarette smoke through the lung occurs because of the
huge surface area of the alveoli and small airways and because of
dissolution of nicotine at physiological pH (approximately 7.4), which
facilitates transfer across cell membranes. Concentrations of nic-
otine in blood rise quickly during cigarette smoking and peak at its
completion (Figure 2). Armitage and coworkers (19751, measuring
exhalation of radiolabeled nicotine, found that four cigarette smok-
ers absorbed 82 to 92 percent of the nicotine in mainstream smoke,
another smoker presumed to be a noninhaler absorbed 29 percent,
and three nonsmokers (who were instructed to smoke as deeply as
possible) absorbed 30 to 66 percent.

Chewing tobacco, snuff, and nicotine polacrilex gum are of
alkaline pH as a result of tobacco selection and/or buffering with
additives by the manufacturer. The alkaline pH facilitates absorp-
tion of nicotine through mucous membranes. The rate of nicotine
absorption from smokeless tobacco depends on the product and the

29


M Cigarettes
A-----A Oral snuff
O--Q Chewing tobacco
F--O Nicotine gum
       N=lo

-10  0       30      60      90      120

            Minutes

FIGURE 2.-Blood nicotine concentrations during and after
      smoking cigarettes (1 l/3 cigarettes), using oral
      snuff (2.5 g), using chewing tobacco (average,
       7.9 g), and chewing nicotine gum (two 2-mg
       pieces)
`0, `I<(`?: Ht.ni.x!:,  ,`<?,rii,.r i'l :i, 1""

route of administration. With fine-ground nasal snuff, blood levels of
nicotine rise almost as fast as those observed after cigarette smoking

30


(Russell et al. 1981). The rate of nicotine absorption with the use of
oral snuff and chewing tobacco is more gradual. PVicotine is poorly
absorbed from the stomach due to the acidity of gastric fluid (Travel1
1960), but is well absorbed in the small intestine (Jenner, Gorrod,
Beckett 19731, which has a more alkaline pH and a large surface
area. Bioavailability of nicotine from the gastrointestinal tract (that
is, swallowed nicotine) is incomplete because of presystemic (first
pass) metabolism. whereby? after absorption into the portal venous
circulation, nicotine is metabolized by the liver before it reaches the
systemic venous circulation. This is in contrast to nicotine absorbed
through the lungs or oral,`nasal mucosa, which reaches the systemic
circulation without first passing through the liver. Nicotine base can
be absorbed through the skin, and there have been cases of poisoning
after skin contact with pesticides containing nicotine ~Faulkner
1933; Benowitz, Lake et al. 1987; Saxena and Scheman 1985).
Likewise, there is evidence of cutaneous absorption of and toxicity
from nicotine in tobacco field workers (Gehlbach et al. 19751.

Because of the complexity of cigarette smoking processes and use
of smokeless tobacco products, the dose of nicotine cannot be
predicted from the nicotine content of the tobacco or its absorption
characteristics. To determine the dose, one needs to measure blood
levels and know how fast the individual eliminates nicotine. This
topic, estimation of systemic doses of nicotine consumed from various
tobacco products, will be considered in a later section after discussion
of relevant pharmacokinetic issues.

Distribution of Nicotine in Body Tissues

After absorption into the blood, which is at pH 7.4, about 69
percent of the nicotine is ionized and 31 percent nonionized. Binding
to plasma proteins is less than 5 percent (Benowitz, Jacob et al.
1982). The drug is distributed extensively to body tissues with a
steady state volume of distribution averaging 180 liters (2.6 times
body weight (in kilograms)) (Table 3). This means that when nicotine
concentrations have fully equilibrated, the amount of nicotine in the
body tissues is 2.6 times the amount predicted by the product of
blood concentration and body weight. The pattern of tissue uptake
cannot be studied in humans, but it has been examined in tissues of
rabbits by measuring concentrations of nicotine in various tissues
after infusion of nicotine to steady state (Table 41. Spleen, liver,
lungs, and brain have high affinity for nicotine, whereas the affinity
of adipose tissue is relatively low.

After rapid intravenous (i.v.1 injection, concentrations of nicotine
decline rapidly because of tissue uptake of the drug. Shortly after i.v.
injection, concentrations in arterial blood. lung, and brain are high,
while concentrations in tissues such as muscle and adipose (major
storage tissues at steady state) are low. The consequence of this

31


TABLE 3.-Human pharmacokinetics of nicotine and
        cotinine

Nicotine           Cotinine

\`olumr of dknbutmn          180 L             88 L

1.300 mL/min


200 mL!min
(acid urinel

7`2 mL/min


12 mL/min

.sonrerx~l Clt31.3nCC           1,100 mlimin         60 mL/min

TABLE 4.-Steady state distribution of nicotine

Tissue to blood ratio

Blood

10

distribution pattern is that uptake into the brain is rapid, occurring
within 1 or 2 min, and blood levels fall because of peripheral tissue
uptake for 20 or 30 min after administration. Thereafter, blood
concentrations decline more slowly, as determined by rates of
elimination and rates of distribution out of storage tissues.

Rapid nicotine uptake into the brain has been demonstrated in
animal studies. Oldendorf (1974) showed a high degree of nicotine
uptake from blood in the first pass through the brains of rats.
Schmiterlow and colleagues (1967) showed by autoradiographic
techniques that high levels of nicotine were present in the brain 5
min after i.v. injections in mice and that most nicotine had been


cleared from the brain by 30 min. Stalhandske (1970) showed that
intravenously injected "C-nicotine is immediately taken up in the
brains of mice, reaching a maximum concentration within 1 min
after injection. Similar findings based on positron emission tomogra-
phy of the brain were seen after injection of "C-nicotine in monkeys
(Ma&re et al. 1976).

Nicotine inhaled in tobacco smoke enters the blood almost as
rapidly as after rapid i.v. injection except that the entry point into
the circulation is pulmonary rather than systemic venous. Because
of delivery into the lung, peak nicotine levels may be higher and lag
time between smoking and entry into the brain shorter than after
i.v. injection. After smoking, the action of nicotine on the brain is
expected to occur quickly. Rapid onset of effects after a puff is
believed to provide optimal reinforcement for the development of
drug dependence. The effect of nicotine deciines as it is distributed to
other tissues. The distribution half-life, which describes the move-
ment of nicotine from the blood and other rapidly perfused tissues,
such as the brain, to other body tissues, is about 9 min (Feyerabend
et al. 1985). Distribution kinetics, rather than elimination kinetics
(half-life, about 2 hr), determine the time course of central nervous
system (CNS) actions of nicotine after smoking a single cigarette.

Nicotine is secreted into saliva (Russell and Feyerabend 1978).
Passage of saliva containing nicotine into the stomach, combined
with the trapping of nicotine in the acidic gastric fluid and
reabsorption from the small bowel, provides a potential route for
enteric nicotine recirculation. This recirculation may account for
some of the oscillations in the terminal decline phase of nicotine
blood levels after iv. nicotine infusion or cessation of smoking
(Russell 1976).

Nicotine freely crosses the placenta and has been found in
amniotic fluid and the umbilical cord blood of neonates (Hibberd,
O'Connor, Gorrod 1978; Luck et al. 1982; Van Vunakis, Langone,
Milunsky 1974). Nicotine is found in breast milk and the breast fluid
of nonlactating women (Petrakis et al. 1978; Hill and Wynder 1979)
and in cervical mucous secretions (Sasson et al. 1985). Nicotine is
also found in the freshly shampooed hair of smokers and of
nonsmokers environmentally exposed to tobacco smoke (Haley and
Hoffmann 1985).

Elimination of Nicotine

Nicot.ine is extensively metabolized, primarily in the liver, but also
to a small extent in the lung (Turner et al. 1975). Renal excretion of
unchanged nicotine depends on urinary pH and urine flow, and may
range from 2 to 35 percent, but typically accounts for 5 to 10 percent
of total elimination (Benowitz, Kuyt et al. 1983; Rosenberg et al.
1980).

33


fi --p- Q%j
  NICOTINE     L 5'4iYDROXYNICOTINE       NICOTINE IMINIUM
1 \,                       ION

FLAVOPROTEIN

ALDEHYDE
OXIDASE

URINARY
EXCRETION

FIGURE 3.-Major pathways of nicotine metabolism

Pathlcays of ,Vicotine Metabolism

The primary metabolites of nicotine are cotinine and nicotine-N'-
oxide (Figure 3). Cotinine is formed in the liver in a two-step process,
the first of which involves oxidation of position 5 of the pyrrolidine
ring in a cytochrome P-450-mediated process to nicotine-A' l5 I-imini-
urn ion (Peterson, Trevor, Castagnoli 19871. In the second step the
iminium ion is metabolized by a cytoplasmic aldehyde oxidase to
cotinine (Hibberd and Gorrod 1983).

Cotinine itself is also extensively metabolized, with only about 17
percent excreted unchanged in the urine (Benowitz. Kuyt et al.
1983). Several metabolites of cotinine have been reported, including
trans-3'-hydroxycotinine (McKennis, Turnbull et al. 19631, 5'-hydrox-
ycotinine (Bowman and McKennis 19621, cotinine-N-oxide (Shulgin
et al. 19871, and cotinine methonium ion (McKennis, Turnbull,
Bowman 1963) (see Figure 4). Little is known about the quantitative
importance of these metabolites. Trans-3'-hydroxycotinine appears
to be a major metabolite (Jacob, Benowitz, Shulgin 1988; Neurath et
al. 1987), with urinary concentrations exceeding cotinine concentra-
tions by twofold to threefold. Cotinine N-oxide is a minor metabolite
in humans, accounting for approximately 3 percent of ingested
nicotine (Shulgin et al. 1987). Subsequent oxidative degradation of
the pyrrolidine ring gives rise to 3-pyridylacetic acid. This compound
has been identified in human urine (McKennis, Schwartz, Bowman
1964), but no quantitative data are available.

34


NICOTINE

COTNNE

TRANS - J' HYDROXYCOTININE       COTININE-N-OXIDE

NICOTINE-N-OXIDE

NORNICOTINE

5'. HYDROXYCOTININE      r. 13. PYR,DYL, -`d-0X0-to-METHYLBUTYRAMIDE

NICOTINE ISOMETHONIUM ION

CCTININE METHONIUM ION

FIGURE 4.-Structures of nicotine and its major
       metabolites

SOURCE P Jacob 111 tw,th perm,simnl

35


Nicotine-l'-N-oxide is quantitatively a minor metabolite of nic-
otine. Oxidation of the nitrogen atom of the pyrrolidine ring depends
on a microsomal flavoprotein syst.em and produces a mixture of the
two diasterisomers, l'-(R)-2'-(S)-&- and l'-(S)-2'-(S)-trurts-nicotine-l'-
N/-oxide (Booth and Boyland 1970). After i.v. injection, 100 percent of
nicotine-N'-oxide is excreted unchanged in the urine, indicating no
further metabolism (Beckett, Gorrod, Jenner 1971a). However, after
oral administration only 30 percent is recovered in the urine as
nicotine-N'-oxide; the remainder is recovered as nicotine and its
metabolites. To evaluate the possibility of reduction of nicotine-N'-
oxide in the gastrointestinal tract, rectal administration of nicotine-
N'-oxide was performed for experimental purposes. Less than 10
percent was recovered in the urine as nicotine-N'-oxide (Beckett,
Gorrod, Jenner 1970). These findings indicate reduction of nicotine-
N'-oxide back to nicotine within the human gastrointestinal tract,
believed to be a consequence of bacterial action.

Experiments in rats indicate that significant amounts of nicotine-
N'-oxide are converted to nicotine both in vitro and in vivo (Dajani,
Gorrod, Beckett 1975a,b). Nicotine and cotinine have been measured
in the blood of rats administered nicotine-N,N'-dioxide and nicotine-
N'-oxide in drinking water (Sepkovic et al. 1984, 1986). Thus, while
reduction of nicotine-N'-oxide to nicotine appears to be bacterial in
humans, it may be mediated by endogenous enzymes in other
species.

Quantitative aspects of the conversion of nicotine to its metabo-
lites have not been well defined. Studies of cotinine excretion in
urine collected for 24 hr after i.v. nicotine injection indicate less than
10 percent of nicotine is excreted as cotinine in nonsmokers
compared with an average of 25 percent in smokers (Beckett, Gorrod,
Jenner 1971b). Another study, comparing 24-hr urinary excretion of
cotinine with nicotine content of cigarette butts after smoking,
indicated 46 percent recovery as cotinine (Schievelbein 1982).
However, both of these studies underestimate the conversion of
nicotine to cotinine because the urine collection period was too short.
In cigarette smokers, cotinine has a half-life averaging 18 to 20 hr
(Benowitz, Kuyt et al. 1983), so that in 24 hr only a little more than
half of cotinine is recovered. Urine collection for at least 72 hr is
necessary to recover more than 90 percent of cotinine in most
subjects. In addition, since only 17 percent of cotinine is excreted
unchanged (Benowitz, Kuyt et al. 1983), urinary recovery analysis
underestimates the cotinine generation rate.

At steady stat.e, the rate of metabolite excretion reflects the rate at
which the metabolites are generated. After i.v. dosing, 100 percent of
nicotine-N'-oxide but only 17 percent of cotinine are excreted
unchanged in the urine. Based on a ratio of urinary cotinine to
nicotine-N'-oxide of 2.9 and based on excretion of that 17 percent of

36


cotinine and 100 percent of nicotine-N'-oxide unchanged in the
urine, the relative generation rate of cotinine compared with that of
nicotine-N'-oxide is calculated to be 17 to 1 (Benowitz 1986b).
Because 4 percent of nicotine is excreted as nicotine-N'-oxide (Jacob
et al. 1986; Beckett, Gorrod, Jenner 1971a), about 70 percent of
nicotine appears to be converted to cotinine. Quantitative data on
other metabolites that may have pharmacologic activity, such as
nicotine isomethonium ion and nornicotine, are not available.

Rate of Nicotine Metabolism

The rate of nicotine metabolism can be determined by measuring
blood levels after administration of a known nicotine dose. In one
study, cigarette smokers were given iv. infusions of nicotine for 30 to
60 min, and total and renal clearances were computed (Benowitz,
Jacob et al. 1982). Total clearance ia term which describes the
capacity to eliminate a drug) averaged 1,300 ml/mix-i. Nonrenal
clearance averaged 1,100 mL/min (Table 31, which represents about
70 percent of liver blood flow. Because nicotine is metabolized
mainly by the liver (data in animals indicate only a small degree of
metabolism by the lung) (Turner, Sillett, McNicol 19771, this means
that about 70 percent of the drug is extracted from the blood in each
pass through the liver. On the average, 85 or 90 percent of nicotine is
metabolized by the liver.

Renal Excretion

Nicotine is excreted by glomerular filtration and tubular secretion
within the kidney. Depending on urinary pH and urine flow rate,
variable amounts of nicotine are reabsorbed by the kidney tubules.
In acidic urine, where nicotine is mostly ionized and tubular
reabsorption is minimized, renal clearance of nicotine may be as
high as 600 mL/min (urinary pH 4.4) (Benowitz, Kuyt et al. 1983;
Rosenberg et al. 1980). In alkaline urine, a larger fraction of nicotine
is not ionized. Tubular reabsorption of nonionized nicotine results in
lower rate of excretion and reduced renal clearances as low as 17
mL/min (urine pH 7.0). When urine pH is uncontrolled, averaging
5.8, renal clearance averages about 100 mL/min, accounting for the
elimination of 10 to 15 percent of the daily nicotine intake.

Nicotine and Cotinine Blood Levels During Tobacco Use
Nicotine Levels

Plasma nicotine concentrations (or concentrations in blood, which
are similar) sampled in the afternoon in smokers generally range
from 10 to 50 ng/mL. The increment in blood nicotine concentration
after smoking a single cigarette ranges from 5 to 30 ng/mL,
depending on how the cigarette is smoked (Armitage et al. 1975;

37


Herning et al. 1983; Isaac and Rand 1972). Peak blood levels of
nicotine are snnilar, although the rate of nicotine increase is slower
for cigar smokers and snuff and chewing tobacco users compared
with that for cigarette smokers (Armitage et al. 1978; Turner, Sillett,
McNicol 1977: Gritz et al. 1981; Russell, Raw, Jarvis 1980; Russell et
al. 1981) (Figure 2). Pipe smokers, particularly those who have
previously smoked cigarettes and who inhale, may have blood and
urine levels of nicotine as high as those of cigarette smokers
(McCusker, McNabb, Bone 1982; Turner, Sillett, McNicol 1977; Wald
et al. 1984).

The earliest published studies of nicotine elimination kinetics
reported half-lives of 20 to 40 min (Armitage et al. 1975; Isaac and
Rand 1972). In those studies, drug blood levels were followed only for
30 to 60 min, which is not long enough to determine the elimination
half-life. Thus, half-lives were based on blood levels which included
the distribution phase. When blood levels are followed for several
hours after the end of nicotine infusion, a log-linear decline of blood
levels with a half-life of about 2 hr is observed (Benowitz, Jacob et al.
1982; Feyerabend, Ings, Russell 1985).

The half-life of a drug is useful in predicting its accumulation rate
in the body with repetitive doses and the time course of its decline
after cessation of dosing. Assuming a half-life of 2 hr, one would
predict nicotine to accumulate over 6 to 8 hr (3 to 4 half-lives) of
regular smoking and persist at significant nicotine levels for 6 to 8 hr
after cessation of smoking. If a smoker smokes until bedtime,
significant nicotine levels should persist all night. Studies of blood
levels in regular cigarette smokers confirm these predictions (Figure
5) (Russell and Feyerabend 1978; Benowitz, Kuyt, Jacob 1982). Peaks
and troughs follow the use of each cigarette, but as the day
progresses, trough levels rise and the influence of peak levels
becomes less important. Thus, nicotine is not a drug to which people
are exposed intermittently and that is eliminated rapidly from the
body. To the contrary, smoking represents a multiple dosing
situation with considerable accumulation during smoking and with
persistent levels for 24 hr of each day.

Cotinine Leljels

Cotinine levels are of particular interest as qualitative markers of
tobacco use and quantitative indicators of nicotine intake. Cotinine
is present in the blood of smokers in much higher concentrations
than nicotine. Cotinine blood levels average about 250 to 300 ng/mL
in groups of cigarette smokers (Benowitz, Hall et al. 1983; Haley,
Axelrad, Tilton 1983; Langone, Van Vunakis, Hill 1975; Zeidenberg
et al. 1977). After stopping smoking, levels decline with a half-life
averaging 18 to 20 hr (range 11 to 37 hr). But because of the long
half-life, there is much less fluctuation in cotinine concentrations

38


  7         --o-- Usual brand
        T
-      T          -A-  Low nicotine
           High nicotine

N = 10

l2 r

N=7

2-l      I      I      I      I            I
0800 ,200 16.X 2016 24'" 0~20 oa3C

             Clock time

FIGURE S-Blood nicotine and carboxyhemoglobin
      concentrations in subjects smoking high
      nicotine (`2.5 mg) and low nicotine (0.4 mg)
      Kentucky reference cigarettes and their usual
      brand (average nicotine yield, 1.2 mg) of
       cigarettes
VOTE Sub,rcts .n,flhrd rin LI i,\id si.hddr n, , ~,c..w,,e I)\, ,> /h`,,' !,.`A' /PI, 1 . :11,1 1, 10 I, SW ,I 11, ,111 :! 1$11,,1
o, 13, c,~z,w,~P, da>. blood ..1,11~1~?, nrrr <1?llrrlK ,.1-l !W11111~ !I ? 11?\1 .l.!>l~l:ilA x IL,i'i'!`.'
SOL'K(`E Rrnm\,t/ ir;~i( .l,ic ,h l'lhl

39


throughout the day than in nicotine concentrations. As expected,
there is a gradual increase in cotinine levels during the day, peaking
at the end of smoking and persisting in high concentrations
overnight.

Intake of Nicotine

Cigarette Smoking

Nicotine intake from single cigarettes has been measured by
spiking cigarettes with "C-labeled nicotine (Armitage et al. 1975).
That study of eight subjects, each smoking a single filter-tipped
cigarette, indicated an intake range of 0.36 to 2.62 mg. Intake was
higher in smokers than in nonsmokers. Intake of nicotine from
smoking a single cigarette or with daily cigarette smoking has been
estimated by methods similar to those used in drug bioavailability
studies (Benowitz and Jacob 1984; Feyerabend, Ings, Russell 1985).
Metabolic clearance of nicotine was determined after i.v. injection.
Metabolic clearance data were then used in conjunction with blood
and urinary concentrations of nicotine measured during a period of
smoking to determine the intake of nicotine. In five subjects, average
intake of nicotine per cigarette was 1.06 mg (range, 0.58 to 1.49 mg)
(Feyerabend, Ings, Russell 19851. In 22 cigarette smokers, 13 men
and 9 women who smoked an average of 36 cigarettes/day (range 20
to 621, the average daily intake was 37.6 mg, with a range from 10.5
to 78.6 mg (Benowitz and Jacob 1984). Nicotine intake per cigarette
averaged 1.0 mg (range 0.37 to 1.56 mg). Intake per cigarette did not
correlate with yields obtained by smoking machine using standard
Federal Trade Commission methods. This is because smoking
machines smoke cigarettes in a uniform way, using a fixed puff
volume (35 mL1, flow rate (over 2 secl, and interval (every minute).
Smokers smoke cigarettes differently, changing their puffing behav-
ior to obtain the desired amount of tobacco smoke and nicotine.

Elimination Rate as a Determinant of Nicotine Intake by
Cigarette Smoking

There is considerable evidence that smokers adjust their smoking
behavior to try to regulate or maintain a particular level of nicotine
in the body (Gritz 1980; Russell 1976). For example, when the
availability of cigarettes is restricted, habitual smokers can increase
intake of nicotine per cigarette 300 percent compared with the
intake of unrestrict,ed smoking (Benowitz, Jacob, Koslowski et al.
1986).
Techniques for measuring daily intake of nicotine (Benowitz and
Jacob 1984) have been applied to study the influence of elimination
on nicotine intake. The rate of renal elimination of nicotine was
manipulated by administration of ammonium chloride or sodium

40


bicarbonate to acidify or alkalinize the urine: respectively (Benowitz
and Jacob 1985). Compared with daily excretion during placebo
treatment (3.9 mg nicotine/day), acid loading increased (to 12
mglday) and alkaline loading decreased (to 0.9 mglday) daily
excretion of nicotine. The total intake of nicotine averaged 38
mg/day. Average blood nicotine concentrations were similar in
placebo and bicarbonate treatment conditions but were 15 percent
lower during ammonium chloride treatment. Daily intake of nicotine
was 18 percent higher during acid loading, indicating compensation
for increased urinary loss. The compensatory increase in nicotine
consumption was only partial, replacing about half of the excess
urinary nicotine loss. Bicarbonate treatment had no effect on
nicotine consumption, consistent with the small magnitude of effect
on excretions of nicotine in comparison to total daily intake.

These results seem compatible with the suggestion of Schachter
(1978) that emotional stress, which results in more acidic urine,
might accelerate nicotine elimination from the body and thereby
increase cigarette smoking. But caution must be exercised in
applying these findings to usual smoking situations. These studies
were performed under conditions of extreme urinary acidification or
alkalinization, so that the changes in renal clearance would be
maximized, Even with extreme differences in urinary pH, differ-
ences in overall nicotine elimination rate and smoking behavior
were modest. This is because renal excretion is a minor pathway for
elimination of nicotine; most is metabolized. Smaller changes in
urinary pH, such as occur spontaneously throughout the day or that
might be related to stressful events, would not be expected to
substantially influence nicotine elimination or smoking behavior.

Biochemical Markers of Nicotine Intake

Absorption of nicotine from tobacco smoke provides a means of
verification and quantitation of tobacco consumption. The general
strategy is to measure concentrations of nicotine, its metabolites
(such as cotinine), or other chemicals associated with tobacco smoke
in biological fluids such as blood, urine, or saliva. Different measures
vary in sensitivity, specificity, and difficulty of analysis. Different
investigators have used blood or urinary nicotine concentrations,
blood or salivary or urinary cotinine concentrations, expired carbon
monoxide or carboxyhemoglobin concentrations, or plasma or sali-
vary thiocyanate (a metabolite of hydrogen cyanide, a vapor phase
constituent) concentrations as measures of tobacco smoke consump-
tion.

Relationships among daily intake of nicotine, daily exposure to
nicotine (that is, blood concentrations of nicotine integrated over 24
hr), various parameters of cigarette consumption, and different
measures of nicotine intake have been examined experimentally

41


during ad libitum cigarette smoking on a research ward (Benowitz
and Jacob 1984). The best biochemical correlate to nicotine intake
and exposure in this study was a random blood nicotine concentra-
tion measured at 4 p.m. This level did not depend on when the last
cigarette was smoked. This finding is consistent with the observation
that nicotine levels accumulate throughout the day and plateau in
the early afternoon (see Figure 5). At steady state, with regular
smoking throughout the day, there should be a reasonably good
correlation between nicotine concentrations and daily intake. Car-
boxyhemoglobin (COHb) concentrations in the afternoon were the
next best markers of nicotine intake. Also, morning (8 a.m.) levels of
nicotine and COHb correlated with intake, presumably reflecting
persistence of nicotine and COHb in the blood from exposure on the
previous day.

Although cotinine is a highly specific marker for nicotine expo-
sure, blood levels of cotinine across subjects in this study did not
correlate as closely with nicotine intake as did blood levels of
nicotine or COHb (Benowitz and Jacob 1984). This is probably due to
individual variability in fractional conversion of nicotine to cotinine
and in the elimination rate of cotinine itself.

Because of its relatively long half-life, cotinine levels are less
sensitive than nicotine levels to smoking pattern, that is, when the
last cigarette was smoked. For longitudinal within-subject studies,
the cotinine level would be expected to be a good marker of changes
in nicotine intake. Cotinine measurements have become the most
widely accepted method for assessing the intake of nicotine in long-
term studies of tobacco use (see also Chapter V).

As expected by the known variation in renal clearance due to
effects of urinary flow and pH, urinary concentrations of nicotine did
not correlate well with nicotine intake (Benowitz and Jacob 1984). In
contrast, urinary cotinine, which is less influenced by urinary flow
or pH, was as good a marker as blood cotinine concentration.
Salivary and urinary cotinine concentrations correlate well (r = 0.8
to 0.9) with blood cotinine concentrations (Haley, Axelrad, Tilton
1983; Jarvis et al. 1984). Therefore, salivary or urine cotinine
concentrations should be almost as useful as blood levels in
indicating nicotine intake.

Analytical Methods for Measuring Nicotine and Cotinine in
Biological Fluids

Determination of nicotine concentrations in biological fluids
requires a sensitive and specific method, because concentrations of
nicotine in smokers' blood are generally in the low nanogram per
milliliter range and a number of metabolites are also present.
Cotinine concentrations in blood are generally about tenfold greater
than nicotine concentrations, and as a result, less sensitive analyti-

42


cal methodology may be acceptable. Methods with adequate sensitiv-
ity for determination of nicotine and cotinine in smokers' blood
include gas chromatography (GC) (Curvall, Kazemi-Vala, Enzell
1982; Davis 1986; Feyerabend, Levitt, Russell 1975; Hengen and
Hengen 1978; Jacob, Wilson, Benowitz 1981; Vereby, DePace, Mule
1982), radioimmunoassay (RIA) (Langone, Gjika, Van Vunakis 1973;
Castro et al. 1979; Knight et al. 1985), enzyme-linked immunosorbent
assay (ELISA) (Bjercke et al. 1986), high performance liquid chroma-
tography (HPLC! (Machacek and Jiang 1986; Chien, Diana, Crooks,
in press), and combined gas chromatograph-mass spectrometry (GC-
MS) (Dow and Hall 1978; Gruenke et al. 1979; Jones et al. 1982;
Daenens et al. 1985). For reasons of sensitivity, specificity, and
economy, GC and RIA are the most frequently used methods. GC-MS
is a highly sensitive and specific technique, but the expense has
discouraged its routine use. HPLC is less sensitive than GC for
nicotine and cotinine determination. Although recently reported
methods (Machacek and Jiang 1986; Chien, Diana, Crooks, in press)
appear to have adequate sensitivity for determining concentrations
in plasma, relatively large sample volumes are required. Concentra-
tions of nicotine and cotinine in urine are tenfold to hundredfold
greater than concentrations in plasma or saliva (Jarvis et al. 1984),
and a variety of chromatographic and immunoassay techniques meet
sensitivity requirements.

The choice of a particular method depends on the biological fluid
to be assayed; the need for sensitivity, precision, and accuracy; and
economic considerations. Chromatographic methods, particularly
those utilizing high-resolution capillary columns and specific detec-
tors such as nitrogen-phosphorus detectors or a mass spectrometer,
provide the greatest specificity. On the other hand, immunoassay
techniques are operationally simpler, generally require smaller
samples, and may be less expensive than chromatographic methods.
A drawback to immunoassay methods is the potential for cross-
reactivity of the antibody with metabolites or endogenous sub-
stances. There is generally a good correlation between results
obtained by GC and RIA for plasma cotinine concentrations (r = 0.94)
(Gritz et al. 1981; Biber et al. 1987). In an interlaboratory comparison
study (Biber et al. 19871, cotinine concentrations in smokers' urine
measured by RIA were generally higher than concentrations deter-
mined by GC, whereas in nonsmokers' urine spiked with cotinine
RIA and GC values were similar. These results suggest that nicotine
metabolites cross-react with the antibody against cotinine, at least in
some of the RIA methods.

Pharmacodynamics of Nicotine
General Considerations

This Section will focus on the relationship between nicotine levels
in the body and their effects on behavior and physiological function

43


(pharmacodynamics). These data show how pharmacodynamic fac-
tors determine some of the consequences of cigarette smoking, Two
issues are particularly relevant in understanding the pharmacody-
namics of nicotine: a complex dose-response relationship and the
level of tolerance that is either preexisting or is produced by
administration of nicotine.

Dose-Response

The relationship between the dose of nicotine and the resulting
response (dose-response relationship) is complex and varies with the
specific response that is measured. In pharmacology textbooks,
nicotine is commonly mentioned as an example of a drug which in
low doses causes ganglionic stimulation and in high doses causes
ganglionic blockade following brief stimulation (Comroe 1960). This
type of effect pattern is referred to as "biphasic." Dose-response
characteristics in functioning organisms (in vivo) are often biphasic
as well, although the mechanisms are far more complex. For
example, at very low doses, similar to those seen during cigarette
smoking, cardiovascular effects appear to be mediated by the CNS,
either through activation of chemoreceptor afferent pathways or by
direct effects on the brain stem (Comroe 1960; Su 1982). The net
result is sympathetic neural discharge with an increase in blood
pressure and heart rate. At higher doses, nicotine may act directly
on the peripheral nervous system, producing ganglionic stimulation
and the release of adrenal catecholamines. With high doses or rapid
administration, nicotine produces hypotension and slowing of heart
rate, mediated either by peripheral vagal activation or by direct
central depressor effects (Ingenito, Barrett, Procita 1972; Porsius
and Van Zwieten 1978; Henningfield, Miyasato, Jasinski 1985).

Tolerance

A second pharmacologic issue of importance is development of
tolerance; that is, after repeated doses, a given dose of a drug
produces less effect or increasing doses are required to achieve a
specified intensity of response. Functional or pharmacodynamic
tolerance can be further defined as where a particular drug
concentration at a receptor site (in humans approximated by the
concentration in blood) produces less effect than it did after a prior
exposure. Dispositional or pharmacokinetic tolerance refers to
accelerated drug elimination as a mechanism for diminished effect
after repeated doses of a drug. Behavioral tolerance refers to
compensatory behaviors that reduce the impact of a drug to
adversely affect performance. Such tolerance can occur following
intermittent exposures to a drug such that there is minimal
development of functional or dispositional tolerance.

44


Most studies of drug tolerance have focused on tolerance which
develops as a drug is chronically administered. If the tolerance
develops within one or two doses, it is referred to as acute tolerance
or tachyphylaxis. If tolerance develops after more prolonged use, the
tolerance is referred to as acquired or chronic tolerance. Individual
differences in sensitivity to the first dose of a drug also frequently
exist. Those individuals who exhibit a reduced response to a specified
drug dose or require a greater dose to elicit a specified level of
response are said to be tolerant to the drug. This form of tolerance is
referred to as first-dose tolerance, drug sensitivity, or innate drug
responsiveness. For sake of clarity, this Report will reserve the term
tolerance to describe reduction in the response to nicotine during the
course of or following a previous exposure and will use acute drug
sensitivity to describe responsiveness to an initial dose.

Studies of tolerance to nicotine began in the late 19th century. In a
series of studies of fundamental importance to the understanding of
the nervous system, as well as to understanding the pharmacology of
nicotine, Langley (1905) and Dixon and Lee (1912) studied the effects
of repeated nicotine administration on a variety of animal species
and on in vitro tissue preparations. Several findings emerged which
have been widely verified and extended to other species and
responses. These include: (1) With repeated dosing, responses dimin-
ished to nearly negligible levels; (2) After tolerance occurred,
responsiveness could be restored by increasing the size of the dose; (3)
After a few hours without nicotine, responsiveness was partially or
fully restored.

After smoking a cigarette, people who have not smoked before
("naive smokers") usually experience a number of effects that
become generally uncommon among experienced smokers. For
example, retrospective reports by smokers indicate that initial
exposure to tobacco smoke produced dizziness, nausea, vomiting,
headaches, and dysphoria, effects that disappear with continued
smoking and are rarely reported by chronic smokers (Russell 1976;
Gritz 1980). Tolerance may also develop to toxic effects, such as
nausea, vomiting, and pallor, during the course of nicotine poisoning,
despite persistence of nicotine in the blood in extremely high
concentrations (200 to 300 ng/mL! (Benowitz, Lake et al. 1987).

A systematic analysis of the various forms of tobacco smoke
tolerance has not been carried out. There are a few studies
comparing the effects elicited by an acute exposure to tobacco in
nonsmokers and smokers. Clark and Rand (1968) studied the effect of
smoking cigarettes of varying nicotine content on the knee-jerk
reflex and reported that high-nicotine cigarettes suppressed this
reflex to a greater degree than did low-nicotine cigarettes. This effect
was more pronounced at each nicotine dose in nonsmokers and light
smokers compared to heavy smokers. These findings suggested that

45


tolerance is due to altered sensitivity to nicotine. Tolerance to
nicotine is not complete because even the heaviest smokers experi-
ence symptoms such as dizziness, nausea, and dysphoria when they
suddenly increase their smoking rates (Danaher 1977). Evidence
indicates that the majority of the psychological actions of tobacco
smoke result from nicotine (Russell 1976; Chapter VII). Thus, most of
the tolerance to effects of tobacco smoke that occurs following
chronic tobacco use is due to the development of tolerance to
nicotine.

Acute Sensitivity
Human Studies

Studies which have indicated that individuals differ in response to
tobacco smoke or nicotine have used smokers as the experimental
subjects. Consequently, whether individual differences are due to
differences in acute sensitivity to nicotine that have persisted during
chronic tobacco use or are due to differences in the development of
tolerance is unknown.

Nesbitt (1973) and Jones (1986) noted that individual smokers
differ with respect to the effects of smoking a standard cigarette on
heart rate, but it is not clear from these studies whether these
differences in responsiveness are due to differences in sensitivity to
nicotine or to differences in the dose and kinetics of nicotine.
Benowitz and colleagues (1982) observed individual differences in the
effects of iv. injections of nicotine on heart rate, blood pressure, and
fingertip skin temperature. Differences were not explained by
differences in blood levels, indicating differential sensitivity to
nicotine.

Animal Studies

Studies using laboratory animals indicate that differences in acute
sensitivity to nicotine exist. Inbred rat and mouse strains differ in
sensitivity to the effects of nicotine on locomotor activity (Garg 1969;
Battig et al. 1976; Schlatter and Battig 1979; Hatchell and Collins
1980; Marks, Burch, Collins 1983b). Mouse strains also differ in the
direction of the effect (increased or decreased activity). The mouse
strains that differ in sensitivity to the effects of injected nicotine on
locomotor activity also differ in the magnitude of response to a
standard dose of tobacco smoke (Baer, McClearn, Wilson 1980).
Inbred mouse strains also differ in sensitivity to the effects of
nicotine on body temperature, heart rate, and acoustic startle
response (Marks, Burch, Collins 1983a; Marks et al. 1985, 1986), as
well as in sensitivity to nicotine-induced seizures (Tepper, Wilson,
Schlesinger 1979; Miner, Marks, Collins 1984, 1986). These findings
indicate that genetic factors may influence the sensitivity of rats and

46


mice to the first dose of nicotine. The importance of genetically
determined differences in human sensitivity to the effects of nicotine
administered in tobacco smoke remains to be determined.

Mechanisms of Differences in Acute Sensiticit?

Differences between inbred mouse and rat strains in sensitivity to
the effects elicited by a single injected dose of nicotine do not appear
to result from differences in rate of nicotine metabolism (Petersen,
Norris, Thompson 1984) or from differences in brain nicotine
concentration following intraperitoneal injection !Hatchell and
Collins 1980; Rosecrans 1972; Rosecrans and Schechter 1972). Thus,
rat and mouse strains differ in tissue sensitivity to the effects of
nicotine. Differences among mouse strains in sensitivity to nicotine
do not appear to be due to differences in the number or affinity of
brain nicotine receptors that are measured via the binding of 3H-
nicotine (Marks, Burch, Collins, 1983b). Mouse stocks that are more
sensitive to nicotine-induced seizures do have greater numbers of
hippocampal nicotine receptors that bind "`1-bungarotoxin (BTX)
(Miner, Marks, Collins 1984, 1986). Some of the differences in
sensitivity to nicotine between genetically defined stocks of animals
may be related to differences in the number of nicotine receptors in
specific regions of the brain.

Tachyphylaxis (Acute Tolerance)
Human Studies

Systematic studies of tachyphylaxis or acute tolerance to effects of
tobacco in nonsmokers have not been reported. There is evidence
that tachyphylaxis does develop to effects of tobacco and nicotine in
humans. Smokers frequently report that the first cigarette of the day
is the best and that subsequent cigarettes are "tasteless" (Russell
1976; Henning-field 1984). Smoking a single standard cigarette after
24 hr of abstinence increases heart rate, whereas smoking an
identical cigarette during the course of a normal day fails to change
heart rate (West and Russell 19871. Fewer standard puffs were
required to produce nausea at the beginning of the day (following 8
to 10 hr of tobacco abstinence) or from high-nicotine cigarettes than
at the end of the day or from low-nicotine cigarettes (Henningfield
1984). Complete tolerance to nausea and vomiting developed over 8
hr in a woman in the course of an accidental nicotine poisoning,
despite persistently toxic blood levels of nicotine (Benowitz, Lake et
al. 1987). These findings suggest that tolerance which is lost and
regained during short periods of abstinence from tobacco is tolerance
to nicotine.

Tolerance develops very rapidly to several effects of nicotine.
Rosenberg and colleagues (1980) studied the effects of i.v. nicotine

47


injections on arousal level, heart rate, and blood pressure. In these
experiments, six healthy smokers, 21 to 35 years of age, received six
series of nicotine injections spaced 30 min apart. Each series of
injections consisted of 10 2+g/kg injections spaced 1 min apart.
Subjects reported a pleasant sensation after the first series of
injections, but this response was not observed thereafter. Heart rate
and blood pressure values remained above baseline, but there was
little increment with successive injections, despite nicotine blood
level increases which were similar to those observed after the first
series of injections, In contrast, skin temperature fell progressively
during the period of nicotine dosing, gradually returning to baseline
at the end of the study. These data indicated rapid development of
tolerance to subjective effects and heart rate and blood pressure
responses, but tolerance was not complete because heart rate and
blood pressure remained above baseline. Henningfield (1984) also
assessed subjective responses of human subjects after i.v. injections
with nicotine at lo-min intervals. The subjective response of "liking"
the effects of nicotine was lost after five or six injections. Benowitz
and coworkers (1982) studied the effect of a 30-min infusion of
nicotine at a rate of 1 to 2 ug/kg/min. Shortly after initiation of
infusion, heart rate and blood pressure increased, but the increase
did not continue even though plasma nicotine concentrations
continued to rise during the continuous infusion. Maximal cardiovas-
cular changes were seen within 5 to 10 min, whereas maximal
plasma nicotine levels were not reached until 30 min. These findings
indicate that tachyphylaxis to the effects of nicotine may develop in
humans within 5 to 10 min, the time required to smoke one cigarette.
In contrast to heart rate, skin temperature (reflecting cutaneous
vascular tone) declined and rose in association with changes in blood
nicotine concentrations, showing no evidence of tolerance.

The above studies indicate rapid development of tolerance to some
(but not all) actions of nicotine in people. These studies were
performed with cigarette smokers who had abstained from smoking
the night before the study. Since significant quantities of nicotine
persist in the body even after overnight abstinence, there is probably
some persistence of tolerance. Experimental data supporting this
conclusion were obtained in a study of cardiovascular responses to
infused nicotine in smokers following either an overnight or 7-day
tobacco abstinence (Lee, Benowitz, Jacob 1987). Heart rate and blood
pressure responses were significantly greater after more prolonged
abstinence. However, within 60 to 90 min, the blood concentra-
tion-effect relationship in subjects after brief abstinence approxi-
mated that observed after prolonged abstinence. Thus, a significant
level of tolerance persists throughout the daily smoking cycle, but is
lost with prolonged abstinence. Tolerance, at least after abstinence
for one week, is rapidly reestablished with subsequent exposure.

48


Animal Studies

Many studies demonstrate that acute tolerance or tachyphylaxis
develops very quickly to actions of nicotine. Barrass and coworkers
(1969) demonstrated that pretreatment of mice with a single i.v. dose
(0.8 mg/kg) of nicotine resulted in an increase in the LD,, (dose
which is lethal to 50 percent of animals) for nicotine. Maximal
protection was seen 5 min after the injection, but this protection
diminished steadily over the next hour. Tachyphylaxis develops to
the effects of nicotine on locomotor activity. Stolerman, Bunker, and
Jarvik (1974) noted that pretreating rats with a 0.75-mg/kg dose of
nicotine 2 hr before challenge doses of nicotine (0.25 to 4.0 mg/kg)
resulted in a shift of the nicotine dose-response curves, indicating
reduced sensitivity. The ED,, values (doses that are effective in
producing the measured response in 50 percent of animals) for
nicotine-induced decreases in locomotor activity were nearly 2.4-fold
greater in nicotine-pretreated rats than in saline-pretreated animals.
Nicotine pretreatment also results in tachyphylaxis to the effects of
nicotine on body temperature (hypothermia) in cats (Hall 1972),
water-reinforced operant responding in rats (Stitzer, Morrison,
Domino 1970), discharge of lateral geniculate neurons of cats
(Roppolo, Kawamura, Domino 1970), repolarization of sartorius
muscle in frogs (Hancock and Henderson 19721, blood pressure
elevation in rats (Wenzel, Azmeh, Clark 19711, contraction of aortic
strips in rabbits (Shibata, Hattori, Sanders 1971), respiratory stimu-
lation in cats (McCarthy and Borison 19721, and gastrointestinal
contraction in squid (Wood 1969) and guinea pigs (Hobbiger, Mitchel-
son, Rand 1969). More recent studies have demonstrated that
pretreatment with as little as one dose of nicotine will attenuate
nicotine-induced elevations of plasma corticosterone (Balfour 1980)
and adrenocorticotropic hormone (ACTH) (Sharp and Beyer 1986)
levels in rats (see also Chapter III).

The interval between the pretreatment and challenge doses of
nicotine is a critical factor that determines whether tachyphylaxis is
observed. Aceto and coworkers (1986) examined the effect of iv.
nicotine infusion on heart rate and blood pressure in the rat.
Tolerance did not develop when the interval between pretreatment
and challenge doses was 30 min; marked tolerance was detected
when the interval was reduced to 1 min. However, Stolerman, Fink,
and Jarvik (1973) observed that after a single intraperitoneal dose of
nicotine to rats, acute tolerance to a second dose did not become
maximal until 2 hr after the initial injection.

Mechanisms of Tachyphylaxis

Although tachyphylaxis has been described for a wide variety of
nicotine's effects, very little is known about mechanisms. A nicotine

49


metabolite may play a role in the development of tachyphylaxis.
Barrass and colleagues (1969) argued that nicotine metabolites may
block nicotine receptors and thereby antagonize nicotine's lethal
effects. This argument was made because pretreatment with nic-
otine-N'-oxide protected mice from the lethal effects of large doses of
nicotine. LD,, values were increased approximately ninefold by
pretreatment with nicotine-N'-oxide. These authors hypothesized
that this protection may involve conversion of nicotine-N'-oxide to
hydroxynicotine. Their results indicated that injection of a reduction
product of cotinine, believed to be hydroxynicotine, gave immediate
protection, whereas maximum protection was not seen until 40 min
after injection of nicotine-N'-oxide. Thus it appears that metabolism,
possibly to hydroxynicotine, is required for the protective action of
nicotine-N'-oxide.

Another hypothesis is that tachyphylaxis is the result of desensiti-
zation of nicotine receptors. Desensitization of the receptor involves
a conformational change that results in increased affinity of the
nicotinic receptor for agonists coupled with decreased ability of the
receptor to transport ions (Weiland et al. 1977; Sakmann, Patlak,
Neher 1980; Boyd and Cohen 1984). Desensitization of nicotinic
receptors at the motor end-plate was first described by Katz and
Thesleff (1957) and has since been studied by a large number of
investigators, using either skeletal muscle or the electric organs of
the eel, Torpedo californica. Although tachyphylaxis has been
commonly suggested as being due to desensitization of brain
nicotinic receptors, the role of desensitization in tachyphylaxis to
specific behavioral effects of nicotine has not been studied. This is
because concentrations of nicotinic receptors in specific areas of the
brain corresponding to the behavioral effects being measured are not
high enough to use available methods.

Chronic Tolerance
Human Studies

Chronic tolerance to tobacco and nicotine has not been studied
systematically in human subjects, but it is clear, as noted previously,
that some tolerance does develop. Tolerance is not complete;
symptoms of nicotine toxicity such as nausea appear when smokers
increase their normal tobacco consumption by as little as 50 percent
(Danaher 1977).

These findings are consistent with the observations that smokers
increase their tobacco consumption and intake of nicotine with
experience. Such escalating dose patterns may be observed for
several years after initiation of either cigarette smoking or smok-
eless tobacco use. Cigarette smokers may achieve such increases by
augmenting the number of cigarettes smoked and by increasing the
amount of nicotine extracted from each cigarette. For users of

50


smokeless tobacco, switching to products with greater nicotine
delivery may also contribute to nicotine dose escalation (US DHHS
1986).

Animal Studies

Animal studies have proved useful in establishing the actual
development of tolerance to nicotine, the magnitude of such toler-
ance, and mechanisms that underlie this tolerance. The majority of
these studies have used the rat and mouse as experimental subjects.

Most of the chronic tolerance studies using the rat have focused on
the effects of nicotine on locomotor activity. Depression of locomotor
activity typically occurs following the injection of nicotine in doses
exceeding 0.2 mg/kg in drug-naive rats. Tolerance to this depression
develops following chronic treatment (Keenan and Johnson 1972;
Stolerman, Fink, Jarvik 1973; Stolerman, Bunker, Jarvik 1974). The
magnitude of this tolerance is influenced by the dose and dosing
interval. Tolerance persists for greater than 90 days when nicotine is
injected chronically. Tolerance to the effects of injected nicotine on
depression of locomotor activity could also be produced with nicotine
administered in the rats' drinking water or through subcutaneously
implanted reservoirs (Stolerman, Fink, Jarvik 1973).

Under certain experimental conditions, rats treated chronically
with nicotine exhibit an increase in locomotor activity following
nicotine challenge (Morrison and Stephenson 1972; BaA5ttig et al.
1976; Clarke and Kumar 1983a,b). A careful analysis of the response
to an acute challenge dose of nicotine demonstrated that soon after
the first dose of nicotine, depressed locomotor activity was observed;
after 40 min or more, increased locomotor activity became apparent
(Clarke and Kumar 1983b). Chronically injected rats exhibited this
enhanced activity progressively earlier postinjection. More recently,
Ksir and others (1985, 1987) demonstrated that chronic nicotine
injections may result in enhanced locomotor activity immediately
after nicotine injection if the rats were acclimated to the test
apparatus for 1 hr before nicotine injection. These findings indicate
that in the rat, tolerance develops to the depressant effects of
nicotine and that this tolerance uncovers a latent stimulatory action.

If mice are injected chronically with nicotine, tolerance develops to
the locomotor depressant effects elicited by a challenge dose of
nicotine (Hatchell and Collins 1977). The degree and rate of
development of tolerance appear to be influenced by the sex, as well
as the strain, of the animals. Tolerance development has been
studied by continuously infusing mice of several inbred strains with
nicotine and assessing tolerance by measuring locomotor activity,
body temperature, respiratory rate, heart rate, and acoustic startle
response following nicotine challenge. Such studies have demon-
strated that: (1) Tolerance to nicotine increases with the nicotine

51


infusion dose (Marks, Burch, Collins 1983a); (2) Tolerance is specific
for nicotinic cholinergic agonists in that nicotine-infused animals are
not cross-tolerant to the muscarinic cholinergic agonist oxotremo-
rine (Marks and Collins 1985); (3) Maximal tolerance is attained
within 4 days following the initiation of infusion and is lost within 8
days following the cessation of infusion (Marks, Stitzel, Collins 1985);
(4) Tolerance development varies between inbred mouse strains, with
some strains exhibiting marked tolerance and other strains showing
very little (Marks, Romm et al. 1986); and (5) Mouse strains that fail
to develop tolerance to nicotine are also relatively insensitive to the
effects elicited by an acute injection of nicotine (Marks, Stitzel,
Collins 1986). More recently these investigators compared the effects
of continuous and pulse infusions of nicotine on tolerance develop-
ment (Marks, Stitzel, Collins 1987). Pulse infusion was used to
simulate the conditions obtained when tobacco is smoked. Although
the total dose infused was the same in continuously infused and
pulse-infused animals, marked differences in tolerance were seen.
The pulse-infused animals exhibited a greater degree of tolerance.
The degree of tolerance was most correlated with peak nicotine
concentrations.

Chronic nicotine administration results in tolerance to a number
of other nicotinic effects. Tolerance develops to depression of operant
responding elicited by high doses of nicotine, such that after
sufficient chronic t.reatment, enhanced rather than depressed oper-
ant responding is seen (Clarke and Kumar 1983c; Hendry and
Rosecrans 1982). Attenuation of the effects of nicotine on electroen-
cephalogram (EEG) activity is seen in the rat following chronic
injection (Hubbard and Gohd 1975). These altered EEG responses
paralleled the development of tolerance to behavioral effects de-
scribed by these authors as "arousal." In contrast to the findings of
Hubbard and Gohd (1975), other studies indicate that chronic
tolerance does not develop to the behavioral stimulation effect of
nicotine (Battig et al. 1976; Morrison and Stephenson 1972; Clarke
and Kumar 1983a,c). Likewise, little or no tolerance to nicotine-
induced prostration after i.v. administration was observed after
chronic exposure in rats (Abood et al. 1981, 1984).

In addition, tolerance has been reported to develop to nicotine-
induced increases in plasma corticosterone, but not adrenal catechol-
amine release in rats (Balfour 1980; Van Loon et al. 1987). Anderson
and colleagues (1985) studied the effects of chronic exposure to
cigarette smoke on neuroendocrine function of the rat hypothala-
mus. These researchers observed that chronic exposure to cigarette
smoke over a period of 9 days did not result in tolerance to the ability
of acute intermittent exposure to cigarette smoke to reduce serum
levels of prolactin, luteinizing hormone, and follicle stimulating
hormone.

52


Mechanisms of Chronic Tolerance

Chronic tolerance to drugs may be due to an increase in the rate of
drug metabolism or to a decrease in sensitivity of the tissue to the
drug. Considerable differences exist among humans in the rate of
nicotine metabolism (Benowitz et al. 1982). Metabolism is faster
(shorter half-life) in smokers than in nonsmokers (Schievelbein et al.
1978; Kyerematen et al. 1982; Kyerematen, Dvorchik, Vesell 1983).
The contribution of enhanced nicotine metabolism to the develop-
ment of nicotine tolerance in humans is unclear. Studies of rats
which clearly demonstrate that chronic nicotine treatment results in
tolerance to nicotine also indicat,e that chronic nicotine administra-
tion does not increase the rate of nicotine metabolism in rats
(Takeuchi, Kurogochi, Yamaoka 1954) or mice (Hatchell and Collins
1977; Marks, Burch, Collins 1983b). These findings indicate that
tolerance to nicotine primarily involves reduced sensitivity of target
tissues.

Chronic tolerance to nicotine may be due to alterations in brain
nicotinic receptors (see Chapter III for further discussion of nicotine
receptors). At least two types of nicotinic receptors exist in rodent
brain (Marks and Collins 1982). One of these receptor types may be
measured with 3H-nicotine or `H-acetylcholine (3H-ACh) (Marks,
Stitzel et al. 1986; Martino-Barrows and Keller 19871, while the other
type may be measured with "`1-bungarotoxin (BTX). The nicotine-
binding site has higher affinity for nicotine than does the BTX site
(Marks and Collins 1982). Chronic nicotine injection, once or twice
daily for approximately 7 days, increased the number of 3H-nic-
otine/3H-ACh-binding sites in the brain (Ksir et al. 1985, 1987;
Morrow, Lay, Creese 1985; Schwartz and Kellar 1983, 1985). This
increase in nicotine-binding sites appeared to correlate with the
emergence of nicotine-induced increases in locomotor activity in the
rat. Studies of tolerance to nicotine in one inbred mouse strain (DBA)
also demonstrated that chronic nicotine treatment elicits an increase
in the number of brain nicotinic receptors as measured with both 3H-
nicotine and BTX as the ligands (Marks, Burch, Collins 1983a; Marks
and Collins 1985; Marks et al. 1985, 1986; Marks, Stitzel, Collins
1985,1986, 1987). These studies have also shown that the number of
3H-nicotine-binding sites increases at lower doses of nicotine than do
the BTX-binding sites. An increase in 3H-nicotine binding (Marks,
Burch, Collins 1983a) paraliels development of tolerance to various
responses during chronic infusion, In chronically infused DBA mice,
tolerance acquisition and disappearance parallel the up-regulation
and return to control, respectively, of brain 3H-nicotine binding
(Marks, Stitzel, Collins 1985). These findings suggest that the
increase in 3H-nicotine binding is related to the development of
tolerance to nicotine. However, further studies indicate that factors
other than receptor number must also be considered, because mouse

53


strains that do not develop tolerance to nicotine also demonstrate up-
regulation of nicotinic receptors following chronic infusion (Marks et
al. 1986; Marks, Stitzel, Collins 1986).

That chronic nicotine treatment results in a decrease in response
to the drug (tolerance) and an increase in the number of nicotinic
receptors was an unexpected finding. Marks, Burch, and Collins
(1983a) and Schwartz and Kellar (1985) have suggested that chronic
nicotine treatment results in chronic desensitization of nicotinic
receptors. Chronic desensitization of the nicotinic receptor is compa-
rable to chronic treatment with an antagonist and could be the
stimulus for up-regulation of the receptors. According to this
hypothesis, there is an increase in number of brain nicotinic
receptors but a decrease in the absolute number of "activatable"
(nondesensitized) receptors. This would result in a decreased re-
sponse to nicotine (tolerance). Marks and coworkers suggest that
inbred mouse strains failing to exhibit tolerance to nicotine, under
the procedures used by these investigators, have brain nicotinic
receptors that resensitize more rapidly than do those strains that do
exhibit tolerance.

By treating rats chronically with the acetylcholinesterase inhibi-
tor disulfoton, Costa and Murphy (1983) have found a decrease in rat
brain 3H-nicotine binding. Disulfoton-treated rats were also tolerant
to the antinociceptive effects of nicotine. Thus, tolerance to nicotine
effects may be seen when the number of nicotinic receptors is
increased or decreased by chronic drug treatment. The observation
that tolerance to at least one effect of nicotine can be obtained by a
technique that decreases brain nicotinic receptor numbers supports
the idea that chronic nicotine treatment results in an increase in the
total number of receptors but a decrease in those that may be
activated by nicotine; that is, a high fraction of the up-regulated
receptors are desensitized.

In contrast to the studies reviewed above, some investigators have
found no change in the number or affinity of 3H-nicotine-binding
sites in the brains of rats chronically exposed to nicotine (Abood et
al. 1984; Benwell and Balfour 1985).

Other potential neurochemical explanations for tolerance to
nicotine have been considered. Several reports (Westfall 1974;
Giorguieff et al. 1977; Arqueros, Naquira, Zunino 1978; Giorguieff-
Chesselet et al. 1979) indicate that nicotine stimulates dopamine
release in vitro, and a recent study demonstrated that nicotinic
agonists are less effective in stimulating dopamine release in slices of
striatum obtained from rats that had been chronically treated with
the nicotinic agonist dimethylphenylpiperazinium (DMPP) (Westfall
and Perry 1986). These findings are consistent with the idea that
chronic nicotinic agonist treatment results in a decrease in the
absolute number of receptors that can be activated.

54


Pharmacodynamics of Nicotine and Cigarette Smoking

As the foregoing review has shown, the intensity of nicotine's
effects is related to the dose given, the time since the last dose, and
the level of preexisting or acquired tolerance. Since nicotine can
produce effects that lead to further use (reinforcing effects! (Hen-
ningfield and Goldberg 1983, and can also produce effects that limit
use (aversive effects, usually at higher dose levels) (Danaher 19771,
the strength of the effect of a given dose can determine whether
more or less nicotine will be subsequently taken. Thus, factors such
as tolerance can affect the manner in which nicotine controls
behavior (Chapter IV). Similarly-, an individual's ability to develop
tolerance to the toxic actions may be critical in determining whether
smoking will occur and, if smoking is initiated, whether there will be
an increase in the number of cigarettes consumed each day.

Pharmacodynamic considerations may help explain the pattern of
cigarette smoking throughout the da)-. Intervals between smoking
cigarettes may be determined at least in part by the time required
for tolerance to disappear. With regular smoking there is accumula-
tion of nicotine in the body resulting in a greater level of tolerance.
Transiently high brain levels of nicotine following smoking individu-
al cigarettes may partially overcome tolerance. But the effects of
individual cigarettes tend to lessen throughout the day. Overnight
abstinence allows considerable resensitization to effects of nicotine,
and the daily smoking cycle begins again.

Pharmacodynamic observations with i.v. dosing of nicotine explain
the pattern of cardiovascular changes observed in cigarette smokers.
That brief infusions of nicotine increase heart rate to a maximum
suggests that heart rate will increase most with the first few
cigarettes of the day, but subsequently will not vary in relation to
the amount of nicotine consumed. That only partial tolerance
develops to heart rate acceleration due to nicorine suggests that
effects on heart rate may persist as long as significant levels of
nicotine persist, including overnight. These predictions were con-
firmed in a study in which volunteer cigarette smokers smoked
either high- or low-yield nonfilter research cigarettes or abstained
from smoking (Benowitz, Kuyt. Jacob 1984). Full compensation for
the low-yield research cigarettes, which contained only small
amounts of nicotine, was impossible. Resultant nicotine blood levels
were different by fourfold. As predicted, heart rate (assessed by
continuous ambulatory electrocardiogram (EKG) monitoring) in-
creased in the morning-more on smoking than nonsmoking days-
and the increase occurred with the first few cigarettes of the day.
Subsequently, heart rate followed a normal circadian pattern, but
was always higher during smoking than during abstinence. Also, as
predicted, heart rate was no different during the smoking of low-

55


yield or high-yield cigarettes, despite the fourfold difference in blood
nicotine concentration.

Pharmacodynamic aspects of the actions of nicotine may explain
in part how cigarette smoking causes coronary heart disease (US
DHHS 1983). As noted before, because of the accumulation of
nicotine and its dose-response characteristics, heart rate is increased
during cigarette smoking for 24 hr a day. Plasma catecholamine
concentrations and urinary catecholamine excretion remain in-
creased as well (Benowitz 1986c), consistent with the theory that
cigarette smoking produces sympathetic neural activation 24 hr each
day. Persistent sympathetic activation could result in the following
effects: (1) Alteration in lipid metabolism, resulting in a more
atherogenic lipid profile; (2) Promotion of platelet aggregation and
hypercoagulability; (3) Induction of vasoconstriction and coronary
spasm; and (4) Increased heart rate and myocardial contractility,
thereby an increase in the oxygen demands of the heart and of
circulating catecholamines, which can promote cardiac arrhythmias.
These factors could accelerate atherosclerosis and contribute to
acute myocardial infarction in a person with preexisting coronary
atherosclerosis (Benowitz 1986a) (see also Appendix B). There is no
apparent correlation between acute coronary events and the time at
which a person smokes a cigarette, perhaps because of the persistent
effects of nicotine throughout the day.

Constituents of Tobacco Smoke Other Than Nicotine With
Potential Behavioral Effects

Tobacco smoke contains more than 4,000 constituents, many of
which may have biological activity (US DHHS 1983). Although
nicotine is the major pharmacologic factor which determines the use
of tobacco, other constituents may also be involved. The behavioral
effects of tobacco constituents other than nicotine are described in
the Section below and in Chapter IV. This Section focuses more on
the chemicals that may be involved, whereas Chapter IV focuses
more on cigarette smoking behavior.

Minor Tobacco Alkaloids

Most of the research on the minor tobacco alkaloids has been
directed to determining physiological effects, such as the effect on
blood pressure and other cardiovascular responses and toxicological
effects, rather than the potential for behavioral effects. The pharma-
cologic effects of alkaloids of the nicotine group have been discussed
by Bovet and Bovet-Nitti (1948) and Clark, Rand, and Vanov (1965).
Nornicotine and anabasine were found to have qualitatively similar
actions but to be less potent than nicotine. Larson and Haag (1943)

56


reported that the potency of nornicotine as determined by effects on
blood pressure in dogs was about one-twelfth that of nicotine.

Nicotine analogs have been studied for discriminative stimulus
effects by using animal models (Chance et al. 1978) (see also Chapter
IV). The only chemical shown to produce a positive response in that
test system was 3-methylpyridylpyrrolidine. Recent research has
focused on binding at specific brain receptor sites. Martin and
coworkers compared binding characteristics of nicotine-related com-
pounds (Martin et al. 1986; Sloan et al. 1985). Lobeline, anabasine,
and cytisine were evaluated for effects on heart rate, blood pressure,
respiration rate, minute volume, and tidal volume (Sloan et al. 1987).
Lobeline and anabasine bound to low-affinity sites in the brain,
whereas cytisine bound only at a high-affinity site. The binding data
are consistent with the pharmacologic data, indicating that lobeline
and anabasine have different pharmacologic actions than cytisine.
Kanne and others (1986) and Abood and Grassi (1986) evaluated two
nicotine analogs, including a new radioligand, to study brain
nicotinic receptors. Kachur and others (1986) studied the pharmaco-
logic effects of a bridged-nicotine analog (methylene bridge between
the methyl of the pyrrolidine ring and the a-position of the pyridine
ring). The magnitude of pressor effect depended on the particular
enantiomer and dosage. These results emphasize that compounds
other than nicotine may act at the nicotine receptors; however, there
may be subpopulations of receptors to which different agonists and
antagonists bind (Chapter III).

N-Methylated derivatives of nicotine, including nicotine isometho-
nium ion IN-methylnicotinium ion, NMNj, have been shown to have
pressor and neuromuscular effects in some species (Shimamoto et al.
1958). Nicotine isomethonium ion was first reported to be a
metabolite of nicotine present in smokers' urine by McKennis and
coworkers in the 1960s and its presence in smokers' urine has been
recently confirmed (Neurath et al. 1987). Recently Crooks and
coworkers (Cundy, Godin, Crooks 1985) have shown that only the (Rj-
isomer of nicotine is converted to nicotine isomethonium ion in vitro
in guinea pig tissue homogenates or in vivo in guinea pigs.
Consequently, it is uncertain as to whether the nicotine isomethoni-
urn ion present in smokers' urine arrives from the small amount of
(Rj-nicotine present in tobacco smoke, or whether the human enzyme
systems have different specifications than the guinea pig enzymes.
Because little if any nicotine isomethonium ion penetrates the blood-
brain barrier (Pool 1987; Aceto et al. 1983j, it would appear that this
met.abolite could have behavioral actions only if it were formed in
the CNS. These findings emphasize the complexity of the pharmacol-
ogy of nicotine-related compounds. It can be concluded from research
on these compounds that some do bind to specific brain receptors and
may result in centrally mediated physiological changes. However,

57


there is inadequate evidence to date that any of these compounds
produces either aversive or rewarding effects in human smokers.

"Tar" and Selected Constituents of Tobacco Smoke Which
Contribute to Taste and Aroma

"Tar" is used to describe the dry particulate matter without t,he
nicotine in tobacco smoke ~Pillsbury et al. 1969). The possible role of
tar in t.he maintenance of the cigarette smoking habit has been
considered. Goldfarb and coworkers (19761 studied the effects of the
tar cont.ent (determined by cigarette smoking machine testing) on
the subjective reactions to cigarette smoking. Ratings of strength
were not related to the tar index of the cigarettes. The results were
interpreted as indicating that tar did not have a role in the
maintenance of cigarette smoking behavior. In a later study, Sutton
and coworkers (1982) found that when nicotine yield was held
constant, smokers of lower-tar cigarettes puffed more smoke and had
higher drug plasma levels. These results suggested that smokers
were compensating for reduced delivery of tar by inhaling a greater
volume of smoke. Because these two studies used different experi-
mental designs, it is difficult to draw a conclusion as to the role of tar
in relation to smoking behavior. However, based on knowledge about
the taste and aroma constituents of cigarette smoke, it is likely that
some of the chemicals in the tar fraction contribute to tobacco use, if
only by providing distinct sensory stimuli (Chapter VI). Consistent
with this possibility, minimal levels of tar are held by tobacco
manufacturers to be important to the taste characteristics of tobacco
smoke.

Several thousand compounds have been isolated from tobacco and
tobacco smoke (Dube and Green 1982), and many of these may be
biologically active (IARC 1986). The precursors to the carotenoids
and diterpeniods, selected nitrogenous and sulfur constituents,
waxes and lipids, and phenolics and acids contribute to the taste and
aroma of tobacco (Enzell and Wahlberg 1980: Heckman et al. 1981;
Davis, Stevens, Jurd 19763. A number of the isoprenoid corripounds
that. influence the taste and aroma of smoke may be formed by
sequential oxidation, rearrangement, and reduction reactions (Davis,
Stevens, Jurd 1976). Enzell and Wahlberg (1980) described several
norisoprenoid comp:iunds which are derived from the cyclic carot-
enoids and are important to smoke aroma. The particular taste and
aroma of a cigarette can be influenced by the selection of the grade
(quality and leaf position on the plant! and type of tobacco used in
the blend.

Taste and smell receptors in the pharynx, larynx, and nose provide
the first sensory input to the smoker as he or she lights up, an
experience which is generally perceived as pleasurable (Rose et al.
1985). The taste and smell of tobacco smoke may be important


reinforcers for tobacco smoking (Jarvik 1977tat least following
repeated association with the reinforcing effects of nicotine adminis-
tration (Chapter VII. By such behavioral conditioning, sensory cues
provided by tar and flavor additives could come to control the
tobacco-consuming behavior of the tobacco user. Changes in smoking
patterns when brands are switched and brand selection may be a
response in part to the particular flavor and aroma of the product
(Thornton 19781.

Carbon Monoxide

The mainstream and sidestream carbon monoxide (CO) deliveries
of cigarettes are influenced by cigarette design and puffing charac-
terist.ics of the smokers. Depending upon these factors, the main-
stream delivery usually ranges from 10 to 20 mg/cigarette. In a
study of 29,000 blood donors in 18 locations around the United
States, smokers were found to have median carboxyhemoglobin
(COHb) levels ranging from 3.2 to 6.2 percent (Stewart et al. 1974).
Anderson, Rivera, and Bright (1977) found the COHb levels in 50
smokers to vary from 3.9 to 14.0 percent, with the mean of 8.1
percent. The mean increment in COHb immediately after smoking 1
cigarette was 0.64 percent. COHb levels gradually decrease in blood
after cessation of smoking. Carbon monoxide is eliminated in expired
air. The rate of elimination depends on pulmonary blood flow and
ventilation. The half-life of COHb is 2 to 4 hr during daytime hours,
but as COHb is related to the level of exercise, the half-life may be as
long as 8 hr during sleep (Wald et al. 1975). For these reasons, many
smokers awaken in the morning with substantial levels of COHb,
despite not smoking overnight (Benowitz, Kuyt, Jacob 1982). Persons
smoking cigarettes with lower nicotine and CO yields have only
slightly lower levels of COHb when compared with those smoking
higher-yield products (Wald et al. 1980, 1981; Sutton et al. 1982; Hill,
Haley, Wynder 1983; Benowitz, Jacob, Yu et al. 1986).

Benowitz and colleagues (1986) studied tar, nicotine, and CO
exposure in smokers switched from their usual brand to low-, high-,
and ultra-low-yield cigarettes. This study indicated that there were
no differences in exposure comparing low- and high-yield, but tar
and nicotine exposure were reduced by about 50 percent and CO by
36 percent while smoking ultra-low-yield cigarettes. Switching from
a high to lower yield cigarette does not significantly reduce blood
COHb although switching to ultra low cigarettes has been shown to
lead to a significant reduction.

The toxic effects of high CO levels are well documented (US DHHS
1983). Some studies have tried to determine whether CO levels in the
blood similar to those observed in smokers can affect behavior. Beard
and Wertheim (1967) and Wright, Randell, and Shephard (1973)
reported performance decrements with COHb levels below 5.0

59


percent; however, Guillerman, Radziszewski, and Caille (1978) found
no psychomotor performance effects at COHb levels of 7 and 11
percent. Thus, the data are inconclusive with regard to the possible
influence of CO on psychomotor performance at levels normally
encountered in smokers.

Acetaldehyde and Other Smoke Constituents

Acetaldehyde is a major constituent of tobacco smoke, with
mainstream smoke levels in commercial cigarettes ranging from 0.5
to 1.2 mg/cigarette (IARC 1986). The delivery of volatile aldehydes is
influenced by cigarette design, with reductions achieved by specific
filtration and air dilution techniques. Yields over 5.9 mg have been
reported for large cigars (Hoffmann and Wynder 1977). Acetalde-
hyde is the primary metabolite of ethanol, and its toxic potency is 20
to 30 times that of ethanol. Acetaldelhyde has been suggested to
have an adverse effect on the heart (James et al. 1970). Acetaldehyde
and acrolein, another important aldehyde in the gas phase of
cigarette smoke, activate the sympathetic nervous system (Egle and
Hudgins 1974). Acetaldehyde, by releasing norepinephrine, results
in a pressor effect (Kirpekar and Furchgott 1972; Green and Egle
1983). Depressor effects occur at high doses of the aldehydes in
guanethidine-pretreated hypertensive rats. Frecker (1983) indicated
that condensation products of acetaldehyde may be active on
endogenous opioid systems. Torreilles, Guerin, and Previero (1985)
reviewed the synthesis and biological properties of beta-carbolines,
the condensation products of tryptophan and indole alkylamines
with aldehydes. Beta-carbolines occur as plant constituents, includ-
ing minor constituents in tobacco. For example, harman (l-methyl+-
carboline) has been identified in tobacco and tobacco smoke (Snook
and Chortyk 1984). Carbolines from other plant species have been
used as hallucinogens. The research conducted to date indicates a
potential pharmacologic effect of the aldehydes, especially with
regard to cardiovascular physiology; however, the evidence is
inadequate to determine if these volatile smoke constituents in the
doses delivered in tobacco smoke contribute to the behavioral effects
of cigarette smoking.

Summary and Conclusions

1. All tobacco products contain substantial amounts of nicotine
and other alkaloids. Tobaccos from low-yield and high-yield
cigarettes contain similar amounts of nicotine.
2. Nicotine is absorbed readily from tobacco smoke in the lungs
and from smokeless tobacco in the mouth or nose. Levels of
nicotine in the blood are similar in people using different forms
of tobacco. With regular use, levels of nicotine accumulate in


the body during the day and persist overnight. Thus, daily
tobacco users are exposed to the effects of nicotine for 24 hr
each day.

3. Nicotine that enters the blood is rapidly distributed to the
brain. As a result, effects of nicotine on the central nervous
system occur rapidly after a puff of cigarette smoke or after
absorption of nicotine from other routes of administration.
4. Acute and chronic tolerance develops to many effects of
nicotine. Such tolerance is consistent with reports that initial
use of tobacco products, such as in adolescents first beginning
to smoke, is usually accompanied by a number of unpleasant
symptoms which disappear following chronic tobacco use.

61


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CHAPTER III

NICOTINE: SITES AND
MECHANISMS OF ACTIONS

75


CONTENTS

Overview .............................................................. .79
  Peripheral Effects of Nicotine ............................. .79
  Central Sites of Nicotine Actions ........................ .80
  Neuroendocrine Effects of Nicotine ...................... .81
  Electrophysiological Effects of Nicotine ................ .81

D

listribution and Cerebral Metabolic Effects of
Nicotine.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82
Distribution of Nicotine,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82
    Tissue Distribution of Nicotine: Time Course
      and Other Considerations . . . . . . . . . . . . . . . . . . . . . . . . . .82
   Heterogeneity of Nicotine Uptake: Microauto-
    radiographic and Subcellular Studies.. . . . . . . . . .85
Effects of Nicotine on Cerebral Metabolism . . . . . . . . . . .85

Nicotine Receptors ................................................. .88
  Peripheral Nicotine Receptors ............................. .88
  Radioligand Binding to Putative Nicotine Choliner-
   gic Receptors in Mammalian Brain ................... .89
    Agonist Binding ......................................... .89
    Radioligand Binding ................................... .91
    Antagonist Binding .................................... .91
  Functional Significance of Nicotinic Binding Sites .. .92
    High-Affinity Agonist Binding Sites .............. .92
    Alpha-Bungarotoxin Binding Sites ................. .92
    Behavioral and Physiological Studies ............. .93
  The Neuroanatomical Distribution of Nicotinic
  Binding Sites in the Brain .............................. .93
    High-Affinity Agonist Binding Sites .............. .93
       Rodent .................................................. .93
     Monkey ................................................. -94
       Human ................................................. .94
    Alpha-Bungarotoxin Binding Sites ................. .94
     Molecular Biology ...................................... .95
  Central Nicotinic Cholinergic Receptors: Pre- or
   Postsynaptic?. ................................................ .95
    Presynaptic Regulation of Neurotransmitter
      Release .................................................. -95
    Somatodendritic Postsynaptic Actions ............ .95

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Neuroendocrine and Endocrine Effects of Nicotine ....... .95
  Cholinergic Effects ............................................ .96
  Modulation of Catecholamine and Serotonin
   Activity ......................................................... 97
     Effects  on Serotonergic Neurons ................... .99
    Effects on Catecholaminergic Neurons .......... 100
  Stimulation of Pituitary Hormones ..................... 101
    Arginine Vasopressin ................................. 102
    The Pro-Opiomelanocorticotropin Group of
      Hormones ............................................. 103
  Thyroid .......................................................... 104
  Adrenal Cortex ............................................... 104
  Androgens ...................................................... 106
  Estrogens ....................................................... 106
Pancreas and Carbohydrate Metabolism .............. 107

Electrophysiological Actions of Nicotine .................... 107
  Electrocortical Effects ....................................... 107
  Spontaneous Electroencephalogram ..................... 108
  Sensory Event-Related Potentials ........................ 112
  Cognitive Ever&Related Potentials ...................... 114
  Motor Potentials .............................................. 115

Other Peripheral Effects Relevant to Tobacco Use.. . , . .115
Psychophysiological Reactivity and Smoking.. . . . . . . . 116
Psychophysiological Reactivity, Smoking Cessation,
  and Relapse.................................................120

Summary and Conclusions.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

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Overview

Nicotine, in tobacco smoking concentrations, is a powerful psy-
choactive drug (Domino 1973; Kumar and Lader 1981; Balfour 1984). A
wide variety of stimulant and depressant effects is observed in
animals and humans that involves the central and peripheral
nervous, cardiovascular, endocrine, gastrointestinal, and skeletal
motor systems. These heterogeneous effects, along with behavioral
and psychological variables, result in self-administration of tobacco,
tobacco dependence, and withdrawal phenomena with abrupt cessa-
tion of tobacco smoking. This Chapter discusses sites and mechan-
isms of nicotine actions that may help to explain why tobacco
products are self-administered.

The first Section of this Chapter provides general summaries of
several major effects of nicotine in the body. Following this broad
overview, the Chapter presents detailed discussions of sites and
mechanisms of nicotine action that may be particularly important to
understand tobacco use. Tissue distribution of nicotine, cerebral
metabolic effects, and nicotine receptor binding are reviewed. Next,
neuroendocrine and endocrine effects of nicotine are discussed.
Then, electrophysiological effects of nicotine are presented. Finally,
the effects of smoking on psychophysiological reactivity are discuss-
ed.

Peripheral Effects of Nicotine

Nicotine exerts its action on the cardiovascular, respiratory,
skeletal motor, and gastrointestinal systems through stimulation of
peripheral cholinergic neurons via afferent chemoreceptors and
ganglia of the autonomic nervous system (ANSI (Ginzel 1967b).
Inasmuch as both sympathetic and parasympathetic ganglia are
stimulated by levels of nicotine derived from tobacco smoking, the
end result depends on the summation of the effects of autonomic
ganglion stimulation and reflex effects. The resulting peripheral
physiological changes generally resemble sympathetic nervous sys-
tem (SNS) arousal, but there are also some effects of nicotine and
smoking that lead to physiological relaxation. For example, there is
usually an increase in heart rate and blood pressure immediately
following cigarette smoking. In addition, there is cutaneous vasocon-
striction of the distal extremities. In contrast, nicotine can relax
skeletal muscles (e.g., reduce patellar reflex) in humans and animals
via effects on Renshaw cells (Domino and Von Baumgarten 1969;
Ginzel and Eldred 1972; Ginzel1987). But it also can enhance tension
in some muscles (e.g., trapezius muscle) (Fagerstrom and Gotestam
1977). Nicotine in small doses can enhance respiration through
stimulation of peripheral chemoreceptors. Yet, high nicotine doses
can cause respiratory failure. (See Appendix B for a discussion of

79


nicotine toxicity.) The gastrointestinal effects of nicotine are com-
plex, involving an increase in secretions and reduced motility for a
short period of time.

The peripheral actions of nicotine as a cholinergic agonist have
made it a valuable pharmacologic tool for studying nicotinic
cholinergic actions and functioning in many physiological systems.
This Chapter focuses on the mechanisms of nicotine's actions
relevant to tobacco use. Several peripheral actions of nicotine, for
instance muscular relaxation, may contribute to the habitual use of
tobacco products (see smoking and stress in Chapter VI). However,
because the central nervous system (CNS) actions of nicotine and
resulting neurochemical and electrical effects mediate subsequent
biological and behavioral responses, a review of these actions
contributes to an understanding of the reinforcing effects of nicotine.

Central Sites of Nicotine Actions

Nicotinic binding sites or receptors in the brain have been
differentiated as very high, high, and low affinity types (Shimohama
et al. 1985; Sloan, Todd, Martin 1984; Sloan et al. 1985). In the rat
brain, when cholinergic muscarinic receptors are blocked, the
autoradiographic distribution of 3H-acetylcholine (ACh) and "H-
nicotine are essentially identical (Clarke and Kumar 1984; Clarke,
Pert, Pert 1984). However, these brain binding sites differ from
peripheral nicotinic receptors in ganglia and skeletal muscle.

Chronic nicotine administration results in up-regulation in region-
al rat brain 3H-ACh binding sites measured in the presence of
atropine to block the muscarinic sites (Schwartz and Kellar 1985).
Up-regulation of 3H-nicotine binding sites also has been reported
after continuous nicotine infusions in mice (Marks, Burch, Collins
1983a). In contrast, most agonists that act on receptor sites in the
body, when given chronically, produce a reduction (or down-regula-
tion) in the number of receptors. Both Marks, Burch, and Collins
(1983b) and Schwartz and Kellar (1983, 1985) have suggested that
nicotinic cholinergic receptors undergo a functional blockade but
that sufficient recovery would allow enhanced behavioral responses
to low doses of nicotine to occur within 24 hr, as has been shown
behaviorally by Clarke and Kumar (1983) and Ksir and coworkers
(1985). This phenomenon may help to explain the tolerance to
nicotine that develops with repeated exposure. However, the time
course of changes in receptor number and other biological effects of
nicotine must be carefully compared to determine mechanisms
underlying tolerance. (See Chapter II for additional discussion.)

Several investigators have used in vitro autoradiography to
identify 3H-nicotine binding sites in the rat brain. These audioradio-
graphic binding studies suggest where nicotine is acting. London,
Waller, and Wamsley (1985) have found the most intense localization

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of 3H-labeled nicotine in the interpeduncular nucleus and medial
habenula.

Cerebral metabolism studies also suggest key sites of action.
London and colleagues (1985) have reported that nicotine stimulated
local cerebral glucose utilization (LCGU) by 139 percent over that of
the control in the medial habenula and by 50 to 100 percent in the
superior colliculus and the anteroventral thalamic and interpedun-
cular nuclei. Other areas of the brain showed moderate or no
significant changes. These effects of nicotine were blocked by
mecamylamine, a nicotinic recept,or antagonist, confirming that they
acted via nicotinic receptors. Furthermore, they correlated well with
the distribution of 3H-nicotine binding in the brain except in layer
IV of the neocortex, which showed nicotine binding but no change in
LCGU. Sites that show increased glucose utilization after nicotine
administration are probably functionally important loci of nicotinic
actions. When nicotine binding and increased energy utilization both
occur at a given site, it is likely to be involved in nicotine's actions.

Neuroendocrine Effects of Nicotine

Some of the actions of nicotine result from the release of ACh and
other neurotransmitters, including norepinephrine (NE). Nicotinic
cholinergic agonists including nicotine, carbachol, and 1,1-dimethyl4-
phenylpiperazinium (DMPP) release endogenous ACh from the
presynaptic cholinergic nerve terminals in addition to stimulating
postsynaptic nicotinic receptors (Chiou 1973; Chiou and Long 1969).
Nicotinic agonists also release ACh from rat cerebral cortical
synaptic vesicles and can release newly synthesized 3H-ACh from
synaptosomes prepared from the myenteric plexus of guinea pig
ileum and from mouse cortical synapses (Briggs and Cooper 1982;
Rowe11 and Winkler 1984). These effects are Ca"+-dependent and are
blocked by hexamethonium, a quarternary nicotinic receptor antago-
nist. In addition, nicotine-induced release of ACh in the hippocampal
synaptosomes is blocked by the ion channel blocker, histrionicotoxin
(Rapier et al. 1987). There is good evidence that nicotine releases
ACh by a presynaptic mechanism. In contrast, presynaptic musca-
rinic receptors, mostly of the M,-subtype, inhibit ACh release.
Nicotine administration increases the amounts of other chemicals in
the blood and brain, including serotonin, endogenous opioid peptides,
pituitary hormones, catecholamines, and vasopressin (Domino 1979;
Gilman et al. 1985; Marty and colleagues 1985). These chemicals may
be involved in reinforcing effects of nicotine (see Chapters IV, VI).

Electrophysiological Effects of Nicotine
Nicotine administration is accompanied by brain wave or electro-
encephalogram (EEG) activation in animals (Domino 1967). The EEG-
activating effects of small doses of nicotine occur in intact as well as

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brainstem-transected animals. Nicotine acts primarily directly on
brainstem neuronal circuits to produce these effects (Domino 1967).
However, stimulation of peripheral afferents (Ginzel 1987) and
release of catecholamines and possibly neurotransmitters and modu-
lators, such as serotonin or histamine, may enhance the direct
central effects of nicotine.

The EEG-activating effects of nicotine result in behavioral arousal
(Domino, Dren, Yamamoto 1967). In cigarette smokers, nicotine
produces sedat.ive and stimulant effects (Kumar and Lader 1981).
Aceto and Martin (1982) have reviewed the large variety of nicotine
effects on behavior including facilitation of memory, the increase in
spontaneous motor activity, nicotine's antinociceptive properties,
and its suppression of irritability. These behavioral and psychologi-
cal effects are discussed in Chapters IV and VI.

Distribution and Cerebral Metabolic Effects of Nicotine

Nicotine, administered by various routes, rapidly enters the brain
and also distributes to specific, peripheral organs. Nicotine produces
a distinct pattern of stimulation of cerebral metabolic activity that
suggests where nicotine acts in the brain. This Section reviews
studies on the distribution of nicotine after its administration to
experimental animals, data on the relationship between tissue levels
of nicotine and the drug's biological effects, and studies on mapping
the cerebral metabolic effects of nicotine in the rat brain.

Distribution of Nicotine

Tissue Distribution of Nicotine: Time Course and Other
Considerations

The distribution in the body of exogenously administered nicotine
has been a topic of interest for more than a century and has been
reviewed several times (Larson, Haag, Silvette 1961; Larson and
Silvette 1968, 1971). As early as 1851, Orfila described experiments
in which he detected nicotine in various organs (e.g., liver, kidney,
lungs) and in the blood of animals after nicotine administration. In
the 1950s the development of radiotracer methods led to a reexami-
nation of nicotine distribution in the body.

Werle and Meyer (1950) found that the brain, compared with other
organs, contained the highest nicotine levels immediately after
injection of a lethal dose in guinea pigs. Tsujimoto and colleagues
(1955) found a high concentration of nicotine in the brain after the
drug was administered to rabbits and dogs. Yamamoto (1955)
observed that 1 hr after a subcutaneous (s.c.) injection of 5 mg/kg in
the rabbit, the nicotine content was highest in the kidney. The
pancreas, ileum, ventricular muscle, skeletal muscle, lung, spleen,
cerebral cortex, omental fat, and liver showed progressively lower

82


levels of nicotine at 3 hr. None of the tissues had detectable levels at
6 hr. In the dog, the highest level at 1 hr was in the kidney, followed
by the pancreas, brain, ileum, liver and omental fat, spleen, heart,
muscle, and lung.

Schmiterlow and colleagues used radiolabeled nicotine and whole-
body autoradiography to study the distribution of nicotine in several
species (Hansson and Schmiterlow 1962; Appelgren, Hansson,
Schmiterlow 1962, 1963; Hansson, Hoffman, Schmiterlow 1964;
Schmiterlow et al. 1965; Schmiterlow et al. 1967). After radiolabeled
nicotine was administered, radioactivity representing nicotine and
its metabolites was concentrated in some organs, particularly the
brain. Hansson and Schmiterlow (1962) injected (Sl-nicotine-methyl-
`*C intramuscularly or intravenously (iv.) in mice. Within 5 min,
high concentrations were found in the brain, adrenal medulla,
stomach wall, and kidney. Lower concentrations were observed in
the liver, skeletal muscle, and blood, but all concentrations were
higher in tissue than in blood. Activity was high in the kidney from 5
min to 4 hr after the nicotine injection, with the highest activity
occurring within the first hour. The adrenal medulla maintained a
high concentration at 1 hr and 4 hr after injection, but little or no
activity was observed at 24 hr. At 30 min, the levels were high in the
walls of large blood vessels and in the bone marrow. Radioactivity
disappeared rapidly from the brain.

Appelgren, Hansson, and Schmiterlow (1962) prepared whole-body
autoradiograms of mice and cats given i.v. injections of 14C-nicotine.
An initial, heterogeneous accumulation of radioactivity occurred in
the CNS. Fifteen minutes after the radiotracer injection, the cat
brain showed distinctly more intense labeling of grey than of white
matter. Also apparent was a regional distribution within grey
matter areas, particularly in the hippocampus. By 30 min, radioac-
tivity was reduced. Studies of mice demonstrated a high concentra-
tion of label in the brain at 5 min. By 30 min, the concentration was
high in salivary glands, stomach contents, liver, and kidneys, while
the brain was almost devoid of radioactivity. The same group also
showed the accumulation of 14C-nicotine in the retina of the eye after
i.v. administration (Schmiterlow et al. 1965).

Fishman (1963) reported that in rats given randomly labeled 14C-
nicotine intraperitoneally (i.p.) and killed 3 hr later, the kidney
contained the highest concentration of radioactivity, followed by the
lung, liver, brain, skeletal muscle, spleen, and heart. In the dog,
more `%-nicotine was present in the stomach wall than in any other
tissue analyzed 3 hr after i.v. injection of radioactive nicotine.

Yamamoto, Inoki, and Iwatsubo (1967) gave mice S.C. injections of 5
mg/kg methyl-`4C-nicotine. Five minutes later, they found 0.5 to 1
pg/g (wet weight) of nicotine in various brain regions, including the
cerebral cortex, superior and inferior portions of the brain stem, and

83


the cerebellum. Highest levels were detected 5 to 10 min after
injection. Maximum levels in liver and whole blood were observed 2
and 10 min, respectively, after the injection.

Yamamoto, Inoki, and Iwatsubo (1968) studied penetration of 14C-
nicotine in rat tissues in vivo and in vitro. They found that 5 mg/kg,
i.p., in male Wistar rats produced the following maximum tissue-to-
blood ratios of 14C-nicotine activity after 10 to 20 min: kidney, 8.7;
liver, 6.7; submaxillary gland, 6.2; cerebral cortex, 3.5; brainstem,
2.4; and heart, 1.8. When they incubated tissue slices with 10e4 M 14C-
nicotine for 30 min at 37"C, the relative uptake of the label was
similar: kidney cortex, 2.6; liver, 2.1; submaxillary gland, 2.1; and
cerebral cortex, 2.0. Penetration in slices was unaffected by uncou-
pling oxidative phosphorylation or blocking metabolic pathways,
indicating that the uptake was not by active transport. In vivo,
tissue-to-blood ratios were greater than slice-to-medium ratios,
indicating that a process other than passive diffusion was involved.

Because the respiratory tract is a major route by which nicotine
from tobacco smoke enters the body, Schmiterlow and coworkers
(1965) sprayed 14C-nicotine solution directly onto the trachea of mice.
Autoradiograms from mice killed at 2 min exhibited a high amount
of radioactivity in the respiratory tract and lungs and showed that
nicotine enters the CNS rapidly by this route as well. At 15 min,
radioactivity still persisted in the lungs, was reduced in the brain,
and appeared in large amounts in the kidneys and stomach.

Uptake and distribution of nicotine from tobacco smoke have also
been assessed. Harris and Negroni (1965) exposed mice to cigarette
smoke and extracted nicotine from the lungs (5 to 25 pg). Mattila and
Airaksinen (1966) exposed guinea pigs to the smoke of one 4-g cigar
over a period of 40 min, with intermittent ventilation with fresh air,
and found that the same tissues which concentrated nicotine
administered by other routes also showed nicotine uptake from
smoke. Organ-to-blood ratios were lung, 2.0; spleen, 3.0; intestine,
2.9; and brain, 1.1.

The use of positron-emitting radiotracers permits in vivo estima-
tion of nicotine uptake into the brain and other organs, offering the
potential of eventually relating nicotine action in the living human
brain to behavioral and disease states. Maziere and coworkers (1976)
prepared (S)-nicotine-methyl-"C, which they administered by i.v.
injection to mice and rabbits. The time course of the radiotracer
confirmed earlier studies and showed a maximum concentration in
the 5 min following injection, except in the liver and spleen. Highest
radioactivity was in kidneys and brain, followed by liver and lungs.
The brain activity dropped rapidly, whereas the kidney concentra-
tion remained high (8 percent of injected dose) at 50 min after the
injection. External imaging by a y camera showed considerable

84


radioactivity in the head, kidneys, and liver. Brain activity decreased
sharply over 1 hr, while activity remained high in liver and kidneys.

Maziere and coworkers (1979) used "C-nicotine and positron
emission tomography (PET) in baboons and found that "C-nicotine
readily penetrated into the brain and then dropped sharply with
time. Radioactivity was high in the temporal lobe, cerebellum,
occipital cortex, pons, and medulla oblongata. There was also a high,
stable radioactivity level in the retina, consistent with the earlier
observation that radioactivity from `V-nicotine is found in the
retina after i.v. administration (Schmiterlow et al. 1965).

Heterogeneity of Nicotine Uptake: Microautoradiographic and
Subcellular Studies

Appelgren, Hansson, and Schmiterlow (1963) used a microautora-
diographic method to study the localization of nicotine within the
superior cervical ganglion of the cat. Most of the radioactivity was
localized in the ganglion cells, with little labeling of satellite cells
and connective tissue.

Schmiterlow and coworkers (19671, using microautoradiograms of
mouse brains after injection of 14C-nicotine and 3H-nicotine, reported
that nicotine is concentrated in nerve cells. Brain areas with a high
density of nerve cells, such as the molecular and pyramidal cell
layers of the hippocampus and the molecular layer of the cerebel-
lum, contained high amounts of radioactivity.

Yamamoto, Inoki, and Iwatsubo (1967) studied accumulation of
14C-nicotine into subcellular fractions (nuclear, mitochondrial, nerve
ending, microsomal, soluble) of mouse brain after i.p. injection of 5
mg/kg (20 $X/kg). Most of the radioactivity was in the soluble
fraction. Less than one-tenth of the radioactivity in the soluble
fraction was found in microsomes and nerve endings; however,
radioactivity levels in microsomes were somewhat higher than in
nerve endings.

Effects of Nicotine on Cerebral Metabolism

Following the demonstration that 3H-nicotine binds stereoselec-
tively and specifically in preparations of rat brain (Yoshida and
Imura 1979; Martin and Aceto 1981; Marks and Collins 19821, brain
binding sites were visualized (Clarke, Pert, Pert 1984) and quantified
(London, Waller, Wamsley 1985) by light microscopic autoradiogra-
phy. However, mapping nicotinic binding sites or identifying specific
binding sites for any drug or neurotransmitter does not necessarily
mean that receptors are coupled to pharmacologic actions. An
example of nonfunctional, stereoselective, specific binding is that of
3H-naloxone to glass fiber filters (Hoffman, Altschuler, Fex 1981). In
addition, because the brain is a highly interconnected organ, drugs

85


may produce effects in brain regions remote from their initial
receptor interactions. Receptor maps would show primary binding
sites but not sites where important secondary actions might occur.

Functional mapping procedures, such as the use of autoradio-
graphic techniques to measure rates of LCGU and regional cerebral
blood flow, are another way to determine the sites of the in vivo
effects of nicotine in the brain. The 2-deoxy-D-[1-`Y$$ucose (2-DG)
method for measuring LCGU (Sokoloff et al. 19771 has been used to
demonstrate a relationship between local cerebral function and
glucose utilization under a wide variety of experimental conditions,
including pharmacologic treatments (Sokoloff 1981; McCulloch
1982). The effects of acute, S.C. injections of nicotine on LCGU were
examined by London and colleagues (1985, 1986) and by London,
Szikszay, and Dam (1986), while Grunwald, Schrock, and Kuschinsky
(1987) measured the effects on LCGU of constant plasma levels of
nicotine produced by iv. infusion.

Subcutaneous injections of nicotine stimulated LCGU in specific
brain regions (Table 1, Figure 11, including portions of the visual,
limbic, and motor systems. Effects of nicotine infusion generally
paralleled those obtained with S.C. injections. The greatest increase
in response to S.C. nicotine occurred in the medial habenula. Marked
increases in LCGU were noted in the anteroventral thalamic
nucleus, interpeduncular nucleus, and superior colliculus. Moderate
increases were seen in the retrosplenial cortex, interanteromedial
thalamic nucleus, lateral geniculate body, and ventral tegmental
area. No significant effects were observed in the frontoparietal
cortex, lateral habenula, or central grey matter. LCGU responses to
S.C. injection of nicotine were completely blocked by mecamylamine,
indicating the specificity of nicotine effects.

The effects of nicotine on LCGU correlate well with the distribu-
tions of 3H-nicotine binding sites (Clarke, Pert, Pert 1984; London,
Waller, Wamsley 1985). Areas such as the thalamic nuclei, the
interpeduncular nucleus, medial habenula, and the superior collicu-
lus, where there is dense labeling with 3H-nicotine, show moderate to
marked nicotine-induced LCGU increases. Areas with less specific
binding show smaller LCGU responses to nicotine, and the central
grey matter, which lacks specific 3H-nicotine binding, shows no
LCGU response. Similarly, nicotine dramatically increases LCGU in
the medial but not the lateral habenula, reflecting different densities
of 3H-nicotine binding sites. In general, 3H-nicotine binding sites
visualized autoradiographically in the rat brain are functional
nicotine receptors. However, layer IV of the neocortex displays
significant 3H-nicotine binding, but lacks an LCGU response.

In most brain areas, significant LCGU stimulation was obtained
with 0.3 mg/kg of nicotine S.C. (London et al. 19861, a dose similar to
one used successfully in training rats to distinguish nicotine from

86


TABLE l.-R&Nicotine effects on glucose utilization in the
        rat brain

Local cerebral glucose utilization
(um01/100 g tissue!mmuteI

Brarn region               Saline control   Nxotine 11.7j mg!kgr

Prontopar1etal cortex. layer I\      110 2 8.1        108 t 6.5

Retrosplenml cortex. law I        98 i 6.5        123 + 5.1'

Thaiamlc nuclei

.L\nteroventral
Interantcromed~al

Lateral gemculatP body

Interpeduncular nucleus


Medial habenula


Supw7or colllculus

109 1 6.5        201 L 61'
125 i- 86        Ii5 t 12.3'


82 z 6.8        106 r 44'


99 -t 9.8        182 + 9.31


70 2 52        167 f 37'


72 i 52        142 f 4.6'

Central grey matter             66 2 4.0         77 f 4.3

FIGURE l.-Effect of subcutaneous R,S-nicotine (1 mg/kg, 2
       min before S-deoxyglucose) on
      autoradiographic grain densities, representing
      glucose utilization

saline in a T-maze apparatus (0.4 mg/kg, s.c.) (Overton 1969).
Nicotine-induced stimulation of LCGU in the ventral tegmental area

87


and the habenular complex (London et al. 1985, 1986) may relate to
the reinforcing properties of the drug (see Chapter IV). These regions
of the brain have been implicated in drug- and stimulation-induced
reward systems, respectively (Wise 1980; Nakajima 1984). Additional
studies, using specific conditions under which nicotine is reinforcing,
are needed to elucidate the anatomical loci involved in nicotine-
induced reward and to identify the neurophysiological mechanisms
by which nicotine acts as a reinforcer.

Nicotine Receptors

Nicotine exerts diverse pharmacologic effects in both the peripher-
al nervous system (PNS) and CNS. The peripheral actions of nicotine
are important, and some may reinforce the self-administration of
nicotine. For example, stimulation in the trachea (Rose et al. 1984)
seems to be involved in some of the pleasurable effects of smoking.
Skeletal muscle relaxation and electrocortical arousal, both stimu-
lated by actions of nicotine in the lung (Ginzel 1967a,b, 1975, 1987),
may contribute to habitual tobacco use (Chapter VI). However, it is
generally believed that the central actions of nicotine are of primary
importance in reinforcing tobacco use (Chapter IV). In animals, the
neuropsychopharmacologic effects of this drug are, with few if any
exceptions, mediated through central sites of action. These effects
are likely to contribute to the drug's reinforcing properties in
animals and humans (Clarke 1987b). In addition, the effects of
nicotinic antagonists on tobacco smoking in humans (Stolerman et
al. 1973) and in rhesus monkeys (Glick, Jarvik, Nakamura 1970)
suggest a central site of reinforcement, but do not rule out a
peripheral site. To understand these actions, it is important to know
exactly where nicotine acts in the body. This Section discusses
evidence for nicotine receptors.

Peripheral Nicotine Receptors

In the mammalian PNS, nicotine and muscarine mimic different
actions of ACh by acting at different types of cholinergic receptors.
Nicotinic cholinergic receptors (nAChRs) have been subdivided
according to location and sensitivity to nicotinic antagonists. Recep-
tors of the C6 or "ganglionic" type are found principally at
autonomic ganglia, in the adrenal medulla, and at sensory nerve
endings; nicotinic cholinergic transmission in autonomic ganglia is
selectively blocked by hexamethonium and certain other compounds.
Receptors of the "neuromuscular" type (sometimes referred to as
Cl0 type) are located on the muscle endplate, where transmission is
selectively blocked by compounds such as decamethonium and alpha-
bungarotoxin (a-BTX).

88


Higher doses of nicotine are required to stimulate nAChRs in
skeletal muscle than at autonomic ganglia. Ganglionic nAChRs
appear to be more sensitive than their neuromuscular counterparts,
not only to the stimulant but also to the desensitizing actions of
nicotine (Paton and Savini 1968). Doses of nicotine obtained by
smoking cigarettes do not appear to affect the muscle endplate
direct,ly. Therefore, if the CNS were to possess both types of nAChR,
doses of nicotine obtained by normal cigarette smoking might affect
only the CG-receptor population. Accordingly, many of the central
effects of nicotine in vivo and in vitro are reduced or blocked by
nicotinic antagonists that are CG-selective in the periphery. The
most widely used CG-selective antagonist is mecamylamine, which
passes freely into the CNS after systemic administration. Mecamyia-
mine ant.agonizes actions of nicotine in the brain and spinal cord, as
revealed by behavioral (Collins et al. 1986; Goldberg, Spealman,
Goldberg 1981) and electrophysiological experiments (Ueki, Koketsu,
Domino 1961) and also by studies of neurotransmitter release (Hery
et al. 1977; Chesselet 1984). There have been few attempts to
determine whether these central nicotinic actions are also blocked
by neuromuscular antagonists, while several studies support the
existence of central C6 nAChRs (Aceto, Bentley, Dembinski 1969;
Brown, Docherty, Halliwell 1983; Caulfield and Higgins 1983; Egan
and North 1986).

The search for putative central a-BTX nAChRs has been hindered
by several factors, including the central convulsant actions of a-BTX
antagonists (Cohen, Morley, Snead 1981) and the probable need to
deliver locally high concentrations of nicotine. Nevertheless, several
studies have demonstrated actions of nicotine or cholinergic agonists
that can be reduced or blocked by a-BTX, which acts selectively at.
neuromuscular nAChRs (Zatz and Brownstein 1981; Farley et al.
1983; de la Garza et al. 1987a).

Radioligand Binding to Putative Nicotine Cholinergic
Receptors in Mammalian Brain

Many receptors for neurotransmitters in the brain have been
identified through the use of radiolabeled probes (radioligands).
Attempts to label putative brain nAChRs have used compounds with
known potency at peripheral sites (see Table 2).

Agonist Binding

The stereospecific, saturable, and reversible binding of 3H-nicotine
to rodent brain is well-described (Roman0 and Goldstein 1980; Marks
and Collins 1982; Costa and Murphy 1983; Benwell and Balfour
1985a; Clarke, Pert, Pert 1984). Most studies have demonstrated the
existence of a population of high-affinity binding sites (reflected by a
dissociation constant in the low nanomolar range) that is potently

89


TABLE 2.-Radioligands for putative nicotinic cholinergic
      receptors in mammals

Antagonists

    Functional
Bmd  antagonism        Sites examned           Agonists

"`[.BTX       Yes     Yes     Muscle endplate            `H-nicotine
           Yes     YE     Autonomic ganglia, spinal cord
           Yes     YCS     Bram cc&am sites only,      JH-methylcarbachol

!"hZlJa tOXln    Yes     ses     Muscle endplate            `H-ACh iwith excess
           Yes     ND1     BLWI              muscarinic antagonist
                                          and AChE inhibitort
`H-dTC        ND     Yes    Muscle. spinal cord, ganglia
           Yes     Yt?S     Brain


`H-DHBE       ND     Yes     Muscle. autonomic ganglia
           Yes     Yes     Dram. spinal cord

Neosurugat0x1n   ND     No     Muscle endplate
           ND     Yes     Autonomic ganglia
           Yes     Yes     Brain lmhlbits `H-nxotinel


' ND-no data

inhibited by nicotinic agonists including ACh. In contrast, most
nicotinic antagonists have very low affinity for this site. Binding
with similar characteristics has been reported in rat brain tissue
with 3H-methyl-carbachol (Abood and Grassi 1986; Boksa and
Quirion 1987) and with 3H-ACh in the presence of excess atropine to
prevent binding to muscarinic receptor sites (Schwartz, McGee,
Kellar 1982).

In the presence of atropine, tritiated nicotine and 3H-ACh proba-
bly bind to the same population of high-affinity sites in rat brain.
Thus, the two radioligands share the same neuroanatomical distribu-
tion of binding (Clarke, Schwartz et al. 1985; Marks et al. 1986;
Martino-Barrows and Kellar 1987). Binding of both ligands is
inhibited with similar potency by a range of nicotinic agents, is up-
regulated by chronic nicotine treatment in vivo, is down-regulated by
chronic treatment with acetylcholinesterase inhibitors, and is dimin-
ished by disulfide reducing agents in vitro (Marks et al. 1986;
Martino-Barrows and Kellar 1987; Schwartz and Kellar 1983).
Although less well studied, it appears that sites labeled by 3H-
methyl-carbachol are the same as those labeled by 3H-ACh and 3H-
nicotine (Abood and Grassi 1986; Boksa and Quirion 1987). High-
affinity nicotine binding sites have been found in brain tissue of mice
(Marks and Collins 1982), rats (Roman0 and Goldstein 1980),
monkeys (Friedman et al. 1985), and humans (Shimohama et al.
1985; Flynn and Mash 1986; Whitehouse et al. 1986).

Some investigators have reported a second class of sites which are
characterized by lower binding affinity and higher capacity for 3H-

90


nicotine. With no demonstrated differential anatomical distribution
or stereoselectivity (Roman0 and Goldstein 1980; Marks and Collins
1982; Benwell and Balfour 1985b), these low-affinity sites are of
questionable pharmacologic significance, but may be the result of
post mortem proteolysis (Lippiello and Fernandes 1986). Careful
analysis of 3H-nicotine binding conducted in the absence of protease
inhibitors has revealed the existence of five affinity sites or states
(Sloan, Todd, Martin 1984). Functional studies (Martin et al. 1986)
suggest that some of these different sites may represent in vivo sites
of action for nicotine, although it is not clear which if any would be
activated by nicotine doses obtained from typical cigarette smoking.

Radioligand Binding

Many receptors of different nicotine binding affinities have been
reported. It is unclear whether these reflect different conformational
states or binding sites of a single type of receptor, distinct receptor
populations, or a single type of high-affinity site which has under-
gone proteolytic degradation. Preliminary evidence supports the
existence of distinct receptor subtypes labeled by agonists. Two
components of high-affinity 3H-nicctine binding, differing in their
affinity for neosurugatoxin, can be distinguished in rat brain. The
relative proportion of these two components differs in different
regions of the rat brain, suggesting that they are physically distinct
receptors (Yamada et al. 1985).

Antagonist Binding

Most studies of nicotine binding in mammalian brain have used
radioiodinated a-BTX (lz51-BTX), which binds with high affinity and
in a saturable manner to sites in mammalian brain (Schmidt, Hunt,
Polz-Tejera 1980; Oswald and Freeman 1981). This binding is
selectively inhibited by nicotinic agents, including nicotine and ACh.
Cobra (naja) alpha-toxin, like a-BTX, is a selective neuromuscular
blocker in the mammal, and appears to label the same sites as a-BTX
in mammalian brain. Binding is potently inhibited by unlabeled a-
BTX and has a regional distribution resembling that of iz51-BTX
binding (Speth et al. 1977). The antagonist dihydro-beta-erythroidine
(DHBE) binds to two sites in rat brain, but the regional distribution
of binding differs from that of lz51-BTX (Williams and Robinson
1984). DHBE acts with similar potency at both types of peripheral
nAChR in vivo. It is not clear whether 3H-d-tubocurarine binding is
selectively inhibited by nicotinic agents. In rat brain, lz51-BTX binds
to a distinct population of sites that are not labeled with high affinity
(nanomolar kD) by tritiated nicotinic agonists. Radioiodinated a-
BTX sites have a different neuroanatomical distribution (Marks and
Collins 1982; Schwartz, McGee, Kellar 1982; Clarke, Schwartz et al.

91


1985) and can be physically separated from tritiated agonist binding
sites by affinity chromatography (Schneider and Betz 1985; Wonna-
cott 1986). This type of study helps to determine the location and
numbers of nicotine binding sites.

Functional Significance of Nicotinic Binding Sites
High-Affinity Agonist Binding Sites

Brain sites which bind 3H-ACh and 3H-nicotine with high affinity
represent nAChRs that respond in some ways like the C6 type of
receptor found in the periphery (Clarke 1987a). Studies using the 2-
DG technique have revealed that the neuroanatomical pattern of
cerebral activation following the systemic administration of nicotine
in rats is strikingly similar to the distribution of high-affinity agonist
binding demonstrated autoradiographically (London et al. 1985;
Grunwald, Schrok, Kuschinsky 1987). Pretreatment with mecamyla-
mine blocks the effects of nicotine on LCGU, suggesting that
putative ganglionic (CG-type) receptors in the brain are associated
with high-affinity agonist binding.

Most of nicotine's actions on central receptors are blocked by the
CG-selective antagonist mecamylamine. The relevant nAChRs are
probably those which are labeled with high affinity by tritiated
agonists. However, the absence of high-affinity agonist binding sites
in PC12 cells (derived from a pheochromocytoma cell line) known to
express CG-type receptors (Kemp and Morley 1986) indicates that
although central and ganglionic nAChRs have pharmacologic simi-
larities, they may not be identical at the molecular level.

High-affinity agonist binding sites are relevant to long-term effects
of human tobacco smoking. Recently, Benwell, Balfour, and Ander-
son (in press) observed that the density of high-affinity 3H-nicotine
binding in post mortem human brain is higher in smokers than in
nonsmokers. The increased density of sites in smokers is consistent
with studies in animals that show that chronic treatment with
nicotine leads to an increased number of nicotinic receptors in the
brain (Schwartz and Kellar 1983; Marks, Burch, Collins 1983b).

Alpha-Bungarotoxin Binding Sites

Although a-BTX does not block nicotinic actions in all areas of the
CNS (Duggan, Hall, Lee 1976; Egan and North 1986), there are
several reports of antagonism (Zatz and Brownstein 1981; Farley et
al. 1983; de la Garza et al. 1987a). In the rat cerebellum, locally
applied nicotine alters single-unit activity in a manner dependent on
cell type: nicotine excites interneurons but inhibits Purkinje cells.
Both actions are directly postsynaptic (de la Garza et al. 1987, in
press(b)). The inhibitory effects of nicotine are blocked by hexame-


thonium but not by a-BTX, which does block the excitatory effects
(de la Garza et al., in press(a)).

Strain differences exist in mice in the physiological and behavioral
effects of nicotine, in the development of tolerance to these effects,
and in the regional distribution of lz51-BTX binding density (Marks,
Burch, Collins 1983a; Marks, Stitzel, Collins 19861. The genetically
determined variation in response is not readily explained by
differences in brain nicotinic receptors. However, a classical genetic
analysis indicates that the density of `""I-BTX binding sites in mouse
hippocampus correlates with susceptibility to seizures induced by
high doses of nicotine (Miner, Marks, Collins 1984). These and other
considerations (Clarke 1987a) suggest that lZ51-BTX may label a
subtype of nAChR in the brain and that this receptor is pharmaco-
logically akin to the nAChR found in muscle.

Although ""I-BTX binding sites are found in human brain, the
available evidence suggests that nicotine at doses obtained from
cigarette smoking does not activate this population of brain nAChRs.
Rather, the pattern of neuronal activation that follows the in vivo
administration of nicotine in animal experiments, even in doses far
greater than those likely to occur during smoking, resembles the
neuroanatomical distribution of high-affinity agonist binding sites
(London et al. 1985; Grunwald, Schrok, Kuschinsky 1987). However,
this issue is not conclusively resolved, and a potential role for
bungarotoxin binding receptors in mediating effects of smoking
cannot be completely excluded.

Behavioral and Physiological Studies

The effects of mecamylamine on several responses elicited by
nicotine in mice have been examined (Collins et al. 1986). The
responses are of two major classes: those blocked by low doses of
mecamylamine (inhibitory concentrations for 50 percent of mice
tested (IC,,) <O.l mg/kg) (seizures and startle response) and those
blocked by higher doses UC,,, approximately 1 mg/kg) (effects on
respiratory, heart rate, body temperature, and Y-maze activity).
Strain differences are also apparent in the sensitivity to mecamyla-
mine blockade. These findings are consistent with the existence of at
least two types of central nAChR.

The Neuroanatomical Distribution of Nicotinic Binding
Sites in the Brain

High-Affinity Agonist Binding Sites
Rodent

Autoradiographic maps of high-affinity nicotinic binding sites in
rat brain are essentially identical for 3H-nicotine, 3H-ACh, and 3H-
methyl-carbachol (Clarke, Pert, Pert 1984; Clarke, Schwartz et al.

93


1985; London, Waller, Wamsley 1985; Boksa and Quirion 1987).
Dense labeling is observed (11 in the medial habenula and interpe-
duncular nucleus, which appear to belong to a common cholinergic
system; (21 in the so-called specific motor and sensory nuclei of the
thalamus and in layers III and IV of cerebral cortex with which they
communicate; (3) in the substantia nigra pars compacta and ventral
tegmental area, where labeling is associated with dopaminergic cell
bodies (Clarke and Pert 1985); and (4) in the molecular layer of the
dentate gyrus, the presubiculum, and the superficial layers of the
superior colliculus. Labeling is sparse in the hippocampus and
hypothalamus.

Monkey

The autoradiographic distribution of high-affinity 3H-nicotine
binding in rhesus monkey brain is similar to that in the rat
(Friedman et al. 1985). Dense labeling has been noted in the anterior
thalamic nuclei and in a band within cerebral cortex layer III. The
latter band is densest and widest in the primary sensory areas.
Several other thalamic nuclei are moderately labeled, but as in the
rat, the label is sparse in the midline thalamic nuclei. In contrast to
findings for the rat, the medial habenula appears unlabeled.

Human

High-affinity agonist binding has not been mapped autoradio-
graphically in human brain. However, assays of a few dissected brain
areas suggest the following pattern: nucleus basalis of Meynert >
thalamus > putamen > hippocampus, cerebellum, cerebral cortex,
and caudate nucleus (Shimohama et al. 19851. Two affinity sites for
3H-nicotine have been detected, and the regional distribution
observed reflects the presence of both sites.

Alpha-Bungarotoxin Binding Sites

Because "j1-BTX sites may not be relevant to tobacco smoking,
they will be discussed only briefly here. There are clear differences of
regional distribution not only between mice and rats, but also
between different strains of mice (Marks et al. 19861. The autoradio-
graphic distribution of lz51-BTX labeling in rat brain is strikingly
different from the pattern of 3H-agonist labeling, with highest site
density in hippocampus, hypothalamus, and superior and inferior
colliculi (Clarke, Schwartz et al. 1985). An attempt to map lz51-BTX
binding in human brain was hampered by a high degree of
nonspecific binding, with diffuse specific labeling in the hippocam-
pus and cerebral cortex (Lang and Henke 19831.

94


Molecular Biology

Goldman and colleagues have mapped regions in the brain which
contain cell bodies expressing RNA that codes for putative nAChRs.
The RN.4 identified is homologous to cDNA clones encoding the
alpha subunits of the muscle nAChR and a putative neuronal
nAChR (Goldman et al. 1986; Goldman et al. 1987). These and
related findings show that a family of genes exists that codes for
proteins similar to, but not identical with, the muscle nAChR. The
functional role of these putative nAChR subtypes in the CNS is not
clear.

Central Nicotinic Cholinergic Receptors: Pre- or
Postsynaptic?

Presynaptic Regulation of Neurotransmitter Release

The release of ACh from some nerve terminals in the CNS (Rowe11
and Winkler 1984; Beani et al. 1985) and periphery (Briggs and
Cooper 1982) is increased by activation of presynaptic nicotinic
"autoreceptors." Preliminary evidence from lesion experiments
suggests that some nicotinic autoreceptors in the brain may be high-
affinity 3H-nicotine binding sites (Clarke et al. 1986).

Nicotine also modulates the release of certain other neurotrans-
mitters by acting at receptors located on nerve terminals. This form
of regulation has been shown for dopaminergic, noradrenergic, and
serotonergic terminals (Starke 1977; Chesselet 1984). Lesion studies
suggest that these receptors are labeled by 3H-agonists (Schwartz,
Lehmann, Kellar 1984; Clarke and Pert 1985; Prutsky, Shaw,
Cynader 1987).

Somatodendritic Postsynaptic Actions

Much of 3H-agonist labeling probably represents nAChRs located
on neuronal cell bodies or dendrites. For example, nicotine excites
neurons postsynaptically in the medial habenula, locus coeruleus,
and interpeduncular nucleus, all areas of moderate to dense 3H-
agonist binding (Brown, Docherty, Halliwell 1983; Egan and North
1986; McCormick and Prince 19871.

Neuroendocrine and Endocrine Effects of Nicotine

Nicotine has direct and indirect effects on several neuroendocrine
and endocrine systems (Balfour 1982; Clarke 1987a; Hall 1982). This
Section reviews research on the effects of nicotine in animals and
humans that are relevant to understanding cigarette smoking.
Nicotine effects on cholinergic and noncholinergic nicotinic recep-
tors, as well as on the release of catecholamines, monoamines,
pituitary hormones, cortisol, and other neuroendocrine chemicals,

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are discussed. Effects on single neuroregulators are emphasized, but
it is important to recognize that there are extensive interrelation-
ships among these substances (Tuomisto and Mtinnisto 1985).

Nicotine has effects on peripheral endocrine as well as on central
neuroendocrine functions. In the early 1900s researchers discovered
that nicotine stimulated autonomic ganglia (ganglia were painted
with tobacco solutions), inducing such effects as the release of
adrenal catecholamines (Larson, Haag, Silvette 1961). As the health
consequences of cigarette smoking have become clearer, many
investigators have sought to determine tobacco's effects on the
endocrine system, with the possibility that understanding such
effects may help to explain smoking behavior. Nicotine is regarded
as the major pharmacologic agent in tobacco and tobacco smoke
responsible for alterations in endocrine function. However, there has
not been a systematic evaluation of the effects of metabolites of
nicotine or constituents of tobacco other than nicotine on the
endocrine system.

The functional significance of nicotine-induced perturbations in
hormonal patterns and the role of neuroregulators in smoking are
poorly understood. Extensive literature using nicotinic agonists and
antagonists indicates relationships between cholinergic activity and
particular behavioral effects (Henningfield et al. 1983; Kumar,
Reavill, Stolerman, in press). Similar strategies have been employed
to explore the contributions of catecholamines to smoking-related
behavior. However, the exploration of the importance of neuroregu-
lators in the reinforcement of cigarette smoking is still at an early
stage.

Cholinergic Effects

Nicotine has cholinergic effects in the PNS and CNS. Nicotine is a
cholinergic agonist. at peripheral autonomic ganglia and somatic
neuromuscular junctions at low doses and becomes an antagonist at
high doses (Voile and Koelle 1975). Nicotine also releases ACh in the
cerebral cortex (Armitage, Hall, Morrison 1968; Rowe11 and Winkler
1984) and in the myenteric plexus of the peripheral ANS (Briggs and
Cooper 1982). Balfour (1982) has suggested that cortical arousal (see
Electrophysiological Actions of Nicotine for a detailed discussion) is
mediated by ACh release but that behavioral stimulation (see
Chapter IV) either is not mediated by ACh release or does not
depend on the action of ACh at a muscarinic receptor.

Studies involving intracerebral administration of nicotine have
been used to determine the loci of nicotine's action (Kammerling et
al. 1982; Wu and Martin 1983). The injection of nicotine into the
cerebral ventricles of cats, dogs, and rats produces a variety of effects
including changes in cardiovascular activity, body temperature,
respiration, salivation, muscle reflex tone, and electrocortical indices

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of sleep and arousal; the direction and duration of effects depend on
dosage and on baseline response parameters (Ha!1 1982).

Nicotine's cholinergic actions can affect other neuroregulators in
the body (Andersson 1985). Nicotine stimulates NE release in the
hypot,halamus by a Ca'- -dependent process that can be inhibited by
prior administration of hexamethonium or ACh (Hall and Turner
1972; Westfail 1974). The mechanism resembles nicotine's effects on
peripheral adrenergic nerve terminals (Westfall and Brasted 1972).
At high dose levels. nicotine stimulates NE release by displacing it
from vesicle stores at sites outside the hypothalamus (Balfour 1982).
These actions are relevant to understanding the reinforcing effects
of nicotine. For example, using drug discrimination procedures,
Rosecrans (1.987) has demonstrated that intact central NE and
dopamine IDA) function were required to elicit the cue properties of
nicotine.

Intravenous administration of nicotine modulates the release of
both neurohypophyseal and adenohypophyseal hormones (Bisset et
al. 1975; Hall, Francis, Morrison 1978). Hillhouse, Burden, and Jones
(1975) found that the in vitro application of ACh to the hypophysio-
tropic area of the rat caused a significant increase in the basal
secretion of corticotropin-releasing hormone (as measured by bioas-
say), which in t,urn controls, via the anterior pituitary, the release of
the pro-opiomelanocortin (POMC) group of hormones-+-endorphin,
@lipotropin, melanocyte-stimulating hormone-releasing factor, and
adrenocorticotropic hormone (ACTH) (Meites and Sonntag 1981).
The humoral mechanism for the release of vasopressin has been
traced from the medulla to the paraventricular nuclei of the
hypothalamus (Bisset et al. 1975; Castro de Souza and Rocha e Silva
1977). Similarly, Risch and colleagues (1980) have demonstrated a
cholinergic mechanism for the release of 8-endorphin.

Modulation of Catecholamine and Serotonin Activity

Dale and Laidlaw (1912) found that the pressor response of the cat
to nicot,ine was due in part to the release of epinephrine from the
adrenal glands. Over the past 75 years, a large body of research has
confirmed and further investigated this phenomenon. Stewart and
Rogoff (1919) quantified the effect of nicotine on adrenal epinephrine
release. Kottegoda (1953) observed that nicotine releases catechol-
amines from extra-adrenal chromaffin tissues. Watt,s (1961) demon-
strated the effect of smoking on adrenal secretion of epinephrine.
Hill and Wynder (1974) reported that increasing the nicotine content
in cigarette smoke progressively increased the serum concentration
of epinephrine, but not NE. Winternitz and Quillen (1977) found that
the excretion of urinary catecholamines tended to be higher on
smoking days than on nonsmoking days. Several recent studies have
focused on the role of nicotine and the mechanisms involved in the

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release of catecholamines from cultured chromaffin cells (Forsberg,
Rojas. Pollard 1986). Earlier experiments by Douglas and Rubin
[1961), using denervated perfused cat adrenal glands, indicated that
nicotine augments catecholamine release from chromaffin cells by
promoting an influx of extracellular calcium. Forsberg, Rojas, and
Pollard (1986) suggested that nicotine-induced catecholamine secre-
tion may be mediated by phosphoinositide metabolism in bovine
adrenal chromaffin cells.

The anatomical localization and importance of biogenic mono-
amines such as serotonin (5-HT [5-hydroxytryptamine]), DA, and NE
have been the subject of intense research for the past 30 years. The
classic studies of Dahlstrom and Fuxe (1966) revealed that neurons
containing these amines were localized in specific ascending projec-
tion systems; descending monoaminergic neurons have also been
described. The physiological integrity of these systems was further
demonstrated by Aghajanian, Rosecrans, and Sheard (1967J who
observed that stimulation of 5-HT cell bodies localized in the
midbrain raphe nucleus released 5-HT from nerve endings located in
the more rostra1 forebrain. The recognition that these amine systems
constitute a unique interneuronal communication system has played
a central role in understanding underlying neurochemical and
behavioral mechanisms.

The cholinergic system has undergone a similar analysis (Fibiger
1982), but the delineation of specific cholinergic pathways has been
more difficult because no histochemical method has been available
for ACh. It does appear, however, that the cholinergic system is
similarly organized and interacts with specific biogenic amine
pathways. For example, Robinson (1983) has clearly shown that both
5-HT and DA systems exert tonic inhibitory control over ACh
turnover in both the hippocampus and frontal cortex regions.
Lesions of the medial raphe nuclei increase the ACh turnover rate in
hippocampal sites, while lesions of the dorsal raphe elicit a similar
effect in frontal cortical areas. Evidence of DA control comes from
the observation that the catecholamine neurotoxin, 6-OHDA, when
injected into the DA-rich septal area, facilitated hippocampal ACh
turnover. The research of Kellar, Schwartz. and Martin0 (1987) and
others also suggests that nicotinic receptors may occupy a presynap-
tic site on select DA and 5-HT nerve endings. Westfall, Grant, and
Perry (1983), using a tissue slice preparation, have shown that the
DMPP-induced stimulation of nicotinic receptors in the striatum will
facilitate the release of both 5-HT and DA. This preparation is devoid
of cell bodies or 5-HT- and DA-containing axon terminals, suggesting
that these nicotinic cholinergic receptors are primarily presynaptic.
Further, hexamethonium, but not atropine, attenuated nicotine-
induced amine release, confirming that these effects are nicotinic in
nature.

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Nicotine may have simultaneous actions on many types of
neurons. Even though only one kind of receptor may be stimulated,
either activation or inhibition of a particular SIIT, NE, or DA
neuron may be the ultimate outcome. Conversely, the activity of
specific cholinergic neurons may also be controlled by one of these
biogenic-amine-containing projection systems. Nicotine appears to
produce its discriminative stimulus effect in at least one major brain
area, the hippocampus. This site is rendered insensitive if DA
neurons innervating this area are destroyed (Rosecrans 1987). The
interrelationships of these amine pathways are important to under-
stand nicotine's effects on behavior and its effects on the neuroendoc-
rine system because of the central role that these amine systems
play in the hypothalamic control of the pituitary.

Effects on Serotonergic Neurons

Research evaluating the relationship between nicotine and 5-HT
has involved several different approaches. Hendry and Rosecrans
(1982) compared the effects of nicotine on conditioned and uncondi-
tioned behaviors in rats selected for differences in physical activity
and 5-HT turnover. Balfour, Khuller, and Longden (1975) observed
that acute doses of nicotine were capable of attenuating hippocampal
5-HT turnover, an effect specific to the hippocampus. Fuxe and
colleagues (19871 did not observe any acute changes in 5-HT function
following acute nicotine dosing but did observe a significant reduc-
tion of 5-HT turnover following repeated doses (3 x 2 mg/kg/hr). This
effect, however, was suggested to be due to cotinine, the primary
metabolite of nicotine.

In addition to attempts to correlate 5-HT function with some
pharmacologic effect of nicotine, investigators have evaluated poten-
tial links between 5-HT and neuroendocrine function. Balfour,
Khuller, and Longden (1975) showed a relationship between 5-HT
and nicotine's ability to induce the release of plasma corticosterone,
presumably by activation of the pituitary-adrenal axis. Following
acute nicotine injections in the rat, a reduction in 5-HT turnover
correlated with an increase in plasma corticosterone. Rats exhibited
tolerance to pituitary activation following repeated nicot.ine doses,
but not to the attenuation of hippocampal 5-HT turnover. Stress
antagonized nicotine-induced reductions of hippocampal 5-HT. Also,
nicotine was reported to inhibit the adaptive response to adrenocorti-
cal stimulation following chronic stress (Balfour, Graham, Vale
1986). One interpretation of these data is that nicotine can modify
how rats adapt to stress, which may be mediated by changes in
hippocampal 5-HT function. At this point, however, it is difficult to
draw firm conclusions concerning how nicotine affects 5-HT neurons
and whether this neurotransmitter is involved in any of nicotine's

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effects on neuroendocrine function. Hippocampal 5-HT turnover
appears to be selectively attenuated by nicotine.

Effects on Catecholaminergic Neurons

Studies of the effects of nicotine on NE-containing neurons have
produced mixed results. Earlier work suggested that nicotine may
affect behavior via a NE component, but recent research has not
supported such claims (Balfour 1982). It has been reported that
nicotine releases DA from brain tissue (Westfall, Grant, Perry 1983).
Lichtenst,eiger and colleagues (1982) observed that nicotine releases
DA through an acceleration of the firing rate of DA cell bodies
located in substantia nigra zona compacta when nicotine is adminis-
tered via iontophoretic application or S.C. (0.4 to 1.0 mg/kg). This
activation was marked by a significant increase in striatal DA
turnover; DHBE, but not atropine, attenuated nigrostriatal activa-
tion. Evidence that nicotine facilitates the firing of DA cell bodies by
stimulating nicotinic cholinergic receptors has recently been report-
ed by Clarke, Hommer, and coworkers (1985), who showed a specific
effect of nicotine antagonized by mecamylamine on pars compacta
cell bodies. Connelly and Littleton (1983) noted t.hat DA release from
synaptosomes lacked stereoselectivity but was blocked by the
ganglionic-blocking drug pempidine.

Fuxe and coworkers (1986, 1987) have studied nicotine's effects on
central catecholamine neurons in relation to neuroendocrine func-
tion. These investigators use quantitative histofluorometric tech-
niques that measure the disappearance of catecholamine stores by
administering a tyrosine hydroxylase inhibitor (AMPT) to rats
receiving various doses of nicotine or exposed to tobacco smoke.
Tissues are then exposed to formaldehyde gas, and histofluorescence
in AMPT-treated rats is evaluated in comparison to controls.

Nicotine is a potent activator of both DA and NE neuron systems
located primarily in the median eminence and in areas of the
hypothalamus. These effects result from a stimulation of nicotinic
cholinergic receptors, generally antagonized by mecamylamine.
Intermittent nicotine dosing (4 x 2 mg/kg, S.C. every 30 min) or
tobacco smoke exposure (rats were exposed to one to four cigarettes
with a smoking machine-determined nicotine yield of 2.6 mg; rats
received 8 puffs at lo-min intervals) results in a decrease of
prolactin, thyroid-stimulating hormone (TSH), and luteinizing hor-
mone (LH) and an increase of plasma corticosterone levels. Nicotine
doses of 0.3 mg/kg administered iv. induce an overall activation of
the hypothalamic-pituitary axis, causing an increase of both ACTH
and prolactin that subsides within 60 min. Tolerance to the
corticosterone response develops after repeated nicotine doses, and
there is evidence that it develops after a single dose of nicotine
(Sharp and Beyer 1986; Sharp et al. 1987). Restraint stress increases

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ACTH, corticosterone, and prolactin levels and decreases DA and NE
levels in hypothalamic regions. This stressor attenuates nicotine's
activation of NE neurons but does not reverse its attenuating effects
on prolactin.

Nicotine appears to be associated with neuroendocrine activity by
NE and DA activation (Fuxe et al. 1987). Immunohistochemical
studies suggest that alterations in NE function are more important
for the control of the pituitary-adrenal-axis, while DA turnover
appears to be crucial for nicotine's effects on prolactin, LH, and
follicle-stimulating hormone (FSH). Moreover, these studies indicate
that similar nAChRs are located within both DA mesolimbic and
neostriatal systems.

Stimulation of Pituitary Hormones

Nicotine administration and cigarette smoking stimulate the
release of several anterior and posterior pituitary hormones. Seyler
and coworkers (1986) had human subjects smoke two high-nicotine
(2.87 mg) cigarettes in quick succession. Plasma levels of prolactin,
ACTH, l3-endorphin/P-lipoprotein, growth hormone (GH), vasopres-
sin, and neurophysin I increased. No change was seen in TSH, LH, or
FSH. The rapid smoking paradigm used by Seyler and coworkers
(1986) may have contributed to the effects of nicotine. Growth
hormone levels exhibited a prolonged increase after subjects smoked
three cigarettes in rapid succession (Sandberg et al. 1973). In
experiments conducted by Winternitz and Quillen (1977) with male
habitual smokers, GH began to rise after two cigarettes, peaked at 1
hr, and then returned to control levels while smoking continued.
Wilkins and colleagues (1982) also found that smoking increases GH
levels and presented evidence that the effect is nicotine mediated.
Coiro and coworkers (1984) reported that the increase in GH
produced by clonidine was greatly enhanced by cigarette smoking,
suggesting that nicotinic cholinergic and adrenergic mechanisms
might interact in the stimulation of GH secretion.

The TSH plasma levels were not affected when nicotine was
administered over a 60-min period to female rats (Blake 1974). In
studies involving exposure to cigarette smoke, Andersen and col-
leagues (1982) reported a lowering of TSH secretion in rats, but as
noted, Seyler and coworkers (1986) found no change in human
subjects. Thus, the data on the effects of nicotine on TSH release are
inconclusive at this time.

ACTH plasma levels increased after i.p. injection of nicotine in the
rat (Conte-Devolx et al. 1981). In similar experiments, Cam and
Bassett (1983b) found that elevated ACTH levels peaked and rapidly
declined to a sustained plateau level. Sharp and Beyer (1986)
reported that the effects of nicotine on ACTH in rats show a rapid
and marked desensitization. Seyler and coworkers (1984) had male

101


subjects smoke cigarettes containing 0.48 or 2.87 mg of nicotine. No
increases in ACTH or cortisol were detected after subjects smoked
0.48-mg-nicotine cigarettes. Cortisol levels rose significantly in 11 of
15 instances after smoking the high-nicotine cigarettes, but ACTH
rose in only 5 of the 11 instances when cortisol increased. Each
ACTH increase occurred in a subject who reported nausea and was
observed to be pale, sweaty, and tachycardic. Seyler and coworkers
(1984) studied smokers and concluded that ACTH release occurs only
in smokers who become nauseated.

LH levels were reduced in male rats exposed to unfiltered
cigarette smoke, while FSH was unchanged (Andersen et al. 1982). In
experiments by Winternitz and Quillen (1977), there were no
differences in LH and FSH among male cigarette smokers while
smoking as compared with not smoking. Seyler and colleagues (1986)
found no change in human LH or FSH levels after smoking. There is
no evidence of gonadotropin release stimulated by nicotine or
smoking.

Prolactin plasma levels were lowered considerably in lactating
rats injected twice daily with nicotine (Terkel et al. 1973). It was
suggested that failure of prolactin release following chronic nicotine
administration was responsible for low milk production and starva-
tion of pups. Blake and Sawyer (1972) found that, in lactating rats,
the rapid suckling-induced release of prolactin into the blood is
inhibited by S.C. injections of nicotine. Ferry, McLean, and Nikitito-
vich-Winer (1974) reported that tobacco smoke inhalation in rats
delays the suckling-induced release of prolactin. Andersen and
coworkers (1982) found that prolactin secretion was reduced in male
rats in a dose-dependent manner by exposure to unfiltered cigarette
smoke. However, Sharp and Beyer (1986) reported that the effects of
nicotine on prolactin in rats shows a biphasic effect, first increasing
and then decreasing. Suppressed prolactin levels were found in
female smokers who were breast feeding (Andersen et al. 1982).
These researchers noted that smokers weaned their babies signifi-
cantly earlier than nonsmokers. However, Wilkins and coworkers
(1982) observed an increased level of prolactin in male chronic
smokers.

Arginim Va.sopressin

In addition t.o its antidiuretic effects, arginine vasopressin acts as a
vasoconstrictor (Munck, Guyre, Holbrook 1984; Waeber et al. 1984).
Arginine vasopressin may also act as a neuromodulator in pathways
that affect behavior. It has been shown to promote memory
consolidation and retrieval in rats (Bohus, Kovacs, de Wied 1978) and
there are reports of memory enhancement following intranasal
administration of a vasopressin analog in both normal and memory-
deficient humans (LeBoeuf, Lodge, Eames 1978; Legros et al. 1978;

102


Weingartner et al. 1981). Nicotinic cholinergic receptors in the
medial basal hypothalamus and muscerinic cholinergic receptors in
the neurohypophysis (posterior pituitary) have been implicated in
the release of vasopressin (Gregg 19851. Nicotine has been found to
stimulate vasopressin release in a dose-related manner in animals
(Reaves et al. 1981; Siegel et al. 1983) and in humans (Dietz et al.
1984; Pomerleau et al. 1983; Seyler et al. 1986). These observations
are consistent, with the effects of nicotine on cognitive performance
(Chapter VI).

The Pro-Opiomelanocorticotropin Group of Hormones

The POMC hormones are released in response to stress and in
response to corticotropin-releasing hormone (Munck, Guyre, Hol-
brook 1984; Krieger and Martin 19811. ACTH has behavioral effects
and stimulates the release of steroids such as cortisol from the
adrenal cortex. ACTH produces rapid cycling between sleeping and
waking as well as sexual stimulation, grooming/scratching, blocking
of opiate effects such as analgesia, and the enhancement of attention
and stimulus discrimination (Bertolini and Gessa 1981). Endogenous
opioids, such as 8-endorphin, potentiate vagal reflexes, cause respira-
tory depression, lower blood pressure, block the release of catechol-
amines (Beaumont and Hughes 1979; Schwartz 19811, have antinoci-
ceptive effects (van Ree and de Wied 19811, and modulate neuro-
transmitter systems leading to amnesic effects (Izquierdo et al. 1980;
Introini and Baratti 19841. It has been suggested that the primary
function of the endogenous opioids is metabolic, serving to conserve
body resources and energy (Amir, Brown, Amit 1980; Margules 1979;
Millan and Emrich 1981).

Nicotine appears to stimulate the release of corticotropin-releasing
hormone from the hypothalamus through a nicotinic cholinergic
mechanism (Hillhouse, Burden, Jones 1975; Weidenfeld et al. 1983).
Using an isolated perfused mouse brain preparation, Marty and
coworkers (1985) demonstrated that nicotine stimulates secretion of
8-endorphin and ACTH in a dose-related manner when applied
directly to the hypothalamus but not when applied to t,he pituitary.
The work of Sharp and Beyer (19861 supports this finding; they
reported that the secretion of ACTH following nicotine was unaffect-
ed by adrenalectomy. Nicotine administration to rats has also been
shown to increase the plasma levels of corticosterone, ACTH, and /3-
endorphin in a dose-related manner (Conte-Devolx et al. 1981).
Termination of chronic nicotine administration reduced hypotha-
lamic 8-endorphin levels (Rosecrans, Hendry, Hong 1985). Hurlick
and Corrigal (1987) have also observed that the narcotic antagonist
naltrexone inhibits some nicotine-modulated behavior in mice,
providing a possible link between nicotine stimulation of endogenous
opioid activity and behavioral responses. Acute administration of

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nicotine increases levels of plasma ACTH and corticosterone sharply
(Cam and Bassett 1983b), while chronic exposure results in complete
adaptation (Cam and Bassett 1984). Melanocyte-stimulating hor-
mone was decreased and &endorphin was increased by i.p. injections
of nicotine in the rat (~Conte-Devolx et al. 1981).

Risch and colleagues (1980. 198211 have accumulated evidence for
cholinergic control of cortisol, prolactin, and 8-endorphin release in
humans. Rapid smoking increases circulating cortisol, 8-endorphin,
and neurophysin I !Pomerleau et al. 1983; Seyler et al. 1984; Novack
and Allen-Rowlands 1985; Novack, Allen-Rowlands, Gann, in press).
Moreover, in a study that examined the role of endogenous opioid
mechanisms in smoking, Tobin, Jenouri, and Sackner (1982) ob-
served that mean inspiratory flow rate increases during the smoking
of a cigarette but is depressed shortly after smoking. Naloxone had
no effect on the initial stimulation of respiration in response to
smoking but did significantly blunt the subsequent depression of
respiration. The significance of these findings for the control of
cigarette smoking remains equivocal (Karras and Kane 1980;
Nemeth-Coslett and Griffiths 1986; Chapter IV).

Thyroid

Most of the earlier work (1930s through 1950s) assessing the
effects of nicotine on thyroid function involved histological studies of
the thyroid glands from animals treated chronically with nicotine.
The findings are inconsistent in that some studies suggest elevated
thyroid activity and others do not (Cam and Bassett 1983a). In a
more recent study of nicotine's action on the plasma levels of the
thyroid hormones, thyroxine (T4) and triiodothyronine (T31, Cam
and Bassett (1983a) found that a single i.p. injection of 200 pg/kg did
not alter the level of either hormone, although it did produce an
increase in plasma corticosterone. As mentioned earlier, nicotine
does not consistently affect TSH in animals or humans (Blake 1974;
Seyler et al. 19861.

Adrenal Cortex

Several studies in animals and human subject.s have reported that
nicotine and cigarette smoking lead to elevated levels of corticoste-
roids. Kershbaum and colleagues (1968) administered nicotine i.v. to
anesthetized dogs and found a 64 percent rise in plasma corticoste-
roids. In rat,s. corticosteroid concentrations increased 50 percent
after i.p. administration of nicotine. Suzuki and coworkers (19731
also reported adrenal cortical secretion in response to nicotine in
conscious and anesthetized dogs. The effects of nicotine on plasma
corticosteroids in stressed and unstressed rats were studied by
Balfour, Khuller, and Longden (1975). The administration of nicotine
to unstressed rats caused a rise in corticosterone which persisted for

104


60 min. Nicotine did not affect plasma corticosterone concentration
in rats stressed by being placed on an elevated platform. Ot.her
studies showed increased plasma corticosteroid levels after nicotine
administration (Turner 1975; Cam, Bassett, Cairncross 1979; Cam
and Bassett 1983b). Andersen and colleagues (1982) exposed male
rats to unfiltered cigarette smoke and found a dose-related increase
in corticosterone secretion. Filtered cigarette smoke was inactive.

Seifert and coworkers (i984) found that the chronic administration
of 0.5 or 1.0 mg/kg of nicotine S.C. twice daily for 8 weeks to rats
produced a marked decrease in plasma aldosterone levels. In this
study, nicotine had no effect on plasma corticosterone concentration.

Hokfelt (1961) report,ed increases in plasma cortisol and urinary
17-hydroxycorticosteroids following cigarette smoking in human
subjects. Kershbaum and coworkers (1968) reported similar results
involving elevations of 11-hydroxycorticosteroids. Hill and Wynder
(1974) found that serum corticosteroids were markedly elevated after
high-nicotine (2.73 mg) cigarettes were smoked. No increase was seen
with cigarettes containing less nicotine. Cryer and colleagues (1976)
also found an increase in circulating levels of corticosteroids after
smoking. Winternitz and Quillen (1977) reported a sharp increase in
circulating cortisol after two cigarettes. The levels were maintained
through the smoking period and fell gradually to normal. Wilkins
and coworkers (1982) also observed increased levels of cortisol after
2-mg-nicotine cigarettes were smoked. No increases in cortisol were
detected after smoking 0.48-mg-nicotine cigarettes, but cortisol rose
significantly in 11 of 15 cases smoking 2.87-mg-nicotine cigarettes
(Seyler et al. 1984). Consistent with these results is the observation of
Puddey and colleagues (1984) that cessation of smoking is associated
with a significant fall in cortisol levels.

In contrast to these findings, Tucci and Sode (1972) reported intact
diurnal circadian variations of cortisol and unchanged 24-hr 17-
hydroxycorticosteroids durin, u smoking. Benowitz, Kuyt, and Jacob
(1984) studied 10 subjects who either smoked their usual brand of
cigarettes, some of which contained 2.5 mg nicotine, or abstained.
Plasma cortisol concentrations throughout the day did not differ
during smoking or abstaining. Thus, while the majority of human
and animal data indicates that nicotine or smoking elevates cortico-
steroid levels, the effects appear to be influenced by dose, time, and
perhaps other factors.

Many investigators cited above have proposed that nicotine's
effects on corticosteroids are mediated by the release of ACTH.
Indeed, hypophysecbomy abolished the increase in adrenocortical
secretion following nicotine administration (Suzuki et al. 1973; Cam,
Bassett, Cairncross 1979) and nicotine-induced increase in plasma
ACTH precedes the increase in cortisol (Conte-Devolx et al. 1981).
However, Turner (1975) found that bilateral adrenal demedullation

105


abolished the rise in corticosterone in response to nicotine and
suggested that the effect of nicotine is mediated via adrenal release
of catecholamines and that centrally mediated stimulation is not
significant. In contrast, the work of Matta and associates (1987)
demonstrates that the effects of nicotine on ACTH secretion are
centrally mediated. Rubin and Warner (1975) have also shown that
nicotine directly stimulates isolated adrenocortical cells of the cat.
The stimulant effect was dose-dependent and required the presence
of calcium. These experiments also indicated that nicotine enhances
the steroidogenic effect of ACTH.

Androgens

In male beagles, chronic smoking of high-nicotine/tar cigarettes
was associated with decreased activity of 7a-hydroxylase active on
testosterone (Mittler, Pogach, Ertel 1983). Testicular 66- and 16a-
hydroxylases were not altered, while the hepatic androgen 6(3-
hydroxylase activity in the testis was stimulated markedly by
smoking. Serum testosterone levels were reduced to 54 percent of
control levels by heavy smoking. It was concluded that chronic
cigarette smoking increased hepatic metabolism of testosterone,
resulting in lowered serum testosterone levels. However, it may be
that total testosterone is lower while free testosterone is not.

Estrogens

Cigarette smoking is associated with antiestrogenic effects in
women, including earlier menopause, lower incidence of breast and
endometrial cancer, and increased osteoporosis. MacMahon and
colleagues 11982) reported lower urinary estrogen levels in premeno-
pausal smokers than in premenopausal nonsmokers and suggested
that the low estrogen secretion reflected lower estrogen production,
based on decreased estrone, estradiol, and estriol. However, 2-
hydroxyestrogens, the major metabolites of estradiol in women, were
not measured. Jensen, Christiansen, and Rodbro (1985) presented
evidence for increased hepatic metabolism of estrogens as a result of
smoking based on an observation of decreased serum estrogen levels
in postmenopausal smokers receiving exogenous hormone therapy.
This study examined 136 women treated for 1 year with different
doses of estrogen. Reduction of serum estrogen was most pronounced
in the highest estrogen-dose group. There was a significant inverse
correlation between the number of cigarettes smoked daily and
changes in serum estrogen. Michnovicz and colleagues (1986) found a
significant increase in estradiol 2-hydroxylation in premenopausal
women who smoked at least 15 cigarettes/day. They concluded that
smoking exerts a powerful inducing effect on the 2-hydroxylation
pathway of estradiol metabolism, which is likely to lead to decreased
bioavailability of hormone at estrogen target tissues.

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Pancreas and Carbohydrate Metabolism

The body weight of smokers is consistently lower than that of
nonsmokers, and smokers tend to gain weight after cessation of
smoking (see Chapter VI for a detailed discussion of these relation-
ships). These phenomena are thought to contribute to tobacco use.
Glauser and coworkers (1970) and Hofstetter and coworkers (1986)
suggested that a change in metabolic rate is partially responsible for
these effects. Schechter and Cook (1976) and Grunberg, Bowen, and
Morse (1984) showed that rats which were administered nicotine lost
body weight without reducing food intake, although the body weight
changes were not as great as when eating behavior declined as well
(Grunberg 1982). Grunberg (1986) has pointed out that differences in
body weight between smokers and nonsmokers result from changes
in energy consumption (via changes in specific food consumption)
and changes in energy utilization. Recently, Grunberg and cowork-
ers (1988) have reported reductions of insulin levels accompanying
nicotine administration in rats which could result in an increase in
the utilization of fat, protein, and glycogen. This finding is consistent
with work of Tjalve and Popov (1973), using rabbit pancreas pieces,
and studies by Florey, Milner, and Miall (1977) of human smokers
versus nonsmokers. Grunberg and coworkers (1988) have suggested
that the effects of nicotine on insulin levels also may be involved in
the nicotine-induced decrease of sweet food preferences.

Electrophysiological Actions of Nicotine
Electrocortical Effects

The brain responds to electrical as well as to chemical stimuli.
Therefore, measurements of the electrophysiological actions of
nicotine complement studies of its chemical effects. In addition,
electrophysiological activity reflects function that may relate to
sensory and cognitive changes observed in humans after smoking
(see Chapter VI). In animals, nicotine produces changes ranging
from subtle latency decreases in the primary auditory pathway to
seizures. The electrophysiological actions of nicotine may help to
relate the anatomical and receptor data (discussed earlier in this
Chapter) with sensory and cognitive data (discussed in greater detail
in Chapter VI).

The human studies on electrocortical effects of nicotine have some
methodological limitations. Most of the human studies had subjects
smoke cigarettes and did not measure blood levels of nicotine. Also,
most studies were performed on smokers whose immediate and long-
term smoking history was determined by questionnaires which may
not accurately reflect tolerance and physical dependence (Chapter
IV). In some studies the subjects were deprived of cigarettes, but no
objective measures such as expired carbon monoxide or blood

107


nicotine levels were collected to verify compliance with the depriva-
tion conditions.

Spontaneous Electroencephalogram

Historically, nicotine and ACh were used in animal experiments to
study the cholinergic mechanisms in the midbrain and thalamus
which produced EEG and behavioral activation (Longo, von Berger,
Bovet 1954; Rinaldi and Himwich 1955a,b). The administration of
nicotine produced EEG activation, consisting of desynchronized low-
voltage, fast activity, and behavioral arousal or alerting. These EEG
and behavioral responses resembled those produced by electrical
stimulation of the midbrain reticulomesencephalic activating system
(Moruzzi and Magoun 1949). With the discovery by Eccles, Eccles,
and Fatt (1956) of nicotinic receptors in the Renshaw cell of the
spinal cord, other investigators began to study the precise pharma-
cology of the EEG and behavioral alerting produced by nicotine and
electrical stimulation of the midbrain. Cigarette smoking in humans
also produced EEG desynchronization (Hauser et al. 1958, Wechsler
1958; Bickford 1960) or EEG desynchronization with an increase in
alpha frequency (Lambiase and Serra 1957). By the late 1950s and
early 1960s it was generally known that nicotine or tobacco smoke
caused EEG and behavioral arousal in animals and humans, but
several important issues were unresolved.

The central effects of nicotine were originally thought to result
from its action on the cardiovascular system (Heymans, Bouckeart,
Dautrebande 1931). Early studies found that EEG desynchronization
occurred when the subjects smoked nicotine cigarettes, nicotine-free
cigarettes, or sucked on glass tubes filled with cotton (Hauser et al.
1958; Wechsler 1958). Schaeppi (1968) injected nicotine into the
vertebral artery, carotid artery, and third and fourth ventricles of a
cat's brain and was able to dissociate the effects of nicotine on the
EEG from those on the cardiovascular system. Kawamura and
Domino (1969) demonstrated that the EEG changes induced by
nicotine could be obtained in animals whose blood pressure increase
was blocked. Prevention of release of catecholamines in reserpine-
pretreated animals did not interfere with the EEG desynchroniza-
tion produced by nicotine (Knapp and Domino 1962).

Inhaled tobacco smoke (2-mL samples with about 2 pg/kg of
nicotine) and 2 pg of nicotine injected every 30 set in a cat encephale
isole preparation produced EEG desynchronization. EEG and behav-
ioral activation after cigarette smoke inhalation was also observed in
unanesthetized cats with implanted electrodes (Hudson 1979). Lukas
and Jasinski (1983) found that i.v. doses (0.75 to 3.0 mg) in human
smokers resulted in dose-dependent decreases in alpha (8 to 12 Hz
EEG activity) power and EEG desynchronization. In an inpatient
study where nicotine deprivation was carefully controlled and

108


monitored by measurement of expired carbon monoxide, the smok-
ing of non-nicotine cigarettes did not change the EEG (Herning,
Jones, Bachman 1983), but EEG changes did occur when subjects
smoked nicotine-containing cigarettes. These studies confirm that
nicotine has a direct action on the CNS separate from the cardiovas-
cular effects and that the effects are produced primarily by the
nicotine in inhaled tobacco smoke.

As experimental physiological manipulations, EEG recording, and
EEG quantification techniques improved, the specific nature of the
nicotine-induced cortical EEG changes and their relationship to
behavior were found to be more complex than originally thought.
The desynchronization produced by nicotine (20 to 100 pg/kg) in the
cat was blocked by anterior pontine transections, but not by
midpontine transections (Knapp and Domino 1962). The midbrain
reticular activating system was needed for the cortical EEG desyn-
chronization produced by nicotine. However, larger doses of nicotine
injections also produced synchronous slow high-voltage EEG activity
in the hippocampus (hippocampal theta). Injections of the muscarin-
ic agonist arecoline (20 to 40 mg/kg) in the anteriorly transected
midbrain preparations still produced the hippocampal theta activity
without the cortical desynchronization. Atropine (1 mg/kg) and
mecamylamine (1 mg/kg), but not the ganglionic antagonist trimeth-
idinium (1 mg/kg) block the nicotine induced EEG desynchroniza-
tion in an intact animal. The convulsions observed after nicotine
injections (1 to 5 mg/kg in cats; 0.05 to 0.25 pg/g in mice) (Laurence
and Stacey 1952; Stone, Meckelnburg, Torchiana 1958; Stiimpf,
Petsche, Gogolak 1962; Stumpf and Gogolak 1967) appear to be due
to nicotine's ability in large doses to stimulate muscarinic choliner-
gic receptors in the hippocampus. Because a high concentration of
labeled nicotine binds to hippocampal cells of the cat (Schmiterlow et
al. 1967) and areas adjacent to the hippocampus in the rat (Clarke,
Pert, Pert 1984), the possibility that nicotine-induced limbic electri-
cal activity contributes to its behavioral effects cannot be discounted.

Nicotine's alerting effect on the brain may also involve a peripher-
al component. Electrocortical and behavioral arousal occurs in the
cat within 1 to 2 set after injection of 10 to 15 pg/kg into the right
atrium of the heart, originating in vagal pulmonary C fiber afferents
(Ginzel 1987). The human counterpart to this finding is the
observation by Murphree, Pfeiffer, and Price (1967) that an initial
EEG change occurred within 5 set after cigarette smoke inhalation,
which is shorter than a chest-to-head circulation time. Another input
from the periphery arises from nicotinic sites in the arterial tree.
Injection of small amounts (2 to 4 pg/kg) of nicotine, even as far
away from the brain as into the lower aorta or femoral artery, causes
instantaneous arousal from all types of sleep (Ginzel and Lucas
1980).

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The nicotine-induced release of ACh (Macintosh and Oborin 1953;
Mitchell 19631 may be responsible for the EEG desynchronization in
animals (Armitage, Hall, Sellers 1969). The effect does not appear to
be due to the direct action of nicotine on the cortex because the
cortical cholinergic receptors are largely muscarinic (Kuhar and
Yamamura 1976; Rotter et al. 1979). Lower doses of nicotine (20
pg/kg/30 set for 20 min) induced EEG desynchronization and ACh
release in the cat, whereas higher doses (40 pg/kg/30 set for 20 min)
produced either an increase or decrease in EEG desynchronization
with corresponding increase or decrease in ACh release (Armitage,
Hall, Sellers 1969). The effect of nicotine on the EEG was short lived
relative to the release of ACh. Two separate pathways have been
proposed to explain these results: an ascending cholinergic pathway
mediating the cortical desynchronization and a limbic pathway
mediating the ACh release.

In one strain of mice, C57BL, nicotine increased cortical high-
voltage activity and decreased homovanillic acid (HVA) and 3-
methoxy-4-hydroxyphenthyleneglycol (MHPG) production in a per-
fused brain preparation (Erwin, Cornell, Towel1 1986). The decrease
in HVA and MHPG levels reflects an increase in brain DA and NE
levels. In intact C57BL mice, nicotine decreased locomotor activity
(Marks, Burch, Collins 1983a). Thus, at least in one strain of mice,
nicotine induces an increase in cortical EEG synchronization, a
decrease in locomotor activity, and an increase in brain catechol-
amines. Little evidence relates the cortical desynchronization ob-
served in animals and humans to an increase in catecholamine
changes in the brain.

As trends in neuroscience research have shifted away from
spontaneous EEG recording in animals to intracellular recording,
receptor localization, and binding techniques, the precise quantifica-
tion of the nicotine-induced EEG desynchronization and hippocam-
pal synchronization has not been done. This type of quantification
has been done in humans by power spectral analysis. This technique
quantifies the EEG by the distribution and amplitude of brain waves
at different frequencies. Alpha power includes EEG activity in the 8-
to 12-Hz frequency range. Theta power includes EEG activity in the
4- to ~-HZ frequency range. Beta power includes EEG activity in the
frequency range of 13 Hz and higher.

The comparison of nicotine-induced EEG changes in animals and
humans is complicated by an important methodological difference.
Animals usually have not previously been given nicotine, while in
studies of humans, the subjects always are experienced tobacco
smokers. Moreover, in human studies that included a deprivation
period, nicotine abstinence may have produced electrophysiological
changes that are reversed by smoking or nicotine.

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EEG desynchronization or increased beta power was observed in
smokers after smoking a tobacco cigarette (Hauser et al. 1958;
Wechsler 1958: Bickford 1960; Ulett and Itil 1969). These findings
essentially replicated the animal studies of nicotine. Using power
spectral analysis, Ulett and Itil (1969) also observed a decrease in
theta power and an increase in alpha frequency. The increase in
alpha frequency was previously noted with visual inspection by
Lambriase. However, the increase in theta was not. The subjects in
the study by Ulett and Itil had smoked one pack or more of
cigarettes/day and had been deprived of tobacco cigarettes for 24 hr
when the baseline EEG was recorded. Comparisons of the postsmok-
ing EEG were made with this baseline period. Therefore, the
decrease in alpha frequency and increase in theta power relative to
the data from the postsmoking session may be the result of nicotine
deprivation (Chapter IV).

Knott and Venables (1978) compared the alpha frequencies of
nonsmokers, 12-hr nicotine-deprived smokers. and nondeprived
smokers. They observed a decrease of about 1 Hz in the dominant
alpha frequency of the deprived smokers relative to the nonsmokers
and nondeprived smokers in a passive eyes-closed situation. An
active behavioral task and other frequencies of the EEG were not
studied. Knott and Venables hypothesize that smokers were consti-
tutionally different from nonsmokers. The slower alpha frequency
was interpreted as an arousal deficit, and smoking as compensation
to reduce the arousal deficit. Knott and Venables (1978) and Ulet
and Itil (1969) both found an attentional deficit during tobacco
deprivation.

Herning and coworkers (1983) investigated the EEG changes
related to cigarette smoking in a hospitalized group of healthy
smokers who smoked at least a pack and a half of tobacco cigarettes
with a machine nicotine delivery of 0.8 mg or more. A serial
subtraction task was administered and EEGs were recorded from
subjects in an eyes-open state. Alpha frequency was not affected by
periods of smoking and deprivation. However, theta and alpha power
increased during periods of deprivation and decreased after smoking
tobacco but not placebo cigarettes. The effects were most pronounced
on theta power. Increases in thet.a power occurred as early as 30 min
after the last cigarette, and were of the same magnitude as those
after 10 to 19 hr of nicotine deprivation. The increase in EEG theta
was interpreted to be a sign of tobacco deprivation (Chapter IV).

An indirect method of observing an increase in cortical activation
was the measurement of alpha power changes after tobacco smoking.
A number of investigators reported a decrease in alpha power or
abundance with cigarette smoking (Murphree, Pfeiffer, Price 1967:
Philips 1971; Caille and Bassano 1974, 1976; Murphree 1979:
Herning, Jones, Bachman 1983; Cinciripini 1986). with nicotine

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polacrilex gum (Pickworth, Herning, Henningfield 1986, in press),
and with i.v. doses of nicotine (Lukas and Jasinski 1983). In spite of
differences in the number of cigarettes regularly smoked by the
subjects, the length of tobacco deprivation, the type of tobacco
cigarette smoked during the experiment, and the route of adminis-
tration, nicotine reduced alpha power.

Brown (1968) measured the resting EEG for heavy smokers and
nonsmokers. No cigarett.es were smoked. The EEG of the heavy
smokers had less alpha and more beta activity. Twelve hours of
nonconfirmed deprivation in the heavy smokers did not change the
EEG patterns.

The EEG of neonates of mothers who smoke is not different from
that of neonates of control mothers (Chernick, Childiaeva, Ioffe
1983). Whether acute periods of smoking may affect the EEG of the
child before birth is not known.

In limited animal and human work, individual or species differ-
ences in the effects of nicotine on the EEG have been observed.
Nicotine produced a dose-dependent cortical EEG desynchronization
in C3H mice and an increase in synchronized EEG similar to
hippocampal theta activity in C57BL mice (Erwin, Cornell, Towel1
19861. Both effects have been observed at different doses in the same
preparation (Kawamura and Domino 1969). Lower doses produce
EEG desynchronization, and higher doses produce hippocampal
theta. Tobacco cigarette smoking decreased EEG alpha power in
Type A subjects and increased theta power in Type B subjects
deprived of nicotine for about 4 hr (Cinciripini 1986). The relation-
ship between hippocampal thet,a in animals and cortical theta in
humans is not yet understood. In nondrugged animals cortical
desynchronization and hippocampal theta activity often occur simul-
taneously. Nicotine at low doses produces cortical desynchronization
and at high doses produces both types of EEG activity. Animal data
indicate that nicotine has effects on at least two systems in the brain:
a midbrain area responsible for EEG desynchronization and a limbic
system generating hippocampal theta activity. These findings are
consistent with the observation that some smokers indicate that they
smoke for nicotine's stimulating effects and others smoke for its
sedating effect.s.

Sensory Event-Related Potentials

In animals and humans, the brainstem auditory-evoked potential
technique provides a noninvasive method for studying the effects of
nicotine on primary auditory sensory function. In the rat, nicotine
reduced the amplitudes of Waves III and IV of the brainstem
auditory-evoked response (BAER) iBhargava and McKean 1977;
Bhargava, Salamy, McKean 1978; Bhargava, Salamy, Shah 1981).
Serotoncrgic mechanisms may mediate the nicotine-induced reduc-

112


tion in latency. Lavernhe-Lemaire and Garand (1985) found essen-
tially the opposite. Nicotine increased Waves I-III and did not
decrease Waves IV and V of BAER.

Auditory event-related potentials (AERPs) recorded directly from
the cortex of rat have provided conflicting information about
nicotine's effects on auditory transmission from the inferior collicu-
lus to the cortical areas. Guha and Pradhan (1976), using pentobarbi-
tal anesthesia, found a dose-dependent increase in PI (40 ms) and Nl
(110 ms) of the AERP. Bhargava, Salamy, and McKean (1978), using
chloralose anesthesia with atropine pretreatment, reported no
nicotine-related change in Pl (11 ms), Nl (28 ms), P2 (75 ms), and N2
(121 ms) of the AERP.

After smoking, the Pl (50 ms) of the human AERP is increased
during passive tasks at all intensity levels and the Nl (110 ms) is
increased in both passive and active tasks (Knott 1985). The N2
(about 215 ms) to P2 (about 260 ms) component of the AERP recorded
during a passive task was reduced after cigarette smoking when
compared with data from the baseline deprivation test (Friedman
and Meares 1980). P2 was also reduced by nicotine in the study by
Knott (1985). These components also increased in amplitude as the
tobacco deprivation period was lengthened. Any attempt to relate
this finding to results in the anesthetized rat would be speculative
because AERPs recorded from the cortex of unanesthetized animals
and humans are difficult to compare (Wood et al. 1984). Alterations
in AERP components in the 75- to 150-ms latency range have been
attributed to change in attention. The decrease in the later N2-P2
component is more likely to reflect reduced habituation to auditory
stimuli.

The effects of nicotine on visual event-related potentials (VERPs)
are more complicated than those on the AERPs. In unaesthetized
rabbits, iv. nicotine (0.025 to 0.500 mg/kg) produced a complex
VERP change (Sabelli and Giardini 1972). At 2 min, nicotine
depressed the Pl (100 ms) and the Nl (250 ms). At 5 min, these
components were enhanced. At doses below 0.050 mg/kg, the Nl was
again depressed from 10 to 20 min after the injection. Pretreatment
with catecholamine inhibitors diminished the nicotine-induced
VERP changes. The authors suggested that the effect of nicotine on
VERPs was mediated in part by catecholaminergic mechanisms.

The effects of nicotine on the human VERP using multiple flash
intensities were the focus of four studies. The studies were designed
to test Buchsbaum and Silverman's (1968) concept of stimulus
intensity control and its modulation by nicotine. According to their
theory, sensory processing in different individuals varies in at least
two ways. Some persons, "augmenters," are more sensitive to higher
intensities than to lower intensities, and others, "reducers," are
more sensitive to lower than to higher intensities. Smokers might be

113


one particular type of stimulus processer and may smoke to alter or
normalize stimulus intensity. In all studies the comparison was
between results after 12 hr or more of unconfirmed tobacco
deprivation and those after recent smoking. Components of the
VERP increased after smoking in three studies (Hall et al. 1973;
Friedman and Meares 1980; Woodson et al. 1982) but decreased in
another study (Knott and Venables 1978). The increases and
decreases occurred in components of the same latency range (75 to
250 ms) after flash onset. The fourth study differed only slightly
from the others in that it used a between-subjects and not within-
subject experimental design. Using a single flash intensity, Vasquez
and Toman (19671 also observed a decrease in components IV (I*0 ms)
and V (170 ms) of the VERP when compared with results after 36 hr
of tobacco deprivation. Two studies found a nicotine-induced increase
at earlier components (III-IV and IV-V) for the lower intensities only.
The other study reported an increase in later components (V-VI and
VI-VII) at the higher flash intensities. Knott and Venables (1978)
observed the decrease after smoking in the middle components (IV-V
and V-VI) for the lower intensities. Because of these divergent
results, it is premature to conclude t,hat smokers are exclusively
augmenters or reducers who are attempting to optimally adjust
stimulus intensity by smoking.

Cognitive Event-Related Potentials

Cognitive event-related potentials reflect neural events which
appear to be related to different aspects of cognition, such as
attention and stimulus evaluation. They usually follow the sensory
components of event-related potentials when human subjects are
performing active behavioral tasks. They provide information not
normally available from performance measures such as reaction
time. Increases or decreases in these potentials after smoking can aid
in our understanding the effects of nicotine on performance.

When two task-relevant stimuli are separated by a short interval
(1 to 3 set), a negative slow wave develops between them. In
particular, this contingent negative variation (CNV) develops in
warned or cued reaction times, successive discrimination, and some
language processing tasks. The CNV appears to reflect brain
preparation to process and respond to the second stimulus. Smoked
tobacco and i.v. nicotine either increase or decrease the CNV (Ashton
et al. 1973, 1974, 1980; Minnie and Comer 1978). Extraverted
smokers took longer to smoke and nicotine increased the CNV.
Introverted subjects smoked faster and nicotine decreased the CNV.
Reaction time was inversely correlated with CNV amplitude; that is,
shorter reaction time was associated with larger CNV. With iv.
doses of nicotine (12.5 to 800.0 pg), larger doses produced a decrease
and small doses produced an increase in the CNV in the same

114


subject. O'Connor (1982) studied the effects of smoking on the
orienting (0 wave) and expectancy (E wave) components of the CNV
in introverted and extraverted subjects. The 0 wave was not affected
by smoking. The E wave, recorded in frontal areas, was increased in
extraverted subjects after smoking. The E wave has been interpreted
by some investigators as cortical preparation for a response. Smok-
ing decreased a positive parietal E wave in introverts. Nicotine's
effect on the E wave suggests the possible enhancement of motor
preparation in the extraverted subjects. The decrease of parietal
positivity indicates a possible enhancement of stimulus-processing
capacities in the introverts.

Poststimulus components PZ(O0) and P3(00) were affected by
cigarette smoking and nicotine polacrilex gum. P2 is thought to be
an index of habituation (Hillyard and Picton 1979), and P3 an index
of stimulus evaluation (Johnson 1986). Both components were
reduced in deprived smokers after smoking (Knott 1985; Herning
and Jones 1979). Knott (1985) interprets the reduction in P2 as a
more efficient habituation of sensory screening of relevant stimuli.
The reduction in P3 amplitude after smoking indicates a poorer
evaluation of task-relevant stimuli. The P3 latency and reaction time
were reduced only by cigarettes with higher machine-tested nicotine
yields (Edward et al. 1985). Such data indicate faster stimulus and
response processing. These authors did not report any P3 amplitude
changes. If none were present or P3 was reduced, the argument for
enhanced stimulus processing would be weak. Herning and Pick-
worth (1985) reported both dose-dependent increases and decreases
in P3 amplitude as a function of background noise levels when
deprived smokers chewed nicotine polacrilex gum (4 mg and 2 mg
doses). The respective increase or decrease was blocked by mecamy-
lamine pretreatment. Thus, the effect of nicotine on stimulus
evaluation remains unclear and is perhaps confounded by cognitive
deficits after periods of nicotine deprivation.

Motor Potentials

O'Connor (1986) investigated the effect of tobacco smoking on
motor potential and motor performance. Smoking increased the
motor readiness potential in extraverts, but not in introverts. These
results are consistent with his earlier finding of an increased E wave
in extraverts after smoking. For introverts, smoking improved task
performance, but did not increase the motor readiness potential.

Other Peripheral Effects Relevant to Tobacco Use
In addition to vast central and peripheral effects, cigarette
smoking and nicotine have other peripheral effects that may
contribute to tobacco use. These additional factors have received less

115


research attention, mainly because they involve relatively new
theory or methodological approaches. For example, there is evidence
that direct stimulation of the trachea is important for cigarettes to
satisfy smokers (Rose et al. 1984) (Chapter IV). There is also evidence
that nicotine acts directly on the lung to stimulate afferent neurons
that, in turn, result in skeletal muscle relaxation and electrocortical
arousal (Ginzel 1987). These effects may contribute to the relation-
ship between smoking and stress (Chapter VI). Other research
indicates that smoking affects psychophysiological reactivity, an
integrative mechanism that is different from the classic, physiologi-
cal approach of examining individual systems or pathways. There-
fore, psychophysiological reactivity and its relevance to smoking are
discussed.

Psychophysiological Reactivity and Smoking

Psychophysiological reactivity is emerging as a useful construct in
smoking research, linking basic biological processes (genetic vulnera-
bility, central neurochemical factors) to behavioral coping and other
psychosocial factors. Psychophysiological reactivity refers to a
physiological response to a specific stimulus or as a result of the
absence of stimulation. This response can, in some cases, act as a
stressor. Within the broader conceptual framework of a stress-coping
model of smoking addiction (Shiffman and Wills 19851, smoking
behavior can be viewed both as a potential stimulus and as a coping
response that modulates psychophysiological reactivity.

Studies of psychophysiological reactivity illustrate the value of
controlled laboratory procedures to study person-environment inter-
actions. Psychophysiological reactivity reflects an interaction of the
organism and the environment. It is affected by individual differ-
ences in multiple response modes (physiological, cognitive, behavior-
al) and takes into account the genetic and learning history and
current state of the organism.

This Section reviews two separate but interrelated lines of
psychophysiological reactivity research with humans. The first is the
effect of smoking on psychophysiological reactivity. Related issues
include identification of mechanisms that may help to reveal why
some individuals smoke and the relationship between smoking and
coronary heart disease (CHD). The second research line addresses
the relationship among situational events (general and drug-specif-
ic), psychophysiological reactivity, and relapse.

The effects of smoking on the cardiovascular aspects of physiologi-
cal reactivity have been well documented and appear to be primarily
due to effects of nicotine and carbon monoxide (Suter, Buzzi, Battig
1983; Koch et al. 1980; Rosenberg et al. 1980). In individuals with no
cardiovascular disease, some of the typical effects of smoking and
nicotine are elevated heart rate and blood pressure and a fall in

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fingertip temperature and capillary blood flow (Richardson 1987;
Ashton et al. 1982; Epstein and Jennings 1986; Henningfield et al.
1983).

Accompanying cardiovascular reactions to smoking are cognitive
reactions, including perceptions of relaxation, and anxiolytic, antino-
ciceptive, euphoric, stimulative, and dysphoric effects (Kozlowski,
Director, Harford 1981). Although there is consistency in the
literature with regard to the self-reported emotional changes experi-
enced as a result of smoking, there are clear differences in response
and direction of effects between individuals and within individuals
over time (Best and Hackstian 1978; Gilbert 1979; Gilbert and
Welser, in press). Smoking can produce physiological changes that
are concurrent with subjective tranquilizing effects (Nesbitt 1973;
Shiffman and Jarvik 1984; Gilbert 1979). This phenomenon has led
investigators to emphasize the importance of incorporating physio-
logical, psychological, and environmental factors into more biobeha-
vioral models to better understand the cognitive and physiological
components of reactivity to smoking (Pomerleau and Pomerleau
1984; Baum, Grunberg, Singer 1982; Abrams et al. 1987; Grunberg
and Baum 1985). For example, nicot,ine has direct and indirect
actions on central neuroregulatory systems and has biphasic effects
of both stimulation and blockade. These factors can help explain
effects such as the anxiolytic and antinociceptive phenomena
(Pomerleau 1986) at a cognitive and neurochemical level, while at
the same time resulting in increased heart rate and blood pressure
and decreased perception of muscle tension (Epstein et al. 1984).

In addition to dosage, biphasic, and physiological factors, the
influence of setting and expectancy set, the current state of the
individual (smoking, deprived, stressed, not stressed), and individual
differences in dependence, genetic, demographic, and learning
history can all influence psychophysiological reactivity. For exam-
ple, smoking a 1.3-mg-nicotine cigarette under conditions of mild
sensory isolation produced consistent arousal effects (i.e., elevations
in heart rate and skin conductance level with decreases in EEG
alpha waves) in smokers compared with sham smoking or a
situational control group. However, under conditions of stress, as
induced by intermittent noise bursts, a mixed stimulant (heart rate)
and depressant (EEG, skin conductance) response was observed
(Golding and Mangan 1982). Woodson and coworkers (1986) also
reported that during noise, smoking induced cardiovascular stimula-
tion (i.e., heart rate acceleration, peripheral vasoconstriction) but
electrodermal depression (i.e., lowered skin conductance response
amplitude). These findings are consistent with the conclusions of
Gilbert and Welser (in press) that unidimensional models are
inadequate to explain the effects of smoking.

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In addition to research on the impact of smoking on psychological
and physiological processes, studies have also examined the com-
bined cardiovascular effects of smoking and stress. In this context
the concept of cardiovascular psychophysiological reactivity is used
to help clarify the relationship among stress, smoking, and CHD
(Epstein and Jennings 1986). MacDougall and colleagues (1983)
randomly assigned 51 male smokers to smoking versus sham
smoking and stress versus no stress conditions in a 2 x 2 factorial
design. The stressor was a difficult video game performed under
challenging conditions. Subjects who sham smoked under no stress
showed minimal cardiovascular response. Subjects who smoked
under no stress or who sham smoked under stress evidenced similar
degrees of response of about a 15-bpm increase in heart rate, a 12-
mmHg increase in systolic blood pressure, and a 9-mmHg increase in
diastolic blood pressure. Subjects in the combined smoking and stress
condition had larger increases in all cardiovascular measures. The
combination of mild stress and smoking produced effects that were
twice those of either condition alone. Smoking and stress combined
to increase cardiovascular response in men.

In a followup study of women, using the same 2 x 2 factorial
design, Dembroski and colleagues (1985) found that the combined
effect of stress and smoking produced blood pressure and heart rate
increases that exceeded the sum of the individual effects. However,
because modifications were made in dosage and psychological
challenge, the two studies were not identical. The gender differences
noted could therefore reflect methodological differences, uncon-
trolled factors, or possibly differences between the sexes in response
to the stress and smoking stimuli. Indeed, it has been noted that
females may be more likely than males to smoke to regulate affect
(Ikard and Tomkins 1973), are more likely to relapse after quitting
(Gritz 1986), may differ in biological factors relating to stress
reactivity/sensitivity (Abrams et al. 1987), and show greater changes
in body weight and eating behavior in response to nicotine (Grun-
berg, Bowen, Winders 1986; Grunberg, Winders, Popp 1987). (See
Chapter VII for a discussion of treatment implications of these
possible sex differences.)

In a conceptually related study, the relationship between physio-
logical responses to cognitive (mental arithmetic) and physical (cold
pressor) stressors was examined in female smokers and nonsmokers
who either used or did not use oral contraceptives (Emmons and
Weidner, in press). All subjects showed some physiological response
(heart rate and blood pressure responses) to the stressors, but in
smokers oral contraceptive use significantly enhanced the systolic
blood pressure response to cognitive stress. This finding may be
related to the fact that smokers who use oral contraceptives are 5.6-
times more likely to have a myocardial infarction than are smokers

118


who do not use oral contraceptives, 9.7-times more likely than
nonsmoking users, and 39-times more likely than nonsmokers who
do not use oral contraceptives (Shapiro et 21. 1979; Jain 1976; Ory
1977).

In studies of psychophysiological reactivity, it is critical to identify,
measure, and control for factors that might confound or alter the
intended impact of the independent variables. For instance, time
since last drink and beliefs, expectations, and setting are important
variables to consider in the study of alcohol addiction (Abrams and
Wilson 1979; Abrams 1983; Marlatt and Rohsenow 1980). The 2 x 2
balanced placebo design (Marlatt, Demming, Reid 19731, where
expectancy set (told to expect the drug or told to expect no drug) and
actual content (drug versus placebo) are fully controlled, has been
used extensively in the alcohol addiction field t.o isolate the separate
and interactive elements of cognitive and pharmacologic effects.
With smoking, little is known about the separate and interactive
impacts of expectations of cigarettes' effects versus their actual
pharmacologic effects. This is partially because it is difficult to find a
method of administration that closely resembles smoking but where
the required manipulations to achieve a credible balanced placebo
design can be accomplished.

Another methodological concern is control over the dosage of
nicotine absorbed by the smoker. Nicotine is thought to be the most
important tobacco constituent responsible for the acute effects of
smoking on reactivity, attention and task performance, mood, and
withdrawal following cessation (Perkins et al., in press; Pomerleau,
Turk, Fertig 1984; Hughes et al. 1984). However, in tobacco smoking,
nicotine is accompanied by more than 4,000 other compounds (Dube
and Green 1982) and smokers are known to smoke in individualized
ways (Epstein et al. 1981) (Chapter IV). The coaching of puff
frequency and other attempts to standardize intake of smoke are
imperfect (Perkins et al., in press). An aerosol nasal spray appears to
be a promising alternative to smoking in studies of behavioral and
physiological effects. It allows for rapid uptake through inhalation,
and a dose-response study indicates patterns of heart rate, blood
pressure, and serum nicotine levels that are very similar to those
obtained by smoking cigarettes of equivalent nicotine content
(Perkins et al., in press).

Perkins and coworkers (in press) studied the separate and interac-
tive effects of nicotine administered by nasal aerosols and stress on
psychophysiological reactivity. The authors note that the previous
studies (MacDougall et al. 1983; Dembroski et al. 1985) could be
confounded because smokers usually smoke more under stress and
therefore they may inhale more nicotine or alter their smoking in
other ways when stressed (Mangan and Golding 1978; Rose, Ananda,
Jarvik 1983) (Chapter VI). In other words, the additive effects of

119


stress and smoking on physiological responses could have resulted
from uncontrolled changes in smoking pattern between the smokers
in the no-st.ress and stress conditions. Perkins and colleagues (in
press) studied 12 male smokers in a repeated-measures design, where
subjects received all 4 conditions (stress plus nicotine, stress plus
placebo, rest and nicotine, and rest and placebo) on separate days
with the order of condition counterbalanced within subjects. Follow-
ing the methodology of previous studies of psychophysiological
reactivity, the researchers used an active stressor consisting of a
video game under conditions of competitive challenge. Nicotine was
administered in measured l.O-mg doses by the aerosol nasal method
(Perkins et al., in press). Consistent with observations of MacDougall
and coworkers (1983), results were additive for heart rate reactivity.
However, effects were less than additive for systolic and diastolic
blood pressure.

Taken together, the studies of the effects of smoking cigarettes and
of nicotine aerosol stimuli on the physiological responses of adult
males demonstrate a consistent effect for the stimuli alone, additive
in combination with stress on heart rate, and additive or less than
additive with stress on blood pressure. There is some suggestion that
effects may be more than additive for women, but this finding
requires replication.

Psychophysiological Reactivity, Smoking Cessation, and
Relapse

Psychophysiological reactivity also serves as a conceptual frame-
work to study relapse after cessation from smoking (Shiffman 1986b;
Abrams 1986). Individual differences in psychophysiological reactivi-
ty and associated coping responses, as a function of general and
smoking-specific stressful stimuli, have been hypothesized to medi-
ate relapse. For example, smokers who smoke more when stressed
might be particularly vulnerable to relapse (Pomerleau, Adkins,
Pertschuck 1978). This idea is consistent with the observation that
relapse may be triggered by life stress events and other psychosocial
demands (Ockene et al. 1982) and by high-risk situations including
negative emotions, social conflicts and pressures, and the presence of
alcohol or smoking cues (Marlatt and Gordon 1985; Shiffman 1979,
1982,1984. 1986a; Abrams et al. 1986). If certain psychophysiological
reactivity responses distinguish potential abstainers from relapsers,
cessation may be better maintained by identifying "relapse-prone"
individuals (Chapter VII).

Stressful environmental demands, sensitivity of the individual to
these demands, and the repertoire of coping responses are important
factors in relapse (Shiffman and Wills 1985; Abrams et al. 1987).
These same factors also may contribute to initiation of smoking
among adolescents. Wills (1985) provides evidence for the stress-

120


coping model of smoking in adolescence, relating both stress and
coping patterns to substance use. Results are consistent wit.h other
findings that, in addition to peer pressure to smoke, adolescents
actively seek methods of coping with their perceptions of stress
(Wills 1985; Friedman, Lichtenstein, Biglan 1985; Botvin and
McAlister 1981). Although these survey studies are consistent with
the notion of smoking as a means of coping with psychophysiological
reactivity to environmental demands, research has not yet measured
reactivity in adolescents prior to smoking onset.

Observational and retrospective studies of relapse have identified
other   smoking-specific   stressful   stimuli   and   cogni-
tive/psychophysiological measures of reactivity that are relevant to
relapse. Situations or stimuli that cue smoking and are associated
with relapse include pharmacologic dependence and withdrawal
symptoms (Jarvik 1977; Pomerleau and Pomerleau, in press; Hughes
et al. 19841, stimuli previously associated with smoking (e.g., coffee
drinking, alcohol) (Shiffman 1984, 1986a; Best and Hakstian 19781,
and urges to smoke (Myrsten, Elgerot, Edgren 1977). Situational
stimuli may or may not have previously been paired with smoking
and may or may not include smoking cues as a trigger for relapse.

Substance use cues themselves (e.g., the sight and smell of
cigarettes) also may precipitate relapse, perhaps in combination with
other stressful stimuli or in a vulnerable individual (Shiffman 1986b;
Abrams et al. 1987). Models of how substance use cues are related to
relapse have been proposed on the basis of classical, operant, and
social learning principles. Reactions may be conditioned to stimuli
repeatedly paired with smoking, resulting in craving and physiologi-
cal reactivity in their presence and moderated by dependence,
tolerance, and nonpharmacologic withdrawal (Siegel 1983; Cooney,
Baker, Pomerleau 1983; Gritz 1980). Psychophysiological reactivity
to smoking cues could mimic the prior drug response (Wikler 19651,
result in a drug-opposite (compensatory) response (Siegel 19831, or
have other effects on psychological processes such as perceived
anxiety, urges to smoke, and self-efficacy in resisting relapse
according to a social learning model of relapse (Marlatt and Gordon
1985).

Abrams and colleagues (1987) studied the psychophysiological
reactivity and behavioral coping responses of male and female
relapsers and quitters in four simulated situational contexts: general
social situations, smoking-specific negative emotional and interper-
sonal role-plays, high-demand social stress, and relaxation. Com-
pared to abstainers, relapsers had higher heart rates and higher
perceived anxiety and were rated as less skillful at coping in the
smoking-specific intrapersonal (negative affect) situations. There
were no differences on any measures in the high-performance-
demand general-social-stress procedure. There were some differences

121


in heart rate and self-reported anxiety in the general social
situations and in heart rate in the relaxation interval, with relapsers
having higher levels than abstainers. Abstainers and relapsers did
not differ in heart rate, perceived anxiety, or coping skills in the
high-demand social anxiety procedure, but they did differ in the
other situations. The results suggest that selected situational
demands prompt situation-specific psychophysiological changes.

Rickard-Figueroa and Zeichner (1985) used a within-subjects
design to examine the responses of smokers to a confederate of the
experimenter lighting and smoking the subject's preferred brand of
cigarette behind a glass window. Cigarette paraphernalia were
piaced adjacent to the subject but smoking was not permitted until
after the session. The cue exposure manipulation resulted in higher
urges to smoke, increased systolic and diastolic blood pressure, and
increased heart rate variability compared with a no-cue condition.
Urges were significantly positively correlated with diastolic blood
pressure, the use of active mastery to cope with urges, and the more
rapid smoking of a standard cigarette after the trial.

In a study that shows some evidence for a conditioned response,
Saumet and Dittmar (1985) measured finger-pulse amplitude, a
measure of peripheral vasoconstrictive activity, while subjects
placed an unlit cigarette into their mouths and waited for it to be lit.
Heavy smokers showed an anticipatory vasoconstrictive response to
the cigarette compared with light smokers and nonsmokers.

Abrams and colleagues (in press) used smoking cues and a social
st,ressor to simulate an interpersonal situation with high risk for
relapse. Relapsers, abstainers, and never smokers were examined for
psychophysiological reactivity. Compared with controls (never smok-
ers), relapsers had significant heart rate reactivity, stronger urges to
smoke, and subjective anxiety. Trained raters, unaware of subject
smoking status, judged relapsers as having significantly less effec-
tive coping skills to resist smoking. In a second study, the same
assessment was used prospectively in a treatment outcome context
to determine whether patt.erns of psychophysiological reactivity
could discriminate between quitters who maintain abstinence from
those who do not. Both heart rate reactivity and subjective anxiety
were greater in quitters who relapsed at 6-month followup compared
with those who continued to abstain. The groups did not differ with
regard to urges to smoke or behavioral judgments of coping skill.
Thus, the two studies were consistent, for heart rate and perceived
anxiety but not for urges or objective ratings of coping effectiveness.

In a reanalysis of the heart rate data from Abrams and coworkers
(in pressj, Niaura and colleagues (in press) examined beat by beat
event-related heart rate during the period immediately before and
for the 10 set following the lighting of a cigarette by a confederate
(subjects did not smoke throughout). Prospective relapsers showed a

122


strong decelerative trend at the point of lighting, whereas prospec-
tive abstainers did not. The results may reflect a conditioned
compensatory response (Siegel 1983) or some other information
processing/attentional phenomenon (Sokolov 1963; Knott 1984). In
another treatment, study, Emmons (1987) examined smokers' cardio-
vascular reactivity to mental arithmetic or deep knee bends before
and 6 months after smoking cessation. There was no change in
reactivity (heart rate, systolic and diastolic blood pressure) to either
stressor before and after quitting. Heightened pretreatment heart
rate reactivity significantly discriminated relapse at g-month follow-
UP.

Individual differences in psychophysiological reactivity may influ-
ence the likelihood of relapse. This possibility is discussed in Chapter
VII.

Summary and Conclusions

1. Nicotine is a powerful pharmacologic agent that acts in the
brain and throughout the body. Actions include electrocortical
activation, skeletal muscle relaxation, and cardiovascular and
endocrine effects. The many biochemical and electrocortical
effects of nicotine may act in concert to reinforce tobacco use.
2. Nicotine acts on specific binding sites or receptors throughout
the nervous system. Nicotine readily crosses the blood-brain
barrier and accumulates in the brain shortly after it enters the
body. Once in the brain, it interacts with specific receptors and
alters brain energy metabolism in a pattern consistent with the
distribution of specific binding sites for the drug.

3. Nicotine and smoking exert effects on nearly all components of
the endocrine and neuroendocrine systems (including catechol-
amines, serotonin, corticosteroids, pituitary hormones). Some
of these endocrine effects are mediated by actions of nicotine
on brain neurotransmitter systems (e.g., hypothalamic-pitu-
itary axis). In addition, nicotine has direct peripherally mediat-
ed effects (e.g., on the adrenal medulla and the adrenal cortex).

123


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CHAPTER IV

   TOBACCO USE
AS DRUG DEPENDENCE

145


CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Cigarette Smoking: Controlled Drug Self-
Administration ................................................... 149
  Measurement of Cigarette Smoking .................... 150
  Characterization of Cigarette Smoking Behavior ... 153
  Patterns of Puffing and Inhaling ....................... 155
  Dose-Related Determinants of Tobacco Intake ....... 158
  Control of Nicotine Intake ................................ 158
     Smoke Concentration ................................. 159
    Cigarette Length ....................................... 161
    Cigarette Brand ........................................ 161
    Cigarette Yield of Nicotine ......................... 162
     Urine pH ................................................ 163
    Tobacco Administration and Deprivation ....... 164
     Nicotine Pretreatments .............................. 165
    Nicotine Antagonist Pretreatments .............. 166
  Effects of Nonnicotinic Drugs on Cigarette
   Smoking ...................................................... 166
  Effects of Nonnicotine Constituents of Tobacco
   Smoke and Citric Acid Aerosol ....................... 168

Nicotine: Psychoactivity, Reinforcing and Related
Behavioral Mechanisms of Nicotine Dependence . . . . . . 169
  Interoceptive, Discriminative, and Subjective Effects
   of Nicotine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
  Drug Discrimination Testing in Animals . . . . . . . . . . . . . 171
    Specificity of the Nicotine Stimulus.. . . . . . . . . . . . 171
    Peripheral Versus Central Discriminative
      Stimulus Effects of Nicotine . . . . . . . . . . . . . . . . . . . . 173
    Interactions with Noncholinergic Neurons.. . . .175
  Subjective Effects of Nicotine in Humans . . . . . . . . . . . . 175
    Psychoactivity of Nicotine . . . . . . . . . . . . . . . . . . . . . . . . . . 176
    Sensory Effects of Nicotine.. . . . . . . . . . . . . . . . . . . . . . . . 178
  State-Dependent Learning . . . . , . . , . . . . . . . . . . . . . . . . . . . . . . . . . 180
  Nicotine as a Positive Reinforcer . . . . . . . . . . . . . . . . . . . . . . . 181
     Animal Studies of Nicotine as a Reinforcer . . 182
     Human Studies of Nicotine as a Reinforcer . . 192
  Nicotine as an Aversive Stimulus . . . . . . . . . . . . . . . . . . . . . . 192

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Nicotine as an Unconditioned Stimulus.. . . . . . . . . . . . . . 194
  Conditioned Place Preference and Aversion.. . 194
  Conditioned Taste Aversion and Rapid
   Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . 195

Nicotine: Withdrawal Reactions (Physical
Dependence) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Criteria for Physical Dependence on Nicotine and
  Clinical Characteristics of the Withdrawal Syn-
   drome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
  Retrospective Survey Data . . . . . . . . . . , ,. . . . . . . . . . . . . . . . . . . . 199
Prospective Data From Laboratory and Nonlabora-
  tory Studies . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201
  Time Course of Responses to Nicotine Abstinence. 204
Alleviation of Withdrawal Symptoms by Cigarette
  Smoking.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Relationship Between Preabstinence Nicotine In-
  take and Magnitude of Withdrawal Syndrome . . .206
Smokeless Tobacco Withdrawal Syndrome.. . . . . . . . . . . 207
Nicotine Polacrilex Gum: Treatment and Physical
  Dependence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
    Treatment of Withdrawal Symptoms.. . . . . . . . . . . 208
    Maintenance of Physical Dependence . . . . . . . . . . .209
  Tobacco Craving.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . 210

Alternate Nicotine Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . .212
  Kinds of Nicotine Delivery Systems. . . . . . . . . . . . . . . . . . . . 212
Safety of Alternate Nicotine Delivery Systems . . . . .213

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

References . . . . . . . . . . . . . . . . . . . . . . . . . ..,...... . . . . . . . . . . . . . . . . . . . . . . . . . 217

148


Introduction

This Chapter reviews the evidence that tobacco is a pharmacologi-
cally addicting substance and that tobacco use can be considered a
form of drug addiction. Specific criteria to identify a substance as
pharmacologically addicting are discussed in Chapters I and V. In
brief, the criteria are: (1) that highly controlled or compulsive
patterns of drug taking occur, (2) that a psychoactive or mood-
altering drug is ingested by use of the substance and is involved in
the resulting patterns of behavior, and (3) that the drug is capable of
functioning as a reinforcer that can directly strengthen behavior
leading to further drug ingestion. Addicting drugs can be character-
ized by other properties that include the following: they can produce
pleasurable effects in users, they can cause tolerance and physical
dependence, and they can have adverse or toxic effects. Drawing
upon data from studies of tobacco and nicotine, involving both
humans and animals, the present Chapter reviews the evidence that
tobacco meets the criteria as a pharmacologically addicting sub-
stance. A specific comparison of tobacco to other pharmacologically
addicting substances is provided in Chapter V.

Cigarette Smoking: Controlled Drug Self-Administration

Highly controlled or compulsive drug use refers to drug-seeking
and drug-taking behavior that is driven by strong, often irresistible
urges. It can persist despite a desire to quit or even repeated
attempts to quit.

Basic observations and experimental research indicate that ciga-
rette smoking is not a random or capricious behavior that simply
occurs at the will or pleasure of those who smoke. Rather, smoking is
the result of behavioral and pharmacologic factors that lead to
highly controlled or compulsive use of cigarettes. The highly
consistent patterns of cigarette smoking illustrate the controlled
nature of the behavior. For example, following initiation of smoking
the individual gradually increases cigarette intake over time until
he or she achieves a level that remains stable, day after day, during
the smoker's lifetime (Schuman 1977; US DHHS 1987a). The
dependent smoker tends to adopt a pattern in which the initial
cigarette of the day is smoked soon after waking (Fagerstrbm 1978)
and in which smoking throughout the day is regular from day to day
(Griffiths and Henningfield 1982; Griffiths, Henningfield, Bigelow
1982). "Occasional" cigarette smoking (or "chipping") occurs just as
does occasional use of other addicting drugs (see Chapter V);
however, the 1985 National Health Interview Survey showed that
only 10.6 percent of current smokers smoke 5 or fewer cigarettes/day
(unpublished data, Office on Smoking and Health; see also Russell
1976 and US DHHS 1987a).

149


Strong evidence that cigarett,e smoking is a highly controlled or
compulsive behavior is provided by survey data showing that a
majority of smokers have tried to quit or at, least would like to quit.
For example, several Gallup surveys have shown that a large
majority of smokers report a desire to quit smoking; in fact, the
proportion of smokers who would like to quit increased from 66
percent in 1977 to 77 percent in 1987 (Gallup 1987), perhaps because
of a declining social acceptability of smoking and the growing
awareness of the health hazards of smoking. In addition, the 1986
Adult Use of Tobacco Survey (US DHHS 1987b) showed that 65
percent of cigarette smokers had made at least one serious attempt
to quit; another 21 percent said that they would try to quit "if there
were an easy way to do so" (Fiore et al., in press; US DHHS 1986).

The compulsive nature of cigarette smoking is most apparent in
extreme cases: for example, the laryngectomized patient who, having
already suffered severe consequences of smoking, continues to smoke
through a tracheostomy hole. Similarly, 50 percent or more of
patients recovering from surgery for a smoking-related disease (e.g.,
cancer, cardiovascular disease) resume smoking while in the hospital
or shortly after discharge (Burling, Singleton et al. 1986; West and
Evans 1986).

In this Section, the behavioral process of cigarette smoking and
the factors which determine the course of the behavior are described.
Evidence that cigarette smoking is repetitious and stereotypic,
common features of compulsive drug use, is reviewed in this Section,
as well as evidence that actions of nicotine are responsible for
patterns of smoking behavior. Initially, however, it is necessary to
briefly review the methods by which the behavioral process of
cigarette smoking is studied, as well as the main findings from such
studies.

Measurement of Cigarette Smoking

Cigarette smoking behavior may be analyzed at different levels
ranging from epidemiological surveys to the analysis of cigarette
puffing. In fact, many thousands of scientific articles have been
published in which some aspect of cigarette smoking is described.
Much of this research has been reviewed in the tobacco research
compendia of Larson and his colleagues (Larson, Haag, Silvette 1961;
Larson and Silvette 1968, 1971, 1975), a previous report of the
Surgeon General (US DHEW 1979), several monographs of the
National Institute on Drug Abuse (NIDA) (Jarvik et al. 1977;
Krasnegor 1978,1979a,b,c; Grabowski and Bell 1983; Grabowski and
Hall 1985) and in articles by others (Russell 1971, 1976; Gritz 1980;
Henningfield 1984).

It is characteristic of drug dependence that the drug-seeking and
self-administration behaviors become stereotypical and automatic in

150


Tobacco campuses:
1 Cigarette constituents
  o ??????? matter
  o Nlwtfnic alkyloids
   o Addltlves

2 Pyrolysis products
   o Carbon dioxide
   o Carbon monoxide

  Filter
1_^_. --

AIM dilution /
and coolrng ua
porous paper

\ To lungs, where
absorption occurs

Absorption factors:

o Inhalation amount
o Inhalation depth
o lnhalatlon duration
o pH of smoke
o Absorption characteristics
of indlvtdual constituents

FIGURE l.-Production and fate of cigarette smoke
        constituents

NOTE Descnpl~on of complexity of process by whxh n~cot~nr is extracted from c+we+te. Amount of nwotme
ultimately absorbed 1s as much a function of smoker beha\lor as of cigarette charactenstlcs
SOURCE: Henningfield (lY841

appearance; cigarette smoking is no exception. The behavior of
lighting, smoking, and extinguishing cigarettes, including puffing
and inhaling, also becomes regular in smokers over time. The
measurement techniques that permit such conclusions, however,
must address a complex behavior. There are many variables (e.g.,
number of puffs, depth of inhalations) that might change and
thereby affect the intake of tobacco smoke and its various constitu-
ents (e.g., nicotine, tar, carbon monoxide (CO)). As shown in Figure 1,
the process of producing cigarette smoke constituents itself is
complex (see US DHEW 1979; US DHHS 1981, for a more thorough
discussion of these factors). This complexity emphasizes the impor-
tance of the use of careful measurement and multiple measures to
ensure accurate characterization of cigarette smoking.

Quantification of cigarette smoking behavior has improved with
the development of automated measurement techniques. These
techniques permit the measurement of puffing and inhalation both
in the laboratory (Gust, Pickens, Pechacek 1983; Epstein, Dickson,
Stiller et al. 1982; Creighton, Noble, Whewell 1978; Herning, Hunt,

151


Jones 1983; Henningfield and Griffiths 1979; Puustinen et al. 1987)
and outside the laboratory (Henningfield et al. 1980; Grabowski and
Bell 1983). Puffing behavior is generally measured by having
subjects smoke through cigarette holders that measure air flow by
use of either temperature-sensitive thermistors (Gritz, Rose, Jarvik
1983; Fagerstrom and Bates 1981) or pressure-sensing transducers
(Henningfield and Griffiths 1979; Gust, Pickens, Pechacek 1983a;
Rawbone et al. 1978). Inhalation behavior has been measured by a
variety of techniques, including mercury strain gauge pneumogra-
phy (Rawbone et al. 1978; Herning et al. 1983), head- and arms-out
whole-body plethysmography (Adams et al. 1983), and impedance
(Nil, Buzzi, Battig 1986) and inductive plethysmography (Herning,
Hunt, Jones 1983; Tobin and Sackner 1982; Tobin, Jenouri, Sackner
1982). Other methods include the use of inert gas radiotracers to
determine the amount of smoke inhaled (Sheahan et al. 1980;
Woodman et al. 1986) and a sensor for directly measuring the
concentration of smoke particles in the holder before puffing
(Jenkins and Gayle 1984).

These procedures have proved to be valuable and reliable methods
of measuring smoking behavior (Woodman et a!. 1984; Herning,
Hunt, Jones 1983). Comparisons of data obtained when simply
observing smokers to data obtained when using the mechanical
devices indicate that such automated measuring techniques are
valid. Such comparisons reveal consistent findings on measures such
as number and duration of puffs and even of patterns of puffing
within cigarettes (Henningfield and Griffiths 1979; Griffiths and
Henningfield 1982). However, other research suggests that the
devices may alter certain characteristics of smoking such as intensi-
ty of puffing (Tobin and Sackner 1982; Ashton, Stepney, Thompson
1978; Ossip-Klein, Martin et al. 1983). In addition, some smoking
behaviors, such as blocking the ventilation holes of filters of low-
yieid cigarettes (which can markedly influence nicotine and tar
intake from the cigarette) are thwarted by the use of a cigarette
holder. Nonetheless, such measurements are useful and appear to
provide valid means of evaluating the effects of specific experimental
manipulations.

Measurement of the intake of cigarette smoke constituents may
also be obtained by analysis of various biological fluids (saliva, urine,
or blood) and expired air. Chapter II reviewed the methods and
practical issues of using such specimens to assess resulting levels of
nicotine, cotinine (a nicotine metabolite), CO, and other tobacco-
associated compounds (see also Jarvis et al. 1987; Benowitz 1983).

Use of the methods described above has led to a much better
understanding of how cigarettes are smoked and factors that affect
intake of smoke constituents such as CO and nicotine. In addition,
these methods permit conclusions regarding which aspects of smok-

152


ing are most robust across individuals, which aspects are strongly
influenced by pharmacologic factors, and which aspects appear to be
determined by other factors. Some of these findings are reviewed in
subsequent sections.

Characterization of Cigarette Smoking Behavior

Although the process of smoking a cigarette may appear to be a
simple behavior, it is actually a complex series of events; a full
characterization requires the measurement of a variety of interde-
pendent indices of frequency, duration, and volume. Even the act of
taking a single puff is complex. Typically, a smoker puffs a volume of
smoke into the mouth, where it is held for a short period of time
(Guillerm and Radziszewski 1978; Medici, Unger, Riiegger 1985). The
puff itself can occur at any point during inhalation, although most
commonly it occurs toward the beginning of an inhalation (McBride
et al. 1984; Guillerm and Radziszewski 1978). During inhalation, the
puff is diluted with ambient air which may be inhaled through the
nose, the mouth, or both (Rodenstein and Stanescu 1985; McBride et
al. 1984; Adams et al. 1983). The postpuff inhalation is generally
longer and larger in volume than normal inspirations (Rodenstein
and Stanescu 1985; McBride et al. 1984). After a variable period of
breath holding, the smoker exhales, usually through the mouth
(Rodenstein and Stdnescu 1985).

All of the above-mentioned behavioral factors can alter nicotine
absorption. The likely impact of some factors is obvious (e.g., number
of puffs taken) (Kozlowski 1981); others are much more subtle (e.g.,
puff shape, which is a function of the air flow rate over time)
(Creighton and Lewis 197813). Analogous but distinct from puffing
factors are inhalation factors (e.g., depth and duration, dilution of
the puff with ambient air) which can also determine the amount of
tobacco smoke constituents which are absorbed. Table 1 lists several
measures of cigarette smoking that have been objectively defined
and measured.

The relationships among these behavioral measures have been
studied. For insta.nce, duration and volume of puffing are generally
highly correlated although they vary somewhat from smoker to
smoker (Gust and Pickens 1982; Epstein et al. 1982; Adams et al.
1983; Nemeth-Coslett and Griffiths 1985; Gust, Pickens, Pechacek
198313; Gritz, Rose, Jarvik 1983). Peak smoke flow rate has been
reported to be moderately correlated with puff volume and weakly
correlated with puff duration (Gritz, Rose, Jarvik 1983). The
relationship between puff volume and interpuff interval is much
more variable (Adams et al. 1983; Gust, Pickens, Pechacek 1983b),
and puffs per cigarette and puff duration have been found to be
inversely related (Lichtenstein and Antonuccio 1981).

153


TABLE l.-Behavioral measures of cigarette smoking

Puffing behavior              Inhalation behavmr

Puffsicigarette               Inhalation volume

Interpuff interval             Inhalation duration


Puff duration               Breathhold duration

Butt length we~ghti          Lung exposure duration


Puff volunle              Percent of puff inhaled

Puff shape

Puff flow rate (puff intensity1

Peak flow rate ~pressure)

Latency to peak flow rate \pressure,

Percent puffing time

When the smoking of individual cigarettes is studied, the mea-
sures of cigarette smoking behavior and the resulting levels of
biochemical markers have also been found to be highly correlated.
For example, four studies found positive correlations between one or
more of the behavioral measures and plasma nicotine levels (Pomer-
leau, Pomerleau, Majchrzak 1987; Sutton et al. 1982; Bridges et al.
1986; Herning et al. 1983). Using another approach, Zacny and
associates (1987) independently varied three aspects of smoking-
puff volume, inhalation volume, and lung exposure duration. They
found that increases in puff volume (from 15 to 60 mL) produced
proportional increases in plasma nicotine level, whereas increases in
inhalation volume (from 10 or 20 to 60 percent of vital capacity) or
lung exposure duration (from 5 to 21 set) had no such effect.

CO intake (measured either from expired air or blood samples) also
tends to be positively related to measures of smoking behavior,
including total puff volume (Gust and Pickens 1982; Guillerm and
Radziszewski 1978; Xl, Buzzi, Battig 1984; Woodman et al. 1986) and
mean puff volume (Zacny et al. 1987; Zacny and Stitzer 1986).
McBride and coworkers (1984) found moderate correlations (r = 0.36
to 0.45) between CO boost and other measures of ventilation (tidal
volume, minute ventilation, and prepuff expiratory volume). These
studies illustrate some of the ways that specific aspects of cigarette
smoking can affect absorption of smoke constituents. These mea-
sures have been used to scientifically describe many features of
cigarette smoking. A summary of findings that have emerged from
such studies is presented in the next Section.

154


Patterns of Puffing and Inhaling

Several studies have characterized the behavior of cigarette
smoking in and outside the laboratory. The values of the most
frequently measured variables are shown in Table 2. Despite a wide
range of variations among studies, including differences in subject
population (age, gender, smoking hist,ory, type of cigarette smoked),
experimental setting, method used to collect the measurements,
apparatus calibration procedures, and operational definitions of the
measured variables, the findings among studies are strikingly
consistent.

Over the course of smoking each cigarette there are striking
consistencies from cigarette to cigarette, both within and between
individuals. For example, during the smoking of a single cigarette,
the duration of each puff tends to decrease and/or the time between
each puff (interpuff interval) tends to increase (Graham et al. 1963;
Griffiths and Henningfield 1982; Nemeth-Coslett and Griffiths 1985;
Herning et al. 1981; Gust, Pickens, Pechacek 1983b; Woodman et al.
1986; Buzzi, Nil, Battig 1985; Adams et al. 1983; McBride et al. 1984;
Chait and Griffiths 1982a). These trends were also found in
nonlaboratory observations by Schulz and Seehofer (1978).

Although these observations reflect a tendency to decrease overall
intensity of smoking over the course of the cigarette, the specific
factors which produce such effects remain to be fully elucidated. The
pattern has been hypothesized to be related to the nicotine dose per
puff (Rickert et al. 1983; Russell et al. 1975; Chamberlain and
Higenbot,tam 1985), because the nicotine concentration of smoke
increases as the cigarette is smoked (Kozlowski 1981). However,
experimental studies suggest that within-cigaret,te changes in puff
intensity are not a simple function of the nicotine dose per puff
(Nemeth-Coslett and Griffiths 1984a,b, 1985). Furthermore, puff
volume may not be controlled by the same factors as puff duration
(Nemeth-Coslett and Griffiths 1985). Thus, the orderliness of the
behavior may be due to a variety of factors.

Various other aspects of puffing and inhaling during the smoking
of single cigarettes have been studied and provide further informa-
tion that helps to characterize this complex behavioral process. For
example, puff shape (puff intensity over time) (McBride et al. 1984),
latency to peak puff pressure (Buzzi, Nil, BBttig 1985), and inhala-
tion volume and duration (Adams et al. 1983) did not change over the
course of smoking single cigarettes. The volume expired from puff to
puff during and immediately after puffing (before inhalation) was
lower for early puffs than for later puffs (Adams et al. 1983).
Woodman and colleagues (1986) reported that the amount of smoke
actually inhaled (range, 46 to 88 percent of puff volume) decreased
proportionately with puff volume as cigarettes were smoked. Finally,
significant changes from cigarette to cigarette in puff volume and

155


TABLE 2.-Published values of common measures of smoking

Study

Number      Puffs/
of subjects    cigarette

Interpuff
mterva1
b32)

Cigarette
duration
kc)

Puff
duration
isec)

Puff
volume
(mLt

Peak
flow
imL/swI

Rawbone et al (1978)                 12         10         41                    1.8

Rawbone et al. (1978~                 9         10         35                    2.1         43
Woodman et al. (1986)                 9         13         18         254         1.9        49                 413
Nemeth-Coslett et al. (1986~             8          8         64         414         18

Nemeth-Coslett et al 11986b)             8         8         47         362         1.4
Nil, Wwdson, Battig (19861             132         13         28                    2.2         30         28        560

Jarvik et al. (1978)                   9         10

Russell et al. (198Ob)                 10         11         35
Ashton. Stepney. Thompson (1978)         14                   24                    1.5

Schulz and Seehofer 11978)             100         11         50                    1.4

Schulz and Seehofer (19781             218         12         42                    1.3
Henningfield and Grifliths (19811           8         10         39         351         1.0
stepney (1981)                     19         13                   400                   38
Battig, Buzzi, Nil (1982)               110         13         26                    2.1         40
Epstein et al. (1982)                 63         13                              2.4         21
Russell et al. (1982)                  12         15         26         324         2.3        40
Gritz. Rose, Jarvik (1983)               8         9         47                    2.2        66         48
OsipKlein, Martin et al. (1983)           9         8                              1.4
OssipKlein. Martin et al. (1983)           9         12                              1.9

Guillerm and Radziszewski (1978)          8         12         41                    1.9         39         35        918
Gust, Pickens. Pechacek (1983b)           8         9         40                    1.6        44

351

339

390

393


Study


Adams et al. (1983)
Moody (1984)
Nil, Buzzi, Battig (19841

Number
of subjects


  10

  517

  20

Puffs.1
cigarette




  9

15

Interpuff
interval
bed



26

26

26

Cigarette
duration
bec)





232

Puff
duration
b32)



1.9

2.1

1.6

Puff
volume
(mL1



44

44

40

Peak
flow
(mL/sec)







40

Inhalation
volume
(mL)



614

McBride et al. (1984)                  9         16         25         352         2.1         42
Medici, Unger. Ruegger (1985)            17         14         19                    2.2         43         31
Burlmg et al. (1985)   ,               24         12         28         330         1.7
Nil, Buzzi, BBttig (1986)               117         13         22                    2.1         42         36
Hughes et al. (1986bl                 46         11                              1.6
Bridges et al. (1986)                 108         11                                       56

Puustinen et al. (1986)                11         13         22                    2.3         44
Hildmg (19561                     27         10

4.5a

Mean                                11         34         346         1.8        43         36        591
Median                               11         28         351         1.9        42.5        35.5       560
Range                               8-16       l&64       232-414       I.&24      21-66       2MR      413-918

NOTE. Data were taken from the baselme phase (or placebo treatment) of studies Involving an experimental manipulation, with at least eight SubJects Values are rounded off to the nearest unit.
and in some cases. were calculated from other variables or estimated from data presented in figures; m&ng values indicate that the vnnable was not measured or was not presented in the publlshrd
study


inhalation volume, as well as their ratio, were reported for individu-
al subjects over the course of a 4-hr smoking session (Herning, Hunt,
Jones 1983).

Dose-Related Determinants of Tobacco Intake

As the preceding material shows, cigarette smoking is a complex
but orderly behavior; it may be qualitatively and quantitatively
described. Furthermore, the behavioral process of tobacco smoke
self-administration substantially determines the amount of smoke
that is actually consumed. Similarly, the behavior of smoking may
change in response to factors related to the delivered smoke and/or
nicotine dose. These interactions are described in the present section.
Much of this research has addressed issues concerning the manipula-
tion of some aspect of cigarette and/or nicotine dose level. Such data
are relevant to comparing this form of drug self-administration with
other forms of drug self-administration, because one of the basic
findings in studies of drug-seeking behavior is that the dose may
affect the behavior. For example, when the dose (quantity) of a
psychoactive drug is high, fewer doses are generally taken compared
to when the dose is very low (Griffiths, Bigelow, Henningfield 1980;
Chapter V).

With regard to cigarette smoking, the control and measurement of
cigarette dose level is more complex than is the case with most other
forms of drug delivery. For example, in opioid and alcohol studies,
the amount of the morphine injected and volume of alcohol
consumed can be precisely measured, but cigarette smoke can vary
in levels of CO, tar, nicotine, and many other potentially important
constituents (see Figure 2). The total smoke dose is positively related
to the number of puffs taken per cigarette. However, total smoke
dose might be changed by diluting the smoke with air or changing
the number of available cigarettes. Alternatively, the smoke concen-
trations can be kept constant while changes are made in the
concentration of nicotine delivered. This Section reviews these and
several other strategies used to investigate some form of tobac-
co/nicotine dose manipulation and the resultant effects on cigarette
smoking.

Control of Nicotine Intake

Among the most robust findings in research on cigarette smoking
is the stability of nicotine intake that occurs from day to day within
cigarette smokers. Several studies have collected blood samples from
cigarette smokers while they are smoking their own cigarettes
(Russell, Jarvis et al. 1980; Benowitz et al. 1983; Gori and Lynch
1985). This research has shown that blood levels of nicotine and
cotinine among different cigarette smokers are stable and are
relatively independent of the machine-estimated nicotine yield of the

158


cigarettes. Similarly, there are generally only modest correlations
between the number of cigarettes smoked per day and resultant
blood nicotine levels. This finding occurs because smokers consume
different amounts of nicotine from their cigarettes, according to how
the cigarettes are smoked. Figure 2 presents data from one of these
studies.

To explain why nicotine intake is not simply determined by the
machine-estimated nicotine yield of the cigarettes or the number of
cigarettes smoked, many other aspects of smoking have been
measured. This research is described in the remainder of this
Section.

Smoke Concentration

The concentration of tobacco smoke delivered to the lung can be
changed by dilution with air. Such dilution is an important means by
which the low smoking-machine-estimated ratings (e.g., Federal
Trade Commission ratings) of tar and nicotine are achieved in the so-
called "light" or "ultra light" cigarettes (Kozlowski 1981, 1982, 1986,
1987). One way to study the possible effects of smoke dilution is to
use the ventilated cigarette holders which have been marketed for
persons who are trying to quit smoking. In principle, the smoker
gradually reduces his or her level of dependence to nicotine by using
holders of gradually increasing ventilation level. Three laboratory
studies have evaluated the effects of such holders on cigarette
smoking behavior (Henningfield and Griffiths 1980; Sutton et al.
1978; Martin et al. 1980). The results of all three were consistent:
smoking was more intense at lower smoke concentrations and less
intense at the highest concentration. In fact, in one of the studies,
expired air CO levels were similar at all four concentration levels,
indicating that the changes in smoking intensity were sufficient to
defeat the holders' intended purpose of reducing the dose taken
(Henningfield and Griffiths 1980). Using a somewhat different
strategy, Zacny, Stitzer, and Yingling (1986) studied cigarette
smoking with commercially available ventilated cigarettes. When
the experimenter systematically blocked the filter vents of "ultra"
low-yield cigarettes, there were decreases in puffs per cigarette, puff
volume, and puff flow rate, and increases in interpuff interval.

These laboratory findings are consistent with findings obtained
outside the laboratory when the cigarette butts of vented cigarettes
are examined following smoking. Kozlowski, Rickert, Pope, and
Robinson (1982) found that the cigarette butts taken from people
who blocked the ventilation holes (often inadvertently) were more
stained by tar and nicotine, reflecting less effective dilution and
hence greater amounts of smoke delivery to the smoker. Data from a
laboratory study suggest that 40 percent or more of smokers may
inadvertently block the holes (Kozlowski, Rickert, Pope, Robinson,

159


  i-  1000
5                  0     o- 1 observation
P                  m-2 observations
  -  800 -
E                  a-3 observations
                     .
  .-
  i;j                    0-4 observations
               0      0
  E
8
A:       0
   0
iz
  .-
  .E
s
x
i

?   10  20  30  40  50  60  70 80 90 100
   Number of cigarettes/day

N= 137
r=0.15
NS

P
m   oir"
      
     0.0 0.2

0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0

. I

FTC nicotine yield (mg)

FIGURE 2.-Afternoon blood cotinine concentrations,
      compared by regression analysis with number
      of cigarettes smoked/day (A) and with U.S.
       Federal Trade Commission @TOdetermined
      nicotine yield (B)

NOTE: The grouped smokers' values (observations 2-A) were so similar to individual values that plots
overlapped Total number 01 subjects in B is lower because data for B few subjects were incomplete. Morning blood
cotinine concentrations (not shown) were on average slightly lower, but had similar correlations with number of
cigarettes Cr=0.45) and FTC yield (r=O.W.
SOURCE: Benowitz et al. (1983).

160


Frecker 1982). These findings imply that there is much greater
exposure to cigarette smoke in the general population than one
would expect based solely on the market share of ventilated
cigarettes (US DHHS 1981; Kozlowski 1987).

Cigarette Length

When cigarettes are shorter, people smoke more of them (Ashton,
Stepney, Thompson 1978; Goldfarb and Jarvik 1972; Gritz, Baer-
Weiss, Jarvik 1976; Jarvik et al. 1978; Chait and Griffiths 1982b).
Cigarette length may also affect how people smoke each cigarette.
Ashton, Stepney, and Thompson (1978) found that smokers short-
ened their intervals between puffs and spent a greater proportion of
time puffing on two-thirds-length cigarettes compared with full-
length cigarettes. Russell, Sutton, and associates (1980) reported that
smokers took relatively more puffs and left shorter butts when
smoking shortened cigarettes. In another study, subjects smoking
half-length cigarettes shortened the interval between puffs, but did
not spend more time puffing on these cigarettes relative to full-
length cigarettes (Chait and Griffiths 1982b). Puff duration and puff
volume were inversely proportional to the length of the tobacco rod,
even for the first puff of the cigarette (Chait and Griffiths 1982a;
Nemeth-Coslett and Griffiths 1984a,b, 1985).

Cigarette Brand

Numerous studies have examined the effects of cigarette brand
manipulations on cigarette smoking, and several reviews are avail-
able (Gritz 1980; Moss and Prue 1982; McMorrow and Foxx 1983).
Such studies are of practical importance because smokers often
switch to lower tar/nicotine yielding cigarette brands in an effort to
reduce this exposure to toxins and to reduce their level of nicotine
dependence (see Chapter VII). One finding of these studies is that the
number of cigarettes smoked per day is only slightly increased when
lower nicotine-yield brands are used. For this reason, it has been
suggested that smokers switch to lower yield cigarette brands (1) to
reduce exposure to smoke constituents and (2) to help them
gradually reduce their dependence on nicotine (see discussion of
these issues in US DHHS 1981 and in Chapter VII (nicotine fading)).
However, as discussed earlier, several other studies indicate that
there is little correlation between the nicotine rating of a cigarette
and the plasma nicotine level of the smoker (Russell, Jarvis et al.
1980; Benowitz et al. 1983; Gori and Lynch 1985). Kozlowski (1981,
1982) has observed that increases of only one or two puffs per
cigarette and possibly other more subtle changes in cigarette
smoking (e.g., blocking ventilation holes and taking deeper inhala-

161


tionst may defeat the intended purpose of the brand-switching
procedure.

Laboratory studies have provided information on the specific
changes in smoking behavior that may reduce the intended impact of
switching to lower yield brands of cigarettes. One confounding factor
in such studies is that machine-estimated nicotine, tar, and CO yields
do not necessarily change to the same degree or even in the same
direction from one cigarette brand to the next (Tobacco Reporter
1985); thus, no definitive conclusions can be drawn about which
specific smoke component was responsible for observed changes in
smoking behavior. Nonetheless, some orderly and consistent findings
emerge from a review of this literature. Several measures suggest
that when tobacco smoke constituent ratings decline, smoking is
more intense so that more smoke is delivered per cigarette;
conversely, when tobacco smoke constituent ratings are higher,
cigarette smoking becomes less intense (Frith 1971; Ashton, Stepney,
Thompson 1979; Stepney 1981; Guillerm and Radziszewski 1978;
Rawbone et al. 1978; Adams 1978; Creighton and Lewis 1978a; Ossip-
Klein, Epstein et al. 1983; Russell et al. 1982; Ashton and Watson
1970; Epstein et al. 1981; Russell, Epstein, Dickson 1983; Tobin and
Sackner 1982; Fagerstrom and Bates 1981; Woodman et al. 1987).

The consensus of the foregoing studies is that smokers tend to
smoke in ways that minimize the effect of attempted reductions in
nicotine intake; however, brand preferences can modulate nicotine
intake. One study employing biochemical measures of smoke intake
illustrated both of these phenomena (Benowitz and Jacob 1984).
Subjects were permitted t,o smoke under each of three cigarette
conditions: using their regular cigarette, using a higher nicotine-
yield brand, and using a lower nicotine-yield brand. Subjects
maintained significant nicotine intake under all three conditions,
but the highest intakes of nicotine were with the subject's preferred
brand. Nicotine intake from the lower nicotine-yield brands was
somewhat lower than intake from the higher yield brands. Taken
together, these studies indicate that brand switching may result in
somewhat decreased levels of intake of nicotine and other constitu-
ents of tobacco smoke. However, because of compensatory changes in
how cigarettes are smoked and in the number of cigarettes smoked,
the decreases are substantially less than would have been predicted
on the basis of the machine-estimated yield of the cigarettes.

Cigarette Yield of LVicotine

Research cigarettes which vary mainly in machine-estimated
nicotine yield ratings but little in the yield of other constituents (e.g.,
tar, CO) have also been used in laboratory and nonlaboratory studies
of cigarette smoking. This literature has been extensively reviewed
(Russell 1971, 1976; Gritz 1980; Henningfield 1984; US DHEW 1979;

162


US DHHS 1981). The consensus of the literature indicates that as
nicotine yield increases, the number of cigarettes smoked per day
tends to decrease, although the converse relationship is not as robust
(Russell 1979). Because few of these studies employed measures of
smoking other than number of cigarettes smoked per day, the degree
to which overall cigarette smoking behavior actually varied as a
function of such manipulations may have been underestimated
(Henningfield 1984).

Laboratory studies in which multiple behavioral measures of
cigarette smoking were employed indicate that smoking is sensitive
to nicotine dose manipulations. When cigarettes with higher nicotine
yield ratings are smoked, there are decreases in measures such as
puffs per cigarette, puff duration and puff volume, number of
cigarettes, and expired air CO; and increases in interpuff and
intercigarette interval (the specific measures were not identical for
the three studies summarized) (Herning et al. 1981; Gust and
Pickens 1982; McBride et al. 1984). These changes in smoking are
consistent with the interpretation that intensity of smoking is
inversely related to nicotine dose, indicating that compensatory
changes in smoking could be affected by nicotine itself.

Urine pH

Because some nicotine is normally eliminated in the urine,
manipulations of the rate of nicotine excretion might be expected to
change cigarette smoking behavior (see Chapter II). Rate of renal
excretion is partially determined by the acidity of the urine: lower
pH values (higher acidity) increase the rate of nicotine excretion.
One study showed that acidification of the urine of cigarette smokers
resulted in small increases in cigarettes smoked per day, and
alkalinization of urine was accompanied by only very small de-
creases in smoking (Schachter, Kozlowski, Silverstein 1977). A
subsequent study in which urine pH was varied showed no change in
cigarette smoking measures (Cherek, Mauroner, Brauchi 1982);
another showed small but significant effects on nicotine intake in
the expected direction (Benowitz and Jacob 1985).

The fact that there is a direct albeit weak relationship between
rate of nicotine excretion and cigarette smoking has suggested to
some that alkaline diets might be useful for persons trying to
decrease their cigarette smoking (Fix and Daughton 1981; Fix et al.
1983; Grunberg and Kozlowski 1986). However, the relatively small
amount of systemic nicotine which is eliminated by this route
(approximately 2 percent in alkaline urine, 10 percent in urine
without cont.rolled pH) (Rosenberg et al. 1980; Benowitz and Jacob
1985; Chapter II) weakens its practical significance as a determinant
of cigarette smoking behavior. The results of clinical studies suggest

163


that such therapies are not useful in the cessation of smoking (see
also Grunberg and Kozlowski 1986; Schwartz 1987).

Tobacco Administration and Deprivation

When tobacco smoke itself is given or withheld, the tendency to
smoke, as well as the way cigarettes are smoked, may be affected.
Kumar and colleagues (1977) reported that pretreating smokers with
a varying number of uniform puffs of tobacco smoke produced dose-
related reductions in the subsequent number of puffs taken, volume
per puff, and total puff volume during a 40-min period of smoking ad
libitum. In a study of similar design, Chait, Russ, and Griffiths (1985)
found that an increasing number of uniform pretreatment puffs
decreased subsequent puffs per cigarette, cigarette duration, and
total puff duration. Analogously, when the number of puffs available
during any period of smoking (smoking "bout") during a given day
was varied by the experimenter from 1 to 12 while the smokers were
free to vary the interbout interval, the intervals between each
smoking bout were directly related to the number of puffs that had
been given (Griffiths, Henningfield, Bigelow 1982). These studies
show that cigarette smoke intake is a function of time since the last
cigarette or the smoke dose given at any smoking opportunity.

Whereas smoke pretreatment decreases several measures of
cigarette smoke intake, other studies have found that deprivation for
just 1 hr increases the tendency to smoke and elevates several
measures of tobacco smoke intake (Henningfield and Griffiths 1979);
furthermore, these effects were not due to "anticipation" by the
subjects of the periods of smoke deprivation (Griffiths and Henning-
field 1982). Several additional studies have confirmed that smoke
deprivation increases one or more measures of cigarette smoking
(Karanci 1985; Griffiths and Henningfield 1982; Zacny and Stitzer
1985; Epstein et al. 1981). Sutton and coworkers (1982) found a small,
but statistically significant, positive correlation between time since
the last cigarette and total puff volume on the subsequent cigarette.
Similarily, when the interval between each smoking opportunity was
varied from 7.5 to 120 min and subjects were free to take as many
puffs per smoking bout as they pleased, the number of puffs per bout
was directly related to the duration of the preceding interbout
interval (Griffiths, Henningfield, Bigelow 1982). Restricting the
number of cigarettes that may be smoked is another way to study
tobacco deprivation. When smokers who on average smoked 37
cigarettes/day were permitted to smoke only 5 cigarettes/day, they
consumed three times as much nicotine per cigarette compared with
unrestricted smoking (Benowitz et al. 1986).

The results of studies of the effects of tobacco administration and
deprivation on subsequent rates and patterns of cigarette smoking
show that tobacco smoke can function as do other primary reinforc-

164


ers such as food, water, and dependence-producing drugs (Thompson
and Schuster 1964). Such studies in themselves, however, do not
reveal which of the many tobacco smoke constituents are critical.
The next two sections will examine evidence that specific manipula-
tions of nicotine and nicotine antagonists can produce analogous
changes in cigarette smoking.

Nicotine Pretreatments

One of the basic ways to demonstrate that a psychoactive drug is
controlling behavior is to determine if pretreatment with the drug
leads to decreases in the amount subsequently taken. Such findings
have been obtained with a variety of dependence-producing drugs
(e.g., Griffiths, Bigelow, Henningfield 1980; Chapter V), and the
strategy has been used to study the role of nicotine in cigarette
smoking. These studies have shown that nicotine pretreatment by a
variety of routes decreases the amount and/or intensity of subse-
quent cigarette smoking although the specific measures that have
been reportedly affected vary across studies. It is possible that
differences across studies reflect variations in sensitivity of measure-
ment techniques and in the measures used.

Cigarette smokers may be pretreated with nicotine by giving them
nicotine polacrilex gum to chew. The gum is available in similar
tasting nicotine dose levels of 2 or 4 mg/piece. A similar tasting
placebo preparation with no nicotine is also available. (In the United
States, the placebo and 4-mg dose are only available for research.)
With various combinations of nicotine gum doses it is possible to
provide a wide range of dose levels. In one study, the chewing of
nicotine polacrilex gum produced a dose-related (dose range = 0 to 8
mg nicotine) decrease in cigarette consumption during subsequent
90-min cigarette smoking sessions: Total puffs, total cigarettes, and
expired-air CO levels were inversely related to nicotine dose; desire
to smoke was also inversely related to dose but this effect varied
considerably and was not statistically reliable (Nemeth-Coslett et al.
1987). Comparable findings have been obtained in several other
studies, although dose manipulations were not as extensive as in the
former study (Kozlowski, Jarvik, Gritz 1975; Nemeth-Coslett and
Henningfield 1986; Brantmark, Ohlin, Westling 1973; Russell et al.
1976; Herning, Jones, Fischman 1985). Another study showed that
nicotine given in capsule form also reduced subsequent cigarette
smoking (Jarvik, Glick, Nakamura 19701, although the low dose and
poor systemic absorption of nicotine given by this route (see Chapter
II) required that much higher dose levels be given (10 mg).

Two studies have also demonstrated that intravenous (i.v.1 admin-
istration of nicotine decreases cigarette smoking (Lucchesi, Schuster,
Emley 1967; Henningfield, Miyasato, Jasinski 1983). Another study
found no change in smoking following iv. nicotine infusions (Kumar

165


et al. 1977); however, the dose (equivalent to about 1.7 mg, given in
10 divided doses over 10 min) was probably inadequate, as suggested
by results of other studies (Nemeth-Coslett et al. 1987). The finding
that even i.v.-delivered nicotine can reduce subsequent cigarette
smoking confirms that neither the tobacco vehicle nor the
oral/respiratory route is necessary for nicotine to control behavior.
The overall consistency of findings using a variety of forms of
nicotine pretreatment is evidence for a specific effect of nicotine as a
determinant of cigarette smoking.

Nicotine Antagonist Pretreatments

Another way to evaluate the specific role of nicotine as a
determinant of rate and pattern of cigarette smoking is to adminis-
ter drugs that block the effects of nicotine on the nervous system.
Nicotine antagonists (ganglionic blockers) are available as drugs
(e.g., pentolinium and hexamethoniuml that do not readily enter the
brain but are active in the peripheral nervous system, and as drugs
(e.g., mecamylamine) that do enter the brain and thus work in both
the peripheral and central nervous system (CNS) (Taylor 1985b). In
theory, such drug administ,ration should produce effects that are
analogous to those that would be expected if the nicotine dose of
cigarettes was decreased: that is, smoke intake should increase.
Moreover, if smoke intake increases, but only when the centrally
acting antagonist is given, such data would suggest the critical
involvement of the effects of nicotine in the brain.

Three studies showed that pretreatment of smokers with mecamyl-
amine produced increases in cigarette smoking that resembled those
expected if the nicotine dose of the cigarettes had been decreased
(Stolerman et al. 1973; Nemeth-Coslett et al. 1986a; Pomerleau,
Pomerleau, Majchrzak 1987). In each of these studies, the short-term
effect of the nicotine antagonists was studied. Similarly, mecamyl-
amine pretreatment increased the preference for high nicotine-yield
cigarette smoke (apparently by reducing its nicotinic effects) when
subjects were tested with a device which blends smoke from high and
low nicotine-yield cigarettes (Rose, Sampson, Henningfield 1985).
The role of nicotine action in the brain was demonstrated in the
study by Stolerman and colleagues (1973) in which a nicotine blocker
(pentolinium) that does not readily enter the brain produced no
effects on cigarette smoking.

Effects of Nonnicotinic Drugs on Cigarette Smoking

In addition to nicotine and nicotine antagonists, the effects of
other psychoactive drugs on cigarette smoking have been studied in
the laboratory. Such studies are important insofar as they constitute
drug-interaction studies whereby it may be determined if the

166


behavioral and physiological actions of nicotine are altered as a
function of pretreatment with other drugs. In addition, studies of
interactions of nicotine with other dependence-producing drugs are
important because tobacco use generally precedes and accompanies
use of many other dependence-producing drugs (Chapter V). Several
classes of psychoactive drugs have been administered in studies in
which cigarette smoking was specifically measured. In general, the
results permit a categorization of these drugs into two groups: (1)
those drugs that produce increases in smoking under standard test
conditions, and (2) those drugs that produce little reliable effect on
cigarette smoking under standard test conditions.

Sedatives, opioid agonists, and psychomotor stimulants have been
shown capable of producing robust and dose-related increases in
cigarette smoking. Specifically, alcohol (ethanol) has been shown t.o
increase cigarette smoke intake (Griffiths, Bigelow, Liebson 1976;
Henningfield, Chait, Griffiths 1984; Nil, Buzzi, Battig 1984; Mintz et
al. 1985; Mello et al. 198Ob). In a study in which alcohol was found to
increase smoking in all of five alcoholic subjects tested, pentobarbital
(a depressant) was found to increase smoking in the two subjects
with extensive histories of barbiturate use (Henningfield, Chait,
Griffiths 1984). The effects of alcohol and pentobarbital were most
robust in heavier drinkers and alcoholics (Henningfield, Chait.
Griffiths 1983, 1984). The opioid agonists, heroin and methadone,
increase cigarette smoking in opioid users (Mello et al. 1980a; Chait
and Griffiths 1984). Methadone produced dose-related increases in
number of cigarettes and puffs, and in puff duration in methadone-
maintained smokers (Chait and Griffiths 1984). Analogously, num-
ber of cigarettes smoked per day gradually decreased as methadone-
maintained clients had their daily methadone doses decreased over
several weeks (Bigelow et al. 1981). Finally, the psychomotor
stimulant d-amphetamine increases a variety of measures of ciga-
rette smoking (Henningfield and Griffiths 1981; Chait and Griffiths
1983).
Three other drugs have been studied and found to produce little
reliable effect on cigarette smoking. Caffeine is of interest because it
might be predicted to either increase smoking by its general
stimulant (amphetamine-like) effects (Rall 1985) or to decrease
smoking by serving as a substitute for some of nicotine's stimulant
effects (Kozlowski 1976). Laboratory studies, however, have found
the effects of caffeine administration on cigarette smoking to be
weak and inconsistent: two studies showed no reliable effect (Chait
and Griffiths 1983; Nil, Buzzi, Battig 1984), another showed weak
decreases in smoking (Kozlowski 1976), and a fourth showed weak
increases in smoking following caffeine administration (Ossip and
Epstein 19811.

167


The opioid antagonist naloxone (naloxone blocks effects of heroin-
like opioids) is another drug of interest because of the possible role of
endogenous opioids as mediators of some of the effects of nicotine
(Chapter III: Pomerleau and Pomerleau 1984). In a test paradigm in
which several drugs have been shown to produce orderly effects on
cigarette smoking (Griffiths and Henningfield 1982), naloxone
produced no consistent changes in cigarette smoking over a wide
range of dose levels (Nemeth-Coslett and Griffiths 1986). Another
study of the effect of naloxone which employed a single dose found a
reduction in smoking (Karras and Kane 1980). No clear reconcilia-
tion of these disparate findings is evident. Finally, marijuana
pretreatment was found to produce no reliable effect on tobacco
intake (Mello et al. 1980b; Nemeth-Coslett et al. 1986b) or on the way
cigarettes were smoked (Nemeth-Coslett et al. 1986b).

Effects of Nonnicotine Constituents of Tobacco Smoke and
Citric Acid Aerosol

Chemicals presumed to act primarily in the respiratory tract and
not in the central nervous system may also affect smoking. The
region of the trachea just below the larynx is assumed to be a site of
some cigarette smoke related sensations (Cain 1980). This site
corresponds to the region 2 cm below the narrow opening of the
larynx where particles entering the trachea change direction (Chan
and Schreck 1980).

The components of cigarette tar and volatile gases in smoke
contribute to the taste, olfactory, and tracheobronchial sensations
elicited by cigarette smoke. In fact, minimal levels of tar are held by
tobacco manufacturers to be important to maintain product satisfac-
tion in smokers (Tobacco Reporter 1985; Gori 1980). Besides its
causal role in lung cancer and other diseases (US DHHS 1982, 1983,
1984), tar may function to mask the harshness and irritation of
nicotine (Herskovic, Rose, Jarvik 1986). Consistent with this hypoth-
esis, nicotine aerosols delivering doses of nicotine similar to those in
mainstream cigarette smoke are rated as extremely harsh and
irritating by cigaret,te smokers (Russell 1986). Similarly, some
gaseous components of smoke, such as acrolein and formaldehyde,
are irritating and could also contribute to the tracheobronchial
sensations elicited by smoke (Lundberg et al. 1983).

Levels of tar and other constituents may also contribute to brand
preference and, conversely, to the difficulty in finding readily
acceptable substitutes for the cigarettes normally smoked by individ-
uals. For example, a nonmentholated cigarette may not be a
desirable substitute for a mentholated one. Moreover, when given
cigarettes made of lettuce or cocoa leaves, smokers complain about
the unpleasant smell and taste (Goldfarb, Jarvik, Glick 1970;
Herskovic, Rose, Jarvik 1986). Tobacco research cigarettes are often

168


found to be less palatable than commercial brands (Benowitz, Kuyt,
Jacob 1982), indicating the importance of specific tobacco blends
and/or additives in determining taste and brand preferences.

The precise nature of the sensations critical to smoking satisfac-
tion has not been elucidated, and the relative roles of taste, olfaction,
and tracheobronchial sensations are not clear. One way to assess the
importance of local respiratory sensations in the subjective response
to cigarette smoke is to block these sensations with a short-acting
topical anesthetic. Two studies have used inhalation of a 4-percent
lidocaine aerosol and mouth rinses and gargling with lidocaine
solutions to assess the importance of airway sensations to cigarette
smokers (Rose et al. 1984, 1985). In both studies, the desirability of
puffs was decreased by local anesthesia of the respiratory tract.
Additionally, the decline in reported craving for cigarettes that
usually occurs after smoking was diminished by local anesthesia.

A study was also conducted in which smokers inhaled a refined
tobacco smoke condensate (Rose and Behm, in press). The condensate
produced a low overall nicotine yield (about 0.2 mg,`lO puffs), while
maintaining a higher ratio of nicotine to tar and a larger particle
size than that of conventional cigarette smoke. Smoke generated in
this fashion was rated as stronger and harsher than smoke of
equivalent nicotine content delivered by smoking a conventional
low-tar and low-nicotine cigarette (Rose and Behm 1987). The
subjects also reported significantly greater satisfaction and dimin-
ished desire to smoke additional cigarettes after inhaling puffs of
refined smoke compared with conventional low-nicotine cigarette
smoke (Rose and Behm 1987). These studies demonstrate that local
sensory effects of smoke may influence the short-term subjective
responses to smoking.

The inhalation of aerosols containing citric acid is a standard
method of eliciting coughing in human subjects (Pounsford and
Saunders 1985). One study found that smokers inhaling puffs of a
nebulized 15 percent aqueous solution of citric acid reported
sensations of strength and harshness comparable to those produced
by their own cigarette brand and considerably stronger than those
elicited by an "ultra" low-tar, low-nicotine cigarette (Rose and
Hickman 1987). Moreover, some pleasure was reported to be
associated with these sensations, and desire for cigarettes was
decreased, suggesting that mild irritation of the respiratory airways
may be involved in satiation of smoking behavior and may have a
role in smoking cessation efforts (Henningfield 1987c; Chapter VII).

Nicotine: Psychoactivity, ReinforcIng and Related Behavioral
Mechanisms of Nicotine Dependence
As the preceding sections have shown, cigarette smoking is an
orderly behavioral and pharmacologic process clearly involving

169


maintenance of the desired levels of nicotine in the body. These data
are sufficient to label tobacco use as a form of drug self-administra-
tion in which the role of nicotine in controlling tobacco self-
administration functions as do morphine, ethanol, and cocaine in the
use of opium-derived products, alcoholic beverages, and coca-derived
products, respectively. However, the question may be asked whether
the behavior-controlling pharmacologic properties of nicotine are
similar to those of prototypic dependence-producing drugs when
evaluated in standard laboratory tests. More specifically, the scien-
tific question is whether nicotine itself shares critical dependence-
producing properties with drugs such as morphine, cocaine, and
alcohol. Standardized testing procedures can be used in both animal
and human studies to objectively determine if a drug is dependence
producing. These procedures, as well as a review of how addicting
drugs control behavior, is presented in Chapter V. Chapter V also
presents data obtained when drugs such as morphine, cocaine, and
alcohol are tested by identical procedures.

In brief, four general kinds of behavior-modifying drug effects can
be differentiated on the basis of the test procedure used. These drug
effects are discussed in Chapter V and include the following: (1)
Drugs may produce interoceptive stimulus effects; that is, they can
produce effects that a person or animal can distinguish from the
nondrug state. Although not identical in meaning, the following
terms are often used to designate interoceptive drug effects: "psy-
choactive, " "discriminative," "subjective," "self-reported." (2) Drugs
may serve as positive reinforcers or rewards, the presentation of
which produces repetition and strengthening of the behaviors which
led to their presentation, i.e., "drug self-administration" or "drug
seeking." (3) Drugs can serve as unconditioned stimuli, in which case
they may directly elicit various responses; these responses may
subsequently be elicited by stimuli which are associated with the
drug (i.e., conditioned stimuli), including the presence of environ-
mental, or even internal, cues. (4) Drug administration or abstinence
can also function as "punishers" or aversive stimuli.

This Section will present data from studies of nicotine with each of
the four testing procedures mentioned above. The convergence of
findings from several distinct approaches provides compelling evi-
dence that nicotine is a drug that can effectively control behavior,
including behavior leading to its own ingestion (i.e., dependence or
addiction).

Interoceptive, Discriminative, and Subjective Effects of
Nicotine

Ingested chemicals can serve as stimuli by actions on either
peripheral or centrally located receptors or by indirect effects
mediated through the release of various biochemicals or neurohor-

170


mones. In general, the term "psychoactive" is reserved for those
drugs whose discriminative effects are known to result from their
actions in the brain. As described by Lewin (1931) and others
(Thompson and Unna 1977) it is, in part, the nature of the
discriminative stimulus effects of a drug within the body that sets
the dependence-producing drugs apart from other non-nutritive
substances. As shown in Chapter II, all commonly used forms of
tobacco are effective means of delivering nicotine to the blood from
which it is rapidly transported to the brain. Research with animals
has shown that nicotine produces distinct effects in the central
nervous system (CNS). In addition, nicotine has diverse peripheral
and hormonal actions that could serve to intensify its CNS stimulus
properties. The biochemical mechanisms of these effects are discuss-
ed in Chapter III.

Three procedurally distinct methods have been used to character-
ize the stimulus properties of nicotine and will be discussed in the
following sequence: (1) discrimination testing in animals and hu-
mans, (2) assessing subjective effects in humans, and (3) testing for
state-dependent learning effects in humans. Each method has been
used to help characterize the stimulus properties of a variety of
drugs including nicotine (Chapter V).

Drug Discrimination Testing in Animals

Animal studies of nicotine discrimination show that nicotine
produces reliable effects that are readily identified by the subjects.
Such studies indicate that fundamental biobehavioral mechanisms
mediate the psychoactive properties of nicotine in humans, and that
such effects are not unique to human psychological processes. These
data also have implications for understanding and treating tobacco
dependence and are summarized below.

Specificity of the Nicotine Stimulus

Although dependence-producing drugs may overlap, to some
degree, in the nature of their effects on mood and feeling, each drug
class and sometimes drugs within *a class produce unique effects. As
this Section shows, nicotine also produces some effects that permit it
to be distinguished from most other psychoactive drugs. These
studies are also useful for testing new drugs that are thought to
produce nicotine-like effects.

Rats can learn to accurately discriminate nicotine from placebo
regardless of the route of administration as long as the nicotine
reaches the brain. Most researchers have utilized the subcutaneous
(s.c.) route of administration iRosecrans and Meltzer 1981); however,
more recent studies have incorporated other routes of nicotine
administration and have found that rats could learn to discriminate

171


nicotine when given nicotine by gavage (oral tube) in a dose of 0.5
mg/kg (Howard and Craft 1987). Oral nicotine-trained rats general-
ized to nicotine administered via either the S.C. or transdermal
routes (nicotine solution was applied to a 1.5cm circular area on the
shaved back of the rat). There was little difference in dose potency
between the oral and S.C. routes; however, the transdermal route was
much less potent and required eight times the oral dose to establish
equivalent response patterns. Taken together, the results of these
studies showed that nicotine given by a variety of routes produces
time- and dose-related discriminative effects.

Several studies have compared nicotine with a variety of drugs by
these drug discrimination testing procedures (Rosecrans and Meltzer
1981; Stolerman et al. 1987). Early research involved testing a wide
variety of chemicals. These studies showed that nicotine-trained rats
did not generalize to drugs of other classes such as the opioids,
barbiturates, or hallucinogens (Rosecrans and Meltzer 1981). Of
special interest was the prototypical stimulant d-amphetamine,
because nicotine also has a variety of stimulant-like actions (Rall
1985). When nicotine-trained rats were tested with amphetamine,
however, they only partially generalized to nicotine. In another
study, Schechter (1981) observed higher levels of amphetamine
generalization to nicotine in a group of rats trained to discriminate
amphetamine from pentobarbital. Thus, nicotine may have some
amphetamine-like effects which are unmasked under certain condi-
tions.

Oxotremorine and arecoline are agonists of the cholinergic ner-
vous system, but these drugs activate muscarinic, and not nicotinic,
cholinergic receptors (Gilman et al. 1985). Consistent with the
mechanisms of action of these cholinergic drugs are the findings that
neither oxotremorine nor arecoline generalized to nicotine in
nicotine-trained animals (Rosecrans and Meltzer 1981).

Nicotine analogs and metabolites have also been studied with the
discrimination paradigm (Rosecrans and Chance 1977; Stolerman et
al. 1987). Such research can help reveal the extent, if any, of the role
of these nicotine-related or nicotine-derived chemicals in determin-
ing the nature of the discriminative effects that follow nicotine
administration. In rats trained to discriminate 100 pgf kg of nicotine,
the analogs cytisine and anabasine generalized to nicotine. The
alkaloid nornicotine generalized partially to nicotine. Cotinine, the
major metabolite of nicotine, was observed to generalize to nicotine
only when the cotinine was given intraventricularly in relatively
high doses to rats trained to discriminate relatively low dose levels
(100 pg/kg) of nicotine. These data show that although metabolites of
nicotine may share some stimulus properties with nicotine, the
degree of generalization is weak, suggesting that the discriminative

172


stimulus effects of nicotine are mainly due to nicotine itself and not
to the metabolites.

Synthetic analogs of nicotine have also been evaluated for their
possible nicotine-like properties in discrimination studies (Rose-
crans, Kallman, Glennon 1978; Rosecrans et al. 1978). Of the several
compounds tested, only one, 3-methyl-pyridylpyrollidine, a chemical
isomer of nicotine, was observed to generalize to the nicotine
stimulus in nicotine-trained rats. This compound was observed to be
8 to 10 times less potent than nicotine. Its effects were significantly
antagonized (reduced or blocked) by mecamylamine, which also
antagonizes the stimulus generated by both S- and R-nicotine; the
naturally occurring tobacco constituent, S-nicotine, is also 8 to 10
times more potent as a stimulus than R-nicotine. The results of
these investigations indicate that the stimulus properties of nicotine
are highly specific.

A finding relevant to pharmacologic treatment efforts (see Chap-
ter VII) involved discrimination studies with lobeline (a constituent
in several over-the-counter aids for quitting smoking). Lobeline is an
alkaloid with some nicotine-like ganglionic effects in the peripheral
nervous system (Gilman et al. 1985). Rosecrans and Chance (1977)
found that lobeline was neither discriminated as nicotine nor did it
block nicotine discrimination in nicotine-trained rats. These results
do not support the use of lobeline-containing compounds as treat-
ment aids for cigarette smoking (see also Schwartz 1987; Chapter
VII).

Peripheral Versus Central Discriminative Stimulus Effects of
Nicotine

The degree to which the stimulus is generated via peripheral
rather than central nervous system (CNS or brain) actions is also
important in understanding the nature of the nicotine stimulus. As
discussed in Chapter III, nicotine has many peripheral autonomic
nervous system CANS) effects which might feed back to the CNS,
thereby indirectly generating or contributing to stimulus effects.
Thus, changes in blood pressure, heart rate, body temperature, and
hormone release could be potential mediators of the effects. Several
approaches have been utilized to address the role of peripheral
actions of nicotine in the generation of the discriminative stimulus.
One approach is to attempt to block nicotine with an antagonist not
able to enter the CNS.

In one study, animals were trained to discriminate a dose of
nicotine (Rosecrans and Chance 19771. Then they were pretreated
with a series of nicotinic cholinergic antagonists and with muscarin-
ic cholinergic antagonists. After pretreatment with an antagonist,
the animals were retested with the training dose of nicotine.
Mecamylamine, a centrally and peripherally acting nicotine antago-

173


nist, was the only drug observed to completely block the nicotine
stimulus. As the dose of this antagonist was increased, percent
correct responses on the nicotine-correct lever, after the injection of
200 or 400 pg/kg of nicotine, decreased to placebo response levels,
indicating a complete antagonism of the nicotine stimulus. In a
similar study, Stolerman, Pratt, and Garcha (1982) increased the
nicotine dose in an attempt to overcome the actions of mecamyla-
mine: the blockade was not overcome by any dose of nicotine. Thus,
these data suggest that mecamylamine is not a competitive antago-
nist (blocking at the receptor itself) but rather may functionally
antagonize nicotine's effects through another mechanism (Stolerman
et al. 1987).

In other studies, a 331 ug/kg dose of mecamylamine antagonized
the stimulus effects of 200 pg/kg of nicotine, while 835 ug/kg was
required for similar antagonism of the 400 ug/kg dose of nicotine
(Rosecrans and Meltzer 1981). All such studies found that the
peripherally acting nicotinic antagonist, hexamethonium, did not
affect nicotine discriminations. The muscarinic antagonist, atropine,
was also without effect. The possible relationships of the nicotine
stimulus to brain norepinephrine and 5-hydroxytryptamine (seroto-
nin or 5-HT) systems were also investigated through the use of the
appropriate antagonists/agonists. Similarly, a quaternary analog of
nicotine, which does not enter the brain, was evaluated and found to
produce no evidence of generalization in nicotine-trained rats
(Rosecrans et al. 1978). Such studies do not support the involvement
of peripheral systems in the generation of the nicotine stimulus.

Another strategy used to investigate the central nature of the
nicotine stimulus compared concentrations of nicotine in the brain
with the resulting stimulus effects of nicotine (Rosecrans and Chance
1977). It was assumed that if nicotine's stimulus effects are mediated
in the brain, then such effects should be related to brain levels of
nicotine. This hypothesis was confirmed. In fact, it was found that
before nicotine functions as a stimulus, it must achieve a minimal
drug level in the brain. In addition to relating drug level in the brain
to the stimulus effect induced by nicotine, Rosecrans and Chance
(1977) showed that systemically administered :lico%ine generalized to
nicotine administered intraventricularly. Taken together, the fore-
going studies show that the nicotine-generated discriminative stimu-
lus is dependent on the actions of nicotine at central nicotine
receptors in the brain.

Drug discrimination research has also examined the stimulus
properties of the muscarinic cholinergic agonist, arecoline. Arecoline
is a constituent of the betel nut mixtures commonly chewed in the
East Indies (Taylor 1985al. Three approaches have been utilized to
investigate the stimulus properties of arecoline. In the first study,
arecoline served as a discriminative stimulus and thereby assumed

174


control of behavior (Rosecrans and Meltzer 19811. These effects of
arecoline were blocked by pretreatment with the muscarinic antago-
nist, atropine, while the quaternary compound, methyl atropine
(which does not readily cross the blood-brain barrier), was ineffec-
tive. These results indicate that the stimulus can also be exerted via
muscarinic stimulation and confirm that the discriminative stimulus
properties of muscarinic agonists. like those of nicotinic agonists, are
centrally mediated. Additional studies indicated that mecamylamine
was not able to antagonize the stimulus effects of arecoline (Rose-
crans and Meltzer 1981). Finally, it was found ihat rats could be
trained to discriminate between the muscarinic and nicotinic
agonists, arecoline and nicotine. Thus, there appear to be two
independent central cholinergic recept,or systems (muscarinic and
nicotinic), each of which can exert stimulus control over behavior
when appropriately stimulated. These findings have been confirmed
by Stolerman and colleagues (1987).

Interactions with Noncholinergic Neurons

In a preliminary study (Takada et al., 1988) two nic;)tine-trained
squirrel monkeys recognized beta-carboline as nicotine. Beta-carbo-
line induces symptoms resembling anxiety in animals; these symp-
toms can be reduced by administration of the anxiolytic, diazepam
(Shephard 1986). In addition to this observation, Colpaert (19771
reported that nicotine can antagonize the diazepam cue, and Heath,
Porter, and Rosecrans (1985) noted that nicotine antagonized the
effects of diazepam on punished responding in rats. Mecamylamine
was also found to attenuate the nicotine-induced antagonism of
diazepam's antianxiety effect. Harris and coworkers (1986) found
that metrazol (a convulsant) partially generalized (35 percent) to
nicotine when tested in the discrimination paradigm in nicotine-
trained animals. A greater degree of generalization of the metrazol
cue to nicotine (50 percent) was observed 48 hr after the cessation of
a 21-day chronic nicotine regimen in rats trained to discriminate
metrazol (5 mg/kg) from saline; these generalizations were not
antagonized by mecamylamine. Harris and colleagues (1986) suggest-
ed that the generalization of metrazol to nicotine was a function of a
nicotine abstinence-induced withdrawal syndrome resembling anxie-
ty. These studies suggest that nicotine may act, at central receptors
capable of eliciting a stimulus cluster which induces anxiety
(Chapter III).

Subjective Effects of Nicotine in Humans
The extensive amount of nicotine discrimination research using a
variety of animal species and several routes of administration
confirms that nicotine is a potent drug that can induce alterations in

175


nervous system function that are distinct and readily identifiable. In
addition, the similar findings observed in studies using different
routes of nicotine administration are consistent with the hypothesis
that the tobacco vehicle is not necessary to produce nicotine-associ-
ated changes of mood and feeling. The next Section examines data
from analogous studies in which humans served as research subjects.

Psychoactivity of Nicotine

The animal research described above indicates that nicotine's
psychoactivity is a result of basic biological actions. Human research
on nicotine corroborates the validity of the animal research. Results
from studies of the interoceptive effects of nicotine in humans are
analogous to those obtained in animal studies described above.

One of the first human studies that used drug discrimination
procedures, as had been developed with animal subjects, was a study
of nicotine discrimination. The study involved the systematic
manipulation of nicotine dose levels with research cigarettes which
varied primarily in the amount of nicotine delivered (Kallman et al.
1982). This study demonstrated that nicotine, as delivered by the
inhalation of tobacco smoke, produces discriminative stimulus
effects. The degree and rate of acquisition of the discrimination
appeared to be dose dependent. The ability of the subjects to make
the discriminations did not appear to be related to either autonomic
(e.g., heart rate) effects of nicotine or to nicotine's effects on other
self-reported measures (e.g., taste of the cigarette).

The data from Kallman and associates (1982) are consistent with
those of several other studies which have found that human
volunteers can differentiate among cigarettes which vary mainly in
the amount of nicotine which they deliver (Goldfarb, Jarvik, Glick
1970; Goldfarb et al. 19'76; Herskovic, Rose, Jarvik 1986; Rose 1984;
Griffiths, Bigelow, Henningfield 1980; Henningfield, Miyasato, John-
son, Jasinski 1985). Furthermore, the conclusion that centrally
mediated effects of nicotine are important in such responsivity is
supported by findings that pretreatment with mecamylamine re-
duced responsivity to nicotine dose levels of the cigarette (Stolerman
et al. 1973; Nemeth-Coslett et al. 1986a; Pomerleau et al. 1987). The
study by Stolerman and associates (1973) also showed that such
antagonism of nicotine's effects was not obtained when peripherally
acting pentolinium was given.

Other research has confirmed that the tobacco vehicle is not
necessary to enable the interoceptive effects of nicotine. Several
studies involving i.v. administration of nicotine in human subjects
have found that humans readily differentiate among nicotine dose
levels given intravenously. In the earliest of these studies, i.v.
injections of nicotine were given to 35 volunteers, most of whom
were cigarette smokers (Johnston 1942). The conclusions of Johnston

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TABLE 3.-Summary of early observations regarding
      psychoactivity of intravenously delivered
       nicotine in humans

1.

"Psychic" effects are directly related to nicotine dose; nonsmokers are
much more sensitive to toxic symptoms ieg., nausea) than smokers

2.

Effect of nicotine is "specific and readily distinguished from that of
cocaine or codeine"'

3.

Nicotine injections are "pleasant" to smokers, and are preferred by some
over cigarette smoking

4.

Orally given nicotine (dissolved in water) also had "psychic" action. but
appeared much less potent than intravenously administered nicotine:
delayed onset of effect

5. - l-3 mg doses appeared tolerable and equivalent to smoking single
   cigarette; - 0.11 mg doses appeared to produce "subjective sensation"
   equivalent to one "deep" cigarette smoke inhalation

`More recent research indm&s that higher dose levels of mcotine can produce cocainelike effects
(Henning&Id. Miyasato. Jasinski 1985).
SOURCE: Johnston (1942).

that are especially relevant to characterization of the psychoactivity
of nicotine are shown in Table 3.

Johnston's findings (Table 3) have been generally confirmed.
Jones, Farrell, and Herning (1978) and Rosenberg and colleagues
(1980) also found that human volunteers could differentiate i.v.
nicotine at dose levels similar to those obtained by smoking
cigarettes. In another study which extended the findings of Johnston
(1942), both i.v. nicotine and nicotine inhaled from research ciga-
rettes across a range of doses were administered to human volun-
teers with histories of using a variety of dependence-producing drugs
(Henningfield, Miyasato, Jasinski 1985). Subjects clearly distin-
guished nicotine from a placebo, and the dose strength estimates
were directly related to the nicotine dose level. A subsequent study
showed that the immediate subjective effects of nicotine were
diminished by pretreatment of subjects with mecamylamine (Hen-
ningfield et al. 1983).

In a study by Henningfield, Miyasato, Jasinski (1985), measures
used to qualitatively describe the nature of the drug stimulus
indicated that nicotine met criteria as a euphoriant. At higher doses
nicotine was sometimes identified as a stimulant (cocaine or
amphetamine); it elevated scores on the Morphine Benzedrine Group
("Euphoria" or "MBG") scale of the Addiction Research Center
Inventory (ARCI) (Haertzen and Hickey 1987); and it produced dose-
related increases in scores on a drug-liking scale. The high-dose
cocaine/amphetamine identifications found in the study by Hen-
ningfield, Miyasato, and Jasinski (1985) were not observed by

177


Johnston, but such similarities between nicotine and cocaine may
only be clearly identifiable by subjects experienced with both cocaine
and nicotine.

Nicotine given in the polacrilex gum form has been evaluated with
similar measures as described above. These studies involved giving
various combinations of 2-mg- and 4-mg-nicotine pieces of polacrilex
gum and placebo to cigarette smokers. Human volunteers were given
the polacrilex gum to chew in doses ranging from 0 to 4 mg in one
study [~Nemeth-Coslett and Henningfield 1986) and 0 to 8 mg in
another study (Nemeth-Coslett et al. 1987). Both studies showed that
subject ratings of several effects (including "dose strength") were
directly related to the total dose of nicotine that was given. In
addition, similarity of the stimulus effects to those produced by
cigarettes was a direct function of dose level. In these studies
"liking" or "positive" effect scores were inversely related to dose
level, suggesting that this nicotine delivery system has low potential
for causing dependence when compared with that of cigarettes
(Chapter VII). The role of centrally mediated nicotinic actions in the
ability of humans to differentiate among polacrilex gum-delivered
nicotine doses was confirmed in a study by Pickworth, Herning, and
Henningfield (in press). These researchers found that mecamyla-
mine pretreatment of human volunteers reduced both the EEG and
subjective effects of nicotine polacrilex gum administration.

Like many other psychoactive drugs (Chapter V), nicotine can also
produce unpleasant or dysphoric subjective effects that are related to
the dose given and the route of administration. Such effects can be
quantified by a psychological scale of the ARCI that is sometimes
referred to as the "dysphoria" scale (Jasinski, Johnson, Henningfield
1984) or the "LSD" scale because ii: was constructed from items
found to be elevated when lysergic acid diethylamide (LSD) was
given to volunteers (Haertzen 1966, 1974).

In one study, Henningfield, Miyasato, and Jasinski (1985) found
that both inhaled (research cigarette smoke) and i.v. nicotine
produced dose-related increases in LSD scale scores. In two other
studies, nicotine polacrilex gum was tested (Nemeth-Coslett and
Henningfield 1986; Nemeth-Coslett et al. 1987). LSD scale scores
were at least slightly increased in both studies and were significantly
increased in the study by Nemeth-Coslett and Henningfield (1986).
These results with nicotine polacrilex gum, combined with no
increases in MBG scale scores, are consistent with the observations
described earlier suggesting a low overall dependence potential for
this formulation.

Sensory Effects of Nicotine

As discussed earlier in this Chapter, nonnicotine constituents of
tobacco smoke can produce functional sensory effects. Nicotine, too,

178


can produce peripherally mediated sensory effects which could
contribute to the taste of the cigarette. Although not generally
termed "psychoactive" drug effects, such effects could contribute to
the control over behavior as they provide discrete cues which may be
associated with centrally mediated nicotinic effects. For example,
nicotine has a bitter taste, elicits burning sensations when placed on
the tongue, and is irritating to the oral and respiratory mucosa
(Windholz et al. 1976). Increasing the nicotine delivery of cigarettes
while holding tar delivery constant leads to an increase in perceived
strength and harshness. The possible effects of nicotine in the upper
respiratory tract on subject ratings cannot be excluded in these
studies. Nicotine also stimulates mechanoreceptors sensitive to
pressure and stretch (Taylor 1985b), and this local action of nicotine
may also contribute to the sensory characteristics of inhaled
cigarette smoke.

Hexamethonium (the nicotine receptor antagonist that only acts
peripherally) has been shown to block cigarette smoke-induced
edema in the tracheobronchial mucosa of rats (Lundberg, Saria,
Martling 1982). Another study showed that mecamylamine produced
dose-related decreases in harshness ratings of individual puffs of
cigarette smoke (Rose, Sampson, Henningfield 1985). In this study,
subjects were asked to rate their preference at different nicotine
concentrations of the smoke: mecamylamine pretreatment shifted
preferences to higher smoke concentrations for individual puffs.

Another method of producing at least some of the nicotine-related
sensations of cigarette smoke is to present nicotine in vapor or
aerosol form without any components of tar. Nicotine vapor is likely
to be deposited mainly in the mouth and pharynx (Russell 1986);
thus it. would be difficult to administer a pharmacologically effective
dose of nicotine without producing excessive local irritation and bad
taste. However, a low dose of nicotine delivered in this fashion might
simulate the sensory effects of smoking, even if the pharmacologic
effects are minimal. A low-dose nicotine aerosol delivering droplets 1
to 5 pm in size would be expected to provide respiratory sensations
even more similar to cigarette smoking, as particles of this size
would impact mainly in the tracheobronchial region.

Three studies have evaluated the effects of a commercially
marketed nicotine vapor delivery system in human subjects. The
delivery system was a version of that originally described by
Jacobson, Jacobson, and Ray (1979); it was marketed as a "tobacco
product" through February 1987, when the Food and Drug Adminis-
tration (FDA) required verification of "safety and efficacy" for
continued marketing as a "nicotine delivery system" (see Chapter
VII). It consisted of a cigarette-size plastic tube with a nicotine-
containing polymer in the end distal from the user's mouth. It was
used by sucking air through the tube and inhaling in a manner

179


similar to that when smoking cigarettes. When the system was used
in this fashion, two studies found that plasma nicotine levels were
not significantly elevated (Sepkovic et al. 1986; Henningfield 1986b).
A third study found significant elevations in plasma nicotine
following use of the nicotine tube (Russell et al. 1987). However, in
the latter study subjects used what may be described as a heroic
puffing procedure: they were instructed to puff 1 nicotine tube 10
times, at intervals of 40 set; after a 4-min pause, subjects then
"puffed and inhaled as hard and as frequently as possible, continous-
ly for the next 20 min, with changes every 5 min to fresh cigarette
[nicotine tube]." Symptoms typical of those associated with higher
levels of nicotine administration were observed, i.e., dizziness,
lightheadedness, and in a few subjects, nausea (Russell et al. 1987).

In another study of the nicotine vapor inhaler, four tubes in which
none, one, two, or four contained nicotine (the others being denico-
tinized) were simultaneously puffed on by volunteers through a
specially designed cigarette holder (Henningfield 198613, 1987a). In
this study, despite the fact that measurable changes in plasma
nicotine levels did not occur, several responses often associated with
nicotine delivery were observed: (1) subject ratings of "harshness"
were directly related to dose (number of nicotine-containing tubes);
(2) post-puffing increases in heart rate occurred as a function of dose;
(3) subjective effects were directly related to dose; and (4) desire to
smoke tobacco cigarettes was inversely related to nicotine dose level.
Taken together, these results show than even with negligible
systemic levels, nicotine can induce feelings of satisfaction and can
reduce urges to smoke when it produces tobacco-like sensations of
throat burn and harshness (Chapter VII).

Some of the short-term satisfaction derived from inhaling nicotine
may explain the apparent short-term efficacy of the vapor inhaler in
reducing desire to smoke despite negligible plasma nicotine levels.
This is in contrast to findings obtained when nicotine is given either
intravenously or in the polacrilex gum (Henningfield, Miyasato,
Jasinski 1983; Nemeth-Coslett et al. 1987). Whether the effects of the
nicotine vapor inhaler are conditioned responses, peripheral nicotin-
ic actions, or both, it remains to be determined if such effects would
provide long-term efficacy as tobacco replacement in the nicotine-
dependent tobacco user (Chapter VII). Such effects may not be
satisfactory for long-term treatment (i.e., they may not satisfactorily
alleviate tobacco withdrawal), although they may prove important in
providing sources of pleasure and reduction of urges in people trying
to quit smoking (Henningfield 1987b).

State-Dependent Learning

The potential of nicotine to induce state-dependent learning
effects as well as how such effects are studied are discussed in

180


Chapter VI. In the present Section, findings are summarized in so far
as they are relevant to assessing the dependence potential of
nicotine. In brief, state-dependent learning refers to the phenome-
non whereby behavior learned in one set of cues or stimulus
conditions (context) is most reliably performed when subsequently
attempted in the same context and/or is adversely affected when
attempted in a novel context (Chapter VI). Psychoactive drugs can
produce state-dependent learning effects, apparently by providing a
recognizable context based on the interoceptive stimulus cues
provided by the drug (see also Chapter V). Several studies have
shown that nicotine exposure can lead to state-dependent learning
effects. For example, a series of studies conducted by Andersson and
colleagues (Andersson 1975; Andersson and Hockey 1977; Andersson
and Post 1974) and by others (Peters and McGee 1982; Warburton et
al. 1986) showed that nicotine exposure in the form of tobacco smoke
could induce state-dependent learning effects in humans. In a study
by Lowe (19851, nicotine's part in the state complex produced by
alcohol and nicotine together was also evaluated.

There are two implications of the above findings regarding the
dependence potential of nicotine. The first is that state-dependent
learning could contribute to the dependence potential of cigarettes,
in that optimal cognitive/behavioral performance may come to
depend upon the continued self-administration of tobacco. These
actions might also contribute to the strength of the reinforcing
effects of nicotine by producing effects on learning and/or perfor-
mance (see also Chapter VI).

Nicotine as a Positive Reinforcer

The primary biobehavioral mechanism by which dependence-pro-
ducing drugs maintain drug seeking is by functioning as positive
reinforcers (Thompson and Unna 1977; Thompson and Schuster
1968). That is, drugs can serve as stimuli that strengthen behavior
leading to their own presentation (Skinner 1953; Thompson and
Schuster 1968). As discussed in Chapter V, studies in the 1960s used
the drug self-administration techniques developed to study morphine
and other dependence-producing drugs in animals (Weeks 1962;
Thompson and Schuster 1964; Chapter V). In the first such study
with nicotine, Deneau and Inoki (1967) found that monkeys would
also self-administer nicotine intravenously. However, some investi-
gators considered these findings equivocal (Russell 1979; Griffiths,
Brady, Bradford 19791. In 1981, Goldberg, Spealman, and Goldberg
showed conclusively that nicotine itself could function as an
efficacious positive reinforcer for animals, although the range of
conditions under which it was effective was somewhat more limited
than for drugs such as cocaine and amphetamine. Analagous studies
with humans in the 1980s (e.g., Henningfield, Miyasato, Jasinski

181


1983) demonstrated that intravenously administered nicotine is a
reinforcer. The results leading to the foregoing conclusions are
summarized in the present Section.

Animal Studies of Nicotine as a Reinforcer

Whether a drug functions as a reinforcer can depend critically on
the dose of drug, the previous exposure of the subject to that or other
drugs, the behavioral history of the subject, and perhaps most
importantly, the immediate contingencies relating responses and
subsequent injections of drug (contingencies are often referred to as
schedules of reinforcement) (Barrett and Witkin 1986; Chapter V).
Nicotine differs from some dependence-producing drugs (e.g., co-
caine) (Griffiths, Brady, Bradford 1979) in that for animals, the
conditions under which it maintains high rates of self-administration
behavior appear to be more limited; however, there are other
dependence-producing drugs which also serve as reinforcers under a
fairly limited range of conditions (e.g., alcohol) (Mello 1973; Meisch
1977).

Table 4 (modified from Henningfield and Goldberg 1983b) is a
summary of the early studies that found i.v. nicotine injection to be
ineffective or marginally effective as a reinforcer as well as more
recent studies that conclusively demonstrated the capacity of
nicotine to function as a positive reinforcer. The studies listed in this
Table employed a variety of species (ranging from rats to human
volunteers), different types and parameters of drug injection sched-
ules, a variety of training histories, and a wide range of nicotine
doses. Much of the research has been reviewed in greater detail
elsewhere (Goldberg and Henningfield, 1988; Swedberg, Henning-
field, Goldberg, in press). The present Section only reviews some of
the more recent studies that have experimentally evaluated nic-
otine's reinforcing effects.

Until 1981, most experiments of nicotine self-administration
involved continuous reinforcement schedules in which each response
by an individual subject resulted in the iv. injection of nicotine
(Table 4). Under these continuous reinforcement schedules, (1) rates
of responding were very low, ranging from about 0.008 to 0.0005
responses/set in different studies; (2) changes in nicotine dose
produced only small and inconsistent changes in rates of responding;
(3) the differences in rates of responding maintained by nicotine
compared with saline were generally small; and (4) marked intersub-
ject differences in self-administration of nicotine were often report-
ed. In one series of studies (Lang et al. 1977; Singer, Simpson, Lang
1978; Latiff, Smith, Lang 1980; Smith and Lang 1980) a concurrent
schedule of periodic deliveries of food pellets to food-deprived rats
was found to increase rates of nicotine self-administration respond-
ing (Chapter V). The concurrent food reinforcement schedule ap-

182


TABLE 4.-Summary of reports in which nicotine was available under intravenous drug self-
     administration (S-A) procedures


Study               Species           Reinforcement schedule            Main findings                 Comments


Deneau and Inok!       Rhesus monkey     FR 1; several nicotine doses       Two monkeys initiated S-A;        Currently accepted reinforcIng
119671                             tested                 others requrcd priming         efficacy assessment criteria not
                                              procedure                    achieved

Clark                 Hooded rat      FR 1; several nicotine doses and      Nicotme a reinforcer relative to      No quantitative data
(19691                            salme tested                  saline                  (from study abstract)

Yanaglta           Rhesus monkey     Experiment 1: FR 1; several        Nicotme and caffeine not         (preliminary report, Yanagita et
119771                        mcotine, caffeme, and saline       reinforcers, compared with         al. (1974) studlesl
                            doses substituted for SPA          saline or SPA

                       Experiment 2. FR 1; several        Nicotine S-A rates stable in        No direct reinlarcmg efficacy
                         mcotme doses continuously       most subjects, but not clearly        test
                               available                   dose related

                       Experiment 3: PR procedures;      0.2 my/kg nicotine and lowest      Nicotine marginally remforcing
                           two nicotine doses, saline, and      cocaine dose (0.03 mg/kg)        compared with saline and higher
                            three cocame doses tested        maintained similar response         cocaine doses
                                           rates, which slightly exceeded
                                           rates maintained by salme
Lang, Latlff, McQueen,      Hooded rat      FR 1; nicotine and saline tested     In food-deprived (not food-sated)
Smger                       in food-sated and food-deprived      rata, nicotine a reinforcer.
119771                              rats                 compared with saline                  -___-
Singer. Simpson, Lang       Hooded rat      CONC ((FR 1:nicotineXF"I' 1        Food satiation decreased nicotine      Results similar to ethanol
( 19781                      min:food pellet)] in food-deprived     S-A rate. but nicotine a          testing results
                        rata; rats subsequently food-sated      reinforcer in both conditions


6   TABLE 4.-Continued

Study               Species

Reinforcement schedule

Main findings

Comments

Griffiths. Brady.
Bradford
t19791


Hansen, lvester. Moreton
(19791

Raboon






Albino rat

FR 160 followed bv 3-hr
timeout; several nicotine doses
and saline substituted for
cocaine

FR 1: several nicotme doses and
saline test-d

Number of nicotine
injections/day did not exceed
saline


Mecamylamine (centrally acting
antagonist), not pentolinium
(peripherally acting antagonist).
altered 5.4 behavior

Caffeine, rphedrlne. and rar~oub
other similarly tested stimulants
were reinforcers relative to
saline

Group data suggest nlcotme as
a reinforcer; no clear dose-effect
curve

Latlff. Smith. Lang
(19801



Smith and Lang
,1%401

llooded rat






Hooded rat

CONC [(FR 1:injectionHFT 1
min:food pellet)]; several nicotine
doses and saline tested


FR 1; one nicotine dose and
salme tested

Nicotine a reinforcer, relative to
saline; mild effects of urine pH
manipulations on S-A rate only
during initial nicotine exposure

Nicotine a reinforcer with and
without CONC food delivery
schedule in food-deprived. but
not food-sated, rats

SA rate mversely dose related
during initial nicotine S-A
behavior acquisition, not after
establishment

Goldberg, Spealman.
Goldberg
119811

Squirrel monkey

Second-order schedule FI 1 or 2
min (FR lfkstimulus). followed
by 3.min timeout; one nicotine
dose and saline tested

Nicotine maintained high rates
of respondmg; rates decreased
markedly when 11) saline
replaced nicotine, 12) brief
stimuli omitted, (3) subjects
mecamvlamine Dretreated

Demonstrated importance of
ancillary environmental strmuli
in maintaining high rates of
responding


TABLE I.-Continued

Study              Species

Reinforcement schedule

Mam findings

Comments

Dougherty, Miller, Todd,
Kostenbauder
11981)



Goldberg and Spealman
(1982)

Rhesus monkey






Squirrel monkey

FI 16 and second-order Fl 1 min
(FR 4:stimulusl; several nicotine
doses and saline tested



FI 5 min followed by 1-min
timeout: several nicotine and
cocaine doses and saline tested

Nicotine maintained higher S-A
rates than saline under Fl and
second-order schedules. but only
a marginally effective remforcer
when continuously available

Nicotine and cocaine
qualitatively similar reinforcers,
compared with saline; cocaine
maintained higher rates of
responding in 1 of 2 monkeys:
mecamylamine pretreatment
reduced nicotine SA rates

Establishing nicotine as
remforcer required several
months. using procedures that
estabhsh cocaine or codeine as
reinforcers in few days

Showed nicotine can be
punisher. sinular to electric
shock

Singer, Wallace, Hall
f 1982)

Long-Evans rat

CONC [(FR 1:nicotineXFT 1
min:fowI pellet)]; one nicotine
dose tested

Lower nicotine S-A rates in rat
group with &OHDA lesions in
nucleus accumbens than in
sham-lesions group

Range of Iwon-Inhibited
scheduled-induced behaviors
extended

Spealman and Goldberg
( 1982)

Squirrel monkey

Second-order FI 1, 2, or 5 min
(FR lOstimulus) and FI 5-min
schedules tested; several nicotine
and cocaine doses and saline
tested

Nicotine and cocaine maintained
similar rates of respondmg and
patterns; nicotine, not cocaine,
S-A decreased to saline-like
rates when mecamylamine
pretreated

Under b&h schedules. mcotmr
and cocaine reinforcing efficacy
comparable


TABLE I.-Continued

Study              Species

Reinforcement schedule

Main findings

Comments

Ator and Grlftiths
(19831

Baboon

Experiment 1: FR 2 followed by
15.sw timeout; several nicotine
doses, cocaine, and saline tested

Nicotine marginally reinforcing,
compared with saline across
narrow dose range

inverted U-shaped initial doss-
response curve; flat final curve
(earlier abstract, Ator and
Griffiths 11981)1

Experiment 2: FI 5 min followed
by 1-min timeout; several
nicotine and cocaine doses and
saline tested; FI duration varied
1-11 mm

Goldberg and
Hennmgfvzld
(1983a, b)

Human and
squirrel monkey

FR 10 followed by l-min
timeout; several nicotine doses
and saline tested

Nicotine maintamed higher
rates of responding than saline,
but much lower than cocaine or
food

Monkey and human patterns of
responding qualitatively similar;
nicotine injection number
exceeded saline injection number
in 3 of 4 of both humans and
monkevs

Nicotine and injections/session
responding rates httle changed
with varied FI duration

In both humans and monkeys,
evidence of nicotine having both
reinforcing and punishing effects
(from study abstracts)

Henningfield, Mlyasato,
Jasinski
(1983)

Human

FR 10 followed by I-min
timeout; several mcotine doses
and saline tested

Nicotine injection number
generally exceeded saline
injection number; nicotine
injection number inversely
related to nicotine dose; nicotine
suppressed postsession cigarette
smokine

Nicotine and intravenous
cocaine subjective effects similar;
nicotine had both reinforcing
effects and punishing effects


TABLE 4.-Continued

Reinforcement schedule

Main findmgs

Comments

R~sner and Goldberg
t lY831







Cox. Goldstein. Nelson
(19841





Prada and Goldberg
119851






Slifer and Baister
IlYX51

Eieagle dog      FR 15 followed by 4.min
             timeout; several nicolme.
             cocaine, and salme doses tested:
              PR schedule also used




W1star rat       FR 1; several nicotme doses and
             saline tested; a second inact;vr
              lever available to assebs
           nonspecific acti\,ity-incfeasiny
               nicotine effects
      __.-__
Squirrel monkey     FR 30 followed by 4.mm or lo-
             set timeout: one nicotme dose
               tested



Rhesus monkey     Experiment 1: FR 1 and CON`C
            [iFR 1:nicotineNlT 5.min:food
            pellet)]; several nicotine doses
              and saline tested

Nicotme and coca~nr maintamed
qualitatively similar patterns "I
responding and WWP rrlnforcers
relative 1" sahne. mecnmylamine
pretreatment reduced nwtiw.
not coci~lne. S-A

Nicotinv S-A rates higher than
salme. but result m part of
nonspecific activit) ~nc~wst+


        ___--
AL 4.min tImeout. "vwali
nicotine-maintained response
rate range W-2.4 responses,`sec.
at IO-set tlmeout. rrspondina
poorly rnainta~nrd
      -__
At CONC condition, nicotme SPA
at rate higher than saline: at
FR 1 condition, nicotine S-A
without (`ONC food

Experiment 2: FR 10; saline and
several nicotine doses
substituted for cocaine

Kicotine a reinforcer relatwe to
saline, but response rates Iou
relative to single cocaine dose
tested


TABLE k-continued

Study

SpfXW            Reinforcement schedule

Main findings

Comments

Human and
squirrel monkfay

Monkeys. FR 10-200. with l-. 2..
or 4.mr timeouts
Humans: FR lCL800. with l-, 5.,
lo-, or 20-min timeouts

Nicotine maintained about
I.O/sec overall rate of FR
responding at high FR and timeout.
in both humans and monkeys

(from text of talk)

Rat

FR 1, FR 4, FR 8; several
nicotme doses and saline tested

Higher nicotine injection doses
(10 and 30 pg/kg) maintained
responding above saline control
levels

Nicotine a relatwly weak
rwnforcer after IS-da)
svailabihty

Dr la Garza and       Khesus monkeys      FR IO; saline and several          Nicotine a reinforcer relatw to
Johanson                       nicotme. d-amphetamine,         saline, but response rates very
Cl9871                        dlazepam, and perphenazine         low relative to cocaine and d-
                               doses substituted for cocaine       amphetamine


SOTE FR. !:xrd :a?:~. SPA. !-2 dg+e~y!-1-d ems-thy1 nmlnwthane-tICI. PR. ~rwrrs~ve wtm, Fr, fixed time: FL fixed interval; CONC, concurrent

Food deprivatmn sigmficantly
mcreascd response rate for low
mcotine dose in only 1 of 3
monkeys


peared to hasten acquisition of the nicotine self-administration
(Smith and Lang 1980).

Since 1981, methodology for studying the reinforcing effects of
nicotine has shifted away from continuous reinforcement schedules
and toward schedules of self-administration in which responses are
only intermittently reinforced by nicotine injection (Goldberg et al.
1983). Such intermittent schedules appear to more closely approxi-
mate the patterns of human cigarette smoking behavior in which
nicotine is taken in intermittent small doses (puffs) and with even
greater intervals between dosing resulting from periods of time
between cigarettes (Henningfield 1984). On a variety of intermittent
schedules, i.v. nicotine was shown to function as an effective
reinforcer, maintaining overall rates of responding ranging from 0.1
to more than 1 response/set (Table 4). These increases in behavioral
responses maintained by nicotine were obtained without the use of
food deprivation or concurrent inducing schedules of food delivery.

In one series of experiments with squirrel monkeys, Goldberg and
Spealman (1982) and Spealman and Goldberg (1982) utilized a fixed-
interval schedule in which the first response to occur after a 5-min
interval elapsed produced an i.v. injection of nicotine followed by a l-
min period of drug nonavailability ("timeout"). Responses during the
5-min intervals had no specified conseqtiences, and daily sessions
ended after 10 intervals or 2 hr. Under these conditions, nicotine
functioned as an effective reinforcer: (1) peak rates of responding
maintained by nicotine ranged from 0.1 to 0.3 response/set and were
similar to those maintained by cocaine; (2) as nicotine dose per
injection was increased from 3 to 300 mg/kg, rates of responding first
increased and then decreased; (3) rates of responding maintained by
nicotine were about fourfold to eightfold higher than those main-
tained during saline substitution; and (4) daily intramuscular
treatment with 1 mg/kg of mecamylamine reduced rates of respond-
ing maintained by nicotine to saline-control levels but had no effect
on responding maintained by cocaine. Thus, nicotine satisfied all the
criteria discussed in Chapter V as an effective reinforcer. Particular-
ly striking was the finding that although injection doses of nicotine
above 30 mg/kg produced vomiting during the session, one or more
of these higher doses continued to be maintained near maximal rates
of responding in four of the six monkeys studied.

The results of Goldberg, Spealman, and Goldberg (1981) showing
nicotine to be an effective reinforcer have been extended in
subsequent studies. For example, high rates of responding were
maintained on reinforcement schedules of nicotine injection in
which the number of responses per injection was fixed at some
intermediate level (e.g., 1 injection/l5 responses; such contingencies
are termed fixed-ratio schedules). Risner and Goldberg (1983) used a
15-response fixed-ratio schedule of nicotine injection with 4-min

189


timeout periods following each injection in beagle dogs. Nicotine was
an effective reinforcer in all dogs: (1) peak rates of responding were
about 0.3 response/set, but higher rates of responding were main-
tained by cocaine; (21 as the injection dose of nicotine increased from
10 to 100 mg/kg, response rates first increased and then decreased at
the highest dose; (3) peak rates of responding maintained by nicotine
were about fifteenfold greater than those maintained by saline; and
(4) rates of responding maintained by nicotine but not by cocaine
were reduced to saline levels by presession treatment with mecamy-
lamine. Although cocaine maintained higher rates of responding
than nicotine in the dog, fixed-ratio patterns of responding main-
t.ained by nicotine and cocaine were similar: a pause in responding at
the start of each fixed ratio was followed by a change to steady
responding at a high rate until nicotine or cocaine was injected.

In other studies Goldberg and Henningfield (1983a,b, 1986) used
lo- to 30-response fixed-ratio schedules of i.v. nicotine injection in
squirrel monkeys. When a l-min timeout followed each injection,
nicotine maintained rates of responding higher than did saline,
although overall rates of responding were very low. When the
timeout value was increased to 4 min (Prada and Goldberg 1985;
Goldberg and Henningfield 1986) making maximum frequency of
nicotine injection comparable to that of earlier studies by Goldberg
and colleagues, nicotine maintained high rates of responding that
ranged from 0.3 to 2.4 responses/set in different monkeys.

Differences between nicotine and cocaine in their overall efficacy
as intravenously delivered reinforcers have been found when the
drugs are compared on progressive-ratio schedules. Risner and
Goldberg (1983) studied beagles under a schedule in which the fixed-
ratio requirement was increased daily until responding was no
longer maintained. Cocaine maintained higher fixed-ratio values
than did nicotine on this progressive-ratio schedule, although
maximal fixed-ratio values for nicotine were well above those for
saline. Yanagita (1977) obtained similar findings on a progressive-
ratio schedule of i.v. nicotine or cocaine injection in rhesus monkeys
(Chapter V).

Nicotine was also studied in the baboon using an intermittent
schedule of reinforcement and was found to be a weak reinforcer.
Ator and Griffiths (1983) used a 5-min fixed-interval schedule of i.v.
nicotine injection in baboons with 1-min timeout periods. Peak rates
of responding were higher than rates maintained during saline
substitution. However, rates of responding maintained by nicotine
were much lower than those maintained by i.v. injection of cocaine.
In addition, as the injection dose of nicotine was increased from 10 to
560 mg/kg, rates of responding first increased and then decreased at
the highest doses in one baboon. With the other two baboons, rates of
responding either showed little change or decreased as injection dose

190


was increased. These variable dose-response data were consistent
with the conclusion that nicotine was only a weak reinforcer in the
baboons.

When cigarettes are smoked, a variety of environmental stimuli
are intermittently associated with the pharmacologic actions of
nicotine (e.g., pleasure and relief from withdrawal). These stimuli
themselves appear important in controlling and strengthening
repetitive cigarette smoking (e.g., removal of the sight and smell of
cigarette smoking) (Gritz 1978). An experimental model for investi-
gating the role of drug-associated stimuli is the second-order
schedule of drug reinforcement. Second-order schedules of reinforce-
ment involve the intermittent pairing or association of an environ-
mental stimulus with the primary reinforcer; these stimuli are used
as "secondary" or "conditioned" reinforcers to maintain chains of
behavior leading eventually to the delivery of the primary reinforcer
(Goldberg, Kelleher, Morse 1975; Katz and Goldberg, in press). These
schedules add an additional component of relevance to the st,udy of
cigarette smoking: cigarette smoking involves the pairing of many
such environmental stimuli (visual, olfactory, tast.e, and tactile) with
the effects of nicotine administration.

Studies of i.v. nicotine on second-order schedules of reinforcement
have shown that (1) nicotine can establish previously neutral stimuli
(e.g., colored lights) as conditioned reinforcers when injections are
paired with light presentations, (2) such schedules can result in high
and persistent rates of drug-seeking behavior, and (3) the presenta-
tion of the stimuli themselves (in the absence of nicotine injections)
could sustain substantial amounts of drug-seeking behavior. Gold-
berg, Spealman, and Goldberg (1981) and Spealman and Goldberg
(1982) used a second-order schedule of nicotine injection in which
completion of each lo-response fixed ratio during a 2-, 3-, or 5-min
interval produced a brief visual stimulus; the first fixed ratio
completed after the specified fixed interval elapsed produced both
the visual stimulus and iv. injection of drug. In these studies,
nicotine functioned as a powerful reinforcer: (1) peak rates of
responding maintained by nicotine ranged from 0.8 to 1.7 respons-
es/set and were similar to those maintained by cocaine; (2) as
nicotine dose increased from 3 to 100 mg/kg, rates of responding first
increased and then decreased; (3) rates of responding maintained by
nicotine were twofold to eightfold greater than those maintained
during saline substitution; and (4) rates of responding maintained by
nicotine, but not by cocaine, were reduced to saline control levels by
presession administration of 1 mg/kg of mecamylamine; (5) the brief
visual stimuli functioned as conditioned reinforcers, as demonstrated
by the finding that rates of responding fell markedly when they were
omitted during the intervals.

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Taken together, the results of the studies described in this Section
confirm that nicotine is self-administered in several animal species
and in the absence of either tobacco or unique human cultural
factors. It appears t.o be most effective as a reinforcer when
intermittently available and when environmental stimuli are paired
with nicotine delivery. Under these conditions, nicotine injections
functioned to motivate behavior as did cocaine injections; however,
cocaine injections maintained more total work output than did
nicotine. Finally, studies with nicotine antagonists further con-
firmed that effects of nicotine in the brain were necessary to
maintain its reinforcing actions.

Human Studies of Nicotine as a Reinforcer

The methods developed in animal studies have also been used to
demonstrate the reinforcing effects of i.v. nicotine injections in
human volunteers (Henningfield, Miyasato, Jasinski 1983; Henning-
field and Goldberg 1983a; Goldberg and Henningfield 1983a,b, 19861.
In these studies all subjects had histories of tobacco use and subjects
were not allowed to smoke 1 hr before or during 3-hr sessions:
During test sessions every 10th lever press produced an i.v. injection
of either nicotine or saline followed by a 1-min timeout. In one study
(Henningfield, Miyasato, Jasinski 19831, nicotine was available on
some days, while saline was available on other days. In other studies
(Henningfield and Goldberg 1983a; Goldberg and Henningfield
1983a,b), nicotine and saline were concurrently available for re-
sponding on alternate levers. With both approaches, all of the
subjects initiated self-administration of nicotine. Nicotine injections
were regularly spaced throughout each session, and the rate of self-
administration was inversely related to dose. When saline was
substituted for nicotine, rates of responding usually decreased;
responding that did occur for saline occurred predominantly at the
start of each session and was erratic in temporal patterns.

In another study, the fixed-ratio value was then increased to 100;
following each injection, subjects then had to wait 20 min before
another injection could be obtained (Swedberg, Henningfield, Gold-
berg, in press). Under these conditions rates of responding increased
and ranged from 0.4 to 2 responses/set, similar to those seen with
squirrel monkeys and dogs in the studies previously described. These
studies of i.v. nicotine self-administration demonstrated conclusively
that nicotine itself can serve as an effective reinforcer in humans.

Nicotine as an Aversive Stimulus

Even dependence-producing drugs do not have invariant positive
reinforcing effects; they may be aversive under some conditions (see
Chapter V). Furthermore, aversive effects are an additional mechan-

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ism by which drugs can modify behavior and may be important in
gradually increasing the total amount of control which is exerted by
the drug over the individual. Such effects of nicotine could be
important in limiting the total amount of cigarett,e smoking or even
in determining when the cigarette is discarded.

The potential effects of nicotine to produce severe discomfort and
thereby limit further intake have been part of the history of nicotine
which has developed over the centuries (Lewin 1931: Dixon and Lee
1912). Two types of laboratory studies have been conducted to assess
possible aversive effects of nicotine. The studies, involving animals
and/or humans, showed that nicotine (at high levels) can serve as a
punisher to suppress behavior leading to the delivery of another
reinforcer, and as an aversive stimulus or negative reinforcer to
maintain behavior that either terminates or prevents injections of
nicotine.

In one series of studies (Goldberg and Spealman 1982, 1983),
squirrel monkeys responded on a two-component fixed-ratio schedule
of food presentation. In both components, every 30th lever press
produced a food pellet,. In the punishment component, which was
signaled by a red light, the first response in each fixed ratio produced
an i.v. injection of nicotine. When responding produced lo- or 30-
mg/kg injections of nicotine during the punishment component,
responding was selectively suppressed in that component in a dose-
related manner. When saline was injected, however, rates of
responding for food were no longer suppressed. Similar findings were
obtained when electric shock was compared with nicotine in the
same studies. Administration of mecamylamine, but not hexametho-
nium, reduced the punishing effects of the nicotine, showing that the
effects were centrally mediated. Futhermore, these antagonists did
not reduce the aversive effects of the electric shock, confirming that
the effects of nicotine were due to nicotine actions at nicotinic
receptors and not to more general possible effects of nicotine.

The potential aversive effects of nicotine have been experimental-
ly demonstrated in human subjects in a preliminary experiment by
Henningfield and Goldberg (1983a). Human volunteers who had
been recruited for studies of i.v. nicotine self-administration and who
did not self-administer nicotine during initial sessions were tested
under a concurrent schedule of nicotine avoidance and nicotine self-
administration. Two levers were present, and injections of nicotine
were programmed to occur every 15 or 30 min. Pressing the left lever
10 times avoided the impending injection, while pressing the right
lever 10 times produced an injection. Higher doses of nicotine (1.5 to
4 mg/injection given over 10 set) resulted in increased rates of
pressing on the left lever, and fewer injections occurred. Subjects
never completed the 10 responses on the alternate lever required to
produce an injection. When saline was subst.ituted for nicotine,

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responding decreased and the number of injections received marked-
ly increased. Analogously, in these same subjects scores on a visual
line analog scale for rating "negative or undesirable" effects were
directly related to nicotine dose, and declined to zero when saline
was substituted for nicotine.

Nicotine as an Unconditioned Stimulus

The preceding studies have largely evaluated the effects of
nicotine administration on some behavior which was associated with
the drug by a specific behavioral contingency. But drugs can also
directly elicit responses which then might become conditioned to
occur in the presence of whatever stimuli were associated with those
effects. The effects may be seen as positive or negative and may be
associated with either increasing or declining drug levels in the body
(i.e., drug taking or drug withdrawal).

Two general conditioning paradigms are used to evaluate the
unconditioned stimulus effects of drugs and have been used to test
nicotine: the conditioned place preference and aversion paradigm,
and the conditioned taste aversion paradigm. In addition to a
discussion of these paradigms, data obtained from t.he practical
application of such findings in the treatment of tobacco dependence
will be summarized.

Conditioned Place Preference and Aversion

The place preference and aversion paradigm has been increasingly
used to evaluate the potential of drugs to produce dependence
(Bozarth 1983). It may be used to assess the positive and negative
subjective states induced by drugs and other chemicals. In the place-
conditioning procedure, an animal is exposed to the effects of a drug
in a novel, distinctive environment. Another environment is paired
wit.h the administration of the drug vehicle (e.g., saline). Subsequent-
ly, the subject is given a free choice of both environments while not
under the influence of the drug. It is currently hypothesized that the
formation of place preferences or place aversions depends on the
association of the interoceptive drug effect with an external stimulus
(e.g., the particular environmental context of the place-conditioning
apparatus). Nicotine has been shown to condition both positive and
negative effects in this paradigm.

The first published study of the place-conditioning effects of
nicotine (Fudala, Teoh, Iwamoto 1985) indicated that nicotine, at
doses from 0.1 to 1.2 mgikg administered S.C. to rats, produced both a
place preference and p!ace aversion depending upon the dose. As
discussed in Chapter V, the ability to condition both place prefer-
ences as well as place aversions is characteristic of several depen-
dence-producing drugs. A dose of 0.8 mg/kg was found to condition a

194


place preference for previously nicotine-paired environmental cues
in the greatest proportion of animals. At the lowest effective place-
conditioning dose of nicotine, 0.1 mg/kg, an almost equal proportion
of animals exhibited place preferences and place aversions. This
investigation also indicated that mecamylamine, but not hexametho-
nium, blocked the place preference-producing effects of nicotine,
suggesting t,hat this nicotine-induced effect was cent,rally mediated.

Subsequent studies have extended the findings of Fudala, Teoh,
and Iwamoto (1985) discussed above. Using a more conservative
classification method in categorizing their subjects, Fudala and
Iwamoto (1986) observed that nicotine produced a conditioned place
preference only within the dose range previously tested. Further-
more, nicotine conditioned a place preference when the drug was
administered immediately prior to conditioning sessions, but not
when administered from 20 to 120 min prior to conditioning.
Depending on the timing of nicot,ine administration, either place
preferences or place aversions may be produced. For example, at
doses between 0.2 and 0.8 mg/kg, a dose-dependent place aversion
was induced when nicotine was administered 5 min or less following
an animal's exposure to the conditioning environment (Fudala and
Iwamoto 1987). One other group of investigators, Clarke and Fibiger
(1987), using the same dose range of nicotine as in the two
aforementioned studies, found no nicotine-induced conditioned place
preference in rats. However, the two investigative groups used
experimental methods that differed considerably, including differ-
ences in apparatus design, olfactory cues, number of conditioning
trials performed, and time of conditioning relative to nicotine
administration. The finding that nicotine administration can lead to
conditioned responses in animals provides additional evidence of
nicotine's potential to control behavior by this basic learning process
(i.e., Pavlovian or classical conditioning, see Chapter V).

Conditioned Taste Aversion and Rapid Smoking

During conditioned taste aversion experiments, the presentation
of an aversive stimulus after the consumption of a distinctively
flavored solution causes rejection of the solution when it is presented
at a later time (Palmerino, Rusiniak, Garcia 1980; Chapter V). A
variety of dependence-producing drugs have been found to be
effective at inducing taste aversions (for example, Wise, Yokel,
DeWit 1976; Suzuki et al. 1983; Hunt and Amit 1987; Chapter V).
Findings specific to nicotine are presented here.

Etscorn (1980) reported that a large intraperitoneal (i.p.) dose of
nicotine, 2 mg/kg, conditioned taste aversions to 20 percent (weight
per volume) sucrose in Swiss-Webster mice with the two-bottle choice
test paradigm. Etscorn and colleagues (1986) also reported that i.p.
injections of 1, 3, and 9 mg/kg of nicotine in gold?-n Syrian hamsters

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induced dose-related conditioned taste aversions to 0.1 percent
sodium saccharin solutions with a single-bottle choice paradigm.

Kumar, Pratt, and Stolerman (19831 reported that S.C. injections of
nicotine bitartrate could condition taste aversions to either 0.1
percent sodium saccharin or 0.9 percent sodium chloride solutions at
doses as low as 0.08 mg/kg in Lister hooded rats with a two-bottle
choice paradigm. The conditioned taste aversion was induced by
nicotine in a dose-related manner; stronger taste aversions were
induced by nicotine after four conditioning trials than after one or
two trials. The S-nicotine (the nicotine form normally delivered in
cigarette smoke) was approximately five times as potent as its
stereoisomer in conditioning taste aversions. Mecamylamine, 0.1 to 2
mg/kg administered before each conditioning trial, blocked the
development of taste aversions produced by 0.4 mg/kg of nicotine;
hexamethonium, 1 to 10 mg/kg, had no effect.

Other studies have confirmed the pharmacologic specificity of
nicotine-induced taste aversions; that is, Iwamoto and Williamson
(1984) also found that the development of nicotine-conditioned taste
aversions could be prevented in rats by pretreatment with mecamy-
lamine, 3 mg/kg, but not with 1 mg/kg of hexamethonium. In an
analogous study, the pharmacologic specificity of apomorphine-
(dopamine agonist chemically derived from morphine) conditioned
taste aversions was investigated in rats by establishing the response
to both apomorphine and nicotine following pretreatment of the
animals with pimozide (Kumar, Pratt, Stolerman 1983). Pimozide is
a dopamine antagonist that blocks many of the effects of apomor-
phine. Pimozide pretreatment reduced the strength of the condi-
tioned test aversions to apomorphine but not to nicotine, confirming
a certain degree of pharmacologic specificity of the conditioning
effects of these two chemicals. Finally, an intraventricular microin-
jection of 5 mg/kg of the quaternary nicotinic cholinergic ganglionic
antagonist, chlorisondamine, in hooded Lister rats blocked the
development of conditioned taste aversions to 0.1 percent sodium
saccharin or 0.9 percent sodium chloride induced by nicotine injected
9 to 16 days after the chlorisondamine (Reavill et al. 1986).

These data indicate that nicotine, like some other drugs, is capable
of conditioning taste aversions in a dose-related manner in rodents
(see Chapter V). Because mecamylamine, but not hexamethonium,
blocks nicotine-conditioned taste aversions, the mechanism by which
nicotine conditions taste aversions appears to be centrally mediated.
Conditioned taste aversion studies in which various combinations of
nicotinic agonists and antagonists are given have also been useful in
helping to identify specific brain mechanisms of nicotine's behavior
modifying properties (see review by Stolerman, in press; also see
Chapters III and VA

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The fact that nicotine can be used to elicit aversive effects has
been put to practical application in the treatment of cigarette
smoking (Chapter V), generally to associate aversive effects of high
doses of nicotine with the taste, smell, and inhalation of cigarette
smoke. Variations on this procedure have been termed "rapid"
smoking or "aversive" smoking procedures; the clinical results of
these procedures have been mixed (see Chapter VII).

Nicotine: Withdrawal Reactions (Physical Dependence)

The preceding Sections have shown that cigarette smoking is an
orderly form of drug self-administration. The role of nicotine in
controlling this behavior is similar to the role of other psychoactive
drugs in the determination of other forms of drug dependence (see
Chapter V). Nicotine can serve as a highly effective positive
reinforcer, and deprivation of cigarette smoking and presumably of
nicotine itself can increase the reinforcing efficacy of cigarettes
(Henningfield and Griffiths 1979). If longer periods of deprivation
are associated with a discomforting withdrawal syndrome, this
would constitute an additional mechanism by which the reinforcing
efficacy of nicotine would be further increased. The drug effect
which enables such discomforting withdrawal is physical depen-
dence. Physical dependence refers to physiological and behavioral
alterations that become increasingly manifest after repeated expo-
sure to a pharmacologic agent. The primary indication of physical
dependence is an abstinence-associated withdrawal syndrome, al-
though tolerance is a frequent concomitant (Kalant 1978; Cochin
1970; Kalant, LeBlanc, Gibbons 1971; Eddy 1973; Clouet and
Iwatsubo 1975; Yanagita 1977). Physical dependence and tolerance
are discussed in greater detail in Chapter V.

Tolerance to nicotine has been studied since the 19th century and
is well documented (Langley 1905; Dixon and Lee 1912; Gillman et
al. 1985). As reviewed in Chapters II and V, nicotine produces
tolerance to a variety of behavioral and physiological responses.
Until the 197Os, however, physical dependence on tobacco was not
rigorously studied, although there was evidence for a syndrome of
withdrawal that could accompany abstinence from chronic cigarette
smoking (Lewin 1931; Weybrew and Stark 1967) and that was
significantly involved in attempts to quit smoking (Dorsey 1936). The
clinical significance of the tobacco withdrawal syndrome has also
been formally recognized by professional organizations such as the
American Psychiatric Association (APA) (1980, 1987) and the
American College of Physicians (1986). These observations, along
with the evidence that nicotine produces tolerance (Chapter II), led
to the conclusion that nicotine exposure produced physical depen-

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dence (Jaffe 1985; Jaffe and Jarvik 1978; US DHHS 1986b; APA
1980).

Conclusions that nicotine exposure produced physical dependence'
were also consistent with early data which suggested that i.v.
nicotine delivery seemed to relieve withdrawal from cigarettes and
may have produced physical dependence in a nonsmoker (Johnston
19421. Other supporting observations included the finding that
abrupt, reduction of the nicotine in cigarettes (i.e., low nicotine-yield
cigarettes) resulted in behavioral and physiological withdrawal signs
including discomfort and the seeking of regular cigarettes (Finnegan,
Larson, Haag 1945; Knapp, Bliss, Wells 1963). However, the rigorous
scientific methods of the kind that were developed to evaluate
withdrawal from opioids and sedatives (Himmelsbach 1942; Isbell
1948; Isbell et al. 1955; Chapter V) were not applied to the study of
the tobacco withdrawal syndrome until the late 1970s. Therefore, the
data available at the time of the 1964 Report of the Surgeon
General's Advisory Committee on Smoking and Health were not
considered conclusive (US DHEW 1964). The present Section reviews
characteristics of physical dependence on nicotine, including the
relationship of nicotine intake to the magnitude of withdrawal signs
and symptoms, and the role of both environmental and pharmacolog-
ic factors which influence the course of the withdrawal syndrome.

Criteria for Physical Dependence on Nicotine and Clinical
Characteristics of the Withdrawal Syndrome

Similar kinds of phenomena characterize withdrawal syndromes
from all drugs that produce physical dependence. If physical
dependence on nicotine occurs, these same phenomena should be
observed (see Chapter V; Martin 1977; Thompson and Unna 1977;
Woods, Katz, Winger 1987). Based on these phenomena, criteria for
establishing that physical dependence on nicotine occurs include the
following: (1) Termination of cigarette smoking should be accompa-
nied by changes in mood, behavior, and physical functioning. (2)
Some of these changes should be in a direction which is opposite to
those produced by cigarette smoking and should return to the
baseline levels observed during chronic tobacco administration
("rebound effects"). (3) Physiological withdrawal effects should be
reversible by nicotine administration.

The tobacco withdrawal syndrome as described by the APA in the
revised Diagnostic and Statistical Manual (DSM III-R) (APA 1987),
provides a clinical description (Table 5). Several of the symptoms of
the nicotine withdrawal syndrome correspond to effects of nicotine
that are either known or suspected to promote tobacco dependence
as discussed in Chapter VI. It should be noted that the sequelae of
tobacco abstinence include a range of responses which do not share
the same underlying mechanisms. For example, some symptoms are

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transient responses which are opposite those produced when nicotine
is given and which subside within a few days or weeks of nicotine
abstinence; such responses are presumed to reflect a physiological
rebound occurring in the absence of chronic drug exposure. Other
responses are also opposite those produced by nicotine administra-
tion but appear to primarily reflect the removal of nicotine exposure,
and which may occur whether or not sufficient nicotine had been
taken to produce physical dependence. An example of the latter type
of response is body weight. Nicotine can directly suppress appetite
and body weight, often below the value at which it would have been
had nicotine not been taken; removal of nicotine is then accompa-
nied by a stable increase in body weight.

Various lines of scientific evidence are available to characterize
physical dependence on tobacco and to evaluate the specific role of
nicotine. These data include surveys, treatment studies, and experi-
mental laboratory studies and are briefly reviewed in this Section.

Retrospective Survey Data

Retrospective studies have been conducted with ex-smokers who
were participating in major surveys (Wynder, Kaufman, Lesser 1967;
Hughes, Gust, Pechacek 1987) or who were patients with chronic
respiratory problems (Burns 1969; Mausner 1970). Other studies
were conducted using subjects who responded to advertisements in
newspapers (Pederson and Lefcoe 1976) or were contacted by word of
mouth (Trahir 1967). The subjects in these studies had either quit
smoking recently, had quit smoking for more than 1 year, or had at
least one episode of remaining abstinent for 24 hr. Although the
reliability of these data is limited because they are from retrospec-
tive self-reports, they provide information on the prevalence and
nature of symptoms which may be experienced by smoke-deprived
persons and acutely abstinent smokers.

Symptoms reported by significant numbers of ex-smokers includ-
ed: "craving" for tobacco (Hughes, Gust, Pechacek 1987; Trahir 1967;
Burns 1969; Mausner 1970; Pederson and Lefcoe 19761; restlessness,
nervousness, or irritability (Trahir 1967; Wynder, Kaufman, Lesser
1967; Burns 1969; Mausner 1970; Hughes, Gust, Pechacek 1987);
anxiety (Hughes, Gust, Pechacek 1987); impatience (Hughes, Gust,
Pechacek 1987); difficulty concentrating (Trahir 1967; Wynder,
Kaufman, Lesser 1967; Hughes, Gust, Pechacek 1987); somatic or
physical complaints (Hughes, Gust, Pechacek 1987; Pederson and
Lefcoe 1976); increased appetite (Wynder, Kaufman, Lesser 1967;
Hughes, Gust, Pechacek 1987); increased food intake (Wynder,
Kaufman, Lesser 1967); and weight gain (Trahir 1967; Wynder,
Kaufman, Lesser 1967; Mausner 1970; Pederson and Lefcoe 1976).

Measures of the incidence and magnitude of signs and symptoms
vary across studies, at least partly because of the diversity of the

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TABLE &-Diagnostic categorbation and criteria for
       nicotine withdrawal

measuring instruments and techniques used, questions asked, and
populations examined. Collectively, the results of many such studies
suggest that most nicotine-deprived cigarette smokers experience at
least, one symptom of the tobacco withdrawal syndrome, that
between one-fourth and one-half show significant withdrawal, and
that about one-fourth report no withdrawal at all (Pederson and
Lefcoe 1976; Wynder, Kaufman, Lesser 1967; Hughes, Gust, Pecha-
cek 1987; Gritz 1980; Henningfield 1984). Of those persons who
retrospectively report experiencing no withdrawal symptoms, it is
unclear whether they were not physicaily dependent, whether the
assessment instruments were not sufficiently sensitive, or whether


some persons are less impaired or discomforted by withdrawal
symptoms.

Prospective Data from Laboratory and Nonlaboratory
Studies

Cigarette smokers have been studied both in laboratory and
nonlaboratory settings using a variety of self- and observer-adminis-
tered tests measuring subjective, behavioral, and physiological signs
and symptoms that accompany tobacco deprivation. The studies have
examined changes in functioning resulting after periods of tobacco
deprivation ranging from 1 hr to 21 days. Most studies have obtained
both baseline and deprivation measures; a few studies have incorpo-
rated a control group of continuing smokers or nonsmokers; and a
few have obtained data after smokers resumed smoking or were
given nicot.ine polacrilex gum. The studies included ones which were
conducted while the subjects were residing on a research ward, were
living in their usual environment, or were paying occasional visits to
a clinic for smoking cessation treatment. The symptoms reported in
these studies were similar to those obtained from the retrospective
studies, demonstrating generality across method and setting. These
symptoms included the following: "craving" for tobacco (Gritz and
Jarvik 1973; Hatsukami et, al. 1984: Gilbert and Pope 1982; Shiffman
and Jarvik 1976; Cummings et al. 1985; Hughes and Hatsukami
1986), irritabi1it.y or anger (Myrsten, Elgerot, Edgren 1977; Elgerot
1978; Weybrew and Stark 1967; Hughes and Hatsukami 1986),
anxiety and tension (Mrysten. Elgerot, Edgren 1977; Hughes and
Hatsukami 1986), restlessness (Hughes and Hatsukami 1986), impa-
tience (Hughes and Hatsukami 1986), depression (Hatsukami et al.
1984), problems with concentration (Hatsukami et al. 1984; Weybrew
and Stark 1967; Myrsten, Elgerot, Edgren 1977; Frankenhaeuser et
al. 1971; Hughes and Hatsukami 1986), drowsiness or fatigue
(Weybrew and Stark 19673, sleep disturbances (Hatsukami et al.
1984; Larson, Haag, Silvette 1961; Weybrew and Stark 1967;
Myrsten, Elgerot, Edgren 1977; Hughes and Hatsukami 1986), and
increased hunger or appetite (Myrsten, Elgerot, Edgren 1977;
Hughes and Hatsukami 1986).

In one study (Hughes and Hatsukami 1986), each subject had a
spouse, relative, or friend rate some of the symptoms of withdrawal
to verify self-report. These observer ratings of irritability, anxiety,
restlessness, drowsiness, fatigue, impatience, and somatic complaints
were all significantly related to their respective subject's ratings,
thus adding to the validity of reports of these symptoms. These
researchers found that the most common self-report symptoms were
increased irritability (80 percent), anxiety (87 percent), difficulty
concentrating (73 percent), restlessness (71 percent), impatience (76
percent), insomnia (84 percent), and craving for tobacco (62 percent).

201


Seventy-eight percent of the subjects reported four or more DSM-III
criteria. This degree of prevalence was higher than that found in a
retrospective study conducted by Hughes, Gust, and Pechacek (1987),
possibly reflecting differences in the measuring instruments or the
populat,ions themselves.

The physiological changes which have been found to occur after
cigarette deprivation include decreased heart rate (Knapp, Bliss,
Wells 1963; Murphee and Schultz 1968; Parsons, Avery et al. 1975;
Benowitz, Kuyt, Jacob 1984; Hatsukaml et al. 1984; Weybrew and
Stark 1967; Gilbert and Pope 1982; Hughes and Hatsukami 1986;
West and Russell 1987; Elgerot 1978; West, Jarvis et al. 1984;
Henningfield 1987a) and decreased cortical arousal as evidenced by
decreases in peak alpha frequency and increases in low frequency
activity which appear to be associated with drowsiness and decreased
vigilance (Knott and Venables 1977, 1979; Ulett and Itil 1969;
Herning, Jones, Bachman 1983; Herning 1987). Knott and Venables
(1978) have also found that the visual evoked response in tobacco-
deprived smokers showed faster latencies and larger amplitudes for
low-stimulus intensities than among nondeprived smokers and
nonsmokers. They concluded that deprived smokers experience CNS
hypersensitivity and, as a result, may experience visual stimulus
input more easily and strongly. Hall and colleagues (1973) reported
reduced auditory evoked response (AER) amplitudes during tobacco
withdrawal. Blood pressure (Benowitz, Kuyt, Jacob 1984; Murphee
and Schultz 1968; Knapp, Bliss, Wells 1963) and respiratory rate
(Parsons et al. 1976) have also been found to decrease during
abstinence. Studies have also reported an increase in skin tempera-
ture among tobacco-deprived smokers (Gilbert and Pope 1982;
Myrsten, Elgerot, Edgren 1977) or no change (West and Russell
1987), and either a decrease (FagerstrBm 1978) or no significant
change (Hatsukami et al. 1984) in body temperature among those
who are classified as more dependent. Although some studies have
reported insomnia and sleep disturbance following tobacco depriva-
tion, tobacco-deprived smokers' total sleep time may be longer
during withdrawal (Soldatos et al. 1980). Reported changes in sleep
pattern include decreased latency to rapid-eye-movement (REM)
sleep (Kales et al. 1970), decreased latency to light (delta electroen-
cephalogram (EEG) wave) sleep onset (Parsons, Luttrell et al. 1975;
Parsons and Hamme 1976), and increased total REM sleep time
(Soldatos et al. 1980; Kales et al. 1970; Parsons, Avery et al. 1975).

Another physical change found among tobacco-deprived smokers is
an increase in weight (Grunberg 1986; see also Chapter VI). Weight
increase has also been found among those who quit smoking in a
number of longitudinal survey studies (Bosse, Garvey, Costa 1980).
This increase in weight has been attributed to increased caloric
intake (Hatsukami et al. 1984; Grunberg 1982; Myrsten, Elgerot,

202


Edgren 1977; Burse et al. 1975; Gilbert and Pope 1982; Wack and
Rodin 1982), decreased basal metabolism (Glauser et al. 1970; Wack
and Rodin 1982), decreased energy expenditure (Hofstetter et al.
1986), or increased activity of lipoprotein lipase (Carney and
Goldberg 1984) (see also Chapter VI).

Several studies have examined the effects of cigarette deprivation
and administration on reaction time and psychomotor performance.
These are reviewed in detail in Chapter VI and are only briefly
summarized here. Two early studies each found considerable across-
subject variability, with some subjects showing distinct deprivation-
induced performance impairments which were reversed by tobacco
administration, and other subjects showing impairments under the
tobacco administration conditions (Bates 1922; Carver 1922). Since
the studies by Bates and Carver, investigators have developed
increasingly sophisticated methods of performance assessment
which have led to a clearer understanding of the performance-
related effects of nicotine administration and deprivation (see details
in Chapter VI). For example, Heimstra, Bancroft, and DeKock (1967)
used a simulated driving task and found that deprived smokers made
significantly more errors on tracking and vigilance tasks than did
nondeprived smokers or nonsmokers, who did not significantly differ
from each other. Other research has demonstrated that smokers who
were allowed to smoke cigarettes during the experimental session
exhibited either no decrease or an improvement in speed and
accuracy in reaction time, cognitive tests, and/or vigilance perfor-
mance tasks, whereas deprived smokers most frequently show some
impairment in performance tasks (Myrsten et al. 1972; Franken-
haeuser et al. 1971; Elgerot 1978; Kleinman, Vaughn, Christ 1973;
Andersson 1975; Wesnes and Warburton 1984; Edwards et al. 1985;
Snyder and Henningfield, in press; Henningfield 1986a, 1987a).

A recent study using a computerized battery of such tasks found
clear impairments beginning within 8 hr of the last cigarette and
improving only somewhat across 10 consecutive days of tobacco
deprivation; resumption of smoking was accompanied by complete
restoration of performance (Henningfield 1987a). The specificity of
these performance effects of nicotine was confirmed by the findings
that administration of nicotine in the polacrilex gum form produced
a dose-related reversal of all performance impairments (Snyder and
Henningfield, in press; Henningfield 1987a); this effect was not
related to satisfaction or reduction of "craving" because the gum
produced dose-related decreases in "liking" scores and produced no
reliable decrease in "desire to smoke" (Henningfield 1987a).

Other changes occurring in tobacco-deprived cigarette smokers
include increases in aggression scores on the Buss aggression
machine (Schechter and Rand 1974) and increases in frequency of
spontaneous jaw contractions (a putative analog of aggression)

203


(Hutchinson and Emley 1973). Analogously, monkeys withdrawn
from chronic oral nicotine exposure (nicotine was placed in their
drinking water) exhibited an increase in frequency of post-shock
biting (Hutchinson and Emley 1973).

The magnitude of tobacco withdrawal is related to the environ-
mental context (see Chapter V for a comparison to other dependence-
producing drugs). For example, Hatsukami, Hughes, and Pickens
(1985) reported that smokers who were deprived of cigarettes on an
outpatient basis experienced more withdrawal symptoms than those
who underwent withdrawal on a clinical research ward. These
findings are consistent with those of Suedfeld and Ikard (1974), who
found that deprivation of normal sensory stimulation reduced
tobacco abstinence-associated discomfort. It has also been observed
that the diurnal variation of withdrawal discomfort found among
abstinent smokers (greater discomfort in the evenings) appears to be
associated with diurnal variation in the social environment (e.g.,
meals, departure from work, or social contact) (Shiffman 1979).

Time Course of Responses to Nicotine Abstinence

Drug withdrawal syndromes generally include some signs and
symptoms which are opposite those produced by administration of
the drug and which then return to approximately the same values
observed when drug intake was stable (rebound phenomena). The
time course of different responses varies (Chapter V). The most
recent studies show that several signs and symptoms of withdrawal
appear to rebound within the first few days following cigarette
abstinence; these signs and symptoms include increases in the urge
to use tobacco, anxiety, problems with concentration, increased
caloric intake, sleep disturbance, performance impairment, and
general subjective distress (Hatsukami et al. 1984; Hughes and
Hatsukami 1986; Schneider and Jarvik 1984; Cummings et al. 1985;
Henningfield 1987a). Heart rate has been found to decrease to levels
found among nonsmokers (Weybrew and Stark 1967) and may
include some rebound, returning to stable levels between those
maintained during normal cigarette smoking and those recorded
during the first week of abstinence (Henningfield 1987a). The P300
response, a cognitive evoked potential component which is related to
the ability to evaluate auditory stimuli (i.e., differentiate one sound
from another by counting only certain sounds), showed a rebound
(decrease in amplitude), with values returning to preabstinence
(cigarette smoking) levels after about 3 to 5 days (Herning 1987).
West, Russel, Jarvis, Pizzey, and Kadam (1984) reported that urinary
epinephrine concentrations rebounded with a significant decrease
during the first 3 days of abstinence followed by a significant
increase. Finally, in the squirrel monkey study of nicotine absti-
nence-associated biting, Hutchinson and Emley (1973) found a

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distinct rebound pattern in some subjects with biting levels sharply
increasing and then returning to the levels observed during chronic
oral nicotine administration.

Other signs and symptoms associated with tobacco abstinence do
not return to levels observed during cigarette smoking. For example,
weight gain has persisted for long periods of time (Blitzer, Rimm,
Giefer 1977) and has also been reported to approach levels of
nonsmokers (Khosla and Lowe 1971; Lincoln 1969; Chapter VI). In
addition, some levels of performance impairment and associated
reduction of a cognitive evoked cortical potential (NlOO), which is
related to attention, persist at least 10 days and may last longer
(Henningfield 1987a; Herning 1987).

As the preceding studies suggest, the duration of withdrawal
reactions varies among studies and as a function of the measure
(Shiffman 1979; West 1984). Urges to smoke cigarettes among ex-
smokers have been reported to occur intermittently, although
sometimes with great intensity, for up to 9 years after cessation of
cigarette smoking. These reported symptoms may represent condi-
tioned responses to environmental stimuli associated with either
cigarette smoking or deprivation, may represent a protracted
physiological phase of withdrawal, or both (e.g., Wikler 1965;
Jasinski 1981; Chapter VI.

Alleviation of Withdrawal Symptoms by Cigarette Smoking

Several studies have demonstrated that the signs and symptoms
resulting from cigarette deprivation are alleviated by the resump-
tion of cigarette smoking. These signs and symptoms include heart
rate (Murphee and Schultz 1968; Weybrew and Stark 1967; Henning-
field 1987a), blood pressure (Murphee and Schultz 19681, skin
temperature (Myrsten, Elgerot, Edgren 19771, epinephrine and
norepinephrine levels (Myrsten, Elgerot, Edgren 19771, EEG changes
(Ulett and Itil 1969; Herning 1987), weight (Noppa and Bengtsson
19861, desire for food (Burse et al. 19751, hand tremor (Myrsten,
Elgerot, Edgren 19771, desire to smoke (Gritz and Jarvik 19731, and
fatigue, irritation, sleeplessness, problems with alertness and con-
centration (Weybrew and Stark 19671, and performance (Henning-
field 1987a).

Hughes, Hatsukami, Pickens, and Svikis (1984) examined the
consistency of tobacco withdrawal signs and symptoms using an
experimental design in which periods of cigarette smoking and
abstinence were alternated in the same subjects. This study demon-
strated both the consistency of the withdrawal symptomology within
subjects as well as the efficacy of resumed smoking in reversing it.
The most consistent withdrawal effects across subjects were supine
heart rate changes, insomnia, caloric intake, irritability, rest-
lessness, drowsiness, general mood disturbance (measured by the

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Profile of Mood States). and withdrawal discomfort. Furthermore,
the intensities of the withdrawal discomfort of subjects during the
two deprivation periods were similar. Similarly, a study at the
Addiction Research Center (Baltimore, Maryland) showed that
resumption of cigarette smoking after 10 days of tobacco abstinence
was accompanied by a return to preabstinence levels of all measures
including EEG, evoked cortical electrical potentials, heart rate,
behavioral performance, and measures of mood (Henningfield 1987a;
Herning 1987).

Relationship Between Preabstinence Nicotine Intake and
Magnitude of Withdrawal Syndrome

The observation that the magnitude of tobacco withdrawal reac-
tions is directly related to preabstinence levels of nicotine intake
provides specific evidence that nicotine is the pharmacologic cause of
the physical dependence. The clinical significance of these relation-
ships is that. both the magnitude of the tobacco withdrawal syndrome
and difficulty in quitting smoking are directly related to the daily
levels of nicotine that were being ingested. The relationship has not
always been observed, however, when only crude indices of nicotine
dosing were used. For example, correlations between number of
cigarettes smoked per day (a poor marker of nicotine intake)
(Benowitz 1983; Abrams et al. 1987; Chapter II) and withdrawal
reaction severity are mixed across studies. Some investigators have
observed a positive correlation between the number of cigarettes
smoked per day and withdrawal severity (Wynder, Kaufman, Lesser
1967; Shiffman 1979; Burns 1969; Hall, Ginsburg, Jones 1986).
Others have report,ed no differences in severity of craving or other
measures of withdrawal between light and heavy smokers or as a
function of number of cigarettes smoked (Gritz and Jarvik 1973;
Shiffman and Jarvik 1976; Myrsten, Elgerot, Edgren 1977; Mausner
1970). Cummings and coworkers (1985) reported that although heavy
smokers reported more withdrawal symptoms than light smokers,
differences between heavy and light smokers were statistically
significant only with respect to irritability.

The most reliable measure of day-to-day nicotine exposure appears
to be cotinine in biological specimens or nicotine itself (Benowitz
1983; Chapter II). Recent studies using such measures have found
significant relationships between either nicotine or cotinine levels
and severity of withdrawal reactions. Pomerleau, Fertig, and Shan-
han (1983) divided subjects by their baseline plasma cotinine levels
(high or low quartiles). They found that subjects in the low-cotinine
quartile exhibited less withdrawal change on the Shiffman Craving
and Perception of Physical Signs subscales compared with subjects in
the high-cotinine quartile. They also found a significant correlation
between preabstinence baseline plasma cotinine levels and absti-

206


nence-associated craving for cigarettes. Hatsukami, Hughes, and
Pickens (1985) established a similar significant correlation between
craving for tobacco and plasma nicotine level, as well as nicotine
boost. Zeidenberg and associates (1977) found that preabstinence
serum cotinine was correlated significantly with the degree of
difficulty in smoking cessation among males but not females.
Finally, West and Russell (1985b I determined that whereas preabsti-
nence plasma nicotine levels significantly predicted craving, hunger,
restlessness, inability to concentrate, and overaii withdrawal severi-
ty, preabstinence rates of daily cigarette consumption did not
significantly predict any withdrawn1 effects.

Smokeless Tobacco Withdrawal Syndrome

A study of withdrawal reactions accompanying abstinence from
smokeless tobacco products helped to determine that the syndrome
did not require inhalation of smoke and its constituents. which are
not present in smokeless tobacco (e.g., tar and CO.). This study
showed that signs and symptoms of smokeless tobacco deprivation
are similar to those occurring in smokers after cigarette deprivation
(Hatsukami, Gust, Keenan 1987). In persons who had been using a
high nicotine containing brand of chewing tobacco, Hatsukami, Gust,
and Keenan (1987) measured a number of potential withdrawal signs
and symptoms over a 6-day period. Baseline data were collected
during 3 days of regular smokeless tobaco use. The significant
changes which occurred during smokeless tobacco deprivation rela-
tive to the baseline included decreased heart rate and an increase in
craving for tobacco, confusion, eating, number of awakenings, and
total scores on a withdrawal symptom checklist for both self-rated
and observer-rated measures. These changes were similar to those
found among cigarette smokers who underwent a similar experimen-
tal protocol, although the smokeless tobacco withdrawal syndrome
appeared to be less severe than the cigarette withdrawal syndrome
(Hatsukami, Gust, Keenan 1987).

Nicotine Polacrilex Gum: Treatment and Physical
Dependence

Nicotine polacrilex gum has been used to evaluate the specific role
of nicotine in tobacco dependence. Experimental research and
clinical observations of the ability of nicotine in the polacrilex gum
form to alleviate tobacco withdrawal symptomatology provide con-
clusive evidence that the tobacco withdrawal syndrome is pharmaco-
logically determined by physical dependence on nicotine. To the
extent that the tobacco withdrawa! nhenomena described above are
specific to nicotine and not characteristic of the delivery system (e.g.,
cigarette smoke), alternate forms of nicotine delivery should be able
to sustain the physical dependence. This would be evidenced by (1)

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blockade of signs and symptoms of withdrawal by nicotine delivery
and (2) subsequent emergence of a t.obacco withdrawal-like syndrome
upon abrupt abstinence from nontobacco-delivered nicotine.

Treatment of Withdrawal S-ymptoms

Clinical trials and experimental studies in which nicotine polacri-
lex gum is evaluated as a means to alleviate signs and symptoms of
tobacco withdrawal are of relevance to the treatment of tobacco
dependence (Chapter VII). In addition, however, such data are
analogous to data from the classic "substitution" study methodology
used to help det,ermine the pharmacologic specificity of withdrawal
reactions following use of opioids, sedatives, and alcohol (described in
Chapter V). In brief, however, the objective is to determine if the
withdrawal reaction from the primary substance upon which the
person is dependent can be alleviated by administration of a test
drug.

Several studies have examined the effects of nicotine polacrilex
gum on tobacco withdrawal (Jarvis et al. 1982; Schneider, Jarvik,
Forsythe 1.984; West, Jarvis et al. 1984; Hughes, Hatsukami,
Pickens, Krahn et al. 1984; Snyder and Henningfield, in press;
Henningfield 1987a). These studies have examined two groups of
cigarette smokers who were assigned in a double-blind fashion (with
the exception of West, Jarvis, and colleagues (19841, who used a
single-blind design) to receive 2-mg polacrilex gum or placebo. The
duration of cigarette deprivation during which the polacrilex gum
(or placebo) was used varied from 24 hr to 6 weeks. In general, the
results consistently showed an attenuation of withdrawal signs and
symptoms. For example, nicotine polacrilex gum significantly re-
duced irritability (Jarvis et al. 1982; Hughes, Hatsukami, Pickens,
Krahn et al. 1984; West, Jarvis et al. 1984), total withdrawal
discomfort (Schneider, Jarvik, Forsythe 1984; Hughes, Hatsukami,
Pickens, Krahn et al. 19841, somatic complaints (Hughes, Hatsuka-
mi, Pickens, Krahn et al. 19841, sleepiness (Jarvis et al. 1982),
unsociability (West, Jarvis et al. 19841, cognitive performance
deficits (Snyder and Henningfield, in press; Henningfield 1987a),
heart rate decreases (Schneider, Jarvik, Forsythe 1984; West, Jarvis
et al. 1984; Henningfield 1987a1, and EEG effects including changes
in cortical evoked potentials (Herning 1987; Pickworth, Herning,
Henningfield, 19881.

Other measures were less reliably alleviated; these included
depression (Jarvis et al. 1982; West, Jarvis et al. 1984), anxie-
ty/tension (Jarvis et al. 1982; Hughes, Hatsukami, Pickens, Krahn et
al. 19841, difficulty concentrating (Hughes, Hatsukami, Pickens,
Krahn et al. 1984; West, Jarvis et al. 19841, and restlessness (Hughes,
Hatsukami, Pickens, Krahn et al. 1984; West, Jarvis et al. 1984). The
urge to smoke cigarettes has not been found to be reliably alleviated

208


by nicotine polacrilex gum administration (West and Schneider
1987; West 1984; Henningfield 1987a; Hughes, Hatsukami, Pickens,
Svikis 1984) except possibly at high dose levels (Nemeth-Coslett,
Henningfield, O'Keefe, Griffiths 1987). Interpretation of such data is
complicated by the diverse strategies used to measure the urge to
smoke or "craving" as discussed further in this Section.

Of these studies, two showed nonsignificant effects of nicotine
polacrilex gum on hunger (Hughes, Hatsukami, Pickens, Krahn et
al. 1984; West, Jarvis et al. 1984) and one showed significant effects
in decreasing hunger (Jarvis et al. 1982). More recent research shows
that the anorectic effect of nicotine polacrilex gum during tobacco
abstinence is directly related to the dose level (i.e., number of doses
taken per day) (Stitzer and Gross 1988; Fagerstrom 1987; Chapter
VI). The dose-response relationship may explain the diversity in
results when studies are compared; in some of these studies, dosing
was either poorly controlled or not reported, or there was no
verification of subject compliance with a dose regimen.

As would be expected, depending on the dose administered, the
efficacy of nicotine polacrilex gum for most measures of withdrawal
symptomology ranges from complete reversal of withdrawal to no
effect. In a study in which periods of tobacco abstinence (3 days) were
alternated with periods of cigarette smoking (4 days), subjects were
given either 0-, 2-, or 4-mg-nicotine-containing pieces of the polacri-
lex gum (Henningfield 1987a). The subjects were given the polacrilex
gum at 1-hr intervals (for 12 hr), and they chewed under the
direction of research staff. Blood nicotine and cotinine levels
confirmed that this procedure resulted in dose-related nicotine
administration; plasma cotinine and nicotine levels at 4 mg were
similar to those obtained during cigarette smoking (ad libitum
smoking); plasma levels at 2 mg were between those at 4 and 0 mg.
Measures included cognitive performance, heart rate, EEG, and self-
reported symptomology. At 4 mg, all signs and symptoms of
withdrawal were reduced or completely reversed except the desire to
smoke. The 2-mg dose produced partial reversal of withdrawal
effects.

Maintenance of Physical Dependence

Two studies have examined withdrawal effects after deprivation of
nicotine polacrilex gum. West and Russell (1985a) conducted a study
in which they examined withdrawal symptoms in six people who
used nicotine polacrilex gum for at least 1 year. Baseline measures of
possible withdrawal effects were collected during days that the
subjects were chewing 2-mg pieces of nicotine polacrilex gum. These
days were the first and third days of a 4-day experiment. On the
second and fourth days, subjects were given either 0.5 mg unbuffered
polacrilex gum (nicotine absorption is negligible in the unbuffered

209


formulation) to chew or no polacrilex gum. West and Russell (1985a)
found significant changes for measures of withdrawal symptomology
including irritability, ability to concentrate, and heart rate and for
composite subjective withdrawal scores. Withdrawal reaction magni-
tude was slight,ly, but not significantly, less in the unbuffered gum
than in the no gum condition.

Hughes, Hatsukami. and Skoog (1986) extended the findings of
West and Russell (1985a) with a longer period of observation (1 week)
and a double-blind, placebo-controlled design. In the study by
Hughes, Hatsukami, and Skoog (1986), eight former smokers who
had been using nicotine polacrilex gum for at least 1 month
participated. The main finding was that when the maintenance dose
levels (2-mg polacrilex gum) were replaced with placebo, reliable
symptoms of withdrawal were produced. The effects included
"craving" for tobacco, irritability/hostility, anxiety, depression,
restlessness, impatience, difficulty concentrating, hunger, and total
withdrawal discomfort; reports from observers verified several of the
effects (i.e., observer estimates of irritability, anxiety, restlessness,
impatience, and total withdrawal discomfort). The scales used to
measure withdrawal discomfort in the study by Hughes and col-
leagues were similar to those used in a previous study of cigarette
withdrawal conducted by the same investigators (Hughes and
Hatsukami 19861, thus enabling an across-study comparison between
abstinence from cigarettes and abstinence from nicotine in the
polacrilex gum form. Intensities and numbers of withdrawal symp-
toms, except heart rate and insomnia, were similar.

Taken together, the results of the above-described studies with
nicotine polacrilex gum have helped to confirm that tobacco
withdrawal is pharmacologically caused by physical dependence on
nicotine. Furthermore, the results of such work are of clinical
significance because they indicate that much of tobacco withdrawal
symptomology can be treated with nicotine polacrilex gum. Two
studies show that nicotine polacrilex gum can maintain physical
dependence; this emphasizes the importance of gradually giving up
use of the gum to minimize the abruptness and severity of
withdrawal symptoms (see Chapter VII).

Tobacco Craving

The measurement of self-reported craving for tobacco and inter-
pretation of resulting data are among the more complicated issues in
tobacco research. Findings discussed in this Chapter that nicotine
polacrilex gum administration can suppress cigarette smoking and
alleviate physical signs of tobacco withdrawal while having little
effect on the urge to smoke indicate that such urges are not solely
determined by nicotine deprivation. Similar observations regarding
urges to use other dependence-producing drugs are discussed in

210


Chapter V (see also Childress et al., in press!. The elicitation and
alleviation of the urge to use tobacco, as for other dependence-
producing substances, can be effected by a variety of pharmacologic
and other environmental stimuli as well as changes in the physiolog-
ical and/or behavioral state of the person (Chapter V).

Conclusions regarding the measurement and treatment of urges to
use drugs are complicated because the questions about urges have
been worded differently among studies. For example, subjects are
somtimes asked to report their "craving." Unfortunately, subjects
vary widely in their interpretations of the word "craving" and in
their answers to questions about it (Kozlowski and Wilkinson 1987;
Ludwig and Stark 1974). In addition, results concerning "craving"
are sometimes discussed when the word was not even used in study
questionnaires, and sometimes craving was inferred from other
observations (e.g., self-reported discomfort or drug abstinence) (Koz-
lowski and Wilkinson 1987). These and other problematic issues
have been discussed in several recent papers (Kozlowski and
Wilkinson 1987; Shiffman 1987; West 1987; Hughes 1987; Marlatt
1987; Stockwell 1987; Henningfield 1987b; Henningfield and Brown
1987; West and Schneider 1987). One consensus that seems to
emerge is that the term "craving" be replaced with "urge" or
"desire" to smoke, and that subjects be asked to report the
"strength" of such responses and not simply whether or not the
response occurred (Kozlowski and Wilkinson 1987; Henningfield
1987b).
In consideration of the above reports and commentaries and the
data reviewed in the present Chapter, the following conclusions may
be drawn regarding the urge to smoke. Many means of measuring
urges are reliably associated with early abstinence from tobacco;
however, urges can also be elicited by a variety of other stimuli
including cigarette smoking itself, tobacco-associated stimuli (e.g.,
sight, smell, advertisements), consumption of other psychoactive
drugs, food deprivation, and mood changes. Furthermore, although
urges are reliably associated with tobacco abstinence, the levels to
which plasma nicotine must fall to produce it are unclear; for
example, West, Russell, Jarvis, and Feyerbend (1984) found that
smokers who switched to a low-nicotine cigarette reported only slight
craving for their usual brand in spite of a drop in nicotine intake of
around 60 percent. In addition, as discussed earlier, some sensory
stimuli are effective at eliciting urges, whereas other sensory cues
accompanying the inhalation of cigarette smoke may be effective at
diminishing such urges (Rose et al. 1985). Chapter V provides a
discussion of these issues in the context of analogous observations
which have been made with other dependence-producing drugs and
Chapter VII discusses the implications for replacement therapy used
in treating tobacco dependence.

211


Alternate Nicotine Delivery Systems

Certain effects of nicotine depend little upon the specific type of
delivery system that is used (see also Chapters, II, III, and VI). For
instance, it appears likely that all forms of nicotine delivery
resulting in systemic absorption are capable of producing tolerance
and maintaining physical dependence (see also Chapter II). Similar-
ly, it follows that a variety of nicotine delivery systems have
potential utility in the treatment of cigarette smoking by the
alleviation of withdrawal symptoms. However, the safety, including
the potential to produce dependence, may vary considerably as a
function of characteristics of the nicotine delivery system itself.

Kinds of Nicotine Delivery Systems

Because nicotine is well absorbed through the common routes of
drug delivery and because the commonly used tobacco vehicle is not
necessary to efficaciously deliver nicotine, nicotine can potentially
be placed in a variety of vehicles and administered via a variety of
delivery systems (Chapter II; Benowitz 1986; Jarvik and Henning-
field, 1988). The nicotine delivery systems thus far discussed in this
Chapter are tobacco smoke, nicotine polacrilex gum, i.v. nicotine,
transdermal nicotine, and a nicotine vapor inhaler. Other potential
therapeutic nicotine delivering systems under development include a
nasal spray (Perkins et al. 1986) and nasal nicotine solutions given in
droplet form (Russell, Jarvis, Feyerabend, Ferno 19831, both of which
have been discussed by Russell (1988). Two other nicotine delivery
systems are a chewable food product (Tobacco International 19871
and a "toothpaste" formulation which contains ground tobacco.
Other nicotine delivering systems (in which the tobacco may be
incidental and not necessary for nicotine delivery) are under
development or consideration for over-the-counter retail marketing
(R.J. Reynolds "Smokeless Cigarette" European Patent Application
1985, 1986; Cleghorn 1987; Mintz 1987).

As noted earlier, the nicotine vapor inhaler was removed from the
retail market in February of 1987 by the FDA because it was a
"nicotine delivery system intended to satisfy nicotine dependence"
which had not been tested for safety and efficacy @lade and Connolly
1987). At least through the end of 1987, the toothpaste-like formula-
tion was available as an over-the-counter product but was under
review by the FDA (FDA letter to Congressman Waxman); this
formulation is distributed in Indian food stores. The chewable
nicotine delivering product marketed by Pinkerton Inc. was test-
marketed as a "tobacco product" for approximately 6 months during
1987. The FDA removed it from the market ruling that it was a "food
product" ["chewing gum"] which was "unlike traditional smokeless
tobacco products," and contained a "food additive [tobacco] deemed

212


unsafe" for human consumption (FDA letter to Congressman
W'axman).

Safety of Alternate Nicotine Delivery Systems

Alternate nicotine delivery systems may be evaluated with respect
to at least three categories of safety issues. These are: (1) short- and
long-term toxic effects resulting from use of the system; (2) the ease
and convenience of using the system; and (3) the dependence po-
tential of the system. All of these factors can affect initiation and
maintenance of nicotine dependence.

The first safety issue is related to the direct behavioral and
physiological toxicity of the preparation itself. In the moderate
nicotine doses that each of these and previously marketed systems
deliver, acute nicotine toxicity would not appear to be a significant
health risk. However, adverse health effects from chronic exposure
to nicotine may occur (see Appendix B), and other potentially
absorbed constituents of the system (e.g., tar) are markedly toxic.

Existing nicotine delivery systems vary widely in their potential
overall toxicity. One product was found to meet FDA criteria for
safety as well as efficacy (i.e., nicotine polacrilex gum). On the other
hand, cigarette smoking is a cause of lung cancer and other cancers,
emphysema, heart disease, and a variety of other diseases; smokeless
tobacco use causes oral cancer and other forms of gum and mouth
disease (US DHEW 1979; US DHHS 1982, 1983, 1984; US DHHS
1986b).
Traditional tobacco products have historically been considered by
the FDA to be outside its regulatory purview (Action on Smoking
and Health vs. Harris 1980). New products, which contain either
small amounts of tobacco (e.g., tobacco-containing food products) or
which appear to contain possibly nonessential amounts of tobacco
(e.g., possibly the case with the R.J. Reynolds smokeless cigarette
(European Patent Application 1985, 1986)) and which are not
regarded as traditional tobacco products, may not be exempt from
such review.

The second safety issue is the potential for the product to actually
sustain tobacco use by alternating use of the substitute with use of
the traditional tobacco product. This is analogous to the nonmedical-
ly approved use of methadone by opioid-dependent individuals when
their drug of choice (e.g., heroin) is not available, and they are not
involved in treatment for opioid dependence. The use of non-tobacco
nicotine products to sustain tobacco use is, similarly, medically
contraindicated and hence a form of nicotine abuse Glade 1986;
Richards 1987). While any alternative nicotine delivery system can
theoretically be used for this purpose, two commercial products (the
chewable nicotine-delivering "food" product and the nicotine vapor
inhaler) were marketed specifically as temporary substitutes for

213


cigarettes when it was inconvenient to smoke (Bosy 1986; Tobacco
International 1987). In contrast, the instructions for use of nicotine
polacrilex gum clearly specify that this preparation should not be
used along with cigarettes (Physicians' Desk Reference 1988). In
addition to product design and formulation, factors such as labeling,
packaging, marketing, retail distribution, and regulatory oversight
might influence the degree to which any particular preparation is
associated with an individual's continued use of the nicotine delivery
system.

The third potential safety concern is related to the dependence
potential of the system. As shown in Chapter V, the potential of a
drug to addict users is associated with its effects on mood, feeling,
and behavior; such effects are related to the bioavailability of the
drug. Systems with a controlled rate of bioavailability or a lesser rate
of absorption than is obtained from conventional tobacco products
may have a lesser dependence potential than tobacco products.
Other factors related to availability of the preparation and cost (both
economic and behavioral) may also affect the likelihood that
dependence will develop in users. For example, nicotine polacrilex
gum is available by prescription only, and use of the gum is
recommended as a temporary treatment aid. Active chewing is
required to extract the nicotine, and swallowing the nicotine too
quickly reduces the amount absorbed. These factors appear relevant
to the observation that less than 10 percent of all subjects entering
smoking treatment trials continue to use nicotine polacrilex gum
after 1 year (Tonnesen et al. 1988; Jarvis et al. 1982). Among people
who have used the polacrilex gum to quit smoking and who have
maintained their tobacco abstinence for 1 year or more, a higher
percentage of polacrilex gum use has been reported (13 to 38
percent); however, it is not clear to what degree such use may be
necessary for some people to avoid relapse to tobacco use (see further
discussion of these issues in Hughes 1988; Jasinski and Henningfield
1988; Hall et al. 1985; Tonnesen et al. 1988; Chapter VII). In contrast
to nicotine polacrilex gum, smokeless tobacco products (particularly
one in which finely ground snuff is placed in a small tea bag-like
pouch) readily lend themselves to initiating as well as to maintaining
nicotine dependence (US DHHS 1986b).

Table 6 compares nicotine polacrilex gum and cigarettes on a
number of dimensions, most of which have been reviewed in either
Chapters II, V, or VII. As shown in the Table, there is considerable
disparity between these two delivery systems: the polacrilex gum
provides a generally safe and medically beneficial form of nicotine
delivery; cigarettes are a known cause of substantial amounts of
death and disease each year (Chapter I; US DHEW 1979; US DHHS
1981, 1982, 1983, 1984, 1985). Such a disparity in potential safety

214


TABLE 6.-Comparison of tobacco cigarettes and nicotine
     polacrilex gum on indices related to safety,
     including potential to cause dependence

Tobacco cigarettes

Nicotine polacrilex gum

Proven carcinogen

Ava&bility

Widely available consumer
product. mcludmg vending
machme availabdit~

Taste

Carefully formulated with
flaror enhancers

Ease of mcotine cxtractmn

Readdy awulable with little
effort

Nicotme kinetxs

Inltiatmn of dependence

Psychoactivity

Reinforcing effects

Withdrawal symptoms
associated with abstinence

Rapid uptake

Highly effective

Dose-related "hkmg"


P0WerfUl

Yes

Socml factors

Often used in soaal
settings as part of social
interactions

Primary regulatory         1T.S Bureau of Alcohol.
ovewght              Tobacco, and Firearms

h-0

Prescription only

Not formulated to provide
dewable taste

Much effort required

Sluw uptake

No reported problem

Dose-related "disliking"

Weak

Yes

L'sed for specific
therapeutic benefit

U.S. Food and Drug
Administration

across systems would suggest that any new system be submitted to
evaluations of safety including dependence-potential testing.

Conclusions

1. Cigarettes and other forms of tobacco are addicting. Patterns of
tobacco use are regular and compulsive, and a withdrawal
syndrome usually accompanies tobacco abstinence.

2. Nicotine is the drug in tobacco that causes addiction. Specifi-
cally, nicotine is psychoactive ("mood altering") and can
provide pleasurable effects. Nicotine can serve as a reinforcer
to motivate tobacco-seeking and tobacco-using behavior. Toler-
ance develops to actions of nicotine such that repeated use
results in diminished effects and can be accompanied by
increased intake. Nicotine also causes physical dependence
characterized by a withdrawal syndrome that usually accompa-
nies nicotine abstinence.

215


3. The physical characteristics of nicotine delivery systems can
affect their toxicity and addictiveness. Therefore, new nicotine
delivery systems should be evaluated for their toxic and
addictive effects.

216


References

ABRAMS, D.B., FOLLICK, M.J., BIENER, L., CAREY, K.B., HITTI, J. Saliva cotinine
as a measure of smoking status in field settings. American Journal of Public
Health 77(7):846-848, July 1987.

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CHAPTER V

  TOBACCO USE COMPARED
TO OTHER DRUG DEPENDENCIES

241


CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Clinical Characteristics of Drug Dependence ............. .248
  Drug Dependence Defined ................................. 248
Diagnostic Criteria for Drug Dependence ............. 249
  Features of Drug Dependence., ......................... .250
    Highly Controlled or Compulsive Drug Use .. .250
    Physical Dependence and Tolerance ............. 251
     Harmful Effects ........................................ 252
     Course of Drug Dependence.. ...................... 252
    Polydrug Dependence and Multiple Psychiat-
     ric Diagnosis ......................................... 254
    Spontaneous Remission .............................. 255
  Chemical Detection Measures ............................ 256

Patterns in the Development of Drug Dependence.. . . . .259
  Current Use of Cigarettes and Other Drugs . . . . . . . . . 259
Epidemiological Studies of the Progression of Drug
   Use . , . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .261
  Tobacco Use as a Predictor of Other Drug Use.. . .262
Frequency of Use of Cigarettes and Other Drugs.. 263
  Initiation of Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Vulnerability to Drug Dependence: Individual and
   Environmental Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

Pharmacologic Determinants of Drug Dependence ..... .267
  How Drugs Control Behavior.. .......................... .267
Dependence Potential Testing: Psychoactive, Rein-
   forcing, and Related Effects ............................ 269
    Effects of Drugs on Mood and Feeling (Psy-
     choactivity) ........................................... 270
      Methods and Results .............................. 272
    Drug Discrimination Testing ....................... 274
       Methods and Results ............................. .275
     Drug Self-Administration ........................... .276
     Initiation of Drug Self-Administration ...... .277
     Evaluation of Reinforcing Effects ............. 279
     Results from Drug Self-Administration
        Studies .............................................. 281

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   Drug Dose as a Determinant of Drug
      Intake ............................................... 282
   Cost of the Drug as a Determinant of
      Intake .............................................. ,283
   Place Conditioning Studies ........................ .284
  Constraints on Dependence Potential Testing. 285
Dependence Potential Testing: Tolerance and
Withdrawal ................................................. .286
   Tolerance ............................................... .287
    Cross-Tolerance .................................... .288
    Mechanisms of Tolerance ....................... .288
    Constitutional Tolerance ........................ .290
   Withdrawal Syndromes ............................. .291
   Spontaneous Withdrawal Syndromes ........ .292
   Precipitated Withdrawal Syndromes ......... .293
   Variability in Withdrawal Syndromes ...... .294
   Cravings  or Urges ................................ .295
  Constraints on Physical Dependence Potential
   Testing ................................................ .296
Therapeutic or Useful Effects of Dependence-Pro-
ducing Drugs .............................................. .298
Adverse and Toxic Drug Effects.. ...................... .298
Identification of Dependence-Producing Drugs ...... .304
  Comparison Among Drugs .......................... 305

Environmental Determinants of Drug Dependence In-
cluding Behavioral Conditioning ........................... .306
  Drug Taking as a Learned Behavior .................. .307
  Drug-Associated Stimuli Modulate Drug Seeking .. .308
  Conditioned Withdrawal Symptoms May Precipi-
   tate Drug Seeking  ........................................ 310

Relapse to Drug Dependence.. ................................. 311
  Definition of Relapse ........................................ 312
  Measurement of Relapse ................................... 313
  Rates of Relapse.. ............................................ 313
  Correlates of Relapse ...................................... .315
  Pretreatment Correlates of Relapse ................... .315
    Severity of Drug Dependence ...................... 315
    Psychiatric Impairment .............................. 316
    Demographic Factors ................................. 320
  Treatment Correlates of Relapse ........................ 320
  Posttreatment Correlates of Relapse ................... 321
    Family Support Factors ............................. 321
    Drug Use Among Peers ............................. 321
     Involvement in Work and Leisure Activities .322

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Negative Emotional States.. . . . . . . . . . . . . . . . . . . . . . . . . 322

Treatment of Drug Dependence ............................... 324
  Goals of Treatment .......................................... 325
Types of Treatment for Drug Dependence .......... .326
  Pharmacologic Treatment of Drug Dependence .... .326
    Replacement Therapy ............................... .326
     Blockade Therapy .................................... .328
    Nonspecific Pharmacotherapy or Symptomatic
       Treatment ............................................. 328
    Pharmacologic Deterrents ........................... 329
  Behavioral Treatment Strategies ........................ 329
    Relapse Prevention Skills ........................... 330
    Leisure Activity Skills ............................... 331
     Stress Management Skills .......................... 332
     Motivation Enhancing Treatments .............. .332

Conclusions .......................................................... 334

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336

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Introduction

The present Chapter compares cigarette smoking and nicotine
with other forms of drug dependence and addicting drugs. Other
chapters in this Report describe the behavior of cigarette smoking,
the known biobehavioral mechanisms and modulators of nicotine's
actions, and techniques for achieving abstinence from smoking. As is
evident from this Report, cigarette smoking is most usefully ex-
plained and characterized as a drug dependence process in which
nicotine is the identified drug of dependence. It is also evident that
by either the World Health Organization (WHO) definition of "drug
addiction" that was issued in the 1950s (WHO 1952) or by the
definitions of "drug dependence" issued since the 1960s (WHO 1964,
1969, 1981), nicotine is appropriately categorized. as an addicting or
dependence-producing drug. Its designation as a drug is also consis-
tent with the definitions provided by the WHO (1981) and the Food
and Drug Administration (FDA) (1987). Nicotine-delivering tobacco
preparations (which include all currently marketed tobacco prepara-
tions) could, therefore, be appropriately categorized as addicting or
dependence-producing drugs. In addition to evaluating nicotine with
respect to definitions of dependence-producing drugs, it is also useful
to compare features of tobacco dependence and the pharmacologic
properties of nicotine to other drug addictions and addicting drugs,
respectively. This comparison is the purpose of the present Chapter.

Two of the most widely studied drug addictions provide standards
to which other addictions may be compared. They are the addictions
to the opium-derived or related substances ("opioids," e.g., morphine,
heroin, methadone, codeine) and to alcohol. For nearly a century, it
has been widely accepted that use of these substances could lead to
addictive behavior and to adverse effects. Moreover, such conse-
quences of use develop in a sufficient number of persons that there
have been recurrent regulatory efforts to restrict access and
conditions of use. Cocaine and related psychomotor stimulants (e.g.,
amphetamine) provide an additional important standard by which to
judge suspected and known addicting chemicals. These stimulants
have been accepted as standards by which to evaluate the addicting
potential of other stimulants since the 1950s.

It is beyond the scope of the present Chapter to review all aspects
of drug dependence in detail. Rather, this Chapter summarizes
primarily the pharmacologic aspects of drug dependence. In particu-
lar, the Chapter provides information that permits a comparison of
the pharmacologic basis of tobacco dependence, as described in the
other Chapters, with the pharmacologic basis of other forms of drug
dependence. More extensive reviews of the topics to be discussed
have emerged from various review panels sponsored by the National
Institute on Drug Abuse (NIDA) (Krasnegor 1978,1979a,b,c; Thomp-
son and Johanson 1981; Grabowski, Stitzer, Henningfield 1984;

247


Sharp 1984) and the National Academy of Sciences (Levison,
Gerstein, Maloff 1983); other reviews have been held under the
auspices of professional scientific societies (Goldberg and Hoffmeis-
ter 1973; Thompson and Unna 1977; Balster and Harris 1982; Taylor
and Taylor 1984; Seiden and Balster 1985). Other important
determinants and consequences of drug dependence are more
thoroughly described elsewhere (Blaine and Julius 1977; Manatt
1983; Tims and Ludford 1984; Petersen 1978; Bell and Battjes 1985;
Richards and Blevens 1977; Dupont, Goldstein, O'Donnell, Brown
1979; Lettieri, Sayers, Pearson 1980; Crowley and Rhine 1985).

Clinical Characteristics of Drug Dependence
Drug Dependence Defined

Before the 1960s it was fairly common to invoke factors such as
"criminality, " "character deficit," "immorality," and "weakness of
will" in the clinical diagnosis of "drug addiction." In addition, these
factors often included various social connotations. In part, it was
because these attributes were not objective or scientifically based
that the WHO in 1964 recommended that the term "addiction" be
replaced with "drug dependence" in an effort to be more precise and
descriptive in definition (WHO 1964, 1981).

According to current conceptualizations, the central and common
element across all forms of drug dependence is that a psychoactive
drug has come to control behavior to an extent that is considered
detrimental to the individual or society (WHO 1981; APA 19873.
Although the precise wording varies, the central concept of drug-
dependence definitions refers to the behavior of the individual who
has come under the control of a psychoactive drug, and this concept
has provided the cornerstone of most definitions of depen-
dence/addiction for at least a century (Berridge 1985) and arguably
for several centuries (Murray et al. 1933; Austin 1979; Levine 1978).
The involvement of a psychoactive drug is the critical feature that
distinguishes drug addictions from other habitual behaviors.

In principle, the term "drug dependence" might be used to
characterize any form of drug ingestion; however, the term is
generally reserved for use when the chemical meets criteria as a
"psychoactive" drug. These criteria are based on drug-induced
changes in brain function; such changes may involve alterations in
mood, feeling, thinking, perception, and other behavior. In this
Chapter the term "drug dependence" or "drug addiction" refers to
self-administration of a psychoactive drug in a manner that demon-
strates that the drug controls or strongly influences behavior. In
other words, the individual is no longer entirely free to use or not use
the substance. Often times, this reduction in the degree to which use


TABLE l.-Diagnostic criteria for psychoactive substance
      dependence

A.  At least three of the following:

Substance often taken in larger amounts or over a longer period than the person
intended

Persistent desire or one or more unsuccessful efforts to cut down or control substance
use

A great deal of time spent in activities necessary to get the substance (e.g.. theft), to
take the substance (e.g., chain smoking), or to recover from its effects

Frequent intoxication or withdrawal symptoms when expected to fulfill major role
obligations at work, school, or home (e.g., does not go to work because of hangover,
goes to school or work "high," intoxicated while taking care of own children), or when
substance `~(se is physically hazardous (e.g., drives when intoxicated)

Important social, occupational, or recreational activities given up or reduced because of
substance use

Continued substance use despite knowledge of having a persistent or recurrent social,
psychological, or physical problem that is caused or exacerbated by the use of the
substance (e.g., continuing heroin use despite family arguments about it, cocaineinduced
depression, or ulcer made worse by drinking

Marked tolerance: need for markedly increased amounts of the substance (i.e., at least
a 50 percent increase) to achieve intoxication or desired effect, or markedly diminished
effect with continued use of the same amount

(Note: The following items may not apply to cannabis, hallucinogens. or PCP)
Characteristic withdrawal symptoms (see specific withdrawal syndromes under
Psychoactwe Substance-Induced Organic Mental Disorders)
Substance often taken to relieve or avoid withdrawal symptoms

B.  Some symptoms of the disturbance persistent for at least 1 month, or occurrent repeatedly
  over longer period of time

SOURCE: American Psychiatric Association (1987).

is considered "voluntary" is described as "habitual" or "compulsive"
drug use.

Diagnostic Criteria for Drug Dependence

The Diagnostic and Statistical Manual (DSM-III-R) of the Ameri-
can Psychiatric Association (APA 1987) provides a useful example of
the objective criteria currently used to define drug dependence. As
stated in DSM III-Revised: "The essential feature of this disorder is a
cluster of cognitive, behavioral, and physiological symptoms that
indicate that the person has impaired control of psychoactive
substance use and continues use of the substance despite adverse
consequences." Specific diagnostic criteria for psychoactive sub-
stance dependence are shown in Table 1.
The APA designated 10 classes of psychoactive substance for
which use may lead to dependence: alcohol; amphetamine or
similarly acting sympathomimetics; cannabis; cocaine; hallucino-

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gens; inhalants; nicotine; opioids; phencyclidine (PCP) or similarly
acting arylcyclohexylamines; and sedatives, hypnotics, or anxiolyt-
its. The fact that dependence criteria are the same for all classes of
drug use highlights the assumption that dependence processes are
functionally similar across substances with different pharmacologic
profiles.

Features of Drug Dependence

Behavior that leads to drug ingestion, as well as the various
behavioral and physiological sequelae resulting from the ingestion,
are determined by both drug (pharmacologic or agent) and nondrug
(behavioral or environmental) factors which will be discussed in this
Chapter. The nondrug determinants include characteristics of the
individual ("host" characteristics) such as age, genotype, and person-
ality.

Highly Controlled or Compulsive Drug Use

Highly controlled or compulsive drug use indicates that drug-
seeking and drug-taking behavior is driven by strong, often irresisti-
ble urges. It can persist despite a desire to quit or even repeated
attempts to quit. Compulsive drug use may take precedence over
other important priorities.

The extent to which compulsive behavior is apparent varies across
individuals and is most easily detected in extreme cases. For
example, to maintain daily drug intake laryngectomized patients
may smoke cigaret.tes through their tracheostomy hole, cocaine
users may take cocaine at the risk of loss of family and job, and
prostitution has been observed to occur in exchange for a variety of
drugs for which availability was low or price was high.

The drug-seeking behavior itself ranges from the routine and licit
procurement of cigarettes or alcohol, to the possibly more extensive
behavioral repertoire necessary to obtain prescriptions for certain
drugs, to the highly intricate chains of behavior required to procure
many illicit drugs. Drug-seeking behavior is not determined entirely
by the specific pharmacologic properties of a particular drug,
however. For instarce, when alcohol or tobacco has been prohibited,
procurement has at times involved as much risk and involvement as
the procurement of illicit drugs in the 1980s (Austin 1979; Brecher
1972).

A drug may be taken to avoid withdrawal symptoms and other
undesirable sequelae of drug abstinence. This factor may contribute
to the level of compulsivity which develops. Addicting drugs often
provide some therapeutic benefit or otherwise useful effect (Chapter
VI); these effects may also contribute to the compulsive nature of
drug use. Whether or not such benefits are considered to be more


important than the adverse effects of drug taking, this factor is
important because it may have been prominent in initial exposure to
the drug, it may have strengthened the control of the drug over
behavior, and it may constitute a potential cause for relapse.

Physical Dependence and Tolerance

The observation of a withdrawal syndrome that accompanies
abstinence from chronic drug exposure is the primary index of
physical dependence induced by the drug (Martin 1965; Kalant
1978). Drug withdrawal syndromes are behavioral and physiological
sequelae of abstinence from chronic drug administration. Tolerance
refers to the diminished responsiveness to successive administration
of a drug; it may occur independently of physical dependence but is a
frequent concomitant (Kalant 1978). The magnitude of tolerance and
physical dependence is directly related to the frequency and
magnitude of the drug-dosing regimen; thus, low or infrequent drug
dosing may not produce measurable levels of tolerance or physical
dependence. Tolerance may develop in the absence of physical
dependence; for example, infrequent dose administration may result
in decreased responsiveness even though no measurable withdrawal
reaction accompanies drug abstinence.

Whereas initial drug exposure may have caused marked behavior-
al and physiological disruption, the development of physical depen-
dence implies that a relatively normal appearing behavioral and
physiological functioning requires continued drug administration
and that disruption will occur when the drug is withdrawn. For
example, at certain doses, opioids, sedatives (including alcohol), and
nicotine can produce marked intoxication in nontolerant individuals.
As tolerance develops, these same dose levels may produce no readily
observable signs of intoxication, and in the case of opioids and
nicotine only extremely high doses or sudden abstinence are
accompanied by disruption of ongoing behavior.

The development of tolerance to repeated drug exposure and of the
onset of a withdrawal syndrome may be observed following a period
of repeated drug exposure and drug abstinence, respectively, but
these factors do not in themselves define a drug dependence
syndrome requiring intervention to prevent relapse to drug use. It is
possible to establish tolerance and physical dependence by repeated
drug administration even when the animal or human never actually
self-administered the drug. In animals, this is often done in
experimental studies; human patients requiring pain relief may
become tolerant to and physically dependent on opioid analgesics in
hospital settings. Such animals and humans do not necessarily
exhibit drug-seeking behavior when drug administration is terminat-
ed. Another such instance is the fetal opioid syndrome, in which
treatment of the withdrawal reaction might be indicated but no

251


drug-seeking behavior would be present for which an intervention
would be needed (Weinberger et al. 1986). Although not always
essential for the occurrence of addictive drug-seeking behavior,
tolerance and withdrawal phenomena are important in principle
because they can serve to strengthen the control of the drug over
behavior. Specifically, tolerance development can result in increased
drug intake in an attempt to maintain the desired drug effects, and
the onset of a drug withdrawal syndrome may constitute an aversive
state which is alleviated by drug taking.

Harmful Effects

The concept that some sort of harm or disadvantage to the
individual or society is a consequence of drug use is another element
in most definitions of drug dependence. This concept is complex and
socially determined, however. For example, drug seeking may result
in illicit production and trafficking as currently occurs for illicit
drugs (Drug Abuse Policy Office 19841, and had occurred for tobacco
at various times when it was banned (Austin 1979; see also Warner
1982 for a discussion of recent cigarette-smuggling issues). Adminis-
tration of drugs, or abstinence in the physically dependent person,
may directly produce adverse behavioral and psychiatric effects
("psychotoxicity"). Finally, toxicity may also be a direct physiological
effect of the addicting drug itself (e.g., liver damage caused by
alcohol) or to associated toxins (e.g., transmission of the human
immunodeficiency virus by needle sharing among i.v. drug users, or
carcinogens delivered by tobacco smoke).

These forms of drug-associated damage can result in a variety of
societal costs such as health care of drug users (including cigarette
smokers), lost productivity of the work force (including tobacco-use-
associated losses in productivity), and criminal justice system
burdens associated with illicit drug use. Such adverse effects of drug
use constitute the "liability" of drug use and may also be factors in
the determination that drug use constituted "drug abuse"..(Yanagita
1987). These societal aspects of drug dependence frequently invoke
debates which pit the "right" to self-damage against the "right" of
society to protect itself from the direct damage or costs incurred as a
consequence of the individual's behavior. A historical appraisal of
psychoactive substance use reveals that societies have often moved
cautiously to restrict the use of drugs when there was little
assumption of drug-use-associated damage.

Course of Drug Dependence

The chronic nature of drug ingestion in the severely dependent
individual suggests that. drug dependence processes themselves may
be long lasting and resistant to termination. In contrast, the direct

252


effects of psychoactive drugs are generally limited to a few hours or
days at most. Peak physical withdrawal signs and symptoms from
opioids, sedatives, alcohol, and tobacco appear to last for about 1 to 2
weeks. However, at least for the opioids, a secondary stage of
withdrawal may last for 1 year or more; this has been termed
protracted withdrawal (Martin 1965; Jasinski 1981). As discussed in
Chapters III and VI, an analogous protracted abstinence syndrome
appears to exist in tobacco dependence and to be of importance for
treatment efforts. Therefore, despite the relatively short-term dura-
tion of the effects of drug administration or withdrawal, the
clinically relevant duration of drug dependence is much longer.

A major implication of post-1960s definitions of drug dependence is
that drug dependence is not an absolute phenomenon, but rather
may vary in degree (Jaffe 1965, 1985; Miller 1979). Often, within an
individual the level of severity increases over time ("progressive"
characteristic). The course may be quite variable, however. For
example, an initially rapidly developed high level of use may be
followed by long-term or transient remissions, while some individu-
als never progress at all beyond levels of use of a given drug that are
sometimes considered safe and acceptable (Vaillant 1970, 1982).
Such low or intermittent levels of drug use are sometimes referred to
as "occasional," "controlled, " "recreational" or "social" drug use or
"chipping"; such use may still be problematic because there may be
acute adverse consequences (e.g., auto accidents following drinking),
as well as a transition to chronic drug use (as is characteristic
following occasional tobacco use) and the possibility that any use
involves illicit behavior (e.g., procurement of alcohol and tobacco by
minors or possession of marijuana).

There are differences among drugs in the relative incidence of
occasional users compared to regular daily users who meet criteria
for dependence. For example, it is generally estimated that less than
15 percent of those who consume alcoholic beverages are dependent
(Miller 1979). Analysis of opioid data are more problematic (Zinberg
and Jacobson 1976); however, observations such as those made of
Vietnam veterans show that opioid chipping is not only a well-
documented phenomenon but may also be common in some social
and environmental settings. Robins and colleagues found (1) that
opioid chipping was a common occurrence among enlisted men in
Vietnam, (2) that 88 percent of heroin-addicted Vietnam veterans
used heroin occasionally upon their return to the United States, and
(3) that most (approximately 90 percent) were able to avoid readdic-
tion (Robins et al. 1977; Robins and Helzer 1975; Robins, Helzer,
Davis 1975; Robins, Davis, Goodwin 1974; Robins, Davis, Nurco 1974;
see also Zinberg 1972, 1980). In contrast, however, chipping appears
relatively rare among tobacco users: the 1985 National Health
Interview Survey showed that 10.6 percent of current smokers

253


smoke 5 or fewer cigarettes/day (unpublished data, Office on
Smoking and Health; see also Russell 1976 and US DHHS 1987).

Polydrug Dependence and Multiple Psychiatric Diagnosis

Another feature of drug dependence is the common use of multiple
substances, including tobacco, by dependent individuals. In fact, the
most consistent feature of such multiple drug use is the high rate of
co-occurrence of tobacco dependence along with dependence on
opioids, alcohol, stimulants, and even gambling (Taylor and Taylor
1984). In addition, drugs used by individuals may sometimes vary
and be interchanged as price and availability vary (e.g., cocaine is
preferred by many but individuals may use opioids, or even
sedatives, when cocaine is unavailable) (Kliner and Pickens 1982).
Several drugs may also be taken simultaneously; for instance, heavy
consumption of nicotine, alcohol, and marijuana is common. Finally,
most surveys indicate that use of drugs such as cocaine, alcohol,
opioids, and marijuana is accompanied (and usually preceded) by use
of nicotine (US DHHS 1987).

Tobacco use concurrent with other drug dependencies is so
prevalent that it is not generally considered to be of diagnostic
significance or considered as a basis of multiple drug dependence
diagnosis. Recently, the possible interactive nature of codependen-
ties to nicotine and other drugs has been given increasing attention
in drug treatment programs (Taylor and Taylor 1984; Kozlowski et
al. 1984). These data are discussed later in this Chapter, as well as
the issue of whether nicotine serves as a "gateway" to the use of
illicit drugs.

Also of clinical significance is the concurrence of drug dependence
and some other psychiatric disorder. This phenomenon is termed
multiple or dual diagnosis (Meyer 1986; McLellan, Woody, O'Brien
1979; Allen and Frances 1986; Rounsaville and Kleber 1986; Jaffe
and Ciraulo 1986). In general, dependence on opioids, alcohol,
cocaine, and nicotine is often associated with elevated rates and
levels of antisocial tendencies and extraversion, but such trends are
not generally regarded as multiple diagnoses (for a review of several
forms of multiple diagnosis, see Taylor and Taylor 1984). The
designation of multiple diagnosis is reserved for the concurrent
appearance of a clinically significant psychiatric disorder and drug
dependence; the most common of such disorders would appear to be
depression, anxiety, and antisocial personality (McLellan, Woody,
O'Brien 1979; Rounsaville et al. 1982; Woody, McLellan, O'Brien
1984).

254


Spontaneous Remission

It is characteristic of drug dependence that some persons discon-
tinue use of the drug while not engaged in a formal treatment
program (i.e., "on their own") although they may have participated
in a treatment program at some earlier point in time (Stall and
Biernacki 1986). Spontaneous remission refers to intentional and
unintentional cessation of drug use, variously referred to as "natural
recovery, " "maturing out," "burning out," or "self-quitting," but
most frequently in current literature as "spontaneous remission."
Such quitting is sometimes reported to be due to "will power" or
"just deciding to quit." However, follow-up studies have revealed
that significant environmental events are often associated with such
quitting (for example, Vaillant 1970,1982). Such data have suggested
to some that the terms such as "self-quitting," "self-help," and
"spontaneous remission" are misnomers (Fisher 1986; Fisher et al.
1988); nonetheless, because the term spontaneous remission is extant
in the scientific literature, it will be used here. This Section provides
a brief summary of available information comparing alcohol, opioids
and tobacco with regard to their rates of spontaneous remission and
of factors associated with remission from drug use.

In studies of spontaneous remission, a minimum criterion for
abstinence, such as 1 year, is often imposed. Although the recorded
history of drug dependence acknowledges that some people can
achieve abstinence without benefit of formal intervention programs,
there was little systematic study of spontaneous remission until the
1970s. Major motivations for the current interest in this phenome-
non are to determine if the so-called spontaneous remitters differ in
behavioral or physiological parameters from other drug-dependent
persons, to identify factors which may be systematically applied in
treatment settings, and to better understand the process of drug
dependence itself.

The percentage of such spontaneous remitters reported in any
given study appears to vary more as a function of population and
study variables than as a function of drug class. For instance, data
averaged across 10 studies show that approximately 30 percent of
opioiddependent persons spontaneously remit (Anglin et al. 1986)
although estimates of remission rates vary from 2 percent to 65
percent (Harrington and Cox 1979; Winick 1962). On the other hand,
approximately 90 percent of people who have quit smoking report
that they quit without the aid of formal treatment programs or
smoking cessation devices (Fiore et al., in press; see discussion of
related issues in Fisher et al. 1988).

Deriving precise quantitative comparisons of rates of spontaneous
remission across the various drug dependencies is problematic due to
the differing criteria used to identify those who are spontaneous
remitters. For example, in tobacco surveys, rates of spontaneous

255


remission are often estimated by retrospective self-reports from a
sample of former smokers, whereas surveys of opioid and alcohol
users generally include only those who were dependent enough to be
involved in formal treatment programs at some time.

The factors which are associated with spontaneous remission
appear to be similar across dependencies on alcohol, opioids, and
tobacco (Stall and Biernacki 1986). Table 2 is a summary of findings
which have been reported on factors related to spontaneous remis-
sion. As shown in the Table, influences such as health problems
associated with use of the drug and social pressures are frequent
precipitants of spontaneous remission among persons who were
dependent on alcohol, opioids, or tobacco. Similarly, spontaneous
remitters have often learned to better manage their drug "cravings"
and to provide contingent reinforcement for quitting to themselves,
and may even undergo significant lifestyle changes (Stall and
Biernacki 1986).

These data regarding spontaneous remission support the conclu-
sion, discussed earlier, that it is somewhat misleading to infer that
spontaneous remitters are truly spontaneous or that they were not
"really dependent" as is sometimes assumed (Fisher 1986; Fisher et
al. 1988; US DHHS 1982). Rather, it seems more plausible that
spontaneous remitters are largely those who have either learned to
deliver effective treatments to themselves or for whom environmen-
tal circumstances have fortuitously changed in such a way as to
provide a therapeutic situation (Fisher 1986; Stall and Biernacki
1986; Vaillant 1982, 1970). In addition, persons most likely to quit
use of tobacco and opioids without benefit of formal intervention do
tend to have shorter histories of use and/or be at lower levels of
dependence (US DHHS 1987). Such issues, relating specifically to
cigarette smoking, have been reviewed in considerable detail in a
previous report of the Surgeon General (US DHHS 1982).

Chemical Detection Measures

Although drug dependence is not reliably diagnosed simply on the
basis of amount of drug intake (Crowley and Rhine 1985; Jaffe 19851,
it can be useful to determine whether or not a person has ingested a
significant amount of a drug. For example, as is discussed later in
this Chapter, many treatment programs require objective verifica-
tion of drug-free patient status.

A potentially useful adjunct for objectively assessing exposure to
drugs is to test for the presence of the drug in biological specimens
(Walsh and Yohay 1987; Hawks and Chiang 1986). For instance,
blood, urine, saliva, expired air, and other biological samples can be
assayed for residual drug or drug-specific markers (e.g., metabolites).
Such testing aids in determining that presumed drug-related effects
were not actually symptoms of some other organic or mental


TABLE 2.-Studies concerning spontaneous remission behavior, by drug and commonly mentioned
     factors important to remission

Factor

Alcohol

Tobacco

Heroin

Significant others

Health problems

Cahalan (1970), Goodwin et al.
(1971). Knupfer (1972). Lemere (19531,
Saunders et al. (19791, Stall (1963),
Tuchfeld (1981)

Social sanctions

Cahalan (1970), Edwards et al. (1977!,
Goodwin et al. (1971), Knupfer
(1972), Stall (1983), Thorpe and
Perret (1959), Tuchfeld (19&U),
Vaillant (1982)

Edwards et al. (19771, Goodwin et al.
(1971), Knupfer (1972), Saunders et
al. (19791, Stall (1983). Tuchfeld
(1981), Vaillant (1982)

Financial problems

Cahalan (1970), Saunders et al.
(19791, Stall (1983). Thorpe and
Perret (1959), Tuchfeld (1981)

Significant accidents

Knupfer (1972), Stall (1983), Tuchfeld
(1981)

Management of cravings    Stall (1983)

Hecht (1978), Pederson and Lefcoe
(1976)

Perri et al. (1977)

DiClemente and Prochaska (1979),
Hecht (1978), Pederson and Lefcoe
(1976), Perri et al. (1977)

Hecht (1978)

Perri et al. (1977)

Baer et al. (1977), DiClemente and
Prochaska (19791, Hecht (1978).
Pederson and Lefcoe (1976), Petri et
al. (1977)

Biemacki (19833

Biemacki (19831, Schasre (19661,
Vaillant (1966a.b, 1970)

Biernacki (1983). Waldorf and
Bicrnacki (1979), Vaillant (1964.
1970)

Biernacki (1963)

Biernacki (1983), Joquez (1963L
Waldorf and Biemacki (1981)

Biemacki (19631, Joqua (1983)


TABLE 2.--Chntinued

Factor                       Alcohol

Tobacco

Heroin

Positive reinforcement
for quitting

Edwards et al. (1977). Stall (1983,

Internal psychic
change/m&v&on

Edwards et al. (1977). Knupfer
(19721, Saunders et al. (1979).
Turhfeld (1981)

Change III lifestyle

Edwards et al. ,1977). Knupfer
(19721. Saunders et al. (1979).
Tuchfeld (1961)

Baer et al. (19771, DiClemente and
Prochaska (1979). Pederwn and
Lefcoe (1976)

Biernacki (19831

Raw et al. (19771. Hecht (19761

Biernacki (19831, Schasre (19661.
Waldorf and Blernacki (19811

DiClemente and Prochaska I 19791,
Hacht (19781

Biernackl 11983~. Jorquez ~19831,
Schasre r1966). Waldorf and
Biernacki (1981 I

SOURCE: Mcdrficd Irom Stall and Birrnacki iI


disorder. One problem with such verification is that the drug level
measured reflects recency as well as amount of drug use and thus
may lead to either underestimation or overestimation of the typical
level of drug use. Furthermore, absolute level of use does not
necessarily determine whether use is pathological or detrimental.
Another problem is that biochemical drug tests vary widely in both
their specificity (correct drug identification) and sensitivity (mini-
mum amount of drug det,ected) (see Grabowski and Lasagna 1987
and Walsh and Yohay 1987 for general reviews of such issues; and
Benowitz 1983 and Muranaka et al. 1988 for a tobacco-related
review; also see Chapter II).

Presently, verification of drug dependence is based largely on the
behavioral factors as described below. The most useful application of
testing for drug levels in the body remains the verification of
compliance with treatment regimens in which drug abstinence is the
goal. These and other issues regarding the methodologies and
applications of chemical detection measures have been reviewed by a
committee of the American Society for Clinical Pharmacology and
Therapeutics (in press).

Patterns in the Development of Drug Dependence

When the relationships among drug dependencies have been
studied in major epidemiological surveys (e.g., NIDA's National
Household Survey (NHS) (US DHHS 1987)), two findings consistent-
ly emerge: persons who use dependence-producing drugs are often
cigarette smokers, and cigarette smoking precedes and may be
predictive of illicit drug use. Some of the data which have led to
these conclusions are summarized in this Section.

Current Use of Cigarettes and Other Drugs

The association of current use of one drug with current use of
other drugs has been studied extensively. One such study is the NHS
conducted by NIDA (US DHHS 1987). The Eighth NHS, conducted in
1985, involved personal interviews with 8,038 persons 12 years of age
and older, representative of the household population of the conti-
nental United States. Questions were asked about the age of
respondents when they first tried a cigarette and age when they first
started smoking daily. This distinction may be important when
comparing cigarette use with the use of other drugs. Persons who do
not make the transition from trying cigarettes to daily use may be
less likely to use other drugs than those who do make this transition.
A similar format was used with alcohol (i.e., age at which respondent
first tried alcohol, not including childhood sips, and age of first using
alcohol once a month or more). Questions about age at the onset of
other drug use were limited to age at first use. In the NHS studies,


TABLE 3.-Current use of alcohol, marijuana, and cocaine
     among "current" cigarette smokers and
     nonsmokers by age group (percentages)

Age group.
current drug use

   "Current" cigarette use
-

      No          YES

Alcohol

12-17                23.5          74.2
E-25                64.7          82.6
2G34                62.5          81.0
235                52.5         68.6

Marijuana

12-17
lb25
26-34
235

5.8          47.3
13.7          35.4
10.6          26.0
1.7          3.5

12-17                0.4          8.8
lW5                3.9          13.9
2634                4.1          9.2
235                 0.4          0.6

NOTE Current use IS any use reported m the 30 days prior to the interwew
SOURCE. Natmnal Household Surwy on Drug Abuse. 1985 tin preparatmn,

current drug use is defined as any use of the drug during the 30 days
preceding the interview.

Based on data from the 1985 NHS on Drug Abuse, Table 3 shows
associations among use of various psychoactive substances. As shown
in the table, rates of current use (i.e., during the past 30 days) of
marijuana, alcohol, and cocaine are much higher among "current"
cigarette smokers than among others. For example, among 12- to 17-
year-olds, almost three-fourths of "current" smokers were current
alcohol users compared with less than one-fourth of the youths who
were not "current" smokers. Approximately 47 percent of the
"current" cigarette smokers report being current marijuana users
compared with 5.8 percent of the youths who were not "current"
smokers.

Differences as large as those shown in Table 3 represent very
strong correlations between use of cigarettes and use of other drugs.
The strength of the correlation between use of cigarettes and use of
other drugs, licit and illicit, suggests the potential importance of
directing prevention efforts to the early gateway drugs: cigarettes
and alcohol (Kandel and Yamaguchi 1985; Clayton 1986; Clayton
and Ritter 1985).


Epidemiological Studies of the Progression of Drug Use

Tobacco use has been found to play a pivotal role in the
development of other drug dependencies. The classic descriptive
model for initiation patterns of drug use was developed by Kandel
(1975), who first divided drugs into two groups of availability: licit
and illicit. Kandel concluded that virtually all persons who ever used
illicit drugs such as marijuana and cocaine had previously used licit
drugs such as cigarettes and alcohol. Kandel's developmental stages
model is based on the assumption that there are relatively invariant
patterns of onset of use. The stages are:
(1) No Use of Any Drugs
(2) Use of Beer or Wine

(3) Use of Cigarettes and/or Hard Liquor
(4) Use of Marijuana
(5) Use of Other Illicit Drugs

Although Kandel's model addresses the initiation or onset of drug
use, it does not account for patterns of early use (e.g., frequency of
occasions or quantity per occasion). Nonetheless, there is general
agreement that the model accurately characterizes the drug initia-
tion process in the United States as one that begins with use of licit
drugs (tobacco and alcohol) and, if progression occurs, involves
greater use of these substances (Kandel, Marguilies, Davies 1978;
Huba, Wingard, Bentler 1981; O'Donnell and Clayton 1982). This
pattern has also been observed in France and Israel (Adler and
Kandel 1981).

In a longitudinal study of the progression of drug use, Yamaguchi
and Kandel (1984a) gathered baseline data in 1971 from subjects in
the 10th and 11th grade in New York State. This representative
sample was followed up in 1981 when the average age was 24.7 years.
The order of onset identified by Yamaguchi and Kandel(1984a) was
alcohol, cigarettes, marijuana, illicit use of psychoactive or prescrip
tive drugs, and other illicit drugs. Among persons who had used both
alcohol and cigarettes 10 times or more, alcohol use preceded
cigarette use in 70 percent of the cases for males and 55 percent of
the cases for females. Among persons who had used cigarettes and
marijuana 10 or more times, 67 percent of the males and 72 percent
of the females reported using cigarettes first.
Using a sophisticated statistical analysis, Yamaguchi and Kandel
(1984a) derived several additional conclusions including the follow-
ing:

(1) For men, the pattern of progression was one in which the use
of alcohol preceded marijuana; alcohol and marijuana preced-
ed other illicit drugs; and alcohol, cigarettes, and marijuana
preceded the illicit use of other psychoactive drugs. Eighty-
seven percent of the men were characterized by this pattern.

261


(2) For women, the pattern of progression was one in which either
alcohol or cigarettes preceded marijuana; alcohol, cigarettes,
and marijuana preceded other illicit drugs; and alcohol and
either cigarettes or marijuana preceded the illicit use of
psychoactive drugs. Eighty-six percent of women shared this
pattern.

Tobacco Use as a Predictor of Other Drug Use

In an analysis of nationwide data from the high school senior class
of 1980, Clayton and Ritter (1985) found that alcohol drinking and
cigarette smoking were the most powerful predictors of the extent of
marijuana use for both males and females. Cigarette use was a
stronger predictor of marijuana use among females. Moreover, this
role of cigarette smoking was especially pronounced when it had
been initiated at age 17 or earlier. Similarly, data from the
longitudinal study by Yamaguchi and Kandel (1984a,b) revealed
that, among persons with some history of alcohol use, cigarette
smoking was a powerful predictor of marijuana use.

Consistent with the above described findings regarding cigarette
smoking, smokeless tobacco use has also been shown to be a predictor
of other drug use, including cigarette smoking (Ary, Lichtenstein,
Severson 1987). More than 3,000 male adolescents were interviewed
twice, at an approximately g-month interval, to determine their
rates and levels of use of various psychoactive substances. The main
findings were that (1) users of smokeless tobacco were significantly
more likely to use cigarettes, marijuana, or alcohol than nonusers;
(2) users of smokeless tobacco were significantly more likely to take
up use of cigarettes, marijuana, or alcohol than nonusers; (3)
smokeless tobacco users who were using these other substances at
the time of the first interview showed substantially greater increases
in levels of use of these other substances over the 6-month interval
than did nonusers of smokeless tobacco; and (4) 71 percent of those
who had been using smokeless tobacco at the first interview
remained users at the second interview.

Cigarette smoking is also a predictor of cocaine use. White and
colleagues (US DHHS 1987) began with a large sample of 12-, 15-,
and 18-year-old adolescents in New Jersey and reinterviewed them
at 3-year intervals. As reported in NIDA's Triennial Report to
Congress (US DHHS 19871, White and coworkers found that there
were several predictors of cocaine use in 18-year-olds who had been
interviewed 3 years earlier: prior use of cigarettes, alcohol, and
marijuana. Furthermore, at the time of the second interview (of the
l&year-olds), the cocaine users used cigarettes, alcohol, marijuana,
and other drugs more often than did nonusers of cocaine.

Although alcohol use frequently precedes tobacco use, the use of
alcohol only progresses to dependence (alcoholism) in about 10 to 15

262


percent of all drinkers (Miller 1979). Use of cigarettes, by contrast,
almost inevitably escalates to a level characterized as dependent use
(Russell 1976; US DHHS 1987). This is consistent with the observa-
tion that although some use of alcohol may precede tobacco use, it is
prior use of tobacco and not alcohol that emerges in the above-cited
studies as the stronger predictor of illict drug use.

The 1985 High School Senior Survey by NIDA (US DHHS 1987)
showed that the first dependence-producing drug tried among users
of alcohol and illicit drugs was often tobacco. For example, among all
respondents 12 years of age and older, first use of tobacco and alcohol
occurred in the same year for 18 percent of the sample; cigarettes
were used first by 62 percent of the sample, and alcohol was used
first by 20 percent. Among those who tried both cigarettes and
marijuana, 14 percent first tried these drugs in the same year, 75
percent tried cigarettes first, and 11 percent tried marijuana first.
Among those who tried both cigarettes and cocaine, 95 percent used
cigarettes first, 3 percent used them first the same year, and only 2
percent used cocaine before cigarettes. These observations show that
when cigarettes and another of these dependence-producing drugs
have been used by the same individual, cigarette use usually is the
first of the two drugs used. One difference between cigarette smoking
and the use of other common substances (e.g., milk, sugar, or aspirin)
that may also precede the use of illicit drugs is that nicotine itself is
a drug that produces the tolerance, physical dependence, and drug-
seeking behavior that meet the criteria of a drug-dependence
syndrome.

Frequency of Use of Cigarettes and Other Drugs

Measures of frequency of drug use also yield important findings.
The data presented in Table 4 show the percentage of persons in
three groups (never smoked, tried cigarettes but never used them
daily, used cigarettes on a daily basis) who report use of alcohol,
marijuana, and cocaine. The criterion for alcohol use is 5 or more
consecutive drinks during at least 1 day in the past 30 days; criteria
for marijuana and cocaine use involve previous use of these drugs
more than 10 times during the respondent's lifetime. These criteria
were used to eliminate those who merely tried the drug on a few
occasions ("experimental" use). The percentages are presented
separately for four age groups.

The main finding shown in Table 4 is that those who become daily
cigarette smokers are considerably more likely than others to report
use of these other drugs, regardless of age group. For example,
among the 12- to 17-year-olds, less than 0.5 percent of the never
smokers report using marijuana more than 10 times compared with
3.3 percent of those who tried but never used cigarettes daily and
22.7 percent of those who have used cigarettes daily. These data


TABLE 4.-Use of alcohol, marijuana, and cocaine among
     "never" cigarette smokers, "occasional"
     cigarette smokers, and daily cigarette smokers,
      by age group (percentages)

Cigarette use pattern

Age group.         Never         Tried, never       Smoked
drug use          smoked        used daily       daily

12-17             2.7             15.9           38.5
18-25            12.3             31.9           49.6
x%34             9.8             23.0           41.3
235             5.6             9.2           20.1

Marijuana'

12-li
la-25
2634
235

0.2             3.3           22.7
3.3             8.3           37.4
2.8             12.9           30.3
0.6             1.8           3.8

12-17             0.2             0.a           6.4
lP25             1.3             4.5           14.2
2634             1.8             7.2           15.6
235             0.2             0.3           1.9

extend those presented in Table 3: associations exist between
cigarette smoking and other drug use when considering "current"
use (any use in the past 30 days) (Table 3) or measures of frequency
of drug use (Table 4). Similarly, a study of alcohol drinking and
cigarette smoking among students in grades 7 to 12 in New York
State showed a positive correlation between the frequency of
consuming alcoholic beverages and both the likelihood of smoking
cigarettes and daily cigarette consumption (Welte and Barnes 1987).

Initiation of Drug Use

Initiation of drug use often occurs through social contacts,
independent of the pharmacologic actions of the drug. Drug seeking
is then sustained and modulated through combined social and
pharmacologic factors. With the possible exception of stimulants
such as cocaine and amphetamine, initial exposure to many psy-
choactive drugs (including opioids, alcohol, and nicotine) is often
associated with aversive consequences (Haertzen, Hooks, Ross 1981;
Haertzen, Kocher, Miyasato 1983). For example, opioids may pro-
duce nausea; alcohol and nicotine not only produce nausea but may

264


produce initially aversive sensory effects in some preparations (e.g.,
high-concentration alcoholic beverages may taste "bad" and ciga-
rette smoke may be "harsh"). As a consequence, lengthy periods of
occasional ("experimental" or %ocial'? drug use frequently precede
the development of daily drug use.

These observations imply that nondrug factors are important in
the initiation and maintenance of drug intake until dependence
upon the drug itself develops (Crowley and Rhine 1985; Vaillant
1970, 1982; Marlatt and Baer 1988; Brown and Mills 1987). As
discussed elsewhere in this Chapter, such factors can also modulate
level of drug use as well as influence the frequency of quitting
attempts and their likelihood of success (see also Chapters IV and
VII in this volume and earlier Reports of the Surgeon General). The
specific factors that have been identified and accepted as prominent
in helping to establish initial exposure to drugs (Crowley and Rhine
1985) include availability of the drug, cost of the drug, social
acceptability of the drug, and other environmental sources of
pressure to use drugs.

The acceptability of the drug preparation itself can be manipulat-
ed by controlling the dose of the drug and increasing its sensory
palatability. For example, the utility of some of the newer smokeless
tobacco formulations as "starter" products for youth is held to be due
in part to the lower concentrations of nicotine, formulations that
facilitate use (e.g., snuff in pouches), as well as nontobacco flavorings
(e.g., mint or cinnamon) (Henningfield and Nemeth-Coslett 1988; US
DHHS 1986, 1987; Connolly et al. 1986). Such strategies of "starter
product" manipulation are analogous to those used to initiate drug
seeking in laboratory animals, described later in this Chapter. Such
product acceptability factors, combined with the ready availability,
peer pressure to use, perceptions that the products were safe, and
marketing strategies aimed at increasing the social desirability of
smokeless tobacco use, appear to have been largely responsible for
the marked rise in use of smokeless tobacco by youth in the 1970s
(Ary, Lichtenstein, Severson 1987; Christen and Glover 1987; Con-
nolly et al. 1986; Connolly, Blum, Richards 1987; Glover et al. 1986;
Guggenheimer et al. 1987; Kirn 1987; Kozlowski et al. 1982; Marty et
al. 1986; Negin 1985; Silvis and Perry 1987; US DHHS 1979;
Appendix A).

Vulnerability to Drug Dependence: Individual and
Environmental Factors

Despite the complexity of the issues, it is useful to identify factors
that differentiate individuals who appear more susceptible to drug
dependence. These factors may collectively be termed vulnerability
factors. Vulnerability factors are diverse, varying among individuals
and within individuals at different times (Radouco-Thomas et al.


1980; Marlatt and Baer 1988; Brown and Mills 1987). Vulnerability
may arise from genetic variation or from environmental sources
including learning (Jones and Battjes 19851. Vulnerability factors
are such that they do not necessarily compel a person to use a drug;
in fact, they might be undetected in a person never exposed to a
dependence-producing drug. Nonetheless, the presence of several
vulnerability factors can increase the likelihood of the development
of drug dependence, including cigarette smoking.
The concept of a predisposition to drug dependence arose from the
observation that not all people are equally prone to becoming
behaviorally dependent. upon drugs (Mann et al. 1985; Radouco-
Thomas et al. 1980; Jaffe 1985; M.N. Hesselbrock 1986; V.M.
Hesselbrock 1986; Mirin, Weiss, Michael 1986). The multiple sources
of differences in predisposition or vulnerability to drug dependence
are not mutually exclusive. One is a genetic predisposition, shared by
family members by virtue of their common biological heritage.
Another is an experiential predisposition, shared by family members
by virtue of their shared life experiences. For instance, children with
parents who are dependent on drugs are at elevated risk of becoming
dependent (Hawkins, Lishner, Catalan0 1986; Begletier et al. 1984;
Kumpfer 1987). For tobacco, the magnitude of the effect is greater
when both parents smoke than when only one parent smokes
(Borland and Rudolf 1975; Green 1979). Other types of vulnerability
factors are physiologic (e.g., pain, sleep deprivation) and psychiatric
(e.g., anxiety, depression) conditions that may constitute undesirable
states for which relief is sought by use of a drug (Crowley and Rhine
1985). Finally, as discussed earlier in this Chapter, a variety of
nonpharmacologic factors are important in the initiation and
development of drug dependence (e.g., price, availability); such
factors may be considered vulnerability factors in their own right.
A recent area under active investigation is the identification of
specific vulnerability factors in youth (Brown and Mills 1987). For
example, cigarette smoking has long been associated with juvenile
behavior problems (Armstrong-Jones 1927; Welte and Barnes 1987;
Kumpfer 1987); more recently, scientific data have confirmed the
statistical association of increased rates of cigarette smoking among
juveniles with a conduct disorder diagnosis (i.e., adolescent deviance)
(Sutker 1984). A related observation is that children with conduct
disorders are at elevated risk of using opioids, cocaine, alcohol,
tobacco, and other psychoactive drugs (Baumrind 1985). In fact,
Kellam, Ensminger, and Simon (1980) found that certain indices of
mental health identified in first graders were highly predictive of
the use of various psychoactive drugs (including alcohol, opioids,
marijuana, and nicotine) when the children were restudied in their
teenage years. These studies do not directly address the degree to
which juvenile behavior problems are causes or consequences of drug


use. It is plausible that either drug use or other behavior problems
can exacerbate each other, possibly alternately contributing to a
gradual escalation of drug use, behavior problems, or both. These
observations suggest that it is especially important to prevent
initiation of drug use among individuals who appear to be at
increased risk (vulnerability) to developing drug dependencies.

Pharmacologic Determinants of Drug Dependence
As discussed earlier in this Chapter and in Chapter I, it is the

involvement of a dependence-producing drug that sets drug addic-
tions apart from the so-called "addictions" to other substances (e.g.,
food) and activities (e.g., gambling). There are scientific methods to
determine if use of a substance involves a dependence-producing
drug. These methods, how they are applied to study drugs such as
morphine, cocaine, and nicotine, and some of the main findings from
such work are reviewed in this Section.

A wide range of drugs can be used to modify behavior (e.g., as used
in psychiatric treatment); however, the term drug dependence is
generally reserved for dependencies which involve drugs that can
sustain repetitive drug self-administration by virtue of their tran-
sient effects on mood, feeling, and behavior. Drugs that exert such
effects via alteration of functioning of the brain or central nervous
system (CNS) are generally termed "psychoactive" (WHO 1981).
When the psychoactivity of a given drug is frequently pleasant, it is
referred to as a "euphoriant," as "reinforcing," or as an "abusable"
drug, although these terms are not precisely interchangeable. This
framework is consistent with that described by Lewin (1931);
namely, that these drugs are chemicals which are "taken for the sole
purpose of producing for a certain time a feeling of contentment,
ease, and comfort." Drugs which produce such effects effectively
control the behavior of a wide range of species, including humans.

How Drugs Control Behavior

Drugs cause addiction by controlling the behavior of users; that is,
addicting drugs come to influence behavior leading to their own
ingestion. The behavioral and pharmacologic mechanisms of such
control have been reviewed elsewhere (Thompson 1984) and will only
be briefly summarized in this Section. Behavior, including drug
taking, is biologically mediated by the electrical and chemical
stimuli which arise from the nervous system. These stimuli may
originate within the body and brain of the individual, but they may
also arise from environmental events and be detected by sensory
processes such as vision and audition. Dependence-producing drugs
control behavior by activating, inhibiting, or mimicking the existing
chemical circuits of the nervous system. Dependence-producing

267


drugs are those that readily exert control over behavior by virtue of
their stimulus properties. It is useful to distinguish among four kinds
of stimulus effects produced by dependence-producing drugs.
(1) Drugs can produce interoceptiue or discriminatiue effects that a
person or animal can distinguish from the nondrug state. These
effects may set the occasion for the occurrence of particular
behaviors. For example, the taste of alcohol or the smell of tobacco
smoke can set the occasion for social interactions, and the "priming"
effects of a single dose of a drug can lead to subsequent drug seeking
and relapse in animals or humans with a history of use (Griffiths,
Bigelow, Henningfield 1980; Colpaert 1986).
(2) Drugs may serve as positive reinforcers or rewards which
directly strengthen behavior leading to their administration. The
reinforcing efficacy may be related to effects termed either "stimu-
lating, " "relaxing," "pleasant," Xseful," "therapeutic," or "euphori-
ant" or may be related to providing relief of withdrawal symptoms or
other undesirable states.
(3) Drug administration or abstinence can also function as
"punishers" or aversive stimuli. For example, high-dose levels of
most psychoactive drugs serve as an upper boundary level of intake;
analogously, decreasing drug levels can also function as aversive
stimuli contributing to the strength of drug taking as a means to
avoid such aversive effects (Downs and Woods 1974; Goldberg et al.
1971; Henningfield and Goldberg 1983b; Kozlowski and Herman
1984). Aversive stimuli may function as negative reinforcers by
strengthening behavior that removes the stimuli (Skinner 1953).
Thus, drug withdrawal symptoms are sometimes referred to as
negative reinforcers that increase drug seeking.
(4) Drug administration, or abstinence following a period of
chronic administration, can serve as unconditioned stimuli, in which
case they may directly elicit various responses, e.g., vomiting at high-
dose levels of opioid administration or during opioid withdrawal,
light-headedness produced by rapid smoking, and a strong urge to
use a drug. As will be discussed later in this Chapter, repetition of
such phenomena can lead to their elicitation by drug-associated
stimuli, e.g., the sight or smell of drug-associated stimuli (O'Brien,
Ehrman, Ternes 1986; Wikler 1965; Wikler and Pescor 19671.
All of these processes may occur whether or not the person has
correctly identified their source, i.e., is "aware" of how the drug led
to the behavior (Fisher 1986). Furthermore, the biological power and
generality of these processes are evidenced by the findings that they
also occur in animals (Young and Herling 1986; Spealman and
Goldberg 1978; Johanson and Schuster 19811.
Drugs differ widely in their potential to control behavior via such
mechanisms. Dependence-producing drugs usually readily control
behavior in all of the above capacities. Quantification of such


characteristics is the cornerstone of testing for the likelihood that
use of a drug will lead to addiction. Observers in the 19th and early
20th centuries (e.g., Lewin 1931) had correctly determined that it
was the psychological (behavioral) effects (sometimes termed "psych-
ic" or "mental" effects) of substances that led to their habitual use.
Practical methods for evaluating the behavior-modifying properties
of drugs did not emerge until the behavioral sciences themselves had
become sufficiently sophisticated in the 1930s and 1940s. Prior to
this time, dependence-producing drugs were identified on the basis of
retrospective observations of their effects. Since the 194Os, however,
drug testing has grown increasingly reliable at identifying ("screen-
ing") drugs for their potential to produce dependence prior to
observations of dependence outside the laboratory. In fact, highly
reliable information can now be obtained on the basis of animal
testing alone (Martin 1971; Thompson and Unna 1977; Brady and
Lukas 1984; Bozarth 1987b).

Methods for evaluating the behavior-modifying properties of drugs
were largely developed beginning in the 1940s in studies with
morphine-like opioids and cocaine-like stimulants, and have only
recently been systematically used to evaluate nicotine. The methods
will be described in the remainder of this Section, along with a
comparison between the behavioral-pharmacologic actions of nic-
otine and those of other drugs.

Dependence Potential Testing: Psychoactive, Reinforcing,
and Related Effects

To scientifically determine if a chemical is dependence producing,
a series of scientific tests may be done. These tests are jointly termed
dependence potential tests. In this Chapter, Dependence Potential
Testing refers to laboratory tests which measure the behavioral and
physiological responses of animals and humans to drug administra-
tion and to termination of chronic drug administration. Taken
together, the results of these tests can be used to objectively predict
whether a drug lends itself to self-administration by persons who are
exposed. The focus of the present Section is on how the methods are
applied to evaluate the potential of drugs to control behavior and to
produce transient alterations in mood or feeling that are predictive
of self-administration. Such effects have essentially defined the
dependence-producing drugs and have set them apart from other
medicinals and food; drugs with such effects are sometimes termed
"psychotropic" or "behaviorally active" but most commonly as
"psychoactive" (President's Advisory Commission 1963; WHO 1981).

Not all psychoactive drugs lead to dependence; many drugs used to
treat behavioral and psychiatric disorders are considered to have
minimal dependence potential (for example, tricyclic antidepres-
sants) or may actually produce effects that substantially impair long-

269


term compliance with therapeutic regimens (for example, major
tranquilizers). How dependence-producing drugs are distinguished
from other psychoactive drugs will be described in this Section. The
next Section will discuss methods used to measure test drugs for
their potential to produce tolerance and physical dependence.

In reviews and proceedings from various expert committees, the
procedures to be described have been referred to as testing for
"Abuse Liability," " Psychic Dependence," "Abuse Potential," "Ad-
diction Liability," " Behavioral Dependence," and "Dependence Po-
tential" (Brady and Lukas 1984; Goldberg and Hoffmeister 1973;
Thompson and Unna 1977; Seiden and Balster 1985; Thompson and
Johanson 1981; Bozarth 1987b; WHO 1981). Whereas there are
differences in focus that are evident when these methods are
compared, the general goals and strategies are consistent. These will
be briefly described in this Section. Detailed descriptions of these
methods have been provided by an expert subcommittee of the
Committee on Problems of Drug Dependence (Brady and Lukas 1984)
and in numerous conferences involving world experts on such
procedures (Goldberg and Hoffmeister 1973; Thompson and Unna
1977; Seiden and Balster 1985; Thompson and Johanson 1981;
Bozarth 198713). The results of the methods are also considered in the
process of reviewing the national and international regulatory status
of various drugs either known or suspected to be addicting by the
FDA, the Drug Enforcement Agency (DEA), and the WHO (WHO
1981, 1987).

Effects of Drugs on Mood and Feeling (Psychoactivity)

Dependence-producing drugs can change the way a person thinks,
feels, and behaves. The effects may be very subtle (e.g., feelings of
relaxation), or they may be profound (e.g., intoxication and impaired
cognitive abilities). The scientific assessment of the effects of drugs
on mood and feeling (also referred to as "psychoactive," "psychologi-
cal," "interoceptive," "subjective," "psychic," or "self-reported"
effects) was essentially an extension of the methods developed to
assess physiological actions of drugs. By the late 194Os, several drug
dependence researchers had concluded that physical dependence
potential testing was of limited value in predicting whether drug-
seeking behavior would develop following exposure to a given drug
(Isbell 1948; Isbell and Vogel 1948). These researchers used observa-
tional techniques to measure interoceptive drug effects. Later, the
reliability and general applicability of the techniques were substan-
tially enhanced by incorporation of the methods developed by Rao
(1952) for assessing changes in subjective state and the methods
developed by Beecher (1959) for the measurement of pain and
analgesia in humans.

270


These methods contributed to the development of what are
generally considered the first objective questionnaires for assessing
addictive drug effects by Fraser and his colleagues (Fraser and Isbell
1960; Fraser et al. 1961). A prominent feature of the questionnaires
was a series of scales to evaluate the ability to feel or discriminate a
drug effect, to rate the liking of the drug effect, and to identify the
drug that was given from a list of widely used and abused drugs.
The next major advance in the quantification of subjective drug
effects was the development of the Addiction Research Center
Inventory (ARCI) by Haertzen and his colleagues (Haertzen, Hill,
Belleville 1963; Haertzen 1966, 1974: Haertzen and Hooks 1969;
Haertzen and Hickey 1987). The ARC1 contained scales that were
empirically derived to be sensitive to the effects of specific drugs and
drug classes (e.g., sedatives, stimulants, hallucinogens). One of the
most useful scales was developed to measure the effects of morphine
and benzedrine (a prototypical opioid and stimulant, respectively);
this scale was subsequently referred to as the "Morphine Benzedrine
Group" or "MBG" or "Euphoriant" scale, because morphine-like and
benzedrine-like drugs increased the scale scores while simultaneous-
ly producing feelings often reported as pleasurable (Haertzen, Hill,
Belleville 1963; Haertzen 1974). Scores on the MBG scale are also
elevated by most other addicting drugs (Jasinski 1977; Jasinski,
Johnson, Henningfield 1984; Henningfield 1984). More recently, the
highly specific drug discrimination testing procedures (described
below) have been added to the human drug dependence potential
testing armamentarium (Chait, Uhlenhuth, Johanson 1984, 1985).
To the extent to which certain common features are identified
using tests such as the above, they may be categorized together, e.g.,
as dependence-producing or addicting drugs. This is referred to as
determining "pharmacologic" equivalence. Conversely, to the extent
to which these same drugs differ in certain respects, they may also
be subcategorized as, for instance, analgesics, sedatives, or stimu-
lants. Such categorization must be viewed with caution, however,
because overemphasis on any particular feature of a drug can be
misleading. For instance, morphine,. alcohol, and amphetamine can
all produce behavioral and physiological effects that are stimulant-
like as well as effects that are sedative-like (Gilman et al. 1985; Dews
and Wenger 1977). Nicotine has been viewed as both a stimulant
("excitant") (Lewin 1931) and a sedative (Armstrong-Jones 1927).
Most commonly nicotine is now categorized as more stimulant-like
than sedative-like, but with an appreciation of its diverse range of
potential effects, which depend upon the dose given and the measure
used (Gilman et al. 1985).


Methods and Results

Assessment of the psychoactivity of drugs in humans essentially
entails giving either drug or placebo to volunteers and then asking
them to report the nature of effects produced. Replicability and
objectivity are increased by using standardized questionnaires such
as those described above (e.g., "liking" scales, ARCI). In practice,
several procedural variations are used to further enhance the
reliability and validity of the results. The dose of the drug is varied
to assess the nature of the dose-effect relationships; for all depen-
dence-producing drugs, ratings of dose strength or the percentage of
accurate drug identifications is directly related to the dose given.
Subjects with histories of use of a variety of drugs can be asked to
report which, if any, of those drugs the test drug feels like; such
testing is useful to determine the extent to which the test drug
produces any effects on mood and feeling that resemble those of
previously studied drugs. Subjects with histories of use of a variety of
drugs and who report "liking" the effects of a range of drugs can be
used to help assess the dependence potential of the test drug by
rating how desirable they find it to be.

Incorporation of several of these methods can add considerably to
the strength of conclusions which can be drawn. For example,
morphine-like opioids, pentobarbital-like barbiturates, amphet-
amine-like stimulants (including cocaine), alcohol, and nicotine all
produce rapidly onsetting and offsetting discriminative effects; the
magnitude and duration of these effects are directly related to dose;
all elevate scores on the liking and MBG scales; the effects of ail are
directly (though complexly) related to pharmacokinetic factors such
as rate of systemic absorption; all produce discriminative effects that
correspond to certain physiological changes; all produce effects that
can be accurately identified by an observer; all are identified as
known addicting drugs by subjects with a history of use of such
drugs; pretreatment with antagonists may block these effects (only
opioids and nicotine have been systematically studied on this
dimension). Such orderly and consistent kinds of effects across drugs
confirm that they are appropriately categorized together as addict-
ing drugs.

The selectivity and sensitivity of such procedures are illustrated in
Figure 1. As shown in the Figure, when persons with multiple drug
dependence histories were given drugs under double-blind condi-
tions, they rated placebo (unconnected data point on each graph) and
the nonaddicting zomepirac at a minimal level of "liking" (Jasinski,
Johnson, Henningfield 1984). As a direct function of dose, however,
the known addicting drugs were rated with greater liking scores. As
also illustrated in Figure 1, nicotine produced comparable dose-
related increases in drug liking scores as did amphetamine, mor-
phine, and pentobarbital. Studies with human volunteers have also

272


MORPHINE
(SC)

BUPRENORPHINE
   w

t   d-AMPHETAMINE
     (SC)

NICOTINE
(IV)

z
5   PENTOBARBITOL
      PO)

1
  /
I
k
  o




  o   ???

CHLORDIAZEPOXIDE
    (PO)

t

.
L-
4



o o? ??????

PENTAZOCINE
  W)

DS-THC
PO)

    c
L
/

.

o   ? ?? o?

ZOMEPIRAC

Drug dose (mg)

FIGURE l.-Liking scale scores of the single-dose
      questionnaire

NOTE: Sample size ranges from 6 ipentobarbxtal and chlordiazepoxide) to 13 (d-amphetaminei The high dose of
each drug (except wmepirac) produced significant (p<O.O5) increases in scores above placebo Data are peak
response. which occurred from approximately 1 minute (mcot;ne) to 5 hours lbuprenorphine). Morphine and
zomepirac data am fmm the same group of subjects as pentobarbital and chlordiazepoxide data The P + T point
on the pentamcine graph is the score given to 40 mg pentazocine combined with 50 mg tnpelennomine. The M
point on the A-9.THC graph is the smre. from the same subjects. obtained after smoking a marijuana cigarette
containing 10 mg I1 percent by weight) A-9.THC.
SOURCE: Jasinski. Johnson, Henningfield 11984).

shown that most of the known addicting drugs (including nicotine)
produced certain changes in mood and feeling that resemble those
produced by morphine or benzedrine enough to significantly elevate
the MBG scale scores (Griffiths, Bigelow, Henningfield 1980; Hen-
ningfield, Johnson, Jasinski 1987).

273


The validity of self-reported drug effects as objective indices of
dependence potential has been tested using similar rating scales by
observers who are blind to the condition. On the basis of their
observations of subject behavior, observers report similar dose-
related increases in scores on the strength of the drug effect and/or
the level of drug liking for alcohol (Henningfield, Chait, Griffiths
1983), pentobarbital (Martin, Thompson, Fraser 1974; Henningfield,
Chait, Griffiths 1983), morphine and heroin (Martin and Fraser
19611, amphetamine (Jasinski and Nutt 1972; Jasinski, Nutt, Griffith
1974), and a variety of other dependence-producing drugs (Jasinski
1977). A similar correspondence between subject and observer
ratings was obtained when subjects were given either i.v. nicotine
injections or research cigarettes which varied in nicotine dose
(Henningfield, Miyasato, Jasinski 1985).

Effects on mood and feeling also correspond to a variety of
physiological effects. Some of these physiological changes vary by
drug class. For example, pupil diameter increases appear to corre-
spond to early nicotine-induced subjective effects and to amphet-
amine and cocaine administration (Henningfield et al. 1983; Jaffe
1985), whereas pupil diameter decreases when morphine is given
(Jasinski 1977). Other physiological effects show a greater degree of
similarity across drug classes. For example, studies of ethanol
administration in human subjects revealed that paroxysmal bursts
of electroencephalogram (EEG) alpha activity paralleled subjective
reports of euphoria during the ascending limb of the plasma ethanol
curve (Lukas et al. 1986b,c), which also paralleled increases in
plasma adrenocorticotropic hormone (ACTH) levels (Lukas and
Mendelson, in press). Similar effects were observed following mari-
juana smoking (Lukas et al. 1985, 1986a) and acute i.v. nicotine
administration (Lukas and Jasinski 1983). In turn, similar changes
in EEG alpha activity have been shown to correspond with subject-
reported pleasurable states which c':r occur in the absence of drug
administration (J,indsley 1952; Brown 1970; Wallace 1970; Matejcek
1982).

Drug Discrimination Testing

Drug discrimination testing in animals is assumed to provide
information analogous to the above-described procedures for assess-
ing the effects of drugs on mood and feeling in humans (Goldberg,
Spealman, Shannon 1981). Drug discrimination testing can provide
two general kinds of information. First, the ability of dependence-
producing drugs to control behavior by serving as positive reinforc-
ers or punishers is associated with whether they produce interocep-
tive effects which are discriminated (or "felt"). Second, drugs can be
compared with each other to determine the degree to which they are
identified as similar or different. The methods used for drug

274


discrimination testing in animals were not systematized and widely
utilized until the late 1960s and early 1970s (Overton 1971; Overton
and Batta 1977; Schuster and Balster 1977; Jarbe and Swedberg
1982).

Extension of animal discrimination study results to humans is
limited by species differences and by other unique human factors
that may contribute to the dependence potential of a drug. Nonethe-
less, animal studies are an important advance because they permit
relatively inexpensive and rapid testing of a broad range of
compounds and allow evaluations to be made without the possible
confounding social and cultural factors. Animal studies also provide
a means of gauging the biological generality of the drug discrimina-
tion data (e.g., to determine if unusual genetic characteristics are
necessary for certain drug effects).

Methods and Results

These procedures and variations have been described in greater
detail elsewhere (Overton and Batta 1977; Colpaert 1986; Rosecrans
and Meltzer 1981). In brief, the basic method is to train animals to
emit one response when given one drug and to emit another response
when given either no drug (i.e., placebo) or a different drug. The
animals are usually trained with either food reinforcement or the
withholding of electrical shock for "correct" responses. When the
animals have been trained to a level of 80 or 90 percent correct
responses, they are said to be discriminating drug from placebo.
Then they are ready for the testing of different doses of the training
drug or different drugs. This testing is often accomplished without
the use of food or shock contingencies, so that it can be determined
which response the animal will make when given the test drug.

A check on the validity is to give lower doses of the training drug;
the lower the dose, the less the animal should respond on the drug
lever and the more on the placebo lever. A similar effect is obtained
when an antagonist is given before testing with the training drug; as
the dose of the antagonist is increased, the ability of the animal to
discriminate the training drug decreases and the animal emits more
no-drug responses. These effects have been demonstrated with both
the opioids and nicotine (Overton 1971; Colpaert 1986; Rosecrans and
Meltzer 1981; Chapter III); i.e., decreasing the dose of the opioid or
nicotine or pretreating with an opioid or nicotine antagonist can
produce decreased drug lever responding.

The specificity of the stimulus produced by a drug can also be
evaluated by testing drugs. The degree to which the animals make
the "drug" responses or "mistake" the test drug for the training drug
is termed "generalization" and indicates the level of similarity of
effects between the drugs (Colpaert and Rosecrans 1978). Morphine
analogs, amphetamine analogs, pentobarbital analogs, and nicotine

275


analogs produce substantial amounts of generalization to morphine,
amphetamine, pentobarbital, and nicotine, respectively. The fact
that there is less generalization across drug classes is an index of the
specificity of the drug stimulus. The cross-drug classifications which
have resulted from animal discrimination studies are generally
consistent with human data (Goldberg, Spealman, Shannon 1981).
For instance, if an animal has been trained to press one lever when
given amphetamine and another lever when given pentobarbital, it
tends to press the amphetamine lever more often than the pentobar-
bit,al lever following a nicotine injection (Schecter 1981). This finding
is consistent with that obtained in a study in which human
volunteers frequently identified nicotine injections as amphetamine
or cocaine at higher nicotine dose levels but not at the lower levels
and only rarely identified the nicotine injections as sedatives
(Henningfield, Miyasato, Jasinski 1985).

A more recent development is the extention of the systematic drug
discrimination procedures to use with human subjects. Similar
methods are used, and initial findings with drugs such as nicotine
and amphetamine are comparable to the results from animal studies
(Kallman et al. 1982; Chait, Uhlenhuth, Johanson 1984). Specifically
human volunteers can readily learn to differentially respond to the
presence or absence of these drugs, and the effects are dose related.

Drug Self-Administration

When given the mechanical means to do so, animals self-adminis-
ter addicting drugs (including nicotine) much like humans; that is,
drugs that function as rewards or reinforcers for humans also tend to
function as reinforcers for animals. The conceptualization of depen-
dence-producing drugs as reinforcers provided the framework for a
highly predictive test strategy, the self-administration study, where-
by animals or humans are given the opportunity to take drugs under
laboratory conditions (Thompson and Schuster 1968). This research
strategy permitted scientific analysis of the single common link
across all forms of drug dependence, namely that the addictive
behavior (for whatever reason) is motivated or controlled by the
drug's reinforcing (rewarding) properties (Goldberg and Hoffmeister
1973; Thompson and Unna 1977; Seiden and Balster 1985). Stimuli
that can maintain and strengthen behavior leading to their presen-
tation are termed "positive reinforcers" regardless of their hypothe-
sized mechanism of action (e.g., alleviation of discomfort or produc-
tion of pleasure) (Skinner 1953; Thompson and Schuster 1968). The
reinforcing power or efficacy of a drug can be enhanced by a variety
of conditions (e.g., deprivation of the drug which the organism had
been repeatedly given, pain, food deprivation, social approval
contingent on drug taking, and perceived useful effects) (Thompson
and Schuster 1968; Thompson and Johanson 1981). Following

276


repeated exposure to a drug, a biologically mediated "drive" state
can be established that did not preexist as do the drives for food,
water, or sex.

The potential of a drug to serve as a reinforcer can be directly
assessed and quantified in laboratory studies of drug self-administra-
tion. Essentially, a human or animal subject is given access to the
drug; then his or her propensity to take the drug (i.e., to "self-
administer" the drug) can be measured. The self-administration test
provides the opportunity to rigorously study the main distinguishing
feature of drug dependence, that is, drug-seeking behavior. As is the
case in drug discrimination testing, animal data help to determine
the generality of the biological basis of the addictive process for a
given drug; for example, such data help to reveal if the process is
unique to humans because of social, genetic, or other factors. If the
drug is taken under a variety of prescribed conditions (summarized
later in this Section), then it is said to be functioning as a
"reinforcer" or "reward."

The validity and generality of self-administration test results were
demonstrated by the observations that (1) there was a remarkable
degree of consistency between patterns of drug self-administration
among laboratory animals and observations concerning human drug
dependence (Jasinski 1977; Griffiths, Bigelow, Henningfield 19801,
(2) drugs that serve as reinforcers in self-administration studies also
tend to be "liked" when given to humans, and (3) there was a high
correlation among drugs which produced morphine-like euphoriant
effects and those which were self-administered by animals (Griffiths
and Balster 1979; Griffiths, Bigelow, Henningfield 1980; see related
data in Schuster, Fischman, Johanson 1981).

Initiation of Drug Self-Administration

As discussed earlier in this Chapter, drugs cannot produce
dependence without initial exposure to them. Initiation of drug use
in humans is often mediated by social and other environmental
sources of pressure. To determine if a drug will reinforce behavior in
animals similarly requires some means of providing exposure to the
drug. Strategies for establishing drug taking in animals are analo-
gous in key respects to how humans may become dependent upon
drugs. Four general categories of methods are most commonly used.
The methods are not mutually exclusive and are sometimes used in
combination.

The first method of establishing drug self-administration in
animals is to provide initial doses ("priming" or "free sampling") and
then to gradually increase the dose ("graduation"). For instance, i.v.
drug infusions may be given to animals on a chronic basis while the
animals are also given the opportunities to take the drug. This
provides an opportunity to determine if simple exposure to the drug

277


is sufficient to result in drug seeking. A minor variation is to
gradually increase the dose of each injection over time. This general
procedure has been used to establish i.v. self-administration of d-
amphetamine, morphine, alcohol, pentobarbital, cocaine, nicotine,
and many other drugs (Deneau and Inoki 1967; Deneau, Yanagita,
Seevers 1969; Yanagita 1977; Woods, Ikomi, Winger 1971; Brady and
Lukas 1984; Griffiths, Bigelow, Henningfield 1980; Meisch 1987;
Henningfield and Goldberg 1983a).
A second method of establishing drug self-administration is to
substitute a new drug for one which was already serving as a
reinforcer. Humans do this as a function of drug availability; they
sometimes learn to like drugs which had not been taken previously
and may even come to prefer the new drug. Using this method with
animals provides a means of exposure to a new drug and may be
useful in comparing one drug with another. In animal studies,
cocaine is the most commonly used starter drug, because in animals
(as in humans) cocaine seems to be a source of reinforcement and/or
pleasure under an extremely broad range of conditions compared
with most other drugs. Variations on this procedure have been used
to evaluate the likelihood of self-administration of a wide range of
drugs including amphetamine, barbiturates, alcohol, opioids, and
nicotine (Griffiths et al. 1976, 1981; Woods 1980; Deneau 1977;
Yanagita 1977; Griffiths, Bigelow, Henningfield 1980; Brady and
Lukas 1984; Meisch 1987; Chapter III).
A third method is to induce the initial use of the test drug by
prearranged environmental sources of "pressure" or "motivation."
Induction of drug taking can be accomplished with very explicit
contingencies. For example, presentation of food or withholding of
electric shock can be made contingent on drug consumption (Mello
and Mendelson 1971a,b). However, such direct contingencies often
result in minimal response output (i.e., drug consumption) to obtain
the positive reinforcer or to avoid the electric shock, and drug self-
administration may not persist after the contingencies are removed
(Mello 1973). For example, even when physical dependence on
alcohol had developed in rhesus monkeys, the animals often rejected
the drug when self-administration was not required to meet the
contingency (Mello and Mendelson 1971a). Thus, these procedures
have not been extensively used to generate animal models of human
drug taking (Griffiths, Bigelow, Henningfield 1980).
The fourth procedure for establishing drug self-administration
seems somewhat more analogous to how drug dependence may
sometimes develop in humans outside the laboratory, and has been
widely used to study drug self-administration in the laboratory; this
method is termed the "adjunctive behavior" or "schedule-induced
behavior" strategy (Falk 1983). The method involves a less direct
means of inducing drug intake; in fact, the drug does not need to be


taken to obtain the reinforcer or to avoid the punisher. Rather, the
animal is simply given the opportunity to take the drug; at the same
time, the experimenter arranges conditions that are highly likely to
engage the animal in cycles of work and breaking from work. For
example, the animal may have to press a lever to obtain food. The
result is that when the animal is unable to work on the food schedule
(e.g., during the brief "timeouts" or "waiting" periods), the animal
tends to take the drug. Eventually, the drug itself might come to
function as a reinforcer in its own right, even in the absence of the
environmental pressures that first led to its use. The dose level of the
drug is then increased gradually over time. Variations on this
procedure have been used to establish self-administration of alcohol
(Falk, Samson, Winger 1972; Freed, Carpenter, Hymowitz 1970;
Meisch 19751, pentobarbital (Meisch, Kliner, Henning-field 1981),
nicotine (Singer, Wallace, Hall 19821, and a variety of other drugs
(Brady and Lukas 1984; Meisch and Carroll 1981; Meisch 1987).
Although many environmental conditions are present outside the
laboratory that appear to function as do adjunctive schedules in the
establishment of human drug dependence (e.g., boredom in occupa-
tional settings), there have been few experimental studies of
adjunctive drug taking by humans (Falk 1983). One such study by
Cherek (1982) showed that volunteers took more puffs per cigarette
when they were given monetary reinforcers at regular intervals: the
volunteers had to press a button to obtain the reinforcer, but their
behavior did not decrease the time they had to wait for each
reinforcer to become available.

Evaluation of Reinforcing Effects

Conclusive demonstration that the effects of the drug itself were
the cause of the drug-seeking behavior is equivalent to showing that
the drug itself is functioning as a positive reinforcer. The basic
procedures were developed in animal studies (Pickens and Thompson
1968; Deneau 1977) and have been reviewed in detail elsewhere
(Johanson and Schuster 1981; Balster and Harris 1982; Fischman
and Schuster 1978; Yanagita 1980; Brady and Lukas 1984).

The most fundamental procedure is to verify that drug self-
administration occurs under conditions in which it is "optional" or
"voluntary"; that is, explicit contingencies for drug taking (e.g., to
obtain food, to avoid shock, or to obtain preferred liquid) are not
required. It is also necessary to ensure that the drug taking is not
simply maintained by the charact,eristics of the vehicle (e.g., water or
a flavored solution into which alcohol is placed, or the tobacco smoke
in which nicotine is delivered to smokers).

If the drug is serving as a reinforcing stimulus, it should be
capable of maintaining controlled behavior. For example, a complex
chain of drug seeking (i.e., "procurement") might be required to

279


obtain the drug. An extension of this principle is to gradually
increase the amount of work (i.e., the "cost") that must be expended
to achieve drug delivery to determine how much the subject works
("pays") for a given drug or drug dose. For example, the ratio of lever
press responses per drug injection is gradually increased in the
"Progressive Ratio" procedure to determine the maximum ratio
("breaking point") that will be sustained (Yanagita 1977; Griffitbs,
Brady, Snell 1978a).
If the drug is serving as a reinforcer, then stimuli associated with
drug administration should also come to serve as reinforcers
("conditioned reinforcers"). Of all dependence-producing drugs, the
importance of this factor may be most pronounced with regard to
nicotine because the various effects of nicotine may be associated
with tobacco smoke and other stimuli hundreds of times each day
over the course of many years of smoking. A fundamental observa-
tion is that even neutral-appearing stimuli can funct.ion as reinforc-
ers in their own right when they are associated ("paired") with
previously established reinforcers such as food, water, sex, or drugs
(Skinner 1953; Thompson and Schuster 1968). For example, the taste
and smell of alcohol are initially highly aversive to animals (Mello
1973), but in one study, the smell of alcohol was established as a
conditioned positive reinforcer for animals: the smell of alcohol was
enough to reinstate drug-seeking behavior even when the alcohol
was not physically available (Meisch 1977). Seemingly arbitrary
stimuli such as lights and tones can come to serve as reinforcers
after association with i.v. self-administered drugs including cocaine-
like stimulants, opioids, barbiturates, and nicotine (Goldberg 1970;
Goldberg, Kelleher, Morse 1975; Griffiths, Bigelow, Henningfield
1980; Goldberg et al. 1983).
The basic methods described above are also used in human drug
self-administration studies, although with various procedural adap-
tations which have been described in detail elsewhere (Nathan,
O'Brien, Lowenstein 1971; Cohen, Liebson, Faillace 1971; Mello,
McNamee, Mendelson 1968; Mello 1972; Meyer and Mirin 1979;
Bigelow, Griffiths, Liebson 1975; Henningfield, Lukas, Bigelow
1986). As in the animal drug self-administration studies, the human
volunteers must emit a measurable response that may lead to drug
ingestion: for example, riding an exercise bicycle (Griffiths, Bigelow,
Liebson 1979; Jones and Prada 1975) or pressing a button on a
portable work station (Mello and Mendelson 1978). Such work
requirements then become established as part of the chain of drug-
seeking behavior. They have an advantage over non-laboratory drug-
seeking behavior in that the amount of work can be carefully
measured. Such data provide quantitative estimates of the time
and/or work expended for drugs (see examples in the following
studies and reviews: Johanson and Uhlenhuth 1978; Bigelow,


Griffiths, Liebson 1975; Mello and Mendelson 1978; Fischman and
Schuster 1982; Henningfield and Goldberg 1983b; Jasinski, Johnson,
Henningfield 1984).

Results from Drug Self-Administration Studies

Most categories of drugs which have been found to cause wide-
spread drug dependence in the nonlaboratory setting have been
tested with animals and humans in laboratory settings. Results of
these studies have been reviewed in detail elsewhere (Griffiths,
Bigelow, Henningfield 1980; Brady and Lukas 1984; Henningfield,
Lukas, Bigelow 1986). Several categories of drugs have been found to
be self-administered by humans and animals in the laboratory
settings, to meet criteria as positive reinforcers, and to exhibit
orderly relations as a function of drug dose, drug pretreatment, and
other factors known to affect the intake of dependence-producing
drugs. These include alcohol, morphine, pentobarbital, amphet-
amine, cocaine, and nicotine in the forms of cigarettes and i.v.
injection.

Self-administration studies with animals are much more extensive
and have also been reviewed in detail elsewhere (Johanson and
Schuster 1981; Balster and Harris 1982; Fischman and Schuster
1978; Yanagita 1980; Brady and Lukas 1984; Young and Herling
1986). In brief, drug self-administration studies in animals in the
1960s showed that a range of drugs including opioids, amphetamines,
barbiturates, certain organic solvents, alcohol, cocaine, and nicotine
were self-administered (Weeks 1962; Thompson and Schuster 1964;
Deneau, Yanagita, Seevers 1969; Deneau and Inoki 1967). All of
these drugs were found to maintain powerful chains of drug-seeking
behavior, even when insufficient drug was taken to produce a
clinically significant degree of physical dependence (Goldberg,
Morse, Goldberg 1976). Drugs that did not serve as reinforcers in
these studies included caffeine, lysergic acid diethylamide (LSD), and
the major tranquilizer chlorpromazine.

The speed of drug delivery can affect its reinforcing efficacy (Kato,
Wakasa, Yanagita 1987). Thus, the inhaled form of cocaine ("crack")
is considered more reinforcing and dependence producing than other
forms of cocaine delivery, with oral cocaine apparently among the
least reinforcing of the commonly used routes of delivery (see also
US DHHS 1987). Analogously, nicotine taken by the slow release
oral preparation (nicotine polacrilex gum) appears to be much less
reinforcing than nicotine taken by quicker release oral preparations
(e.g., chewing tobacco) or cigarette smoke (Chapters IV and VII).

Research findings have continued to extend the early observations
(Deneau, Yanagita, Seevers 1969) that the results with animals were
remarkably consistent with observations regarding human drug
dependence. For example, initial exposure of humans to drugs such


as opioids and stimulants led to addictive patterns of use, whereas
chlorpromazine rarely did, and LSD infrequently did (Jasinski 1977;
Griffiths et al. 1980). Earlier studies had suggested that alcohol,
caffeine, and nicotine were not reinforcers in animals (Mello 1973;
Russell 1979; Griffiths et al. 1986). However, by the early 1970s for
alcohol (Meisch and Thompson 1971; Meisch 1977,1982) and 1981 for
nicotine (Goldberg, Spealman, Goldberg 1981), it had been confirmed
that these drugs could also serve as effective reinforcers for
nonhumans. The relatively little research done to assess the
dependence potential of caffeine has not as conclusively demon-
strated that it serves as a reinforcer in animals (Griffiths and
Woodson 1988b).

Drug Dose as a Determinant of Drug Intake

Drug dose per administration is a major factor that affects self-
administration of dependence-producing drugs, The resultant
dose-response relationships are orderly, and the data have been
reviewed extensively (Griffiths, Bigelow, Henningfield 1980; Johan-
son and Schuster 1981; Young and Herling 1986). In brief, the
relationship between the dose size available and the number of doses
taken is often referred to as an inverted U-shaped function because
of the shape of a graph that results when the number of injections (y-
axis) is plotted as a function of dose (x-axis) across a wide range of
doses to which a subject is given access.

Over the range of doses which appear to be functioning as effective
reinforcers, changes in dose are accompanied by compensatory
changes in number taken such that total drug intake is somewhat
stabilized. It appears that a determinant of such compensatory
changes in drug self-administration is the apparent upper and lower
"boundaries" or "thresholds" for aversive effects that might occur
when either too much drug is obtained or when insufficient drug is
obtained to prevent withdrawal responses (Kozlowski and Herman
1984). It should be noted, however, that in most studies, compensato-
ry changes in drug intake as dose level is changed are almost never
perfect and are frequently quite crude (Griffiths, Bigelow, Henning-
field 1980). (See Yokel and Pickens 1974 for an example of a study in
which drug intake was unusually stable across a range of amphet-
amine doses.) Thus, the usual observation related to drug dose is that
as dose is increased, the rate of drug taking decreases somewhat but
more total drug is obtained. This relationship is observed in studies
of i.v. nicotine in animals (Goldberg et al. 1983) and humans
(Henningfield, Miyasato, Jasinski 1983) and when tobacco smoke
dose is manipulated in humans (Chapter IV).

A misinterpretation of dose-response relationships by tobacco
researchers, largely in the 197Os, led to the controversy that marked
the so-called "titration studies" of tobacco intake. Specifically, it was

282


assumed that if a drug was serving as a reinforcer, then compensa-
tion for changes in dose level should have been more effective than
they appeared to be. Hence, some questioned whether nicotine was
serving as a reinforcer because dose-response relationships in
nicotine studies appeared very crude (Russell 1979). The question
that arose was not whether cigarette smokers showed compensatory
changes in responses to changes in dose level; they did. In fact, the
nicotine dose-response relationship has probably been better studied
and established, over a wider range of conditions and t.echniques of
study, than have dose-response relationships with any other class of
drugs which are self-administered by humans (Gritz 1980; Griffiths,
Bigelow, Henningfield 1980; Henningfield 1984). The question was,
rather, why compensatory changes in cigarette smoke intake often
appear to be inadequate to maintain stable levels of nicotine intake.
There are two main problems in interpreting these data, however.
The first is that in the vast majority of human cigarette smoking
studies, attempts to manipulate the dose delivered were not well
controlled and the measures used to assess the possible effects of
intended dose manipulations were not necessarily sensitive to
compensatory changes (see Chapter IV and Henningfield 1984b). The
second problem is that there is simply no basis for determining what
degree of compensation should occur, because the degree of compen-
sation observed in animal studies varies widely by drug and test
condition, and because there are relatively few human data involv-
ing drugs other than nicotine to which such a comparison might be
made (Griffiths, Bigelow, Henningfield 1980; Henningfield, Lukas,
Bigelow 1986).

Cost of the Drug as a Determinant of Intake

Cost of the drug is a determinant of intake in both laboratory and
non-laboratory settings. Evaluation of this phenomenon is objective-
ly carried out in the laboratory in which the amount of work
required to obtain the drug can be varied. From an economic
perspective, this is similar to varying the price of the commodity
which is available for purchase. Such manipulations with both
humans and animals have shown that cost (e.g., amount of work
required) affects drug intake: usually, the lower the cost, the greater
the intake. In some studies manipulations of both cost and drug dose
have been carried out (e.g., Moreton et al. 1977; Lemaire and Meisch
1985). These studies show that when the dose of the drug is reduced,
drug-seeking behavior may increase at first and thereby maintain
fairly stable intake, but if dose continues to decrease (or cost
continues to increase), the behavior will not be maintained (Lemaire
and Meish 1985). Early studies with cocaine, for example, showed
that if access to cocaine was limited, either by time or work ("cost")
requirements, cocaine self-administration could be maintained indef-

283


initely without serious apparent adverse effects (Pickens and
Thompson 1968). However, if access to cocaine was nearly unlimited
and the cost requirement low, monkeys might self-administer toxic
dose levels (Deneau, Yanagita, Seevers 1969).

Use of tobacco in humans and intravenous nicotine self-adminis-
tration by animals appear to be similarly affected by manipulations
of cost as is use of other dependence-producing drugs. Specifically, as
the amount of work required to obtain nicotine injections in animals
is increased, the number of injections is decreased (Goldberg and
Henningfield, 1988). Analogously, human cigarette smokers and
other drug users can also be motivated with both positive and
negative cost incentives (Bigelow et al. 1981; McCaul et al. 1984;
Stitzer et al. 1982, 1986; Stitzer and Bigelow 1985). These laboratory
findings with animals and humans correspond to the effects of
changes in the price of cigarettes on cigarette sales (Lewit, Coate,
Grossman 1981; Lewit and Coate 1982; Warner 1986a). Such
relationships are also observed with other dependence-producing
drugs including opioids, sedatives, alcohol, and amphetamines
(Griffiths, Bigelow, Henningfield 1980; Yanagita 1977).

Place Conditioning Studies

Ingestion of dependence-producing drugs can lead to both positive
and negative associations with the setting in which the drug effects
were experienced. Whether the effects of a particular drug are
positive or negative depends on the dose that was given and other
factors that are discussed in this Section.

A scientific methodology for studying such phenomena is the
"place-conditioning" or "place-preference-aversion" procedure (Bo-
zarth 1987a). This procedure provides an indirect means of assessing
the potential of a drug to establish drug seeking in the absence of
any explicit contingencies on the behavior. These procedures deter-
mine if exposure to a drug in a given environmental setting
enhances the preference of the animal for that setting. Conversely,
the procedure can be used to determine if exposure to a drug in a
specific environmental setting establishes an aversion of the animal
to that setting.

Because of their convenient size and the general validity of their
use as models for behavioral dependence potential testing, rats most
commonly are used as subjects in place-conditioning studies. The
general experimental procedure is to place the animal in one
environment (e.g., one chamber of a multiple-chamber test appara-
tus) when a drug is given and in another environment (e.g., distinct
in color, shape, or odor) when a placebo is given. Then, the animal is
given access to both environments (i.e., placed in a connecting
passage or placed in one chamber or the other) to determine which
environment (chamber) it prefers (van der Kooy 1987; Bozarth

284


1987a), and, conversely, which environment it avoids. Studies have
shown that conditioned preferences can be established for morphine
(Bardo and Neisewander 1986), cocaine (Spyraki, Fibiger, Phillips
19821, alcohol (Stewart and Grupp 19851, and nicotine (Fudala, Teoh,
Iwamoto 1985; Fudala and Iwamoto 1987; Chapter IV).

The relevance of place conditioning as a factor that increases the
control of nicotine over behavior in human cigarette smokers may
exceed that of other dependence-producing drugs. This possibility
follows from the fact t.hat the cigarette smoker has the ability to
readily produce a critical environmental cue associated with smok-
ing (cigarette smoke itself). Therefore, it should be possible for the
smoker to "enhance" the reinforcing efficacy of a range of environ-
ments (Iwamoto et al. 1987); the highly discriminating sight, smell,
and taste stimuli produced by tobacco smoke may effectively permit
the smoker to establish a "preferred environment." This could
contribute to the dependence potential of nicotine. The observation
is also consistent with the finding that removal of the tobacco smoke-
associated stimuli is accompanied by decreased pleasure and/or
smoking (Gritz 1977; Goldfarb et al. 1976; Rose et al. 1987). As early
as 1899 it was observed, for example, "that the pleasure derived from
a pipe or cigar is abolished for many persons if the smoke is not seen,
as when it is smoked in the dark" (Cushny 1899).

Constraints on Dependence Potential Testing

The main constraint on procedures used to evaluate the depen-
dence potential of drugs is that they may fail to identify drugs which
only lead to dependence under unusual or uniquely human circum-
stances. For example, LSD does not serve as an effective reinforcer
for animals, and although its effects may be liked by humans under
certain conditions, it also produce feelings of fear, paranoia, and
other adverse effects (Griffiths, Bigelow, Henningfield 1980; Haert-
zen 1966, 1974). Caffeine provides an example of another kind of
drug which is sometimes used in the face of adverse effects, even
though the overwhelming majority of users do not use it in ways that
are considered to be of significant adverse health effect (Gilbert 1976;
Greden 1981). The anticholinergic drug atropine is another that is
representative of a class of drugs that occasionally are used in
nontherapeutic settings but do not appear t.o possess a marked
dependence potential when objectively tested (Penetar and Henning-
field 1986).

The wide range of factors that may result in occasional harmful
use of some substances (e.g., caffeine) or which may contribute to the
use of dependence-producing substances such as nicotine (Chapters
IV and VI) is not routinely explored in current laboratory depen-
dence potential tests. Thus, these drug dependence potential testing
procedures appear more likely to underestimate than to overesti-


mate the pharmacologic potential of a drug to cause dependence
outside of the laboratory. Furthermore, as discussed by Katz and
Goldberg (1988), because a variety of drug and nondrug factors
determine the actual prevalence of drug dependence outside of the
laboratory, dependence potential data are most reliable when
drawing qualitative conclusions. For example, such data are used to
determine whether a drug is dependence producing, or whether it is
more sedative- or stimulant-like.

Dependence Potential Testing: Tolerance and Withdrawal

In addition to taking control over behavior by virtue of reinforcing
and other behavior modifying effects, many addicting drugs can also
produce a physiological change termed physical dependence. Once
physically dependent, the person may experience an even greater
loss of control over use of a particular drug because abstinence from
the drug may be accompanied by discomfort and heightened urges to
take the drug (withdrawal syndrome).

Technically, physical dependence refers to physiological and
behavioral alterations that become increasingly manifest after
repeated exposure to a pharmacologic agent. As noted earlier, the
primary indication of physical dependence is the observation of drug-
abstinence-associated withdrawal signs and symptoms, although
tolerance is a frequent concomitant (Kalant 1978; Cochin 1970;
Kalant, LeBlanc, Gibbins 1971; Eddy 1973; Clouet and Iwatsubo
1975; Yanagita 1977). This phenomenon is also referred to as
"neuroadaptation" or "physiological" dependence (WHO 1981; Wool-
verton and Schuster 1983). It should be noted that use of the term
"physical" imports no greater degree of objectivity to phenomena
associated with physical dependence than to the phenomenon of
compulsive drug seeking: both physical dependence and drug seeking
involve physiologically mediated drug receptor interactions that
vary with the dose, kinetics, and type of drug. Furthermore, both of
these kinds of drug-associated phenomena involve behavioral and
physiological effects. For example, conventional measures of physi-
cal dependence include responses that are often considered behavior-
al (e.g., urge to use a drug, sleep time, food intake).

Research on opioid dependence in the 1940s focused largely on the
physical dependence that developed when opioids were given to
humans or certain animals (Martin and Isbell 1978). In particular,
characterizing the level of tolerance that was acquired when
morphine was repeatedly given, as well as the behavioral and
physiological sequelae of abrupt termination of such administration,
was a major contribution to the development of objective methods for
testing dependence-producing drugs in general. Observations emerg-
ing from such research in the 1940s led to strategies that are still
accepted as the definitive means to measure what may be termed the

286


TABLE &-Observations pertaining to the evaluation of
     physical dependence potential, derived from
     studies of morphine-like drugs

Repeated drug administration leads to diminished responsiveness fi.e., tolerancel that is
more or less complete, depending upon the response measured. Responsiveness might be at
least partialI) overcome by increasmg the dose. The degree of tolerance that develops is
generally directly related to the overall dosing level. but varies widely across various
possible measures.

The cstablishmenr of tolerance to one opimd is shared among many opium-derived and
related chemicals; the principle of "cross-tolerance" emerged as one means to further
classify a dependence-producing chemical.

Abrupt termination of use leads to behavioral and physiological responses that often tend to
be opposite of responses produced by acute drug administration. When these opposite
responses actually exceed normal baseline levels (e.g., apioid-induced constipation may be
replaced by diarrhea for a few days), they are termed "rebound" responses; hence the
frequent labeling of withdrawal as "rebound s,vndrome." Together, these responses are
termed "the withdrawal syndrome."

Severity of the withdrawal syndrome is related to the duration and dose levels of
preabstinence exposure to the drug.

During withdrawal, readministration of the chronically given opioid can reverse the signs
and symptoms of the syndrome.

A range of opioids can substitute for the one LO which an organism was chronically
exposed, thereby maintaining the level of physical dependence and preventing the onset of a
withdrawal reaction. These same drugs can be used to reverse the syndrome of withdrawal
precipitated by removal of the chronically given opioid. This observation provided the
rational basis for the systematic development of "substitution" or "replacement" therapy for
drug dependence.

NOTE Details of the original expenments, and subsequent research upn whxh these observations follow. have
been reviewed (Martin and Isbell 1978: Martin 1977; Sharp 1984. see also Lkncau 19771.

"physical dependence potential" of a chemical (Jasinski 1977).
Specifically, these tests could be used to evaluate the likelihood that
(1) repeated use of a drug would lead to tolerance (physiological
adaptation) such that effects of repeated use would diminish and (2)
abrupt abstinence would be accompanied by a syndrome of behavior-
al and physiological disruption (withdrawal syndrome). Table 5
summarizes the prominent observations that emerged from these
early studies (Martin and Isbell 1978; Martin 1977). These observa-
tions provide the conceptual framework within which physical
dependence is assessed (Thompson and Unna 1977).

Tolerance

As noted earlier, repeated ingestion of most dependence-producing
drugs leads to diminished effects unless larger doses of the drug are
taken: this phenomenon is termed tolerance. One reason that
tolerance is an important factor in drug dependence is that it may
contribute to the escalation of drug self-administration that occurs
over time. This relationship is often misinterpreted, however.
Specifically, it is sometimes stated that tolerance results in a

287


continuous escalation of drug dose; however, lethal or aversive dose
levels prevent indefinite escalation.

Procedures for assessing tolerance development rely heavily on
procedures developed for assessing the direct effects of drugs
(Kalant, LeBlanc, Gibbins 1971; Abood 19841. Because psychoactive
drugs exert effects on numerous physiological systems and behavior-
al responses, almost any of a wide range of response measures can
serve in studies. Perhaps the most fundamental strategy of tolerance
assessment is to repeatedly present a given drug dose while
measuring the subsequent responses to drug administration. When
the response diminishes across drug presentations, tolerance to that
response is said to have occurred. Among the most frequent
measures of tolerance which have been used to assess psychoactive
drugs are discrimination of drug administration, analgesia, heart
rate, nausea, sedation, EEG activity, and performance on a behavior-
al task. Some measures (e.g., sedation from barbiturates) are more
specific to certain drug classes, whereas others (e.g., pleasurable and
dysphoric effects) are useful across a wider range of psychoactive
drugs. A variation on the foregoing procedure is to increase the drug
dose after responses have diminished to determine if the original
response level can be partially or completely restored.

Cross-Tolerance

Cross-tolerance is demonstrated when pretreatment with one drug
or formulation type produces tolerance to another drug or formula-
tion type (Wenger 1983; Yanura and Suzuki 1977; Martin and Fraser
1961). For example, a person who is maintained on an adequate dose
level of methadone will experience relatively little effect if he or she
injects his or her usual dose of heroin (Kreek 1979). Similarly,
persons given nicotine polacrilex gum may experience attenuated
effects from cigarettes, including reduced satisfaction from smoking
(Nemeth-Coslett et al. 1987).

Mechanisms of Tolerance

Several mechanisms of tolerance can be differentiated (Kalant,
LeBlanc, Gibbins 1971; Abood 1984; Haefely 1986; Sharp 1984; WHO
1981). For instance, if a drug impairs the ability to perform a task
that produces some form of reinforcement (e.g., humans working for
money or animals pressing a lever for food), the performance may
return to predrug exposure levels after repeated drug exposure over
time. In this example, at least four distinct mechanisms of tolerance
may have been operational; they are not mutually exclusive and may
co-occur (Kalant, LeBlanc, Gibbins 1971; Abood 1984; Haefely 1986;
Sharp 1984; WHO 1981; Eikelboom and Stewart 1979; Siegel 1975,
19761.

288


(1) The rate at which the drug was eliminated from the blood by
metabolism (detoxification) or excretion (in urine, feces, sweat, or
expired air) may have increased. This is frequently termed "disposi-
tional" or "metabolic" tolerance. A general method used to assess
dispositional tolerance is to measure the rate of decline in plasma
drug levels after varying amounts of drug exposure.

(2) The response at the cellular level might have decreased as the
drug receptor physiologically adapted to the drug or as the number
of receptors was altered (thereby functioning as though the systemic
dose had been reduced). This is frequently termed "functional" or
"pharmacodynamic" tolerance. One method used to assess function-
al tolerance is to hold the plasma drug levels constant while
measuring the response after varying amounts of drug exposure.

(3) The learning and motivational aspects of a behavioral situation
may have resulted in compensatory behaviors that reduced the
magnitude of the performance effects. This is frequently termed
"behavioral" tolerance, "drug sophistication," or "behavioral adap-
tation." Behavioral tolerance can be assessed by presenting the drug
at such long intervals so as to minimize the possible development of
functional or metabolic tolerance (e.g., Stitzer, Morrison, Domino
1970), or by using a variety of other controlled procedures (Krasne-
gor 1978b).

(4) Another behavioral mechanism that can lead to the develop-
ment of tolerance results from the classical or Pavlovian condition-
ing process that may occur where a drug is given. Pavlov (1927)
found that drug administration could produce an unconditioned
response that could subsequently occur as a conditioned response to
an associated environmental stimulus. However, sometimes the
conditioned response is opposite that of the drug response (Siegel
1975); when a drug-opposite response has been established, this
conditioning mechanism may reduce the strength of the response to
the drug it,self (Goudie and Demellweek 1986).

The kinds of tolerance described above are sometimes categorized
together as "acquired" tolerance, which emphasizes the fact that
they have developed in an organism as a function of drug exposure
(WHO 1981). Tolerance development can be affected by the unit drug
dose, total daily dose, route of administration, prevailing environ-
mental stimuli, and exposure dynamics (exposure dynamics refers to
whether exposure to a drug is relatively continuous (Way, Lob, Shen
1969) or via multiple, discrete doses (Lukas, Moreton, Khazan 1982))
(see also, Dewey 1984; Adler and Geller 1984; O'Brien 1975; Bhisig et
al. 1973; Okamoto, Rao, Walewski 1986). Acquired tolerance has
been demonstrated to occur with opioids and with most nonopioid
dependence-producing drugs, including nicotine (Martin 1977; Ka-
lant, LeBlanc, Gibbins 1971; Abood 1984; Haefely 1986; Domino
1973; Chapter III). In fact, classic techniques of measuring tolerance

289


evolved in a series of studies involving nicotine by Langley, Dixon,
and others near the end of the 19th century (Langley 1905; Dixon
and Lee 1912); these researchers found that tolerance to nicotine was
rapid and could be partially overcome by increasing the dose.

Constitutional Tolerance

Historically, although less commonly in recent years, tolerance
has been used to differentiate individuals or populations with regard
to their "preexisting" or "constitutional" level of drug responsive-
ness (Shuster 1984). This phenomenon has been designated "initial"
tolerance by a subcommittee of the WHO (WHO 1981) and is also
often referred to as "drug sensitivity" or "innate drug responsive-
ness." The mechanisms may be similar to those described above; for
example, individuals may be born with differing numbers of
receptors for a particular drug or with different. abilities to detoxify a
drug on the basis of enzymatic capacity of their liver. Analogously,
for reasons that are not related to drug exposure, certain populations
or individuals may be more effective in general at behaviorally
compensating for impediments to learning or performance. Genetic,
dietary, and early (including prenatal) developments are possible
sources of such variation that are under study (Abood 1984).

Whereas a fairly wide range of variation among such preexisting
levels of drug sensitivity has not been shown to affect the course of
development of drug dependence, extreme or qualitative differences
may have some impact. Such differences are sometimes held to alter
the vulnerability of various individuals or populations to the
development of drug addiction. One apparent example of such an
effect is the markedly higher percentage of Oriental persons who,
compared with most other populations in the United States, show an
aversive reaction to alcohol ("flushing" response). This reaction
results from slower metabolism of the alcohol metabolite, acetylal-
dehyde, in Orientals compared with many other ethnic groupings
(Nagoshi et al. 1987). However, cultural factors also appear to
strongly influence rates of alcohol use in Orientals so that even
persons who show the flushing response may develop alcoholism
(Sue 1987; Johnson et al. 1987).

Differences in constitutional levels of tolerance among individuals
have been observed for all dependence-producing drugs, including
nicotine (Chapter II). However, the importance of such individual
and/or population differences remains unclear. In fact, a remarkable
feature of opioids, sedatives (including alcohol), and stimulants
(including nicotine) is the degree to which use has become en-
trenched in nearly any culture into which they have been introduced
(Austin 1979). Similarly, initial exposure to opioids, sedatives,
alcohol, cocaine-like stimulants, and nicotine has been shown for
each to lead to drug-seeking behavior in a wide range of animal


species including primates, dogs, and rodents (Deneau 1977; Yanagi-
ta 1977; Woods, Ikomi, Winger 1971; Brady and Lukas 1984;
Griffiths, Bigelow, Henningfield 1980; Meisch 1987; Meisch and
Carroll 1981).

Withdrawal Syndromes

As discussed earlier, documentation of a drug withdrawal syn-
drome is the primary line of evidence used to decide whether a
particular drug can cause physical dependence. The methods used to
properly conduct such tests and provide definitive results are
complex. This Section provides a summary of how such tests are
conducted and some of the main findings from tests of drugs such as
morphine, pentobarbital, and nicotine.

Measurement of drug withdrawal phenomena entails recording
physiological, subjective, and behavioral responses that occur when
drug administration is terminated, as well as those that occur
following drug administration. If the organism has developed a
sufficient degree of tolerance, such that levels of drug which
formerly disrupted physiological and behavioral functioning have
become necessary for relatively normal functioning, then the
organism is said to be physically dependent. Such drug abstinence-
induced disruption of functioning is termed a drug "withdrawal" or
"abstinence" reaction or syndrome. The behavioral and physiological
responses include some that are opposite those produced by drug
administration. For instance, opioid-induced pupillary constriction,
alcohol-induced muscle relaxation, and nicotine-induced tachycardia
may be replaced by pupillary dilation, convulsive muscle activity,
and bradycardia, respectively. Each drug withdrawal syndrome is
unique to a particular drug class and animal species and also varies
somewhat within individuals of a given species which are tested with
the same drug. Both frequency and magnitude of withdrawal
responses are typically measured.

In human studies, the range of measures available to assess
withdrawal reactions is considerable. They may be designated by
three categories: autonomic (e.g., blood pressure, pulse, core temper-
ature, respiratory rate, pupillary diameter, diarrhea), somatomotor
(e.g., nociception, neuromuscular reflexes, auditory and visual
evoked potentials), and behavioral (e.g., irritability, sleep/awake
cycle, hunger, urge to take the drug, i.e., "craving"). Himmelsbach
and Andrews (1943) incorporated these distinctions into a weighted-
point system used for rating the severity of these signs and
symptoms of withdrawal (Fraser and Isbell 1960; Jasinski 1977).
Refinements in the scaling of opioid withdrawal responses have
continued (e.g., ARCI, weak opiate withdrawal scale) (Haertzen 1966;
Bradley et al. 1987; Handelsman et al. 1987).

291


Opioid withdrawal phenonena remain the most rigorously studied
and well characterized among the dependence-producing drugs. In
part, this is because of the ready observability of many of the signs
(e.g., dilated pupils, sweating, diarrhea). Other drugs for which
withdrawal reactions are now known or suspected to occur in
humans (e.g., amphetamine, cocaine, marijuana, phencyclidine) have
been much less thoroughly studied than the opioids and sedatives
(Mendelson and Mello 1984; Jones and Benowitz 1976). Studies with
these drugs are also hindered by the fact that there are fewer readily
observable signs of withdrawal, placing a greater burden on sophisti-
cated technology (e.g., EEG and neurohormonal assessment) and
procedures (e.g., performance assessment).
Two basic methods are used to measure withdrawal reactions.
After a period of chronic drug administration, behavioral and
physiological responses are measured following either abrupt drug
abstinence ("spontaneous withdrawal") or the administration of a
drug antagonist ("precipitated withdrawal") (Thompson and Unna
1977; Martin 1977).

Spontaneous Withdrawal Syndromes

Experimental studies of spontaneous withdrawal reactions include
two procedures for obtaining subjects which have been chronically
exposed to the drug. One procedure, termed the "direct addiction"
procedure, is to administer the drug to the subject at gradually
increasing dose levels, then to stabilize the dose for a predetermined
time interval. Drug administration is then abruptly discontinued,
and withdrawal measures are taken. This method has been used to
study withdrawal from opioids, barbiturates, benzodiazepines, stimu-
lants, ethanol, PCP, and gaseous anesthetics in a number of animal
species and humans (Brady and Lukas 1984). A variation on this
procedure is to abruptly withdraw subjects from a drug which they
had been chronically receiving in the nonlaboratory environment. In
human subjects, withdrawal reactions following cessation of use of
opioids, alcohol, nicotine, sedatives, and other drugs have been
studied using this procedure (Brady and Lukas 1984; Chapter IV).

A second procedure, termed the "substitution procedure," involves
maintaining subjects at a given dose level of a standard or baseline
drug; periodically, doses of the standard drug are replaced with
either a placebo or a test drug to determine if there are signs of
withdrawal that occur before the next dose of the baseline drug
(Fraser 1957). This procedure provides information analogous to that
obtained from studies of cross-tolerance; namely, it permits determi-
nation of whether cross-dependence exists. If the test drug prevents
the expected onset of a withdrawal syndrome that should have
accompanied abstinence from the maintenance drug, then it is
possible that the two drugs produce similar kinds of physical


dependence. Because it is possible to suppress certain withdrawal
responses by using unrelated drugs (e.g., clonidine can suppress
certain aspects of morphine and nicotine (Jasinski, Johnson, Hen-
ningfield 1984)), a variety of control procedures are necessary to
identify the mechanism by which the replacement drug suppressed
the withdrawal responses (Martin 1977; Deneau and Weiss 1968;
Yanagita and Takahashi 1973; Okamoto, Rosenberg, Boisse 1975;
Jones, Prada, Martin 1976; Yanaura and Suzuki 1977).

In human subjects, both the direct addiction and substitution
strategies were used to evaluate withdrawal reactions from opioids,
barbiturates, and alcohol at the Addiction Research Center in the
1940s and 1950s (Himmelsbach 1941; Himmelsbach and Andrews
1943; Isbell et al. 1950, 1955). However, since those classic studies,
most dependence potential studies in humans have been conducted
with subjects who had been using the drug in a nonexperimental
setting prior to the study. The effects of abstinence from chronic
administration of opioids, barbiturates, benzodiazepines, caffeine,
and nicotine have been studied using these variations of spontaneous
withdrawal assessment (Benzer and Cushman 1980; Charney et al.
1981; Jaffe et al. 1983; Griffiths and Woodson 1988a; Greden 1981;
Hatsukami, Hughes, Pickens 1985; Chapter IV). A disadvantage of
such approaches is that it is not always possible to stabilize the
subjects at a known dose level, which results in considerable cross-
subject variation. The consequence of such dose-related variability is
that it can raise the threshold for the detection of significant effects.
This source of variability probably contributed to some of the earlier
inconsistent findings regarding the nature and severity of withdraw-
al reactions from tobacco (see further discussions in Murray and
Lawrence 1984). Early in the 20th century, analogous seemingly
inconsistent data led to debates about the existence of an alcohol
withdrawal syndrome (Isbell et al. 1955).

Precipitated Withdrawal Syndromes

Precipitated withdrawal responses may occur when a drug antago-
nist abruptly displaces the dependence-producing drug from its
binding sites on receptors. The viability of this approach depends on
the availability of a specific receptor antagonist which does not have
other actions that would preclude assessment of a withdrawal
syndrome. The antagonist is often given parenterally (e.g., intrave-
nously or intramuscularly) to maximize its rate of onset and hence
the likelihood of precipitating a withdrawal reaction.

Because of the availability of specific opioid antagonists, precipita-
tion of withdrawal phenomena associated with abstinence from the
morphine-like drugs has been most thoroughly studied using this
strategy (Martin et al. 1987). The studies have shown that the
process that leads to physical dependence begins with the first dose

293


of morphine (Higgins et al. 1987; Bickel et al. 1988) although such
low levels of physical dependence are not generally considered
sufficient for the clinical diagnosis of physical dependence. Analo-
gous studies have been conducted using the antagonists of the
benzodiazepines (e.g., diazepam (Lukas and Griffiths 1982, 1984)) and
are one element in the conclusive demonstration that these drugs do
produce physical dependence (WHO 1981, 1987). With regard to
tobacco or other forms of nicotine delivery, no such comparable
studies have been conducted, although, as discussed in Chapter IV,
preliminary and related data suggest the theoretical possibility that
nicotinic antagonists may be used to precipitate nicotine withdrawal
responses (Pickworth, Herning, Henningfield, 1988).

Variability in Withdrawal Syndromes

There are multiple determinants of the course and magnitude of
the withdrawal reaction from a drug. Factors which have been
studied in the laboratory are similar to those which affect the
development of tolerance described earlier. These include the total
daily dose of the drug that was given, specific drug type, the duration
of exposure, the schedule of termination, genetic constitution,
gender, and the prevailing environmental stimuli (Suzuki et al. 1987;
Suzuki et al. 1983; O'Brien et al. 1978; Suzuki et al. 1985; Yanagita
and Takahashi 1973; Yanagita 1973). In general, the magnitude of
the withdrawal reaction is directly correlated with the dose level
given, the duration of exposure, and the rapidity with which drug
levels at the receptor sites decrease. Conversely, lower dose levels,
shorter times of exposure, and gradual dose reduction (as opposed to
abrupt abstinence) can attenuate the withdrawal syndrome (Kalant,
LeBlanc, Gibbins 1971; Abood 1984; Jaffe 1985; Okamoto 1984).

Because withdrawal signs and symptoms vary among individuals
using the same drug, the syndrome may not be apparent when a
small number of individuals are studied. Lack of general understand-
ing of such factors probably contributed to the fact that the nature of
morphine withdrawal phenomena in humans was not rigorously
documented until the studies by Himmelsbach and his coworkers in
the 1940s (Himmelsbach 1941; Himmelsbach and Andrews 1943).
Similarly, withdrawal responses from chronic alcohol administra-
tion were not conclusively characterized and demonstrated until the
pioneering studies by Isbell and his coworkers in the 1950s (Isbell et
al. 1955). Research involving comparable strategies of assessment of
physical dependence on cocaine, amphetamine, marijuana, PCP, and
nicotine, only began in the late 1970s. In the absence of such data,
these drugs were sometimes held to be nonaddicting (e.g., President's
Advisory Commission 1963). Nonetheless, for several of such drugs it
had long been recognized that some drug withdrawal phenomena did
occur (Jaffe 1970, 1976, 1980, 1985) and that such phenomena were

294


of clinical significance in the treatment of persons who were
attempting to abstain from them (Jaffe 1970, 1976, 1980, 1985;
Zweben 1986). For example, even prior to the rigorous studies of
tobacco withdrawal phenomena in the early 1980s (Chapter IV), the
Tobacco Withdrawal Syndrome had been recognized by the Ameri-
can Psychiatric Association (APA) as an Organic Mental Disorder in
its Diagnostic and Statistical Manual (DSM) of Mental Disorders
(APA 1980) on the basis of the extensive clinical observations and
other sources of information prior to the 1980s (Chapter IV). The
specificity of tobacco withdrawal to nicotine itself was acknowledged
in the revised DSM III (APA 1987).

Cravings or Urges

Among the most frequently discussed aspects of drug dependence
is the recurrent and often persistent urge to use drugs in drug-
dependent persons. The urge or desire to use a drug is widely termed
"craving." However, how craving is defined and how craving-related
data are interpreted comprise one of the most problematic areas in
drug dependence research. For example, the term craving has been
used in such a variety of ways that its use may actually impede
accurate communication (Kozlowski and Wilkinson 1987; Henning-
field 1987). In the present Report, where possible, the term "craving"
has been replaced by more descriptive terms and phrases such as
"strength of an urge to use a drug" wherever the original meaning of
the referent material is not changed.

Whereas the urge to use a drug is a correlate of drug abstinence, it
is not an invariant one. For example, although urges to take drugs
reliably increase during early abstinence from morphine- and
pentobarbital-like (short-acting sedatives-hypnotics) drugs, they are
not a necessary concomitant of withdrawal reactions from other
opioids (e.g., cyclazocine) (Martin et al. 1965; Jasinski 1978), and
alcoholics often "voluntarily" abstain and undergo withdrawal even
when alcohol is available (Mello 1968; Mendelson and Mello 1966).
Moreover, such urges are also evoked by stimuli associated with
drugs and even by administration of the drug itself (O'Brien,
Ehrman, Ternes 1986; Childress et al., in press). Thus, urges to use
drugs also occur (often at high levels) when there is little other
evidence that physical dependence is present (e.g., many years after
drug abstinence) or when drug intake is sufficient so that no other
withdrawal signs or symptoms are present.

Because drug abstinence is only one of many factors that can
evoke the urge to use a drug and because such urges are not
necessarily alleviated by suppressing physiological withdrawal signs,
conclusions based upon such data must be carefully considered and
appropriately qualified. For instance, although methadone can block
withdrawal responses (at adequate dose levels), it does not reliably

295


diminish urges to use other opioids or opioid self-administration
(Jones and Prada 1975; Grabowski, Stitzer, Henningfield 1984;
Henningfield and Brown 1987). It would not be appropriate to
conclude that methadone did not effectively block withdrawal
reactions from morphine-like drugs simply because it did not
eliminate such urges, because by other measures, methadone is
effective at blocking opioid withdrawal (Kreek 1979; Jaffe 1985;
Jasinski and Henningfield 1988). Analogously, as reviewed in
Chapters IV and VII, most tobacco withdrawal responses are
effectively suppressed by nicotine replacement even though urges to
use cigarettes are not reliably diminished (see also Henningfield and
Jasinski 1988).

Constraints on Physical Dependence Potential Testing

There are both practical and conceptual constraints on physical
dependence potential testing. The practical constraints have been
discussed above and are related to the multiple sources of variability
in the intensity of withdrawal responses, which can result in failure
to detect withdrawal or in unreliable data.

The main conceptual constraint is that physical dependence is
neither a necessary nor sufficient condition to establish or maintain
drug-seeking behavior. For instance, drug-seeking and drug-taking
behaviors can persist at small doses of cocaine or morphine which
produce no significant degree of physical dependence in animals
(Schuster and Woods 1967; Deneau, Yanagita, Seevers 1969; Johan-
son, Balster, Bonese 1976; Jones and Prada 1977; Bozarth and Wise
1981) or in human subjects (Zinberg 1979). Conversely, animals in
the laboratory and humans in hospitals can be made physically
dependent on drugs such as opioids and barbiturates and yet never
display controlled or addictive drug-seeking behavior (WHO 1981;
Bell 1971). Similarly, compounds such as propranolol, cyclazocine,
and nitrites have clear physical dependence potentials in that
tolerance develops after repeated dosing and an abstinence syn-
drome appears upon cessation, yet drug-seeking or drug-taking
behavior does not reliably occur (Myers and Austin 1929; Crandall et
al. 1931; Rector, Seldon, Copenhaver 1955; Jasinski 1976; Jaffe 1985).

Another constraint is the difficulty in determining whether
abstinence-associated symptomology is specific to an individual or to
an underlying medical disorder that became evident upon removal of
the drug (Woody, McLellan, O'Brien 1984; Zweben 1986; Kosten,
Rounsaville, Kleber 1986; Stitzer and Gross 1988). For instance, an
opioid might alleviate depression in a person w:+h primary affective
disorder. In general, as will be described below (s    "lapter IV),
withdrawal responses may be distinguished from i ..lie: .bstinence-
associated symptomology by their relative consistency among indi-


viduals, by their transient nature, and by the direct relationship
between their magnitude and the level of preabstinence drug intake.

Finally, although the magnitude of the withdrawal syndrome is a
widely used index for assessing the degree of physical dependence, it
should be noted that this single measure is not always sufficient. For
instance, several studies have demonstrated that spontaneous with-
drawal from chronic levo-alpha-acetylmethadol (LAAM) or bupre-
norphine administration failed to result in pronounced signs of
withdrawal (Jasinski, Pevnick, Griffith 1978; Young, Steinfels,
Khazan 1979). Such observations could lead to the false conclusion
that LAAM and buprenorphine do not produce significant degrees of
physical dependence, when in fact a variety of other lines of evidence
confirm that they do. For example, administration of an opioid
antagonist such as naloxone precipitates a marked and intense
withdrawal syndrome in LAAM-maintained animals (Young, Stein-
fels, Khazan 1979). Analogously, Dum, Blasig, and Herz (1981)
performed a substitution type of experiment demonstrating that
chronic administration of buprenorphine also results in physical
dependence. The explanation for the misleadingly weak spontaneous
withdrawal phenomena for LAAM and buprenorphine seems to be
the slow elimination of these drugs from the plasma, which permits
the body to adjust more gradually to drug abstinence. The long
elimination half-life of LAAM's active metabolites (Kaiko and
Inturrisi 1975) and buprenorphine's unique affinity for the opiate
receptor and long elimination half-life (Cowan, Lewis, MacFarlane
1977) contribute to the lack of observed withdrawal signs after
chronic exposure is terminated. A similar example exists for the
long-acting benzodiazepine, diazepam. A delayed and relatively mild
withdrawal syndrome appears after spontaneous withdrawal, but
administration of the benzodiazepine receptor antagonist, Ro15-1788
(flumazenil), precipitates an immediate, intense abstinence syn-
drome (Lukas and Griffiths 1982, 1984). Analogous results are
produced when the daily dose level of shorter acting drugs is
gradually decreased.

A practical application of the finding that the magnitude of
withdrawal reactions tends to be inversely related to rate of drug
elimination is the gradual elimination of drugs from individuals who
are suspected of being highly physically dependent. Such gradual
elimination reduces the magnitude of the withdrawal syndrome.
This is the basis of the gradual withdrawal of morphine, alcohol, or
nicotine after a period of chronic intake at high dose levels (Jaffe
1985). Although gradual dose reduction of opioids and nicotine
reduces the magnitude of most aspects of the withdrawal syndrome,
it is not clear that such an approach improves overall treatment
outcome compared with much more rapid drug cessation (i.e., "cold
turkey") (Jasinski and Henningfield 1988; Chapter VII).

297


Therapeutic or Useful Effects of Dependence-Producing
Drugs

With many dependence-producing drugs, the same biological
properties that are important in their dependence-producing proper-
ties may also lend them to therapeutic application. In fact, most
classes of drugs which cause dependence, including opioids, seda-
tives, alcohol, cocaine-like drugs, and nicotine, have been used as
medicinals to treat specific medical disorders and human discom-
forts. Descriptions of the approved and general uses are available in
the American Hospital Formulary Service (1988), the Physician's
Desk Reference (Medical Economics Company 19881, the United
States Pharmacopeia (Griffiths, Fleeger, Miller 19861, and Goodman
and Gilman's Pharmacological Basis of Therapeutics (Gilman et al.
1985) (see also Table 6).

Although each of the drugs listed in Table 6 has a range of
potential or actual therapeutic applications, past and current uses
are often related to their effects on mood, feeling, and behavior. For
instance, the stimulants may be used to modulate arousal level, the
opioids to alleviate pain, the sedatives to alleviate anxiety; the drugs
are sometimes systematically used to treat the dependence which
may have previously developed on them or on another drug in the
same class. Nicotine is no exception to these observations. Historical-
ly, tobacco was used to treat a range of disease states, although
usually without evidence of efficacy (Corti 1931; Austin 1979).
Nicotine in the polacrilex gum form is a drug approved by the FDA
for treatment of nicotine dependence (see Chapter VII).

The therapeutic effects of dependence-producing drugs not only
illustrate an important point of commonality among these drugs, but
these effects also may be important in the drug dependence process
itself. Such potential drug actions can be important in the initiation,
maintenance, and relapse to drug dependence. The dependence
process may have been precipitated by the therapeutic use (medical-
ly approved or self-initiated) of a drug. The dependence process may
be exacerbated by the real or perceived benefit of the drug to the
individual as such actions strengthen the reinforcing power of the
drug. The therapeutic actions of a drug may be associated with
relapse to drug use after many years of abstinence. These aspects of
dependence potential as they pertain to nicotine are discussed in
Chapter VI.

Adverse and Toxic Drug Effects

As discussed earlier, adverse drug effects are important clinical
features of drug dependence. These effects may be used as factors in
objective determinations of the overall liability associated with a
drug (Yanagita 1987; Griffiths et al. 1985). For instance, chronic
administration of sedatives or alcohol can produce intoxication and


TABLE 6.-Effects that may be produced by addicting drugs

Attribute                          Nicotine o

Cocaine

Morphinelike

Alcohol

Discriminable interoceptive
(subjective) effects

       +
Henningfield and Goldberg
(1985), Morrison and
Stephenson (1969)

       +
Fischman et al (1976)

       +
Terry and Pellens (19701

      +
Carpenter (1962)

Produce dose-related increases
in self-reported "liking" scores

Produce elevated response on MBG
(euphoria) scale of ARC inventory

Positive reinforcer in animal
drug self-administration studies

Positive reinforcer in human
drug self-administration studies

       +
Henningfield, Miyasatc,
Jaainski (1985)

       +
Henningfield, Miyasato,
Jasinski (1985)

       t
Goldberg, Spealman,
Goldberg (19811, Deneau
and Inoki (1967), Ando and
Yanagita (1981),
Henningtield and Goldberg
(1983a)

       +
Henningfield, Miyasato,
Jasinski (1983)

       +
Henningfield et al. (1987)

       +
Fischman et al. (19761

+

Pickens and Thompson
(1968J. Deneau et al. (19691

       +
Fischman and Schuster
(1982)

       +
Martin and Fraser (1961)

       +
Haertzen et al. (1963)

       +
Headlee, Coppock. Nichols
(1955). Thompson and
Schuster (1964)

       t
Jonas and Prada (1975)

     i?
Mello (1968)

      +
Henningfield et al. (1984).
Stitzer et al. (1981)

      +
Deneau et al. (19691,
Winger and Woods (1973)

t

Bigelow et al. (1975). de
Wit et al. (1987)


E   TABLE 6.-Continued



    Attribute                          Nicotine o               Cocaine            Morphine-like              Alcohol

Place conditioning

Physical dependence develops such that
withdrawal accompanies
abrupt abstinence

Tolerance develop

Therapeutic use in treatment of
medical disorder

       +
Fudala, Teoh, Iwamoto
m8.51

       +
Hatsukami et al. (1984).
Hughes and Hatsukami
(19861

       +
Langley (1905). Domino
(1978), Marks, Burch,
Collins (19831, Jones,
Farrell, Herning (1978)

+'

AMA (1983), Gilman et al.
(1985), Medical Economics
Company (19871, and others

       +
Spyraki, Fibiger. Phillips
(1982)

      +?
Carroll and Lac (1987),
Jones (1984)

       +
Tatum and Sewers (19291,
Downs and Eddy (1932),
Wcolverton and Schuster
(19781, Wood and Emmett-
Oglesby (19871

AMA (1983), Gilman et al.
(19851, Medical Economics
Company (1987). and others

       +
Bardo and Neisewander
(1988)

      +-
Stewart and Grupp (1985)

       +
Light and Torrance (1929a),
Kolb and Himmelsbach
(1938), Himmelsbach (1941)

      +
Isbell et al. (1955)

       t-
Light and Torrance (1929b3

+3

AMA (1983), Gilman et al.
(1985). Medical Economics
Company (19871, and others

Goldberg (1:431

+-*

AMA (1983), Gilman et al.
(1985), Medical Economics
Company (1987). and others


TABLE 6.-Continued

Attribute

Caffeine

Marijuana

Lysergic acid diethylamide

Chlorpromazine

Discriminable interoceptive
(subjective) effects

       +
Gilbert (1976), Grifiiths and
Woodson (1988b)

Siler et al. (:933)

Produce dose-related increases
in self-reported "liking" scores

Produce elevated response on MBG
(euphoria) scale of ARC inventory

Positive reinforcer in animal
drug self-administration studies

Positive reinforcer in human
drug self-administration studies

Place conditioning                      ?

+-

Griffiths, Bigelow, U&son
et al. (19866). Chait and
Grifiiths (1983) t, Griffiths
and Woodson (1988b3

Chait and GriftXhs (1983)

       -?
Deneau et al. (1969),
Griffiths and Woodson
(1988b)

      +?
GrifIiths, Bigelow, Liebson
et al. (1986), Griffiths,
Bigelow, Liebson (1986),
Griftiths and Woodson
(1988b)

       +
Higgins and Stitzer 11986),
Cone et al. (19861

Higgins and Stitzer (19861,
Cone et al. (1986)

Harris et al. (1974)

       +
Mendelson and Meilo (1984)

?

       +
Hofmann (1975)

      +
Grifliths. Bigelow. Liebson
11979)

?                   7

Haertzen et al. (1963)

Stitzer et al. (1981)

Hoffmeister and Wuttke
(1976)

Hoffmeister and Goldberg
(19731. Hoffmeister 119751,
Deneau et al. (1969)

7

Griffiths. Bigelow, Liebson
(1979)

?


g   TABLE B.-Continued

Attribute                           Caffeine

Marijuana

Lysergic acid diethylamide

Chlorpromazine

PhysIcal dependence develops such that          t                  +?
withdrawal accompanies        Griffith& Bigelow, Liebson    Jones and Benowitz (1976),     Isbell et al. (1956)          Baldessarini (1980
abrupt abstmence            (1986). Dreisbach and       Mend&on et al. (1984),
                     Pfeiffer (1943). Horst et al    Ford and McMillan (1972).
                     (1934). Griftiths and       Beard&y et al. (1986)
                       Woodson (1988a)

Tolerance develops

       +                    t                    +                   7
Carney (19821, Eddy and     McMillan et al. (19701, W&l    Isbell et al. (1956)          Baldessarini (1980)
Downs (19281, Griffiths and    et al. (19681, Babor et al.
Wmdson (1988a)         (1975). Cone et al. (1986)

Therapeutic use in treatment of
medical disorder

       +s
AMA (1983). Gilman et al.
(19851, Medical Economics
Company (19871. and others

      +O
AMA (1983). Gilman et al.
(19851, Medical Economics
Company (lYU71, and others

       ?'
AMA (19831, Gilman et al.
(1985). Medical Economics
Company t1987). and others

      +R
AMA (1983). Gilman et al.
(1985). Medical Economics
Company (19871, and others

NOTE: + Indicates that drug administration produces the effect; - indicates that drug administration does not produce the effect: ? indicates that available scwntific data are madequate to draw a

conclusion.
* Further discussion can be found in other chapters of this Report.
) As aid to stop cigarette smoking and to treat nicotine dependence.
2 As topical anesthetic (rarely used1 for ear. nose. eye. and throat.

"(II As strong analges~es for treatment of both acute and chronic pain. (2) treatment for myocardial infarction (analgesia, anxialysis. and reduced left ventricular work-load and myocerdial oxygen
requirrmentsl. (31 for obstetric analgesia. (4) as preanesthetic medication to smooth induction, (5) treatment for pulmonary edema. (6) as cough suppressant, (7) treatment for severe diarrhea.
`(I) As antiseptIc agent on skin, 121 intravenously to treat premature labor (uterine relaxant), (3) treatment of spasticity by local or intrathecal injection of dilute absolute alcohol solutwn, (41 as
vehicle in dermatologx preparations (antiseptic actron, astringent action, cooling eNect). (5) treatment of alcohol withdrawal.
Sill Incorporated with over-thecounter analgesics (e.g.. aspirin) to treat ordinary headache and relieve inflammatory pain (scant scientific data to substantmte), (21 in combination wth ergot
alkaloid to treat migraine headache, (3) in combination with sympathomimetic agents possessing anorectic properties in weight-loss medications, (4) as stimulant. (5) treatment (clinical trials) for
preterm infant apnea of undetermined origin, (6) rarely for treatment of central nervous system depressant poisoning.
`(1) As antiemetlc for cancer chemotherapy patlent. (2) glaucoma treatment.


TABLE b.-Continued
' None at present, but several proposed in past: (11 as psychotherapy aid, (2) as adjunct in alcohol and opioid addiction treatment, (3) as adjunct in terminal cancer patient therapy to reduce opioid
analgesic need and induce tranquility.
*Cl) Management of psychotic disorder manifestations. (2) treatment for nausea and vomiting, (31 relief of presurgery restlessness and apprehension, (4) treatment for acute. intermittent porphyria.
(5) as adjunct in tetanus treatment. (6) to control mania manifestations in manicdepressive illness, (7) treatment for intractable hxcups, 03) treatment of children's severe behavioral dwrdcrs
characterized by combativeness or hyperexcitable behavior, (9) pceible second-hne treatment for nonpsychotic anxiety.
t "Liking" was not measured. but the increased scores on a tension and anxiety scale suggested dose-related "disliking."


severe mood swings (Mello and Mendelson 1970; Mello 1968; Isbell et
al. 1950); erratic supplies of opioids may be associated with socio-
pathic drug-seeking and withdrawal-related mood effects (Jasinski
1977); erratic supply of tobacco can also result in disruption of
ongoing activities in an effort to obtain tobacco or as a consequence
of withdrawal symptoms.

Consideration of multiple factors such as the dependence potential
of a drug, the extent of its actual use, and the degree to which it
produces adverse effects can be used to assess the overall liability
associated with the use of a drug (i.e., "abuse liability") (Brady and
Lukas 1984; Griffiths et al. 1985; Yanagita 1987). For example,
caffeine produces only minimal (if any) disruptive behavioral or
physiological effects and is not generally regarded as posing a serious
public health problem even though self-administration may be
widespread (e.g., caffeine in tea or coffee) (Griffths and Woodson
1988a,b). In contrast, drugs which produce disruptive physiological
and behavioral changes even when self-administered infrequently
may be considered to represent a more serious health hazard (e.g.,
LSD). Drugs may fall anywhere on the continuum defined by these
parameters, and the relative impact on health is most effectively
determined by a comprehensive assessment of these interactive
behavioral and physiological dimensions (Griffiths, Brady, Snell
1978b; Griffiths et al. 1985; Brady and Lukas 1984; Yanagita 1987).

Identification of Dependence-Producing Drugs

Independent, of whether use of a substance has been observed to
lead to addiction, it is possible to directly and objectively test a
chemical to determine if it is addicting. Such tests provide data used
by Federal (e.g., FDA, Drug Enforcement Administration) and
International (e.g., WHO) agencies as to how to regulate chemicals.
In fact, new drugs are usually evaluated and regulated ("scheduled")
before they are ever made available for medical application. Such
decisions rely heavily upon the known properties of addicting drugs
and on the methods used to test for such properties (both described in
this Chapter). Although the physicochemical structure of the drug is
one determinant of the stimulus effects produced by drug adminis-
tration, simply knowing the drug structure is rarely sufficient to
predict the nature and magnitude of possible drug effects (Barnett,
Trsic, Willette 1978); behavioral and physiological testing in animals
and humans is usually necessary. When there is convergent evidence
from multiple measures of dependence potential, then the drug is
appropriately regarded as addicting or dependence producing.
Whether humans outside the laboratory actually become addicted
will depend on additional factors such as availability, price, and
social acceptability of the drug (US DHHS 1987; also see discussion
by Katz and Goldberg 1988).

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Table 6 provides a comparison of several drugs in terms of the
major measures that have been reviewed in this Chapter. As shown
in the table, drugs known to produce widespread problems in a given
population are characterized by positive responses with most of these
measures (cocaine, morphine-like drugs, alcohol, and nicotine).
Conversely, drugs not contributing to such problems have fewer
positive responses on the various tests (cholorpromazine). Intermedi-
ate drugs are associated with intermediate levels of difficulty in
management of use.

Comparison Among Drugs

Within a given class of drugs, it is sometimes possible to rate their
relative efficacy as reinforcers by how much behavior was affected
(e.g., how many lever presses would occur or how much money would
be paid) (Griffiths et al. 1981; Yanagita 1987). For instance, the
slower onsetting/offsetting formulations of opioids, barbiturates,
stimulants, and nicotine appear to have a lower dependence poten-
tial than the quicker onsetting and offsetting formulations (Jaffe
1985).
The practical generality of such comparisons, however, is limited
because many other factors determine the overall level of depen-
dence that might develop, the extent of social and/or personal
damage, and the resulting level of social concern (Yanagita 1987;
Katz and Goldberg 1988). For example, the increasing availability
and decreasing relative price of cocaine in recent years are major
factors contributing to increased levels of use and resultant social
damage (US DHHS 1987). Analogously, the widespread ready
availability and the relatively low cost of tobacco products and
alcohol have probably contributed to the much higher rates of
addiction and mortality associated with alcohol and tobacco than
with drugs such as cocaine, even though cocaine may appear to be a
more effective reinforcer in animals. Social or cultural factors may
also contribute to the spread and levels of drug use. For example,
sensational press reporting may have contributed to the populariza-
tion of barbiturates in the 1960s (Brecher 1972), and the mass
marketing and advertising of tobacco products is likely to have
contributed to the use of these products, especially among women
and especially in the case of smokeless tobacco products (Ernster
1985, 1986; Warner 1986b; Davis 1987; Tye, Warner, Glantz 1987).

Four examples of drugs associated with striking changes in the
prevalence of use among various populations as well as associated
morbidity are: alcohol, for which use and associated diseases
decreased during the Prohibition years early in the 20th century;
lysergic acid diethylamide (LSD), for which use and associated
hospitalizations were elevated during the 1960s; cocaine, for which
use and associated hospitalizations increased during the 1970s


(Crowley and Rhine 1985; Levine 1984; Nahas and Frick 1981;
Dupont, Goldstein, Brown 1979; Holder 1987; US DHHS 1987);
tobacco, in which consumption of smokeless tobacco products in-
creased among youth in 1970s and cigarette consumption increased
sharply among women in the 1950s and 1960s (US DHHS 1981,1986;
Appendix A). As discussed in the aforementioned references, the
changes in use of these drugs were not due to changes in the
pharmacologic actions of the drug or sudden changes in genetic
constitution of the populations, but rather to changes in factors such
as availability, cost, social acceptability, regulatory controls, market-
ing efforts, and general perceptions about the risks associated with

use.

Finally, various other factors contribute to the level of social
concern and may be only indirectly related or unrelated to the
pharmacologic properties of the drug itself. For instance, the
observations on transmission of AIDS by way of shared needles
among i.v. drug users and on cancer caused by tobacco smoke
carcinogens have greatly increased the liability of use attributed to
these drugs in recent years.

Environmental Determinants of Drug Dependence Including
Behavioral Conditioning

A common feature of use of all dependence-producing drugs is that
the positive (satisfaction symptoms) and negative (e.g., withdrawal
symptoms) effects may become conditioned responses to associated
environmental stimuli. The implications of this are important for
understanding the chronic and self-sustaining nature of drug
dependencies. Such conditioning is a powerful behavioral mechan-
ism by which the drug comes to control an increasing amount of the
behavior of the drug user (Thompson and Schuster 1968; Goldberg
1976a).

Some of the important environmental determinants of drug
dependence are discussed elsewhere in this Chapter in the context of
drug self-administration studies. These factors include: (1) the
behavioral or economic cost of the drug itself or of taking the drug,
(2) direct pressure to take the drug by making other reinforcers
contingent upon drug taking, and (3) the other ongoing activities of
the person (e.g., demanding work schedule) that tend to enhance
drug taking. The focus of the present Section is on environmental
stimuli that may contribute to drug dependence by evoking urges to
use drugs, and by eliciting bodily responses that mimic the usual
effects of either drug taking or drug withdrawal reactions.


Drug Taking as a Learned Behavior

The interface between a drug and its effects is the behavior of
obtaining and ingesting the drug. Such behavior is learned behavior,
and as discussed earlier in this Chapter, many of the factors that
modulate this behavior are similar to those which modulate other
learned behaviors including eating, exercise, and occupational skills
(Thompson and Schuster, 1968). Technically, drug taking is "operant
behavior" and includes "respondent" or "classically conditioned"
components. The basic governing principle of operant behavior is
that it occurs in the context of certain stimuli and is either
strengthened or weakened by the nature of the consequence (a
positive reinforcer strengthens the response and a punisher weakens
the response) (Skinner 1938,1953). Thus, for example, a friend might
offer a drug (antecedent stimulus); the drug is ingested (operant
behavior or response); and the effects of the drug strengthen the
behavior (positive reinforcement). Respondent conditioning occurs
simultaneously and further contributes to the strength of the
behavior (Bouton and Swartzentruber 1986). A drug might serve as
an unconditioned stimulus which elicits a relatively involuntary
response (e.g., nicotine and morphine can elicit feelings of pleasure
and/or nausea); when physical dependence has occurred, drug
abstinence can also elicit certain responses (e.g., anxiety and urges to
take the drug). Any environmental or even internal stimulus can
become part of this conditioning process by repeated association with
the elicited response. For example, the taste of alcohol, the smell of
smoke, "thinking" about use of the substance, and the sight of
cocaine- or opioidassociated paraphernalia can elicit feelings associ-
ated with either the administration or withdrawal of the drug
(Childress, McLellan, O'Brien 1986a,b; Ludwig 1986; Ludwig and
Stark 1974; Erben 1977; Gotestam and Melin 1983; Pickens, Bigelow,
Griffiths 1973; Rickard-Figueroa and Zeichner 1985; Levine 1974).

The simultaneous operation of both operant and respondent
conditioning can converge to generate and maintain powerful chains
of behavior over which the individual may have little control. As
shown earlier in this Chapter, highly addicting drugs are those
which are very effective at reinforcing behavior and eliciting
responses. Their power can be increased by factors such as drug
deprivation, which may be associated with a discomforting with-
drawal syndrome. In the presence of withdrawal, the person may
behave in a way to relieve the discomfort of a withdrawal syndrome;
in this case the withdrawal syndrome itself may be said to be
functioning as a negative reinforcer. When drugs are readily
available, as with tobacco for most people or opioids for physicians,
these behavioral conditioning processes may be very subtle because
the drug can be taken in a pattern that avoids excessive discomfort.
For example, early interoceptive or subjective withdrawal cues that

307


are evident upon waking in the morning signal that "it is time to
smoke a cigarette," and thus the smoker neither "forgets to smoke"
nor experiences pronounced withdrawal symptoms.

As implied by the foregoing discussion, the strength and persis-
tence of drug-seeking behavior are not just functions of the drug
itself or of withdrawal. Rather, they are determined by many factors,
such as the number of times that certain responses are associated
with certain stimuli, the presence or absence of such stimuli, the
subjective discomfort occurring as part of withdrawal, and the
availability of the drug. The convergence of so many environmental
and subjective forces can result in extremely persistent behavior
that may appear disproportionate to the pleasure actually experi-
enced when the drug is taken (e.g., the few minutes of pleasure from
the postdinner cigarette or when heroin is taken after 8 to 12 hr of
deprivation). In fact, the subjective pleasure itself may be very mild,
and the person may describe the role of the drug as "simply
maintaining feelings of normalcy or comfort" and not as "getting
high" per se. The scientific basis for these observations has been
actively and systematically studied since the pioneering work of
Wikler and others (Wikler 1973) and has been reported and reviewed
in detail elsewhere (Goudie and Demellweek 1986; O'Brien, Ehrman,
Ternes 1986; Grabowski and Cherek 1983; Grabowski and O'Brien
1981; Childress, McLellan, O'Brien 1986a,b; McLellan et al. 1986;
Wikler 1973; Meyer and Mirin 1979).

Drug-Associated Stimuli Modulate Drug Seeking

Stimuli associated with drug effects may come to elicit ("trigger")
those same effects or sometimes opposite effects (withdrawal re-
sponses). For example, increased heart rate induced by stimulant
administration may become associated with multiple environmental
stimuli-the color of the tablet, the individual who provided it, and
the office environment in which the drug was taken. These stimuli
may act alone or in concert. One stimulus may produce a slight heart
rate change; two such stimuli may produce a larger change; and the
presentation of many such stimuli may have a synergistic effect.
Other stimuli may counteract or facilitate these effects (Schindler,
Katz, Goldberg, in press).

The response produced in relation to environmental correlates
may differ qualitatively from the direct drug effect. For instance, the
direct effect of a drug may be a heart rate increase, whereas the
conditioned or learned response to drug-associated stimuli may be
either a decrease or an increase in heart rate. Changes may be
particularly evident for agents with biphasic effects such as nicotine.
Whatever the direction of change in response value, the events may
be of physiological and behavioral significance (for example, see
Childress, McLellan, O'Brien 1986a,b; O'Brien, Ehrman, Ternes

308


1986; Stewart, de Wit, Eikelboom 1984; Grabowski and O'Brien 1981;
Childress et al., in press). These complex conditioning processes
which can function to precipitate drug taking appear to function
similarly for a variety of drugs including opioids and tobacco (Ternes
1977).
Since the 1960s many researchers have shown that the role of
associated stimuli is important for diverse biological reinforcers such
as drugs, food, and sex. For example, Thompson and Schuster (1964)
demonstrated that environmental stimuli paired with drugs could
themselves come to generate drug seeking in monkeys. Schuster and
Woods (19681, Davis and Smith (19761, and Carnathan, Meyer, and
Cochin (1977) demonstrated that stimuli previously associated with
drug taking could generate much drug-seeking behavior in animals
during extinction of use when the drug is no longer available.
Similar findings were obtained in a study of i.v. cocaine self-
administration in which human volunteers emitted high rates of
lever pressing in the presence of cocaine-associated stimuli when the
drug was not available (Katz and Goldberg 1988).

Goldberg (1976b) reported that environmental stimuli associated
with drug taking could help sustain substantial behavioral reper-
toires in monkeys often far in excess of the behavior that was
maintained when just the drug was given. Similarly, Meisch found
that the taste and smell of alcohol, which were normally found to be
highly aversive to rats, became highly effective stimuli in their own
right in the maintenance of alcohol-seeking behavior, even when
alcohol was not actually available for the rats to consume (Meisch
1977). La1 and colleagues (1976) demonstrated that environmental
stimuli previously associated with drug effects could, by producing
drug-like responses, attenuate opiate withdrawal signs in rats. These
and many other studies have shown conclusively that specific
environmental stimuli associated with drug taking exert control
over drug seeking, drug taking, and characteristics of the drug
response itself.

Environmental conditions in many forms can contribute to
sustained drug use, and specific stimulus conditions can have well-
defined drug-like properties. This phenomenon, which has been well
documented in laboratory settings, is recognized as being powerful in
clinical pharmacology, in which "placebo" effects (conditioned
responses to drug-taking conditions) may be dramatic and difficult to
separate from so-called direct drug effects. Both direct drug effects
and those established through learning influence physiology and
behavior, thereby contributing to the strength of addictive behav-
iors. Recent reports suggest that conditioned effects can be attenuat-
ed for some individuals through effective treatment specifically
designed to extinguish, or alter through learning, these responses
(Childress, McLellan, O'Brien 1986a,b; M&Alan et al. 1986).

309


The stimuli associated with drug effects also may generate further
drug seeking and drug taking. Wikler (1973) and more recently
Meyer and Mirin (1979) contributed substantially to both the
conceptual framework and the data describing these complex
phenomena. These investigators found that environmental stimuli
which correlated with direct drug effects are pertinent to the
acquisition, maintenance, and elimination of opioid taking by
humans. Similar findings were observed in an intensive study of an
alcoholic subject: alcohol-associated stimuli produced orderly re-
sponses including urges to drink and even drinking itself (Pickens,
Bigelow, Griffiths 1973). A series of studies by Goldberg and his
colleagues (Goldberg 1970; Goldberg, Kelleher, Morse 1975; Goldberg
and Kelleher 1977; Goldberg, Spealman, Kelleher 1979) showed that
environmental stimuli occasionally associated with morphine injec-
tions or with early withdrawal effects could lead to increased drug
seeking and/or drug taking.

Conditioned Withdrawal Symptoms May Precipitate Drug
Seeking

Wikler (1948) first described the discomfort of long-abstinent
patients on their return to environments in which they had
previously used drugs and experienced withdrawal symptoms. Subse-
quently, Wikler (19731, O'Brien (1975) and colleagues (O'Brien,
Ehrman, Ternes 1986; O'Brien et al. 19751, and several other
researchers (Siegel 1975, 1976, 1978; Eikelboom and Stewart 1979;
Stewart, de Wit, Eikelboom 1984; Childress et al., in press) have
made fundamental contributions to the identification of the complex
interplay of factors modulating the physiological and behavioral
components of abstinence. These and other studies have shown that
the conditions established by abrupt withdrawal after chronic
administration of a drug can serve as setting conditions which may
result in further drug taking. In other words, for some individuals
the onset or anticipation of abstinence symptoms may be strongly
linked to reinitiation of drug self-administration. In turn, the drug
effect reinforces the reinitiation of drug taking (Stewart, de Wit,
Eikelboom 1984). Withdrawal symptoms and drug taking may thus
become closely associated with a range of environmental stimuli.
These stimuli then come to elicit abstinence symptoms and generate
drug taking through a variety of powerful biobehavioral mechan-
isms. In fact, McNeil1 and colleagues (1986) have concluded that the
pattern of abstinence symptoms itself may be in part determined by
conditioning factors.

Environmental stimuli can lead to drug seeking by eliciting
distressing conditioned withdrawal effects. Several thorough reviews
on conditioning factors in drug dependence indicate that correlated
behaviors and stimuli dramatically alter drug effects, withdrawal

310


symptoms, and other features of substance use behaviors (Goudie
and Demellweek 1986; O'Brien, Ehrman, Ternes 1986; Grabowski
and Cherek 1983; Grabowski and O'Brien 1981). These interacting
factors have also been described in a number of prominent medical
and scientific texts (Jaffe 1986,1987), as well as in the recent Second
Triennial Report to Congress from the Secretary, Department of
Health and Human Services (US DHHS 1987).

One of the clearest observations of the contribution of environmen-
tal factors in tobacco withdrawal was made by Hatsukami, Hughes,
and Pickens (1985). They noted that the number of withdrawal signs
increased substantially when cessation occurred in the natural
environment. Parallels exist in both laboratory research and natu-
ralistic observation. Stitzer, Bigelow, and McCaul (1983) reviewed
this literature and noted that individuals restrained from access to
drugs for prolonged periods tend to return to use when the agents
are again available; the implicat.ion is that environmental stimuli
contribute to relapse. In a laboratory study, Thompson and Ostlund
(1965) found that relapse to self-administration occurs rapidly for
animals removed from, and then after extended periods returned to,
the original environment but not for animals that undergo extinc-
tion of self-administration within that environment. In a reverse
situation in humans, Robins, Davis, and Goodwin (1974) reported
that individuals who experienced initial drug use in the stressful and
ready-access conditions of the Vietnam war tended not to continue
use on return to the United States.

Relapse to Drug Dependence

For many drug-dependent persons, achieving at least brief periods
of drug abstinence is a readily achievable goal. Maintaining absti-
nence, or avoiding relapse, however, poses a much greater overall
challenge. There is a substantial base of data for these conclusions.
Treatment outcome reviews concerning opioid (Platt 1986), alcohol
(Miller and Hester 1986a; Peele 1987), and tobacco (Brownell et al.
1986; Lichtenstein 1982; Schwartz 1987) dependence show that
clinical interventions are often successful in producing short-term
cessation of drug use but that relapse to use is a frequent
posttreatment occurrence (Hunt, Barnett, Branch 1971; Brownell,
Marlatt et al. 1986).

An important issue in the contemporary study of addictions is the
degree to which relapse and recovery are generalizable across
categories of substances (US DHHS 1986; Tims and Leukefeld 1986;
Marlatt 1979; Miller and Hester 1986a,b; Schwartz 1987). This
Section examines rates and predictors of relapse across drug classes
with emphasis on comparisons among alcohol, opioids, and tobacco.

311


Implications of these observations for the prevention of relapse will
be described in the next Section of this Chapter.

Definition of Relapse

In general, relapse refers to resumption of drug use following
abstinence from such drug use; however, the criterion for abstinence
and resumption of drug use must be specified. Principles for such
specification are generally similar among drugs; however, there are
drug-specific issues which complicate comparisons of data and will be
discussed in this Section. Only when an individual has achieved
criteria for abstinence is he or she "eligible" for the possibility of
relapse. Defining abstinence over some time period as the eligibility
criterion is useful because it permits distinctions to be drawn
between continuous users and those who are able to "quit" drug use,
however briefly. Definitions of "quit episodes" differ dramatically
among published studies, leading to quite different interpretations of
subsequent relapse. With regard to tobacco, a consensus conference,
held under the auspices of the National Heart, Lung, and Blood
Institute, recommended 24 hr of continuous abstinence from tobacco
as the criterion for defining a quit episode and establishing eligibility
for relapse to tobacco use (see Chapter VII). With regard to other
dependence-producing drugs, patients of residential alcohol and drug
abuse treatment facilities are usually deemed eligible for relapse at
discharge without reference to the duration of treatment or absti-
nence.

Two general ways of defining relapse after a period of abstinence
have appeared in the literature. Relapse has been defined as a
discrete event occurring with the single use of a drug or as a process
developing over time (Wesson, Havassy, Smith 1986). When relapse
is defined as a discrete event, distinction is often made between first
use of the primary drug of dependence and first use of any other
psychoactive agent. Return to use of the primary drug holds clear
potential for return to addiction (Hubbard and Marsden 1986).
However, there has been less consensus regarding whether use of a
substitute drug should be defined as relapse. When relapse is defined
as occurring over time, the endpoint of the process has been
variously defined as daily drug use for a specified period, a return to
drug use at or above pretreatment or baseline level, a consequence of
drug use such as readmission for treatment, a return to dependence
defined by one or more diagnostic instruments, or a return to drug
use at levels above criteria specified in terms of quantity and/or
duration of drug use (APA 1987; Litman et al. 1983; O&p-Klein et
al. 1986; Simpson and Marsh 1986).

The choice of definition is also influenced by the treatment
modality being evaluated and by the theoretical orientation of the
investigator. For example, relapse is usually discretely defined in

312


clinical applications of aversive counterconditioning to treatment of
alcohol and tobacco dependence (Boland, Mellor, Revusky 1978;
Schwartz 1987). In. contrast, investigations- of skills training ap
proaches to alcohol, tobacco, and other drug use treatment typically
employ continuous or process measures of relapse, e.g., number of
days of abstinence (Chaney, O'Leary, Marlatt 1978; Marlatt and
Gordon 1985) because new skills are not lost after a slip but rather
could be used repeatedly to reestablish abstinence (Catalan0 and
Hawkins 1985).

Measurement of Relapse

Relapse is usually assessed by one of two measurement procedures
(Wesson, Havassy, Smith 1986). Current drug use measures ascer-
tain drug use at selected posttreatment intervals (e.g., 3, 6, and 12
months). Intermittent drug use occurring between these time
intervals may not be captured by this procedure. Continuous status
measures ascertain whether there was drug use at any point in the
posttreatment interval. Current use measures typically yield higher
abstinence rates than continuous status measures, because of the
variable course of drug abuse careers (Pickens et al. 1985). Current
use measures provide point-in-time estimates of relapse status
among a sample of treated users, while continuous status measures
allow for determining the percentage of individuals who have
managed to achieve relatively enduring abstinence (Ossip-Klein et
al. 1986). The implications of different measurement approaches for
interpretation of relapse phenomena have been reviewed (Wells,
Hawkins, Catalano, in press; Brownell et al. 1986).

While self-reported drug use status has been the primary method
of detecting relapse, detection of the drug in biological fluids or in
expired air is being used as an adjunct with increasing frequency
(Wesson, Havassy, Smith 1986). As discussed earlier in this Chapter,
biochemical methods of assessing drug use vary widely in their
sensitivity and in the period during which drug use can be detected
(Walsh and Yohay 1987).

Rates of Relapse

Hunt and his colleagues were the first to investigate commonali-
ties in relapse processes among substances (Hunt, Barnett, Branch
1971; Hunt and Bespalec 1974; Hunt and General 1973; Hunt and
Matarazzo 1970). They compared relapse rates for clients discharged
from opiate, alcohol, and tobacco dependence treatment programs
and noted the remarkable similarity of the relapse curves they
obtained (Figure 2). Relapse was defined as any use of the primary
drug of abuse. They then formulated a learning theory of relapse
that was presumed to operate in alcohol, opioid, and tobacco
dependence.

313


o ? ? ? a Heroin Use

b----d SmoC ting
w Alcohol Abuse

2 weeks I 2 3 4 5 6 7 8 9 IO II 12
             Months

FIGURE 2.-Relapse over time for heroin use, smoking,
        and alcohol abuse
SOURCE- Hunt et al ,19711

Although attempts t.o base theories of relapse on cumulative
survival curves, such as those depicted in Figure 2, are complicated
by a variety of factors (Litman, Eiser, Taylor 1979; Sutton 1979;
Brownell et al. 19861, such curves do possess heuristic value. They
indicate that abstinence rates fall precipitously in the early post-
treatment period; that most treated smokers, alcoholics, and heroin
addicts relapse to at least single use of the primary drug of use by 3-
month followup; and that those who have maintained abstinence for
at least 6 months are much less likely to relapse.

Similar large-scale reviews of relapse rates for multiple substances
have not been published in recent years. Instead, a voluminous

314


literature has accrued regarding treatment effectiveness (Schwartz
1987; Miller and Hester 1986a; Platt 1986; Simpson and Sells 1982).
However, data from studies of alcohol, opioid, and tobacco relapse
consistently support the similarities in relapse rates and patterns
across these three forms of drug dependence, as well as the operation
of similar determinants of relapse. For instance, high rates of relapse
characterize most treatment programs for dependence to opioids
(Maddux and Desmond 1986; Platt 1986; McAuliffe 1975; McAuliffe
et al. 1986; Waldorf 1983), alcohol (Belasco 1971; Bruun 1963;
Robson, Paulus, Clarke 1965; van Dijk and van Dijk-Koffeman 1973;
Vaillant 1982; Imber et al. 1976; Kendell and Staton 1966; Orford
and Edwards 1977), and tobacco (Brandon, Tiffany, Baker 1986;
Erickson, Rugg, Tunstall, Jones 1984: Hunt and Mat,arazzo 1973;
Marlatt and Gordon 1985; Shumaker and Grunberg 1986; Schwartz
1969; see also Chapter VII). The remainder of this Section will
address the parallel in the correlates of relapse to these three
substances.

Correlates of Relapse

Factors found to be associated with relapse fall into three domains.
Background or pretreatment factors are those that seem to heighten
the individual's vulnerability to relapse (Shiffman et al. 1986). These
variables may be measures of fixed pretreatment characteristics
such as demographics and drug use history. Pretreatment factors
appear to account for between 10 and 20 percent of the variance in
posttreatment relapse (Cronkite and Moos 1980; Simpson, Savage,
Lloyd 1979; Simpson and Sells 1982). Variables measured during
treatment are also thought to influence the probability of relapse at
posttreatment. These include treatment length, intensity, setting,
type, and compliance with treatment. Treatment factors appear to
account for 15 to 18 percent of the variance in drug abuse outcome
studies (Simpson, Savage, Lloyd 1979). Posttreatment factors are
those associated with the subject's posttreatment environment or
internal state. These include degree of family support, drug use
among peers, involvement in work and leisure activities, and
emotional states. Posttreatment factors have been shown to account
for roughly 50 percent of the variance in posttreatment relapses
(Finney, Moos, Mewborn 1980) and thus may be the most important
focus for relapse prevention efforts. The rest of this Section will
review prominent relapse factors that have been systematically
studied for opioids, alcohol, and tobacco.

Pretreatment Correlates of Relapse
Severity of Drug Dependence

Severity of pretreatment drug dependence is one determinant of
the likelihood of relapse. Several studies have found that light

315


smokers are more likely to succeed at abstinence than heavy
smokers (see Table 7 and Chapter VII). Similarly, with regard to
opioid dependence, a shorter pretreatment period of dependence is
associated with better posttreatment outcomes (Riordan et al. 1976),
and level of drug craving was directly related to the amount of
variance in relapse (McAuliffe et al. 1986). Estimating the contribu-
tion of severity of alcohol dependence to relapse is more problematic
because there has been such a wide variety of measures (e.g., severity
of social harm, illness, withdrawal, or craving) used among studies.
Thus, the seven alcohol studies cited in Table 7 provide equivocal
results, and it is unclear whether there is actually no relationship or
whether variability in measurement among studies precludes mean-
ingful conclusions. Furthermore, there is some evidence that predic-
tions of relapse based on severity of dependence are moderated by
age, marital status (Polich, Armor, Braiker 1981), and gender
(Hesselbrock et al. 1983).

A factor that complicates the relationship between duration of
drug dependence (as a measure of severity) and likelihood of relapse
is that the age of the individual is directly related to remission (see
discussion of spontaneous remission earlier in this chapter). Mill-
man, Khuri, and Nyswander (1978) reported that length and
intensity of addiction were positively associated with relapse, except
that older opioiddependent persons were more successful at avoid-
ing relapse than younger ones. In a followup study of 38 treated
methadone clients, Riordan and colleagues (1976) found that re-
lapsed subjects were more likely than nonrelapsed subjects to have
been addicted longer prior to treatment.

Psychiatric Impairment

As previously discussed, both depression and anxiety are common-
ly observed as dual diagnoses in persons dependent on alcohol and
other psychoactive drugs. These diagnoses are also predictive of high
rates of relapse and poor treatment outcomes. As shown in Table 7,
several studies suggest that overall severity of psychiatric sympto-
matology may be an important predictor of treatment outcome. For
example, McLellan and colleagues (1983) evaluated 6-month post-
treatment outcomes for 460 alcoholics and 282 opioid addicts drawn
from 6 rehabilitation programs. Using an intervention-based assess-
ment of the severity of psychiatric symptomatology, they observed
that patients with low psychiatric severity improved in every
treatment program, while patients with high psychiatric severity
showed almost no improvement in any treatment program. Patients
with midrange severity levels of psychiatric disorder showed differ-
ential responses as a function of treatment modality.

316


TABLE 7.Ctudies showing evidence for factors associated with relapse, by substance

Studies

FactorS

Tobacco

Opioids

Alcohol

Pretreatment

Degree of dependence

Hall, Herning et al. (1984).
Pomerleau et al. (1978), Jarvik
(1979), Shiffman (1979, 1964)

McAuliffe et al. (19861, Millman
et al. (1978). Riordan et al. (1976)

Foy et al. (1984). Heather et al.
(1983), Hesselbrock et al. (1983).
Kivlihan et al. (in press), Litman
et al. (19&U, Orford et al. (19761,
Polich, Armor, Braiker (1980)

Psychiatric impairment             No studies

Criminality

Demographics

Mclellan et al. (1983), Rounsaville
et al. (1985)

Abbot and Gregson (1981), Gregson
and Taylor (1977), Heilbrun and
Tarbox (1978). O'Leary et al.
(1979). Donovan et al. (1984).

Mclellan et al. (1983) Rounsaville
et al. (1987)

No studies

Simpson and Sells (1982), LIeLeon
(1985)

No studies

Tucker et al. (1985). Swan et al.
(1965), Eisinger (1971), Campbell
ww

Tucker et al. (19851, Simpson and
Sells (1982)

Tucker et al. (1985), Pemberton
(1967). Armor et al. (1978).
Voegtlin and Broz U949), Fox and
Smith (1970)


0
z   TABLE 7.-Continued


                                                                 Studies

Factors

Tobacco

Opioids

Alcohol

Treatment

Length

No studies

Simpson and Sells (1982), DeLeon
et al. (1982)

Miller and Hester (1966b)

Modality

Row et al. (1960), Foxx and Brown
(19791, Elliott and Denney (1976).
Erickson et al. (1963). Tiffany,
Martin, and Baker (19%)

Simpson and Sells (1962), Bale et
al. (1980)

Emrick (1974), Miller and Hester
(1966a)

Use of drugs/Involvement in crime

Positive expectations of outcome

Posttreatment

No studies

Brandon, Tiffany, Baker (1966)

Simpson and Sells (1962)
Simpson and Sells (1962)

No studies

Eastman and Norris (1962)

Family

Marlatt and Gordon (1960). Horwitz
et al. (1965), Coppotelli and
Orleans (1965), Mermelstein et al.
(1963)

Dell orto (1974), Levy (1972).
Stanton, Todd, Steir (19791, Rhoads
(1963), Wellisch and Kaufman
(1975), Harbin and Mazier (1975).
Hejinian and Pittel (1978).
Kaufman (19651, Stanton (1976,
1979)

Finney et al. (1960). Moberg et al.
(1962), Burton and Kaplan (1966),
Moos and Mow (19&Q Marlatt and
Gordon (1960), Billings and Moos
(19%. b), Moos et al. (1979).
Orford et al. (1976)

Peel.8

Isolation

Lack of involvement in work

Cummings et al. (1960), Shiffman
(1992), Evans and Lane (1981),
Lichtenstein et al. (1977), Marlatt
and Gordon (19&l), Cummings et
al. (1960)

Hawkins and Fraser (1987), Chancy
et al. (1982), Marlatt and Gordon
(1960, 1965)

Chaney et al. (1978). Marlatt
(19781, Marlatt and Cordon (1960)

No studies

Hawkins and Fraser (1967)          Stead and Viders (1979)

Ronnlxxg (1979), Savage and
Simpson (1979), Simpson (1981),
Simpson et al. (1966). Simpson and
Lloyd (1979)

Bromet and Moos (19771. Finney et
al. (1960)


TABLE 7.-Continued

Studies

FMOl-3

T&%X0

Opioids

Alcohol

Lack of active leisure             Shiffman (1984)

Simpson et al. (1981), NIDA (1980)

Finney et al. (1980), Moberg et al.
11982), Moos et al. (1979). Stead
and Viders (19791, Tuchfeld WEl),
Tuchfeld et al. (1983)

Negative emotional states

Hataukami et al. (19841, Marlatt
and Gordon (1980). Lichtenstein et
al. (1977), Mermelstein (1983).
Mermelstein et al. (19W, Shiffman
et al. (19%). Lichtenstein (19%)

Stephens and Cottrell (19721,
Cummings et al. (1980). Marlatt
and Gordon (1980). Hatsukami et
al. (1981). Chaney et al. (1982)

Ludwig (1982). Marlatt (197%
Chaney et al. (1978). Finney et al.
i1980), Slater and Linn (19&Z-1987),
Pickens et al. (19&j, Samsonowitz
and Sjoberg (1981), Sandahl (1984).
Hatsukami et al. (1981)

Negative physical states

Pomerleau (1979), Shiffman (1979)

Khatami et al. (1979). Chaney et
al. (i982). Marlatt and Gordon
(1980, Martin (1972)

Finney et al. WX?0. Mws et al.
(1979)

Skills deficits




Negative life events

Marlatt and Gordon (1980).
Shiffman (1982, 1984). Curry and
Marlatt (1965)

Etringer et al. (1984)

Brill (1963), Cheek et al. (1973).
Fort (1966). Catalan0 and Hawkins
(1985)

Judson and Goldstein (1983),
Rhoads (1983)

Miller et al. !1974), O'Leary et al.
(1976), Rosenberg (1983). Miller and
Eisler (1977)

Moos et al. (1979, 1981). Finney et
al. (1980), Rosenberg (1983). Hull
and Young (1983). Vuchinich and
Tucker (19%)

Lack of needed services

No studies

Ogborne (1978). Hawkins and
Catalan0 (1985). McAuliffe et al.
(1985)

Feit (19801, Ashley et al. (1976).
Oghorne (1978), Ahles et al. (1983),
Ito and Donovan (1986)


Demographic Factors

Demographic correlates of relapse have been widely studied.
Consistent demographic predictors of relapse, either within or
among substances, have not been identified (Tucker, Vuchinich,
Harris 1985 and see Table 7). It is possible that the wide historical
diversity of methods and definitions used contributes to greater
apparent diversity when data are evaluated both within and among
drug classes.

Treatment Correlates of Relapse

In treatment studies of opioiddependent persons, it has been
found that treatment type and duration as well as treatment
expectancies affect posttreatment relapse. Length of time in treat-
ment has been positively associated with outcomes across modalities
of drug dependence treatment (McLellan et al. 1983; Simpson and
Sells 1982). In addition, treatment completers have shown more
positive outcomes than those who do not complete treatment.
regimens (DeLeon, Wexler, Jainchill 1982). Expectations of positive
treatment outcome have also been related to lower relapse rates
(Simpson and Sells 1982). Finally, modality of treatment has been
related to treatment outcome in opioid addicts. Methadone mainte-
nance, long-term inpatient treatment, and outpatient drug-free
programs have all produced better outcomes than detoxification
treatment or no treatment in both a followup study (Simpson and
Sells 1982) and a prospective study (Bale et al. 1980). In the alcohol
treatment literature, however, few differences have been detected
among the most popular treatment techniques, including residential
and outpatient modalities (Emrick 1974, 1975; Miller and Hester
1986a).

Schwartz (1987) has recently examined the effectiveness of more
than 20 types of smoking cessation interventions (see Table 2 in
Chapter VII). Seven methods showed good short-term results:
educational techniques, nicotine chewing gum when combined with
behavioral treatment, group hypnosis, physician intervention with
cardiac patients, rapid smoking, satiation, and contingency contract-
ing. Multicomponent programs that combined several interventions
appeared to produce especially encouraging outcomes.

Expectations regarding alcohol's effects may enhance susceptibili-
ty to relapse. Eastman and Norris (1982) examined this relationship
in 89 persons participating in outpatient treatment for alcohol
dependence. At a 2-month followup, 71 percent of subjects with
positive expectations about alcohol's effects had relapsed (any level
of consumption was the criterion), compared with only 7 percent of
subjects with negative expectations about the effects of alcohol.
Analogously, in cigarette smokers, expectations regarding one's

320


ability to successfully abstain may also predict relapse to tobacco use
(Brandon, Tiffany, Baker 1986; Chapter VII).

Posttreatment Correlates of Relapse

Evidence from a number of sources suggests that posttreatment
experiences are particularly important to the relapse process. For
example, Finney, Moos, and Mewborn (1980) found posttreatment
factors to account for roughly half of all variance in treatment
outcome. Further, recent investigations of the effectiveness of
aftercare in the treatment of drug and alcohol abuse suggest that
interventions which target the posttreatment interval may be
particularly effective (Ahles et al. 1983; Catalan0 and Hawkins 1985;
Catalan0 et al., in press; Marlatt and Gordon 1985). Specific
categories of posttreatment factors associated with relapse are
described below.

Family Support Factors

Family support has been a strong predictor of posttreatment
success for opioid users, alcoholics, and cigarette smokers (Table 7).
For example, Orford and colleagues (1976) found a marital cohesion
factor to predict treatment outcome for drinking variables measured
12 months later. Similarly, in a survey of 219 subjects who were
interviewed at l-year followup after treatment in a minimal
intervention smoking cessation program, abstainers reported signifi-
cantly more support from spouses, parents, family, and friends than
did relapsers (Horwitz et al. 1985). Similarly, Orford and colleagues
(1976) found that high marital discord was a predictor of relapse
drinking at the 1Zmonth followup among treated alcoholics,
whereas Burton and Kaplan (1968) found reduction in the number of
areas of disagreement between the alcoholic and his or her spouse to
be associated with improvement in drinking behavior. These obser-
vations are consistent with the retrospective reports of relapsed
subjects indicating that interpersonal conflict that was family or
peer related was a trigger for drug use following a period of
abstinence (Marlatt and Gordon 1980). Taken together, these data
suggest that family support plays an important role in preventing
relapse to substance use and that family conflict and lack of support
for posttreatment recovery may increase levels of relapse for treated
users of alcohol, opioids, and tobacco.

Drug Use Among Peers

Relapse to drug use following a period of abstinence after
treatment often occurs when there is peer pressure to use drugs or
when drugs are offered by the nonabstinent peer. A series of reports
by Marlatt, Chaney, and their associates (Chaney, O'Leary, Marlatt

321


1978; Chaney, Roszell, Cummings 1982; Marlatt 1979; Marlatt and
Gordon 1980, 1985) examining determinants of relapse for various
substances suggested that social pressure is a factor for approximate-
ly 15 to 40 percent of relapse episodes among alcohol and opioid
users. In a followup study of treated heroin users, Hawkins (1979)
found that 69 percent of those who returned to heroin use after drug
treatment reported that they did so in response to informal pressure
from peers, suggesting an even stronger effect of social factors on
relapse among opioid users. Similarly, living with smokers (Shiffman
1982) and failure to avoid smoking peers (Graham and Gibson 1981)
are related to relapse in treated smokers. Specifically, Shiffman
(1982) found that 30 percent of the relapse cases of 183 ex-smokers
were associated with the presence of other people smoking. Other
investigators have also found the presence of other smokers (Lichten-
stein, Antonuccio, Rainwater 1977) or social pressure to smoke
(Cummings, Gordon, Marlatt 1980) to be a risk factor for relapse
(Chapter VII).

Involvement in Work and Leisure Activities

Although active employment and involvement in leisure activities
may be distinguished (as shown in Table 71, there are similarities in
their effects on relapse. Furthermore, the factors are similar in that
both may be incompatible with active involvement with some
dependence-producing drugs. In brief, research on posttreatment
experiences of both opioid users and alcoholics has shown a
consistent positive relationship between involvement in active
recreational leisure activities (sports, hobbies, crafts, and volunteer
work) and reduced use of opioids, alcohol, and tobacco (Table 7).
Similarly, unemployment is associated with relapse to opioids and
alcohol (Table 7).

Negative Emotional States

One of the most consistent findings from retrospective studies of
relapse is the involvement of negative emotional states in relapse
episodes. Data supporting this conclusion regarding tobacco use are
discussed in detail in Chapters VI and VII and are only briefly
summarized in this Section to enable a comparison of findings with
opioids and alcohol. Ludwig (1972) interviewed 161 relapsed alcohol-
ics and reported that 25 percent relapsed in response to "psychologi-
cal distress." Marlatt (1978) interviewed 48 alcoholics who relapsed
within 90 days of discharge from treatment and found that 10
percent relapsed in negative mood states and 29 percent in situations
arousing frustration or anger. Negative emotional states are also
prominent determinants of relapse to cigarette smoking. For in-
stance, Marlatt and Gordon (1980) reported that 43 percent of the

322


relapse episodes of 35 subjects who had completed a smoking
cessation program were in response to negative mood states.

Drug use has also been reported as a means of alleviating negative
emotional states. For example, Stephens and Cottrell (1971) studied
236 opioid users who had received 6 months of inpatient methadone
treatment. One-quarter of the clients they studied relapsed, report-
edly using the drug to alleviate stress or to combat personal faults or
depression. Consonant with these findings, reports of former drug
users suggest that approximately one-fourth to one-third of the
incidents of first drug use following treatment are precipitated by
negative emotional states (Cummings, Gordon, Marlatt 1980; Mar-
latt and Gordon 1980).

, Potential sources of negative emotions cited by relapsers include
stressful interpersonal interactions (e.g., anger, frustration) and
negative life events such as death, illness, job loss, or change. The
role of negative life events has long been recognized as an important
factor that can influence psychopathology, illness, and drug depen-
dence; recently, systematic studies of these latter factors have also
been conducted (Bloom 1985). For example, Moos, Finney, and Chan
(1981) found that relapsed alcoholics reported nearly twice as many
negative events and approximately one-half as many positive events
as either recovered alcoholics or controls (Hull and Young 1983;
Vuchinich and Tucker 1985).

Another potential source of negative emotions is illness or somatic
discomfort from a variety of sources. In this regard, drug dependence
researchers have documented the tendency of some drug users to use
drugs as a form of self-medication (see Chapter VI for tobacco-
specific data). For instance, opioid dependence may develop during
the course of treatment for chronic pain (Khatami, Woody, O'Brien
1979) and other forms of somatic discomfort (Marlatt and Gordon
1980; Chaney, Roszell, Cummings 1982). Similarly, physical symp
toms, including allergies, back pain, headache, and insomnia, during
the posttreatment period were related to opioid and alcohol use in a
sample of treated alcoholics (Finney, Moos, Mewborn 1980; Moos et
al. 1979). A possibly related finding is the suggestion from a number
of studies that protracted withdrawal symptoms are factors in
relapse to opioid (Martin 1972) and tobacco (Pomerleau 1979;
Shiffman 1979) use.

As shown in this Section, relapse is characteristic among persons
treated for opioid, alcohol, nicotine, and other forms of drug
dependence. Rates and patterns of relapse appear to vary more as a
function of treatment charact.eristics, client parameters, and post-
treatment environmental factors than as a function of drug type
when alcohol, opioids, and nicotine are compared.
Posttreatment factors appear to be the most important determi-
nants of treatment success and relapse avoidance for users of

323


tobacco, opioids, and alcohol. These are summarized in Table 7.
Specifically, the most common predictors, similar for alcohol,
opioids, and nicotine, include posttreatment family support factors,
peer substance use factors, leisure and recreational activities, and
occurrence of stressful or negative affect situations in the form of
intrapersonal mood states, somatic complaints, negative life events,
or stressful interpersonal interactions. Additional factors that ap-
pear important include pretreatment severity of use (tobacco and
opioids), length of treatment (opioids), and type of treatment (tobacco
and opioids).

Treatment of Drug Dependence

Scientifically based methods of helping drug dependent persons to
achieve and maintain drug abstinence are available and can be
efficacious. The methods are being continually refined, however, as
new data are collected on how to better address the needs of clients
or patients and how to make treatments more readily available and
acceptable for those who want help. This Section briefly reviews
some of the kinds of treatment approaches that are available for the
various drug dependencies.

Treatment strategies designed to address dependence on opioids,
alcohol, nicotine, and many other dependence-producing drugs are
remarkably similar. This phenomenon provides additional evidence
that the processes that determine addiction are similar for the
various dependence-producing drugs. Some of the differences in
treatment are related to variations in detoxification strategies,
which depend on the route of drug administration and on differences
in the duration of drug action. There is also need to tailor the
content and/or intensity of treatment delivered to groups with
different substance dependencies. For example, the need for medical
intervention to alleviate acute withdrawal symptoms varies among
and within drug classes as a function of the physical dependence
level. This Section will discuss the goals of treatment for drug
dependence and three types of interventions that are commonly
employed: (1) pharmacologic substitution therapy designed to
suppress withdrawal, (2) interventions designed to redress deficits in
skills and/or deficits in social support that are potentially related to
relapse, and (3) interventions designed to bolster or sustain motiva-
tion for abstinence. These kinds of intervention strategies are not
mutually exclusive, and are often used in combination to yield better
overall rates of success than any single approach (Grabowski et al.
1984).

324


Goals of Treatment

Reducing or eliminating self-administration of the substance to
which the person is dependent is the primary goal of treatment.
Traditionally, there has been a tendency for treatment programs to
rely on a goal of complete abstinence rather than reduction of use to
manageable or nonproblematic levels. The appropriateness of this
goal may, in part, vary by drug class, as well as by severity of
dependence. For example, problems associated with alcohol use vary
considerably, and it would appear that many persons with low levels
of dependence are able to maintain stable levels of "social drinking,"
whereas persons with more severe levels of dependence must
maintain total abstinence (Miller and Joyce 1979; Miller 1979).
Because it has been estimated that only about 10 to 15 percent of
adults (United States) who drink warrant the designation "problem
drinker" and only a subset of these warrant the designation
"alcoholic," such variation in treatment goals is not surprising
(Cahalan 1970; Miller 1979). Analogously, it appears that only a
small fraction of caffeinated beverage (e.g., coffee and tea) drinkers
display distinct adverse consequences and apparent loss of control
over caffeine intake (Griffiths and Woodson 1988l-observations
consistent with the rapidly growing decaffeinated beverage market.
On the other hand, with drugs for which any nonprescription use is
illicit (e.g., opioids) or on which the overwhelming majority of users
are dependent (e.g., only 10.6 percent of current smokers smoke 5 or
fewer cigarettes/day according to the 1985 National Health Inter-
view Survey (unpublished data, Office on Smoking and Health)), a
goal of reduction of use may be especially problematic (Chapter VII).
Two additional problems with low-level cigarette use as a therapeu-
tic goal are that no level of cigarette smoking has been found safe
(US DHHS 1986) and that even if the smoker is only smoking a few
cigarettes, by taking more puffs per cigarette and by inhaling the
smoke more deeply, the smoker might actually maintain substantial
levels of tobacco toxin intake and nicotine dependence (Kozlowski
1981; Benowitz et al. 1983; Chapter IV). The percentage of persons
using amphetamine or cocaine who are unable to control their
intake is unknown, but because nonmedical use of these drugs is
illicit and because animal and human research indicates that these
drugs are powerful reinforcers (US DHHS 1987), total abstinence is
similarly recommended (US DHHS 1987).
Maintenance of abstinence or avoidance of relapse is another
major treatment goal. Because relapse factors can remain functional
for many years in individuals who are abstaining from use of a drug
to which they had been dependent (Chapters VI and VII), designing a
long-range program to minimize the impact of such factors is an
integral part of many drug treatment programs (e.g., Thompson,
Koerner, Grabowski 1984; Stitzer et al. 1984). These factors may


include some assumed to be physiologically related to the drug
dependence process (e.g., anxiety or stress), while others are assumed
to function at more of a behavioral level (e.g., the sight of drug-
associated stimuli).

Types of Treatment for Drug Dependence

Treatment approaches can be divided into those which involve the
administration of drugs (Pharmacologic Treatment Approaches) and
those which do not (Nonpharmacologic or Behavioral Treatment
Approaches). Sophisticated methods involving both pharmacologic
and behavioral approaches are more recent developments and show
considerable promise for the treatment of dependence to alcohol,
opioid, cocaine-like drugs, and nicotine (Grabowski, Stitzer, Henning-
field 1984). Although considered separately in this Section, pharma-
cologic and behavioral treatment approaches are commonly com-
bined and may be most effective when used in combination (Grabow-
ski, Stitzer, Henningfield 1984; Crowley and Rhine 1985). Combined
treatment approaches specific to cigarette smoking are discussed in
Chapter VII.

Pharmacologic Treatment of Drug Dependence

Four pharmacologically based approaches for the treatment of
drug dependence can be differentiated: (1) replacement or substitu-
tion therapy (e.g., methadone for opiate dependence), in which a
more manageable (and ideally, less addicting) form of the drug is
provided; (2) blockade therapy (e.g., naltrexone for opiate depen-
dence), in which the behavior-controlling effects of the abused drug
are blocked by pretreatment with an antagonist; (3) nonspecific
pharmacotherapy, in which the patient is treated symptomatically
(e.g, use of clonidine during opioid detoxification); and (4) deterrent
therapy, in which administration of the treatment drug results in the
occurrence of aversive effects when the abused drug is subsequently
taken (e.g., the use of disulfiram to treat alcoholism (Grabowski,
Stitzer, Henningfield 1984; Jaffe 1985). Each of these approaches has
been described in greater detail elsewhere and will be only briefly
described below (Cooper, Altman, Brown, Czechowicz 1983; Bigelow,
Stitzer, Liebson 1985; Jaffe 1985; Jasinski, in press; Jasinski and
Henningfield 1988; Jarvik and Henningfield, in press).

Replacement Therapy

The most widely investigated and evaluated pharmacologic treat-
ment approach for drug dependence is replacement therapy. The
general principle of replacement therapy is to provide the patient
with a safer and more manageable form of drug that directly
alleviates signs and symptoms normally suppressed by the substance


upon which the patient is dependent (Jaffe 1985, 1987; Jasinski and
Henningfield 1988). Ideally, it should also be of lower dependence
potential so that its use may be more readily discontinued than use
of the original form on which the person is dependent.

Replacement therapies function through four general actions: (lj
they block the onset of the physiologically mediated aspects of
withdrawal; (2) they maintain a level of tolerance that attenuates
the reinforcing properties of the abused chemical; (3) they treat
("suppress") other signs and symptoms such as dysphoria that may
constitute vulnerability and pose an impediment to normal function-
ing and well-being; (4) they directly suppress drug-taking behavior,
much as caloric loading can suppress eating.

The drugs that are widely used to alleviate withdrawal symptoms
by providing some level of pharmacologic replacement are the
following:  methadone for opiate withdrawal (Cooper, Altman,
Brown, Czechowicz 19831, benzodiazepines for alcohol withdrawal
(Sellers et al. 1983; Newsome and Seymour 1983; Liskow and
Goodwin 19871, and nicotine polacrilex gum for tobacco withdrawal
(Chapters IV and VII). The potential effectiveness of these agents in
prevention or relief of withdrawal symptoms has been well docu-
mented (Jaffe 1985). However, relief of early withdrawal symptoms
does not necessarily yield improved overall treatment outcomes.
Primary withdrawal symptoms for all dependence-producing drugs
are time limited, and their duration does not span the entire high-
risk period for postcessation relapse. These observations are consis-
tent with the finding that withdrawal symptomology is only one of
several potential relapse determinants.

Besides relief of withdrawal symptoms, there are several other
functions that a replacement therapy might serve that would make
continued long-term treatment beneficial. One of these functions is a
reduction in the need for the primary addicting drug, along with a
similar reduction in drug seeking. Just as importantly, the replace-
ment therapy may reduce or eliminate symptomology (e.g., anxiety,
antisocial behavior, inability to concentrate on tasks) that may
interfere with the person's ability to perform in occupational
settings and maintain social relationships. Analogously, nicotine
replacement therapy during cigarette abstinence can reduce or
eliminate tobacco intake and symptoms that interfere with normal
social or occupational activities, even though urges to smoke may not
be eliminated (Chapter VII).

The constraints on the efficacy of replacement therapies are
generally similar across drug classes. Most importantly, the clinical
application of replacement therapies is impeded by the influence of
nonpharmacologic factors, which vary among individuals and/or
situations (e.g., the specific drug delivery system customarily used
and ritualistic aspects of the behavior). Pharmacologically related

327


differences may also mitigate acceptability of the replacement drug;
e.g., orally administered replacements are generally not as satisfying
to the user as i.v. or inhalation systems, such as the "crack" form of
cocaine or tobacco smoke. In addition, replacement therapies do not
reliably diminish the urge to use the drug or specific drug formula-
tion (e.g., cigarette brand or alcoholic beverage) to which a person is
accustomed. (Issues related to craving are discussed in greater detail
in Chapt.ers IV and VII; Childress et al., in press; Henningfield and
Brown 1987.)

Blockade Therapy

A pharmacologic alternative to replacement therapy is to produce
a pharmacologic blockade of receptors which mediate the reinforcing
as well as the toxic effects of the drug (Jaffe 1985). For opioid
agonists such as morphine and heroin, t.he short-acting antagonist
naloxone can be used to reverse the effects of an overdose of the
opioid agonist. The longer acting antagonist naltrexone can be given
on a daily basis to opioid users to prevent them from experiencing
the reinforcing and toxic effects of opioid agonists. Unfortunately,
clinical trials have shown that there is frequently poor compliance
with blockade therapy (Ginzburg 1986). Lack of compliance results in
limited clinical utility. No clinically tested antagonist treatments
are currently available for the treatment of alcohol or nicotine
dependence, although experimental research with the nicotine
blocker, mecamylamine, suggests that such an approach may hold
promise (Chapter VII; Jarvik and Henningfield, in press).

Nonspecific Pharmacotherapy or Symptomatic Treatment

Administration of and abstinence from dependence-producing
drugs produce a cascade of effects involving a variety of neurochemi-
cal and physiological effects. As discussed with regard to nicotine in
Chapters III and VI, such drug actions mediate many of the desirable
and undesirable effects. In principle, it is possible to target treat-
ment approaches on a symptomatic basis.

One example of such an approach is the use of an antidepressant
(desipramine) to help achieve and maintain abstinence from cocaine
(Gawin and Kleber 1984); cocaine abstinence is often accompanied by
symptoms of depression. Somewhat analogous is the use of clonidine
to treat opioid withdrawal symtomology (Gold, Dackis, Washton
1984). Clonidine seems to exert its primary actions by suppressing
aspects of opioid withdrawal that are mediated by the activity of the
sympathetic nervous system (SNS). In one study, clonidine was just
as effective as morphine in the reduction of certain physiological
signs of opioid withdrawal (Jasinski, Johnson, Kocher 1985); how-
ever, in that study, clonidine did not reduce the self-reported

328


"discomfort" as effectively as did morphine. These observations are
consistent with the conclusion that some but not all of the effects of
the opioid withdrawal syndrome are mediated by the SNS and that
treatment of these effects may provide limited but objective benefit.
An analogous approach has been explored for application of cloni-
dine in the treatment of tobacco withdrawal (Glassman et al. 1984,
19881, but conclusions are only suggestive of the possible viability of
this approach (Chapter VII; Jarvik and Henningfield, in press).

Pharmacologic Deterrents

Drug taking can sometimes be reduced or eliminated if the
consequences are immediate and/or severe enough (Crowley and
Rhine 1985). There has been some effort to develop pharmacologic
treatments that ensure immediate, reliable, and highly aversive (but
safe) effects following self-administration of the drug of dependence.
Only one such agent has provided a near approximation of these
criteria: disulfiram, which is used in the treatment of alcoholism
(Jaffe and Ciraulo 1985; Miller and Hester 1986a). When disulfiram
has been taken, a small amount of alcohol can produce rather severe
discomfort and acute illness. Reviews of controlled treatment
outcome studies (Miller and Hester 1986a) suggest that many of the
therapeutic effects of disulfiram may also derive from placebo
effects. Thus, in some studies (e.g., Fuller and Roth 1979), outcomes
have been similar for placebo and active drug groups, with only
medication-compliant individuals (about 20 percent in each group)
showing good outcomes.

No deterrents comparable to disulfirum in potential efficacy have
been clinically tested for treatment of dependence on opioids or
nicotine (see also Chapter VII). As with antagonists, a practical
problem in treatments using deterrents is compliance, i.e., maintain-
ing adequate levels of use of the medication itself. A deterrent is
ineffective if it is not taken, and development of contingencies to
ensure that the patient takes the deterrent has proceeded slowly
(Bigelow, Stitzer, Liebson 1984, 1985; Stitzer, Bigelow, Liebson,
McCaul 1984). Therefore, even if theoretically effective deterrents
become available for treatment of other drug dependencies, their
utility might be limited.

Behavioral Treatment Strategies

Despite the powerful sequelae which may accompany both drug
administration and drug abstinence, most drug-dependent persons
(possibly excluding opioid users) are not systematically treated with
pharmacologic approaches. Drug dependent persons may eventually
"spontaneously remit" (discussed earlier in this Chapter), but many
others enter formal treatment programs that provide supportive and

329


behavioral therapy. Behavioral treatment approaches have a hetero-
geneous array of theoretical bases and means of implementation
(Stitzer, Bigelow, McCaul 1983). Although the term "behavioral
treatment" is often reserved for approaches which involve the
systematic application of behavior modification, it is sometimes
applied to any nonpharmacologic approach. Thus, behavioral strate-
gies may involve group support, individual counseling, skills train-
ing, or family intervention (Krasnegor 1979a; Grabowski, Stitzer,
Henningfield 1984). The present Section will provide a brief review
of behavioral approaches aimed largely at relapse prevention.

The major challenge in the treatment of drug dependence is no
longer in the initial attainment of abstinence; rather it is in the
maintenance of abstinence. In fact, it is worth noting that the shift
in emphasis from achievement of abstinence to the maintenance of
abstinence is an important advance in treatment efficacy in itself
(McAuliffe et al. 1986). This current focus has resulted in the
development of nonpharmacologically based approaches aimed at
what is often termed relapse prevention. In the past decade, relapse
prevention interventions have been increasingly founded on empiri-
cal investigations of situational precipitants of relapse and/or have
addressed factors known to predict relapse that can be manipulated
(Catalan0 and Hawkins 1985; Catalan0 et al., in press; Hawkins and
Catalan0 1985; Marlatt and Gordon 1985; Tucker, Vuchinich, Harris
1985; Brownell et al. 1986; Todd, 1984).

A specific goal of approaches to relapse prevention is to increase
the impact of those factors that are negatively associated with
relapse and to decrease the impact of factors that are positively
associated with relapse. These approaches have led to the develop
ment of a number of techniques that hold promise for prevention of
posttreatment relapse. Some of the better documented approaches
are summarized below.

Relapse Prevention Skills

Marlatt and his associates (Marlatt and Gordon 1980, 1985;
Cummings, Gordon, Marlatt 1980) have developed a cognitive
behavioral model of relapse which includes skills training for each
phase of the relapse process. They advocate training: (1) to recognize
"apparently irrelevant decisions leading to relapse"; (2) to identify
and cope with personal high-risk relapse situations; (3) to practice
behaviors which increase perceptions of self-efficacy and control
such as reading, relaxation, and meditation; (4) to recognize the
negative effects in biphasic drug action which follow immediate
positive effects; (5) to cope with a slip; and (6) in some cases, to
practice a relapse under controlled circumstances called a "pro-
grammed relapse" (although the general efficacy of this approach
has not been confirmed).

330


Reports of skills training with alcoholics far outnumber reports of
similar training with users of other drugs. Treatment in these
studies usually involves assertion/social skills training, problem-
solving training, and/or practice of high-risk situations using a
combination of methods, including didactic presentation, modeling,
role play, feedback, generation and evaluation of alternative prob-
lem solutions, and homework assignments. Skills improvement has
been achieved as indicated by role play, self-report, and question-
naire measures, and a positive impact of skills training procedures
has been shown in the treatment of alcohol use (Watson and Maisto
1983; Van Hasselt, Hersen, Milliones 1978) and cigarette smoking
(Shiffman 1982; Hall, Rugg et al. 1984).

The effectiveness of skills training with users of drugs other than
alcohol has not been as thoroughly evaluated as for alcohol. In five
single-case and uncontrolled group studies involving primarily
opioid users, two reported reduced drug use at followup (Cheek et al.
1973; Polakow and Doctor 1973); four found self-reported improve-
ments in social functioning (Cheek et al. 1973; Matefy 1973; Polakow
and Doctor 1973; Wolpe 1965); and one reported improved role play
performance (Callner 1973). Four studies of users of a variety of
illicit drugs (Callner and Ross 1978; Hawkins, Catalano, Wells 1986;
Smith 1982; Lin et al. 1982) have reported improvements in skills
related to high-risk relapse situations, and one found decreased use
of marijuana (Smith 1982). In one study, skill changes generalized to
untrained situations and were maintained l-year posttreatment
(Hawkins, Catalano, Wells 1986). As discussed in Chapter VII,
preliminary studies suggest that skills training strategies may be of
some utility in the treatment of tobacco dependence. For example,
Hall, Rugg, Tunstall, and Jones (1984) found that smokers receiving
relapse prevention skills training were significantly less likely to
relapse than smokers assigned to a discussion control condition.
Subsequent studies and reviews indicate mixed results (Hall et al.
1985; Schwartz 1987).

Leisure Activity Skills

In recognition of the association of relapse with an absence of
active leisure activity, a number of aftercare programs have
attempted to increase participation of clients in organizations
beyond work or treatment (Catalan0 and Hawkins 1985; McAuliffe
et al. 1986; Nurco et al. 1983; Wolf and Kerr 1979). Controlled studies
have shown that drug users can be encouraged to participate in
voluntary community organizations and activities following inpa-
tient treatments and that these contacts can be maintained over a l-
year period following treatment, but in these studies there were no
beneficial effects in reducing relapse rates (Catalan0 and Hawkins
1985; Hawkins and Catalan0 1985).

331


For alcoholics and cigarette smokers, physical exercise has been
examined as a potential relapse prevention strategy. Murphy,
Marlatt, and Pagan0 (1986) found that problem drinkers trained in
running reported greater reductions in drinking at followup than did
drinkers trained in meditation. In a retrospective self-report study,
Koplan, Powell, Sikes, Shirley, and Campbell (1982) found at l-year
followup that of the 2,500 runners competing in the 10K Peachtree
Road Race in Atlanta and returning questionnaires, 81 percent of
males and 74 percent of females who smoked cigarettes before they
started running had stopped smoking after they began running.

Stress Management Skills

As discussed earlier in this Chapter and in Chapters VI and VII,
negative emotions associated with stressful events or interpersonal
interactions have been strongly implicated in relapse precipitation.
In principle, such emotional states can be addressed through stress
management training, relaxation, meditation, or other "lifestyle"
interventions (Marlatt and Gordon 1985; Charlesworth and Dempsey
1982). Although stress reduction techniques are frequently included
as a part of drug abuse treatment, there are a surprisingly small
number of well-controlled studies addressing the effectiveness of
anxiety-reduction techniques with drug-abusing clients (Marlatt and
Gordon 1985). As indicated earlier in this Section, there is evidence
that programs which may reduce anxiety by use of aerobic exercise
or relaxation practice can bring about significant reductions in
alcohol use among heavy drinkers (Marlatt and Marques 1977;
Marlatt et al. 1984; Murphy, Marlatt, Pagano, 1986). Further
research is needed to assess the effectiveness of these techniques in
reducing the use of substances following treatment for alcohol,
opioid, and tobacco dependence.

Motivation Enhancing Treatments

Treatment interventions in which the primary purpose is to
improve or bolster motivation for continued abstinence can take
many forms. Many drug-dependent persons enter treatment as the
result of some form of pressure from friends, employers, family,
medical practitioners, or legal agencies. Sometimes treatments can
be designed that incorporate these sources of community pressure
and support for abstinence. The present Section will focus on
interventions that involve social support from professional thera-
pists, peers, and family.

Social support strategies designed to bolster environmental sup-
port for abstinence include enlistment of support from families and
existing social networks, the creation of new primary social support
such as self-help groups or linkages with community volunteers, and

332


supportive services provided by professional human service workers.
Only preliminary systematic research has been conducted utilizing
such interventions; however, the approach appears of similar
applicability and utility in the treatment of opioid, alcohol, and
tobacco dependence (Ashery 1979; Nurco et al. 1983; Leach 1973;
Madsen 1974; Janis and Hoffman 1970).

Professional contact is a special kind of support strategy which has
been used in drug use treatment. Typically, it involves ongoing
contact with professionals from the primary treatment program.
This approach may include booster sessions of individual or group
counseling, followup phone calls or letters from therapists, or
followup visits by counselors to former clients in the community to
review progress and problems. Fitzgerald and Mulford (1985) found
that bimonthly phone calls to alcoholic patients by an alcohol
counselor did not affect drinking outcome. Pokorny and others (1973)
found that weekly group therapy sessions following 60-day inpatient
treatment for alcoholism produced relapse results equivalent to
more expensive go-day inpatient treatment with no followup.
Colletti and Supnick (1980) found that weekly contact with thera-
pists during the first month following treatment for smoking
resulted in better smoking outcomes at 6 months than when subjects
received no aftercare, though these differences were not maintained
at 12-month followup. Chapter VII describes additional analogous
strategies used to treat tobacco dependence.

Family support is a potentially cost-effective and long-lasting form
of motivation enhancement. The potential importance of family
support is emphasized by the correlation between stable family
environment and good treatment outcomes previously discussed. In
recognition of this relationship, self-help groups to assist family
members of addicts and alcoholics have proliferated since the early
1970s. They include Alcoholics Anonymous (AA), Narcotics Anony-
mous (NA), and Families Anonymous groups for families coping with
alcoholism and drug abuse (Ashery 1979; Brown and Ashery 1979),
and service-agency-based aftercare groups for families (Dunlop,
Skorney, Hamilton 1982). Agencies which have also focused on
broader informal social networks have also arisen (Collins and
Pancoast 1976; Gottlieb 1981; Speck and Attneave 1973; Whittaker
and Garbarino 1983). A study by Stanton, Todd, and Steier (1979)
provides support for the benefits of involving the families of opioid
users in treatment. They found that in families of opioid users which
received structured family therapy, there were more days free of the
use of opioids, nonopioid illegal drugs, and alcohol than for opioid
users whose families did not receive such treatments. While not
reporting drug use outcomes, others have enlisted family members
and close friends of drug dependent persons as supportive sponsors
in drug treatment programs (Sorensen and Gibson 1983; Callan,

333


Garrison, Zerger 1975). Such networks are being increasingly
developed in recent years to help tobacco dependent persons
(Chapter VII; see also Schwartz 1987).

Peer support constitutes a potentially powerful motivation-en-
hancing approach. A difficulty of peer support is that it often
involves establishing a new peer group for the drug dependent
person if his or her current peer group continues to support drug use.
Self-help groups such as AA and NA, for example, provide former
substance abusers with a new social support network of individuals
in like circumstances (Ashery 1979; Nurco et al. 1983). Descriptive
followup studies of non-probability samples of AA members have
suggested that AA is an effective approach for assisting some
recovering alcoholics to maintain their sobriety (Leach 1973; Madsen
1974; Maxwell 1962). Several studies of the effectiveness of residen-
tial AA programs have also found better outcomes associated with
participation (Alford 1980; Smith 1984,1985). However, these studies
have either failed to utilize control groups or utilized "matched"
comparison groups that differ on pretreatment criteria which may
influence outcome. Thus, these studies do not provide conclusive
efficacy data.

A few studies have attempted to create or enhance existing peer
social support, with mixed results. For example, a volunteer sponsor
program for "skid-row" alcoholics was described by Fagan (1986), in
which sponsor groups from churches were assigned alcoholics in a
rehabilitation program. This program was not evaluated in a
controlled manner. Janis and Hoffman (1970) investigated the effects
of a self-help social support intervention on relapse following
smoking cessation treatment. Clients paired in a high-partner-con-
tact condition (daily calls for 5 weeks) were more successful in
maintaining abstinence at l- and lo-year followups than were clients
in low-contact or control conditions. The critical dimension appeared
to be quality of peer support.

Conclusions

1. The pharmacologic and behavioral processes that determine
tobacco addiction are similar to those that determine addiction
to drugs such as heroin and cocaine.
2. Environmental factors including drug-associated stimuli and
social pressure are important influences of initiation, patterns
of use, quitting, and relapse to use of opioids, alcohol, nicotine,
and other addicting drugs.

3. Many persons dependent upon opioids, alcohol, nicotine, or
other drugs are able to give up their drug use outside the
context of treatment programs; other persons, however, re-

334


quire the assistance of formal cessation programs to achieve
lasting drug abstinence.

4. Relapse to drug use often occurs among persons who have
achieved abstinence from opioids, alcohol, nicotine, or other
drugs.

5. Behavioral and pharmacologic intervention techniques with
demonstrated efficacy are available for the treatment of
addiction to opioids, alcohol, nicotine, and other drugs.

335


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CHAPTER V1

   EFFECTS OF NICOTINE
THAT MAY PROMOTE TOBACCO
           USE

377


CONTENTS

Tobacco Use, Nicotine, and Human Performance ....... .382
  Attention ....................................................... 382
     Sustained Attention ................................... 382
     Selective Attention .................................... 385
     Distraction ............................................... 385
  Learning and Memory ...................................... 386
    Learning ................................................. 386
     Immediate Memory ................................... 388
    Comparison of Immediate and Delayed
      Recall .................................................. 388
    State-Dependent Memory ............................ 389
  Problem Solving .............................................. 391
  Motor Control ................................................. 392
     Tremor ................................................... .392
    Simple Reaction Time ................................ 392
     Choice Reaction Time ................................ 392
  Implications for Tobacco Use ............................ .393

Tobacco Use, Nicotine, Stress, and Mood Regulation.. .394
Subjective Well-Being, Stress, and Mood
  Regulation.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
  Perceived Functions of Smoking.. . . . . . . . . . . . . . . . . . . . . . . . 395
  Stress and Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
     Stress and Smoking Initiation.. . . . . . . . . . . . . . . . . . . . 399
    Stress and Cigarette Consumption . . . . . . . . . . . . . . .401
Do Smoking and Nicotine Reduce Stress and Im-
   prove Mood?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .405
    Self-Reported Stress Reduction and Affect
     Modulation.. . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . .405
    Behavioral Indices of Stress Reduction and
      Af feet Modulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Suggested Mechanisms Underlying Nicotine's Ef -
    fects on Stress and Mood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
    An Emphasis on Nicotine Withdrawal
     Symptoms.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .408
     Neurochemical Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .408
    Biphasic Action on the Sympathetic Nervous
     System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .409

379


     Altered Body Activity ............................... .410
     Hedonic Systems Model ............................. 411
     Lateralized Affective Processors Model ......... 412
    Hypothalamic Consummatory Drive Model ... .412
    Indirect Models: Psychological Enhancement
       and Sensory Gratification ........................ 413
  Implications for Tobacco Use ............................. 413
Tobacco Use, Nicotine, and Body Weight ................. .414
The Relationship Between Smoking and Body
   Weight.. ...................................................... 414
    Cross-Sectional Evaluations of Smoking and
     Body Weight ......................................... 415
    Longitudinal Evaluations of Smoking and
     Body Weight ......................................... 431
     The Role of Nicotine.. ............................... 432
  Mechanisms Underlying the Relationship Between
   Smoking and Body Weight.. .......................... ,432
    Dietary Intake ......................................... .432
    Physical Activity ...................................... .434
     Metabolic Rate ......................................... 435
    Summary of Mechanisms Literature ............ 437
  Does the Relationship Between Smoking and
   Weight Promote Either the Initiation or Mainte-
     nance of Smoking Behavior?. ......................... .438
  Implications for Tobacco Use ............................. 440

Summary and Conclusions.. . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . .441

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .442

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Despite the well-known health hazards associated with cigarette
smoking and tobacco use, more than 50 million Americans continue
to use these products. (See Chapter I for a brief review of health
hazards and Appendix A for prevalence of use data.) Chapter IV
presents evidence that tobacco use is an orderly form of drug-seeking
behavior that involves nicotine self-administration. It is clear from
Chapter IV that tobacco use involves several biobehavioral processes
of drug dependence, including nicotine reinforcement and withdraw-
al. The initiation and maintenance of this dependence process may
be promoted by other actions of nicotine. For example, some
cigarette smokers report that smoking helps them to think better, to
cope with stress, and to keep body weight under control. The fact
that people believe that tobacco use has these effects may contribute
to initiation, maintenance, and relapse.

This Chapter examines the evidence on the following three effects
of nicotine:

o enhancement of human performance
0 control of stress responses
o control of body weight.
These particular topics are presented because there is scientific

literature relevant to each topic and because nicotine has been
suggested to be central to each of these effects.

The three topics are discussed separately in this Chapter because
the substantive material and relevant data are distinctly different
for each topic. Also, the research on each topic is at a markedly
different evidentiary stage at this time. Whereas studies on nicotine
and performance are intriguing, there are some serious methodologi-
cal concerns that force caution in the interpretation of the available
experimental investigations. In contrast, the relationship between
stress and smoking (i.e., that stress increases smoking) is well
documented by self-report data, and several investigators have
offered detailed theoretical explanations and mechanisms to account
for this phenomenon. However, much of this speculation has
preceded experimental investigations. In still another stage of
investigation, extensive data have been gathered on the relationship
between cigarette smoking and body weight, and laboratory studies
have carefully assessed the role of nicotine. Explanations for the
relationship between nicotine and body weight are based on investi-
gations that were designed to test specific variables involved in this
relationship. All three topics are currently receiving research
attention and are considered to be important areas for more
extensive investigation. This Chapter is meant to complement the
information presented in Chapter IV to provide a more complete
understanding of tobacco use. Most of the studies discussed in this
chapter have examined effects of cigarette smoking. Some studies
present data on effects of nicotine alone. The similarity in findings of

381


these two types of studies supports the conclusion that nicotine is
responsible for the effects of cigarette smoking.

Tobacco Use, Nicotine, and Human Performance

Some cigarette smokers believe and report that smoking helps
them to think and to concentrate (Russell, Peto, Pate1 1974). These
possibilities have been studied in the laboratory using several
different tasks. Unfortunately, this research literature has method-
ological limitations. Most of the published studies compare smokers
smoking with smokers not smoking. Few studies have included
nonsmokers not smoking as a control group. When smokers smoking
perform better than smokers not smoking, it is impossible to know if
smoking actually improved performance, if abstinence from smoking
impaired performance, or both. In addition, most studies allowing
smoking and evaluating performance did not measure nicotine levels
in the subjects. Therefore, the role of nicotine generally is inferred
but not directly assessed. A few studies administered nicotine by oral
tablets to smokers and to nonsmokers. This Section examines the
effects of cigarette smoking and nicotine on attention, learning and
memory, problem solving, and the control of motor function.
Implications of these effects for tobacco use are discussed.

Attention

Effects of cigarette smoking on attention have been examined in
the laboratory using sustained attention tasks, selective attention
tests, and perceptual intrusion or distraction measures. The results
using each measure are reviewed separately.

Sustained Attention

Vigilance tasks are the fundamental paradigm in the laboratory
for defining sustained attention. Attention is directed to one or more
sources of input for long periods of time. The subject is required to
detect and respond to small, infrequent changes in the input.
Performance in vigilance situations is often assessed in terms of the
detection rate, i.e., the proportion of signals correctly detected, and
the false-alarm rate, i.e., the number of occasions on which a signal is
reported when one has not been presented. Measures of stimulus
sensitivity and response criterion can be derived from the detection
rate and the false alarm rate using the Theory of Signal Detectabil-
ity (Green and Swets 1966) in order to assess performance. During a
typical vigilance session, the detection rate decreases (the vigilance
decrement), but it is also important to know if there is a decrease in
false alarms, which would mean a criterion shift. If the rate at which
a subject detects the stimuli falls, but there are no changes in false
alarms, then there is a reduction in stimulus sensitivity.


In a study of smoking and visual vigilance, the Mackworth Clock
(Mackworth 1950) was used because it produces a reliable vigilance
decrement. Cigarette smokers who were allowed to smoke at 20-min
intervals throughout the 80-min vigilance task maintained their
stimulus sensitivity to experimental targets (Wesnes and Warburton
1978). In contrast, sensitivity was reported to drop for a group of
nonsmokers and for a group of smokers who were not allowed to
smoke. This finding suggests that smoking helped t.o maintain
vigilance, but it could be that abstinence from smoking contributed
to the performance decrement for smokers who were not allowed to
smoke.
Tong and coworkers (1977) studied the performance of nonsmok-
ers, smokers not smoking, and smokers smoking on a 60-min
auditory vigilance task. While nonsmokers and smokers not smoking
detected fewer signals as the test progressed, smokers smoking
increased their number of detections. Again, it seems that smoking
improved vigilance. However, this conclusion is tempered by the fact
that the nonsmokers generally performed better than did the
smokers on this task. Wesnes and Warburton (1978) reported that
smokers maintained their initial level of stimulus sensitivity to
auditory targets over an 80-min vigilance session when they smoked
cigarettes at 20-min intervals. When they performed the task while
smoking nicotine-free cigarettes, their sensitivity decreased over
time. A similar study with a higher target density found a similar
result: smoking was accompanied by maintained stimulus sensitivity
(Mangan 1982). Whether smoking increased vigilance or whether
abstinence decreased vigilance is not clear.
To determine whether nicotine was responsible for these effects of
cigarette smoking on attention, Wesnes, Warburton, and Matz (1983)
gave subjects nicotine tablets under the tongue and examined visual
vigilance. The tablets consisted of nicotine placed on an alkaline
matrix material to permit buccal absorption. Nicotine helped reduce
the vigilance decrement by maintaining stimulus sensitivity. The
nicotine tablets produced the same effects in nonsmokers, light
smokers, and heavy smokers (Wesnes, Warburton, Matz 1983).
Wesnes and Warburton (1978) found a similar effect of nicotine
tablets on smokers but found no effect on performance by nonsmok-
ers. Wesnes and Warburton (1984b) reported a small improvement in
performance by nonsmokers given 1.5-mg-nicotine tablets; l.O-mg-
and O.Bmg-nicotine tablets did not improve performance.
The effects of smoking on sustained reaction time performance,
which has a vigilance component, were studied by Frankenhaeuser
and others (1971). The experimental sessions lasted 80 min during
which subjects continually performed a simple visual reaction time
test. In the nonsmoking condition, the speed of reaction decreased
over time; in the smoking condition, there was little change over the


session. Subjects abstained from smoking the night before participat-
ing in this study. Therefore, the smokers in the nonsmoking
condition were deprived for many hours.

Wittenborn (1943) factor analyzed attention tests and found that
picking out various sequences of numbers or letters from an array
was most heavily loaded on what he called an "attention" or "mental
concentration" factor. Williams (1980) assessed the effects of smok-
ing by smokers on a test of this sort that involved crossing out each
letter "E" found in sheets of randomly ordered letters arranged in
lines of 30 letters. Smoking cigarettes produced significant improve-
ment in performance of the letter cancellation task compared to
sham smoking an unlit cigarette (Williams 1980). Because the
subjects had abstained from smoking overnight before the experi-
ment, it is not clear whether smoking improved performance or
whether deprivation caused a decrease in performance.

A computer version of the letter crossing test is the Bakan task
(Bakan 19591, in which a series of digits is presented at the rate of
l/set from which subjects are required to detect certain specified
three-digit sequences. Measures of both the speed and the accuracy
of detection rate are made! Performance on this rapid visual
information processing task after smoking was improved in both
speed and accuracy above baseline levels, whereas either not
smoking or smoking nicotine-free cigarettes resulted in a decline in
speed and accuracy below baseline levels (Wesnes and Warburton
1983). The improvement in both speed and accuracy indicates that
there is no speed and accuracy tradeoff. Higher-yield cigarettes
improved performance more than low-yield ones, suggesting that
nicotine is involved in these effects (Wesnes and Warburton 1984a).
This interpretation is supported by studies with cigarettes with
similar nicotine content but varying levels of tar and carbon
monoxide (CO); cigarettes with the same nicotine content have the
same effect on speed and accuracy (Warburton, in press). However,
these conclusions must remain tentative until nicotine levels in the
body are measured.

Analyses of performance during cigarette smoking indicate a 15-
percent increase in speed and accuracy (Wesnes 1987) and improve-
ment puff by puff (Warburton, in press). Rapid visual information
processing has been studied during cigarette smoking puff by puff.
Even with one puff, the probability of correct detections in the
smoking conditions was higher than in the nonsmoking condition,
and a single puff produced a change in reaction time (Warburton, in
press). These findings suggest that smoking improves performance.
However, these within-subject analyses need to be replicated and
compared to nonsmoker control groups.

384


Selective Attention

Selective-attention tasks involve either focused or divided atten-
tion. Focused-attention tasks require subjects to attend to one source
of information to the exclusion of others. Divided-attention tasks
require subjects to divide their monitoring between two or more
sources of information.

One study of selective attention (Tarriere and Hartemann 1964)
combined central guiding with peripheral visual monitoring. The
task lasted for 2.5 hr, and the measure of performance reported was
the percentage of the peripheral visual signals that were missed
during the session. Monitoring performance was maintained by
smoking, in contrast to the large increase in t,he percentage of signal
omissions when the subjects (all of whom were smokers) were not
smoking.

In a study of divided attention, a test was based on the rapid visual
information task (Warburton and Walters, in press; Wesnes and
Warburton 1984a). Subjects were presented with digits at a rate of
50/min in both the visual and auditory modalities, with a different
sequence for each modality. The detection of sequences in both parts
of the divided attention task improved significantly after the
smoking of one cigarette in comparison with not. smoking. Smoking a
cigarette also prevented the increase in reaction times that occurred
in the control condition (smokers not smoking).

These studies show that smokers who smoke before selective
attention tasks perform better than smokers who abstain from
smoking before these tasks. Both the sustained and selective
attention data indicate that smoking helps the smoker to perform.

Distraction

The Stroop test has been used in smoking research to examine
distraction effects. The Stroop test uses three sets of displays: a list of
color words printed in black, a set of color patches, and a list of color
words with the words printed in incongruent colors (e.g., the word
"Green" printed in blue). Subjects' word reading is faster than color
naming, while naming the incongruently printed color words takes
much longer than naming the patches. The time difference between
naming the colors in the two conditions is the Stroop effect. This
score indicates the subject's ability to focus attention on a relevant
stimulus dimension of print color and to ignore an irrelevant
semantic one.

The effects of nicotine on the Stroop performance of smokers and
nonsmokers have been studied (Wesnes and Warburton 1978;
Wesnes and Revel1 1984). Wesnes and Warburt,on (1978) reported
that nicotine reduced the size of the Stroop effect and that there
were no differences between smokers and nonsmokers in the amount

385


of improvement produced by nicotine. This finding supports the
argument that the effects of nicotine on attention are similar in
smokers and nonsmokers. However, only six smokers and six
nonsmokers participated in this study. Also, the performance by
nonsmokers was not improved by nicotine tablets in the Wesnes and
Bevel1 (1984) study. Therefore, conclusions must be tentative until
the findings of Wesnes and Warburton (1978) are replicated.

Evidence from the few distraction studies that have been reported
is consistent with the results for sustained and selective attention. It
may be that smoking and nicotine improve a general attentional
processing capacity including improved attention to relevant stimuli
(sustained and selective attention data) and ability to disregard
irrelevant stimuli (distraction data). However, until studies include
nonsmoker control groups and measure nicotine levels in the body,
the conclusion that smoking improves attention remains plausible
but equivocal. It is reasonable to conclude that the attention of
smokers is better after smoking than after deprivation from ciga-
rettes.

Learning and Memory

Numerous animal studies have demonstrated that nicotine im-
proves learning and memory when it is administered pretrial and
posttrial (Battig 1970; Bovet-Nitti 1965; Castellano 1976; Erickson
1971; Evangelista, Gattoni, Izquierdo 1970; Stripling and Alpern
1974; Szekely, Borsy, Kiraly 1974). The effects of smoking and
nicotine on human learning and memory are surprisingly complex
in comparison with the effects described in reports of animal studies.
Some studies of the effects of smoking on human learning and
memory have shown that smoking improves this aspect of mental
ability (Mangan 1983; Mangan and Golding 1978; Warburton et al.
1986). Studies of the effects of pure nicotine on human learning and
memory have shown that nicotine improves memory just as smoking
does (Warburton et al. 1986). However, Hull (1924) found evidence of
impairment in auditory memory and in the efficiency of rote
learning immediately after smoking, and later studies also have
found that smoking can interfere with learning and memory,
especially immediate memory (Gonzales and Harris 1980). The
effects of smoking and nicotine on learning, immediate memory,
delayed recall, and state-dependent memory are addressed separate-
IY.

Learning

There is no evidence for improved acquisition of information (i.e.,
general learning) after smoking. For example, Carter (1974) reported
a higher number of correct responses from 10 smoking subjects than

386


from 10 nonsmoking subjects on a letter-digit substitution task for
the second of 2 lo-trial blocks given in the first 2 sessions (7 days
apart). However, there was no difference between groups in savings
(number of trials) for serial learning of a letter-digit substitution
task.

Kleinman, Vaughn, and Christ (1973) had nonsmokers, 24-hr
deprived smokers, and nondeprived smokers do paired-associate
learning of a low- or high-meaningful list of nonsense syllables.
There was no difference in learning among the groups on both trial
and errors to a criterion. However, deprived smokers performed
better on the high-meaningful list and worse on the low-meaningful
list than did either of the other two groups.

The effects of nicotine on learning also have been investigated.
Andersson and Post (1974) compared the effects of nicotine cigarettes
with those of nicotine-free cigarettes in subjects learning a nonsense
syllable list. Significant increases in heart rate indicated that
nicotine was absorbed from the nicotine cigarettes. The first
cigarette was given after the first 10 trials of learning the list, and a
second cigarette, of the same kind, was given after 20 trials. The
learning curves were identical for the two conditions prior to
smoking. After nicotine, the number correct decreased and remained
below the scores in the nicotine-free condition, but the learning
curves were parallel. Thus, the rate of learning was not changed by
smoking. After the second nicotine cigarette, the number of correct
syllables increased significantly to the same level of acquisition
performance as in the nicotine-free cigarette condition. Relative to
the previous performance, nicotine had improved recall of the
syllables. The difficulty in interpreting the effects of nicotine in this
study is that learning and recall occurred over a 20-min period, while
plasma and brain levels of nicotine would be expected to fall well
below their peak levels. These data give no evidence of nicotine
impairing acquisition, because the learning curves are parallel after
the nicotine cigarette. However, it appeared that after the first
nicotine cigarette, the information stored in the non-nicotine state
was less available in the nicotine state, a phenomenon known as
state-dependent learning. (See "State-Dependent Memory" below for
a fuller discussion of this phenomenon.)

In another study, Andersson (1975) examined the effects of
smoking on verbal rote learning using a similar procedure. Ten
smokers were tested on two occasions during which they were
initially given 10 successive trials followed by an B-min break. In one
condition, the subjects smoked a 2.1-mg-nicotine-delivery cigarette
during this period, and in the other they simply rested. Then,
another 10 trials took place, after which a 45-min break was given,
followed by a final learning trial. As in the previous study, recall was
significantly lower immediately after smoking. This lowered recall

387


tended to recover on successive trials. After the 45-min break, the
recall in the two conditions was again identical.

Immediate Memory

In a study of immediate memory (Williams 19801, subjects were
tested within 15 min after smoking one cigarette. They were given
lists of numbers to memorize and then were immediately asked to
recall them in the correct sequence (constrained recall). No main
effects were significant. Controlling for presmoking performance,
the number of errors increased with strength of cigarettes smoked.

Houston, Schneider, and Jarvik (1978) had 23 heavy smokers,
deprived of cigarettes for 3 hr, read a list of words. The subjects were
matched on a free-recall test prior to smoking. Each member of one
group smoked a 1.5-mg-nicotine cigarette, and each member of the
other group smoked a non-nicotine cigarette. The subjects were given
three lists with free recall tests after each one. The immediate recall
scores showed that the nicotine group had significantly less recall
than the placebo group did. When testing was given once just after
the input, however, facilitation was seen (Warburton et al. 1986).
After smoking a 1.4-mg-nicotine cigarette, each of these subjects was
shown a list of nouns and immediately asked to write down as many
as possible. Measures of immediate recall were improved in smokers
after smoking compared with not smoking.

Comparison of Immediate and Delayed Recall

Gonzales and Harris (1980) assessed the effects of smoking or
abstinence on immediate and delayed memory of new and old
(previously presented) words, as well as category clustering. Smokers
smoking showed significantly poorer immediate and delayed recall
of old words and less clustering of words into categories on the
delayed recall test as compared with smokers who were not allowed
to smoke before the tasks.

Mangan (1983) examined the effects of smoking a low- (0.7 mg) and
a middle- (1.3 mg) nicotine-yield cigarette on paired-associate and
serial learning and retention. Conditions included high and low
intralist interference. Cigarettes improved retention in paired-a&o-
ciate learning, with task difficulty apparently having little rele-
vance. Smoking impeded learning under low-interference conditions,
but facilitated learning of high-interference sets.

Mangan and Golding (1983) studied the effects on memory of
smoking deprivation and of smoking a single cigarette immediately
after acquisition of a paired-associate learning task. Subjects were
retested for retention of the memorized material at intervals of 30
min, 1 day, 1 week, and 1 month. At 30-min retest, nonsmokers
showed superior recall compared with all smokers. After 1 month,

388


subjects who each smoked a low- and medium-nicotine cigarette were
better than those who smoked high-nicotine cigarettes. They also
achieved superior recall compared with nonsmokers.

Peeke and Peeke (1984) tested the effects of smoking one cigarette
on verbal memory and attention in four experiments. In one study,
subjects were allowed to smoke before the test ("pretrial smoking"),
after the test ("posttrial smoking") or not at all ("no smoking").
Recall of a 50-word list was tested immediately after intervals of 10
and 45 min. Pretrial smoking resulted in improved recall 10 and 45
min after learning, but not immediately. Posttrial smoking was
ineffectual. Tests at 1,5, and 30 min after presentation of a 20-word
list were compared with results from pretrial smoking. Improved
recall occurred for pretrial smoking. The high-nicotine cigarette
produced improved recall on both immediate- and delayed-recall
tests. The low-nicotine cigarette was less effective. Light and heavy
smokers did not differ in the effect of smoking on recall.

Andersson and Hockey (1977) presented words in different posi-
tions on a computer screen to smokers allowed to smoke or not
allowed to smoke. In one condition, subjects had to remember the
words in presentation order. In the second condition, subjects were
asked to remember words, word order, and location. There were no
differences between the smoking and no-smoking conditions in the
percentage of words that were recalled in the correct order or for the
percentage of words that were recalled correctly, regardless of word
order. However, recall of position on the screen was poorer for the
smoking group. When the subjects were asked to attend to all three
aspects of the material, the groups did not differ significantly in
their recall, although there was a trend for location to be recalled
better after nicotine use than after deprivation. This study suggests
that nicotine can enhance storage of information only if the subjects
perceive that the information is relevant.

State-Dependent Memory

In a state-dependent design, one group of subjects learns after a
dose of drug while a second group learns after a placebo or nothing.
For the recall test both groups are divided: half of each group is
tested with the agent presented during learning and half is switched
to the other condition. If the recall scores are better for those groups
that learned in the same chemical state, then state-dependent
learning is said to have occurred. Numerous animal studies have
provided evidence of state dependency with cholinergic drugs
(Warburton 1977). The possibility that nicotine produces state-depen-
dent learning in human subjects has been investigated in several
studies.

Kunsendorf and Wigner (1985) examined state-dependent recall on
text material. Subjects spent 15 min studying a 550-word article on

389


education and answered 6 factual questions based on the article after
a lo-min break. The treatment conditions were smoking versus no
smoking during the study period and during testing. When studying
and testing were conducted for the same subject state (either
smoking or no smoking), memory was better than when study and
testing were conducted for different states.
Other investigators also have found evidence for state-dependent
learning with smoking. Peters and McGee (1982) used the state-
dependent design t.o test smoking's effect on recall and recognition
memory. After smoking a 1.4-mg-nicotine cigarette, each subject was
shown a list of nouns and immediately asked to write down as many
as possible. There was no evidence of any difference in immediate
recall, a finding in agreement with Andersson and Hockey (1977)
and Houston, Schneider, and Jarvik (1978). However, on the
following day, there was a state-dependent effect on the recognition
test but no difference between the same-state groups.
In another recognition study (Warburton et al. 1986), smokers who
were deprived of cigarettes for more than 10 hr were each given a
1.6mg-nicotine cigarette or nothing immediately before serial pre-
sentation of a set of Chinese characters. Subjects were divided into
four equal groups: Those who did not smoke prior to learning or
recall; those who did not smoke prior to learning, but had a cigarette
prior to recall; those who had a cigarette prior to both learning and
recall; and those who had a cigarette prior to learning, but none
prior to recall. Subjects who smoked prior to learning had signifi-
cantly better recognition scores than the subjects who did not smoke
in the first part of the experiment. There was no effect of smoking on
recall performance. A significant interaction term indicated that
changing the chemical state interfered with recognition.
Warburton and colleagues (1980) used nicotine tablets in the state-
dependent design. After ingesting the tablet, each subject listened to
words and then performed successive subtractions for 1 min to
prevent rehearsal. Immediate free recall was improved. One hour
later, the subjects were given either nicotine or placebo tablets. They
were asked to recall as many of the words as they could in another
lo-min free recall test. Long-term recall was significantly better
when subjects had taken nicotine prior to learning, but was not when
taken prior to recall. A significant interaction term gave evidence for
a state-dependent effect of nicotine and showed that nicotine was
facilitating the input of information to storage, but had no direct
effect on storage or retrieval.
These findings suggest that there is a state-dependent effect of
smoking on cognitive performance. The seeming impairment of
immediate memory, however, complicates any simple generaliza-
tions about smoking and memory or nicotine and memory. As with
the attention literature, studies need to include nonsmokers as


controls to determine whether smoking or abstinence from smoking
affects learning or memory. In addition, task characteristics and
individual differences among subjects must be considered in future
investigations. Based on the available evidence, there are no clear
effects of smoking on learning or memory.

Problem Solving

Human problem-solving capabilities involve both attention and
memory. Attention is important because distraction from the task
will cause a deterioration in problem-solving performance. Memory
also plays a critical role in thought, both guiding the operations of
the thought processes and limiting their power. Problems can be
broadly categorized as well defined and ill defined. A well-defined
problem has a clearly stated goal with a clear method to ascertain if
the problem solving will lead to the correct solution. A well-defined
problem can be solved by convergent thinking that produces
logically correct answers. A simple example of a well-defined
problem is addition. Ill-defined problems are solved by divergent
thinking that leads to inventive solutions.

Hull (1924) found that smoking increased the rate of complex
mental addition, but had no measurable effect on the accuracy of
addition. Kucek (1975) found that the reduced efficiency of mental
addition that was produced by doing a tracking task was ameliorated
by smoking. The improvement was especially manifested in the most
neurotic subjects. One interpretation of this improvement is that the
attentional effects of nicotine enabled the filtering out of the
distracted thoughts that interfered with performance.

A task that has elements of both convergent and divergent
thinking is the Luchins Jar test (Luchins 1942), in which subjects are
asked to solve a number of "numerical problems" involving the
measurement of a quantity of water by means of a set of measuring
jars. For the first six trials, exactly the same solution can be used,
but after trial six, both the old formula and a new, easier formula are
appropriate. A measure of convergent thinking is performance on
the first six trials, while divergent thinking is assessed from the time
taken to discover the new, easier solution. Smokers who were
allowed to smoke performed better on the first half of the test in
which subjects used the same solution repeatedly (convergent
thinking), but were slower to change to a simpler solution when it
was available, divergent thinking (Warburton 1987). While it could
be argued that nicotine had impaired divergent thinking, it has been
argued that it is more efficient for a subject to use a known strategy,
no matter how clumsy it might be, than to attempt to invent, a new
one, i.e., to maintain attention (Norman 1980).

391


Motor Control

The effects of smoking on motor control were investigated in the
early laboratory study of Hull (1924). He found a marked increase in
hand tremor, a slight increase in resistance to muscular fatigue and
in speed of reading reaction time, and no measurable effect on the
rate of tapping or on the rate or accuracy of eye-hand reaction.
These reports have received support from more recent studies (Lyon
et al. 1975; Smith, Tong, Leigh 1977). West and Jarvis (1986)
reported that nasal administration of nicotine increases tapping rate
in nonsmokers.

Tremor

Lippold, Williams, and Wilson (1980) recorded finger tremor
during a control period, sham smoking, or cigarette smoking with a
strain gauge and an accelerometer. Smoking increased tremor
amplitude at least twofold.

Simple Reaction Time

Cotten, Thomas, and Stewart (1971) investigated the immediate
effects of smoking one cigarette on simple reaction time after each
subject smoked a cigarette with a 1.5-mg nicotine yield. The mean
reaction times immediately following and 5 min after smoking were
significantly slower than for all other test intervals. Reaction times
for the 40- and 55-min intervals were significantly faster than the
reaction time before smoking.

Morgan and Pickens (1982) examined whether reaction time
performance after smoking varied as a function of cigarette smoking.
Twelve regular smokers were tested on a reaction time task
immediately after smoking on three different. occasions. In each
session, they were allowed ad libitum smoking of their own cigarette,
or ad libitum smoking of a standard cigarette, or they had to smoke a
standard cigarette with a prescribed puff pattern. Reaction time
performance was significantly faster after smoking under the latter
two of the three conditions. Mean reaction times were significantly
shorter for the smokers smoking than for the smokers not smoking.

Choice Reaction Time

Myrsten and Andersson (1978) compared the effects of smoking for
both simple and complex reaction time tasks. In the simple reaction
time testing periods, smoking prevented the significant increase in
reaction time that occurred over time in the nonsmoking condition.
In the complex reaction time periods, smoking significantly reduced
reaction time, whereas reaction time increases were not significant
in the nonsmoking condition.

392


Decision time and motor time scores on a choice reaction time task
were measured after smoking (Lyon et al. 1975; Smith, Tong, Leigh
1977). Decision time scores were significantly decreased by smoking,
and the high-nicotine cigarette had the greatest effect. Motor time
scores were not improved, and hand steadiness was significantly
impaired by smoking.

Smokers, deprived smokers, and nonsmokers performed a compen-
satory tracking task while simultaneously performing a cross-adap-
tive loading task (Schori and Jones 1975). With the cross-adaptive
technique, the size of the subject's total work load (tracking and
loading tasks combined) was individually tailored to use each
subject's entire attentional capacity. No differences were detected as
a function of smoking either in tracking or in loading task
performance.

Smokers, deprived smokers, and nonsmokers performed a complex
motor task, consisting of five subtasks, for an extended period of time
at two levels of task complexity (Schori and Jones 1974). On only one
subtask, on one of the two performance measures obtained, were
differences as a function of smoking condition evident. Specifically,
response latencies for nonsmokers were shorter than those for
smokers and deprived smokers at the high level of task complexity,
but were longer at the lower level. Because the performance
differences were small, Schori and Jones (1974) concluded that for all
practical purposes, smoking had no effect on performance.

Implications for Tobacco Use

Some cigarette smokers report that smoking helps them to think
and perform. Laboratory studies of attention and state-dependent
learning are generally consistent with this perception, but studies of
memory and learning do not support this perception. Data on
problem solving are too limited to allow clear conclusions. The
improvement in attention, statedependent learning, and some
motor performance tasks are, in most cases, superior in smokers who
are allowed to smoke compared with a smoking abstinence condition.
Therefore, these effects may, in part, reflect reversal of the
deleterious effects of smoking abstinence. In contrast to this cautious
interpretation, however, it should be noted that the experiments
that administer nicotine and report similar improvements in non-
smokers and smokers are consistent with the interpretation that
smoking improves some cognitive performance. In light of these
data, smokers' self-reports and perceptions may be correct that
smoking helps them to attend, think, and perform. However, until
more careful investigations are reported, conclusions concerning the
effects of smoking and nicotine on human performance must remain
tentative. Future studies should include nonsmokers as controls and
should measure nicotine levels after smoking or abstinence.


Current methods in cognitive psychology indicate that different
paradigms for evaluating memory and performance (e.g., datadepen-
dent versus context-dependent memory measures) produce opposite
effects in many cognitive tasks (Richardson-Klavehn and Bjork
1988). The effects of smoking and nicotine on these different types of
tasks need to be evaluated. A recent presentation on smoking and
performance, for example, reported that smoking improved perfor-
mance on simple reaction tasks but impaired performance on more
complex comprehension and motor performance tasks (Spilich 1987).
Tasks requiring different levels of demand must be examined.
Moreover, future research should evaluate performance over time to
determine whether any short-term effects of smoking or nicotine on
performance persist or are reversed later on. Nonetheless, the fact
that smokers smoking generally perform better on some cognitive
tasks (especially attention tasks) than do smokers not smoking may
encourage smokers to continue smoking and may encourage relapse.

Tobacco Use, Nicotine, Stress, and Mood Regulation

Cigarette smokers commonly report that they smoke in response
to stressful situations and that smoking calms them. In addition,
many smokers report that smoking helps to regulate dysphoric mood
or affect. Reports of a relationship between stress and smoking
generally have been regarded as puzzling in light of the sympathomi-
metic effects (i.e., sympathetic nervous system (SNS) activating
actions) of nicotine, but the consistency of these claims has brought
research attention to these topics. The possibility that smoking may
help to regulate dysphoric moods that involve low arousal states is
easier to understand. This Section reviews the relevant research
literature and presents current thinking to help explain these
phenomena.

Subjective Well-Being, Stress, and Mood Regulation

The state of subjective well-being is construed as one in which
positive affect (pleasure, happiness) is high and negative affect
(frustration, anger, tension) is low (Watson and Tellegen 1985).
Departures from an optimal state may occur because of internally
generated affect (worry, anxiety) or through environmental events
that strain the coping ability of the individual (Dohrenwend and
Dohrenwend 1981). A state of subjective stress is postulated to be a
joint function of the current environmental demands and the
current coping abilities of the individual (Lazarus and Launier 1978;
Lazarus and Folkman 1984). When demands exceed coping ability, a
state of subjective st,ress may arise that manifests at the psychologi-
cal level as symptoms of psychological distress and at the physiologi-
cal level as changes in (SNS) arousal, changes in endocrine systems,

394


and decrements in specific task performance (Baum, Grunberg,
Singer 1982; Cohen, Kamarck, Mermelstein 1983). In natural
settings, stress may occur because of discrete events that cause a
transient peak in subjective distress or in conditions that persist over
considerable periods of time and thus present sources of chronic
strain to affected individuals (Pearlin and Schooler 1978; Pearlin et
al. 1981).

Overall mood states are related to independent contributions by
dimensions of positive affect and negative affect: well-being is
determined by low negative affect and by high positive affect (Diener
1984). Studies of mood states in natural settings over intermediate
time periods of 1 day to 1 week show that the dimensions of negative
and positive mood are independent, that is, they both occur on a
regular basis in daily life and both contribute to overall mood states
(Stone, Helder, Schneider 1987). Mood may be regulated both by
reduction of negative affect and by increase of positive affect
(Tomkins 1962, 1963; Wills and Shiffman 1985).

Subjective well-being could be improved through reducing the
perceived environmental demands, through physiologically influenc-
ing stress-related arousal states, through reducing perception of
unpleasant physical states, or through altering the balance of
positive/negative affect in daily life. These mechanisms are relevant
to understanding the relationship between stress and cigarette
smoking (Tomkins 1965).

Perceived Functions of Smoking

A number of epidemiological studies have examined the perceived
functions that smoking provides for users by employing large
samples that are usually representative of communities; in some
cases, representative national samples have been obtained. These
studies ask respondents about various functions that smoking is
perceived to provide for them, and the researchers aim to determine
basic functional dimensions through factor analysis or cluster
analysis of the motive reports. The questionnaire items used to elicit
smoking functions vary considerably, including items that elicit
agreement/disagreement with statements about smoking, items that
elicit the frequency or likelihood of smoking in defined situations, or
items that ask about a desire to smoke in certain settings. Although
the methodology and sampling procedures have varied considerably
across studies, there is consistency in the results. One higher order
domain of inter-correlated motive dimensions indicates that smoking
is perceived to provide negative affect reduction; another domain
indicates that smoking is perceived to provide positive affect
enhancement. Findings from the relevant studies, classified in terms
of these higher-order domains, are presented in Table 1. (Survey
studies also indicate that many smokers report that smoking keeps

395


weight down and that weight control is one of their major concerns
(Charlton 1984a,b; Feldman, Hodgson, Corber 1985; Page 1983).
However, for purposes of expositional clarity, this Section focuses on
affect regulation and stress. Smoking and body weight are discussed
in the next Section of this Chapter.)
A typical study of perceived functions was conducted in the United
States by Ikard, Green, and Horn (1969) with a representative
national sample of 2,094 adult respondents. In this study, subjects
were presented with a list of 23 statements about smoking, repre-
senting various combinations of situation and emotion and were
asked to indicate their agreement or disagreement about whether
the statement was true for them. Orthogonal factor analysis of the
items indicated that six basic motives were represented in the data.
A factor termed "Reduction of Negative Affect" was loaded by items
such as "When I feel upset about something, I light up a cigarette"
and "Few things help better than cigarettes when I'm feeling upset."
The domain of positive affect enhancement was represented by a
factor dimension termed "Pleasurable Relaxation," which included
items such as "Smoking cigarettes is pleasant and relaxing." This
factor was not correlated with any of the other five factors found in
the study, indicating that it is an independent functional dimension.
A factor concerning addictive smoking, which included items report-
ing a strong desire or craving for cigarettes, was substantially
correlated with the negative affect factor and for that reason is
included under the domain of negative affect reduction.
Other studies of smoking motives have replicated the two domains
of negative- and positive-affect regulation. Under the general domain
of negative affect reduction, McKennell (1970) surveyed a represen-
tative national sample of 1,140 adolescents and adults in Great
Britain and found that three factors termed "Nervous Irritation
Smoking," "Smoking Alone," and "Food Substitution" were strongly
intercorrelated, all representing an increased probability of smoking
during unpleasant states. Coan (1973) and Leventhal and Avis (19761,
in studies with college students, found almost identical factors
termed "Negative Affect Reduction" and "Anxiety Reduction,"
which in each case were substantially correlated with another factor
representing addictive smoking. Additionally, Coan (1973) found a
factor termed "Distraction," which included items suggesting that
smoking was sometimes used as a means of diverting attention from
disturbing stimuli. (This self-report is consistent with the discussion
of distraction studies presented in the first Section of this Chapter.)
Best and Hakstian (1978) surveyed a sample of 331 adult commuters
with an inventory about the relative strength of their urge to smoke
in each of 63 situations. Intercorrelated dimensions termed "Ner-
vous Tension," "Frustration," "Embarrassment," "Discomfort,"


TABLE l.-Summary of studies of perceived functions of smoking

Domain/Factors

Ikard et al.
(1969)

MeKennel
(1970)

Cam (1973)

Leventhal and
Avis (1976)

Best and
Hakstian (1978)

Saumann and
Chenoweth (1964)

Negative affect
reduction

Negative affect
  reduction
Addictive smoking

Nervous irritation


Food substitution
Smoking alone

Negative affect
reduction

Addiction

Distraction
Agitated state

Anxiety reduction


  Addiction

Nervous tension


Frustration
Discomfort
Anger/Impatience
Restlessness

n.a.'

Positive affect         Pleasurable
enhancement          relaxation

Relaxation


Social confidence
  smoking

Pleasurable
relaxation
Dependence on
mental state

Sensorimotor
pleasure

Pleasure/Taste

Relaxation

Pleasure

Other functions

Habitual smoking
Stimulation


Senaorimotor
manipulation

Activity
accompaniment



Social smoking

Habitual action
Stimulation


Concentration

  Habit

Stimulation


Fiddling


Social reward

Automatic smoking
Sensory stimulation


Concentration


Social smoking

Habit

Unpleasant habit

Inactivity/Boredom
Time structuring

Positive peer
relationships

     NOTE: Factors of comparable content are on the same line.
     ' ma. =fackm not available because relevant items not in study.
%
4


"Restlessness," and "Anger/Impatience" all indicated elevated rates
of smoking in different types of negative affect situations.
Under the domain of positive-affect enhancement, findings are less
consistent because studies typically included relatively few items on
pleasurable aspects of smoking. Despite this methodological limita-
tion, each of the studies contains one or two factors that represent a
function of smoking to produce positive affect. A factor termed
"Pleasurable Relaxation" found by Coan (1973) indicated smoking in
circumstances that were relaxed and comfortable, and comparable
factors termed "Pleasure" were found among adults (Leventhal and
Avis 1976) and adolescents (Baumann and Chenoweth 1984). In each
case, these dimensions were uncorrelated with negative affect
factors or with other dimensions found in the study. Factors that
were termed "Relaxation" by two investigators (Best and Hakstian
1978; McKennell 1970) represent smoking in conditions where one is
alone or wants to cheer up.
The studies have indicated some additional functional dimensions
not included within the two affective domains. Some dimensions
represent habitual or automatic smoking that occurs without
conscious attention. These self-reported dimensions are consistent
with the data presented in Chapter IV that address compulsive drug-
seeking properties of nicotine and tobacco use. Another common
dimension represents smoking to increase stimulation, typically in
conditions of inactivity or boredom; sometimes another dimension is
included, indicating that smokers report that smoking helps improve
concentration (Best and Hakstian 1978; Coan 1973; Leventhal and
Avis 1976). This latter perceived effect is discussed in detail in the
first Section of this Chapter. Dimensions representing smoking in
social situations indicate that smoking occurs primarily at parties or
social gatherings, and these factors typically are uncorrelated with
affective dimensions.
With regard to individual differences in motives for smoking,
there are some consistencies across studies. Amount of smoking
tends to be greater for persons scoring high on negative affect
reduction (Ikard, Green, Horn 1969; McKennell 19701, although
persons scoring high on habitual smoking may have a greater
frequency of smoking (Ikard, Green, Horn 1969; Leventhal and Avis
1976). Sex differences are sometimes found in functional dimensions,
with females scoring higher on negative-affect reduction (Frith 1971;
Ikard, Green, Horn 1969; Ikard and Tomkins 19731, whereas males
score higher on habitual, relaxation, or stimulation smoking (Frith
1971; Ikard, Green, Horn 1969; McKennell 1970). Findings on
external correlates of motive dimensions indicate that adolescents
who score high on the Pleasure dimension are more likely to initiate
or increase smoking over time (Baumann and Chenoweth 19&Q, and
adult smokers who score high on Negative Affect reduction are more


likely to relapse after smoking cessation treatment (Pomerleau,
Adkins, Perstchuk 1978).

McKennell (1970) found 65 to 75 percent of adults reporting that
they perceived smoking to reduce nervous irritation, and comparable
levels of endorsement were found for other dimensions of negative-
and positive-affect regulation factors. Some data indicate that
endorsement rates for habitual, stimulation, sensorimotor manipula-
tion, and social confidence smoking are low in absolute terms (Ikard,
Green, Horn 1969; McKennell 1970). A study of young children
(Eiser, Walsh, Eiser 1986) found that mood regulation effects of
smoking were clearly perceived by subjects in the 7- to 8- and lo- to
11-year-old age ranges; this suggests that perceived functions of
smoking may be learned partly by observation rather than through
direct experience.

The conclusion from this literature is that in the general popula-
tion, persons perceive that smoking has functions that are relevant
for mood regulation. Persons report that they smoke more in
situations involving negative mood, and they perceive that smoking
helps them to feel better in such situations. Additionally, smoking is
perceived to increase positive mood in some situations. These data do
not necessarily indicate that the various functions characterize
different types of smokers; rather, they suggest that most functions
are salient to an individual but are operative at different times or in
different situations. Similar to the discussion of smoking and
performance in the first Section of this Chapter, self-reports by
smokers that they smoke under stress may indicate direct effects of
smoking and nicotine or may reflect effects of smoking deprivation
that are relieved by smoking. Whichever interpretation is correct,
individuals certainly report that stress is associated with smoking.

Stress and Smoking

There is evidence that stress can increase the likelihood of
initiation of smoking if cigarettes are available. Further, consider-
able evidence exists to link negative-affect states to smoking
behavior. The database includes studies of stress as a risk factor for
smoking initiation during adolescence and studies on stress and
rates of smoking among adults.

Stress and Smoking Initiation

Several studies have shown stress to be related to the onset of
smoking in early adolescence. Studies of smoking initiation typically
survey a large sample of adolescents beginning at approximately 12
years of age, because the onset of cigarette smoking is greatest
during the junior high school period (Fishburne, Abelson, Cisin 1980;
Green 1979). Measures of psychosocial risk factors are obtained from


questionnaire scales, and indices of smoking status are usually
obtained from self-report by respondents, sometimes accompanied by
a biochemical index of smoking. There is evidence indicating that
self-reports of smoking by adolescents are generally accurate,
although the accuracy of self-report data may be increased by
administration of biochemical measures (Murray et al. 1987).
Convergent results from cross-sectional and prospective studies show
that stress is antecedent to substance use onset and is not a
consequence of the initiation of smoking (Gorsuch and Butler 1976;
Kandel 1978; Kandel, Kessler, Margulies 1978; Kaplan et al. 1986).

The most direct evidence linking smoking to negative mood states
is based on measures of subjective stress. A cross-sectional study by
Mitic, McGuire, and Neumann (1985) surveyed a random sample of
1,684 school students in grades 7 through 12 in a medium-sized
Canadian community and obtained measures indexing whether
students felt nervous, anxious, or worried as a result of 12 potential
problem areas. Analyses for the total sample indicated that regular
and heavy smokers scored higher on perceived stress, compared with
nonsmokers. A related study by Hirschman, Leventhal, and Glynn
(1984) employed as the criterion variable a retrospective report of
smoking experiences during the previous 2 years. Data were
obtained from a stratified sample of 386 students in grades 2 through
10 in a midwestern community. Analyses of data on smoking
transitions indicated that a measure of affective distress was related
to rapid transitions from experimental to regular smoking. These
results were obtained in multivariate analyses with control for other
variables including age, peer and parental smoking, and risk-taking
tendency.

Comparable findings occurred in a prospective study by Wills
(1985, 1986) of a population sample of 675 students in the 7th grade
in a New York City school district. Analyses for a 1Citem scale of
subjective stress reactions showed that high stress was related to
increased levels of smoking over a 2-year period. Additional data
from this cohort and a replication cohort of 901 students were
obtained with measures of everyday negative events and major life
events. Multivariate analyses of these data indicated that all three
measures of stress were related to smoking, with major negative
events being the statistically strongest predictor. These analyses
indicated that the effect of stress on smoking was not attributable to
other variables including sex, race, locus of control, self-esteem,
social activity, and assertiveness. These findings are consistent with
laboratory data indicating that females under stress are more
willing to try additional cigarettes after an initial smoking experi-
ence (Silverstein et al. 1982).

It should be noted that adoption of cigarette smoking has been
shown to be a risk factor for subsequent adoptions of other types of

400


substance use. Although many adolescents who smoke do not become
regular users of other drugs, there are typically a concurrent
correlation between smoking and other types of drug use (Hays,
Stacy, DiMatteo 1984; Single, Kandel, Faust 1974; Revell, Warbur-
ton, Wesnes 1986) and a statistical relationship between early
cigarette smoking and subsequent use of hard liquor and marijuana
(Kandell975; Donovan and Jessor 1983). There is no direct evidence
linking multiple drug use to mood regulation effects, but it has been
shown that negative life events are a risk factor not only for
cigarette smoking, but also for several types of other drug use (Bruns
and Geist 1984; Kellam, Brown, Fleming 1982; Newcomb and
Harlow 1986).

For interpretation of data on stress and smoking in adolescents,
the primary methodological issue concerns a possible third confound-
ing variable. It may be that high levels of subjective stress are most
prevalent among adolescents who have difficulty adjusting to school
and family because of underlying psychopathology (Depue and
Monroe 1986) and who identify with the values of a deviant lifestyle
that includes substance use and delinquent behavior (Jessor and
Jessor 1977). The current evidence argues against this interpreta-
tion; some data show that stress-smoking correlations remain
significant with control for variables such as risk-taking, perceived
control, and self-esteem (Hirschman, Leventhal, Glynn 1984; New-
comb and Harlow 1986; Wills 1985), and it has been shown that
negative life events that could not be self-caused by adolescents show
an independent predictive relationship to smoking (Wills 1986). The
current evidence, however, is minimal and does not clearly rule out
the alternative interpretation. At present it can be concluded that
subjective stress may be a risk factor for adolescent smoking.

Stress and Cigarette Chwmaption

In considering evidence on affective factors and cigarette consump
tion among regular users, both epidemiological and laboratory data
are available. Designs in the epidemiological studies are relatively
weak because studies are largely cross-sectional, making causal
interpretation difficult. When longitudinal data are available, the
followup periods are rather short (approximately 1 year) in relation
to the probable time course of stress-smoking relationships in adult
populations. The following section presents the epidemiological
evidence and laboratory studies of stress and smoking.

A large body of personality research has linked measures in the
category of "neuroticism" to cigarette smoking among adult popula-
tions (Kozlowski 1979). These measures, which include scales of
nervousness, emotionality, and anxiety, are conceptually similar to
the concept of negative affectivity as defined by Watson and Clark
(1984); that is, the tendency to perceive and experience negative

401


affect. Theoretically, this is the most relevant construct for examin-
ing links between affective factors and smoking. Of the 50 studies
reviewed by Kozlowski (1979), half showed a significant relationship
between neuroticism and smoking. Three studies in this literature
showed the relationship between neuroticism and smoking to be
more characteristic of females than males (Cherry and Kiernan
1976; Clausen 1968; Waters 1971). These studies were mostly cross-
sectional, making inferences of causality problematic because of the
possibility that smoking caused feelings of anxiety and depression.
Also, Cherry and Kiernan (1976) analyzed longitudinal data and
found that neuroticism predicted initiation of smoking by women but
neuroticism predicted decreased likelihood of quitting by men. One
prospective study (Seltzer and Oechsli 1985) related personality
measures obtained at age 10 to smoking status at age 16 in a sample
of 1,127 subjects from health maintenance organizations in the
Oakland, California, area. The prospective analyses showed that
measures of anger, restless sleep, and Type A personality were
significantly related to onset of smoking. These analyses were
performed with control for parental socioeconomic status and
smoking. Measures of neuroticism and anxiety did not discriminate
smokers in these analyses.

In the laboratory, smokers tend to smoke more during stressful
situations (Epstein and Collins 1977; Rose, Ananda, Jarvik 1983;
Schachter et al. 1977). Individuals attempting to quit smoking tend
to experience relapses into a state of continued smoking during
stressful situations (Shiffman 1986). Such findings are consistent
with the self-reported claims of smokers that they smoke in order to
reduce stress-induced negative affect. However, there is no convinc-
ing research evidence to indicate whether smoking actually reduces
stress. It may be that smoking reduces stress relative to smoking
deprivation or that smoking increases during stress without attenu-
ating it.

It has been suggested that smokers smoke as a technique to deal
with stress (Wills 1985). If smoking is indeed used as a coping
mechanism, individuals with poor coping skills and/or with high
degrees of chronic stress would be expected to have a higher
prevalence of smoking. Three prospective studies have found associa-
tions between anxious, aggressive, and generally neurotic personali-
ty traits in childhood and the tendency toward smoking later in life
(Cherry and Kiernan 1976; Lerner and Vicary 1984; Seltzer and
Oechsli 1985). Cross-sectional surveys have repeatedly supported
these findings, showing that neurotic, depressed, angry, and rebel-
lious individuals are more likely to smoke compared with more
emotionally stable individuals (Spielberger 1986). Ninety percent or
more of alcoholics smoke (Istvan and Matarazzo 1984) compared with
about 30 percent of the general adult non-alcoholic population in the

402


United States. Individuals who commit suicide are much more likely
to be smokers (Cederlof, F&erg, Lundman 1977; Doll and Peto
1976). It has been argued that individuals with personality distur-
bances and related psychological problems may, in some cases, be
using nicotine as a form of self-medication (Brown 1973; Warburton,
Wesnes, Bevel1 1963). It has also been noted that the symptoms of
nicotine withdrawal syndrome are very similar to those of clinical
depression (Gilbert and Welser, in press). Emotional and psychologi-
cal disorders with high incidences of tobacco consumption are
characterized by high degrees of negative affect, and it seems likely
that, like other tobacco consumers, individuals with such disorders
use tobacco as a means of coping with negative affect and stress.

Recent studies have used measures more directly linked to the
experience of stress. In a survey of a sample of 505 Navy men on
amphibious assault ships, Burr (1984) employed a 19-item measure
indexing perceived stress from the domains of job, organization, and
family and related the stress scales to a single item about smoking
status. Results showed that two scales from the stress measure,
indexing Role Conflict and Family Strain, were significant discrimi-
nators of smokers and nonsmokers in this sample. These results are
cross-sectional, but were obtained in a multivariate analysis that
included a measure of locus of control. Similar results were found in
a cross-sectional study by Tagliacoxzo and Vaughn (1982) in a sample
of 448 hospital nurses, using a 26&m inventory of job-related stress.
In this study, the stress-smoking relationship was found primarily
among respondents who were younger (<28 years) and single.
Billings and Moos (1983) studied a community sample of 608 adult
respondents in the San Francisco area and found that heavy smokers
differed from nonsmokers in showing higher levels of anxie-
ty/depression symptoms and negative life events (during the previ-
ous year) in the areas of work strain and family illness. Correlations
between stressors and amount of smoking were found primarily for
heavy smokers, not for light smokers in this population. These data
are consistent with findings from a community sample of 938 adults
in New Haven (Lindenthal, Myers, Pepper 1972). This study found
that a high level of negative events (during the previous year) was
related to increased rates of smoking, with some data suggesting that
this effect occurred primarily among persons scoring high on
psychological impairment as measured by the Gurin Index. In this
study the relationship between stress and smoking held with control
for sex, race, age, marital status, and social class.
Only two studies have examined smoking and stress at more than
one time point. Conway and associates (1981) studied a sample of 34
Navy officers in a training setting. Data were obtained on stressors
and smoking for 14 study days over an &month period. The days
were categorized by independent raters for stress level; additionally,

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subjects made a daily rating on an eight-item scale of mood and
subjective stress. Results showed that rates of smoking were
significantly correlated with both the daily subjective stress mea-
sures and with the objective categorization of days for stress level.
Items on perceived stress, anger, fatigue, and fear were significantly
related to smoking in the overall sample, but an item on depression
was not significantly correlated with smoking. Within-subject analy-
ses of stress-smoking relationships indicated that the significant
overall correlations were apparently due to a small number of
individuals, but there were no data presented to discriminate these
more reactive individuals from other members of the sample. A
prospective study by Aneshensel and Huba (1983) was based on
longitudinal data from four time periods with a community sample
of 742 adult respondents in the Los Angeles area. Data on cigarette
smoking, scored on a l-to-5 scale, were obtained at baseline and at a
l-year followup interval. Results showed that a baseline measure of
depression was not related to smoking either concurrently or over
the l-year interval.

The field studies are, for the most part, ambiguous with respect to
causal interpretation, This difficulty is alleviated in laboratory
studies in which subjects are randomly assigned to conditions and
predictor variables are experimentally manipulated. Several studies
of stress and smoking in laboratory settings have consistently found
that stress increases rates of smoking. The stressors manipulated
include threat of electric shock (Schachter et al. 1977), noise (Cherek
1985; Golding and Mangan 19821, and performance anxiety (Rose,
Ananda, Jarvik 1983). These latter researchers also employed a
concentration task and found that smoking increased in both the
anxiety and concentration conditions, compared with a control
condition. One study, using a public speaking manipulation, failed to
find a significant effect of stress on smoking (Glad and Adesso 1976).

Based on epidemiological and laboratory research, it can be
concluded that stress increases the rate of smoking among regular
smokers. The convergence of results from cross-sectional,' retrospec-
tive, and repeated-measures studies, in combination with findings
from laboratory research, supports the interpretation of a causal
relationship. There is some evidence suggesting that life stress has a
greater impact among heavy smokers and among persons scoring
high on negative-affect measures, but evidence on individual differ-
ences in this literature is minimal. The psychological mechanisms
linking stress to increased smoking have not been clearly demon-
strated (Leventhal and Cleary 1980; Schachter, Silverstein, Perlick
1977; Pomerleau and Pomerleau 1984). It may be that smoking
attenuates stress (e.g., by regulating mood), that smoking increases
during stress but does not attenuate it, or that smoking during stress
is experienced as less stressful only when-compared with smoking

404


deprivation during stress. Some laboratory studies and substantial
theoretical speculations have addressed these issues and are dis-
cussed below.

Do Smoking and Nicotine Reduce Stress and Improve
Mood?

There is evidence that smoking is perceived as helpful for coping
with stress and dysphoric mood. A further question is whether
smoking actually reduces stress or improves mood. In epidemiologi-
cal studies, this question has not been directly addressed, a major
limitation in the literature. There are some laboratory studies that
bear on this question. This Section summarizes experimental
findings concerning the effects of smoking and nicotine on stress and
affect modulation.

Self-Reported Strvss Reduction and Affect Modulation

Smoking-deprived smokers usually report more negative affect
than do smokers who are allowed to smoke if the setting is one which
tends to produce mild-to-moderate negative affect. Compared with
those deprived for an hour or more, individuals allowed to smoke
report leas anxiety (Gilbert and Spielberger 1987; Heimstra 1973;
Pomerleau, Turk, Fertig 1984; Jarvik et al., in press) as well as less
anger and irritation (Cetta 1977; Heimstra 1973; Neetx 1979) during
performance of a variety of slightly stressful tasks. Tobacco depriva-
tion is also associated with self-reports of decreased alertness,
lessened mental efficiency, and increased boredom during a variety
of cognitive tasks (Frankenhaeuser et al. 1971; Heimstra 1973).

Experimental research suggests that nicotine is the most impor-
tant, and possibly the essential, component of the affect-modulating
properties of tobacco use (Gilbert and Welser, in press; Pomerleau
and Pomerleau 1984). For example, studies comparing the effects of
nicotine-containing gum with no-nicotine placebo gum report that
nicotine reduces negative affect in nicotine-deprived habitual smok-
ers (Hughes et al. 1984; Jarvis et al. 1982; West et al. 1984). In
addition, habitual smokers assigned to smoke cigarettes of normal
nicotine yield report less negative affect than those who smoke very-
low-nicotine-yield cigarettes (Gilbert 1985; Perlick 1977).

However, a number of studies have not observed reduced negative
affect due to smoking high- versus low-nicotine-yield cigarettes
(Bowen 1969; Dubren 1975; Fleming and Lombard0 1987; Gilbert and
Hagen 1980; Gilbert 1985; Hatch, Biemer, Fisher 1983). Gilbert and
Welser (in press) suggest that these studies included inadequate
periods of tobacco deprivation and excessively rapid smoking of
multiple cigarettes (probably producing nicotine toxicity). Degree
and type of stress to which subjects are exposed may also influence
outcomes. There is evidence suggesting that nicotine has stress-

405


attenuating effects when stressor stimuli are mild or moderate,
distal (anticipatory), and ambiguous, but fails to have such effects
when stressors are brief, proximal, and/or intense (Gilbert and
Welser, in press). More research is needed to evaluate these
possibilities.

Behavioral Indices of Stress Reduction and Affect Modulation

A small number of studies that used behavioral indices of affect
support the hypothesis that nicotine can reduce negative affect.
Several studies report that smoking, or smoking a high-nicotine
relative to a low-nicotine cigarette, is associated with reduced
aggression (Cherek 1981; Schechter and Rand 1974). However, Jones
and Leiser (1976) found no such effects on aggressive behavior by
using similar procedures. In addition, without nonsmokers as
controls, it is impossible to know whether the differences that were
reported between conditions resulted from nicotine administration
or nicotine deprivation.

Hughes and colleagues (1984) asked spouses to provide daily
ratings of the subjects' behavioral indications of mood. These
subjects had abruptly quit smoking and were randomly assigned to
chew placebo gum or gum containing nicotine. Subjects who chewed
the placebo gum were rated by their spouses as exhibiting signifi-
cantly more anger and tension after quitting smoking, while those
who chewed nicotine polacrilex gum showed little change in these
emotional states. Thus, it appears that the nicotine provided by the
gum replaced the nicotine previously obtained by smoking, so that
there was little change in mood. However, it also appears that
nicotine deprivation resulted in the tension and anger and that
nicotine did not reduce these variables below baseline values.

Several studies have used pain thresholds as dependent variables
in assessing the effects of smoking and nicotine on anxiety. Two
studies that tested the effects of smoking cigarettes of different
nicotine yield on electric shock endurance report elevated endurance
thresholds in subjects who smoked relative to those who did not and
in the high-nicotine-cigarette conditions relative to the low-nicotine
cigarette conditions (Nesbitt 1969; Silver-stein 1982). The increased
willingness to endure electric shock by individuals in the smoking
and high-nicotine conditions was interpreted by these investigators
and others (Schachter 1973) as indicating that nicotine reduces the
anxiety associated with the electric shock. Other studies used the
length of time that individuals are willing to endure pain associated
with immersion of a hand or foot in ice water (the cold-pressor test)
as an indicator of anxiety. These studies also showed that smoking
and another means of nicotine administration (snuff) increase
endurance in this test. However, the anxiolytic interpretation of
increased pain thresholds has been questioned (Gilbert 1979),

406


because of the observation that in some situations nicotine has been
reported to increase detection thresholds for tactile (including
electrical) stimuli. It may be that nicotine reduces sensitivity to pain
directly, rather than via reduction of anxiety. Several studies have
failed to find increased shock endurance thresholds associated with
smoking (Jarvik et al., in press; Milgrom-Friedman, Penman, Meares
1983; Shiffman and Jarvik 1984). In addition, it is unclear whether
smoking and nicotine reduced these operational estimates of stress
or whether smoking deprivation increased them.

Studies of the effects of acute doses of nicotine on behavioral
measures of activity in animals indicate that nicotine may reduce
negative affect in a number of different species (Bell, Warburton,
Brown 1985; Emley and Hutchinson 1983). However, close inspection
of the procedures used in these studies reveals that doses that
suppress behavioral indices of emotion also may produce nicotine
toxicity. Such high doses may decrease a large variety of behavioral
indices due to the induction of physical distress. However, Silverman
(1971), using doses of nicotine comparable to smoking doses, reported
nicotine-induced reductions of aggression. Careful evaluation of
studies of the effects of nicotine on indices of emotion in nonhuman
subjects indicates that while these studies generally support the view
that nicotine has inherent negative-affect-reducing properties inde
pendent of withdrawal effects, most have administered such high
doses of nicotine as to make their relevance to habitual nicotine use
in humans questionable.

Overall, evidence from experimental studies supports survey
findings suggesting that tobacco use and nicotine consumption are
associated with decreases in negative affect in habitual tobacco
users. As was true for the learning and performance literature,
caution must be exercised in generalizing about smoking and
nicotine's effects on stress and mood because most laboratory studies
compare smokers smoking with smokers not smoking. Few studies
include the important control group of nonsmokers not smoking to
allow unequivocal determinations of whether smoking and nicotine
are stress reducing or whether smoking abstinence and nicotine
deprivation are stress increasing. Certainly, it seems that smoking
by smokers is stress reducing compared with smokers not smoking.
The experimental literature suggests that smoking and nicotine may
reduce negative affect most effectively in situations involving mild
or moderate distal (anticipatory) anxiety and/or ambiguous stres-
sons. The roles that individual differences in personality, tempera-
ment, and psychopathology may play in determining the nature or
degree of the stress-reducing effects of nicotine are yet to be
determined.

407


Suggested Mechanisms Underlying Nicotine's Effects on
Stress and Mood

Based on the extant epidemiological literature linking stress and
smoking and the laboratory studies indicating that stress increases
smoking, several investigators have offered mechanisms to explain
these relationships. These theoretical positions are varied and none
has yet received unequivocal support to the exclusion of the other
proposed mechanisms. Perhaps several or all, of these mechanisms
are operating. The major positions are reviewed below.

An Emphasis on Nicotine Withdrawal Symptoms

Schachter (1979) suggested that nicotine reduces negative affect in
smokers simply by reducing symptoms of nicotine withdrawal.
Increased irritability, anxiety, and depression are the most common
symptoms of smoking withdrawal (Murray and Lawrence 1984), and
these are the very emotions that appear to be most consistently
reduced by acute doses of nicotine in nicotinedeprived smokers
(Gilbert and Welser, in press). Thus, alleviation of withdrawal
symptoms may account for the capacity of nicotine to reduce
negative affect in nicotine-deprived smokers.

The degree to which an individual is physically dependent on
nicotine may account for the variable effects observed. Perlick (1977)
found that normal-nicotine-delivery cigarettes alleviated annoyance
in heavy but not light smokers. On the other hand, the reduction in
negative affect following nicotine administration may not be simply
and solely a consequence of withdrawal symptom relief, because
several investigations showing such effects used minimally deprived
individuals who had not developed withdrawal symptoms (Pomer-
leau 1981).

A variant of this proposed mechanism suggests that smoking
increases under stress and in dysphoric mood states because
biological and psychological effects of stress and dysphoric moods are
similar to the experience of nicotine withdrawal. From past experi-
ence, smokers learn that smoking alleviates these unpleasant states.
Therefore, stressors and dysphoric moods come to elicit smoking
because of conditioned responses or because of misattribution of the
unpleasant experiences to nicotine withdrawal (Barefoot and Girodo
1972; Grunberg and Baum 1985). This misattribution model has
some empirical support but requires careful examination.

Neurochemical Models

Evidence has been offered in support of the hypothesis that
nicotine-induced release of glucocorticoids and other neuromodula-
tors, such as the endogenous opioid beta-endorphin, may account for
nicotine's capacity to reduce stress and negative affect (Gilbert 1979;

408


Pomerleau and Pomerleau 1984). While high doses of nicotine and
rapid smoking of cigarettes after a period of smoking deprivation
cause reliable increases in plasma concentrations of such neuromo-
dulators (Seyler et al. 1986), it is not clear whether normal smoking
during nonstressful conditions causes increases in these neuromodu-
lators (Gilbert and Welser, in press). However, normal smoking in
combination with mild-to-moderate stress may result in such in-
creases. In addition, even if such neurochemical changes occur, it is
not clear whether they act to modulate stress or dysphoric moods.

Biphasic Action on the Sympathetic Nervous System

Studies of human performance show that performance on simple
tasks is improved by higher arousal, but performance on complex
tasks is impaired by a high arousal level (Levine, Kramer, Levine
1975). In coping with the varying demands of daily life, at times it
may be advantageous to vary the level of sympathetic nervous
system (SNS) arousal. The ability to regulate arousal in this fashion
would enable individuals to appraise stressful situations as less
threatening and could result in improved performance in various
conditions. There is some evidence suggesting that nicotine may
have biphasic effects on SNS responses, producing either stimulatory
effects or dampening effects under different conditions. Under
conditions of low environmental demand, the effect of nicotine is
generally to produce stimulatory or SNS arousal effects, including
increases in heart rate and blood pressure (Grunberg and Baum
1985; MacDougall et al. 1983, 1986). This effect may be responsible
for the perceived functions of "stimulation" or coping with "inactivi-
ty/bored.om" (Best and Hakstian 1978; Coan 1973; Ikard, Green,
Horn 1969; Leventhal and Avis 1976), and there is evidence
indicating that smoking improves performance on simple tasks
(Suraway and Cox 1986; Wesnes and Warburton 1983). At high levels
of arousal, however, there is some evidence that nicotine produces
central nervous system (CNS) tranquilization effects or reduces
reactivity to stressful stimulation (Armitage, Hall, Sellers 1969;
Ashton et al. 1974; Golding and Mangan 1982; Woodson et al. 1986).
Evidence suggests that nicotine can restore high brain activation to
moderate levels. In low-arousal situations, such as vigilance tasks,
nicotine produces cortical activation and increased alertness (Ed-
wards et al. 1985). Increased cortical activation could increase
hedonic tone directly or indirectly by allowing the individual to
perform more effectively on desired tasks and thus to experience
indirect rewards such as the perception of increased self-efficacy. In
contrast, nicotine has been associated with decreased cortical
activation and reduced anxiety in stressful conditions (Gilbert 1985;
Golding and Mangan 1982). Nicotine administration by smoking and

409


other means may allow individuals to achieve a hedonically more
desirable level of cortical activation (Eysenck 1972).

At present, there is no direct evidence linking these physiological
effects to perceived stress reduction or improved performance under
stressful conditions. This position is also consistent with the findings
reported in the first Sect.ion of this Chapter.

ALtered Body Activity

Several mechanisms based on altered body activity may account
for nicotine's stress-reducing effects. First, based on evidence that
nicotine may in some situations increase the threshold for electric
shock (Mendenhall 1925) and on the observation that nicotine-
induced increases in cardiovascular activity typically do not produce
corresponding increases in perceived heart activity (Gilbert and
Hagen 19801, nicotine may reduce the intensity of emotional
experiences by increasing perceptual thresholds for emotion-related
feelings of bodily arousal (Gilbert 1979). The small number of studies
evaluating this hypothesis have provided mixed results (Sult and
Moss 19861, possibly because some have not been carried out under
conditions of high stress. This elevated perceptual threshold model is
consistent with the CNS arousal modulation model and with the
neuromodulator model in predicting that under conditions of height-
ened stress, nicotine should elevate perceptual and pain-endurance
thresholds.

A related possibility is that smoking reduces sensitivity to painful
stimuli and sensitivity to internal proprioceptive cues that produce
discomfort. Antinociceptive action (i.e., reducing perception of pain
stimuli) has been documented in several animal studies (Friedman,
Horvath, Meares 1974; Sahley and Berntson 1979; Tripathi, Martin,
Aceto 1982). Evidence from humans is mixed, with several studies
showing that smoking increases tolerance to painful stimuli (Pomer-
leau, Turk, Fertig 1984; Nesbitt 1973; Silverstein 1982), and the
effect is attributable specifically to nicotine intake rather than to the
physical act of smoking (Fertig, Pomerleau, Sanders 1986). Several
studies have failed to find effects of smoking on pain thresholds
(Shiffman and Jarvik 1984; Suit and Moss 1986; Wailer et al. 1983).
These null results may be attributable to methodological details such
as gender differences or differences in current. nicotine level.

Another possibility is that nicotine produces a state of tranquillity
or relaxation by reducing the level of tonic and/or phasic muscular
activity (Gilbert 1979). Experimental evidence strongly supports the
view that nicotine depresses certain muscular reflexes (Domino
1979; Hutchinson and Emley 1973). Ginzel and Eldred (1972) and
Ginzel (1987) have shown that nicotine produces muscle relaxation
in the cat. Epstein and coworkers (1984) have reported that smoking
by humans reduces sensitivity to perception of muscle tension.

410


Schachter (1973) suggests that nicotine reduces emotional experi-
ence by reducing emotion-induced phasic increases in autonomic
nervous system (ANS) activity. Because nicotine typically increases
activation of the ANS, this increase in tonic ANS activation should
produce a ceiling effect such that the additional arousal increase
associated with the onset of emotional stimulation is less than the
emotion-induced arousal that occurs without nicotine. This third
hypothesis assumes that phasic, rather than tonic, activation of the
ANS is an important contributor to the subjective experience of
emotion. Consistent with this possibility, nicotine increases tonic
heart rate, but reduces phasic heart rate responses to stressors
(Schachter 1973; Woodson et al. 1986).

Hedonic Systems Model

Nicotine-induced modulation of one or more systems in the brain
associated with pain and pleasure may account for the capacity of
nicotine to reduce negative affect and increase feeling of well-being
(Eysenck 1973; Jarvik 1973). Eysenck (1973) suggests that feelings of
well-being produced by nicotine and other means can be increased by
influencing three hedonic systems: the primary reward, the primary
aversion, and the secondary reward systems. Activating the primary
system is thought to produce pleasure directly, while activating the
secondary reward system produces rewarding effects indirectly, by
inhibiting the aversion system. Eysenck suggests that nicotine
administered during highly stressful situations may improve mood
by means of the secondary system, while nicotine administered
during low-arousal conditions may directly stimulate primary re-
ward systems. Any primary rewarding effect of nicotine appears to
be very subtle; many smokers and a smaller percentage of nonsmok-
ers report pleasurable stimulant effects following the administration
of nicotine (Jones, Farrell, Herning 1978). However, the subjective
effects of nicotine appear to depend greatly upon expectations
(Hughes et al. 1985); individuals who are not habitual tobacco users
typically report that nicotine administered in any form produces
unpleasant effects (Nyberg et al. 1982). In addition, the biochemical
representation of affective states is not well understood (McNeal and
Cimbolic 1986), and these states are a joint function of physiological
and psychological factors (Reisenzein 1983; Schachter and Singer
1962). Experimental studies of stressful situations have shown that
smoking produces reduction in subjective ratings of anxiety (Jarvik
et al., in press; Pomerleau, Turk, Fertig 1984), but several studies
have failed to find effects of smoking for subjective anxiety (Fleming
and Lombard0 1987; Shiffman and Jarvik 1984) or emotional
behavior (Hatch, Bierner, Fisher 1983). It appears that anxiety-
reduction effects are observed primarily when smoking occurs
before, rather than during, the stressful situation (Gilbert, in press).

411


Therefore, the anxiety reduction may result from cognitive appraisal
rather than from direct reduction of negative affect, but it should be
noted that comparable patterns of findings are commonly observed
for most anxiolytic medications (Janke 1983).

Regarding positive affect, it has been suggested that effects of
nicotine on endogenous opioid systems may relate to experienced
pleasure (Pomerleau and Pomerleau 1984). There is some evidence
that effects of cigarette smoke on the upper and lower respiratory
airways contribute to pleasurable functions of smoking (Bose et al.
1985), but direct evidence of an influence on positive affect has not
been demonstrated.

Lateralized Affective Processors Model

The capacity of nicotine to decrease negative affect may stem from
its capacity to increase activation of the left cerebral hemisphere
compared with the right hemisphere (Gilbert 1985). Lateralized
effects on electrocortical (Elbert and Birbaumer 1987; Gilbert 1985;
Gilbert, in press) and electrodermal (Boyd and Maltzman 1984)
activity have been reported. These electrophysiological studies along
with behavioral studies (Gilbert and Welser, in press) suggest that
during stressful/high-arousal conditions, nicotine reduces right-
hemisphere more than left-hemisphere parietal activation, while
during low-stress situations it may activate the right hemisphere
more than the left. Activation of the right hemisphere appears to be
more related to the experience of negative affect (Davidson 1984),
while the left hemisphere is more the biological seat of logical
sequential and verbal information processing (Tucker and William-
son 1984). Thus, nicotine-induced reductions of right-hemisphere
activation are associated with reductions in negative affect. Consis-
tent with this finding, simultaneous reductions in right-hemisphere
EEG activation and in negative affect have been reported while
subjects viewed a stressful movie (Gilbert 1985). These lateralized
effects may occur as a result of nicotine's influence on one or more
relatively lateralized neurotransmitter systems (Gilbert and Hagen
1980). The lateral&d effect model suggests a common biological
basis for a diverse set of psychological and physiological effects of
nicotine.

Hypothalamic Consummatory Drive Model

Both exposure to nicotine and the activity of the hypothalamus are
linked to hunger and body weight, as well as to affective, cognitive,
and perceptual processes. Stimulation of the ventromedial hypothal-
amus or deactivation of the dorsolateral hypothalamus produces
effects similar to those produced by the administration of nicotine:
decreased emotionality, decreased sensitivity to distracting stimuli,

412


heightened activity level, low taste responsivity, and weight loss
(Nisbett 1972). Nicotine withdrawal, as well as lesions of the
ventromedial hypothalamus or stimulation of the dorsolateral
hypothalamus (Nisbett 19721, leads to the opposite effects: increased
emotionality, increased distraction by external stimuli, decreased
activity level, increased taste responsivity, and weight gain (Grun-
berg and Baum 1985; Perlick 1977). There are a number of
commonalities between nicotine and food consumption (Grunberg
and Baum 1985). Food consumption, like nicotine, reduces anxiety
(Schachter 1971), and many individuals smoke (Rose, Ananda, Jarvik
1983) and/or eat more (Morley, Levine, Rowland 1983) when
anxious. Nicotine may reduce aspects of the hunger drive (Grunberg
and Baum 1985) and may be reinforcing for this reason. The
hypothalamic consummatory drive model suggests that consumma-
tory drive reduction by nicotine should reduce the agitation and
irritability associated with a high drive state.

Indirect Models: Psychological Enhancement and Sensory
Gratification

Nicotine may reduce negative affect indirectly by enhancing
cognitive functioning and associated task performance (Ashton and
Stepney 1982; Wesnes and Warburton 1978). The effects of smoking
and nicotine on performance (reviewed earlier in this Chapter) are
consistent with this interpretation. Nicotine may improve affect
both directly, by one or several of the mechanisms discussed above,
and indirectly, by enhancing certain psychological processes. More-
over, there is evidence that smoking improves visual sensory
processing while blunting auditory distracters in humans (Friedman
and Meares 1980).

Sensory experiences related to tobacco consumption may contrib-
ute to the motivation for its use and its affect and stress-related
effects. Some smokers report smoking because they like handling
cigarettes, watching smoke, and/or the sensory experience of smoke
in the throat and lungs (Russell, Peto, Pate1 1974). Experimental
studies, although limited in number, have supported the view that
sensory factors are important contributors to the satisfaction and
craving-reduction associated with smoking (Rose et al. 1985). The
strong sensory impact associated with all forms of common tobacco
use may also reduce negative affect by providing distraction from
negative thoughts and stimulation that relieves boredom (Gilbert
and Welser, in press).

Implications for Tobacco Use

Stress is a risk factor for smoking initiation and increases
cigarette smoking (e.g., puffs per cigarette) among regular users.

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Smoking is stress reducing for many smokers, and nicotine appears
to be involved in this effect. It is likely that the effects of nicotine on
stress and on mood involve several mechanisms including alleviation
of withdrawal symptoms, peripheral muscle relaxation, central
neurochemical changes and electrocortical arousal, interaction with
consummatory reward systems, and indirect effects such as psycho-
logical enhancement and sensory gratification. Future research
needs to address and compare the possible mechanisms. Regardless
of which mechanisms are operating, the relationship between stress
and smoking undoubtedly reinforces habitual tobacco use and may
contribute to initiation and relapse.

Tobacco Use, Nicotine, and Body Weight

Cigarette smokers weigh less than comparably aged nonsmokers,
and many smokers who quit smoking gain weight (Grunberg 1986a;
Rodin and Wack 1984; Wack and Rodin 1982). It has been suggested
that some people smoke to prevent weight gain as the result of
smoking cessation (Birch 1975; Charlton 1984b; Grunberg 1986a).
Therefore, methods to control weight gain following cessation have
been recommended (Birch 1975; Ducimetiere et al. 1978; Grin&ad
1981; Grunberg and Bowen 1985a). How much weight gain actually
occurs following smoking cessation (Albanes et al. 1987; Bosse,
Garvey, Costa 1980; Rabkin 1984; Wack and Rodin 1982), the specific
mechanisms (i.e., changes in dietary intake, physical activity, and/or
changes in resting metabolic rate) responsible for this weight gain
(Grunberg 1986b; Hofstetter et al. 19861, and whether weight gain (or
fear of weight gain) affects either cessation or relapse efforts (Hall,
Ginsberg, Jones 1986; Klesges and Klesges, in press; Kramer 1982)
remain controversial. This Section reviews data relevant to the
smoking/body weight relationship.

The Relationship Between Smoking and Body Weight

The relationship between smoking and body weight has been
extensively examined and reported for more than 100 years (Kitchen
1889; Otis 1884). Human studies can be summarized into two broad
areas: (1) cross-sectional evaluations that have compared the weights
of smokers, nonsmokers, and in some cases, ex-smokers; and (2)
longitudinal, within-subject evaluations that have measured weight
changes in smokers, ex-smokers, and nonsmokers over time. The
cross-sectional evaluations reported since 1970 are tabulated in
Table 2, and the longitudinal studies reported since 1970 are
summarized in Table 3. Both tables present the reference and year, a
brief description of the sample design, major findings, observed
moderator variables (e.g., gender, number of cigarettes per day) for
weight, and major limitations of the study. Only studies published

414


since 1970 are summarized in this Report because there are so many
studies and because reviews of earlier investigations (Bosse, Garvey,
Costa 1980; Grunberg 1986a) indicate that the results are completely
consistent with the studies presented in Tables 2 and 3.

Cross-Sectional Evaluations of SmoRing and Body Weight

Of the 28 cross-sectional evaluations presented in Table 2, 25 (89
percent) reported that smokers weigh less than nonsmokers. An
additional study (Sutherland et al. 1980) found this relationship for
women but not for men and another study (Hjermann et al. 1976)
found this relationship for older (45 to 49 years) but not younger (40
to 44 years) men. Only one study did not report an inverse
relationship between smoking and body weight, and that study
examined visitors to a "health exhibit," a population that may be
health conscious and predisposed to making positive health changes
(Waller and Brooks 1972). This one discrepant study included a high
percentage of cigar and pipe smokers (many of whom do not inhale).
While it is difficult to summarize the cross-sectional studies because
of differences in reporting techniques, it was found that smokers
overall weighed an average of 7.13 lb (range: 2.36 to 14.99) less than
nonsmokers.

Because smoking and alcohol consumption are correlated, one
study (Williamson et al. 1987) examined, through multivariate
methods, the effects of smoking and alcohol consumption on body
weight. This study reported that alcohol consumption accounted for
approximately 44 percent of the reduction in body weight in women
who smoked compared with women who did not smoke. For men,
statistical adjustment for alcohol consumption did not alter the
weight-lowering effect of smoking.

Cigarette consumption, age, and gender have been adequately
evaluated to reach some conclusions regarding their impact on the
relationship between smoking and body weight. The effect of
cigarette consumption has been parametrically evaluated in eight
studies. Six (Albanes et al. 1987; Hjermann 1976; Holcomb and Meigs
1972; Jacobs and Gottenborg 1981; Khosla and Lowe 1971; Lincoln
1970; Stephens and Pederson 1983) of the eight investigations (75
percent) reported a nonlinear relationship. In all of these reports,
nonsmokers had the greatest body weights; moderate smokers
(typically 10 to 20 cigarettes/day) had the lowest body weights; and
some heavy smokers (typically > 20 cigarettes/day) had body weights
approaching that of nonsmokers. Two studies (Bjelke 1971; Kopczyn-
ski 1972) reported no relationship between level of smoking and
weight.

The effect of age on the smoking/body weight relationship was
examined in six investigations. Five of six studies (86 percent)
(Albanes et al. 1987; Bjelke 1971; Hjermann et al. 1976; Jacobs and

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TABLE %-Cross-sectional evaluations of smoking and body weight


Study            Design and sample             Major results               Moderator variables           Limitations



Albanes et al.     12.103 me" and women.         Smokers weighed 5.95 lb less      Age: current smokers gained      Smoking self-report
( 1987)         NHANES II Survey           than nonsmokers, controlled for     less after age 25 than either
                            age, sex; smokers taller and        nonsmokers or exsmokers
                               leaner than nonsmokers, based      Smoking duration: body mass
                                     on skinfold               index decreased with smoking
                                                              duration increase
                                               Smoking rate: moderate smokers
                                                 leaner than low or high rate
                                                              smokers

Andrew and     All 18,831 pregnant women,       Across all heights, smoking                          Pregnant women only;
McGarry        Cardiff, Wales, 1985-1988        mothers lighter than nonsmokers                        birth survey record
(1972)                                                                  data; actual weight
                                                                    changes not presented

Biener         274 (174 men, 100 women) ex-      49% women, 39% men gained                         Retrospective
w81)         smokers, worksite setting        weight following cessation; quitter                       postcessation gain self-
                             approximate average gain: women                       report; no nonsmoker
                                11 lb, men 15 lb                               control group

Blair et al.      183 white male, 284 white female    Smokers 2.647.5 lb lighter than                       Small sample size;
(1980)        insurance company employees;      nonsmokers, 0.88-15.21 lb lighter                           white office workers
           average age 34             than ex-smokers; smaller                            only
                                 skinfolds for smokers of both
                                   sexes than nonsmokers


TABLE 2.-Continued

Study             Design and sample

Major results

Moderator variables

Limitations

Bjelke
(1971)

8,638 male, 10,331 female
respondents. mail survey, Norway
general population "systematic
sample"

Used "bulk index"
(weight/height'); both sexes
current smokers less bulky than
quitters and never smokers

Fehily et al.
(1984)

211 nonsmoking, 282 smoking
men, aged 45-59, heart disease
study

Smokers weighed 7.5-10.3 lb less
than nonsmokers. 6.6-9.4 lb less
than ex-smoken: pipe/cigar
smokers weighed 2.4 lb more
than nonsmokers; weight/height'
index results similar

Smoking rate: not related to
weight
Age: older respondents greater
smoker/nonsmoker bulk
differences
Sex: women greater
smoker/nonsmoker bulk
differences

Self-report by mail; no
weights, no statistical
analyses presented







            -
Small, all white.
restricted sample;
smoking self-report

Fisher and Gordon
(19851

15% random sample, 10 U.S.,
Canadian clinics; 2,269 male,
2,105 female whites, aged 20-59,
LRC Prevalence Study

Men: smoking nondrinkers
weighed 6.6 lb less than
nonsmoking nondrinkers; smoking
drinkers weighed 2.2 lb less than
nonsmoking drinkers
Women: smoking nondrinkers
weighed 2.2 lb less than
nonsmoking nondrinkers; smoking
drinkers weighed 4.4 lb less than
nonsmoking drinkers

All white population;
smoking self-report

Friedman et al.
(1981r

38 smoking-discordant
monozygotic twin pairs, average
age 40 years

Smokers weighed 5.07 lb lass
than nonsmokers

Self-report by mail;
small restricted sample


e   TABLE 2.4hntinued

Study             Design and sample

Major results

Moderator variables

Limitations

Garn et al.
(1978bI

17,649 pregnant women, national
health survey

Smoking mothers prepregnancy
weight less than nonsmoking
mothers; difference: whites 2.43
lb. blacks 3.53 lb

SEIS and race: no
smoking/weight relationship
influence

Pregnant women only;
self-reports

Garrison et al.
(1983)

Framingham study participants;
zL6xx.d 194!+1952

Nonsmokers 55% of highest
weight group; smokers 80% of
lowest weight group

Goldbourt and
Medalie
(1977)


-
Gyntelberg and
Meyer
(1974)

10,059 male government workers,
aged 40-65




______
5,249 employed men. aged 40-59,
Denmark

Current smokers l/4 inch taller,
2.35 lb less than nonsmokers; ex-
smokers in between: leaner
skinfolds for smokers than ex-
smokers and nonsmokers

Nondrinking smokers 1.5
percentile points lighter than
nondrinking nonsmokers: light
drinking smokers 2.9 percentile
points lighter; heavy drinking
smokers 5.9 percentile points
lighter than drinking nonsmokers

Sample sire. weights
not given; no statistical
evaluation

Limited age range.
employment group;
smoking self-report



All-male sample. one
city; smoking self-
report

Hjermann et al.
( 1976)

Approximately 18,090 male
participants, aged 40-49, coronary
risk factor screening, Oslo

Aged 45-49 smokers body weight
3.09 lb less than nonsmokers;
aged 40-44 difference not
significant; no group
weight/height* index differences

Smoking rate: heavy smoker
( > 20/day) body weights higher
than lighter smoker
Age: older smokers (45-491
weighed less than nonsmokers;
younger smokers (40-44) no
effect

Smoking self-report:
limited age range; one
city; all men


TABLE S.--Continued

Study

Design and sample

Major results

Moderator variables

Limitations

Holcomb and
Meigs
(1972)

226 manufacturing company male
hourly employees, aged 56-59

Mild to moderate smokers 14 lb
lighter than never smokers, ex-
smokers, and heavy smokers

Smoking rate: heavy smokers
(> 1 pack/day) heavier than
lighter smokers, equivalent to
nonsmokers

Smoking self-report;
limited age, incomes;
all men

Huston and
Stenson
(1974)

184 men, British Field Regiment

5 10 mm subscapular skinfold
men averaged 22 cigarettes/day;
2 15 mm subscapular skinfold
men averaged 12 cigarettes/day

Limited male sample;
smoking self-report; nq
separate smoker/
nonsmoker data

Jacobs and
Gottenborg
(1981)

3,291 white men and women,
aged 29-59, no cardiovascular
disease or elevated risk factors;
randomly selected middleclass
suburb census tract blacks

Smokers lighter than never

smokers and quitters

Smoking rate: male moderate

Smoking self-renort:

                            I .
smokers (14-29 cigarettes/day)      restricted population
6.39 lb lighter than nonsmokers,
2.65-9.93 lb lighter than light
and heavy smokers; female
moderate smokers 5.07 lb lighter
than never smokers, 1.54-8.38 lb
lighter than heavy smokers
Age: moderate/never smoker
weight difference increased with
ak?P

Khosla and Lowe
(1971,

10,482 male steel workers, Wales

Per weight/height* index,
smokers lighter than nonsmokers

Smoking rate: heavy smokers
(> 35 cigarettes/day) heavier
than moderate smokers (15-34)
Age: group weight differences
increased after age 35

Smoking self-report;
restricted population

Kittel et al.      8,284 male factory workers,
(1978)         Belgium

Relative weights significantly
lower for cigarette smokers than
never smokers, ex-smokers, and
pipe/cigar smokers

Limited population,
risk factor Rx program


           -


is  TABLE 2.-Cmtinued

Study           Design and sample

MJor results

Moderator variables

Limitations

Kopcsynski
(1972)

3.059 random selectees,
pulmonary disease study, Poland

Nonsmokers heavier than
smokers, except 26year-old men

Sex. age. smokii rate: no
smoking/weight relationship
influence

Smoking self-report;
weights not reported

Lincoln
(1970)

3,220 male household heads, aged
41-70, acroea United States

Smokers weighed 3-14 lb less
than nonsmokers

SES smoker/nonsmoker weight
difference increased as income
decreased
Smoking rate: heavy smokers
(221 cigarettes/day) weighed 4
lb more, moderate smokers
(11-20 cigarettes/day) 4 lb less
than all-smoker average

Restricted population;
men

Matsuya
(1982)

90 telephone employees, Japan

Examokera weighed 5.29 lb more
than nonsmokers; light smokers
2.87 lb leas, heavy smokers 0.44
lb less than ex-smokers

Small,
nonrepresentative
sample; data self-report

Nemery et al.
(1963)

210 steelworkers. aged 4555.
2 10 years' service, FJelgium

Smokers weighed 12.13 lb less
than never smokers, 14.33 lb less
than ex-smokers

Restricted population;
smoking self-report

Stamford et al.
(1984al

164 (56 smokers, 108 nonsmokers)
premenopausal women;
smokers: 220 cigarettes/day, 25
years, inhale

Smokers weighed 11.96 lb less,
had lower average Quetelet Index
than nonsmokers

Small sample size;
premenopausal women
only; data self-report

Stamford et al.
(1964b)

269 adult men, fitness center
SCWd"ed;
smokers: 2 20 cigarettes/day, 2 5

Smokers weighed 14.99 lb leas.
had 12% leas body fat than
nonsmokers

years, inhale

Select sample.
exercising men;
smoking self-report;

heavy smokers


TABLE t.-Continued

Study            D&i and sample

Major results

Moderator variables

Limitations

Stephens and
Pedemon (1933)

15.518 persons aged >lo;
questionnaire, anthropometry

Smokers weighed less than
nonsmokera; female smokers
weighed 1.32 lb more to 5.73 lb
less than female nonsmokers;
men weighed 3.09-7.7 lb less;
smokers averaged 3.445 lb less
than nonsmokers

White women self-
report. smoking self-
report; no statistical
significance tests

Sutherland et al.
(1960)

Random sample, 175 men and
women, rural town, New Zealand

Weight/height* index and
&infolds significantly higher in
nonsmoking than smoking
women; higher for nonsmoking
men, but not signiftcant

Wailer and Brooks
(1972)

2,169 health exhibit visitors

"Little weight difference" among
current smokers, nonsmokers,
and ex-smokers

Sax: male smokers not
significantly leaner than
nonsmokers; smoking women
lighter than nonsmoking women

Smoking self-report:
small sample size

Smoking self-report;
bathroom scale weight;
healthconscious
population; high %
cigar/pipe smokers; no
statistical evaluations

Zeiner-Henriksen
( 1976)

Approximately 15,0(x) randomly
s&cted Norwegians

Current smokers average and
relative weight lower than
nonsmokers or exsmokers

Smoking and weight
self-report,
questionnaire


is  TABLE S.-Longitudinal evaluations of smoking and body weight

Study

Design and sample

Major results

Moderator variables

Limitations

Blitzer et al.
(19771

`57,032 women, aged 20-59, self-
help weight loss groups

Bosse et al.
(198th

1,749 adult men, Normative
Aging Study, as=cssed over 5
years

Burse et al.
(19821

4 paid volunteers; llday
baseline, 2lday quit period, 26
day resumption period

Quitters gained 7.0-10.2 lb more
than continuing smokers

Average &year gains: never
smokers 1.81 lb, former smokers
1.87 lb; current smokers 2.00 lb;
ex-smokers who quit 6.34 lb

Smoking rate: weight          Smoking and weight
gain/previous smoking rate       self-reports; all women
proportional              trying to lose weight

Age: younger quitters gained
more

Adiposity: fatter quitters gained
more

Smoking self-reports;
all men; actual weights
not presented

Tar rate: higher pretest tar rate
smokers gained most
Anxiety: high related to higher
gain

3 of 4 gained weight; 1.98 lb
increase during cessation: 1.76 lb
loss on resumption

Very small sample,
paid volunteers; short-

term evaluation

Cambien et al.
(1981)

1,097 Paris civil servants, aged
25-35, screened, randomly
assigned, cardiovascular risk
factor reduction intervention or
control groups; a-year followup
evaluation

Treatment group quitters gained
4.85 lb, control group quitters
7.50 lb; nonsmokers and no
change smokers gained 1.54 lb in
treatment group, 2.2 lb in control

Smoking self-report;
risk factor reduction
program participants

Carney and
Goldberg
09841

13 women, 5 men, aged 28-67,
smoked 2 20 cigarettes/day. 2 5
years; 12 male controls; 15
smokers abstained 2 weeks

Quitters weight change range:
-3.09 to +9.0 lb

Smoking rate/duration: no
weight change relationship
Biological variables: weight gain
positively related to lipoprotein
lioase activitv in adiwse tissue

Smoking self-report;
controls weight
changes not reported;
short-term evaluation


TABLE 3.-Continued

Study             Design and sample

Major results

Moderator variables

Limitations

Coates and Li
(1983)

373 male asbestosexposed
smokers, aged 242; 87% white,
mean education 12.8 years; 12
months assessment after cessation
effort

Continuous quitters gained 5.15
lb; continuous smokerv gained
0.35 lb

Smoking self-report; all
male, nonrandom
sample

Cornstock and
Stone
(1972)

502 male telephone workers, aged
40-59. mostly white; 2
assessments 5 years apart

5.year followup average gains:
never smokers 2.43 lb, ex-
smokers 5.07 lb, continuing
smokers 2.42 lb; quitters 11.24 lb
and showed greatest skinfold
increases

Smoking rate: increasing quitter
weight gain with heavier prequit
smokmg

Smoking self-report;
men only

Dallosso and
James
(19841

16 (8 men, 8 women) antismoking
clinic participants; mean age,
men 47.1, women 35.4; assessed
before and 6 weeks after clinic

10 quitters gained 3.06 lb; 5
continuing smokers lost 0.99 B

Small sample sire;
smoking self-report;
limded followup

Emont and
Cummings
I1987J

125 stop-smoking clinic
participants; pretreatment and l-
month followup assessments

76% quitters and shppers ( 5 5
cigarettes/day) averaged 5.8 lb
gain

Nicotine gum. gain/gum use
reliable negative correlation for
heavy smokers: gain not related
to age. sex. marital status,
baseline body weight

Weight gain. smoking
self-report. confounded
by gum use; limited
followup: incomplete
data

Fagrrstrom
llY87)

28 nicotine gum users; abstinent
at 6 months

Infrequent gum users gained 6.83
lb, frequent users 1.98 lb

Nicotine gum: frequent users
gained less weight

Small sample sire;
measures unclear

Friedman snd
Siegclaub
(19801

Multiphasic health checkup
patients; smoked, then quit 12-18
months later (N=3,825) or
continued (N=9,3921

Quitters gained 2-3 lb more than
continuing smokers

Smoking rate: higher initial
smoking rate related to greater
weight gain after cessation

Smokmg self-report;
whites only data


!s  TABLE 3.-Continued


   Study            Design and sample            Major results              Moderator variables           Limitations

Cam et al.      6,979 women followed through
(1978b)        2 2 pregnancies

Higher prepregnancy weights for
habitual nonsmokers than
habitual smokers: whites 3.4 lb,
blacks 4.1 lb; lower habitual
smoker gains between
pregnancies for both races

Race: no weight/smoking
relationship influence

Smoking self-reports;
restricted population

Garvey et al.
(1974)

670 white male veterans. aging
study, asaeswd 4-l years after
initial assessment

Smoking/weight change
significantly related; recent
quitters (55 years) gained 4.19 lb
more than smokers, nonsmokers,
former smokers

Age: 4W quitter weight
increase greatest

Smoking self-report;
exact quit date
unknown

Glauser et al.
(1970)


Cordon et al.
(1975)

I male smokers, cessation
program; assessed preprogram. 1
month postprogram
4,798 Framingham study
participants: 1,498 male smokers,
492 male nonsmokers, 1,634
female nonsmokers, 1.174 female
smokers; examined short-term
changes after biennial exam 1.
long-term effects between
biennial exams 4, 10

At l-month followup, participants
gained 6.4 lb

At entry, male smokers weighed
8.0 lb less than nonsmokers;
short-term male quitters gained
3.8 lb, nonsmokers 0.5 lb,
continuing smokers 0.3 lb; new
smokers lost 9 lb; too few female
quitters to evaluate

Smoking self-report;
exact quit date
unknown

Smoking self-report;
change analysis, men
only

Gormican et al.
(1960)

301 pregnancy obstetrics records,
women, aged 17-35

Smoker, nonsmoker prepregnancy
weight similar; no last 2
trimester weight gain difference
(nonsmokers 24.6 lb, smokers 22.6
lb)

Clinic record data;
pregnancy weight gain
data only


TABLE 3.-bntinued

Study             De&n and sample

Major results

Moderator variables

Limitations

Grinstead
(1981)

45 subjects (38 women, 7 men),
average age 40; evaluated 6
months after cessation treatment;
saliva thiocyanate verification

During program, 63% subjects
averaged 2.86 lb increase, 34%
averaged 2.46 lb decrease; at
followup, 37% averaged 6.97 lb
gain, 43% averaged 3.27 lb lees

Questionnaire, phone
interview data

Grits et al.
(in press)

554 selfquitters (245 men. 309
women), mean age 41.4, 85%
Caucasian, 9% black, 4% Asian,
1% Asian-American, 1% Native
American; l-year followup

35% previous quitters gained. 3%
last; at 1 year, abstainers
averaged 6.1 lb gain; relapsers
gained 2.71 lb while abstinent,
lost 1.3 lb upon relapse;
continuous smokers gained 0.3 lb

Questionnaire, phone
interview data

Grassarth-Maticek
et al.
(1983)

1,353 subjects, Yugoslavian
village of 14,ooO, every 2d
household oldest member;
evaluated 1965-1966. 1969

Smoking reduction/weight
increase relationship (regression
coefficient -0.30)

Smoking self-report;
weights. weight
changes not reported

Gunn and
Shapiro
(1985)

89 cessation clinic participants;
all quit at initial evaluation: 3
month followup assessment

43 of 54 030%) quitters gained
Z-30 lb

Smoking, height,
weight self-report:
inadequate statistical
evaluation

Hall et al.
(1986)

255 smoker participants (122
men, 133 women), 2 smoking
treatment trials; 6, 1Zmonth
followups; biochemical verification

Abstainers gained more than
smokers at 1 year

Smoking rate: pretest smoking
levellpostcessation weight gain
positively related
Chronic dieting: chronic diet
subjects gained most

Multiple Rx (e.g.,
nicotine gum)
participant data
included

Hataukami et al.
(1964)

27 smokers hospitalized 7 days;
20 subjects smoked 3 days, then
quit 4 days; 7 control group
subjecte smoked throughout

Quitters gained 1.76 lb in 4 days

Small sample size;
inpatient environment


E   TABLE 3.-Continued


   Study             Design and sample             Major results               Moderator variables            Limitations

Haworth et al. t1990) 536 women (2.74 nonsmokers, 302
            smokers) interviewed last
          prenatal visit (18%) or within
           day after delivery (82%1

No smoker/nonsmoker pregnancy
weight gain difference

Hickey and       150 men 1124 smokers); Bmonth.
Mulcahy        2.year followups after myocardial
(1973)           infarction

Quitter, reducer, continuing
smoker differences not signilicant

Smoking self-report:
pregnancy weight gain
data only

Smoking self-report;
postmyocardial
infarction may
motivate heahhy
behavior

Iiolme et al.
(1985)

16,202 Oslo men, aged 4049,
screening program; 1,232
(elevated cholesterol or upper
quartile coronary risk score)
randomly assigned diet/smoking
intervention or control: &year
fOlLOWID

17% controls, 24% intervention
quit; l- to 2.yearquitter weight
increased more than controls,
then decreased to below prequit
level

Smoking self-report;
confounded by high
cardiovascular disease
risk health
intervention; weights
not reported

Howell
(1971)

Retrospective, 1,121 men, aged
40-54; 15 to 20year weight gain
examinations

Light smokers (~20
cigarettes/day) gained 1.9 lb less
than heavy smokers, 3.1 lb less
than ex-smokers, 3.6 lb less than
never smokers

Smoking rate: lower rate related
to less weight gain

Retrospective report

Hughes and
Hutchinson
(1963)

37 smokers and 19 ex-smokers
with pulmonary emphysema
followed 23 years

Smokers lost 0.32 lb/yr, ex-
smokers gained 1.17 lb/yr;
significant difference

Smoking self-report;
pulmonary emphysema
population


TABLE 3.-Continued

Study            Design and sample

Major results

Moderator variables

Limitations

Jenkins et al.
( 1973)

2,318 men (546 never smokers,
359 previous quitters, 547 light
smokers, 666 heavy smokers),
aged 39-49, 11 California
corporations in Western
Collaborative Group Study;
changes asses& since age 25;
1960-1969 studv

Weight loss more likely for light
and heavy smokers than never
smokers and quitters

Smoking self-report;
weights not presented

Kramer
( 1982)

175 subjects, commercial
cessation prcgram (41
nonparticipants or nonlocated, 59
quitters. 75 continuing smokers)
2 l-year followup

76% nonsmokers, 56% smokers
gained weight: these smokers
mean gain 1.7 lb, these
nonsmokers mean gain 3.0 lb

All date self-report;
high attrition. data
loss; presentation
incomplete

Lund-Larsen and
Tretli
(1992,

12,329 men and women, aged
2049. cardiovascular disease
project; 2 screenings 3 years
apart

Stpokers mean and relative
weight less than nonsmokers;
female quitters gained 5.95 lb,
male quitters 7.64 lb; smoking-
starter men lost 1.96 lb, women
5.5 lb; smokers and nonsmokers
little/no change

Sex: men. women weight
change/smoking cessation and
initiation similar

Self-report

Manley and
Roland
(1963)

39 male, 55 female smokers,
cessation program; randomly
assigned, 1 of 3 4-week
treatments or attention placebo
control; Bmonth followup; CC
verification

31% abstinent at followup:
abstainers averaged 10.93 lb gain,
relapsers 6.92 lb

Relapser definition
unclear


TABLE 3.-Continued

Study             Design and sample

M.?+ar zwults

Moderator variables

Limitations

Noppa and
Rengtsmn
(1980)

1,362 Swedish women, aged 38-W

Current smokers leaner than
nonsmokers; At 6 years, quitters
gained 7.72 lb; smoking-starters
lost 1.54 lb, nonchangers gained
3.09 lb

Smoking self-report

Pincherle
(19711

222 upper-class male quitters;
followup 2 1 year after first visit

28% gained weight; 22% last

Smoking self-report;
limited population;
incomplete report; no
weights presented

Powell and
McCann
(1981)

29 women, 22 men, 5day
cessation project; 2- and 6month
followup

At 2 months, 54% gained weight,
range 3-20 lb. mean 8.96 lb; all
subjects mean 4.69 lb

Smoking self-report; no
separate abstainer,
smoker data; small
sample sire

Puddey et al.
(1985)

66 cessation program volunteers,
pair-matched by age, sex, body
mass index; randomly assigned
experimental, control groups; 2-
week baseline, &weak treatment,
6week followup; thiocyanate, Co
verification

14 quitters gained 3.97 lb;
controls 0.44 lb

Small sample sire

Rabkin
(1964)

40 male, 67 female smokers,
assigned to 3 cessation groups;
followup 3 weeks w&completion;

67.3% gained weight, average
1.76 lb; skinfold increase 6.6 mm

bicchet&l verification

No age. age at smoking start,
rate. relative weight, anxiety
correlation to male or female
weight change

Small sample size;
weight self-report


TABLE 3.-Continued


Study            Design and sample             Major results               Moderator variables            Limitations



Rantakallio and    12.068 pregnant women. n.        No smoking/nonsmoking                           Pregnant women only;
Hartikainen-Sorrin   Finland, 1966, 15% smokers       pregnancy weight gain difference                        smoking self-report;
(1981)         (smoked after 2 months                                               pregnancy weight gain
         pregnant); nonsmoking controls                                            data only
          matched for age. parity, place of
           residence, marital status

Rush         162 low-income urban pregnant      Mean pregnancy weight gain       Smoking rate: higher rate        Pregnant women only;
(1974)         women, no known medical         lower for smokers (0.73 lb/wk)      related to lower pregnancy       smoking self-report;
          problems, < 140 lb preconception     than nonsmokers (0.90 lb/wk)       weight gain              pregnancy weight gain
          weight; had borne low                                                 data only
          birthweight infant; randomized
            controlled nutritional
          supplementation trial
Schoenenberger    4,421 male MRFIT volunteers,       With MRFIT intervention,                            Smoking self-report;
(1982)        aged 35-57, good health but       significant body weight decrease                        confounded by risk
          upper lO-15% coronary risk       in smokers (mean 4.6 lb).                                  factor reduction
          factor score; randomly assigned      nonsmokers (mean 5.6 lb),                           program participation;
          to intervention or control groups;     reducers (mean 3.75 lb); quitters                        restricted population
          followup 3 annual visits        average weight change minimal
                                (mean 0.55 lb)

Seltzer         794 adult white male veterans,      At admission, ex-smokem 5.9 lb                           White veterans;
(1974)        average age 45, Normative Aging     heavier than nonsmokers, 8.1 lb                         smoking self-report
          Study; screened for "high" health     heavier than currant smokers; at
         level, geographic stability; 214      5 years, quitters gained 8.0 lb,
           screened at 5 years           continuing smokers 3.5 lb


TABLE 3.-Continued

Study            Design and sample

Major results

Moderator variables

Limitations

Stamford et al.
(1966)

13 sedentary women, 48day
su-ful quitters; l-year
follow"p

At 48 days, weight increased 4.85
lb; at 1 year, quitters increased
18.07 lb; 3 relapsers reduced
weight to baseline levels; per
hydrostatic weighing, gain was
96% fat

Small female sample;
smoking self-report

Tuomilehto et al.
(198.5)

10,940 cardiovascular disease
prevention program participants.
aged 25-59, random sample. e.
Finland; selectees with high blood
pressure or hypertensive medicine
asses& 5 years apart; smoking
data from 2,264

Quitters body nmss increased 2.31
lb/m*; starting smokers decreased
1.46 lb/m'

Smoking self-report;
hypertensives

Vandenbroucke
et al.
(1984)

3,091 Netherlands civil servants,
spouses (1,583 men. 1,508
women), aged 40-65, general
health exam: 25year followup

76.6% lean, 65.1% obese men
smoked; 22.1% lean, 11.3% obese
women smoked

Smoking self-report;
restricted population


Gottenborg 1981; Khosla and Lowe 1971) documented increasing
weight differences between smokers and nonsmokers with advancing
age. Typically, aging smokers failed to gain as much weight as aging
nonsmokers.

Three evaluations systematically compared males with females
(Bjelke 1971; Kopczynski 1972; Sutherland et al. 1980). Two of the
three (Bjelke 1971; Sutherland et al. 1980) reported the differences in
body weight between smokers and nonsmokers to be greater in
females than in males.

Longitudinal Evaluations of Smoking and Body Weight

Table 3 presents the results of 43 longitudinal evaluations of the
effects of smoking on body weight. Consistent with the cross-section-
al evaluations, the overwhelming majority (86 percent, 37 of 43)
present evidence that smokers who quit smoking gain weight, that
people who quit smoking gain more weight than nonsmokers, and
that people who initiate smoking lose weight relative to nonsmokers.
Of the six studies that did not find these relationships, three limited
their examination to smoking and weight changes in pregnant
women (Gormican, Valentine, Satter 1980; Haworth et al. 1980;
Rantakallio and Hartikainen-Sorri 1981). two relied on participants
making broad cardiovascular risk factor reduction efforts in subjects
at high risk for cardiovascular disease (Hickey and Mulcahy 1973;
Holme et al. 19851, and the remaining study supplied incomplete
reports of the data (Kramer 1982). Of those studies on the effects of
smoking cessation on weight, the length of followup ranged from 4
days to 7 years. According to these investigations, those who quit
smoking gained an average of 6.16 lb (range: 1.76 to 18.07) during the
year after cessation.

Daily cigarette consumption was the only moderator variable that
received sufficient attention in this group of studies reaching specific
conclusions. Seven of nine studies (78 percent) (Blitzer, Rimm, Giefer
1977; Bosse, Garvey, Costa 1980; Comstock and Stone 1972; Fried-
man and Siegelaub 1980; Hall, Ginsberg, Jones 1986; Howell 1971;
Rush 1974) reported a positive relationship between cigarette
consumption and weight change; that is, as pretest cigarette
consumption increased, postcessation weight gains also increased.
Two studies (Carney and Goldberg 1984; Rabkin 1984) did not find a
relationship between cigarette consumption and postcessation
weight gain.

In summary, there is substantial evidence of an inverse relation-
ship between cigarette smoking and body weight. Of 71 studies
reported since 1970, 62 (87 percent) collectively indicate that
smokers weigh less than nonsmokers and that people who quit
smoking gain weight. Older smokers, females, and those smoking
approximately one pack of cigarettes/day may experience the

431


largest weight control effects of cigarette smoking. Smokers who
smoke heavily tend to gain the most weight following smoking
cessation. These generalizations are consistent with reviews based on
other studies reported since 1880 (Grunberg 1986a). Not all smokers
who quit smoking gain weight. Further, for ex-smokers who do gain
weight, the amount of weight infrequently poses a serious health
risk.

The Role of Nicotine

Animal studies indicate that nicotine administration results in
weight loss or decreased weight gains and that cessation of nicotine
results in body weight gains greater than those of controls (Bowen,
Eury, Grunberg 1986; Grunberg 1982, 1985, 198613; Grunberg,
Bowen, Morse 1984; Grunberg, Bowen, Winders 1986; Grunberg,
Winders, Popp 1987; McNair and Bryson 1983; Morgan and Ellison
1987; Schechter and Cook 1976; Wager-Srdar et al. 1984; Wellman et
al. 1986). Most of these studies report inverse dose-response relation-
ships between nicotine and body weight.

Becent research on nicotine polacrilex gum with humans corrobo-
rates the role of nicotine in body weight effects. Fagerstriim (1987)
reported that subjects who quit smoking were much less likely to
gain weight when they consistently used nicotine polacrilex gum.
Abstinent subjects who regularly used the gum gained less than 2 lb
at a 6month followup. In contrast, the infrequent gum users gained
almost 7 lb (p< 0.05). Emont and Cummings (1987) reported a
significant negative relationship (r=-O.37) between the number of
pieces of nicotine polacrilex gum chewed per day and weight gain for
heavy smokers ( > 26 cigarettes/day). No such relationship between
gum use and weight gain was observed for lighter smokers (< 26
cigarettes/day).

Mechanisms Underlying The Relationship Between
Smoking and Rody Weight

The inverse relationship between smoking and body weight may
result from changes in energy intake, changes in energy expendi-
ture, or both. Energy intake involves dietary intake. Energy
expenditure is affected by behavioral factors (physical activity1 and
biological factors (e.g., metabolism). These potential mechanisms are
examined below.

Dietary Intake

Several prospective investigations have evaluated dietary intake
changes following smoking cessation in humans. Hatsukami and
coworkers (1984) hospitalized 27 smokers for a 7day period. After a
3day baseline, 20 of the subjects were deprived of smoking for 4 days

432


while the remaining 7 served as a control group. During this I-day
period of abstinence, caloric intake increased significantly (from
1,397 to 1,651 kcal), which corresponded with a significant 1.76lb
increase in weight. In the most comprehensive study to date,
Stamford and coworkers (1986) evaluated changes in dietary intake,
physical activity, and resting metabolic rate in 13 sedentary females
who quit smoking for a 48day period. Following smoking cessation,
mean daily caloric consumption increased by 227 kcal, which
accounted for 69 percent of the variance in postcessation weight gain
(4.85 lb). Robinson and York (1986) followed 11 smokers who quit for
7 days. Mean dietary intake significantly increased, but changes in
resting metabolic rate were not observed. Dallosso and James (1984)
followed 10 subjects for 6 weeks after they participated in a stop
smoking clinic. There was a 4percent drop in resting metabolic rate
in smokers who quit, a drop which was reliable when the data were
expressed per kilogram of body weight. The average dietary intake
increased by 6.5 percent, but this difference did not reach statistical
significance.

Preliminary results of a recent investigation indicate gender
differences in the effects of short-term smoking cessation on body
weight and food intake (Klesges, Meyers et al. 1987). Female smokers
who quit for 1 week increased their body weight and dietary intake
significantly more than male smokers who quit. This sex difference
is consistent with animal studies (Grunberg, Bowen, Winders 1986;
Grunberg, Winders, Popp 1987). Given females' marked concerns
regarding postcessation weight gain (Klesges and Klesges, in press),
future studies will need to investigate possible gender differences in
response to smoking cessation.

Several studies indicate that smokers may differ from nonsmokers
in their intake of sweet-tasting simple carbohydrates (sugar) in
particular. In a human laboratory study, Grunberg (1982) observed
that smokers who were allowed to smoke ate less sweet food than
smokers who were not allowed to smoke or nonsmokers. Smokers not
allowed to smoke also reported the greatest preference for sweet
foods. There were no differences among the three subject groups in
consumption of other types of foods. Rodin (1987) conducted a
prospective study in which food intake after smoking cessation was
carefully evaluated. Smokers who gained weight after quitting
smoking increased their sugar consumption in particular. Further,
smokers increase consumption of sweet snack foods when they are
deprived of cigarette smoking (Duffy and Hall, in press; Perlick
1977). On the other hand, two early investigations (Bennett, Doll,
Howell 1970; Richardson 1972) found higher sugar consumption in
smokers relative to nonsmokers. However, Richardson (1972) found
that this difference was because of low-sugar intake in ex-smokers,
while Bennett, Doll, and Howell (1970) argued that the differences

433


were largely due to increased added sugar intake because of hot
beverage consumption. These two studies, which are inconsistent
with the more recent studies, did not carefully measure all food
intake and did not assess intentional changes in food intake to
control body weight.

Several animal experiments have documented that food intake
decreases during nicotine administration and increases after admin-
istration has ceased and that these changes in food intake corre-
spond with changes in body weight (Bowen, Eury, Grunberg 1986;
Grunberg 1982; Grunberg, Bowen, Winders 1986; Levin et al. 1987;
McNair and Bryson 1983; Wager-Srdar et al. 1984). Consumption of
sweet foods by male rats is particulary affected by nicotine (Grun-
berg 1982; Grunberg et al. 1985). However, nicotine also reduces
bland food intake in female rats and has a greater effect on body
weight of female rats than of male rats (Grunberg, Winders, Popp
1987; Grunberg, Bowen, Winders 1986; Levin et al. 1987).
Several investigations have reported that changes in body weight
in animals also occur without observing decreases in food intake as
the result of nicotine administration (Grunberg, Bowen, Morse 1984;
Schechter and Cook 1976; Wellman et al. 1986). In one investigation,
chronic exposure to cigarette smoke reduced body weight and food
intake in rata; however, hamsters exposed to cigarette smoke
decreased body weight without reducing food intake (Wager-&&r et
al. 1984). Several methodological factors complicate these results,
including the use of different strains of animals, different routes of
administration and dosages of nicotine, and whether acute versus
chronic effects of nicotine were reported. However, these results
indicate that more than the mechanism of food intake was involved
in producing nicotine- and smoking-related weight changes.

Data from short-term human studies and several animal experi-
ments indicate that dietary intake is involved with smoking-related
energy imbalance. Based on self-reported cross-sectional surveys, it
has been reported that smokers' dietary intake is the same as
(Albanes et al. 1987; Fehily, Phillips, Yarnell 1984; Fisher and
Gordon 1985; Matsuya 1982) or significantly higher than (Picone et
al. 1982; Stamford et al. 1984a,b) that of nonsmokers while the
smokers simultaneously maintained a lower body weight. Assuming
that smokers are not consistently biased in their reports of dietary
intake, it appears that either differences in physical activity or
metabolic rate are maintaining the body weight differences between
smokers and nonsmokers.

Physical Activity

The data available from cross-sectional investigations, short-term
prospective studies, and animal investigations seem to indicate that
changes in physical activity do not play a role in either differences in

434


body weight between smokers and nonsmokers or the weight gain
associated with smoking cessation. Some cross-sectional investiga-
tions have found that smokers have lower levels of physical activity
compared with nonsmokers (Karmas 1981). Others have not found
differences in physical activity and physical fitness between smokers
and nonsmokers (Gyntelberg and Meyer 1974; Stamford et al. 1984b;
Stephens and Pederson 1983). A recent review (Blair, Jacobs, Powell
1985) that addressed the relationships among exercise, physical
activity, and smoking concluded that smoking and physical activity
are negatively associated; however, the relationship was extremely
weak and variable.

Animal studies on the relationship between nicotine and physical
activity have generally found that physical activity plays a small
role or fails to correspond to decreases in weight during nicotine
administration (Bowen, Eury, Grunberg 1986; Cronan, Conrad,
Bryson 1985; Grunberg and Bowen 1985b). One study found that
decreases in physical activity after cessation of nicotine appeared to
contribute to postdrug body weight increases (Grunberg and Bowen
1985b), but this effect was quite small and occurred only in males.
A few prospective human investigations have evaluated physical
activity changes following smoking cessation (Hatsukami et al. 1984;
Hofstetter et al. 1986; Klesges, Brown et al. 1987; Rodin 1987;
Stamford et al. 1986). These investigations found no changes in
physical activity as a result of smoking cessation.

Metabolic Rate

Metabolic rate is an important consideration in energy imbalances
associated with smoking cessation because approximately 75 percent
of total energy expenditure is in the form of metabolism (Bernstein
et al. 1983; Ravussin et al. 1982). Metabolism increases as the result
of acute nicotine administration and immediate effects of smoking
(Ghanem 1973; Ilebekk, Miller, Mjos 1975; Robinson and York 1986;
Schievelbein et al. 1978; Wennmalm 1982). The major question,
however, is whether these effects persist long enough to have a direct
impact on body weight. Given that (1) smokers do not have higher
levels of physical activity compared with nonsmokers (Blair, Jacobs,
Powell 1985). (2) some studies report smokers' dietary intakes are the
same as or higher than those of nonsmokers (Picone et al. 1982;
Stamford et al. 1984a,b), and (3) smokers maintain lower body
weights than nonsmokers, it is reasonable to postulate that changes
in metabolism contribute to the relationship between smoking and
body weight. Additionally, there are several reports in the literature
on animals that have documented nicotine-induced reductions in
body weight without a concomitant reduction in food intake (Grun-
berg, Bowen, Morse 1984; Schechter and Cook 1976; Wellman et al.
1986).

435


Direct evidence supporting a chronic metabolic mechanism that
modulates the smoking/body weight relationship is beginning to
emerge. Metabolic rate was chronically measured in a study of rat
and hamster exposure to cigarette smoke (Wager-Srdar et al. 1984).
Higher resting metabolic rates were observed on only one of the test
days compared with the pretest in the rat investigation, while no
significant differences were observed in the hamster study. Another
recent investigation (Wellman et. al. 1986) evaluated brown adipose
tissue (BAT) thermogenesis at different levels of nicotine and
caffeine injections. No differences in BAT thermogenesis were
observed in response to either nicotine or caffeine. The group that
received a combination of caffeine and nicotine showed a 63 percent
increase in BAT thermogenesis.

The few studies that have evaluated metabolic rate changes in
response to smoking cessation in humans have produced inconclu-
sive results. Three investigations found metabolic changes after
cessation in human smokers. An early report (Glauser et al. 1970)
found decreases in oxygen consumption for seven male subjects who
quit smoking for 1 month (neither food intake nor physical activity
was monitored). A more recent investigation found a 4-percent drop
in metabolic rate (reliable when data were expressed per kilogram of
body weight) and no significant increase in dietary intake for 10
subjects who quit smoking for 6 weeks (Dallosso and James 1984). In
the only study that used a respiration chamber, Hofstetter and
others (1986) reported that total energy expenditure was 10 percent
higher during a 24-hr period of smoking versus a 24-hr period of
abstinence in eight smokers. No changes were observed in physical
activity or mean basal (sleeping) metabolic rate (dietary intake was
held constant). However, this difference in energy expenditure
disappeared after 24 hr.
Three investigations did not find a change in metabolic rate as the
result of smoking cessation. Burse and associates (1982, 1975) did not
observe changes in resting metabolism in a sample of four smokers
who quit for 3 weeks. This investigation did find reliable increases in
desire for food, however. In another study, 11 smokers were studied
after a `I-day period of smoking abstinence (Robinson and York 1986).
Total energy expenditure following a meal did not change during the
cessation period. Stamford and colleagues (1986) failed to fmd
changes in oxygen consumption in 13 subjects who quit smoking for
48 days. This investigation did find marked dietary intake changes
that accounted for 69 percent of the variance of postcessation weight
gain.

There are several possible explanations for the inconsistency
observed in the literature on metabolic rate. Different investigators
have used different criteria (e.g., resting oxygen consumption, BAT
thermogenesis) for operationalizing metabolism. It is possible that

436


previous dieting history (Brownell et al. 1986) and the use of nicotine
polacrilex gum (Fagerstrom 1987) may directly impact the metabolic
response to smoking cessation. It is not clear what the metabolic
response to nicotine with added agents is likely to be. For example,
one study found that while neither nicotine nor caffeine alone
produced a change in BAT thermogenesis, the two combined
increased thermogenesis by 63 percent (Wellman et al. 1986). This
finding is particularly interesting given that smokers may be more
likely to drink caffeinated beverages than nonsmokers (Blair et al.
1980). Finally, the available literature on human studies used very
small subject groups, making it impossible to detect subtle but
potentially meaningful changes in resting metabolic rate. The small
sample sizes do not allow for an evaluation of variables that may
potentially moderate the metabolic response to smoking cessation.

Summary of Mechanisms Literature

Changes in dietary intake appear to be involved in weight gains
after cessation of smoking or cessation of nicotine administration.
Physical activity plays little or no role in the relationship between
smoking and body weight. The data on metabolic contributions to
postcessation weight gain are suggestive, but further research is
needed. Unfortunately, much of the relevant human research
literature is characterized by small sample sizes, short followup
evaluations, and inadequate evaluations of energy balance following
smoking cessation. To date, only one investigation has comprehen-
sively evaluated (i.e., simultaneous assessment of dietary intake,
physical activity, and metabolic rate) energy balance changes as the
result of smoking cessation. This was a sample of 13 sedentary
females followed for 48 days (Stamford et al. 1986). Comprehensive,
prospective evaluations of energy balance changes in response to
smoking cessation are needed. Additionally, no study has evaluated
possible long-term changes in dietary intake, physical activity, and
metabolic rate as a result of smoking cessation. The longest followup
period reported in the literature to date is 2 months (Dallosso and
James 1984). Finally, evaluation of potential moderator variables of
dietary intake, physical activity, and metabolic rate as the result of
cessation is needed. Gender (Grunberg, Winders, Popp 1987; Klesges,
Meyers et al. 1987), previous dieting history (Brownell et al. 1986;
Hall, Ginsberg, Jones 1986). pretest levels of lipoprotein lipase
(Carney and Goldberg 1984), and the use of nicotine polacrilex gum
(Fagerstrom 1987) appear to be important variables influencing
weight gain and need further investigation.


Does the Relationship Between Smoking and Weight
Promote Either the Initiation or Maintenance of Smoking
Behavior?

Some research attention has been given to body weight as a
potential moderator of smoking initiation, maintenance, and cessa-
tion. Unfortunately, many investigations do not report weight-
related issues (Borkon, Baird, Siff 1983; Eiser et al. 1985; Pederson
and Lefcoe 1976; Perri, Richards, Schultheis 1977). The investiga-
tions that have evaluated these issues consistently report relation-
ships between body weight and smoking initiation (Charlton 1984a)
and maintenance (Klesges and Klesges, in press).

A survey of 16,000 school children (Charlton 1984a) in England
found that the heaviest regular smokers were the most likely to
agree that smoking controls weight (42.2 percent) compared with
those students who never smoked (16.6 percent). Agreement in-
creased with increased levels of smoking. More girls than boys
agreed with this statement, and girls were also more likely to be
regular smokers. Charlton (1984b) also reported that among the
perceived effects of smoking, smokers viewed "calming the nerves"
as the most popular reason (72 percent) followed by "smoking keeps
your weight down" (39 percent).

Other investigations are consistent with the Charlton (1984a,b)
report. In a recent study of 1,000 adolescents in Canada (Feldman,
Hodgson, Corber 1985), significantly more girls than boys were
concerned about becoming overweight (36 vs. 14 percent, p<O.OOl).
In girls 18 years or older, 52.6 percent of smokers reported worrying
about their weight, whereas only 31 percent of nonsmokers reported
weight-related concerns (p < 0.05). In a study of smoking intentions
among 406 U.S. high school males, Tucker (1983) reported that
overweight boys scored much higher on smoking intent than either
normal weight or underweight boys (p<O.O05). Another survey
evaluated gender differences in a sample of 221 college cigarette-
smoking intenders and nonintenders (Page 1983). Results indicated
that females were much more likely to intend to smoke than males.
Females were also more likely to believe that smoking maintains
body weight, and smoking intenders were also more likely to believe
that smoking controls weight. Finally, in a retrospective survey of
more than 1,090 young adults (Klesges and Klesges, in press),
overweight females reported that they were much more likely (20
percent) to start smoking for weight-related reasons compared with
normal-weight females (2 percent). No differences between over-
weight versus normal-weight males (8 vs. 6 percent) were observed.

Several surveys on smoking maintenance have shown that individ-
uals report that weight control is a powerful motivator to continue to
smoke. Physicians who smoked were much more likely than those
who had quit (46 vs. 22 percent) to believe that smoking cessation

438


increases appetite and weight (Fletcher and Doll 1969). Nurses who
failed to quit smoking listed (in order) loss of determination, stress,
and weight gain as the major reasons for failure (Knobf and Morra
1983). Beliefs regarding the weight-control effects of smoking and
quitting differentiate smokers and nonsmokers (Hill and Gray 1984;
Loken 1982; Shor et al. 1981). Females are particularly worried
about postcessation weight gains (Klesges and Klesges, in press;
Sorensen and Pechacek 1987). They are more likely to endorse
smoking as an active weight-loss strategy (39 vs. 25 percent) and are
more likely to report relapse for weight-related reasons (20 VS. 7
percent) (Klesges and Klesges, in press).

The research cited above is based on self-reports of the weight-
control effects of smoking and, as such, could be viewed as an excuse
for smoking. Two recent worksite-based investigations evaluated
whether pretest concerns regarding smoking and weight-related
issues prospectively predicted cessation. Maheu (1985) evaluated 49
subjects who either received a competition-based (n=32) or a no-
competition condition (n = 17). In the competition-based condition,
participants were told that they would be rewarded if those at their
worksite lost more weight than those at a neighboring worksite. At a
3-month followup, 78 percent of the subjects in the competition and
76 percent of the subjects in the no-competition condition were
reportedly abstinent. Regression analysis at followup indicated that
the best pretest predictors of smoking cessation (in order) were
negative responses to the questions: (1) "Do you think smoking helps
control your weight?"; (2) "Did one of your parents smoke when you
were young?"; and (3) "If you have tried to quit before, did you suffer
any withdrawal symptoms ?" Klesges, Brown, and associates (1987)
found that the best predictors of cessation at posttest were pretest
cotinine levels and anticipated weight gain as the result of smoking
cessation. The best predictors of cessation at followup were the
number of coworkers who smoked followed by anticipated cessation-
related weight gain.

A recent community survey evaluated predictors of current and
former smoking status in a sample of 611 nonsmokers, ex-smokers,
smokers who had tried to quit smoking, and smokers who had not
attempted cessation (Klesges, Somes et al. 19871. The best predictors
of smokers who had never attempted cessation versus those with a
history of cessation efforts were a greater concern related to weight
control, followed by knowledge of the health consequences of
smoking. Smokers who had not attempted cessation were significant-
ly more likely to cite weight-control issues compared with smokers
who had made active attempts at smoking cessation. Collectively,
these investigations indicate that weight-related concerns may not
only predict successful smoking cessation, but also attempted
smoking cessation.

439


Weight gain following smoking cessation as a predictor of smoking
relapse has been evaluated in two recent investigations. Hall,
Ginsberg, and Jones (1986) found a relationship between smoking
status at a l-year followup and weight gain at 6 months; greater
weight gain during the first 6 months predicted continued absti-
nence. This finding was contrary to expectations. In another
investigation, Gritz, Carr, and Marcus (in press) found that continu-
ous abstainers had gained an average of 6.1 lb, relapsers had gained
2.7 lb and subsequently lost half the gain (1.3 lb), and never quitters
had gained only 0.3 lb. While it was expected that postcessation
weight gain would be predictive of relapse, one would expect that
those who have been abstinent from cigarettes would have gained
more weight than those whc either failed to quit or those who
relapsed, because these latter groups have regained the weight
reducing effects of smoking. Additional research will need to
evaluate the impact of weight gain on relapsers at the point of
relapse compared with the impact on abstainers at a comparable
point in time. Further, it is clear that actual weight may have little
relationship with subjects' perceptions of their weight status. For
example, overweight males consistently view themselves as normal
weight, while underweight and normal-weight females consistently
view themselves as overweight (Klesges 1983). Very small weight
gains in some subjects (e.g., normal-weight females) may be much
more predictive of relapse than very large weight fluctuations in
others (e.g., overweight males) (Klesges 1983). Future research
should evaluate potential variables (e.g., gender, obesity) that may
moderate the relationship between weight gain and smoking relapse.

In summary, weight-related issues may be important in the
maintenance and cessation of smoking. Weight-reducing effects of
smoking may encourage smoking initiation by some people, but the
data on this point are currently unconvincing. Future research
should focus on who (e.g., males versus females, those with a history
of chronic dieting) is most at risk to smoke because of weight-related
concerns. In particular, prospective studies on weight-related issues
as they predict smoking initiation, cessation, and relapse are needed.

Implications for Tobacco Use

Cigarette smokers weigh less than comparably aged nonsmokers,
and many smokers who quit smoking gain weight. This inverse
relationship between smoking and body weight is well established,
and the role of food intake and energy expenditure as mechanisms
for this relationship is currently receiving research attention. The
post-smoking weight gains are frequently undesired by the ex-smok-
er. People are quite aware of the relationship between smoking and
body weight, and this relationship may encourage some people to
initiate smoking and to keep smoking. However, other people may

440


modify food intake and avoid weight gains after cessation of
smoking.

Summary and Conclusions

1. After smoking cigarettes or receiving nicotine, smokers per-
form better on some cognitive tasks (including sustained
attention and selective attention) than they do when deprived
of cigarettes or nicotine. However, smoking and nicotine do not
improve general learning.

2. Stress increases cigarette consumption among smokers. Fur-
ther, stress has been identified as a risk factor for initiation of
smoking in adolescence.

3. In general, cigarette smokers weigh less (approximately 7 lb
less on average) than nonsmokers. Many smokers who quit
smoking gain weight.

4. Food intake and probably metabolic factors are involved in the
inverse relationship between smoking and body weight. There
is evidence that nicotine plays an important role in the
relationship between smoking and body weight.

441


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CHAPTER VII

TREATMENT OF TOBACCO
    DEPENDENCE

459


CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465

Treatment ............................................................ 470
  Nicotine Replacement Strategies ....................... .470
    Forms of Replacement and Rationale.. ........ .471
       Nicotine Polacrilex Gum ........................ .471
        Withdrawal Symptom Relief ................ .472
      Cravings-Urges-Desires ......................... 475
       Efficacy Trials .................................... 475
        Dose and Patient Relationship ............. .478
      Nasal Nicotine Solution .......................... 479
       Nicotine Transdermal Patch ................... .479
       Nicotine Aerosols ................................... 480
    Comparisons of Preparations ...................... .480
    Dependence on Nicotine Replacement ........... 481
  Other Pharmacologic Approaches ...................... .481
    Nonspecific Pharmacotherapy-Symptomatic
       Treatment ............................................. 481
      Treatment of Discomfort Associated With
       Tobacco Withdrawal ............................ 482
      Treatment of Abstinence-Associated Mood
      Changes ........................................... .483
     Nicotine Blockade Therapy ........................ .484
      Deterrent Therapy ................................... .485
     Conclusions ............................................. .486
  Behavioral Treatment Strategies ....................... .487
     Aversion Procedures ................................. .488
       Satiation ............................................. .488
     Rapid Smoking ...................................... 491
                                  .492
       Reduced-Aversion Techniques ..................
     Relaxation Training ................................. .493
    Contingency Contracting ............................ 494
     Social Support ......................................... .495
    Coping Skills Training .............................. .496
     Stimulus Control ...................................... .497
     Nicotine Fading ........................................ 497
     Controlled Smoking ................................... 499
    Multicomponent Programs .......................... 500
  Other Treatment Strategies ............................... 504

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  Hypnosis ................................................ .504
  Acupuncture ........................................... .504
Treatment of Special Smoker Populations ........... .505
  Applying Smoking Interventions to Women .. .505
   Sex Differences in Cessation and Relapse
      Rates ............................................... .505
      Motivation to Quit ............................. .506
     Education ......................................... .506
     Social Values and Beliefs .................... .507
   Achieving Abstinence ............................ .507
     Weight Gain ..................................... .507
     Stress Management ............................ .508
      Social Support ................................... .508
  Smoking Cessation Initiatives for Black
    Americans ............................................ .508
   So&demographic Factors ....................... .509
    Restricted Health Care Access.. .............. .509
   Social Norms and Advertising Influences .. .509
   Determinants of Quitting Motivation and
    Success Among Black Smokers.. ........... .510
   Smoking and Quitting Patterns Among
      Black Americans ............................... .510
   Quit-Smoking Treatments ....................... .511
    Quitting Methods ............................... .511
     Sources/Treatment Agents ................... .511
    Messages/Methods .............................. .511
    Channels/Delivery Modes .................... .511
  Interventions for Smoking Cessation Among
   Hispanics ............................................. .512
    Prevalence ............................................ 512
   Smoking Antecedents ............................ .512
   Smoking Interventions ........................... ,513
Methodological Issues in Treatment Study Design
and Evaluation.............................................513
Conclusions .................................................... .516

Relapse .............................................................. .517
  Defining Relapse ............................................. 518
  Conceptual Frameworks .................................... 518
  Predisposing Factors ....................................... .520
    Demographics .......................................... .520
    Smoking and Quitting History ................... .521
     Smoking History .................................. .521
     Smoking Typologies ............................... .521
     Quitting History ................................... .522
     Withdrawal and Dependence ....................... 522

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  Cognitive Factors ..................................... .523
    Concern About Weight Gain.. ................. .523
   Self-Efficacy ......................................... .524
    Outcome Attributions ............................ .525
   Social Factors ........................................... 526
   Smoking Cues ....................................... 526
    Social Support ....................................... 526
    Global Support ..................................... .527
   Smoking-Specific Support ....................... .527
   Stress .................................................... .528
Precipitating Factors ....................................... .529
  High-Risk Situations .................................. 529
  Coping Strategies ...................................... 530
   Abstinence Violation Effect ....................... .532

Summary and Conclusions ..................................... .532


References .......................................................... .534

463


Introduction

The previous chapters have established that nicotine is a drug of
dependence. Chapter II provided a detailed description of the
pharmacokinetics and pharmacodynamics of nicotine from various
forms of tobacco. Chapter III addressed sites and mechanisms of
nicotine action. Chapter IV documented addictive properties of
tobacco including those related to its use as a vehicle for nicotine
delivery and physiological dependence produced by nicotine adminis-
tration. Chapter V demonstrated the commonalities between tobacco
use and use of other drugs such as heroin and cocaine. Chapter VI
discussed effects of nicotine that may promote to tobacco use.

Unfortunately, much of this work has seen limited clinical
application in the treatment of the tobacco user. Most current
treatment approaches are primarily psychological. Relatively few
studies have addressed pharmacologic determinants of tobacco use
(Pomerleau et al.). An increased understanding of the addictive
properties of nicotine should lead to improved treatment approaches.
Interventions for tobacco users who seek assistance should consider
the addictive properties of tobacco and the ways that these can be
overcome. They should also be sensitiv  to other effects of nicotine
that may promote tobacco use. The fail & e to address these types of
issues may be an important cause of the less%han optimal results
attained by existing treatment approaches.

It is evident that smoking is maintained by both pharmacologic
and psychological determinants. The relative contributions of these
factors are virtually impossible to separate and are likely to vary
dramatically not only among individual smokers, but perhaps also
within individuals at different times and stages of their smoking
histories. Pharmacologic and psychological factors become closely
linked in a conditioning process in which smoking is associated with
multiple cues. A typical smoker who has averaged 20 cigarettes/day
over a 15-year period is likely to have taken more than 1 million
puffs during the course of his or her smoking history. The highly
dependent smoker who presents for treatment tends to have an even
longer and more extensive history of nicotine self-administration
than does the average smoker. The sheer magnitude of this
overlearning appears unmatched in any other form of drug abuse.

Cues associated with smoking (an ashtray, the sight of another
person smoking) can elicit strong cravings not only in current and
newly abstinent smokers, but also in individuals who have achieved
longer term abstinence (Abrams 1986). Some cues may extinguish
relatively quickly upon cessation. Others may be more problematic,
especially in long-term dependent smokers (Abrams et al., in press).
Smokers who report smoking more when they are angry, frustrated,
or unhappy may be especially vulnerable to a crisis even when the
crisis occurs after an extended period of abstinence (Pomerleau,

465


Adkins, Pertschuk 1978). Cues associated with smoking that are
encountered only infrequently might continue to elicit conditioned
cravings over a longer time period (Abrams et al., in press).

Individual differences should also be considered. Conditioning
histories vary among smokers, although there are also likely to be
important commonalities. Some smokers have relied more heavily
upon nicotine in regulating mood, especially negative affect (Chapter
VI). Others have used cigarettes as a means of sustaining attention
to monotonous tasks. Still others have used cigarettes more frequent-
ly as an aid to relaxation (Ikard, Green, Horn 1969; Chapter VI). Few
experimental studies have related individual differences to reasons
for smoking (Ikard and Tompkins 1973; Leventhal and Avis 1976).

Physiological reactions (e.g., elevated heart rate) to smoking cues
have been documented to persist for extended intervals (Abrams et
al., in press). The interaction of physiological, social, conditioning,
and cognitive factors may be critical. The combination of tobacco
pharmacology and users' conditioning histories can help to explain
cravings even after long periods of abstinence. Expectations concern-
ing the consequences of tobacco use also appear to be extremely
important. Thus, among individuals who are currently abstinent, the
anticipation of highly reinforcing physiological reactions to tobacco
use is predictive of relapse (Marlatt and Gordon 1985).

It is ironic in light of the broad-spectrum treatment of other drug
dependencies that tobacco prevention and cessation treatments have
been focused so narrowly. Even where pharmacologic strategies have
been employed (e.g., nicotine replacement therapy; Fagerstriim
1982b; Schneider et al. 1983), these often have not been integrated
systematically with behavioral treatments. Chapter V details some
of the physiological and psychosocial interventions for various drug
dependencies including those on alcohol, opiates, cocaine, and other
illicit substances. This body of literature may have important and
largely overlooked implications for the clinical treatment of tobacco
dependence.

According to the 1985 National Health Interview Survey (NHIS),
there are approximately 41 million former smokers in the United
States. Approximately 90 percent of former smokers report that they
quit smoking without formal treatment programs or smoking
cessation devices (Fiore et al., in press). Achieving abstinence from
tobacco and other substances outside the context of formal treatment
programs (spontaneous remission) is discussed in Chapter V. Not
only smokers but other drug takers often discontinue use of the
dependence-producing substance outside the context of formal
intervention. Several common factors may be operating to influence
smokers to quit (e.g., response to social pressures, observed and
anticipated health consequences). Unfortunately, millions of new
individuals have been recruited to smoking.

466


Despite the well-known health hazards of smoking and the
documented difficulties in quitting, few intensive treatment options
are available to the highly dependent smoker (Sachs 1986). Cigarette
dependence or addiction can be as intractable as any addictive
disorder (Russell 1976). Studies have found considerable similarity in
relapse processes between tobacco and other drugs of dependence
(Hall and Havassy 1986; Marlatt and Gordon 1980; see also Chapter
VI.
As shown in Chapter IV, cigarette smoking is not a random or
capricious behavior; rather it is orderly and controlled. The role of
nicotine in cigarette smoking is functionally similar to the roles of
other addicting, psychoactive drugs in behaviors that lead to their
self-administration (Chapter V; US DHHS 1984b, 1987).

A practical result of these conclusions has been the development of
methods to treat cigarette smoking that are similar to methods used
to treat other forms of drug dependence. An additional implication is
that because cigarette smoking, like other forms of drug dependence,
involves both pharmacologic and behavioral factors, treatment
approaches also may involve pharmacologic agents, behavioral
strategies, or a combination of these. There is some evidence, as
discussed in the present Chapter, that treatment approaches which
address both pharmacologic and behavioral factors are most effec-
tive.

Current data indicate that smoking prevalence is declining much
more rapidly among certain segments of the population (e.g., better
educated, higher income, professional) than among others (blue
collar, minority, less educated, lower income) (Appendix A). Individu-
als from lower socioeconomic status (SES) backgrounds appear to
have less access to treatment and may be less likely to enroll in
treatment programs when they are available. Participants in most
formal treatment programs have been from the middle and upper-
middle class (US DHHS 1987). To have maximum impact upon the
prevalence of smoking, interventions must be responsive to and meet
the needs of lower SES smokers in a variety of circumstances.
Women represent an additional population that could benefit from
tailored programming. Women may be more likely to use cigarettes
for stress reduction and mood regulation (Brunswick and Messeri
1984; Mitic, McGuire, Neumann 1985). Potential weight gain may
represent an especially serious concern for many female smokers
(Jacobson 1981; US DHEW 1980; Chapter VI).

Knowledge of the dependence-producing aspects of tobacco unders-
cores the need for early intervention in preventing habitual chronic
tobacco use. This approach needs to be sensitive to both pharmaco-
logic and social aspects of smoking. Intervention for children and
adolescents also may need to focus upon cessation of well-established
smoking patterns in addition to the prevention of smoking onset.

467


Treatments that assist smokers to achieve initial cessation and to
maintain long-term abstinence are needed. High rates of relapse
plague the vast majority of treatment programs as well as self-
initiated quit attempts. Close examination of the physiological,
psychological, and social factors that promote relapse should suggest
more effective intervention strategies. Conceptualizing the quitting
process as ongoing may also be useful (Marlatt and Gordon 1985;
Prochaska and DiClemente 1983). Work is needed not only to reduce
the risk of initial relapse, but to accelerate recycling of quitting
attempts in the event that relapse does occur (Glasgow, Lando, Rand
1986).
Although discussed in earlier chapters in this Volume, it is
appropriate to summarize some observations about cigarette smok-
ing that are important in the development and implementation of
treatment strategies.

1. Chronic tobacco use produces physical dependence such that
cessation may be accompanied by a withdrawal syndrome that
includes feelings of discomfort or distress, reduced capacity to
work or handle stressful situations, and heightened urges to
resume smoking.

2. Consumption of tobacco products, which inevitably results in
administration of nicotine, can produce effects which are
perceived as desirable or otherwise useful to the cigarette
smoker, thereby providing a strong incentive for cigarette
smoking. There is evidence that nicotine can enhance perfor-
mance of smokers on certain types of attention and memory
tasks. Nicotine also exerts an important role in the relation-
ship between smoking and body weight.

3. The desire to handle cigarettes may be an important reason for
smoking (Leventhal and Avis 1976). Such stereotypical behav-
iors are characteristic of other forms of drug addiction and
other compulsive behaviors not involving psychoactive drug
self-administration. For cigarette smoking, the behaviors ap
pear to occupy small periods of time with hand-oral manipula-
tions (Ikard, Green, Horn 1969).

4. Nicotine may reduce the aversiveness of stressors for smokers
(Pomerleau, Turk, Fertig 1984). Stress has been demonstrated
to increase the rate of smoking (Leventhal and Clear-y 1980;
Schachter, Silverstein, Perlick 1977; Chapter VI).
5. There are numerous environmental factors that can facilitate
the initiation and maintenance of smoking (e.g., peer pressure,
family influences, images conveyed in tobacco advertising,
association with social and work activities) (Flay 1985b;
Warner 1986).

Smoking treatment programs are designed to counter these
important motivations to smoke. For example, skills training

468


treatments are designed tc inculcate skills so that individuals can
cope with stressors or negative affective states without smoking.
Aversion treatments are designed to condition cigarette aversions so
that smokers anticipate little pleasure from smoking. Nicotine
polacrilex gum and nicotine fading treatments are designed to
reduce the magnitude of the nicotine withdrawal syndrome. This
Chapter attempts to summarize what is known about how pharmaco-
logic and behavioral treatments exert their clinical effectiveness.
Knowledge of how treatments influence smoking will be the base on
which more effective treatments are designed.

This Chapter describes pharmacologic, behavioral, and combined
treatments applied in clinical and laboratory settings. It concen-
trates on work published since the last major Surgeon General's
review of smoking treatment (US DHEW 19791, but refers back to
that Report for historical perspective. Pharmacologic and behavioral
treatment strategies are reviewed in light of the current acceptance
of tobacco use as a form of drug self-administration that has clear
addictive properties as well as commonalities with other forms of
drug abuse.

The review of treatment approaches is necessarily selective.
Smoking interventions can be placed along a clinical-public health
continuum. At the extreme clinical end are intensive and costly one-
to-one interventions, often with a highly trained provider. Examples
include one-to-one behavioral or psychological counseling. Proceed-
ing somewhat toward the public health end, one finds group
programs, many of them offered by nonprofit or voluntary organiza-
tions, but some also conducted on a proprietary basis. These
programs typically entail 4 to 10 sessions and are usually led by
facilitators with some background in health education and psycholo-
gy, although trained lay facilitators are also used. Further along the
public health segment of the continuum are minimal interventions
emphasizing self-help manuals and including brief contact with
physicians during office visits.
The current Chapter focuses primarily upon the treatment of
smokers who seek assistance in quitting. There is no intent, however,
to deny the importance of public health interventions that will
ultimately reach a far greater number of smokers. Roth clinical and
public health approaches are absolutely essential. The reader is
referred to previous Surgeon General's Reports and other publica-
tions for more detailed discussions of such topics as physician
intervention, self-help strategies and outcomes, workplace and
community interventions (US DHEW 1979; US DHHS 1982, 1984b,
1985; Schwartz 1987).

469


Treatment

Although most pharmacologic treatment strategies also encom-
pass behavioral components and some studies have systematically
combined pharmacologic and behavioral interventions, it is concep
tually useful to consider these two major types of approaches
separately.
One major pharmacologic approach has involved various nicotine
replacement strategies. As discussed in Chapter V, the general
principle of replacement therapies for drug dependence is to present
the patient with a safer and more therapeutically manageable form
of the drug that directly alleviates signs and symptoms of withdraw-
al and craving (Jaffe 1985). These strategies are modeled after those
originally developed to treat dependence on heroin and other opiates
(Henningfield and Jasinski 1988). A variety of nontobacco-based
delivery systems provide potentially effective means for nicotine
replacement. Experimental and theoretical aspects of each of these
delivery systems have been described in part in Chapter IV. In the
present Chapter, data regarding those nicotine delivery systems that
are most relevant to direct treatment application will be summa-
rized.

In addition to nicotine replacement approaches, the following
additional pharmacologic treatment approaches developed for other
forms of drug dependence may be applied to tobacco dependence:
Nonspecific Pharmacotherapy, in which the patient is treated
symptomatically; Nicotine Blockade Therapy, in which the behavior-
controlling effects of the dependence-producing drug are blocked by
pretreatment with an antagonist; and Deterrent Therapy, in which
administration of the treatment drug results in the occurrence of
aversive consequences. All three approaches have potential applica-
tions in the treatment of cigarette smoking. Each of these strategies
is discussed.

Nicotine Replacement Strategies

To date, only one form of nicotine replacement has been approved
by the Food and Drug Administration (FDA): nicotine polacrilex
chewing gum (2-mg pieces only). Three other nicotine delivery
systems that will be briefly discussed are (1) a transdermal patch for
delivery of nicotine through the skin, (2) a nasal nicotine solution,
and (3) a nicotine vapor inhaler (smokeless cigarette).

There is considerable current interest in nicotine replacement
strategies for smoking cessation because (1) nicotine is the critical
dependence-producing component in tobacco, (2) some treatment
outcome data on the efficacy of the first nicotine replacement
procedure to be evaluated (nicotine polacrilex gum) are encouraging,
and (3) other forms of nicotine substitution may hold further

470


potential for more effective treatment. The assumption underlying
this treatment approach is that nicotine-specific withdrawal inter-
feres with successful cessat,ion and can be prevented or attenuated
by nicotine replacement, thereby both promoting cessation and
aiding the inhibition of relapse. For a more extensive review of
nicotine replacement, see Grabowski and Hall (19851 and Pomerleau
and associates (1988).

Forms of Replacement and Rationale

The first reported systematic use of nicotine replacement to help
people quit smoking was the intravenous administration of nicotine
by Johnston (1942). This approach is not clinically practical because
of the short half-life of nicotine (Chapter II) and its potential toxicity
with excessively rapid administration (Appendix B). The next
systematic approach was the development of nicotine polacrilex gum
by Ferno, Lichtneckert, and Lundgren (1973). The weaning from
nicotine would actually begin with the switch from cigarettes to gum
in that nicotine polacrilex (1) produces slower-rising plasma nicotine
levels than cigarettes and (2) reduces the inhaled nicotine bolus
effect believed to contribute to nicotine's addictive potential in
smoke (Russell and Feyerabend 1978; Chapter II).

The same rationale applies to other replacement approaches
(Jarvik 1986; Russell 19861 including nicotine transdermal delivery
systems, nasal nicotine solution (NNS), and smoke-free nicotine
cigarettes. The different forms allow variations in delivery (dose and
speed) which may influence effectiveness, relief of withdrawal,
patient acceptance, and outcome.

Nicotine Polacrilex Gum

"Nicotine polacrilex" or "nicotine resin complex" (American
Hospital Formulary 1987) is also commonly referred to as nicotine
gum. It is a nicotine delivery system in which the nicotine is
incorporated into an ion exchange resin base which permits release
of nicotine in the proper environment (i.e., saliva in the mouth) when
appropriate physical pressure (i.e., chewing) is applied. Twenty to
thirty minutes of proper chewing can result in the release of
approximately 90 percent of the nicotine (Ferno, Lichtneckert,
Lundgren 1973), although there are multiple determinants of how
much nicotine actually is absorbed. As discussed in Chapter II, 10 to
15 min of chewing results in the release of approximately 50 to 60
percent of the nicotine in a piece of gum. However, considerable
variability exists both within and across subjects (Benowitz, Jacob,
Savanapridi 1987; Nemeth-Coslett et al. 1987; Pickworth, Herning,
Henningfield 1986; Chapter II). Swallowed nicotine is approximately

471


70 percent detoxified as a result of its first pass through the liver
(Benowitz, Jacob, Savanapridi 1987; Chapter II).

Nicotine polacrilex gum does not usually lend itself to full
replacement of the nicotine provided by cigarette smoking. Russell,
Feyerabend, and Cole (1976) and McNabb, Ebert, and McKusker
(1982) reported that 4-mg-nicotine gum produced plasma nicotine
levels approximating that of a 1.2-mg-nicotine-yield cigarette. How-
ever, Benowitz, Jacob, and Savanapridi (1987) found only about 50
percent replacement of nicotine levels with 4-mg gum. Benowitz,
Jacob, and Savanapridi (1987) reported that chewing 10 pieces of 2-
mg gum on an hourly schedule resulted in blood levels of nicotine
that were one-third of those achieved while smoking. Therefore, ad
libitum chewing of the 2-mg nicotine polacrilex gum probably results
in even lower nicotine levels. When nicotine polacrilex gum is
chewed, drug levels in plasma rise slowly, peaking in around 20 to 30
min. Although the 4-mg nicotine polacrilex gum replaces nicotine
more completely, most testing has proceeded with the 2-mg dose;
only the 2-mg dose has been approved for use in the United States. It
should be noted, however, that effective nicotine replacement
strategies may not require the same range of nicotine blood levels as
those produced by cigarette smoking. Even the 2-mgdose nicotine
polacrilex gum has increased smoking cessation rates significantly
in several placebo-controlled studies (Table 1).

Withdrawal symptom relief: Several short-term trials (8 hr to 5
days) have found that nicotine polacrilex gum reduced symptoms of
withdrawal in comparison to placebo controls (Hughes et al. 1984;
Schneider, Jarvik, Forsythe 1984; West, Jarvis, Russell, Carruthers
et al. 1984). Jarvis and associates (1982) reported relief of several
symptoms for a 6-week period, with scores averaged over weekly
sessions. Expectancy may also play a role in withdrawal symptom
relief, as suggested in a study by Gottlieb and others (1987).
Interpretation of this study is limited, however, by a brief (2-week)
observation period and by the possibility that subjects failed to
achieve adequate nicotine plasma levels.
In previous studies, not all symptoms were relieved with replace-
ment nor was there consistency among the studies in which
symptoms were relieved (Fagerstrom 1988; West 1984). Irritability
was consistently relieved in all studies, whereas hunger, depression,
anxiety, difficulty in concentrating, restlessness, annoyance, hostili-
ty, and somatic complaints were reduced in some but not others. The
degree to which most symptoms are relieved is directly related to the
dose of nicotine that is actually obtained when the polacrilex gum is
used (Henningfield and Jasinski 1988). The urge to smoke (craving)
is not reliably decreased by nicotine replacement (Henningfield and
Jasinski 1988; West and Schneider 1987).

472


TABLE l.-Efficacy trials for nicotine polacrilex gum:
      Followup abstinence rates (percentages)

I. Placebo-controlled studies

Study          Number'    Active gum      Placebo     Followup      P

Puska et al.
119791

Malcolm et al.
I19801

Fee and Stewart
I19821

Fagerstrtim
11982bt

Jarvis et al
rl9821

British Thoraclc
Society (1983)

Schneider et al.
( 1983)

Hjalmarson
(1984)

Jamrozik et al.
,19841

Campbell et al.
11987,

Hall et al.
( 1987)

160



210

352

96

116

802



60



205



200



9E45



139

35



`3



13



49



47



10



30



`29



10



3



44

28

5

9

3;

21

14

20

16

8



2



21

6 mo



6 mo



1 Y'


1 yr


1 yr


1 Yr


1 Y=


1 Yr


6 mo



1 yr


1 Yr

N.S.

pi 0.05

N.S.

N.S.

p c 0.01

N.S.

N.S.

p < 0.05

N.S.

N.S.

pco.01

II. No-gum control studies

Study          Number'    Nicotine gum     No gum     Followup      P

Russell et al.
(1983)

1.938

9

4

1 yr     p<o.o1

Fagerstrom
(1984)

145

25

9

1 Yr     p<o.o5

Hjslmarson
(19851

2,404

25

18

1 Yr     pco.05

Page et al.         221         12           9        6 mo      N.S.
( 1966)

473


TABLE l.-Continued

111. Nuhvz polacrilex yum vs. other active treatment

  Behavioral counseling and vapid smokmg

Ran et al.          118         `33
l!%(o)

Hall et al.          7x         36
119.%l

  Skills training

Killen et al.'         42         23
iI

1 Yr     p<-0.01


1 Yr      N.S.





10 mo      N.S.

  Acupuncture

Claw1 et al. i
1198.51

The studies noted above used ad libitum administration of the 2-
mg gum. This level of replacement may be insufficient to reverse
some of the symptoms of nicotine withdrawal. Studies which have
shown little difference between the 2-mg dose and placebo are not
clearly interpretable unless they have confirmed adequate dosing
through biochemical markers (e.g., plasma cotinine). When the
nicotine polacrilex dose has been increased to 4 mg, more complete
reversal of withdrawal (Henningfield, Sampson, Nemeth-Coslett
1986), of electroencephalogram (EEG) changes with abstinence
(Pickworth, Herning, Henningfield 1986), and of performance de&
tits during cessation (Snyder, Davis, Henningfield 1985) is observed.

Different withdrawal symptoms may also require different levels
of nicotine replacement. Whether a particular withdrawal symptom
is nicotine specific cannot be determined until there is systematic
testing by dose and speed of delivery of nicotine replacement. In
addition, recent studies show that intrasubject and intersubject
variability in chewing can affect the amount of nicotine reaching the
circulation (Benowitz et al. 1983; Nemeth-Coslett et al. 1985).

474


There is also some evidence that weight gain, a significant problem
in cessation, can be reduced by nicotine replacement (Fagerstrom
1987). Even low-dose, 2-mg-nicotine gum has been shown to produce
significantly less weight gain over a lo-week period compared with a
placebo (Stitzer and Gross 1988).

Cmvings-urges-desires. Findings regarding urges or craving are
complicated by semantic and measurement considerations (Kozlow-
ski and Wilkinson 1987) and by ambiguity as to what constitutes
craving (West and Schneider 1987). Definitions of craving have
proven elusive. It is often described as an increase in the desire or
urge to use a drug. Although the term craving is used in the present
context, a more appropriate phrase might be substituted, e.g.,
"strength of an urge to use a drug" (Chapters IV and V).
In the tobacco abstinence studies cited above, craving generally
was not relieved by nicotine replacement. By contrast, significant
relief of craving has been reported with 2-mg-nicotine polacrilex gum
compared with placebo controls in an outcome trial (Hjalmarson
1984), in a clinical trial with NNS (Jarvis 1986), and with a nicotine
patch in an acute placebo-controlled trial (Rose et al. 1985). The
discrepancies may be due to how "craving" is assessed. In a study by
Schneider and Jarvik (19851, treatment had no effect on "craving"
but did significantly affect %rges to smoke" and "missing a
cigarette" from the ShiffmanJarvik (1976) "craving" subscale.
Because nicotine seeking is believed to precede most relapse and its
relief is a goal of replacement systems, appropriate operational
definitions and testing are essential.

Craving should not be viewed simply as a symptom of a negative
withdrawal state. Smokers clearly seek desired effects of nicotine in
addition to relief from withdrawal (Chapters II and VI). Nicotine
polacrilex gum may reduce negative withdrawal symptoms without
providing other effects (e.g., a "high") sought by many smokers.
Effxucy trials. Table 1 summarizes efficacy trials that evaluated
nicotine polacrilex gum against placebo controls, no-gum controls, or
other active treatment. This Table does not include all the studies
that combined nicotine polacrilex gum with behavioral interven-
tions.
The early studies of nicotine replacement involved testing of the
nicotine regulation hypothesis (e.g., the extent to which cigarette
smokers show compensatory changes in their cigarette smoking
behavior; Chapter IV). These studies assessed the capacity of
nicotine in polacrilex gum to replace nicotine in cigarettes (Brant-
mark, Ohlin, Westling 1973; Russell et al. 1976; Turner et al. 1977).
Several studies have demonstrated that cigarette smoking can be
decreased in laboratory subjects by replacement of the nicotine
normally obtained by smoking with nicotine delivered by gum
(Nemeth-Coslett and Henningfield 1986). Early clinical outcome

475


trials, although supporting the efficacy of nicotine polacrilex gum,
were flawed by statistical problems, inadequate nicotine delivery,
concurrent smoking and use of gum by subjects, and lack of
validation or inappropriate controls (Malcolm et al. 1980; Puska,
Bjorkqvist, Koskela 1979; Raw et al. 1980). In the placebo-controlled
clinical trials, nicotine polacrilex gum significantly increased success
rates for as long as 6 months in some studies (Fagerstrom 1982a;
Schneider et al. 1983) and 1 year in others (Hjalmarson 1984; Jarvis
et al. 1982; Table 1). It should be noted, however, that in most of
these studies, other treatment procedures (e.g., group therapy) were
applied in addition to either nicotine polacrilex gum or placebo.

Subsequent efficacy trials proceeded without regard to control of
dose or scheduled use of nicotine polacrilex gum. The trials may be
divided into those conducted in clinic settings versus physician or
dispensary trials. Different trials compared active gum with a
placebo, active gum with no-gum conditions, or gum with other
treatments (Fagerstrom 1988).

Hall and coworkers (1985) assessed nicotine polacrilex gum plus an
intensive contact behavioral treatment (14 sessions over an g-week
period), nicotine polacrilex gum plus low-contact behavioral treat-
ment (4 sessions over a 3-week period), and the intensive behavioral
treatment alone. The combination of intensive behavioral treatment
and nicotine polacrilex gum was significantly superior to the other
interventions through Smonth followup. Differences were no longer
significant at 1 year, however. In a subsequent study, Hall and
colleagues (1987) assigned subjects to intensive behavioral or to low-
contact smoking treatment and to 2-mg-nicotine gum or to placebo
gum in a 2-by-2 factorial design. Results at l-year followup indicated
significant effects only for nicotine polacrilex gum. No differences
were found between low-contact treatment and intensive behavioral
intervention. In a study by Killen and colleagues (19841, the success
rate of nicotine polacrilex gum combined with behavioral treatment
at a lO.Bmonth followup was 50 percent as opposed to 23 percent for
gum and 30 percent for behavioral treatment alone. However, these
differences between treatment conditions were not significant.

Physician trials have resulted in lower overall success rates for all
groups and some equivocal findings. These lower success rates may
be attributable, at least in part, to a selection bias. Clinics may
attract only a small proportion of smokers who are interested
specifically in treatment. Physician trials sometimes have included
all smoking patients regardless of their level of interest in quitting.
The British Thoracic Society (1983) reported no differences among
four conditions involving active nicotine polacrilex or placebo gum.
However, this study included patients who were not actively seeking
treatment and failed to instruct patients in the use of the prepara-
tion. Jamrozic and coworkers (19841, using patients who were

476


motivated to quit, reported no differences between patients given
nicotine polacrilex or placebo gum. In that study, only 70 percent of
the subjects even tried the active nicotine polacrilex gum, and only
one-half of the subjects used it regularly. In a dispensary study with
nicotine polacrilex versus placebo gum, all individuals started gum
but most stopped use within 3 to 5 days and failed (Schneider et al.
1983).
Differences in outcome comparing the clinic setting versus physi-
cian offices have been interpreted as indicating the requirement for
support treatment with nicotine polacrilex gum. However, it is not
clear whether support treatment per se is necessary or whether it
serves to encourage sufficient use of the preparation. In fact,
compliance with gum use instructions is often unsatisfactory in both
clinic and physician office settings. In a large physician trial,
Russell, Merriman, and colleagues (19831 reported that 47 percent of
subjects given active nicotine polacrilex gum did not use it. However,
use of nicotine polacrilex gum resulted in significantly higher
success rates (8.8 percent) compared with no gum (4.0 percent) at 1
year, and when patients used a total of at least three boxes of
nicotine polacrilex gum, success rates tripled to 24 percent without
further intervention. It is unclear whether these substantially
increased success rates are a function of gum use per se or simply a
reflection of a greater overall commitment to treatment.

Followup may also prove to be important for a good outcome.
Fagerstriim (1984) assigned subjects to either short or long followup
and to either nicotine polacrilex gum or no-gum conditions. Short
followup consisted of one physician appointment approximately 14
days after cessation. Long followup included two physician appoint-
ments (approximately 14 and 30 days after cessation), a telephone
call (after about 7 days), and a personal letter inquiring about
patients' smoking status (3 months after cessation). Results at l-year
followup indicated significant differences in favor of nicotine polacri-
lex gum over no gum. Initial effects were also found for long over
short followup. However, these effects were no longer significant at
l-year followup. At this point 27 percent of the subjects assigned long
followup and nicotine polacrilex gum were abstinent, compared with
22 percent of those receiving short followup and nicotine gum, 15
percent of those assigned long followup and no gum, and 3 percent of
those receiving short followup and no gum. In a recent physician
trial by Hughes and associates (19881, with minimal intervention and
a followup visit, significant differences in favor of active gum over
placebo gum were observed at 1 and 6 months, although the
differences were no longer evident at 1 year.

The high long-term relapse rate observed in their own and other
published reports led Hughes and coworkers (1988) to conclude that
nicotine polacrilex gum in the physician setting is not more effective

477


than placebo. However, the issue may be a different one. In several
studies, early significant effects reported at 1 month (Fee and
Stewart 1982) and 6 months (Fagerstrom 1982a; Hall et al. 1985;
Schneider et al. 1983) disappeared at 1 year although the trends
continued to favor active nicotine polacrilex gum. Rather than being
interpreted as a failure for nicotine polacrilex gum versus a placebo,
this may mean that what is effective treatment for initial quitting
(e.g., relief of withdrawal symptoms) is different from effective long-
term relapse prevention.
Another variable which may affect outcome is duration of nicotine
polacrilex gum use. It has been suggested that longer use will be
more effective (Russell, Raw, Jarvis 1980, Wilhelmsen and Hjalmar-
son 19801, yet duration of use remains an untested and unresolved
issue. The one prospective trial comparing l- with 6-month use of
nicotine polacrilex gum (Fagerstrom and Melin 1985) was flawed by
differential clinical intervention for the l-month group. Duration of
use is also an issue in evaluating followup results. Followup is
virtually never calculated as time since discontinuation of nicotine
polacrilex gum. One-year followup results might be considerably
shorter if the end of treatment were defined as the point at which
nicotine polacrilex gum is no longer consumed. In fact, a significant
proportion of subjects appear to persist in their use of this gum for at
least 6 months to 1 year (Hughes 1988).
Dose and patient relationship. A few trials have used both 2- and 4-
mg doses of nicotine polacrilex gum (Kornitzer et al. 1987; Toenne-
sen et al., in press; Toennesen 1986). These studies have not found a
direct effect of dose but report that dose interacts significantly with
degree of nicotine dependence in the smokers tested. Four-milligram
nicotine polacrilex gum improved success rates for more highly
dependent smokers, whereas 2-mg nicotine polacrilex gum was
superior in less-dependent smokers. The problem, once again, is that
ad libitum dosing (thus uncontrolled dose-response testing) reduces
the interpretability of the observed effects. Otherwise, the logic is
reasonable: smokers who have a greater degree of dependence on
nicotine may require treatment with higher doses than those
required by less-dependent smokers.
With respect to the selection of subjects for treatment with
nicotine polacrilex gum, Hall and colleagues (1985) reported a
significant positive correlation between smokers with high prequit
cotinine levels and abstinence with nicotine polacrilex gum. Jarvik
and Schneider (1984) reported that individuals scoring high on the
Fagerstrom Tolerance Scale had greater success with replacement.
Other selection issues may be equally important. For example,
Toennesen and coworkers (in press) reported a substantial difference
in outcome at 1 year between healthy subjects (45 percent success)
and those with chronic bronchitis (16.2 percent). Patient selection


and variations in severity of nicotine dependence are expected to
interact with success rates for any replacement therapy (Chapter
IV).

Nasal Nicotine Solution

Russell, Jarvis, and colleagues (1983) have investigated nicotine
replacement in the form of an NNS. NNS is a gel-like droplet of
nicotine squeezed into the nose from a small vial. NNS was
formulated to provide more rapid and efficient absorption of nicotine
than is possible with use of nicotine in polacrilex gum (Russell 1986;
Jarvis 1986).

Russell, Jarvis, and colleagues (1983) reported average peak
plasma nicotine levels of 25.7 ng/mL in three male smokers for a
single cigarette (1.4-mg machine-determined nicotine yield), 8.5
ng/mL for one piece of 2-mg gum, and 14.1 ng/mL for NNS (0.1 mL
of a 2 percent aqueous solution of nicotine, 2 mg, at pH 5.0 without
added buffer). Higher levels with hourly dosing of NNS versus
nicotine polacrilex gum were also documented (West, Jarvis, Russell,
Feyerabend 1984).
Only very preliminary data are available with respect to the
clinical efficacy of NNS. Jarvis (1986) reported decreased craving
and encouraging abstinence outcomes in a sample of 26 consecutive
new attenders at the Maudsley Smokers Clinic (approximately two
thirds of the subjects achieved initial abstinence and one-third
remained abstinent at l-year followup). The faster absorption and
higher plasma nicotine levels attained with NNS as opposed to
nicotine polacrilex gum suggest that NNS may be more effective and
better accepted by smokers as a replacement for cigarettes. However,
subjects in the Jarvis study reported NNS to be somewhat embar-
rassing to use in the company of others.

Nicotine Transdermal Patch

Rose, Jarvik, and Rose (1984) initially suggested that a transder-
ma1 nicotine delivery system might be an effective route of adminis-
tration. In a short-term (hours) laboratory trial, Rose and colleagues
(1985) reported a decrease in craving and nicotine preference in
subjects using a nicotine patch versus a placebo patch.

A transdermal delivery system could eliminate some of the
compliance and chewing problems associated with nicotine polacri-
lex gum. Steady-state administration expected from such a system
may be more effective in preventing withdrawal symptoms. While
the patch does not allow for self-dosing in response to smoking urges,
it could potentially be used in combination with the other rapidly
absorbed forms of nicotine replacement. Transdermal delivery

479


systems have not yet been tested in clinical trials or in nonlaborato-
ry settings.

Nicotine Aerosols

Devices have been marketed that provide for inhalation of nicotine
without other components of tobacco. One such product was on the
commercial market for approximately 18 months, but was removed
by the FDA (Chapter IV). Because the nicotine vapor inhaler was
devoid of tobacco (other than the tobacco constituent nicotine), it was
deemed by the FDA to be a nicotine delivery system. Because
nicotine is regarded as a drug with clinical application (namely to
treat nicotine dependence), the FDA ruled that it could not be sold
until it had been shown to be safe and effective in appropriate
clinical trials.

Technical engineering problems have also been encountered. The
shelf life of the unrefrigeratecl vapor inhaler was apparently limited
to approximately 1 month. In addition, this device delivers little
nicotine unless there is extraordinary effort on the part of the user
(Sepkovic et al. 1986). Russell and associates (1987) reported negligi-
ble plasma nicotine levels when vapor inhalers were puffed at a
regular rate for 10 min. When the nicotine vapor inhalers were
puffed at the rate of 10 puffs/min and 4 of these inhalers were used
in a 20-min period, plasma nicotine levels increased to 17.3 ng/mL,
levels similar to those seen after cigarette smoking.

If nicotine aerosols can be improved, they may be of value to
smokers for whom slow-release nicotine replacement preparations
are inadequate to produce the desired effects of nicotine. Such
aerosols would allow nicotine replacement with some replacement
also of the oral, handling, and sensory reinforcements (Rose 1986) for
individuals who need to be weaned more slowly. Whether these
aerosols will be effective in smoking cessation treatment is unknown.

Comparisons of Preparations

All nicotine replacement products produce side effects. Nicotine
polacrilex gum may produce mouth sores, gastric upset, and hiccups.
NNS produces runny nose and irritation, whereas transdermal
devices can result in skin irritation. Transdermal devices have the
advantages of better patient compliance with treatment and steady-
state drug levels, whereas NNS and nicotine polacrilex gum have the
advantage of ad libitum access to replacement. Because triggers to
smoke can appear at any time, the flexibility offered by the latter
may be essential. Ultimately, a combination of preparations may be
most useful to control symptoms as well as to allow instant responses
to smoking urges. At this point, the replacement therapies in
development must undergo testing for bioavailability, safety, and

480


toxicity as well as testing for dose-response effectiveness in relief of
withdrawal and efficacy in treat,ment.

Dependence on Nicotine Replacement

West and Russell (1985) and Hughes and coworkers (1986) reported
the appearance of withdrawal sympt.oms upon abrupt cessation of
nicotine polacrilex gum. However, the authors have different
interpretations of these findings. Hughes and coworkers (1986)
consider this phenomenon as an indication that. nicotine polacrilex
gum produces physical dependence. West and Russell (1986) point
out that any dependence on this gum is part of the continued
dependence on nicotine that. originated with smoking and is bound to
transfer during weaning (Chapt.er IV).

A more complicated issue is that of continued compulsive long-
term use. The definition of excessive long-term use cannot be
resolved without studies to determine the length of treatment
necessary and sufficient for successful intervention. No such studies
are available in the current published literature. Hughes (1988)
reports that many abstinent smokers are unable to discontinue
nicotine polacrilex gum use (35 to 90 percent. of abstinent smokers at
6 months and 13 to 38 percent at 1 year continued to use nicotine
polacrilex gum despite advice to stop!.

An important additional issue is whether it is possible to initiate
and maintain physical dependence on nicotine with replacement
products alone. Nicotine polacrilex has been used widely with no
reported cases of such development. This would suggest that nicotine
polacrilex gum, through a combination of regulatory, packaging,
marketing, and physical characteristics, does not readily lend itself
to such abuse. Systematic investigation of the dependence-producing
potential of other replacement products is needed.

Other Pharmacologic Approaches
Nonspecific Pharmacotherapy-Symptomatic Treatment

As reviewed in Chapters III and IV, administration and withdraw-
al from nicotine produce a number of neurohormonal and other
physiological effects. These effects, as well as those on receptors in
the central nervous system, mediate the various actions of tobacco
(Chapters IV and VI). Because several such effects are functional in
the maintenance of cigarette smoking and in relapse, it is generally
assumed that addressing such factors would enhance treatment
programs (Pomerleau and Pomerleau 1984; Shumaker and Grunberg
1986). Such strategies are also an integral part of many interven-
tions for drug addiction in general, as described in Chapter V.

Prevention of relapse to tobacco may be aided by specific interven-
tion (pharmacologic or behavioral) for needs met by t.he use of

481


tobacco. The present summary will mainly address pharmacologic
methods, excluding nicotine replacement, that have been either used
or suggested as means to alleviate the effects of tobacco abstinence
that are considered adverse by patients themselves. The categories of
such adverse effects for which pharmacologic treatment intervention
appears viable are derived from the effects of tobacco in the
regulation of mood, weight, performance, and the prevention of
specific withdrawal-related discomfort. In addition, the results of
studies involving pharmacologic approaches to directly alter ciga-
rette consumption will be summarized.
The emphasis in this Section is upon recent research. It should be
noted that there is a long history of generally unsuccessful pharma-
cologic treatment of smokers (Gritz and Jarvik 1977; Jarvik and
Gritz 1977). Experimentation with lobeline sulfate as a smoking
substitute dates back to the early 1900s (Edmunds 1904). Lobeline
appears to be no more effective than a placebo in facilitating
abstinence (Schwartz 1987). Medications intended to reduce with-
drawal symptoms (sedatives, tranquilizers, anticholinergics, sympa-
thomimetics, and anticonvulsants) also have failed to improve
outcome relative to placebos (Gritz and Jarvik 1977).

Treatment of Discomfort Associated with Tobacco Withdrawal

The signs and symptoms of tobacco withdrawal vary to some
degree in nature and severity among individuals, as shown in
Chapter IV (also Hughes and Hatsukami 1985). Because symptoms
can be treated independently of their origin, symptomatic therapy
approaches might be useful in alleviation of tobacco abstinence-
associated discomfort. This approach was used in a study by
Glassman and his colleagues (1984). In this study, alprazolam (1 mg
orally) and clonidine (0.2 mg orally) were compared with a placebo
for heavy cigarette smokers on days when they abstained from
tobacco. The subjects were exposed to one of the medication
conditions on each of 3 smoking abstinence study days, which were
separated by at least 3 days of normal smoking. Alprazolam, a
benzodiazepine tranquilizer, was included as a control because of the
known sedative effects of clonidine. Both clonidine and alprazolam
were more effective than the placebo in reducing anxiety, irritabili-
ty, restlessness, and tension. Only clonidine, however, successfully
reduced the craving for a cigarette. Because craving tended to
increase during the day, the difference between clonidine and the
other two conditions became more evident as the day progressed.
Glassman and colleagues (1988) reported a clinical intervention
study with clonidine in a sample of 71 smokers who consumed at
least 1 pack/day and who had made at least one previous unsuccess-
ful quit attempt. Each smoker began taking one 50-w tablet of
clonidine (N= 33) or a matched placebo (N=38) at least 3 days before

482


a designated quit date. Dosage was increased by one tablet every day
(or as tolerated) until subjects were taking four tablets by the quit
date. Subjects were seen weekly for the next 4 weeks. After 4 weeks
of treatment, clonidine was gradually withdrawn (50 Kg every 3 days
over an average of 12 days). Success rates both at the end of 4 weeks
on clonidine or placebo and at followup 6 months after discontin-
uance of medication favored clonidine. At g-month followup, 27
percent of the subjects receiving clonidine and 5 percent of those on
placebos reported abstinence. An unexpected finding, however, was
that clonidine appeared to be effective only for women; among male
subjects, drug treatment did not significantly affect outcome.

Before any recommendation of clonidine as an adjunct to smoking
cessation, potentially hazardous side effects must be weighed careful-
ly. Clonidine has been extensively used in the treatment of hyperten-
sion. Abrupt cessation has sometimes led to severe hypertension and
in rare instances to hypertensive encephalopathy and even death.
Far more common is sedation, which could be dangerous if individu-
als use this drug while driving or operating dangerous machinery.

It is interesting to compare the utility of clonidine in the
treatment of tobacco withdrawal with its utility in the treatment of
opioid withdrawal (Chapter V). When assessed in a paradigm
analogous to that described for tobacco abstinence, clonidine was as
effective as morphine in reducing certain physiological signs of
opioid withdrawal (Jasinski, Johnson, Kocher 1985). However, in the
study by Jasinski and colleagues, clonidine did not reduce the self-
reported "discomfort" as effectively as did morphine (measures of
"desire to use narcotics" or narcotic-seeking behavior were not
collected).

Treatment of Abstinence-Associated Mood Changes

As discussed in Chapter VI, nicotine may serve as a regulator of
mood. This observation suggests that for certain persons, selective
use of minor tranquilizers, antidepressants, or even psychomotor
stimulants may be beneficial in preventing relapse. Again, issues of
possible side effects and drug dependence must be considered before
such an approach would be recommended in clinical practice.

Laboratory studies with human subjects have shown that stressful
situations lead to increased smoking and that smoking may reduce
smoker distress responses to stressful stimuli and enhance reported
mood (Gilbert 1979; Golding and Mangan 1982; Rose, Ananda, Jarvik
1983). Also, relapse to cigarette smoking often occurs in response to
stressful situations (Gunn 1983a; Ockene et al. 1982; Shiffman 1982;
Marlatt and Gordon 1980; Lichtenstein, Glasgow, Abrams 1986).
There have been no clinical trials in which the targeted use of more
specific anxiolytics (e.g., benzodiazepines) has been evaluated in the
maintenance of tobacco abstinence. The only study involving a

483


benzodiazepine was that of Glassman and associates (1984), who
compared alprazolam with clonidine during a brief abstinence.

Nicotine Blockade Therapy

Whereas the goal of both replacement therapies and symptomatic
treatments is to relieve withdrawal by mimicking critical effects of
the drug from which the person is attempting to abstain, blockade
therapy provides no such potentially rewarding or therapeutic effect.
Rather, the goal of blockade therapy is to reduce or eliminate any
rewarding pharmacologic effects should the person attempt to
resume drug use. The prototypical blockade therapy is that used in
the treatment of opioid dependence (Jaffe 1985). The long-acting
opiate antagonist naltrexone can be given on a daily basis to opioid
abusers to prevent them from experiencing the reinforcing effects of
opioid agonists. Unfortunately, only about 5 percent of opioid-
abusing patients are willing to comply with such a therapeutic
regimen. Success in naltrexone treatment is correlated with the
following characteristics: the patient is highly motivated, well
adjusted in society, and has a steady job (Greenstein et al. 1983).

Relapse to former levels of cigarette smoking begins with the first
few cigarettes which are smoked. If smoking levels do not progress
beyond these few cigarettes, the incident is generally referred to as a
"slip" (Shumaker and Grunberg 19861. Slips can lead to relapse
because they provide the stimuli which were important in mainte-
nance of the smoking behavior in the first place. Because nicotine
itself is the source of many of the effects which are sought by
cigarette smokers (Chapters II, IV, and VI), blocking the effects of
nicotine should assist in the prevention of relapse. As described in
Chapter V, such an approach is effective in preventing relapse to
opioid use if the morphine-blocking drug (opioid antagonist) is taken
(see also Greenstein et al. 1983).

Pharmacologic antagonists of nicotine, the administration of
which could diminish a variety of responses to nicotine, have been
known for several decades (Domino 1979). Those antagonists which
act both centrally and peripherally (mecamylamine), but not those
which only act peripherally (e.g., pentolinium and hexamethonium),
appear to have functional effects on patterns of cigarette smoking in
humans. Central antagonists also alter the behavioral effects of
nicotine (including self-administration) in animals (Henningfield
1984; Stolerman 1986).
Preliminary data suggest the possibility that mecamylamine could
be used as an antagonist to block the nicotine-mediated reinforcing
consequences of cigarette smoking. The following findings are of
particular relevance: (1) Mecamylamine pretreatment produces a
dose-related blockade of the ability of animals and humans to
discriminate nicotine from a placebo (mecamylamine is injected in

4a4


animals and administered orally to humans) (Rosecrans and Meltzer
1981; Stolerman 1986; Henningfield et al. 19821, (2) mecamylamine
pretreatment diminishes the reinforcing efficacy of intravenous
nicotine administration in animals (Goldberg et al. 1983) and
possibly in humans (Henningfield and Goldberg 19831, (3) mecamyla-
mine pretreatment increases the preference for high-nicotine-deliv-
ering cigarette smoke (apparently by reducing its nicotinic effects)
when subjects are tested with a device which blends smoke from
high- and low-nicotinedelivering cigarettes (Rose, Sampson, Hen-
ning-field 198.51, and (4) mecamylamine pretreatment increases
various measures of cigarette smoking behavior and tobacco smoke
intake when subjects are allowed to freely smoke (Stolerman et al.
1973; Nemeth-Coslett et al. 1986; Pomerleau, Pomerleau, Majchrzak
1987). Results from the study by Pomerleau and colleagues also
suggested that the toxicity of nicotine exposure was reduced
substantially by mecamylamine pretreatment.

In one clinical trial, Tennant, Tarver, and Rawson (1984) attempt-
ed to determine if mecamylamine could be used safely and effica-
ciously to treat cigarette smoking. Mecamylamine was given to
heavy cigarette smokers in conjunction with counseling to quit
smoking. Mecamylamine reduced tobacco craving in i3 of 14
subjects, and half of the subjects quit smoking within 2 weeks of
initiation of mecamylamine treatment. The mean dose of mecamyla-
mine at the time of quitting was 26.7 mg/day. Mecamylamine was
not used to maintain abstinence as naltrexone is used for opioid
dependence. Rather, it was used as an aid to initial quitting. In
theory, because mecamylamine blocks the effects of nicotine, it
should precipitate withdrawal and, therefore, would not be indicated
for acute cessation. Despite this theoretical problem and the lack of
placebo controls in the trial, these data suggest that nicotine
blockade warrants further exploration.

The main obstacles to this treatment approach are the ganglionic
blocking and antihypertensive effects of mecamylamine, the strong
likelihood of considerable difficulty in obtaining adequate therapeu-
tic compliance, and conditioned and non-nicotine-mediated reinforc-
ers of tobacco use which may be powerful enough to sustain urges to
smoke even when they are no longer associated with the pharmaco-
logic effects of nicotine.

Deterrent Therapy

Deterrent therapy is based on the premise that pretreatment with
an agent may transform smoking from a rewarding to an aversive
behavior. Disulfiram treatment of alcoholism provides the pharma-
cologic analogy for this form of treatment (Chapter V).
With regard to cigarette smoking, the main analog to disulfiram
treatment is the administration of silver acetate. Variants on this

485


method have been market,ed for over-the-counter purchase for a
number of years. The physiological basis of the approach is that
sulfide salts are produced when silver acetate contacts the sulfides in
tobacco smoke. The resulting silver sulfides are extremely distasteful
for most people. The approach is not specific to nicotine intake, but
rather to sulfide-containing smoke. Most recently, a gum prepara-
tion of silver acetate has been tested as a means to maintain
abstinence from tobacco smoking (Malcolm, Currey, Mitchell, i(ei1
1986). The gum must be chewed upon awakening and then repeated-
ly during the day to assist in abstinence, because a single piece of
gum is apparently only effective for a few hours. Although many
over-the-counter silver acetate smoking remedies are available, their
efficacy never has been validated scientifically.

Conclusions

In evaluating experimental and clinical trials involving nicotine
polacrilex gum, it should be noted that actual nicotine intake may
have been significantly less than had been intended or reported if
there were not systematic procedures to standardize administration
(Benowitz et al. 1986; Nemeth-Coslett et al. 1987; Chapters II and
IV). Criteria for the determination of successful outcome in nicotine
replacement studies are ambiguous. It is unclear how to interpret
results in which nicotine replacement is significantly more effective
than a placebo at 6 months, but not at 1 year (Fagerstrom 1982a;
Schneider et al. 1983). Nicotine replacement may be effective in
facilitating cessation and in developing early resistance to relapse
(withdrawal symptoms, reported cravings for tobacco; Harackiewicz
et al. 1987; Hjalmarson 1984; Hughes et al. 1984; West et al. 1984a),
but may not have residual effects that prevent relapse (Chapter IV).

Overall, the outcomes of experimental and clinical trials of
nicotine polacrilex gum are modestly encouraging, at least for short-
term results. In the vast majority of these trials, however, nicotine
polacrilex gum has been combined with additional treatment
components.

The combination of low doses (with the 2-mg gum), poorly defined
criteria for self-administration, compliance problems, and variable
absorption of nicotine from polacrilex gum is part of the rationale for
the development of alternative replacement strategies (Pomerleau et
al. 1988). At the same time, additional work with nicotine polacrilex
gum is continuing to address compliance and dosage problems.
Availability of a 4-mg preparation might be useful for highly
tobacco-dependent individuals. Little clinical application of other
replacement strategies has been reported to date. Alternative forms
of nicotine replacement should help to determine the relative roles of
nicotine and sensory/ritual phenomena in compulsive tobacco use

486


and improve the therapeutic effectiveness of nicotine replacement
strategies.

The precedent for the use of pharmacologically based therapies to
help establish and maintain abstinence from tobacco products is the
use of similar kinds of techniques to treat other substance-use
disorders. It should be noted, however, that some variant on each of
the pharmacologic treatment approaches described in this review
has been applied to other forms of substance abuse, but with limited
success. Individual differences are very important. Some smokers
appear to be much more dependent upon the pharmacologic proper-
ties of nicotine (both withdrawal relief and positive mood enhance-
ment) than are others (Chapters IV and VI). The efficacy of
pharmacologic intervention may be limited by the extent to which
the substance-seeking behavior and the desired effects have become
functionally autonomous from the drug itself. This problem is not
unique to tobacco (Henningfield and Brown 1987). It is known that
treating opiate users involves considerably more than blocking
physiological withdrawal; an entire lifestyle may require change
(Grabowski and Hall 1985; Bigelow, Stitzer, Liebson 1986).

Behavioral Treatment Strategies

Pharmacologic strategies may have a useful role in alleviating
withdrawal symptoms or in blocking gratification typically derived
from smoking, but these agents do not address conditioned cues and
reinforcers or the social context of tobacco use. Effective treatment
of the dependent smoker requires behavioral intervention in addi-
tion to any pharmacologic agents that might be administered.
Research generally indicates that pharmacologic intervention is
most effective when applied in a context that includes social support
and skills training (Fagerstrom 1988; Hall, Ginsberg, Jones 1986).
Furthermore, behavioral intervention may also be useful in increas-
ing adherence to pharmacologic treatment procedures (Epstein and
Cluss 1982).

Behavioral interventions have been applied in treating dependent
smokers for many years. This Section will provide an overview of
that research, with an emphasis upon current approaches. The
review of the literature is necessarily both selective and limited. A
major review in a previous Report of the Surgeon General (US
DHEW 1979) listed 452 references. Schwartz (1987) prepared a
comprehensive monograph reviewing smoking cessation in the
United States and Canada. Although he focused upon the period
1978-85, he included 883 references. As noted above, some topics are
deliberately either excluded or minimized because they have re-
ceived extensive coverage in recent Reports. These topics include
physician intervention, community trials, and worksite smoking
programs. Excellent reviews of other approaches such as self-help

487


and use of the mass media are available elsewhere (Flay 1985a;
Schwartz 1987). These methods are not considered in the current
Report. It is recognized, however, that self-help, mass media,
physician, worksite, and community interventions can have critical
impact in overall public health initiatives designed to address the
smoking problem. The vast majority of smokers who have quit to
date have done so in the absence of formal treatment.

Schwartz (1987) compiled a summary table listing quit rates of 416
smoking cessation trials by method. This Table is reprinted here as
Table 2. The Table provides overall outcomes for a number of
different intervention techniques. As discussed by Schwartz, how-
ever, considerable caution is needed in interpreting these data.
Methodology in the various studies is uneven. Many studies suffered
from deficient followup procedures and from an exclusive reliance
upon subject self-reports. Noteworthy perhaps is the difference in
outcome between nicotine polacrilex gum trials using gum alone and
those combining nicotine polacrilex gum with behavioral interven-
tion. Reported outcomes for programs including multiple compo-
nents (40 percent l-year median abstinence) are encouraging. The
relative success achieved by cardiac patients indicates that treat-
ments delivered at the time of a health crisis may be especially
effective.

Aversion Procedures

Aversive strategies have involved pairing smoking with unpleas-
ant imagery scripts (covert sensitization), with electric shock, or with
the unpleasant effects produced by smoking itself (directed smoking
procedures). All these techniques are designed, at least in part, to
create aversions to cigarette smoke-affective reactions character-
ized by distaste, disgust, fear, or displeasure. The presumption is that
such reactions will reduce the incentive to smoke. A wide variety of
directed smoking strategies have been used. These include satiation,
rapid smoking, and focused smoking.

Satiation

In this procedure cigarette consumption is dramatically increased
prior to attempted abstinence. Smokers typically are asked to at
least double their smoking intake. Despite promising early results
(60 percent abstinence at 4-month followup, N=40; Resnick 19681,
satiation procedures by themselves do not produce effects greater
than those of attention/placebo interventions (Claiborn, Lewis,
Humble 1972; Lando 1975; Sushinsky 1972).

In its most recent application, satiation has been used in multi-
component programs (Best, Owen, Trentadue 1978; Lando 1977), in
which its contribution to outcomes has been difficult to ascertain.

488


TABLE 2.-Summary of followup quit rates (percentages) of 416 smoking cessation trials, by method,
      reported 1959-1985


                           Quit rate (at least 6mo followup)                  Quit rate (at least 1-yr followup)

                        Number                          Percent        Number
Intervention method                                                                           Percent
                         of trials     Range       Median       33%         of trials      Range       Median      33%


Self-help                       11         O-33        17         18            7         12-33        18        14

Educational                      7         XL50        36         71            12        15-55        25        25

Five-day plan                    4        11-23        15          0           14         1640        26        21

Group '                        15         o-54        24         20           31         5-71        28        39

Medication                      7         O-47        18         14           12         6-50        18.5       17

Nicotine chewing gum               3         17-33        23         33            9         a38        11        11

Nicotine chewing gum and
behavioral treatment or therapy         3         23-50        35         67           11         12-49        29        36

Hypnosis, individual                11         O-60        25         36            8         13-66        19.5       38

Hypnosis, group                  10         868        34         50            2         14-68        -        50

Acupuncture                     7         5-61        16         29            6         E-32        27        0

Physician advice or counseling          3         5-12         5          0           12         3-13         6        0

Physician intervention
more than counseling                3         23-40        29         33           10         13-38        22.5       20

Physician intervention,
pulmonary patients                10        10-51        24         20            6         25-76        31.5       50


TABLE %.-Continued

Intervention method

Nlllllber
of trials

Quit rate (at least 6mo followup)


  Range       Median

Percent
33%

    Quit rate (at least 1-yr followup)

NUIlllW                        Percent
of trials     Range       Median     33%

Physician intervention,
cardiac patients                   5        21-69        44         60           16        11-73        43       63

Risk factor                     -          -         -         -            7        12-46        31        43

Rapid smoking                   12         7-62        25.5        33            6         6-40        21        17

Rapid smoking and other procedures      21         6-67        36         57           10         l-52        30.5       50

Satiation smoking'                 11        14-76        36         64           12        16-63        34.5       56

Regular-paced aversive smoking'         13         o-56         29         31            3        20-39        26        33

Nicotine fading*                   7        26-46        27         29           16         7A6        25        44

Contingency contracting'              9        25-76        46         89            4         14-36        2l        25

Multiple programs'                13        la-52        32         36           17         676        40        66


NO'lX Percent 33% is percentage of trials wth quit rates of at least 33 percent. Median not calculated for fewer than three trials. Caution: Quit rates provided suggest overall trends. Most quit
rates were based on self-repxts. Some quit rates were recalculated to include all subjeetn. but meet quit rates were based on reports by investigators. Some quit ratea omitted subjects who did not
complete treatment or persons who did not reply to followups. Definitions of followup may very between trials.
' Three group trials had Cmonth followups.
`Other procedures may have been wed, end enme trials may be included in more than one method.
SOURCE: Sehwertz (1987).


Lando (1982) conducted a dismantling strat.egy in which he attempt-
ed to isolate the specific contributions of individual treatment
components to gauge the relative contribution of satiation to a
multicomponent treatment. By itself satiation produced dismal
results (15 percent l-year abstinence, N = 13). When satiation has
been incorporated into multicomponent treatments that include
maintenance, l-year followup results have approached 50 percent
(Land0 and McGovern 1985). Lando (1986) has suggested that
satiation represents a plausible preparation strategy for quitting.
However, there is little evidence that satiation results in an aversion
to cigarettes (Baker et al. 1984; Tiffany, Martin, Baker 1986).

Rapid Smoking

Rapid smoking typically requires smokers to inhale cigarette
smoke every 6 set until they reach the point that they would become
ill if they were to continue. Whereas early interventions varied the
number of rapid smoking sessions to fit client needs (Lichtenstein et
al. 19731, more recent applications have tended to use standardized
regimens involving six to eight sessions (Erickson et al. 1983; Hall,
Rugg et al. 1984).

Multicomponent programs including rapid smoking generally
yield good outcomes, but when used by itself, rapid smoking
continues to yield variable results. Raw and Russell (1980) found
that rapid smoking, cue exposure, and group/therapist support all
produced poor outcomes when used separately (only 1 of 16 (6
percent) rapid smoking subjects was abstinent at 1 year). Similarly
discouraging results have been reported by Poole, Sanson-Fisher,
and German (1981) and by Corty and McFall(1984). In contrast, Hall
and associates have consistently obtained high rates of success (50
percent 6-month abstinence levels) using rapid smoking alone, both
with normal volunteers (Hall, Sachs, Hall 1979) and medical patients
(Hall, Sachs et al. 1984).

Hall, Sachs, and colleagues (1984) observed that, in contrast to
many recent applications of rapid smoking, their procedure was
similar to that of early, successful rapid-smoking interventions
(Lichtenstein et al. 1973). Their procedure involved (a) a single client
form& (b) a warm client-therapist relationship, (c) positive expecta-
tions of success, (d) individualized scheduling, (e) offlice rather than
home treatment, and (f) warnings against smoking outside of
therapy sessions (Danaher 1977). However, Hall's research involved
either elaborate physiological/medical assessment (Hail, Sachs, Hall
1979) or the use of medical patients as subjects (Hall, Sachs et al.
1984). Either of the latter two factors could have enhanced the
effectiveness of rapid smoking. At this point, the weight of evidence
suggests that rapid smoking by itself can have a substantial
immediate impact on cessation (Poole, Sanson-Fisher, German 1981).

491


The long-term effects of rapid smoking do not appear to be sufficient
by themselves to prevent relapse. Hall's results suggest that rapid-
smoking effectiveness is greatly influenced by auxiliary treatment
elements such as a warm interpersonal atmosphere, positive expec-
tations, and admonitions regarding smoking.

Multicomponent programs involving rapid smoking have general-
ly obtained reasonably high long-term cessation rates, i.e., 40 percent
abstinence at 6 to 12 months posttreatment (Brandon, Zelman,
Baker, in press; Erickson et al. 1983; Hall, Rugg et al. 1984; Tiffany,
Martin, Baker 1986). The relative success of multicomponent pro-
grams comprising rapid smoking has been noted by earlier reviewers
(Lichtenstein 1982; Pechacek 1979). Considerable research has been
conducted to characterize the nature of the processes subserving
rapid-smoking effectiveness. One approach to this problem is to
determine whether rapid smoking results in a conditioned aversive
response. In this regard, researchers have demonstrated that after
rapid smoking, individuals show a conditioned tachycardia to
cigarettes. The magnitude of this tachycardiac response is increased
when the aversive smoking procedure produces intense gastrointesti-
nal discomfort. The magnitude of this response is positively related
to relapse latency-the greater the tachycardiac response, the longer
smokers take to relapse (Erickson et al. 1983; Tiffany, Martin, Baker
1986). The similarity of these results to those found with chemical
aversion treatments of alcoholism (Baker, Cannon et al. 1984;
Cannon et al. 1986) suggests that part of the success of rapid smoking
may be due to taste aversion learning. Thus, some aversion indices
may constitute rare examples of therapy process measures that are
predictive of treatment success. Previous attempts to assess aversion
acquisition may have yielded inconsistent findings because the
investigators attempted to relate clinical outcomes to unconditioned
stimulus magnitude (e.g., number of cigarettes smoked in aversion
sessions) or to unconditioned response magnitude (rapid-smoking-
induced malaise) rather than to conditioned response magnitude
(e.g., the cardiac response elicited by the taste of cigarettes; Glasgow
et al. 1981; Norton and Barske 1977; Merbaum, Avimier, Goldberg
1979; Russell, Epstein, Dickson 1983).

Reduced-Aversion Techniques

Some investigators have compared rapid smoking and alternative
low-aversion treatments for their abilities to enhance the effective-
ness of a behavioral counseling or self-management treatment.
Focused smoking, in which the person smokes for a sustained period
but at a slow or normal rate, and rapid puffing, in which a person
smokes rapidly but does not inhale, often are used as comparison
conditions in order to permit assessment of specific effects of
aversion (Danaher et al. 1980; Erickson et al. 1983; Hall, Rugg et al.

492


1984). While these treatments are unpleasant, they differ from rapid
smoking in that they do not elicit the dysphoria produced by rapid
smoking and they are less risky (Erickson et al. 1983; Glasgow et al.
1981; Tiffany, Martin, Baker 1986). Most research suggests that
these alternative treatments produce long-term outcomes that are
quite similar to, or just moderately lower than, those produced by
rapid smoking (Danaher et al. 1980; Erickson et al. 1983; Hall, Rugg
et al. 1984; Powell and McCann 1981; Tiffany, Martin, Baker 1986).
Moreover, research shows that these treatments do not produce the
conditioned cardiac response produced by rapid smoking. Thus, these
treatments probably produce their effects through routes other than
aversion conditioning. That low-aversion treatments produce effects
comparable to those of rapid smoking indicates that aversion
acquisition per se is not essential to successful treatment outcome.
Other active components might be habituation to cigarettes, with-
drawal reduction due to nicotine intake, and removal of control over
smoking.
There has been concern about the possible effects of rapid smoking
on the cardiovascular system. Horan and coworkers (1977) reported
that rapid smoking produced elevations in blood pressure, heart rate,
and carboxyhemoglobin levels as well as electrocardiographic abnor-
malities. Lichtenstein and Glasgow (1977) provided recommenda-
tions for screening and subject selection. Recent research suggests
that the rapid-smoking procedure is fairly safe when used with
healthy adults screened for such conditions as cardiovascular
disease, diabetes, chronic obstructive pulmonary disease, seizure
disorder, and hypertension (Hall, Sachs, Hall 1979; Sachs et al. 1979).
Rapid smoking has been used safely even with medical populations
(cardiac and pulmonary patients) in the presence of close medical
supervision (Hall, Sachs et al. 1984). However, given that in the
context of multicomponent programs focused smoking and rapid
puffing yield results roughly comparable to those of rapid smoking,
there appears to be little need to use rapid smoking with at-risk
populations (e.g., cardiac and pulmonary patients).

Aversion therapies for smoking are constrained by some of the
same limitations that apply to the use of aversion therapies for other
forms of substance seeking. The aversions are rarely permanent, and
the aversive conditioning is less effective in attempts to establish an
aversion to substances that have had a history of repeated use.

Relaxation Training

Progressive relaxation is a popular treatment for anxiety-related
disorders (Haugen, Dixon, Dickel 1958). As noted previously, smok-
ers often report smoking to cope with anxiety and stress (Chapter
VI). A large proportion of smoking relapses occurs during negative
emotional states (Brandon, Tiffany, Baker 1986; Marlatt and Gordon


1980; Shiffman 1982). In theory, relaxation training should provide
smokers with a means other than smoking for coping with stress and
negative emotion. In a nontreatment experiment, relaxation was
found to reduce levels of smoking in the face of external stress
(Dobbs, Strickler, Maxwell 1981). Today, relaxation is rarely used as
a sole treatment and is instead incorporated into multicomponent
behavioral skills training programs (Erickson et al. 1983; Hall, Rugg
et al. 1984; Hall et al. 1985; O'Connor and Stravynski 1982; Tiffany,
Martin, Baker 1986); it may best be conceptualized as one of many
possible stress-coping skills taught to clients. Poole, Sanson-Fisher,
and German (1981) found that relaxation training did not improve
the outcome of a rapid-smoking treatment. Seventy-five subjects
were assigned to rapid smoking only; rapid smoking and relaxation
training; rapid smoking, relaxation, and contingency contracting; or
contingent rapid smoking. In none of these conditions did l-year
abstinence exceed 25 percent.

Contingency Contracting

Operant conditioning techniques have been used in smoking
treatments to reward clients for not smoking and/or to punish them
for smoking. The usual procedure is to collect monetary deposits
from clients early in treatment with periodic repayments contingent
on client achievement of abstinence goals. Variations include having
the client pledge to donate money to a disliked organization or
individual for every cigarette smoked, or contracting for nonmone-
tax-y rewards and punishments based on smoking status CLando 1977;
Tiffany, Martin, Baker 1986).

The rationale behind contracting techniques is that they may
bolster commitment to abstinence by providing contingent concrete
rewards. Contracts are in effect until withdrawal has abated and the
individual has had an opportunity to begin alternative, nonsmoking
activities that may be rewarding. Murray and Hobbs (1981) com-
pared the effects of self-reinforcement ($1 reward per day for
meeting smoking reduction goal), self-punishment ($1 forfeited for
not meeting goal), combined self-reward and self-punishment, and
self-monitoring alone on cessation. They found that only self-punish-
ment led to improved outcomes: 11 of 20 subjects (55 percent) in the
two self-punishment conditions reached abstinence versus only 1 of
20 subjects (5 percent) in the other two conditions. Three years
posttreatment, 25 percent of self-punishment subjects still reported
abstinence. A small sample size and reliance on self-report, however,
indicate the need for caution in interpreting these findings.

Paxton (1980) compared multicomponent behavioral interventions
with and without contingency contracting (weekly repayments if
subjects were abstinent) and found that contracting significantly
improved maintenance of abstinence, but only during the 8 weeks of

494


repayment. The end of the repayment schedule was followed by a
sharp increase in relapse, and no subsequent difference between
conditions was found. Overall abstinence at 6-month followup was 42
percent (25 of 60 subjects). Bowers, Winett, and Frederiksen (1987)
also reported that extended contingency contracting delayed and
decreased relapse, but they did not report abstinence rates. In a
variation of the contracting procedure, Stitzer and Bigelow (1982)
provided contingent payments of $5 to subjects for reducing carbon
monoxide (CO) levels by 50 percent. Other attempts to increase the
effectiveness of contingency contracts by manipulating the length,
frequency, or amount of repayment or the frequency or size of
deposits have largely been unsuccessful (Paxton 1981, 1983). Yet
when it is part of a multicomponent program, contingency contract-
ing appears to aid smoking cessation, at least over the short term.

Social Support

Attempts to capitalize on the effects of social support in treatment
settings have met with mixed results. Hamilton and Bornstein (1979)
developed a package that included a buddy system among group
members and public announcements of client successes at quitting
smoking. When this package was appended to a behavioral treat-
ment program, it significantly increased abstinence rates compared
with those for behavioral treatment alone both at treatment
termination (55 vs. 27 percent) and during the 6 months of followup
(27 vs. 9 percent; N=12 in each of these two conditions). Etringer,
Gregory, and Lando (1984) were able to improve smoking treatment
outcome over the short term by emphasizing group cohesion.
McIntyre-Kingsolver, Lichtenstein, and Mermelstein (1986) exam-
ined the effects of including clients' spouses in a smoking cessation
program and teaching them how to be supportive of the clients'
quitting attempts. At the end of treatment, 73 percent of clients in
the spouse-training condition (total N = 33) were abstinent compared
with only 48 percent in the condition without spouse training (total
N=31). This difference failed to reach significance, however, and
diminished during followup. In another study, the outcome of a
work&e-controlled smoking program was not affected by encourag-
ing the social support of quitting coworkers (Malott et al. 1984).
Lichtenstein, Glasgow, and Abrams (1986) summarized the results of
five recent smoking cessation studies from three separate research
programs (including McIntyre-Kingsolver, Lichtenstein, and Mer-
melstein (1986) and Malott and coworkers (1984)). Results generally
indicated a positive relationship between measures of social support
and treatment outcome. However, specific attempts to improve
outcome by enhancing social support were uniformly unsuccessful.

495


Coping Skills Training

The value of coping skills training is suggested by evidence that
smokers who use cognitive and/or behavioral coping responses when
they are tempted to smoke reduce their likelihood of relapsing
(Shiffman 1984a). The rationale for coping skills training of tobacco-
dependent individuals is similar to that for such training in other
forms of drug dependence. Alternative behavioral repertoires are
developed that help to maintain comfortable, satisfactory function-
ing in the absence of drugs (Grabowski and Hall 1985; Jasinski and
Henningfield 1987).

Examples of behavioral coping responses are distracting activities,
escape from a stressor, relaxation, and physical activity. Cognitive
coping may involve reminding oneself of the benefits of quitting or
the negative consequences of smoking or simply telling oneself that
smoking is not an option. Coping responses may be directed either at
the smoking temptat.ion/urge itself or at a precipitating stressor
(Wills and Shiffman 1985).

Coping skills training is generally used in cessation research as
part of multicomponent treatments (Brandon, Zelman, Baker, in
press; Davis and Glaros 1986; Erickson et al. 1983; Hall, Rugg et al.
1984; Tiffany, Martin, Baker 1986). There is considerable variation,
however, in the specific coping skills taught, in the strategies used to
teach them, and in the names given to the treatment. Coping skills
training appears to be effective in enhancing short-term outcomes,
especially when combined with an aversive-smoking procedure. The
long-term effects are less clear. This strategy has the potential for
maintaining changes in smoker behavior because, presumably, once
the skills are learned they may be used long after treatment has
terminated. Nevertheless, in studies of maintenance of abstinence,
results are mixed but generally negative (Glasgow and Lichtenstein
1987). These generally negative results may be a function of the
diversity of treatments in which coping skills training is incorporat-
ed and of inadequate compliance with coping skills techniques.
Adherence to coping skills instructions should be monitored more
closely. Hall, Rugg, and colleagues (1984) found that the outcome
differences between coping skills and discussion conditions were seen
only in clients who smoked 20 or fewer cigarettes/day. It should be
noted, however, that the outcome differences were computed for the
number of cigarettes smoked per day and not for abstinence rates.
Coping skills training may be most effective for certain subpopula-
tions of smokers, such as less-dependent smokers (Hall, Rugg et al.
1984; Hall et al. 7985) who smoke primarily to cope with emotional
stress (O'Connor and Stravynski 1982).

496


Stimulus Control

Stimulus control treatments are based on the assumption that a
wide variety of environmental cues are associated with and serve to
trigger smoking. A gradual reduction in smoking is accomplished by
having clients progressively eliminate situations in which they
smoke. In some cases, temporal, rather than situational, constraints
upon smoking are instituted (e.g., the individual is permitted to
smoke only on the half hour; Shapiro et al. 1971). In theory, a
gradual reduction in smoking should result in a weaker, more
manageable withdrawal syndrome.

Stimulus control procedures generally have produced weak, tran-
sient results when used alone and have been of questionable value
when combined with other self-management techniques (Land0
1978). In more recent studies stimulus control has been used
primarily as an element in multicomponent programs in which its
effectiveness is difficult to ascertain (Best, Owen, Trentadue 1978;
Colletti and Kopel 1979; Colletti, Supnick, Rizzo 1982; Karol and
Richards 1981; Lando 1982; Rabkin et al. 1984).

Nicki, Remington, and MacDonald (1984) added a stimulus control
component, which was designed to maximize client self-efficacy
(Bandura 1977a), to a nicotine fading treatment. The combined
treatment produced a 5-month abstinence rate of over 50 percent-
twice that of the fading procedure alone. This level of success is
unusual in research on stimulus control techniques and may be due
to the self-efficacy manipulation rather than stimulus control per se.
Also, as is true for so much of the smoking cessation literature, the
small sample size used by Nicki and colleagues (fewer than 15
subjects per condition) requires that their results be interpreted
cautiously.

Nicotine Fading

Nicotine fading (or brand switching) is based on a straightforward
pharmacologic rationale. The intensity of the withdrawal syndrome,
including both physical and psychological discomfort, can be reduced
when the dependence-producing drug is gradually withdrawn (at
least within certain limits). The procedure generally involves clients
monitoring their nicotine consumption while switching (in three to
six stages) to cigarette brands with progressively lower rated tar and
nicotine deliveries, and then quitting completely. Chapter V sup-
ports this approach for drugs other than nicotine, and Chapter IV
indicates this for nicotine as well. Foxx and Brown (1979) specifically
assumed that nonabstinent nicotine fading subjects would benefit
from continued smoking of low-tar and low-nicotine brands. In this
study as well as in more recent nicotine fading studies, actual
nicotine dose levels have been uncontrolled. At least some compensa-

497


tion is likely to be occurring, and nicotine reduction is undoubtedly
significantly less pronounced than would be expected based upon
machine-rated nicotine yields (McMorrow and Foxx 1983).

The treatment is based primarily on the idea that a gradual
phaseout of smoking will minimize nicotine withdrawal symptoms.
Nicotine fading can be viewed as an alternative to "cold turkey'*
quitting. However, to the extent that actual nicotine intake is not
decreased or is decreased only minimally (Benowitz et al. 1983), this
procedure might more appropriately be viewed as an additional
preparation method for abrupt cessation. Furthermore, even when
nicotine intake is decreased, thereby potentially reducing physiologi-
cal dependence, postcessation cravings may be relatively unaffected.
These continued cravings can be important in leading a newly
abstinent individual to relapse. Lando and McGovern (1985) suggest-
ed that self-efficacy is increased by allowing clients to experience a
series of successes (in reducing apparent nicotine intake) prior to
quitting.

Nicotine fading should be distinguished from gradual reduction
procedures in which smokers are instructed to progressively reduce
their number of cigarettes. .Procedures that emphasize progressive
reductions in the number of cigarettes generally have been ineffec-
tive. Smokers typically report that the remaining cigarettes are
more reinforcing. Furthermore, they often reach a %tuck point"
beyond which additional reduction does not occur (Levinson et al.
1971).

A preliminary study by Foxx and Brown (1979) assessed a
combination of nicotine fading and self-monitoring, nicotine fading
alone, self-monitoring alone, and a modified American Cancer
Society clinic program. Results at 18-month followup favored the
combined nicotine fading and self-monitoring procedure (4 of 10
subjects or 40 percent were abstinent in this condition as opposed to
no more than 10 percent of the subjects in any of the other three
conditions). In several other studies, however, nicotine fading and
self-monitoring produced less encouraging results (Beaver, Brown,
Lichtenstein 1981; Brown et al. 1984; Foxx and Axelroth 1983; Nicki,
Remington, MacDonald 1984). Lando and McGovern (1985) added a
systematic behavioral maintenance procedure to nicotine fading
with disappointing results (only 8 of 42 or 19 percent of subjects
assigned this procedure were abstinent at l-year followup). Lando
(1987) obtained somewhat more positive findings for a treatment
including nicotine fading and behavioral maintenance (35 percent
abstinence at 1Zmonth followup). However, nicotine fading subjects
in this study were self-selected.

Results for nicotine fading in a field application (community
rather than laboratory setting, lay rather than professional group
leaders) have been encouraging (Land0 1986). Participants were

498


given a choice of preparation strategy (satiation or nicotine fading).
Approximately 80 percent elected the nicotine fading procedure.
Outcomes for nicotine fading and satiation treatments were virtually
identical. Survival analyses performed on field data for several
hundred participants yielded a projected permanent smoking cessa-
tion rate of 32 percent. This projection was based on relapse curves
from 3 to 5year followup data. The choice of preparation strategy
may be effective in enhancing both compliance and outcome.
There is also some evidence that nicotine fading may be useful in
minimal intervention programs (Prue et al. 1983; Scott et al. 1986). A
strategy similar to nicotine fading involves the use of progressively
stronger graduated filters (Martin et al. 1981). Hymowitz, Lasser,
and &&u-stein (1982) found low abstinence rates with this method
and also continued use of the filters by few nonabstinent smokers
after the end of treatment. Improved outcomes might occur if filters
are more systematically linked with multifaceted behavioral inter-
vention.

Controlled Smoking

Controlled+moking programs have been developed to treat smok-
ers who are unable or unwilling to quit completely. This approach is
based in part on the assumption that reduced smoking will be
associated with diminished health risk. The prototypical program
attempts to decrease risk by reducing cigarette consumption, alter-
ing smoking inhalation patterns (e.g., number of puffs, duration of
puffs, CO intake), and minimizing the tar and nicotine content of
cigarettes (e.g., nicotine fading). A key is to change multiple aspects
of the smoking behavior to minimize compensation.

Stimulus control procedures may also be used (Glasgow, Klesges,
Vasey 1983). In addition, clients may be taught coping skills to use as
substitutes for smoking (Frederiksen 1979). Controlled-smoking
treatments have produced reductions of at least 50 percent in the
rated nicotine content of cigarettes smoked, with more modest
reductions in reported numbers of cigarettes, the percentage of each
cigarette smoked, and CO levels (Glasgow, Klesges, Vasey 1983;
Godding and Glasgow 1985; Malott et al. 1984). In general, however,
by the &month followup the magnitude of these initial reductions
had diminished by approximately one-half.

Reservations about the controlled smoking approach center
around the premise that smokers can substantially diminish their
health risk without total abstention. The change in health risks
associated with moderate reduction is not known. Moreover, there is
experimental evidence that smokers regulate their bodily levels of
nicotine through compensatory changes in smoking patterns
(McMorrow and Foxx 1983). These compensatory changes are not
complete, however. In a short-term (3- or 4day) restriction study, a


reduction from an average of 37 cigarettes to 5 cigarettes/day was
associated with a threefold increase in the intake of tobacco toxins
per cigarette (Benowitz et al. 1986). Daily exposure to tar (estimated
by mutagenic activity of the urine), nicotine, and CO declined only 50
percent from the baseline. Thus, consistent with the tendency to
maintain intake of nicotine, the benefit of smoking fewer cigarettes
was much less than expected. Benowitz and associates used laborato-
ry volunteers rather than smokers who were specifically concerned
with reducing their levels of tar and nicotine exposure.

The basic premise of the controlled-smoking approach-that it
reduces health risk-remains to be validated. Some investigators
have argued that until there is clear evidence that controlled
smoking actually decreases health risks, it should not be recom-
mended as a treatment option. Finally, there is concern both that
smokers who otherwise may have been successful quitters will
instead be attracted to controlled-smoking programs (at this point no
data are available) and that these programs may provide an illusion
of safety.

If reductions in smoke exposure can be maintained over time, if a
reduction in health risk can be established, and if clients can be
limited to those for whom the prospect of total abstinence is highly
unlikely, then reduced smoking may be an alternative for recalci-
trant smokers. Given all these conditions, controlled smoking does
not appear likely to represent an effective treatment. However,
possible risk reduction is not the only rationale for this type of
approach. Controlled-smoking interventions may appeal to a larger
cross-section of smokers, may have a positive impact upon self-
efficacy, and may facilitate subsequent progress toward complete
abstinence. Currently, empirical data on these points are lacking.

Multicomponent Programs

In recent years, multicomponent programs have been a principal
target of research. This is due to both the relatively high level of
clinical success produced by these programs (Lichtenstein 1986) and
the recognition that smoking is multidetermined and relatively
invulnerable to any single intervention (Schwartz 1987). The most
effective multicomponent programs yield almost universal short-
term abstinence and long-term abstinence rates that approach or
exceed 50 percent (Brandon, Zelman, Baker, in press; Elliott and
Denney 1978; Erickson et al. 1983; Hall, Rugg et al. 1984; Hall et al.
1985; Fagerstrom 198213; Killen, Maccoby, Taylor 1984; Lando 1977;
Tiffany, Martin, Baker 1986). These results are extremely encourag-
ing and are rarely matched in trials that place exclusive emphasis
upon pharmacologic intervention. Dismantling or constructive stud-
ies have shown that combinations of treatments generally outper-
form any single constituent treatment (Land0 1982).

500


Best, Owen, and Trentadue (1978) compared satiation and rapid
smoking in the context of self-management training. Subjects
rehearsed possible alternatives or coping strategies for each antici-
pated problem situation. Suggested techniques were applied on an
individualized basis and included relaxation, deep breathing, contin-
gency contracting, social support, stimulus control, and behavioral
rehearsal. The overall result with 60 subjects was 47 percent
abstinence at 6month followup.

Powell and McCann (1981) achieved successful results with a
combination of lectures, self-control techniques, and aversive smok-
ing. Aversive smoking consisted of rapid puffing without inhalation
and holding the cigarette in an awkward position. Efforts were made
to increase the unpleasantness of the procedures by providing
ashtrays that were full of cigarette litter, dipping cigarettes in a
bitter-tasting solution, and showing slides of diseased organs. Sub-
jects were randomly assigned to one of three maintenance condi-
tions: a 4week support group, 4 weeks of telephone calls between
subjects, or a no-contact control group. Results for the 51 subjects at
l-year followup were impressive, although there were no significant
differences between conditions. The support group and the no-
contact controls achieved 65 percent abstinence, and telephone
contact subjects achieved 59 percent abstinence.

Hall, Rugg, and colleagues (1984) assessed two levels of relapse
prevention (skills training versus discussion control) and two levels
of aversive smoking (6- vs. 30-set inhalations) in a 2-by-2 factorial
design. Of 135 subjects recruited, 123 completed treatment. Of 14
treatment sessions, 8 included aversive smoking. Six sessions were
devoted to relapse prevention. Specific skills training components
included cue-produced relaxation, commitment enhancement, and
rehearsal of commonly experienced relapse situations. Subjects
assigned to the skills training condition were more likely to report
use of coping skills. One-year abstinence outcomes were as follows:
52 percent for 6sec inhalations/skills training, 39 percent for 30-set
inhalations/skills  training,  34 percent for 6-set inhala-
tions/discussion, and 26 percent for 3O-sec inhalations/discussion.
Skills training was superior to the discussion control at the l-year
followup (dropouts were excluded from this analysis). No differences
were observed between the 6 and 3O-see smoking procedures.

Lando (1977) compared a comprehensive treatment procedure
(satiation, contingency contracts, group support, booster aversion)
against a satiation control. Subjects were seen in small groups. All
subjects attended six treatment sessions over a l-week period.
Subjects assigned the comprehensive intervention attended an
additional seven sessions during 2 months of maintenance. Results
at 6-month followup indicated 76 percent abstinence for the compre
hensive procedure and 35 percent abstinence for the satiation

501


condition. However, it should be noted that these results were based
upon a total of only 34 subjects and 2 small groups per condition.
Lando (1981) assigned 99 subjects to a 2-stage treatment (aversion
and maintenance) similar to that employed in his 1977 study or to a
3-stage procedure that also included fear appeals and stimulus
control. Subjects were in addition randomly assigned to intensive or
minimal contact conditions. Efforts to implement a maintained
reduction procedure among nonabstinent subjects were unsuccessful.
One-year followup results favored the two-stage intensive contact
procedure. The group of subjects in this condition achieved a 46
percent abstinence rate whereas subjects in each of the other
conditions attained abstinence rates less than 20 percent. In a 3-year
followup, Lando and McGovern (1982) again found 46 percent
abstinence among subjects in the two-stage intensive treatment
(continuous abstinence from the end of treatment in this condition
was 33 percent).
Elliott and Denney (1978) developed a package treatment encom-
passing self-reward and punishment, cognitive restructuring, applied
relaxation, behavioral rehearsal, systematic desensitization, emo-
tional role playing, covert sensitization, and rapid smoking. This
comprehensive program was compared against rapid smoking by
itself and two control conditions. Six-month followup results (N=60)
indicated a significant effect in favor of the package treatment.
Subjects in this condition achieved a 45 percent abstinence rate as
opposed to 17 percent for rapid smoking by itself, 12 percent for a
nonspecific control, and 0 percent for an untreated control.
Erickson and colleagues (1983) assigned subjects to either rapid
smoking or to a less-aversive rapid-puffing procedure. These subjects
also were assigned behavioral counseling which included training in
problem-solving strategies. A comparison group underwent only
behavioral counseling, without any aversive smoking. Results fa-
vored the combination of rapid smoking and behavioral counseling.
At l-year followup 70 percent of rapid-smoking subjects and only 33
percent of rapid-puffing and 14 percent of behavioral counseling
subjects reported abstinence. A total of only 26 subjects were
included in this study.
Tiffany, Martin, and Baker (1986) assessed full-scale rapid smok-
ing with full counseling, truncated rapid smoking with full counsel-
ing, rapid puffing with full counseling, and full-scale rapid smoking
with reduced counseling. Eighty-two subjects completed treatment.
During behavioral counseling, subjects learned to anticipate poten-
tial problem situations and to plan coping strategies for these
situations. The full-scale rapid-smoking and rapid-puffing proce-
dures included three trials per session. Truncated rapid smoking
consisted of only one trial per session. Reduced counseling empha-
sized support and encouragement rather than specific behavioral


procedures. Six-month followup results favored the fullacale rapid-
smoking and rapid-puffing conditions combined with full-scale
counseling (59 and 55 percent abstinence, respectively). Either
truncated rapid smoking or reduced counseling appeared to detract
from effectiveness (35 percent of subjects in each of these conditions
were abstinent at C-month followup).

As noted in the section on methodological issues in treatment
(below), many multicomponent treatments are based on clinical
intuition or on the effectiveness of a treatment when used by itself
and few are based on an explicit theory or model of addiction and
behavioral change. Moreover, few multicomponent evaluative stud-
ies contain sound process measures that tap processes theoretically
linked to particular interventions. Therefore, even though multicom-
ponent treatments are often effective, the basis of their efficacy is
little understood.

It is unclear why particular treatment elements are effective when
combined. Perhaps these elements interact so that an individual who
would not be especially helped by one treatment is aided by the
combination. Perhaps the treatment components are additive be-
cause their individual effects are largely independent. To investigate
the nature of multicomponent treatment effects, researchers might
strive to develop experimental designs that are sensitive to particu-
lar components and to determine whether these reflect interactive
effects when auxiliary treatments are added. It is recognized,
however, that required numbers of subjects and statistical power
issues often render this type of approach impractical. Furthermore,
isolation of very precise or subtle treatment elements, as opposed to
major differences, appears both impractical and unlikely (Land0
1982).
Some multicomponent treatments contain elements that are
labeled as "maintenance" and are delivered during the postcessa-
tion, followup interval. These are based on the notion that extending
therapist contact or skills training in the followup interval will
prolong treatment gains. Evidence is mixed as to whether such
maintenance treatments significantly enhance the long-term effec-
tiveness of complete, multicomponent programs (Brandon, Zelman,
Baker, in press).

Although multicomponent programs are often very effective, more
is not always better (Land0 1981). Inclusion of too many procedures
may overwhelm subjects and thereby reduce adherence to treat-
ment. A point of diminishing returns may be reached by simply
adding additional components to an already complex intervention.
Combinations of multicomponent behavioral treatment and pharma-
cologic intervention may be promising for highly dependent smok-
ers, especially for those who have been unable to achieve even short-
term abstinence despite repeated attempts.

503


Other Treatment Strategies
Hypnosis

The usual intent of hypnosis is to increase client motivation or
ability to quit smoking through posthypnotic suggestions. The most
commonly used posthypnotic suggestions are variations of those
originated by Spiegel (1970): (1) smoking is a poison to your body; (2)
you need your body to live; and (3) you owe your body this respect
and protection (Berkowitz, Ross-Townsend, Kohberger 1979; Hyman
et al. 1986; Javel 1980; Perry, Gelfand, Marcovitch 1979). Sugges-
tions may also involve problem-solving techniques (Frank et al. 1986;
Javel 1980), review of the client's history of smoking (Javel 1980),
desensitization to environmental cues (Wagner, Hind&Alexander,
Horwitz 1983), and an assortment of other elements (Katz 1980).
Despite the variety of possible hypnotic procedures, some research
reports fail to describe the procedure used (Lambe, Gsier, Franks
1986; Schubert 1983). Hypnosis might most usefully be applied to the
small percentage of the population that is highly susceptible to
hypnotic induction. Some individuals are essentially unresponsive to
hypnosis, .whereas others evidence varying degrees of susceptibility.
Individual differences in hypnotic susceptibility have in fact influ-
enced outcome (Perry and Mullen 1975; West 1977), although this
has not been reported by all investigators (Mott 1979).

No significant outcome differences were found when posthypnotic
suggestions were compared with suggestions without hypnosis (Javel
1980), with suggestions after relaxation (Schubert 1983), with
focused smoking or an attention placebo control condition (Hyman et
al. 1986>, or with behavior modification or health education interven-
tions (Rabkin et al. 1984). Most studies have found hypnosis to be
superior to no-treatment control groups, although Lambe, Osier, and
Franks (1986) found no such difference. Followup abstinence rates
reported for hypnosis in recent studies have ranged from less than 4
percent (Perry, Gelfand, Marcovitch 1979) to 60 percent (Javel 1980),
with a mean of approximately 28 percent. These figures may be
spuriously high because several studies reported less than 6 months
of followup and most relied exclusively on subject self-report.

There is little evidence that hypnotic induction per se facilitates
smoking cessation and maintenance above and beyond the effects of
other treatment components (including the posthypnotic suggestions
themselves) (Holroyd 1980; Katz 1980).

Acupuncture

Acupuncture involves the use of needles or staple-like attachments
and commonly is given at the ear either by press needle or staple
puncture. Acupuncture has gained popularity over the past 10 years
(Schwartz 1987). There are few carefully controlled evaluations of

504


this procedure for smoking cessation. Many published reports have
suffered from serious methodological shortcomings (e.g., lack of
control conditions, short or nonexistent followup periods, failure to
include data from all treated subjects). Six studies have compared
acupuncture at the "correct" site for smoking cessation against an
"incorrect" or sham site. In only one study (MacHovec and Mann
1978) was the correct site significantly superior to the sham site. As
with hypnosis, most evaluations of acupuncture have relied exclu-
sively on self-reports. At this point, there is little evidence that
acupuncture relieves withdrawal symptoms or promotes smoking
cessation. A combination of acupuncture and supportive counseling
or skills training may be more effective (Schwartz 1987).

Treatment of Special Smoker Populations

Recognition of smoking as a dependence-producing behavior leads
to important implications in treating several populations of smokers
including women, blacks, and Hispanics. Current trends (Appendix
A) indicate that the burdens of smoking in the future may be
disproportionately felt by lower socioeconomic and minority popula-
tion groups. For treatment to have optimal impact, it must meet the
needs of smokers from diverse circumstances. Presently, the vast
majority of those who avail themselves of formal intervention are
white and are from relatively advantaged socioeconomic back-
grounds.

It is not obvious that interventions for special populations should
differ substantially from those that are currently available. There
are indications based on smoking patterns and environmental and
social factors that suggest the importance of tailored intervention. A
great deal more research is needed, however. At this point, for
example, it is unclear whether self-help treatment manuals oriented
to specific target groups are preferable to more general manuals.
Currently there are almost no materials or programs prepared
especially for blacks or Hispanics. If the needs of lower SES and
minority smokers are not met, the trend for smoking to be
disproportionately concentrated among these groups is likely to
continue. Considerations of treatment for the dependent smoker are
not complete without substantial attention to issues of application
and dissemination, especially to smokers not being served by current
interventions.

Applying Smoking Interventions to Women
Sex Differences in Cessation and Relapse Rates

Trends in cigarette smoking among men and women in this
century have followed roughly similar curves, except that increases
and decreases in smoking prevalence among women have lagged 15


to 30 years behind rates for men (Harris 1983; US DHEW 1980,
Appendix A). Recent declines in overall smoking prevalence are
attributed to lower initiation rates among teenage males and higher
cessation rates among adult males Remington et al. 1985). The
percentage of former smokers in the male population has increased
more dramatically than the percentage of former smokers in the
female population (Appendix A). Jarvis (1984) adjusted cigarette
cessation rates in Britain and in the United States to reflect the
proportion of males who switched from smoking cigarettes to
smoking pipes and cigars. After this adjustment, sex differences in
cigarette cessation rates disappeared for individuals under age 50.
Several recent, well-controlled prospective evaluations of cigarette
cessation programs found no differences in the proportions of women
and men who achieved initial cessation and/or long-term mainte-
nance (Curry 1986; Gritz 1982; Hall, Ginsberg, Jones 1986). The
question of whether previously observed gender differences in
cessation and relapse rates (the magnitude of which is often small)
reflect real and stable sex differences, historical effects true only in
older smokers, or statistical artifacts due to analytical limitations is
not resolved,
Motivation to quit. In one of the few studies addressing gender
differences in motivation to quit, Curry (1986) found that successful
male and female abstainers did not differ in their overall reasons for
quitting (e.g., "Smoking is inconsistent with my commitment to good
health"). However, women in Curry's (1986) study differed signifi-
cantly from men on questions related to four more specific subdimen-
sions of motivation: self-determination (,`I will like myself better"),
reinforcement ("My hair and clothes won't smell"), influence of
significant others (,*I can get praise from people I am close to [for
quittingr'), and social consequences ("Smoking is less socially
acceptable"). Perhaps these more specific reasons for quitting should
be considered in tailoring the content of smoking treatments to
female subjects.
Education. The personalization (perception of the personal rele-
vance) of abstract information has been shown to be an important
aspect of behavioral change in general (Mahoney 1974) and of
health-related behavioral change in particular (Ben-Sira 1982;
Schinke and Gilchrist 1984). Available evidence suggests that many
women may not fully be aware of some important gender-specific
health consequences of smoking (Shiffman 1986b; Sorensen and
Pechacek 1987). Adolescent women in particular often either are not
well informed or choose to ignore information on the harmful effects
of smoking during pregnancy (Simms and Smith 1983; Stewart and
Dunkley 1985). It may be useful to develop educational campaigns
that publicize the gender-specific risks of smoking.


Information that might be used in such educational campaigns
comes from studies of important adverse interactions between
smoking and female physiology, especially estrogen-related pro-
cesses. Several studies have found a positive association between
cigarette smoking and early menopause (Baron 1984; Willett et al.
19831, estrogen-related postmenopausal osteoporosis and associated
fractures (Daniel1 1976; Paganini-Hill et al. 1981), and invasive
cervical cancer (Brinton et al. 1986).

Social values and beliefs. Cigarette smoking is a multidetermined
behavior shaped by both personal and environmental variables
(Chassin, Presson, Sherman 1985; Jones and Battjes 1985). The bulk
of research on smoking has assumed that the developmental
pathways leading to cigarette use and later dependence are the same
for males and females. Several lines of recent research suggest that
this assumption is overly simplistic (Barton et al. 1982; Baumrind
1985; Ensminger, Brown, Kellam 1982; Gritz 1982; Yamaguchi and
Kandel 1984). The developmental and social dynamics that propel
female adolescents into smoking may differ from those operating on
young males. Several studies suggest that female smokers appear
attracted to cigarette smoking by a need to identify with a particular
social image (Gritz 1982, 1984; Jacobson 1982, Mausner and Brand-
Spiegel 1985). Studies of advertising influence show that women,
more than men, choose cigarette brands for image reasons (Bergler
1981; Fisher and Magnus 1981). Cigarette smoking today is often
associated in the media with independent women who are not only
sexually desirable (and slender) but also successful in traditionally
male activities (Baker, Dearborn et al. 1984; Godley, Lutzker,
Lamazor, Martin 1984). Reliance on cigarettes for bolstering an
important, self-selected social image may make some women resis-
tant to educational messages on the health consequences of smoking.
Another factor bearing on women's use of cigarettes for social
image reasons involves body size and weight control (Gritz 1985;
Jacobson 1982; US DHEW 1980). Data from junior high students
suggest that even at young ages females more than males are
interested in cigarettes as a weight control aid (Charlton 1984;
Chapter VI).

Achieving Abstinence

Weight gain. Women's fear of weight gain has been widely
observed (US DHEW 1980). Some animal data (Grunberg, Bowen,
Winders 1986; Grunberg, Winders, Popp 1987; Levin et al. 1987) as
well as preliminary results from a study with human subjects
(Klesges, Meyers et al. 1987) suggest that females are more likely
than males to gain weight following removal of nicotine. In contrast,
Hall, Ginsberg, and Jones (1986) found that although all subjects
gained weight after achieving abstinence, weight gain was no more

507


likely to cause female subjects than male subjects to relapse (Chapter
VI). More studies are needed to determine whether fear of weight
gain in the early stages of cessation is a more powerful obstacle for
women than is actual weight gain later in the cessation process.

Stress manogenent. Social, psychological, and epidemiological
studies consistently report the greater importance of cognitive
appraisal processes and monitoring of internal states and feelings on
the part of females compared with males (Blechman 1984). Several
studies have characterized women as negative-affect smokers-i.e.,
individuals who smoke in response to emotional discomfort and for
purposes of tension reduction (Brunswick and Messeri 1984; Christen
and Glover 1983; Dembroski 1984; Livson 1985; Mitic, McGuire,
Neumann 1985; Rust and Lloyd 1982; US DHEW 1980). Other
researchers have found that negative-affect smokers grow more
reliant on cigarettes than do smokers who respond to social or
external stimuli (Ockene et al. 1981; Pomerleau, Adkins, Pertschuk
1978). In current cessation studies, female subjects, compared with
male subjects, have reported more stress during the quit process
(Abrams et al. 1987) and more concern about finding alternatives to
cigarettes for coping with stress (Abrams et al. 1987; Moreton and
East 1983; Sorensen and Pechacek 1987; Chapter VI).
Social support. Women, more often than men, report a preference
for interacting and learning in settings that involve close, informal,
personal, dyadic, or small-group interactions (Brady 1987; Glynn,
Pearson, Sayers 1983; Grady, Brannon, Pleck 1979; Linehan 1984).
Both the quantity and the quality of women's participation increase
in groups composed solely of women (Burden and Gottlieb 1987;
Linehan and Egan 1979; Gambrill and Richey 1986). Grits (1982)
concluded that women are more successful in programs that provide
social support and individualized therapist-client contact, and less
successful in programs in which such support is absent or when
external environmental supports are lacking. Data continue to
indicate the importance of social support (and partner support in
particular) for maintenance of smoking cessation among women
(Coppotelli and Orleans 1985; Sorensen and Pechacek 1987).

Smoking Cessation Initiatives for Black Americans

Black Americans constitute the Nation's largest minority group,
making up 12 percent of the population, and have the highest
smoking rate of the major U.S. ethnic/racial groups; 34.8 percent of
all black American adults smoke, compared with 29.7 percent of non-
Hispanic whites and 25.7 percent of Hispanic adults (Appendix A).
Blacks also suffer the Nation's highest rates of mortality and
morbidity from cardiovascular diseases and cancer, including core-
nary heart disease and lung cancer (Cooper and Simmons 1985; US
DHHS 1985, 1986). Moreover, smoking represents an especially

508


serious health risk for blacks, given the disproportionate incidence of
infant mortality and low birth weight, hypertension, diabetes, and
hazardous occupational exposures within the U.S. black population
(US DHHS 1985). To date, relatively little research has been done to
clarify smoking/quitting patterns and determinants among black
Americans or to test smoking cessation interventions in black
populations.
The 1985 Cancer Prevention Awareness Survey (US DHHS 1987)
found that blacks were less likely than the general public to report
hearing or reading about cancer prevention in the preceding 6
months, and were less likely to view tobacco use as a cancer risk.
There is also evidence that blacks have less belief in personal control
over health outcomes and disease, particularly cancer (Deniston
1981; Snow 1983; US DHHS 1987).

Sociodemographic Factors

The so&demographic correlates of smoking status among black
Americans are similar to those for the U.S. population as a whole:
these include lower income, lower education levels, lower occupa-
tional status, unemployment, being male, and being unmarried
(never married, separated, or divorced) (Eisinger 1971; Marcus and
Crane 1987; Orleans et al. 1987; US DHHS 1985; Warneke et al. 1978).

Restricted Health Care Access

More limited access to health care, particularly to preventive
health services, may also play a role in the higher black smoking
rate (Eisinger 1971; Green 1975; Rogers and Shoemaker 1971; US
DHHS 1985; Warneke et al. 1978). Fewer blacks (54 percent) than
whites (70 percent) report a physician's office as their regular source
of care, and twice as many blacks as whites say they receive their
regular care from hospital outpatient clinics and emergency rooms
or public health clinics (where continuous care and preventive
health services are less likely) (US DHHS 1985). Therefore, it is not
surprising that the 1985 National Health Interview Survey (NHIS)
found fewer adult black smokers (33 percent men, 43 percent
women) than white smokers (40 percent men, 47 percent women)
reporting medical advice to quit smoking (Marcus and Crane 198'7).

Social Norms and Advertising Influences

Peer and family modeling appears to play the usual role in the
initiation and maintenance of smoking as well as in smoking
cessation (Orleans et al. 1987; Warneke et al. 1978). However, the
combination of a higher smoking rate among blacks and a pervasive,
well-financed, black-focused tobacco advertising campaign may lead

509


to stronger smoking norms within the black community (Cooper and
Simmons 1985; Cummings, Giovino, Mendicino 1987; Davis 1987).

Determinants of Quitting Motivation and Success Among Black
Smokers

Factors influencing quitting motivation and success among black
smokers appear to be similar to those among smokers in general,
including beliefs in smoking-related health harms and quitting
benefits; personal relevance of the health threat; a greater number
of sources of support and communication about smoking health risks
and quitting; the extent to which family, friends, and health
professionals provide personal information about smoking risks;
personal medical advice to quit; self-mastery motivation; past efforts
to quit or cut, down; degree of tobacco dependence; and primary
group social supports for quitting and nonsmoking (Eisinger 1971;
McDill 1975; Orleans et al. 1987; Pechacek and Danaher 1979;
Prochaska and DiClemente 1983; Warneke et al. 1978). Again,
however, considerably more research is needed.

Smoking and Quitting Patterns Among Black Americans

Although black smokers smoke fewer cigarettes per day than
white smokers, they smoke brands with higher tar/nicotine yields,
especially menthol brands (Friedman, Sidney, Polen 1986; Appendix
A). The 1981 NHIS showed that 65 percent of black smokers smoked
brands with 1.1 mg or more of nicotine, in contrast to only 35 percent
of white smokers, and that 67 percent of black smokers smoked
menthol cigarettes, in contrast to only 26 percent of white smokers,
In fact, it has been estimated that three high-nicotine menthol
brands account for more than 60 percent of cigarettes purchased by
blacks (Cummings, Giovino, Mendicino 1987). Menthol additives may
pose additional health risks (Cummings, Giovino, Mendicino 1987);
these additives could conceivably influence puffing patterns (e.g., by
reducing the perceived "harshness" of the tobacco) so as to heighten
nicotine delivery or smoking risks (e.g., by enabling the smoker to
tolerate inhaling more often or more deeply or to smoke the cigarette
to a shorter length). However, to date no studies that address this
issue have been published. National survey data (US DID-IS 1985)
suggest that black smokers attempt to quit at the same rate that
white smokers do. However, blacks appear to be less likely to remain
abstinent (Appendix A). Quitting barriers faced more often by blacks
include the same so&demographic factors that explain their higher
smoking rate, including the greater life stress and more limited
resources associated with lower SES.

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Quit-Smoking Treatments

Quitting methods. A recent survey of black ex-smokers showed
that like U.S. ex-smokers as a whole, the vast majority had quit "on
their own": 9 in 10 said they relied on "willpower," and only 1 in 10
reported using formal treatment programs, self-help guides or aids,
or nicotine polacrilex gum (Orleans et al. 1987). There are, to date, no
published data on the extent to which black and white U.S. smokers
differ specifically in their access to, or use of, quit-smoking services
and resources.

Sources/treatment agents. Physicians and other health care provid-
ers are powerful sources of quit-smoking assistance (Orleans 1985)
and may be especially important sources for black Americans. In the
1985 Cancer Prevention Awareness Survey (US DHHS 19871, blacks
reported more often than the general population that they would be
very likely to follow a doctor's advice about ways to reduce cancer
risks (US DHHS 1987).
Messages/methods. It is currently unclear whether black smokers
would benefit any more or less than other groups from generally
effective quit-smoking strategies and treatments. When outreach has
assured equal black-white access to treatments and information
(broadly defined in terms of recruitment efforts, location, affordabili-
ty, appeal, and readability), outcomes for black and white smokers
have been similar. For instance, Windsor and colleagues (1985)
offered clearly worded pregnancy-focused self-help materials on
quitting to women in public health maternity clinics and found no
differences in quit rates between black and white participants of
similar SES. High-coronary-risk black men assigned to the Special
Intervention of the Multiple Risk Factor Intervention Trial (MRFIT)
achieved 6-year quit rates (43 percent) essentially comparable to
those of white participants (46 percent) despite lower SES (Connett
and Stamler 1984). On the other hand, preliminary unpublished
results from several ongoing trials suggest that interventions
developed for the general population may not be appropriate for or
acceptable to lower SES minority smokers.

Channels/delivery modes. Church groups, fraternal organizations,
and other groups within the black community have a unique role to
play in bringing effective programs and resources to the attention of
smokers and to provide support needed for compliance (Eng, Hatch,
Callan 1985; Orleans et al. 1987). Besides improving treatment
accessibility, these organizations have the potential to provide
ongoing assistance and support for quitting efforts and nonsmoking
maintenance. Eng, Hatch, and Callan (19851, for instance, describe
working through black churches in rural North Carolina to offer
smoking cessation, weight control, diet modification, and stress
management health education and behavioral change programs. Lay
health advisers were recruited to work with local professionals to

511


organize church-based health fairs and to provide screening and
referral on an individual basis.

Interventions for Smoking Cessation Among Hispanics

As the most rapidly growing ethnic group in the United States,
Hispanics have caught the attention of demographers, social scien-
tists, and health planners, yet relatively little is known of their
smoking behaviors or responses to various intervention and treat-
ment approaches. There is recent evidence (Davis 1987) that
cigarette advertising is increasingly targeted to specific groups and
that Hispanics have become a major focus of sophisticated marketing
approaches.

Prevalence

Smoking prevalence among Hispanic males is comparable to that
amcng white males and considerably less than that among blacks.
Smoking among Hispanic women, in contrast, is considerably lower
than smoking among either white or black women (Marcus and
Crane 1985). Hispanics consume considerably fewer cigarettes per
day than do whites. Heavy smoking among Hispanics is relatively
infrequent (Marcus and Crane 1985,1987; Samet et al. 1982; Stem et
al. 1975).

Data from the 1985 Current Population Survey indicate substan-
tial differences in smoking status by Hispanic subgroup. More
Puerto Ricans reported smoking than did other subgroups (Mexican-
Americans, Cubans, and Central and South Americans). Caution is
needed in interpreting these data as they are based on limited
numbers of respondents. Marcus and Crane (1985) reported that the
pattern of high smoking prevalence among Hispanic men and
relatively low prevalence among Hispanic women held true across a
number of Hispanic subgroups. Overall, the data suggest consider-
able ethnic diversity within the Hispanic population. Diversity in
smoking prevalence among Hispanics also has been found in the
Hispanic Health and Nutrition Examination Survey (HHANES)
conducted between 1982 and 1984 (Appendix A). Cultural differences
among divergent Hispanic groups may need to be considered in the
design and content of treatment programs.

Smoking Antecedents

Markides, Coreil, and Ray (1987) used data from a three-genera-
tional study and found that smoking behavior among younger
Mexican-Americans was positively correlated with that of their
middle-aged parents. This association was stronger for women. In a
study of Mexican-American high school students who were identified
as potential school dropouts, Bruno and Doscher (1984) found more

512


smokers in this group than among other students. These researchers
found that 56 percent of their survey population of 78 potential
dropouts had increased their cigarette consumption in the previous
year. Otero-Sabogal and colleagues (1986) reported that "positive
social presentation" as a consequence of smoking was mentioned by
Hispanics in their study group. Castro and coworkers (in press) state
that smoking and other habitual behaviors do not occur in isolation,
but are part of a lifestyle. Smoking has been identified by these
authors and others as a "core unhealthy behavior" that is associated
with other such behaviors as use of illicit drugs, alcohol abuse,
driving while intoxicated, nonuse of seat belts, and a pattern of little
aerobic exercise. However, on a test of knowledge about the health
consequences of smoking, moderate-to-heavy cigarette smokers were
the highest scorers, suggesting an intellectual awareness of the risks
involved in their behavior.

Smoking Interventions

The only available study that specifically targeted Hispanics was
reported by Wittenberg (1983). During a market survey for the
"Healthy Mothers, Healthy Babies" campaign, focus groups were
organized to gather information from minority women. Researchers
held sessions with eight groups of black women and seven groups of
Mexican-American women. The results of these sessions suggested
that the women involved largely ignored health advice, including
advice to quit smoking, believing that the negative consequences
would affect the mother and not the baby. Wittenberg (1983) found
that the physician was considered the most credible source of health
information but that family and friends were also important sources
of information, which sometimes was in conflict with professional
advice. Mexican-American women cited a paucity of Spanish-speak-
ing health providers, and both minority groups stressed the need for
such providers to have a better understanding of dietary preferences
and traditional cultural patterns to more adequately serve pregnant
minority women. The roles of the family, the Catholic Church, and
the Spanish language have been said to be at the heart of the
cultural identity of Hispanics in the United States (Guernica and
Kasperuk 1982; Perez-Stable 1987). These influences have not been
systematically assessed or harnessed in the design of smoking
intervention programs for Hispanics.

Research addressing other ethnic groups is virtually nonexistent.

Methodological Issues in Treatment Study Design and
Evaluation

Since the late 1970s researchers and theoreticians have made
progress in developing theoretical comparison strategies in evaluat-
ing pharmacologic and behavioral treatment interventions. This has

513


gradually resulted in the use of more sophisticated analytic compari-
sons in at least a few studies (Brandon, Tiffany, Baker 1987; Hall,
Rugg et al. 1984; Harackiewicz et al. 1987; Raw and Russell 1980;
Tiffany, Martin, Baker 1986). The development of specific measures
and investigator adoption of theory-driven analytic strategies (A-
brams et al. 1987; Davis and Glaros 1986; Erickson et al. 1983; Hall,
Rugg et al. 1984; Harackiewicz et al. 1987; Mermelstein, Lichten-
stein, McIntyre 1983; Shiffman and Jarvik 1976; Tiffany, Martin,
Baker 1986) should result over the next 10 years in a clearer
understanding of therapeutic change processes. Integrated theoreti-
cal approaches in which treatment, subject, and context factors are
considered simultaneously may prove especially fruitful.
A second major methodological concern is the typical smoking
intervention study design. Most researchers, when they do use
control or comparison treatments, merely pit one treatment against
another, often with no clear theoretical basis. Some investigators
systematically remove or add treatment elements largely on prag-
matic grounds. Unfortunately, such experimental designs permit
only weak inferences concerning the specific effective elements of
treatment (McFall 1978).

Earlier reviews (Pechacek 1979) noted that the principal problem
plaguing smoking treatment evaluation was that clinical outcomes
were typically inferred from data of suspect validity. Previously,
most long-term outcome data were based on client self-reports of
smoking status, possibly supported by informant reports. Both self-
and informant reports are vulnerable to biases that make them
inadequate in research settings as sole measures of outcome (Glynn,
Gruder, Jegerski 1986; Li et al. 1984; Murray et al. 1987). Fortunate-
ly, over the last 9 years biochemical verification of self-reports has
become a more common practice, although it is by no means
universal.

Carboxyhemoglobin estimates from breath samples and measure-
ments of thiocyanate in urine, saliva, or plasma and of cotinine in
saliva and serum have been used most frequently to assess smoking
status. Carboxyhemoglobin has a relatively brief half-life and is
affected by ambient CO, activity level, and some drugs (Ringold et al.
1962; Henningfield, Stitzer, Griffiths 1980). However, this measure is
inexpensive and can provide subjects immediate feedback on an
important health risk factor. Thiocyanate may remain elevated for
up to 12 to 14 days after smoking cessation (BarylkoPikielna and
Pangborn 1968; Pettigrew and Fell 1973). Thiocyanate levels may be
quite variable within individuals (Barylko-Pikielna and Pangborn
1968). Assays of thiocyanate are insensitive to low levels of smoking
(Vogt et al. 1977) and are often poorly correlated with self-reported
smoking rates or actual measures of puffing patterns (Abueg,
Colletti, Rizzo 1986; Burling et al. 1985; Vogt et al. 1977). Further-

514


more, thiocyanate levels may be considerably affected by consump
tion of common foods (e.g., almonds, tapioca, cabbage, broccoli, and
cauliflower; Bliss and O'Connell 1984). For these reasons, cotinine is
a generally preferred assay. Cotinine, a major metabolite of nicotine,
is detected above nonsmoker levels for up to 48 hr after a single
cigarette is smoked (Zeidenberg et al. 1977). Cotinine levels may
persist for up to 7 days after cessation of habitual smoking (Benowitz
et al. 1983). Cotinine assays tend to be expensive, limiting their
usefulness. Readings will not accurately reflect smoking in individu-
als who use nicotine polacrilex gum. Immediate feedback to subjects
is not possible with thiocyanate and cotinine measures.

Biochemical assays do not provide complete information concern-
ing posttreatment smoking status. Self-report, although not ade-
quate when used alone, is a necessary measure. Also, when subjects
are aware of the use of biochemical assays, their self-reports of
abstinence agree well with assay results (Hall, Rugg et al. 1984; Hall,
Sachs et al. 1984; Glynn, Gruder, Jegerski 1986; Raw and Russell
1980). However, other studies have found no improvement in the
accuracy of reporting with the use of physiological measures (Bliss
and O'Connell 1984).

Insufficient attention has been devoted to length and intensity of
treatment as determinants of outcome (Chapter V). As noted
previously, the vast majority of individuals who have quit to date
have done so in the absence of formal intervention. Spontaneous
remission among chronic drug users has been observed not only for
tobacco but for opioids and alcohol as well (Chapter V). However,
evidence of spontaneous remission does not justify a failure to treat
chronic smokers who are (or who perceive themselves to be) unable
to achieve abstinence on their own.

Changing social norms appear to be extremely significant in the
recent decline in smoking prevalence (Appendix A). Public health
approaches have the potential of reaching far larger numbers of
smokers than do intensive clinical treatments, yet some individuals
obviously are resistant to these normative influences. Many tobacco
users do not appear responsive to minimal contact or community
interventions. Sachs (1986) has argued that highly intensive clinical
procedures may be cost-effective for certain populations of high-risk
smokers (e.g., those who already have suffered myocardial infarc-
tions). Some individuals persist in their tobacco use despite the
presence of immediate life-threatening health problems related to
their dependence.

Other issues with which the field still struggles are definitional,
e.g., the operational definitions of abstinence and relapse. Studies
that report abstinence rates during followup split on whether they
require continuous abstinence from the end of treatment or merely
abstinence at the point of followup. Abstinence levels can differ

515


substantially depending on which measure is used. Failure to follow
a common practice in reporting outcome (or to provide sufficient
information to allow independent calculations) substantially in-
creases the difficulty of comparing success rates across studies
(Bigelow and GssipKlein 1986).

The National Interagency Council on Smoking and Health formu-
lated stringent standards for the evaluation of smoking cessation
programs. Complete cessation including total abstinence from tobac-
co in all forms for a period of 1 year was defined as the primary
criterion for success. Several major health agencies (the American
Cancer Society, the American Heart Association, and the American
Lung Association) have endorsed these standards. Biochemical
validation of self-reported abstinence is not required in these
guidelines. The guidelines fail to distinguish between an isolated
"slip" and actual relapse in the definition of successful quitting
(GssipKlein et al. 1986).

Many studies still fail to include enough subjects to permit
adequate statistical power and to promote generalixability of results.
Few cessation studies have used validity checks to determine the
extent to which treatment manipulations actually were implement-
ed effectively. This is especially important when counseling strate-
gies are being compared (Hall, Rugg et al. 1984; Tiffany, Martin,
Baker 1986). Counseling manipulations and therapist training and
experience should be adequately described, and validity checks of
counseling differences should be incorporated into the assessment
plan. Selection of subjects represents another important issue (e.g.,
type of smoker, cigarette consumption, prior history of failures).
Treatment outcome may be influenced substantially by the charac-
teristics of the smokers assigned to intervention.

In sum, cessation research has made methodologically notable
strides in that, in the best studies, outcomes are verified with
multiple assays (including biochemical ones), the design and evalu-
ations of treatments are now theory driven, improved therapy
process measures are used, and a variety of specific pragmatic
problems such as subject attrition have been reduced. These im-
provements are recent, however, and characterize a relatively few
published studies.

Conclusions

Smoking treatment research has been marked by considerable
progress since it was reviewed in the 1979 Report of the Surgeon
General (US DHEW 19791, both in methodological sophistication and
to a lesser extent in the consistency of success achieved by the best
multicomponent cessation programs.

In contrast to the generally positive outcomes of multicomponent
treatments, there is mounting evidence that no single intervention

516


constitutes a generally effective method. In the case of multicompo-
nent treatment interventions, individual components should comple-
ment one another. Interventions that hold promise and deserve
additional attention are low-aversion directed-smoking strategies,
skill-training treatments, interventions that enhance the self-attri-
bution of treatment success, and interventions that train individuals
to obtain and use social support resources. Low-aversion smoking
treatments are important because of their acceptability, ease of
administration, and generally promising results when used with
other treatment elements. Research on skills training should explore
the extent to which enhanced clinical outcomes depend on the
acquisition and actual use of specific smoking-relevant skills. Thera-
peutic manipulations that enhance self-attributions of success or
self-efficacy estimates could have wide treatment applicability. The
combination of increased knowledge and skills, self-efficacy, and
social support should enhance treatment outcomes.

Investigators should make more explicit the relationship between
theory and therapeutic manipulations, valid assessments should be
tailored to tap processes implicated by theory in behavioral change,
and greater sample sixes should be included in treatment evaluation
studies. Individual differences may be important in assigning
smokers to combined pharmacologic and behavioral treatment
(Hughes 1986). Some smokers appear to resist pharmacologic inter-
vention. Smokers who attribute their success to pharmacologic
agents may be at increased risk for relapse when these agents are
withdrawn (Davison and Valins 1969). Conversely, some smokers
accept pharmacologic treatment but refuse behavioral approaches.
Many of these refusals stem from required time commitments that
the smokers view as excessive.

Dissemination of effective treatment strategies is critically need-
ed. Considering the vast body of treatment literature that has
accumulated, surprisingly little systematic transfer to community
settings has occurred. Many treatment programs that are available
(e.g., proprietary, public service) have not been subjected to rigorous
evaluation. Furthermore, these programs often do not reflect recent
laboratory findings. This is especially true for pharmacologic ap-
proaches. Very few applied programs adequately address nicotine
replacement therapies or other potentially relevant pharmacologic
adjuncts to treatment. Dissemination is especially lacking for
minority and lower SES populations, which may have the greatest
need for these types of services.

Relapse

As in many areas of clinical practice, therapeutic interventions
have been developed and implemented in the absence of a complete

517


understanding of the processes being treated. Future development of
smoking cessation treatments designed to maintain abstinence in
the face of high relapse prevalence should benefit greatly from an
expanded knowledge base that is being accumulated concerning the
correlates and determinants of smoking relapse.

Research has shown that smoking cessation is a process involving
several discrete stages. These stages include precontemplation,
contemplation, decision, action, and maintenance (Prochaska and
DiClemente 1983, 1985, 1986; DiClemente and Prochaska 1985;
Prochaska et al. 1985; Velicer et al. 1985; Wilcox et al. 1985). This
Section considers recent research on factors related to successful
maintenance of nonsmoking once initial cessation has been achieved
during the action stage. Studies of long-term outcomes in smoking
cessation indicate that relapse, rather than maintenance, is the most
prevalent outcome during this stage. Hunt and his colleagues (Hunt,
Barnett, Branch 1971; Hunt and Matarazzo 1973) showed that over a
wide range of treatments, relapse rates of 75 to 80 percent could be
expected among smokers who achieved initial cessation (Figure 2,
Chapter V). These findings have been replicated many times in
recent treatment outcome studies (Schwartz 1987). It should be
noted, however, that these relapse rates are based on single quit
attempts. Cumulative long-term abstinence rates covering multiple
quit attempts may be considerably better (Schachter 1982).

Defining Relapse

Given that relapse depends on the achievement of initial cessation,
definitions of relapse must include a definition of cessation. In
addition, many investigators distinguish between a "slip" or smoking
one's first cigarette and a "relapse" or return to regular smoking
(Brownell et al. 1986). The National Working Conference on Smok-
ing Relapse recommended a duration of 24 hr of continuous tobacco
abstinence to define initial cessation. A slip was defined as a "period
of not more than 6 consecutive days of smoking following at least 24
hr of abstinence" (Ossip-Klein et al. 1986). Smoking beyond 6
consecutive days was then defined as a relapse. These definitions of
quit episode, slip, and relapse are somewhat lenient. Many investiga-
tors require a longer period of initial abstinence (e.g., 48 hr or 1
week) for a quit episode and regard even a few smoking occasions as
a relapse rather than a slip. Considerable data indicate that an
initial slip is highly predictive of subsequent relapse (Brandon,
Tiffany, Baker 1986; OssipKlein et al. 1986).

Conceptual Frameworks

Research on the relapse process has focused on two general areas:
(1) identifying factors that predispose individuals to relapse or to
successful maintenance and (2) identifying factors that precipitate or

518


immediately precede the return to smoking following initial success
(Shiffman et al. 1986). Predisposing factors include characteristics of
individuals and their environments that make them more or less
vulnerable to relapse as they begin the maintenance process.
Precipitating factors relate to the circumstances surrounding a
specific relapse situation or smoking the first cigarette following a
period of abstinence.

Social learning theory has provided a useful framework for much
of the research on predisposing factors (Bandura 1977b; Brownell et
al. 1986; Leventhal and Clear-y 1980; Shiffman et al. 1986). From this
perspective, the effects of environmental or behavioral elements on
maintenance of nonsmoking are mediated by individual factors such
as prior experience with smoking cessation and beliefs about the
cessation process. In addition to personal demographic characteris-
tics, predisposing, variables examined that are consistent with this
framework include smoking and quitting history, social factors
(social support and the presence of smoking cues in the social
environment), stress, and cognitive factors such as self-efficacy,
outcome attributions, and perceptions about the consequences of
quitting smoking (Chapter VI).

Marlatt and Gordon's model of the relapse process (Marlatt and
Gordon 1980, 1985) has provided the foundation for much of the
research on the circumstances associated with initial slips and
suggests specific hypotheses regarding factors that mediate the
transition from an initial slip to a full-blown relapse. This model
proposes that initial smoking following a period of abstinence is
likely to occur in certain types of high-risk situations. As suggested
by the types of predisposing factors listed above, high-risk situations
could include intrapersonal factors such as negative affect and
severe withdrawal symptoms following a long history of heavy
smoking. The first determinant of whether smoking occurs in a high-
risk situation is whether the individual uses specific strategies to
cope with the situation. Successful coping is assumed to lead to
increased confidence in one's ability to maintain abstinence, thereby
decreasing the probability of relapse. Failure to cope in the situation
coupled with positive expectations about the effects of smoking can
lead to an initial slip. The Abstinence Violation Effect (AVE) is
proposed as the major mediating factor between an initial slip and a
full-blown relapse. Defined as an attributional construct (Curry,
Marlatt, Gordon 1987; Marlatt and Gordon 19851, the AVE is
characterized by internal, stable, and global causal attributions for
smoking the initial cigarette. Research on specific factors within
these conceptual frameworks is reviewed below.

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Predisposing Factors
Demographics

To the extent that demographic factors are related to initial
cessation, the population of individuals who achieve cessation and
are "eligible" for relapse is relatively homogeneous. It is not
surprising, therefore, that the majority of studies that examined
these variables have not found differences in relapse rates by
socioeconomic status (Campbell 1983; Eisinger 1971; Evans and Lane
1981; Garvey, Heinold, Rosner, in press; Hirvonen 1983; Horwitz,
Hindi-Alexander, Wagner 1985; Jacobs et al. 19711, age (Coppotelli
and Orleans 1985; Cummings et al. 1985; Evans and Lane 1981;
Hirvonen 1983; Horwitz, Hindi-Alexander, Wagner 1985; Jacobs et
al. 1971), or gender (Eisinger 1971; Evans and Lane 1981; Shapiro
and Gunn 1985; Horwitz, Hindi-Alexander, Wagner 1985). Excep
tions to the findings for age include one study that found an inverse
relationship (Garvey, Heinold, Rosner, in press) and two studies
reporting a positive relationship between age and long-term success
(Campbell 1983; Eisinger 1971). One study did report that males
were more successful than were females at long-term maintenance
(Hirvonen 1983).

Although women and men may be equally likely to relapse, data
suggest that their return to smoking is precipitated by different
factors. Hirvonen (1983) reports that men more frequently cited
alcohol consumption and strong cravings as causes of relapse,
whereas women more often cited the influence of other smokers and
negative affect. In a prospective study, Swan and colleagues (in
press) found that craving predicted relapse for women and not for
men, while psychological withdrawal symptoms predicted relapse
among men but not women. Studies that have analyzed reports of
specific relapse episodes (Shiffman 1982, 1986a) have found no
gender differences.

The large study by Swan and coworkers (in press) of treated
smokers suggests that sex differences in factors associated with
relapse may be pervasive. They found almost no overlap between
men and women in the factors that predicted relapse. The following
factors predicted relapse among women, but not men: the machine-
rated nicotine delivery of cigarettes, employment status, rated
likelihood of success, and lower work strain. Among men, relapse
was predicted by greater stress (hassles) and higher work strain.
Campbell (1983) also reports sex differences in predictors of outcome,
some of which contradict Swan's findings, and Guilford (1967)
reports sex differences on almost all aspects of cessation and
maintenance. Although it may be premature to draw conclusions
about the causes of relapse among males and females, clearly sex
differences must be examined in future work.

520


Smoking and Quitting History
Smoking History

Most studies indicate that the length of a person's smoking history
influences the process of initial cessation (Pomerleau, Adkins,
Pertschuk 1978) but is unrelated to relapse (Ashenberg 1983; Carl
1980; Coppotelli and Orleans 1985; Cummings et al. 1985; Evans and
Lane 1981; Garvey, Heinold, Rosner, in press; Hirvonen 1983;
Horwitz, Hindi-Alexander, Wagner 1985; Jacobs et al. 1971; Pomer-
leau, Adkins, Pertschuk 1978; Swan et al., in press). The two studies
that report relationships between length of smoking history and
relapse are contradictory, with one reporting that smoking longer
increased reiapse risk (Graham and Gibson 1971) and the other
reporting an inverse relationship between the duration of smoking
and the risk of relapse (Eisinger 1971).

Conflicting findings have been reported for the number of ciga-
rettes smoked per day. Although there are some positive findings
(Ockene et al. 1982; Shapiro and Gunn 1985). most studies suggest
that the number of cigarettes smoked is not a good predictor of
relapse (Campbell 1983; Coppotelli and Orleans 1985; Cummings et
al. 1985; Eisinger 1971; Evans and Lane 1981; Graham and Gibson
1971; Hirvonen 1983; Horwitz, Hind&Alexander, Wagner 1985;
Jacobs et al. 1971; Pomerleau, Adkins, Pertschuk 1978; Swan et al.,
in press). A few studies do find an effect of the number of cigarettes
smoked on initial cessation (Hirvonen 1983). Precessation cigarette
consumption has been positively associated with the length of time
between having an initial lapse and a return to regular smoking
(Brandon, Tiffany, Baker 1986). It should be noted, however, that
number of cigarettes is only a rough indicator of actual intake,
particularly for levels above 20 cigarettes/day.

Kabat and Wynder (1987) reported that the time between waking
up and smoking the first cigarette was a good predictor of outcome.
This variable represents one item on the Fagerstriim Tolerance
Questionnaire (Fagerstrom 1978) and appears to be strongly related
to physical dependence.

Smoking Typologies

Although their predictive value has been questioned (Joffe, Lowe,
Fisher 19811, smoking typologies have been widely used in an
attempt to classify smokers or smoking situations (e.g., smoking for
stimulation, handling, relaxation; Ikard, Green, Horn 1969). The
strongest evidence for the relationship of type of smoking to relapse
has been found with people who smoke to control negative affect. In
a widely cited study, Pomerleau, Adkins, and Pertschuk (1978)
reported that people who said they smoked when experiencing
negative affect were more likely to relapse. Similarly, Campbell

521


(1983) reported that smokers who experience craving when emotion-
ally upset were more likely to relapse. These findings are diluted,
however, by those of other studies showing no relationship between
negative-affect smoking and relapse (Coppotelli and Orleans 1985;
Eisinger 1971; Garvey, Heinold, Rosner, in press; Jacobs et al. 1971).

Quitting History

Several studies have found a positive relationship between number
of previous quit attempts and success in quitting smoking (Brandon,
Zelman, Baker, in press; Tiffany, Martin, Baker 1986). However,
other studies report no relationship between the number of prior
quit attempts and relapse (Swan et al., in press; Horwitz, Hindi-
Alexander, Wagner 1985; Cummings et al. 1985; Coppotelli and
Orleans 1985; Ockene, Benfari et al. 1982). Some studies in fact
report that subjects with fewer previous quit attempts are more
successful in maintenance (Horwitz, Hind&Alexander, Wagner 1985;
Graham and Gibson 1971; Garvey, Heinold, Rosner, in press). Garvey
and Hitchcock (1987) found that among recidivists, smokers with
more past experience in quitting showed a slower rate of progression
to regular smoking. Gottlieb and coworkers (1981) and Hirvonen
(1983) also report data that suggest a positive relationship between
duration of the longest previous cessation effort and successful
maintenance. Clearer descriptions of quitting history with respect to
both number of previous quit attempts and duration of abstinent
periods would be helpful in evaluating the relationship between quit
attempts and outcome.

Withdrawal and Dependence

Withdrawal symptoms, whether elicited by acute deprivation or by
conditioned stimuli, are hypothesized to be the link between
dependence and relapse (Baker, Morse, Sherman 1987; Shiffman
1979; Wikler 1965). The tobacco withdrawal syndrome consists of a
cluster of symptoms that are typically experienced after even brief
or partial tobacco deprivation (Hughes and Hatsukami 1986, Ameri-
can Psychiatric Association 1980,1987; Chapter IV). The symptoms
include craving for cigarettes, irritability, anxiety, difficulty in
concentrating, restlessness, and increased appetite (American Psy-
chiatric Association 1987). Some physical signs are also commonly
reported, but with the possible exception of bradycardia, these
appear to be less consistent (Shiffman 1979; Hughes and Hatsukami
1986). Especially significant is the fact that the syndrome has a rapid
onset and generally declines within 2 weeks (Shiffman 1979;
Shiffman and Jarvik 1976; Cummings et al. 1985; Gottlieb 1985).

Several studies have examined the role of withdrawal symptoms
as predisposing factors for relapse. In a retrospective study, Burns

522


(1969) reported that recidivists cited withdrawal symptoms as the
most common reason for relapse. Other retrospective studies at least
partially support this finding (Garvey, Heinold, Rosner, in press;
though see Evans and Lane 1981). Gottlieb (1985) found that both
physical and psychological withdrawal symptoms predicted early
relapse in a group of treated smokers; symptoms accounted for 14
percent of the variance in smoking after 2 weeks. Other investigators
have also found that mood disturbance, a possible withdrawal
symptom, predicts relapse (Hall et al. 1984; Hirvonen 1983; Manley
and Boland 1983). Manley and Boland (1983) found that mood
disturbance characterized relapsers even before they quit and after
they resumed smoking. The literature also includes negative find-
ings (Garvey, Heinold, Rosner, in press; Hughes and Hatsukami
1986; Swan and Denk, in press; Swan et al., in press).
Although craving is difficult to define precisely (Kozlowski and
Wilkinson 19871, a number of studies have reported relationships
between craving and relapse (Campbell 1983; Garvey, Heinold,
Rosner, in press; Gottlieb 1985; Hirvonen 1983). The effect appears to
be more marked among female smokers, with several studies
reporting that it is a significant predictor of relapse only among
women (Guilford 1967; Gunn 1986; Swan et al., in press).

Cognitive Factors
Concern About Weight Gain

Quitting smoking often results in weight gain (Grunberg 1986;
Chapter IV). Multiple factors may contribute to postcessation weight
gain, including decreased metabolism, increased food consumption,
and increased preference for sweet-tasting, high-caloric foods (Grun-
berg 1982). Highly dependent smokers and those who tend to eat in
response to specific emotional and environmental cues appear to be
at greatest risk of gaining weight following smoking cessation
(Emont and Cummings 1987; Hall, Ginsberg, Jones 1986; Chapter
VI).
The data relating concern about weight gain to relapse are
inconsistent. Klesges and Klesges (in press) found that women were
more likely to report relapse for weight-related reasons. Other
studies have found that concern about weight gain was not a major
detirminant of relapse (Fuller 1982; Greaves, Barnes, Vulcan0 1983;
Hirvonen 1983; Shapiro and Gunn 1985). Though there are excep
tions (DiClemente 19811, studies typically report that recidivists
experience less weight gain than successful abstainers (Manley and
Boland 1983; Hall, Ginsberg, Jones 1986). In at least some of these
studies, this cannot be confounded by the effects of continued
abstinence, because the studies used prospective designs in which
weight gain was assessed prior to relapse (Hall, Ginsberg, Jones


1986). Even so, the possibility remains that relapsers are more
weight conscious in the first place and exert greater efforts to curtail
initial weight gain (Hall, Ginsberg, Jones 1986; Herman and Polivy
1975). Smoker perceptions concerning weight gain may be critical.
For some individuals, a gain of only 2 or 3 pounds may be viewed as a
cause for great concern. Other individuals may be essentially
indifferent to weight gains of 15 to 20 pounds.

Self-Efficacy

Bandura (1977a, 1982) proposed a common mechanism underlying
behavioral change achieved by different procedures: successful
psychological interventions all function by creating and strengthen-
ing expectations of personal mastery or efficacy. An efficacy
expectation is the conviction that one can execute the behaviors
necessary to achieve a desired outcome. Such expectations are
assumed to affect the initiation of coping behavior, the amount of
effort that will be expended to maintain coping behavior, and the
persistence of coping behavior in the face of external and internal
obstacles.

Self-efficacy is an important construct in Marlatt's theory of
relapse. Marlatt's theory specifies that people's ability to resist the
use of a substance (e.g., cigarettes) in a high-risk situation depends
on, among other factors, their self-efficacy level (Marlatt and Gordon
1980). If people have expectations that they can cope with a smoking
urge without smoking, they are less likely to relapse. Moreover,
people who successfully resist temptation should experience an
increase in self-efficacy. The theory also states that selfefficacy is a
determinant of whether people who experience an initial lapse are
able to prevent escalation to full relapse.

Various scales assumed to measure selfefficacy have predicted
smoking status at followup (Coelho 1984; DiClemente 1981; Killen et
al. 1984; McIntyre, Lichtenstein, Mermelstein 1983; Ockene et al.
1982; Yates and Thain 1985) and latency from treatment end to
relapse (Brandon, Tiffany, Baker 1986, Brandon, Zelman, Baker, in
press; Erickson et al. 1983; Tiffany, Martin, Baker 1986). Efficacy
ratings have also predicted smoking intake after a controlled-smok-
ing intervention (Godding and Glasgow 1985) and have differentiated
joiners from nonjoiners of a smoking treatment program (Brad and
Hall 1984).

Important qualifications, however, relate to the timing of the
relapse assessment and the subject sample observed. Studies predict+
ing relapse that are based on all treatment subjects (including those
who never achieve abstinence) will achieve higher correlations with
outcome than will studies assessing only abstinent subjects. Self-
efficacy is a less useful predictor when measured shortly after

524


cessation rather than after 1 or 2 months of abstinence (Baer, Holt,
Lichtenstein 1986).
Condiotte and Lichtenstein (1981) reported seven distinguishable
clusters of smoking situations and found a congruence between the
situation clusters for which subjects indicated low self-efficacy and
the clusters that comprised their actual relapse situations. However,
a conceptual replication of the use of efficacy subscales has not
demonstrated utility (Baer, Holt, Lichtenstein 1986). Thus, at this
point situation-specific selfefficacy assessments have not proved to
be of value.

Self-effrcacy may reflect the influence of diverse treatments or
smoking history variables related to cessation success. Skills train-
ing, for example, might be effective to the extent that it enhances
smokers' beliefs that they can cope with temptation. Aversion
therapy might be effective to the extent that smokers attribute their
self-punishment to their high motivation to quit and their ability to
use available resources to help stay abstinent. Self-efficacy may in
fact be confounded with Bandura's (1977a) concept of outcome
expectancy. Rather than measuring subjects' convictions that they
could execute specific coping behaviors, most of the studies simply
assess& subjects' confidence that they would resist the urge to
smoke in the future.

The global construct of self-efficacy is somewhat ambiguous. Self-
efficacy may include not only response effectiveness, but also
motivation to quit and judgment of skills necessary to undertake the
quitting program. Selfefficacy as a global predictor can be useful.
However, it may be more important to assess what skills individuals
learn from different treatment components. A better understanding
of the process of acquiring competency in quitting is needed.
Knowledge of the specific treatment components that enhance self-
efficacy could be significant in developing and refining effective
interventions.

Outcome Attributions

Attribution theory suggests that individuals who attribute their
behavioral change to internal factors are more likely to successfully
maintain their change (Davison and Valins 1969). This hypothesis
was supported in a study by Harackiewicz et al. (1987) which found
that, for individuals participating in intrinsically oriented treatment
programs (a self-help manual emphasizing individual cessation
efforts either with or without nicotine polacrilex gum), internal
attributions for initial success were significantly related to longer
maintenance of nonsmoking. Contrary to the hypothesis, however,
these investigators found that external attributions were positively
related to long-term maintenance for individuals participating in
extrinsically oriented treatment (nicotine polacrilex gum with a self-


help manual emphasizing a doctor's prescribed program). These
findings suggest that the degree of consistency between attributions
for initial success and the orientation of the cessation approach can
affect the probability of relapse.

Social Factors

Smoking Cues

Most exposure to smoking-specific cues is socially mediated-e.g.,
watching others smoke. Such exposures have been labeled "social
contagion" (Shiffman and Jarvik 1987). Few studies have 888e88ed
social contagion directly. Many studies have, however, examined the
effect of having a spouse, friends, or coworkers who smoke.

The literature on the effect of spouse smoking status is surprising-
ly contradictory. Several studies report moderate-to-large increases
in the probability of relapse among subjects with a smoking spouse
(Campbell 1983; Graham and Gibson 1971; McIntyre-Kingsolver,
Lichtenstein, Mermelstein 1986; Tongas, Patterson, Goodkind 1976).
Some studies, though, report no effect of spousal smoking (Horwitz,
Hind&Alexander, Wagner 1985; Garvey, Heinold, Rosner, in press;
Swan et al., in press).

One possible explanation for the inconsistent findings is that the
influence of spousal smoking is so strong that it often prevents initial
cessation. This would cause the effect to be only sporadically
observed in maintenance. The effects of spouse smoking status may
also be complicated by interactions with social support. The risk
incurred by having a smoking spouse may be reduced or eliminated
if the spouse is supportive (Mermelstein, Lichtenstein, McIntyre
1983). This may be especially true if the spouse refrains from
smoking in the presence of the subject, thereby resulting in fewer
exposures to smoking cues.

The data on friend smoking are clearer. Several studies find that
subjects who have more smokers among their friends are more likely
to relapse (Eisinger 1971; Garvey, Heinold, Rosner, in press; Ockene
et al. 1982; Gottlieb et al. 1981; Goldstein 1981). One study failed to
replicate this effect (Swan et al., in press). Brandon, Tiffany, and
Baker (1986) found that smokers having a lapse cigarette in the
presence of other smokers progressed to regular smoking more
quickly than did other lapsers. The most parsimonious explanations
of these social contagion effects are that people with many smoking
friends tend to experience more exposure to smoking cues and that
cigarettes are likely to be more readily available to them.

Social Support

Social support can serve as a buffer to reduce the negative
psychological effects of stressors (Cobb 1976; Cohen, Sherrod, Clark

526


1986; Cohen and Wills 1985; Dean and Lin 1977). Correlational
studies have found that the level of perceived social support is
related to smoking cessation and maintenance. Coppotelli and
Orleans (1985), for example, examined the determinants of mainte-
nance among women who recently quit smoking. They found that a
measure of "partner facilitation" (problem solving, rewarding quit-
ting, understanding, listening, and facilitating coping responses)
accounted for 32 percent of the outcome variance at 6 to 8 week
postcessation. General social support from spouses, as well as
smoking-specific spousal support, has been related to smoking
treatment outcome (Horwitz, Hindi-Alexander, Wagner 1985; Mer-
melstein et al. 1986; Mermelstein, Lichtenstein, McIntyre 1983;
although see Glasgow et al. 1985).

Global Support

Global support has usually been assessed as perceived support.
Using the Interpersonal Support Evaluation List (ISEL; Cohen and
Hoberman 1983) to measure support, Mermelstein and coworkers
(1986) found that greater perceived support (having someone to talk
to about personal matters) predicted maintenance at a 3-month
followup. However, the ISEL was unrelated to smoking status at 6 or
12 months, and the 3-month findings were not replicated in a second
study by the same investigators (Mermelstein et al. 1986). As noted
above, Coppotelli and Orleans (1985) found that women who reported
receiving greater support from their husbands were more likely to
maintain abstinence. There was no comparison group of male
subjects.

Smoking-Specific Support

Several studies have examined the role of social support directed
at smoking cessation. The most thorough investigations of specific
support have been conducted by researchers at the University of
Oregon, who developed the Partner Interaction Questionnaire (PIQ;
Mermelstein, Lichtenstein, McIntyre 1983) to assess perceived
helper behaviors. These investigators found that perceived help
fulness of partner behaviors was related to cessation and mainte-
nance. The actual number of partner behaviors was not related to
outcome; however, a measure of the character of the interactions
was related. A cluster of partner behaviors labeled "Support and
Encouragement" (e.g., expressing understanding or pride) was
related to maintenance of abstinence. In contrast, a cluster of
behaviors involving "Nagging and Policing" (Mermelstein, Lichten-
stein, McIntyre 1983) predicted relapse. Subsequent studies using
the PIQ have only partially replicated these findings (Lichtenstein,

527


Glasgow, Abrams, in press; Malott et al. 1984; McIntyre-Kingsolver,
Lichtenstein, Mermelstein 19861.

Other studies using other measures have also yielded mixed
results. In a large prospective study, Prochaska, DiClemente, and
colleagues (Prochaska and DiClemente 1983; DiClemente and Pro-
chaska 1985; Prochaska et al. 19851 reported that social support
predicted continuing abstinence. However, several other research
groups have failed to find evidence that smoking-specific support
aids maintenance (Evans and Lane 1981; Ockene et al. 1982; Garvey,
Heinold, Rosner, in press).

stress

Some studies have used the life events approach to the assessment
of stress (Holmes and Rahe 1967). This technique asks subjects about
major life events that have occurred since the subjects stopped
smoking. Most studies have found little or no relationship between
life stress events and relapse (Shapiro and Gunn 1985; Shiffman,
Read, Jarvik 1985). This may be because life stress events are
relatively uncommon.

Recent research on stress has begun to focus on more frequent and
smaller-scale stressors, which Lazarus and colleagues (1981) and
DeLongis and coworkers (1982) have called "Hassles." The Hassles
Scale assesses the frequency and perceived severity of everyday
stressors, such as having difficulties with coworkers or not having
enough time for recreation. Swan and colleagues (Swan and Denk, in
press; Swan et al., in press) found that hassles during the second
month of abstinence only weakly predicted outcomes at 1 year. The
effect of hassles was more reliable for men than for women.

A somewhat different approach to examining background stress
was taken by Cohen and his colleagues, who developed and used the
Perceived Stress Scale (PSS). The PSS measures perceived stress and
demoralization without reference to particular events or sources of
stress. Cohen and colleagues found that PSS scores did predict
relapse and that they were strongly associated with daily cigarette
consumption among recidivists.

Stress and coping theories of smoking imply that deficiencies in
personal resources for coping with stress may enhance the risk of
relapse (Wills and Shiffman 1985). Using the Ways of Coping
checklist, Ashenberg (1983) assessed how subjects who had quit
smoking coped with stress in situations that are often associated
with relapse. There were no differences between relapsers and
abstainers in the kinds of coping reported, but abstainers reported
using fewer coping strategies. The meaning of this finding is unclear.
Abstainers could have experienced less severe stress or less severe
threats to abstinence, and therefore needed fewer coping responses.
Conversely, abstainer coping responses could have been more

528


effective, therefore mitigating the need for more coping. Also, when
Ashenberg examined recidivists, stressful situations associated with
coping were found to be less likely to lead to relapse than those not
associated with coping.

Precipitating Factors
High-Risk Situations

A number of studies support the theory that initial smoking
following cessation tends to occur in specific t.ypes of high-risk
situations. Work by Marlatt and his associates (Marlatt and Gordon
1980, 1985) has identified craving/withdrawal, intrapersonal nega-
tive emotional states (e.g., frustration, boredom, and anxiety),
interpersonal conflict situations, and social pressure, both direct and
indirect, as common types of high-risk situations. Shiffman (1986c)
and Baer and Lichtenstein (in press) clustered data on the precipi-
tants of relapse crises and lapses.

Data from studies of relapee episodes confirm that smoking cues
are often involved in smoking relapse. Several studies report the
smoking of others in the immediate environment in one-half to
three-quarters of all relapse episodes (Brandon, Tiffany, Baker 1986;
Colletti, Supnick, Rizzo 1981; Baer and Lichtenstein, in press;
Shiffman 1982, 1986c; Cummings, Jaen, Giovino 1985). Many of
these same studies report that specific smoking stimuli (usually
seeing someone smoking) are responsible for precipitating 24 to 32
percent of all relapses (Shiffman 1982,1986c; GssipKlein et al. 1986;
Shapiro, OssipKlein, Stiggins 1983). Studies also report that relapse
crises in which someone else is smoking are more likely to result in a
smoking episode and in a shorter interval between the initial slip
and relapse (Brandon, Tiffany, Baker 1986; C&p-Klein et al. 1986;
Shiffman 1982).

Abrams and his colleagues (Abrams et al., in press; Chapter III)
have recently published data suggesting that individual differences
in reactivity to smoking cues may influence cessation and relapse. In
retrospective and prospective studies, these researchers found that
recidivists responded more strongly than successful quitters to
verbally presented smoking situations or to observations of another
smoking. Recidivists displayed more anxiety and showed greater
heart rats responses. It may be that responses elicited by smoking
stimuli (Saumet and Dittmar 1985) reflect conditioned responses to
nicotine effects.
Other smokers serve not only as cues for smoking but as sources of
cigarettes. In half of all relapse episodes, another smoker provides
the cigarettes that are smoked (Colletti, Supnick, Rizzo 1981; Baer
and Lichtenstein, in press; Cummings, Jaen, Giovino 1985). This does
not imply that the smokers exert social pressure to smoke; in most

529


cases, the ex-smoker specifically asks for a cigarette (Brandon,
Tiffany, Baker 1986).

Data on relapse episodes suggest that relapse also can be cued by
other stimuli or activities that have become associated with smoking
through contiguity, for instance, food, drink, or relaxation (Baer and
Lichtenstein, in press; Brandon, Tiffany, Baker 1986; OssipKlein et
al. 1986; Shiffman 1986b).

Studies of specific relapse episodes consistently suggest that stress
and negative affect play major roles in relapse. Findings from many
studies encompassing diverse samples reveal that the majority of
relapse episodes are preceded by negative affect (Brandon, Tiffany,
Baker 1986; Shiffman 1982, 198613; Marlatt and Gordon 1980;
Cummings, Marlatt, Gordon 1980; O'Connell and Martin 1987;
Gregory 1984; Baer and Lichtenstein, in press; O&p-Klein et al.
1986; Shapiro, OssipKlein, Stiggins 1983; Giovino et al. 1986;
Shapiro 1984). In some studies, as many as 9 out of 10 subjects report
negative affect (Coppotelli and Orleans 1985). The most frequently
reported emotion is anxiety, but boredom, depression, and anger are
also common.

Data suggest that the more severe the stress surrounding a
temptation to smoke, the higher the likelihood of smoking. Shiffman,
Bead, and Jarvik (1985) report a significant linear relationship
between stress and smoking in relapse crises. There are contradicb
ry data as to whether lapses associated with negative affect are
particularly likely to progress to full relapse (Brandon, Tiffany,
Baker 1986; O'Connell and Martin 1987). In sum, momentary stress
and distress are major factors in relapse episodes. It should be noted,
however, that these studies involve retrospective accounts of relapse
episodes.

The role of negative affect in relapse may change over time.
Cummings, Jaen, and Giovino (1985) report that early relapse
episodes are more likely to be precipitated by stress; later in
abstinence, alcohol and other appetitive cues become more promi-
nent.

Coping Strategies

Coping strategies can be used both to prevent (anticipatory coping)
and to directly respond to (immediate coping) high-risk situations. In
either case, the strategies used can be behavioral, consisting of
responses that are outwardly visible (e.g., leaving a party where
others are smoking, engaging in physical activities), or cognitive,
consisting of internal responses such as thoughts or images.

One of the most commonly used and studied anticipatory coping
strategies is stimulus control-the avoidance of stimuli associated
with smoking. Research on this strategy shows mixed outcomes,
yielding no definitive conclusions (Evans and Lane 1981; Horwitx,

530


Hind&Alexander, Wagner 1985; Prochaska and DiClemente 1983;
DiClemente and Prochaska 1985). Data on the relative efficacy of
cognitive and behavioral strategies weakly support the superiority of
cognitive strategies. Evans and Lane (1981) report weak indications
that successful maintainers were more likely to use cognitive
techniques rather than behavioral ones.

Immediate coping has been assessed in studies that examined
situations in which an ex-smoker was tempted to smoke. Studies of
immediate coping with the temptation to smoke typically compare
episodes in which smoking was averted with episodes in which
relapse occurred. Shiffman (1982, 1984b, 1985) found that failure to
perform any coping response was the single best predictor of
smoking in a tempting situation, accounting for nearly a quarter of
the variance in the outcomes of high-risk situations. This finding has
been directly and indirectly supported in several other studies
(Curry, Marlatt, Gordon 1987; OssipKlein et al. 1986; Shapiro, Ossip
Klein, Stiggins 1983; Sjoberg and Johnson 1978; Sjoberg and
Samsonowitz 1978). These studies consistently show immediate
coping to be effective in preventing smoking in a relapse-promoting
situation. One problem with all of these studies, however, is
retrospective bias. Subjects may introduce a self-justifying slant into
their responses. Unfortunately, it may be virtually impossible to
obtain prospective data on immediate coping.

Although there is no evidence that greater numbers of coping
responses are more effective, there is evidence that it is better to use
both cognitive and behavioral coping strategies when faced with a
risk situation (Curry, Marlatt, Gordon 1987; Shiffman 1982, 1984b).
Cognitive and behavioral coping are rather broad categories of
responses. The relative efficacy of specific responses within those
categories has also been examined in an attempt to identify effective
and ineffective coping responses. Shiffman (1984b) examined the
effectiveness of seven behavioral and eight cognitive coping strate-
gies. Only one type of coping was not more effective than no coping:
subjects who reported using self-punitive cognitions (berating oneself
for being tempted to smoke) to cope were as likely to relapse as
subjects who made no cognitive coping response. (See Glasgow et al.
1985, for parallel findings on cessation.) Self-punitive cognitions may
diminish self-efficacy and engender negative affect, which in turn
promotes smoking. Another finding from these comparative analyses
was that subjects who reported "willpower" as a means of cognitive
coping were significantly more likely to relapse (nearly half re-
lapsed) than subjects who used other cognitive coping responses.
Nevertheless, subjects who reported willpower fared better than
subjects who made no cognitive coping response at all.

These two distinctions notwithstanding, the effectiveness of vari-
ous coping responses was surprisingly uniform: 13 of the 15

531


responses were better than no response, but there were no signifi-
cant differences among these 13 responses. Curry, Marlatt, and
Gordon (1987) conducted a very similar set of analyses and arrived at
a similar conclusion.

Several studies have examined whether individual differences in
coping skill are associated with maintenance. The studies used
similar analog methods to assess coping skill: subjects were present-
ed with situations known to elicit desire to smoke, and their
responses to these situations were rated. These studies used both
retrospective and prospective analyses and had subjects respond
either to written or role-played coping scenarios (Abrams et al. 1987,
in press; Davis 1983; Davis and Glaros 1986; Shiffman, Maltese,
Jarvik 1982). Results of retrospective analyses showed that 6month
abstainers did not differ in coping skill from recidivists (Abrams et
al. 1987; Shiffman et al. 1985). Prospective studies also yielded little
evidence that coping skill protects against relapse. Such studies have
found no relationship between skill level and relapse likelihood,
although there was evidence that high-skill subjects took longer to
relapse (Abrams et al. 1987, in press; Davis 1983; Davis and Glaros
1986). Also, Davis and Glaros (1986) showed that a skill-based
treatment increased the level of smoker coping skills asses&
immediately posttreatment but did not enhance smoker followup
performance.

Abstinence Violation Effect

Marlatt and Gordon (1980, 1985) define the Abstinence Violation
Effect (AVE) as an attributional construct that mediates the
transition from an initial lapse to a full-blown relapse. Curry,
Marlatt, and Gordon (1987) found that individuals who smoked but
did not return to regular smoking ("slippers") reported significantly
greater AVEs than those who relapsed following an initial slip.
Brandon, Tiffany, and Baker (1986) reported that only one-third of
their subjects (N= 72) used any coping response after a lapse and
that the occurrence of coping was unrelated to relapse probability or
speed of relapse.

Summary and Conclusions

1. Tobacco dependence can be treated successfully.
2. Effective interventions include behavioral approaches and
behavioral approaches with adjunctive `pharmacologic treat-
ment.

3. Behavioral interventions are most effective when they include
multiple components (procedures such as aversive smoking,
skills training, group support, and self-reward). Inclusion of too

532


many treatment procedures can lead to a less successful
outcome.

4. Nicotine replacement can reduce tobacco withdrawal symp
tams and may enhance the efficacy of behavioral treatment.

533


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560


APPENDIX A

TRENDS IN TOBACCO USE
IN THE UNITED STATES

561


CONTENTS

Introduction ..,,..................................................... 565

Prevalence of Smoking in the United States ............ .565


Trends in Cigarettes Consumed .............................. .565

Trends in the Tar and Nicotine Content of Cigarettes
Consumed ......................................................... 566

Surveys of Self-Reported Cigarette Smoking in Adults. 567
  General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .567
  National Health Interview Surveys.. . . . . . . . . . . . . . . . . . . .568
Demographic Trends in Smoking Prevalence in
   Adults.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
  Other Social Correlates of Smoking. . . . . . . . . . . . . . . . . . . . 571
  Other Surveys Reporting Adult Prevalence of
   Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572

Trends in Adolescent Smoking . . . . . . . . . . ..*................... 573

Trends in the Proportion of Smokers Who Are Heavy
Smokers.. . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . , . . . . . . . , . . . . . . . . . . . . 577

Trends in Quitting Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .577

Trends in Cigar, Pipe, and Roll-Your-Own Cigarette
Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580

Trends in Smokeless Tobacco Use.. . . . . . . . . . . . . . . . . . . . . . . . . . . 580

Summary and Conclusions ...................................... 582


References ........................................................... 585

563


Introduction

The focus of this Appendix is on trends in the prevalence and
demographic correlates of tobacco use. Findings from selected data
sources (US DHHS 1986b; USDA 1986; US FTC 1981, 1986; US
DHHS 1988) will be reported as well as findings from analyses of
trend data found in these sources.

Prevalence of Smoking in the United States

Several surveys using different methodologies have reported the
prevalence of current cigarette smoking in the United States. The
reported prevalence of smoking between 1944 and 1986 is shown in
Table 1. However, different methodologies can lead to variations in
the estimation of prevalence. The same general survey methodology
has been used throughout the National Health Interview Surveys
(NHIS 1965 to 1985). These surveys have indicated a steady decline
in smoking prevalence beginning in the late 1960s to 30.4 percent of
adults 20 years of age and older in 1985. These data parallel the per
capita consumption of cigarettes in the United States, which has
declined each year since 1973 (Table 2). Based on population
estimates and the NHIS, the total number of adult smokers (aged 20
years and older) in the United States declined from approximately
52,400,OOO in 1976 to approximately 51,100,OOO in 1985. The total
number of former smokers increased from approximately 29,500,OOO
to 40,900,OOO within this time period.

Trends in Cigarettes Consumed

In the United States, cigarettes are taxed at the wholesale level, in
advance of retail sales. Tax data may not reflect retail sales in any
particular year insofar as different inventory levels are held over
time. However, the number of cigarettes taxed is a standard index
used to estimate the number of cigarettes consumed over time. Total
cigarette consumption as estimated by this index in the United
States increased steadily from 1920 until 1981 when an estimated
total of 640 billion cigarettes were smoked (Table 2). Since 1981,
there has been a steady decline in consumption and the number of
cigarettes smoked in 1987 is estimated at 574 billion.

These data are frequently divided by the population of adults 18
years of age and older to give a per capita estimate of consumption. It
should be noted that this per capita estimate could be biased if there
is a trend over time for more people to start smoking regularly under
18 years of age.

Since 1973, there has been a decline of 23 percent in the number of
cigarettes smoked on a per capita basis. Although there has been a


TABLE l.-Percentage of current cigarette smokers among
      adults, by year and survey, United States,
        1944-1986

Year

Surrey

Current cigarette smokers (percentage)


  Men      Women     Total

1944
1949
1955
1964
1965
1966

196;
196-S
1970

1974
1975
1976
1978
1960
1983
1985

1986

GP        18       48.0       36.0      41.0
GP        18       54.0       33.0      44.0
CPS       18       54.2       24.5      37.6
WSH       21       52.9       31.5      40.3
NHIS       17       51.1       33.3      41.7
CPS       17       500       32.3      40.6
NCSH       21       51.9       33.7      42.2
CPS       17       49.1       32.1      40.1
CPS       17       47.0       312      38.6
NHIS       17       43.5       31.1      36.9
NCHS       21       42.3       30.5      36.2
NHIS       17       42.7       31.9      37.0
NCSH       21       39.3       28.9      33.8
NHIS       20       41.9       32.0      36.7
XHIS       11       37.5       29.6      33.2
NHIS       20       38.3       29.4      33.6
NHIS       20       35.7       29.4      32.4
CPS       16       31.8       25.4      23.4
NHIS       20       33.2       27.9      30.4
OSH       17       29.5       23.8      26.5

NOTE GP. Gallup Poll, CPS. Current Population Survey (SupplementI; NCSH. National Clearinghouse for
Smokmg and Health (Adult Use of Tobacco Surveys: NHIS, Natmnal Health interview Survey: OSH. Office on
Smokmg and Health (Adult Use of Tobacco Survey). NHIS data are not age adjusted
SOURCE LX DHHS 11987~1

decline in every one of these 15 years, the rate of decline has varied
from 0.2 to 7.2 percent with a mean of 1.9 percent per year (Table 2).

Trends in the Tar and Nicotine Content of Cigarettes
Consumed

Data on the market share of cigarettes of different smoking
machine determined tar and nicotine yield have been published by
the Federal Trade Commission (FTC) from information supplied to
the agency by cigarette companies. The FTC is no longer generating
these data. Trends in the sales-weighted average yield of tar and
nicotine for cigarettes sold are shown in Figure 1. The sales-weighted
average represents the tar and nicotine content found in specific
brands averaged by the quantity of sales for that specific brand.
Throughout the 1970s there was a steady decline in the sales-
weighted average. This decline may have occurred because of
consumer beliefs that lower-yield brands are less hazardous. The
impression that low-yield brands may be less hazardous may have
resulted in part from cigarette advertising implying that low-yield
brands are less hazardous or safe (Davis 1987).

566


TABLE 2.-Total cigarette consumption and consumption
     per capita 18 years of age and older, 1973 to
      1987, United States

Year

  Total
consumption
iblllionsl

            Per raprta
Per capita    consumption change
consumption    from previous year
/ 2 1P years old!      `percentagel

1973

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1964

1985

1986

1987 lest I

58Y 7

599.0

607.2

613 5

61i 0

616.0

621 5

6315

640.0

634 0

6000

600.4

594 0

583 8

574.0

4.14P

4.141

4.123

4.OY2

4,051

396i

3,661

3,644

3.836

3.iY9

3,488

3.446

3.370

3x74

3.196

-0.2

a.4

4.8

-10

-2.1

-2 7

a.4

-0.2

-2.6

-7 2

-1.2

-2.3

-2.9

-2.4

SOURCE USDA 1986,

From 1982 to 1985, the declining sales-weighted tar and nicotine
yield leveled off. This change may be related to one or a combination
of the following factors: (1) a persistent brand loyalty of some
smokers to moderate- or high-yield brands because of brand image;
(2) a diminishing perception that low-yield brands are less hazard-
ous; (3) some smokers are now smoking cigarettes of such low tar and
nicotine yields that further reductions in those yields may be
unacceptable; i.e., the "lower boundary" of comfortable cigarette use
has been reached (Kozlowski 1987; Chapter IV). The 1981 Surgeon
General's Report (US DHHS 1981) cautioned that the health benefits
of switching to low-yield brands are minimal compared with giving
up cigarettes entirely.

Surveys of Self-Reported Cigarette Smoking in Adults
General Considerations

The validity of self-reported smoking status from community
surveys affects the usefulness of these data in reporting historical
trends. Respondents' sensitivity to social stigma associated with

567


18 -

   16 -
lE   14-
z
-
2   12-

E
.P
T  '0:
2   8-

h?   6-

   4-

2-

-0.6

- 0.4



- 0.2

ol     I   .   I   .   ,   .   I     I     I   1   I     I   .   I Lo.0
67    69    71    73    75    77    79    81    63    85

                    1959~1985

FIGURE l.-Sales-weighted averages of tar and nicotine
      per cigarette, MB-1985 (1985 data preliminary)
SOURCE: U.S. Federal Trade Commission (February 1988l.

smoking is cited as a major reason why persons might underreport
their smoking status (Warner 1978; Kozlowski 1986). Whereas
biochemical assessment is significantly more reliable than self-
reports in assessing level of nicotine intake (see Chapters II and IV),
self-reported data appear valid for estimating prevalence of smoking
in the population. For example, studies of patients in several settings
(Petitti, Friedman, Kahn 1981; Pojer et al. 19841, as well as two large
community studies (Fortmann et al. 1984; Pierce, Dwyer et al. 1987),
have shown that measurements of smoking by self-report and
biochemical markers give approximately the same estimates of
prevalence. It is possible that the accuracy of self-reported data will
vary depending on whether the data collection method is face-to-face
or by telephone interview. However, biochemical validation data do
not exist to allow quantification of such a difference. In addition,
serious concerns have been expressed about the validity of data
(Thornberry 1987) reported by one person on behalf of another
(proxy response).

National Health Interview Surveys
The National Health Interview Survey (NHIS), which is conducted
regularly by the National Center for Health Statistics, uses a

568


sampling frame developed by the U.S. Bureau of the Census and is
based on a multistaged random probability sampling design. Infor-
mation on behavioral health risk factors is collected in face-to-face
interviews. Basic smoking information has been collected for several
years, including 1965, 1976, 1978, 1979, 1980, 1983, and 1985 (data
for 1965 are based on both self-report and proxy reporting; all of the
more recent surveys were based on self-reports). The 1987 survey
results were not available for this Report. Beginning in 1985, an
adequate sample of blacks was ensured by the survey design (using
the technique of oversampling). The NHIS generally has a response
rate of 96 percent (Thornberry 1987). However, the smoking informa-
tion is collected only by self-report in a supplement. This extra step
in data collection procedures leads to a decrease in the response rate
to approximately 90 percent.

Demographic Trends in Smoking Prevalence in Adults

Between 1965 and 1985, smoking prevalence decreased in all age,
sex, and race categories with the exception of women aged 65 years
and older (Table 3). This exception can be explained as a birth cohort
effect (Warner and Murt 1982).

Both black and white males have decreased their smoking by an
average of a percentage point per year over this 20-year period.
However, in 1985,41 percent of black males smoked, compared with
32 percent of white males. For all races, the largest decrease in
smoking occurred in younger males; the 20- to 24-year-old age group
decreased an average of 1.4 percentage points per year. The marked
gradient in the degree of change per year across age groups suggests
that a birth cohort effect may have occurred, with many more young
males never having become regular smokers.

Proportionately fewer women smoke than men within every age
group and race category except for persons 20 to 40 years old in 1985
(31.0 percent for men, 32.1 percent for women). However, the yearly
rate of decline in smoking prevalence across these categories is, on
average, three times less than the male rate of decline. Moreover,
the decline in female smoking appears mainly in the under-44-year
age group. This may indicate that uptake of smoking among women
in the more recent birth cohorts is beginning to decline. Of
particular importance is the almost complete lack of change in
smoking prevalence among black women from 1965 to 1985.

Smoking rates among Hispanics have been reported using NHIS
data (Marcus and Crane 1985,1987), but the small sample size of this
subpopulation reduces the reliability of the estimates. According to
the 1985 NHIS, the prevalence of smoking among Hispanic males
and females aged 18 and older was 31.3 percent and 20.8 percent,
respectively (Marcus and Crane 1987). Information on Hispanic
smoking is also available from the Hispanic Health and Nutrition

569


TABLE 3.-Twenty-year trends in smoking prevalence
     (percentage) among adults 20 years of age and
     older, by sex, race, and age, United States

                                      Difference
sex. race. age     1965     1976     1980     1985     196s1985

Men

Total ' z       52.1     41.6     37.9     32.7       -19.4

Race '
whm       51.3     41.0     37.1     31.8       -19.5
Black       59 6     501     44.9     40.6       -19.0

Age 2
20-24       59.2     45.9     39.7     31.0       -28.2
25-34       607     48.5     43.1     38.2       -22.5
3%       58.2     47.6     42.6     37.6       -20.6
45-64       51.9     41.3     40.8     33.4       -18.5
265        28.5     23.0     17.9     19.6       4.9

Total 1.1       34.2     32.5     29.8     28.3       -5.9

Race '
White
Black

34.5     32.4     30.0     28.3        -6.2
32.7     34.7     30.6     31.6       -1.1

Age2
20-24
25-34
w4
4s64
>a

41.9     342     32.7     32.1        -9.8
43.7     37.5     316     32.0       -11.7
43.7     38.2     349     31.5       -12.2
32.0     34.8     30.8     29.9       -2.1
9.6     12.8     16.8     13.5       13.9

: Age-adjusted prevalence rates.
`Includes white. black. and other
SOURCE U.S. PHS i19R7)

Examination Survey (HHANES), which was conducted by the
National Center for Health Statistics between 1982 and 1984. This
study surveyed 9,OW Mexican-Americans in the Southwest, 4,000
Puerto Ricans in the Northeast, and 1,500 Cuban-Americans in
Miami. For males aged 20 to 74 the age-adjusted smoking rates were
43 percent for Mexican-Americans, 42 percent for Cuban-Americans,
and 40 percent for Puerto Rican-Americans. Among females, the
smoking prevalence was 24 percent for Mexican-Americans and
Cuban-Americans and 30 percent for Puerto Rican-Americans
(Haynes 1987). Estimates of smoking prevalence among other
minority groups may be unreliable because of small sample sizes
included in the NHIS. Trend data are not available because Hispanic
status was not ascertained on earlier surveys.

570


TABLE 4.-Smoking prevalence (percentage) among adults
     18 years of age and older, by sociodemographic
     subgroups, United States, 1985

subgroup

Men       Women      Total

Education

Less than high school          40.1         31.4       35.4
High school graduate          36.6         31.0       33.4
some college               29.9         24.9       27.3
College graduate             22.6         17.1       20.1
Postgraduate               17.3         15.1       16.5

Occupation

Employed
  White-collar
  Blue-collar
  setice
Unemployed
Not in workforce!Unknown

33.8         30.0       32.1
264         28.0       27.5
40.1         33.9       39.7
40.3         354       37.2
443         28.0       36.1
28.6         25.3       26.4

Marital status

Never married              30.0         26.3       28.3
Divorced/Separated            48.2         42.4       44.7
MarriedKohabitating          31.9         27.7       29.7
Widowed                  29.3         20.1       21.6

Income

< 510,ooo                 36.3         29.7       32.3
$10,ooa-19,999              37.0         29.8       33.1
t20,-,999              33.1         28.1       30.7
2 835,ooo                 27.0         25.1       26.1

SOURCE: Natwnal Center for Health Statistics, National Health Internew Survey 1985.

Other Social Correlates of Smoking

The prevalence of smoking varies across so&demographic catego-
ries. A detailed analysis of the sociodemographic correlates of
smoking status in the 1985 NHIS survey is presented below.
Current smoking prevalence by sex, occupation, marital status,
employment, education, and income groups for 1985 is shown in
Table 4. Current smoking prevalence was inversely related to
educational status. Persons who were employed were less likely to be
current smokers than unemployed persons. Persons employed in
white-collar jobs were less likely to be smokers than persons
employed in blue-collar or service jobs. Persons with higher income
and persons who were single, married, or widowed had a lower
prevalence of smoking than persons with lower income or who were
divorced or separated.

Because blacks were oversampled in the 1985 NHIS and subse-
quent sample designs, it is possible to make detailed comparisons

571


TABLE B.-Percentage of current smokers in 1985, by age,
      race, and sex

sex. age

White         Black

         Men

           R-24               291          26.6
           25-34               37.1          45.2
           :35-44               36.3           449
           4!G54               33.4          47.4
          55-64               30.1           44.6
          65-74               21.2          31.0
         275               13.9           21.4


         Women

          lb24               33.0           24.2
          25-34               32.6          35.7
          35-44              31.4          40.2
          45-54               32.9          37.0
          5=4              27.4          26.9
          674               17.8          18.6
         275                7.1           8.0


SOURCE National Center for Health StaLlstirs. National Health Interview Sur'vey 1985.

between blacks and whites in smoking prevalence. Table 5 shows
that across all age categories, except among those aged 18 to 24
years, blacks have higher smoking prevalence than whites. The
lower smoking prevalence among blacks in this age group may
reflect an older age of initiation among blacks.

In a multivariate analysis of NHIS data, controlling for sex, age,
employment, poverty status, education, and marital status, blacks
were no more likely to be ever smokers than whites (Novotny et al.,
in press). In this study, blacks were less likely than whites to quit
smoking. Blacks also were less likely than whites to be heavier
smokers (2 15 cigarettes per day).

Other Surveys Reporting Adult Prevalence of Smoking

The 1986 Adult Use of Tobacco Survey showed slightly lower rates
of smoking than that expected from the trends observed in the
National Health Interview Surveys (NHIS). These data, based on a
telephone interview of 13,031 adults aged 17 and older, were
weighted to reflect the U.S. population according to age, sex,
education level, and region. An estimated 29.5 percent of males (95
percent confidence interval, 28.4 to 30.6) and 23.8 percent of females
(95 percent confidence interval, 22.7 to 24.9) smoked cigarettes
regularly. Differences from the NHIS may reflect differences in age
of respondents (NCHS-age 18 and above, Adult Use Survey-age 17
and above), methodology (Waksberg 19781, or response rates (NCHS
approximately 90 percent, Adult Use Survey approximately 74

572


percent). The exclusion of households lacking telephones appears to
account for an underestimate of approximately 1 percentage point in
telephone surveys; persons living in households without telephones
have a higher smoking prevalence than those in households with
telephones (US DHHS 1987c).

In 1985, a supplement to the Current Population Survey contained
smoking information collected by household interviews. These data
are particularly relevant because of the large sample population.
However, 45 percent of responses were by proxy. Of the 114,342
persons surveyed, the overall smoking prevalence for persons 16
years of age and older was 31.8 percent for males and 25.4 percent
for females (Table 1). A detailed analysis of this data set is available
from the Office on Smoking and Health (Marcus and Crane 1987).

Since 1981, the Centers for Disease Control has coordinated the
collection of State-specific data on several behavioral risk factors in
the Behavioral Risk Factor Surveillance System (BRFSS). In 1986,25
States and the District of Columbia participated in this telephone
interview system (Table 6). Median State smoking prevalence among
adults 18 years of age and older varied between 18 percent and 35
percent (US DHHS 1987c), with marked geographical distribution
patterns. States east of the Mississippi appeared to have the highest
smoking prevalences (US DHHS 1987dl. These States also had the
highest adult per capita consumption of cigarettes (Tobacco Institute
19861, as measured by sales of cigarettes taxed in each State.

Trends in Adolescent Smoking

The National Institute on Drug Abuse (NIDA) conducted house-
hold surveys on drug use in 1979,1982, and 1985. Data were obtained
from a stratified random sample of 8,000 U.S. households; approxi-
mately 2,000 interviews were conducted with respondents in the 12-
to 17-year-old age group. Questions included whether any cigarettes
were smoked within 30 days as well as within the previous year.
These surveys indicated that approximately 26 percent of the
teenage population surveyed smoked at least one cigarette at some
time during 1985 (Table 7). In 1985, 15.6 percent of this population
had smoked within the previous month. However, these overall
mean values probably underestimate the level of experimentation
and uptake of smoking during these ages due to response bias or
underreporting. Comparisons with 1979 are not appropriate, because
in that year, there was a markedly different definition of smoking
compared with later years ("at least 100 cigarettes in lifetime"
compared with "any smoking in last 30 days").

The "Monitoring of the Future" project, sponsored by NIDA, is
conducted by the Institute for Social Research at the University of
Michigan. It consists of a yearly survey of a representative sample of

573


TABLE 6.-Current smoking prevalence (percentage) in 25
      States and the District of Columbia, 1986

Current smokers

state

Sample
size

Men

Percentage


Women

Total

95 percent
confidence
interval

Alabama                559       30.3       20.0

ACZ0na               1,175       24.4       24.7

Cahfornia             1,579       25.4       23.9

District of Columbia       1,145       32.1       22.5

Florida               1,162       309       27.8
Georgia              1,140       29.3       24.8

Hawaii               1.551       27.8       20.3

Idaho                1.165       30.9       16.2

Illinois               1,142       32.7       23.6

Indiana              1,162       31.6       23.5
Kentucky             1,216       37.2       32.6

,2Iassachusetcs           1,105       27.1       27.5

Minnesota              3.023       25.3       25.0

Missouri                673       29.4       23.0

Montana              1,176       23.5       22.6

Sew Mexico            1,139       29.9       22 4

New York             1,135       26.7       26.1

North Carolma          1,622       30.7       22.5

North Dakota           1.182       27.4       25.1

Ohio                 1.158       29 4       26.9

Rhode Island           1,535       31.0       31.1
South Carolina          1,793       28.6       24 4

Tennessee              1.779       30.7       25.5

Urah                 1,188       208       15.1
West I'Lgmia           1.380       32.2       26.9

Wisconsin             1,268       31.5       21.1

24.6       -24.1

24.5       k2.8

24.6       12.4

26.7       k3.1

29.3       f2.8

26.7       rt2.9

24.1       22.9

23.4       k-2.6

27.9       k2.8

27.3       23.0

34.8       +3.2

27.3       k3.0

25.1       k1.7

26.0       23.3

23.0       22.7

26.1       k2.8

27.4       23.0

26.4       k2.4

26 2       22.9

28.1       k2.8

30.9       t2.5

26.3       +2.4

28.0       k2.4

17.8       k2.5

29.5       22.8

26.2       r2.6

SOURCE: US DHHS 1198iai

high school seniors. This approach does not include students who do
not complete high school (estimated to be about 15 percent of the
population by the U.S. Bureau of Census in 1978). Dropouts tend to
have a higher smoking prevalence than in-school students (Kandel
1980; Pirie, Murray, Luepker 1988); however, Johnston and
O'Malley (1985) estimate that the underestimate of the true popula-
tion prevalence is no more than 5 percentage points. The latter
researchers argue that the magnitude of this bias is unlikely to
change between the yearly surveys; thus, the estimate of the rate of
change should reflect the true rate of population change.

Smoking prevalence among female high school seniors was higher
than among males in 1986 (Table 81, and there are marked

574


TABLE `I.-Prevalence (percentage) of cigarette use among
     youth 12 to 17 years of age, 1979, 1982, 1985
      surveys, United States

Survey year


1979 '


1982

Any use in      Used I" !ast
last year       30 days


  13.3           1' 1


  24.8           14 7

TABLE &-Thirty-day prevalence of daily use of cigarettes
     by subgroups, high school class of 1986

Percentage who used qaettes
  daily in last :jO dnxs

Subgroups

  s
1approx )

One
or ","I?

    All seniors               15.200


    sex

     Me"                  7.100
     Women                l.ioo

   college plans

     None or under 4 wars       5.100
    Complete 4 fears          9.100

   Region

     Northeast               3.600
     North-central             4.300
     South                 4.7cK!
     west                2.600

SOURCE: Johnston. O'Malley. Bachmar. !195:1

18.i        11.4




16.Y        10.:
19.8        116




28.2        19 2
12.8         64




24.9        15.6
19 9        12.3
15 8        10.0
I3 4         6.5

geographic differences in smoking prevalence among students. In
addition, those students who plan to complete 4 years of college have
a smoking rate less than half that of students without such plans.
The prevalence of daily use within the previous 30 days among
high school seniors fell substantially from 1975 to 1986 for males and
females (Figure 2). Since 1976, there has been an overall 35 percent
reduction in smoking prevalence in this population. Most of this
decline occurred between 1977 and 1981. For all students, the
prevalence has fallen an average of 0.68 percentage points per year
during this period (to 18.7 percent in 19861, similar to the rate of

575


"[ - Any daily use

\
    r1/2 pack daily

o Men
0 Women

FIGURE 2.-Trends in 3May prevalence of daily cigarette
      use (smoking one or more cigarettes/day)
      among high school seniors, by sex
SOURCE Johnston. O'Malley. Bachman (1987).

decline noticed in adults (see Tables 1, 3). However, the rate of
decline has tapered off in recent years. The smoking rates among
females have consistently exceeded the rates among males.

The Monitoring of the Future Project has also followed representa-
tive samples from each graduating class since 1976. This was done by
selecting two matched panels from each graduating class and
following each panel in alternate years. The data obtained from
these surveys are presented in Figure 3. Recently, differences in
prevalence of any cigarette smoking within the last 30 days has
disappeared between those still in high school and those who have
graduated, suggesting that far fewer young adults are taking up
smoking after high school, and that most uptake has occurred by the
time of high school graduation. However, when either the 30day
prevalence of daily use or the 30-day prevalence of the use of half a


pack or more per day is considered, there is a clear marked increase
in smoking prevalence in the early years after high school, suggest-
ing that occasional and experimenting high school smokers become
regular smokers once they leave school.

Trends in the Proportion of Smokers Who are Heavy Smokers

The average reported number of cigarettes smoked per day in 1985
by age, race, and sex is presented in Table 9. There are marked
differences between the black and white population in the number of
cigarettes reported. Both black males and females report smoking
one-third fewer cigarettes per day than do their white counterparts.
Even though blacks smoke fewer cigarettes per day than whites,
their smoking patterns and choices of brands may provide the
nicotine content necessary to maintain daily blood nicotine levels
similar to whites (Chapter VII; Cummings, Giovino, Mendicino 1987).
Across all race and age categories, females report smoking fewer
cigarettes than males. In the over 35 age groups this difference is
approximately 20 percent.

Successful quitting behavior may not be uniform across all
smokers. Heavy smokers (defined as those who report smoking 25 or
more cigarettes per day) are more likely to have a strong nicotine
dependence (Chapter IV) and, therefore, are less likely to be
successful at quitting than lighter smokers. Thus, one would expect
the cross-sectional surveys over time to indicate an increasing
proportion of heavy smokers as the smoking prevalence declined.
These data from self-reported consumption measures are presented
in Table 10. The percentage of heavy smokers reported by the 1965
survey may be biased due to the use of proxy interviews which were
not used in subsequent surveys.

Between 1976 and 1985, there was no substantial change in the
proportion of smokers reporting smoking 25 or more cigarettes per
day. In 1985, approximately one-third of all male smokers and one-
fifth of all female smokers were classified as heavy smokers. Three
times as many white as black adults were classified as heavy
smokers. For both males and females, the proportion peaked in the
group aged 35 to 44, possibly indicative of a higher mortality rate
among older smokers.

Trends in Quitting Activity

Public health efforts to reduce the prevalence of smoking concen-
trate on reducing the proportion of the population that begins to
smoke cigarettes as well as increasing the proportion of smokers who
quit. One indicator of quitting activity is the prevalence of former
smokers. However, this variable is of limited use due to marked

577


  40 -




  30 -

Pi
2
& 20-
c:
B

  lo-

Years bevond h CI ,hrc hwl

o ??????  !n.odal age ia)
A 1.2Yea:s (maaalage 19-20)
0 3.4 Years modal a9e 21-Z)
o 5-6 Years (mood age 23-24)
0 7-E Years (modal age 25-26)
0 9.10 Years (modal ac,e 27-W

  40-




  30 -

$
i!?
E 20-
0
h

  10 -

.   .   .
76  77  78 79  80 it  8;  83  84  85  86
             Year

Daily use

0'   I   1   1   1   I   I   I   1   .   1   1
   76  77  78  79  80  81  82  83  64  85  66
                 Year

  40-




  30 -

0)
9
z al-
0
d

  10 -

2 Half-pack/day

o' , r r , r r r . . r r
   76 77 78 79 80 81 02 83 84 05 86
                 YE%

FIGURE 3.-Trends in 30-day cigarette smoking prevalence,
      daily use, and use of a half-pack or more per
      day among young adults, by age group
SOURCE Johnston. O'hlalley. Bachman 11987).

578


TABLE R-Average number of cigarettes smoked per day
      by current smokers, by race, age, and sex,
      united states, 1985


        h/Age       Men       Women     Difference


          All races        21.8        18.1        3.7

            BladU        14.7        13.5        1.2
           Whites        23.4        19.1        4.5

18-24        17.2        15.3        1.9
2534         20.3        18.0        2.3
3a44        24.3        20.1        4.2
4554        24.7        19.9        4.8
!55-64        23.9        18.0        5.9
265         20.2        16.0        4.2

SXJRCX: National Center for Health Statistica, National Health Interview Survey 1985

TABLE IO.-Twenty-year trends in the proportion of
      smokers reporting smoking 26 or more
      cigarettes per day, by sex, race, and age,
       united states

ser. race, age       1965      1976      1980     1985

24.1       30.7       34.2     32.8

Bate
White
Black

he
  !20-24
  2x34
  35-44
  45-64
  265

Women

Total

Bace
White
Black

Age
  20-24
  25-34
  3544
  4544
  265

28.0      33.3      37.3     36.5
8.6       10.8       13.8      10.7

15.4       18.5       19.8      17.1
24.3       `28.7       30.1     28.5
31.5       39.2       40.7      42.3
28.0      37.4       42.6     39.3
13.8       18.2      25.2     25.4

13.0

13.9       20.9       25.2     22.8
4.6       5.6       8.6      6.7

9.1       14.5       15.9     12.2
15.5       20.5      24.2     21.3
17.1       21.8       32.7     27.8
13.6       21.5       24.9     22.7
6.4       11.8       13.1     13.4

19.0

23.2

20.6

SCNJRCR: National Center for Health Statistics, National Health Interview Surveys 1965, 1976, 198i), 1986.

579


differences in uptake of cigarettes between males and females in
different birth cohorts (Warner and Murt 1982). A more meaningful
index of quitting behavior has been defined as the quit ratio (Pierce,
Aldrich et al. 1987tthe proportion of former smokers in a given
population divided by the proportion of that population who have
ever been smokers.

Trends in this quit ratio are presented in Figure 4. The quit ratio
has consistently been higher among men compared with women.
Quit ratios among both males and females increase with age. In
1985, nearly one-third of those persons aged 25 to 34 who reported
that they had ever smoked had quit smoking by 1985. Among those
aged 65 or older, the quit ratio was over 60 percent for women and 70
percent for men. Moreover, over the last 20 years, successful quitting
activity has been increasing in all age groups. The quit ratio
differences between men and women increased with age from 1965 to
1985 (several possible explanations for this phenomenon exist; see
Chapter VII).

Trends in Cigar, Pipe, and Roll-Your-Own Cigarette Smoking

Figure 5 shows 20-year trends in pipe and cigar smoking among
adult males. For both tobacco products, there has been an 80 percent
decline in prevalence. In fact, cigar smoking in 1964 (30 percent) was
as prevalent as cigarette smoking in 1985 (30.4 percent).
Hand-rolled cigarettes are the least expensive cigarettes to con-
sume. According to the 1986 Adult Use of Tobacco Survey, only 0.4
percent of smokers aged 17 and older use roll-your-own cigarettes
(US DHHS 1988).

Trends in Smokeless Tobacco Use

The prevalence of both snuff and chewing tobacco use by younger
men has increased substantially between 1970 and 1986, as shown in
Figure 6. Among women, use of smokeless tobacco products de-
creased between 1970 and 1986, but prevalence of use in this group
has always been low. In 1986, less than 0.4 percent of females used
snuff or chewing tobacco, whereas 8.2 percent of men used these
products (Novotny and Lynn, in press). Additionally, among men,
almost half of current users reported initiation of smokeless tobacco
use before age 17 (Table 11).

In 1985, the NIDA National Household Survey of persons 12 years
of age and older found that 12 percent of men and 1 percent of
women used chewing tobacco, snuff, or other kinds of smokeless
tobacco in the year of the survey. Smokeless tobacco use rates were
highest among young males (12-25 years old) who were residents of
nonmetropolitan areas (Rouse, in press).

580


   Age 20 24, Age 25 34
8o 11

70 j  0 Men      9 Men
   + Women     9 Women
60       I

&so-
-m
g 40
i,v

  Ol.,.,.,.,.,.,.,.,.,.,.
   64 66 68 70 72 74 76 78 80 82 84 86
             1964 - 1986

64  66  68  70  72 74  76 76  80 82  84  86
          1964 1966

80 I

Age 45 64

o!,,.,.,.,.,.,.,.,.,.,.
64  66  66  70  72 74  76  78  80  82  84  86
          1964 1986

20 -
. 0 Men
lo- + Women

0 .,.,.,.,.,.,.,.,.,.,C

64  66  68  70  72 74  76 76  80  82  84  86
          1964 1986

FIGURE 4.-Quit ratios (ratios of former smokers to ever
      smokers), by age and sex, 1965-1985
SOURCE: US DHHS (1986bl

The BRFSS collected data from 25 States and the District of
Columbia in 1986. In this survey, smokeless tobacco use among men
ranged from 0.7 percent in New York to 21.4 percent in West
Virginia (median State prevalence, 6.5 percent) (US DHHS 1987b).
In addition, there was a regional pattern of use, with highest

581


80

70

60

64

0 Cigarette
O Cigar
O Pipe

L
86

1964 - 1986

FIGURE 5.-Trends in prevalence of cigarettes, cigars, and
      pipes, adult men, 1964-1986
SOURCE US. PHS 11970. 1975. 19861, US DHHS (1987~~).

prevalence found in Southern and North Central States, just as in
the NIDA survey mentioned above.

Summary and Conclusions

1. An estimated 32.7 percent of men and 28.3 percent of women
smoked cigarettes regularly in 1985. The overall prevalence of
smoking in the United States decreased from 36.7 percent in
1976 (52.4 million adults) to 30.4 percent in 1985 (51.1 million
adults).

2. In 1985, the mean reported number of cigarettes smoked per
day was 21.8 for male smokers and 18.1 for female smokers.
3. Smoking is more common in lower socioeconomic categories
(blue-collar workers or unemployed persons, less educated
persons, and lower income groups) than in higher socioeconom-
ic categories. For example, the prevalence of smoking in 1985
among persons without a high school diploma was 35.4 percent,
compared with 16.5 percent among persons with postgraduate
college education.

582


7

6

  5

5  4

E
8
$3

1970

2-


      1.2

r-l  Chewing tobacco      6.5

u
El  Snuff

       2.0



1.9  r 1

-

Age

+I  1986

4 -I

2.7

4.2

FIGURE B.-Prevalence of chewing tobacco and snuff use
      among men, 1970 and 1986
SOURCE C S DHHS `1986a, Sorotn> and Lynn tan pm6

583


TABLE Il.-Reported age at initiation, by current
       smokeless tobacco users (percentage), both
       sexes, 1986, United States

Age at imtiatlon    An?; smokeless tobacco

Chewmg tobacco

Snuff

< 17years              44.3             42.5       43.5

17-24 years             37.9             27.3       35.1


2 25 years              17.8             30.2       21.4

SOURCE Novotny and Lynn i,n press,.

4. An estimated 18.7 percent of high school seniors reported daily
use of cigarettes in 1986. The prevalence of daily use of one or
more cigarettes among high school seniors declined between
1975 and 1986 by approximately 35 percent; the smoking
prevalence among females has consistently been slightly
higher than among males. Most of the decline occurred
between 1977 and 1981.

5. The use of cigars and pipes has declined 80 percent since 1964.
6. Smokeless tobacco use has increased substantially among
young men and has declined among older men since 1975. An
estimated 8.2 percent of 17- to 19-year-old men were users of
smokeless tobacco products in 1986.

584


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KOZLOWSKI, L.T. Pack size, self-reported smoking rates and public health. American
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December 1982.

587


APPENDIX B

TOXICITY OF NICOTINE

589


CONTENTS

Introduction ........................................................ .593

Acute Intoxication. ................................................ 593

Chronic Nicotine Toxicity ....................
  Cardiovascular Disease ..................
  Hypertension ...............................
  Wound Healing ............................
  Reproductive Hazards ....................
    Teratogenicity .......................
    Pregnancy ............................
  Pulmonary Toxicity .......................
Genotoxicity and Carcinogenicity .....
  Gastrointestinal Disease .................

......

......

......

......

......

......

......

......

......

......

..,,..

. . . . . .

.*,...

. . . . . .

. . . . . .

. . . . . .

. . . . . .

. . . . .

. ...*.

. . . . . .

* . . 596

. . 596
. . . 600
. . . 601
. . . 601
. . . 601
. . . 602

. 603
. . 604
. . . 605

Summary and Conclusions ...................................... 607


References ........................................................... 609

591


introduction

Knowledge of the toxicity of nicotine is important to help
understand tobacco-induced human disease as well as to assess the
potential risks associated with the therapeutic use of nicotine (e.g.,
nicotine polacrilex gum) as an aid to assist smoking cessation.
This Appendix provides a brief overview of the toxic actions of
nicotine per se, focusing on human studies wherever possible and
selecting only those animal data which have direct implications in
understanding mechanisms of human disease. The toxicity of
cigarette smoke has been extensively reviewed in prior Surgeon
General's reports (US DHHS 1982, 1983, 1984, 1985, 1986). In most
cases the pathogenesis of tobacco-related diseases, including the role
of nicotine, has not been fully elucidated. Therefore the potential
contribution of nicotine to development of tobacco-related disease,
even if unproved, will be considered.
The chemistry and general pharmacology of nicotine have been
reviewed in previous chapters (Chapters II and III) of this report and
are not presented in detail in this Appendix. An appreciation of the
basic pharmacologic actions of nicotine is, however, a necessary
foundation for understanding the issues of toxicity which are
discussed in this Appendix.

Acute Intoxication

As discussed in Chapter II, nicotine is a water and lipid soluble
drug which, in the free base form, is readily absorbed via respiratory
tissues, skin, and the gastrointestinal tract. Nicotine may pass
through skin OF mucous membranes when in alkaline solutions, in
which circumstance nicotine is primarily un-ionized.

In experimental animals, the dose of nicotine which is lethal to 50
percent of animals (LD,,) varies widely, depending on the route of
administration and the species used. Intravenous (i.v.) LD,, doses of
nicotine in mice range between 0.3 to 1.8 mg/kg body weight
(Borzelleca, Norman, McKennis 1962; Lindner 1963; Wirth and
Gosswald 1965; Barlow and McLeod 1969). The intraperitoneal (ip.)
LD,, values for nicotine bitartrate in mice and rats have been found
to be 13 and 83 mg/kg body weight, respectively, while the values for
five inbred hamster strains varied between 125 to 320 mglkg body
weight (Bernfeld and Homburger 1972). The wide variation in
sensitivity to the toxic effects of nicotine in rodents appears to be
genetically determined (Garg 1969; Marks, Burch, Collins 1983;
Miner, Marks, Collins 1984).

In interpreting animal toxicity data it is important to recognize
that the rate of administration is an important determinant of
toxicity. Rapid i.v. injections result in the highest blood and brain
concentrations and produce toxicity at the lowest doses. In contrast,

593


with oral or i.p. administration higher doses are required to produce
toxicity. This is due to presystemic ("first pass") metabolism of
nicotine and the gradual time course of absorption as compared with
after i.v. dosing. With intermittent dosing, such as practiced by
smokers, the total dose of nicotine absorbed per day could exceed the
toxic or even lethal dose of a single injection.

In humans, acute exposure to nicotine even in low doses (similar to
the amounts consumed by tobacco users) elicits autonomic and
somatic reflex effects as described in detail in Chapters II and III.
Dizziness, nausea, and/or vomiting are commonly experienced by
nonsmokers after low doses of nicotine, such as when people try their
first cigarette. However cigarette smokers rapidly become tolerant to
these effects (Chapter II).

A number of poisonings and deaths from ingestion of nicotine,
primarily involving nicotine-containing pesticides, have been report-
ed in humans (Beeman and Hunter 1937; McNally 1923; Franke and
Thomas 1936; Saxena and Scheman 1985). The lethal oral dose of
nicotine in adults has been quoted to be 40 to 60 mg (Goldfrank,
Melinek, Blum 1980; Larson, Haag, Silvette 19611, but it has not
been well documented. Nicotine intoxication produces nausea,
vomiting, abdominal pain, diarrhea, headaches, sweating, and pallor.
More severe intoxication results in dizziness, weakness, and confu-
sion, progressing to convulsions, hypotension, and coma. Death is
usually due to paralysis of respiratory muscles and/or central
respiratory failure.

Dermal exposure to nicotine can also lead to intoxication. Such
exposures have been reported after spilling or applying nicotine-
containing insecticides on the skin or clothes (Lockhart 1933;
Faulkner 1933; Benowitz et al. 1987) and as a consequence of
occupational contact with tobacco leaves.

Green tobacco sickness, an occupational illness in field workers
harvesting tobacco leaves, has been attributed to dermal absorption
of nicotine found in the dew on tobacco leaves (Weizenecker and Deal
1970; Gehlbach et al. 1974). The levels of cotinine in the urine of
exposed workers exceed those of novice smokers who had smoked
three cigarettes in succession (Gehlback et al. 1975). The symptoms
of green tobacco illness are described in Table 1 (Gehlbach et al.
1975; Gehlbach, Williams, Freeman 1979). A similar syndrome has
been reported in Asian Indian tobacco workers who harvest green
tobacco leaves and handle cured tobacco (Ghosh et al. 1979).

Tobacco harvesters who use tobacco products, either in the forms
of cigarettes or smokeless tobacco, are usually not affected by green
tobacco sickness owing to development of tolerance to nicotine
(Gehlbach et al. 1974). Tolerance to the toxic effects may even
develop during the course of nicotine poisoning, despite the persis-

594


TABLE l.-Symptoms of systemic nicotine poisoning (Green
      Tobacco Sickness)

       Symptom


       Nausea, vomiting

         Pallor

         Weakness

       Dizziness, hghtheadedness

         Headache

       Sweating
       Abdominal pain

        Chills

         Increased salivation

SOURCE Adapted from Gehlbach et al 119741

Pt?KZelltage
I53 Casesl



  98

  89

  81

  81

  81

  56

  42

  36

  17

tence of nicotine in the blood at extremely high concentrations (200
to 300 ng/ml) (Benowitz et al. 1987).

Acute intoxication may occur in children following ingestion of
tobacco materials. Four children, each of whom ingested two
cigarettes, developed salivation, vomiting, diarrhea, tachypnea,
tachycardia, and hypertension within 30 min; followed by depressed
respiration and cardiac arrhythmia within 40 min; and convulsions
within 60 min (Malizia et al. 1983). All recovered and suffered no
complication. Another six children who ingested one-half of a
cigarette experienced salivation and vomiting only. In a Swedish
report (Werner 19691, 355 children who ingested tobacco had only
very mild symptoms. Severe poisoning has occurred in children who
swallowed tobacco juice (expectorated by tobacco chewers). Although
ingestions of tobacco are common, deaths due to ingestion of tobacco
are extremely rare, due to early vomiting and first pass metabolism
of the nicotine which is absorbed.

Conceivably, intoxication from nicotine polacrilex gum could occur
after accidental use by children or nonsmokers, or if an ex-smoker
gum-user consumed several pieces at once or in rapid succession.
One case report describes a smoker who developed apparent symp-
toms of nicotine intoxication within 1 min of chewing a piece of 2-mg
gum (Mensch and Holden 1984). However, based on the known
absorption kinetics and the amount of nicotine in the gum, true
nicotine intoxication is unlikely in this case.

Swallowing nicotine polacrilex gum appears not to be of concern
for development of toxicity. Although 30 to 85 percent of the nicotine
content can be released from the gum into the gastrointestinal tract,
the chances of nicotine intoxication are quite low because nicotine is

595


released slowly (transit time of the gums through the gastro-intesti-
nal tract is 16 to 48 hr) (Brantmark and Fredholm 1974), and because
the nicotine which is released undergoes extensive presystemic
metabolism. Simultaneous ingestion of 10 unchewed pieces of 4-mg
gum resulted in a peak blood concentration of nicotine of less than
10 ng/ml (Brantmark and Fredholm 1974), which is similar to the
level attained by a smoker after smoking a single cigarette.

Chronic Nicotine Toxicity

As attested to in the Surgeon General's reports since 1964,
smoking causes coronary and peripheral vascular disease (1983),
cancer (1982), chronic obstructive lung disease (1984), peptic ulcer
disease, and reproductive disturbances, including prematurity
(1980). Tobacco smoke is a complex mixture of chemicals, including
carbon monoxide, many of which have been implicated in human
disease. Nicotine may contribute to tobacco-related disease, but
direct causation has not been determined because nicotine is taken
up simultaneously with a multitude of other potentially harmful
substances that occur in tobacco smoke and smokeless tobacco.

However, particularly now that nicotine per se may be prescribed
in the form of gum or other delivery systems, the potential health
consequences of chronic nicotine exposure deserve careful consider-
ation.

Cardiovascular Disease

Smoking causes coronary and peripheral vascular disease (US
DHHS 1983). Both nicotine and carbon monoxide may contribute to
atherosclerotic vascular disease (Figure 1). Nicotine could contribute
both to the atherosclerotic process and to acute coronary events by
several mechanisms. Nicotine could promote atherosclerotic disease
by its actions on lipid metabolism and coagulation, by hemodynamic
effects, and/or by causing endothelial injury. Compared to nonsmok-
ers, cigarette smokers have elevated low-density (LDL) and very-low-
density lipoproteins (VLDL), as well as reduced high-density lipopro-
tein (HDL) levels (Criqui et al. 1986; Brischetto et al. 1983), a profile
associated with an increased risk of atherosclerosis. Chronic oral
nicotine feeding has been shown to increase LDL in monkeys
(Cluette-Brown et al. 1986). In one patient the use of nicotine
polacrilex gum was reported to increase serum total and LDL
cholesterol and triglycerides (Dousset, Gutierres, Dousset 1986).
Nicotine may act by releasing free fatty acids, enhancing the
conversion of VLDL to LDL, impairing the clearance of LDL and/or
by accelerating the metabolism of HDL (Brischetto et al. 1983;
Cluette-Brown et al. 1986; Gnasso et al. 1986; Hojnacki et al. 1986).

596


DIsturbed hpld

hypercoagulability

     I
Reduced myocardfal
02 SUPP'Y

FIGURE l.-Smoking, nicotine, and coronary heart disease
SOURCE Benowtz 11986dl

Thrombosis is believed to play an important role in atherogenesis
(Mehta and Mehta 1981). Platelets may release a growth hormone
which promotes the growth of vascular endothelial cells, contribut-
ing to the atherosclerotic plaque (Packham and Mustard 1986). The
blood of smokers is known to coagulate more readily than the blood
of nonsmokers (Billimoria et al. 1975). According to several studies,
platelets of smokers are more reactive, and have a shorter survival
than those of nonsmokers (Belch et al. 1984; Siess et al. 1982;
Mustard and Murphy 1963). The importance of nicotine as a
determinant of platelet hyperaggregability is supported by a study
showing that the blood concentrations of nicotine, after smoking
different cigarettes, correlated with the platelet aggregation re-
sponse (Renaud et al. 1984). Nicotine could affect platelets by
increasing the release of epinephrine, which is known to enhance
platelet reactivity, by inhibiting prostacyclin, an antiaggregatory
hormone secreted by endothelial cells, or perhaps directly (Cryer et
al. 1976; Sonnenfeld and Wennmalm 1980). Alternatively, by in-
creasing heart rate and cardiac output and thereby increasing blood
turbulence or by direct action nicotine may promote endothelial
injury.


Structural damage and increased mitotic activity in the aortic
endothelial cells of nicotine-treated animals have been reported
(Booyse, Osikowicz, Quarfoot 1981; Zimmerman and McGeachie
1985, 1987). Nicotine has also been shown to modulate the structural
and functional characteristics of cultured vascular cells (Csonka et
al. 1985; Thyberg 1986). In rats, nicotine given i.v. or per OS p.o.
produced dose-dependent increases in circulating anuclear carcasses
of endothelial cells (Hladovec 1978). In support of the relevance of
animal or in vitro studies to humans, Davis and colleagues (1985)
reported an increase in the number of endothelial cells found in
venous blood (reflecting endothelial injury) and a decrease in the
platelet aggregate ratios (reflecting platelet aggregation) in non-
smokers who smoked tobacco but not nontobacco (made from wheat,
cocoa, and citrus plants) cigarettes.

The above findings suggest that some substance unique to tobacco,
such as nicotine, may contribute to the pathogenesis of atherosclero-
sis and complications of atherosclerotic vascular disease. Although
several potential mechanisms by which nicotine may promote
atherogenesis have been considered, nicotine has not been demon-
strated to produce or accelerate atherosclerosis in experimental
animals. Wald and colleagues (1981) have presented an argument
against the role of nicotine in promoting coronary heart disease in
that pipe smokers, who consume comparable amounts of nicotine
and have similar levels of nicotine but lower levels of carbon
monoxide in the blood as cigarette smokers, do not share the same
magnitude of increased risk for coronary heart disease. However, the
possibility that nicotine inhaled in cigarette smoke, either due to
rapid absorption or effects on pulmonary afferent nerves, affects the
cardiovascular system differently than nicotine absorbed more
slowly through mucous membranes must be considered (Benowitz
and Jacob 1987).

Based on its pharmacologic actions, it is likely that nicotine plays
a role in causing or aggravating acute coronary events. Myocardial
infarction can be due to one or more of three precipitating factors -
excessive oxygen and substrate demand, thrombosis, and coronary
spasm. Nicotine increases heart rate and blood pressure and,
therefore, myocardial oxygen consumption. Carbon monoxide in-
haled in cigarette smoke reduces the oxygen carrying and releasing
capacity of the blood. When a healthy person smokes a cigarette,
coronary blood flow increases to meet the increased demand (Nicod
et al. 1984). In the presence of coronary artery stenosis, coronary
blood flow cannot increase and ischemia may develop, resulting in
angina pectoris, myocardial dysfunction, or myocardial infarction
(Jain et al. 1977). Nicotine may also directly reduce the increase in
coronary blood flow which occurs in response to increased metabolic
demand, or even cause an inappropriate decrease in coronary blood

598


flow, so that flow no longer matches increased myocardial oxygen
consumption (Kaijser and Berglund 1985; Klein et al. 1984; Nicod et
al. 1984; Martin et al. 1984). The decrease in coronary blood flow
with smoking appears to result from alpha-adrenergically mediated
coronary vasoconstriction, due to sympathetic activation and/or
increased circulating catecholamines, either of which is likely to be
an effect of nicotine (Winniford et al. 1986). Chronic nicotine
exposure has been reported to increase the size of experimentally
induced myocardial infarcts in dogs (Sridharan et al. 1985).

Nicotine consumed in the form of nicotine gum has been studied in
patients with coronary artery disease. Nicotine gum (4-mg) increased
myocardial contractility in healthy people, but in patients with
coronary artery disease nicotine gum decreased contractility in the
ischemic regions of the myocardium, consistent with aggravation of
ischemia (Bayer, Bohn, Strauer 1985). In the most severe cases of
coronary artery disease, overall contractility decreased after nic-
otine polacrilex gum. This study supports the idea that nicotine
contributes to smoking-induced myocardial ischemia in susceptible
people.

In addition to creating an imbalance between myocardial oxygen
supply and demand, nicotine may promote thrombosis, as discussed
previously. Nicotine may also induce coronary spasm by sympathetic
activation or inhibition of prostacyclin. Coronary spasm has been
observed during cigarette smoking (Maouad et al. 1984).

Sudden cardiac death in smokers might result from ischemia, as
discussed above, combined with the arrhythmogenic effects of
increased amounts of circulating catecholamines released by nic-
otine. However, smoking has not been demonstrated to increase the
prevalence or magnitude of ventricular ectopy in patients with
ischemic heart disease (Davis et al. 1985; Meyers et al. 1988).
Cigarette smoking, most likely mediated by nicotine, facilitates AV
nodal conduction, which could result in an increased ventricular
response during atria1 fibrillation (Bekheit and Fletcher 1976; Peters
et al. 1988). Thus, even if the frequency of arrhythmias is not
increased by smoking, the actions of nicotine may render those
arrhythmias which do occur more life-threatening.

With respect to the arrhythmogenicity of nicotine, two case
reports are of note. The first concerns a man who developed atria1
fibrillation with a rapid ventricular response rate (150) while
chewing 30 pieces of 2-mg nicotine polacrilex gum per day (Stewart
and Catterall 1985). The other case was that of a man with known
paroxysmal atria1 fibrillation who developed a recurrence 5 min
after chewing the day's first piece of nicotine gum (Rigotti and Eagle
1986).
Cigarette smoking has been associated with an increased risk of
cardiomyopathy, that is a generalized reduction in contractility of

599


heart muscle (Hartz et al. 19843. Cigarette smoke exposure induces
cardiomyopathy in rabbits (Gvozdjakova et al. 1984). A role of
nicotine is suggested by a study in which dogs received injections of
nicotine fbr 2% months and developed impaired contraction of the
heart muscle with evidence of some interstitial fibrosis on anatomi-
cal examination (Ahmed et al. 1976).

Exercise tolerance in patients with intermittent claudication
improves after stopping cigarette smoking (Jonason and Bergstrom
1987; Quick and Cotton 1982). Nicotine could aggravate peripheral
vascular disease by constricting small collateral arteries and/or by
inducing local t.hrombosis. The effect of nicotine replacement
therapy on symptoms of peripheral vascular disease, as on exercise
tolerance, in comparison to cigarette smoking, requires further
investigation.

On balance, short-term nicotine administration, such as nicotine
replacement therapy as an adjunct to smoking cessation therapy,
presents little cardiovascular risk to healthy individuals. Patients
with coronary or peripheral vascular disease are likely to suffer
some increase in risk when taking nicotine, but considerably less
risk than with cigarette smoking, which exposes them also to both
carbon monoxide and higher levels of nicotine.

Hypertension

Although cigarette smoking and nicotine per se increase blood
pressure, cigarette smoking alone is not a risk factor for chronic
hypertension (Green, Jucha, Luz 1986). Conceivably, factors such as
lower body weight or altered dietary intake, which may be associated
with cigarette smoking, might lower blood pressure to compensate
for any blood pressure elevation due to nicotine.

However, progression of chronic hypertension to accelerated or
malignant hypertension is much more likely in cigarette smokers
(Isles et al. 1979; Petitti and Klatsky 1983). Nicotine could contribute
to this progression by aggravating vasoconstriction, either via
sympathetic activation or inhibition of prostaglandin synthesis.
Animal studies indicate that nicotine may reduce renal blood flow
which, in a patient with marginal renal blood flow due to hyperten-
sive vascular disease, could cause renal ischemia and aggravate
hypertension (Downey, Crystal, Bashour 1981). Thus, there is
concern about nicotine replacement therapies in patients with
severe hypertension.

Tobacco, most likely due to effect of nicotine, may interact with
particular hypertensive diseases. For example, a patient with
pheochromocytoma (a catecholamine-secreting tumor) developed
paroxysmal hypertension and angina pectoris following the use of
oral snuff iMcPhau1 et al. 1984). Within 10 min, blood pressure
increased from 110/70 mmHg to 300/103 mmHg and heart rate from

600


70 to 110. Rechallenge with snuff after surgical removal of the
pheochromocytoma revealed only a mild blood pressure increase.
Another patient with previously controlled essential hypertension
presented with a blood pressure of 210/115 mmHg prior to surgery
(Wells et al. 1986). A mass of snuff was found in the patient's cheek.
The snuff was removed and blood pressure returned to 150!85
mmHg within 15 min.

Wound Healing

Adequate blood flow to the skin is important for wound healing.
Cigarette smoking and nicotine polacrilex gum reduce skin blood
flow (Fredholm and Sawe 1981; Allison and Roth 1969; Carlsson and
Wennmalm 1983). In rats, exposure to cigarette smoke decreases
survival of surgical flaps (Kaufman et al. 1984; Lawrence et al. 1984;
Craig and Rees 1985). Cigarette smoking has been associated with a
twelvefold increased risk of experiencing skin slough after facelift
surgery (Rees, Liverett, Guy 1984). It is conceivable that nicotine
substitution therapy might also delay wound healing, but no human
data are as yet available.

Reproductive Hazards
Teratogenicity

Nicotine rapidly crosses the placenta and enters the fetus (Suzuki
et al. 1974). Nishimura and Nakai (19581, Landauer (19601, and Khan
and coworkers (1981) have described teratogenic effects of high doses
of nicotine, which interfered with skeletogenesis in mice and chick
embryos. Chronic nicotine treatments of pregnant rats throughout
gestation produced subtle neurological changes which manifested
themselves as behavioral or electrophysiological alterations in the
offspring (Peters and Ngan 1982; Hudson, Meisami, Timiras 1973;
Martin and Becker 1971). Wang, Chen, and Schraufnagel (1984)
found that pre- and postnatal exposure to nicotine induced structur-
al changes in the lungs of fetal mice. Maternal exposure to nicotine
also inhibited glucose metabolism in fetal lung tissue (Maritz 19861.
Thus, several studies suggest that nicotine, at least in high doses,
may have toxic effects on the fetus.

Whether cigarette smoking is associated with increased rates of
congenital malformations in humans is controversial. Several stud-
ies show no association or a lower incidence of malformations in
offspring of smoking mothers (Comstock and Lundin 1967; Goujard,
Rumeau, Schwartz 1975; Meyer and Tonascia 1977; Evans, New-
combe, Campbell 1979; Shiono, Klebanoff, Berendes 1986; Hem-
minki, Mutanen, Salonieni 19831, but others report positive associa-
tions (Himmelberger, Brown, Cohen 1978; Fedrick 1978; Kelsey et al.
19781. One study has reported an association between paternal

601


smoking and the incidence of congenital malformations (Mau and
Netter 1974).

Pregnancy

Cigarette smoking during pregnancy increases the risk of low
birth weight, prematurity, spontaneous abortion, and perinatal
mortality in humans, which has been referred to as the fetal tobacco
syndrome (Nieburg et al. 1985) (also reviewed in detail in the 1980
Surgeon General's Report). Nicotine influences implantation and
embryo development in some laboratory animal studies (Hudson and
Timiras 1972; Card and Mitchell 1979; Hammer and Mitchell 1979).
At least one adverse outcome, reduced birth weight, is correlated
with the level of cotinine, the major metabolite of nicotine, in the
mother's serum (Haddow et al. 1987).

Nicotine in high concentrations markedly decreases the in vitro
development of rabbit preimplantation embryos and inhibits DNA
synthesis (Balling and Beier 1985). Injection of nicotine, 7.5 mg twice
each day from proestrus through pregnancy in rats, resulted in a
delay in the entry of the ovum into the uterus, implantation, and
subsequent development of the ovum (Yoshinaga et al. 1979). It was
suggested that nicotine acted by delaying progesterone secretion,
which is necessary to prepare the uterus for implantation, and by
other disturbances of hormone release. Another study in rats
reported that low doses of nicotine injected subcutaneously (0.1
mg/kg/day) from day 14 to the end of pregnancy had no effect on
litter size or fetal development, but higher doses (1 mg/kg/day),
comparable to those consumed by heavy smokers, reduced litter size
and increased the number of still births (Hamosh, Simon, Hamosh
1979). Further research is needed to determine if there are direct
adverse effects of nicotine on the embryo or fetus at levels of nicotine
comparable to those observed in cigarette smokers.

A likely mechanism for the reproductive problems in pregnant
cigarette smokers is placental insufficiency, which is supported by
evidence of placental hypoperfusion in cigarette smoking mothers
(Naeye 1978; Philipp, Pateisky, Endler 1984). The factors most likely
to affect the placenta are carbon monoxide and nicotine, both agents
having the potential of impairing oxygen supply to the fetus.

Inhalation of carbon monoxide results in elevation of both
maternal and fetal carboxyhemoglobin (Asmussen and Kjeldsen
1975; Longo 1977). Nicotine infusion in pregnant sheep increases
uterine vascular resistance and reduces uterine blood flow, effects
which appear to be mediated by catecholamine release (Ayromlooi,
Desiderio, Tobias 1981; Resnick, Brink, Wilkes 1979). Both cigarette
smoking and nicotine gum increase fetal heart rate during the
second trimester in humans, consistent with sympathetic activation
(Lehtovirta et al. 1983). During the third trimester in humans,

602


cigarette smoking or nicotine gum chewing decreases fetal heart rate
and reduces fetal breathing movements, both of which may be signs
of fetal hypoxia (Lehtovirta et al. 1983; Gennser, Marsal, Brantmark
1975; Manning and Feyerabend 1976). Elevated levels of catechol-
amines in amniotic fluid in human smokers during the third
trimester indicate sympathetic activation in the fetus, consistent
with fetal hypoxia and/or direct effects of nicotine (Divers et al.
1981X The above findings suggest that nicotine contributes to the
adverse effects of cigarette smoking on reproduction probably by
acting on the utero-placental circulation. Besides producing func-
tional changes, carbon monoxide and nicotine might also be responsi-
ble for the injury to the intimal ultrastructure of the umbilical
artery seen in smoking mothers (Asmussen and Kjeldson 1975). Fetal
hypoxemia has also been considered as a contributory cause of
behavioral abnormalities, such as hyperactivity, short attention
span, lower scores on spelling and reading tests, which occurred at a
higher frequency in children whose mothers had smoked throughout
pregnancy than in those born to nonsmoking mothers (Naeye and
Peters 1984).

Pulmonary Toxicity

Cigarette smoking is the major cause of chronic obstructive lung
disease (US DHHS 1984). Nicotine may directly or indirectly
influence the development of emphysema in smokers. It rapidly
accumulates in the pulmonary epithelial cells and some of its
metabolites are retained in the lung for prolonged periods (Waddell
and Marlowe 1976; Szuts et al. 1978).

Chronic bronchial wall inflammation with accumulation of alveo-
lar macrophages and polymorphonuclear neutrophils into the lung
occur in response to habitual cigarette smoke exposure (Janoff 1983,
1985). Macrophages and neutrophils release elastase, an enzyme that
destroys alveolar structure. Stone and colleagues (1983) found that
alpha-1-antitrypsin, an inhibitor of elastase, may also be partially
inactivated by cigarette smoke, probably related to effects of oxidant
gases. Nicotine, which possesses chemotactic properties for neutro-
phils (Totti et al. 1984; Jay, Kojima, Gillespie 1986) and can
stimulate the production of elastase as shown for the pancreas in
vivo (Morosco et al. 1981), may play a role in increasing elastase
levels in the lungs. In addition, nicotine may adversely affect the
repair of connective tissue since it has been reported to cause
structural alterations and inhibition of collagen synthesis in fibro-
blast cultures (Chamson et al. 1980; Chamson, Frey, Hivert 1982;
Hurst and Gilbert 1979).

Several other studies suggest that nicotine may contribute to the
development of emphysema in smokers. Lai and Diamond (1987)
showed that repeated inhalation of smoke from high, but not from

603


low, nicotine cigarettes significantly augmented experimentally
induced emphysema in rats. Lelcuk and coworkers (1986) reported
that nicotine instilled directly into the airways induced edema. In
the rat, a variety of ingredients of both the particulate and vapor
phase of cigarette smoke are capable of increasing vascular perme-
ability and producing edema in the tracheobronchial mucosa (Lund-
berg et al. 1983). This effect, which was traced to the stimulation of
substance P-containing pulmonary vagal afferent neurons, was
duplicated by nicotine (Lundberg, Saria, Martling 1982). In the
guinea pig, inhaled cigarette smoke damaged the mucosal barrier
and increased permeability to horseradish peroxidase by disrupting
the intercellular tight junctions of the bronchial epithelium (Bouch-
er et al. 1980). In smokers, Mason and coworkers (1983) documented
an increase in pulmonary epithelial permeability in all lung regions
using a radioaerosol procedure. In contrast, neither aerosolized nor
injected nicotine, given over a period of 2 to 3 weeks, causes secretory
cell hyperplasia (Rogers, Williams, Jeffery 1986) and there is little
evidence that nicotine contributes to the development of chronic
bronchitis. Further research is needed to define the magnitude of the
contribution of nicotine to the pathogenesis of smoking-induced
chronic lung disease.

Nicotine can also worsen pulmonary function in smokers who
already have lung disease. Acute exposure to nicotine induces
constriction of both central and peripheral airways (Yamatake,
Sasagawa, Yanaura 1978). The increase in airway resistance by
nicotine involves vagal reflexes and stimulation of parasympathetic
ganglia in the bronchial wall (Nakamura et al. 1986). The magnitude
of bronchoconstriction observed in experimental animals and hu-
mans following acute inhalation of cigarette smoke is correlated
with the level of nicotine in the smoke (Shepherd, Collins, Silverman
1979; Rees, Chowienczyk, Clark 1982; Lee et al. 1983; Nakamura et
al. 1985; Hartiala et al. 1985; Beck et al. 1986), suggesting that
nicotine may be an important factor in the increased airway
resistance of smokers.

Genotoxicity and Carcinogenicity

Smoking of cigarettes is causally related to cancer of the respira-
tory tract, the upper digestive tract, pancreas, renal pelvis, and
bladder; cigarette smokers also face an increased risk for cancer of
the cervix (US DHHS 1982; IARC 1986). Many carcinogenic agents
have been identified in cigarette smoke, however, not a single
component nor chemical group(s) of components is solely responsible
for the carcinogenic activity of cigarette smoke in the various organs.
Laboratory bioassays suggest that polynuclear aromatic hydrocar-
bons and N-nitrosamines play significant roles in the induction of
cancer in smokers (US DHHS 1982; IARC 1986). Nicotine, the

604


principal alkaloid in tobacco smoke, has also been examined for its
genotoxic and carcinogenic activity. In the Ames' Salmonella
typhimurium mutagenesis and mammalian cell cytogenetic assays,
nicotine did not possess any genotoxic activity, although it induced
reparable DNA damage in the Escherichia coli pol A+ /A- system
(Bishun et al. 1972; Florin et al. 1980; Riebe, Westphal, Fortnagel
1982; Riebe and Westphal 1983).

In earlier studies, nicotine and its primary metabolites were
reported to possess weak tumorigenic activity (Truhaut, De Clercq,
Loisillier 1964; Boyland 19681, which subsequent investigations did
not confirm (Schmahl and Osswald 1968; Martin et al. 1979; Toth
1982; LaVoie et al. 1985). Nicotine lacked cocarcinogenic activity in
the urethane-induced mouse pulmonary adenoma model (Freelander
and French 19561, but was found to be a cocarcinogen in the
benzo(a)pyrene-tetradecanoyl phorbol acetate mouse skin tumorigen-
esis model (Bock 1980). The mechanism of cocarcinogenic activity is
not clearly understood. Two primary metabolites of nicotine, coti-
nine and nicotine-N'-oxide, failed to promote N-(4-(5-nitro-2-fury&2
thiazyl) formamide (FANFTtinduced urinary bladder tumors in rats
(LaVoie et al. 19851. On balance, it appears that nicotine does not
possess direct carcinogenic activity.

During processing and pyrolysis of tobacco, nicotine can be N'-
nitrosated to form N'-nitrosonornicotine and other related com-
pounds (Figure 2) (Hoffmann and Brunnemann 1983; Hoffmann and
Hecht 1985). These tobacco-specific N'nitrosoamines are found in
substantial concentrations in American snuff, as well as in main-
stream tobacco smoke (Table 21, and in the saliva of snuff dippers
(Hoffmann and Adams 1981; Palladino et al. 1986). Tobacco specific
N-nitrosoamines are highly carcinogenic in animals and are suspect-
ed to contribute to cancer related to cigarette smoking and smokeless
tobacco use (Hoffmann, LaVoie, Hecht 1985; Hoffmann and Hecht
1985). There is also concern that nicotine may be N-nitrosated within
the human body. Endogenous formation of N-nitrosoproline (a
noncarcinogenic marker of endogenous N-nitrosation) has been
documented in cigarette smokers (Hoffmann and Brunnemann 1983;
Tsuda et al. 1986). Whether nicotine-derived nitrosoamines are
formed endogenously in amounts sufficient to contribute
humans exposed to nicotine per se (such as with
ment therapy) remains to be determined.

Gastrointestinal Disease

In peptic ulcer disease, cigarette smoking is a risk factor for its
development, and an even stronger risk factor for delayed healing,
failure to respond to therapy, and relapse (Kikendall, Evaul,
Johnson 1984). In animals, nicotine potentiates peptic ulcer forma-
tion induced by histamine or pentagastrin (Konturek et al. 1971; Lee

605


NICOTINE NORNICOTINE ANABASINE ANATABINE
Qe @Y & &

Nl I-ROSATION

NNAL             NNK      NNN      NAB     NAT

FIGURE 2.-Formation of tobacco-specific nitrosamines

SOTE: NNAL. 4~methyln~trosamino~l~3-pyr~dylIbu~n-l-ol; NNK. Umethylnitroeamino~l~kpyridyl~l-buts-
none: NNN. N'-nltroso:`ornicotine. NAB. N'-nitrosoanabasine NAT, N'-nitrcexmatabine.
SOURCE US DHHS f1986).

TABLE 2.-Tobacco-specific nitrosamines in commercial
      U.S. tobacco products

Tobacco product                 NNN           NNK       NAT + NAB



Smokeless tobacco

Chewmg tobacco ' Ippb)         3500-8200          KC-3ooo       500-7Ocm
Snuff' `ppbl               80049,ooo         2oe4300       2oo4oo


Mainstream smoke

Cigarette. NF Ing/cig)           120-950           80-770        140-990
Cigarette. French Black, NF       500             220           350
Ctgarette. F lng/cigl            x-310           30-150         m-370
Llrtle cgnr. F Ingicigar)         5500            4200          1700
Cigar \nyicigarl              32co            1900          1900


Sidestream smoke

Cigarette. NF u&c@          1700             410           270
Cqarette. F !ng/clgj            150             190           150


SOTE .VNN. N'-nltrosonornicotine. NNK. 4~methylnitrcsamino~liSpyridyl~I-butanone; NAT, N'-nitromena-
rablne. NAB. N -natresoanabasme. NF. without filter tip, F, with Filter tip.
~`herw~~ tobacco and snuff also contam ~2CO ppb NNAL. 4~methylnitrosamino~l-(3pyridyl)butsn-lal.
SOL'RCE Hoffman. IaVow. Hecht (19851

and Gruber 1952). Several mechanisms by which nicotine acts in this
regard have been proposed. (1) Chronic treatment in rats increases
basal acid secretion, an effect which appears to be mediated by
parasympathetic mechanisms (Thompson and George 1972). Chronic
cigarette smoking may induce hypersecretion of acid in response to
secretory stimuli. (2) Infusion of nicotine in animals and cigarette
smoking by people reduces pancreatic bicarbonate secretion, which
normally neutralizes acid entering the duodenum (Solomon et al.

606


1974; Murthy et al. 1977). This could result in increased acid delivery
to the duodenum, thereby increasing the risk of ulceration. (3)
Smoking may impair the mucosal barrier to acid-mediated injury.
Smoking, apparently acting through nicotine, decreases mucosal
blood flow and inhibits mucosal prostaglandin synthesis, both of
which may impair the effectiveness of the gastric mucosal barrier,
which protects the stomach lining against acid (Chujoh and Nakaza-
wa 1981; Kawano et al. 1982; Quimby et al. 1986). (4) Cigarette
smoking reduces both lower esophageal and pyloric sphincter
pressures (Chattopadhyay, Greaney, Irvin 1977; Valenzuela, Defilip-
pi, Csendes 19761, resulting in gastroesophageal reflux and duodeno-
gastric reflux, respectively. The former may result in reflux symp-
toms (heartburn) (Stanciu and Bennett 19721, while the latter may
cause reflux of bile acids and lysolecithin, which are known to break
down the gastric mucous barrier. A direct role of nicotine is
suggested by studies in opposums showing that intravenous nicotine
reduces lower esophageal sphincter pressure (Rattan and Goyal
1975).

The relative importance of local exposure to nicotine (as from
swallowing nicotine from nicotine polacrilex gum) versus exposure to
nicotine via the bloodstream in producing the above effects is
unclear. In view of the extremely high concentrations of nicotine in
saliva as compared to blood, local toxicity must be considered until
proven otherwise to be an additional risk of nicotine polacrilex
chewing gum for patients with ulcer disease or symptoms of
esophageal reflux.

Summary and Conclusions

1. At high exposure levels, nicotine is a potent and potentially
lethal poison. Human poisonings occur primarily as a result of
accidental ingestion or skin contact with nicotine-containing
insecticides or, in children, after ingestion of tobacco or tobacco
juices.

2. Mild nicotine intoxication occurs in first-time smokers, non-
smoking workers who harvest tobacco leaves, and people who
chew excessive amounts of nicotine gum. Tolerance to these
effects develops rapidly.

3. Nicotine exposure in long-term tobacco users is substantial,
affecting many organ systems (Chapters II and III). Pharmaco-
logic actions of nicotine may contribute to the pathogenesis of
smoking-related diseases, although direct causation has not yet
been determined. Of particular concern are cardiovascular
disease, complications of hypertension, reproductive disorders,
cancer, and gastrointestinal disorders, including peptic ulcer
disease and gastroesophageal reflux.

607


4. The risks of short-term nicotine replacement therapy as an aid
to smoking cessation in healthy people are acceptable and
substantially outweighed by the risks of cigarette smoking.

608


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617


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618


INDEX

ABSORPTION
buccal, 29
chewing tobacco, 281
cigarette smoke, 29, 281
lung, 29

nicotine polacrilex gum, 281
other tobacco expoeure, 29
smoking behavior, 153

ABSTINENCE
(See also CESSATION OF SMOK-
  MG; DEPRIVATION; WITH-
  DRAWAL SYMPTOMS; WITH-
  DRAWAL SYNDROME)
aggression, 203
spontaneous withdrawal assessment,
   293

weight gain, relapse predictor, 440
withdrawal syndrome, reinforce-
ment, 197

ACBTYLCHOLINE
desynchronisation of electroenceph-
  alograms, 110

high-affinity binding sites, 90, 92
nicotinic cholinergic agonista, 81
receptor measurement, 53
release in cerebral cortex, 96
turnover in hippocampus and fron-
tal cortex, 98

ADDICTION

definitions, 7, 149, 247-248, 249-
25(x296

effecta of selected drugs, 299-303
identification of hazardous drugs,
304

nicotine and tobacco, 6, 8
perceived functions of smoking, 397
relationship to physical dependence,
296

ADOLIBCENTS
epidemiological studies, 261-262
initiation of use, 259-265
multidrug use, 259265

ADOLESCENTS-ConM.
negative- and positive-affect regula-
  tion, smoking, 399
perceptions of stress, 121
smoking prevalence, 573-577
vulnerability factors, 266-267
weight control and smoking, 438

ADVERTISING
increased drug use, 365
low-yield cigarettes, health risks,
   566

AGE FACTORS
body weight effects, 415, 41-18,
  424, 431
relapse, 316
smoking cessation, 580-581
smoking prevalence, 569, 579

ALCOHOL
aversive stimuli, 286
discriminative effects, 272
multidrug use, 261-264
place conditioning, 285
prohibition and decreased use, 365
reinforcement, 282

ALCOHOL CONSUMPTION
abuse, smoking as risk factor, 401
body weight, smokers vs. nonsmok-
  ers, 417-418, 431
cigarette consumption effects, 167
smoking prevalence among alcohol-
   ics, 402

ALKALOIDS, TOBACCO
2,3'dipyridyl, structure, 27
G'oxoanabasine. structure, 27
anabaseine, structure, 27
anabasine, structure, 27, 28
anatabine, structure, 27, 28
metanicotine, structure, 27
myosmine, structure, 27, 28
N-formyl-nornicotine, content, 28
N'-methylanabasine, structure, 27
N'-methylanatabine, structure, 27

619


INDEX

ALKALOIDS, TOBACCO-Contd.
N'-nitrosonornicotine, structure, 27
nicotine N-oxide, structure, 27
nicotyrine, structure, 27
nornicotine, structure, 27, 28
nornicotyrine, structure, 27
pharmacologic effects, 56
pseudooxynicotine, structure, 27

AMPHEH'AMINES
cigarette consumption effects, 167
discrimination, 172, 275-276

ANABASINE
content, 28
discrimination, nicotine-trained ani-
  mals, 172
respiratory and cardiovascular ef-
  fects, 57
structure, 27

ANTAGONISTS
mecamylamine, 484-485
naloxoneprecipitated withdrawal
  syndrome, 297
nicotine effects in brain, reinforce
  ment, 192
precipitated withdrawal syndrome,
   293
pretreatment, smoke intake, 166

ANIURTY
consumption increases, 404
deprivation, 405
neuroticism and adult smoking
  habit, 402
pain thresholds, abstinence vs.
  high-nicotine cigarettes, 406-407
reduction, affect regulation, smok-
  ing, 396, 397
reduction, cognitive appraisal, 411-
   412
weight gain, smokers vs. nonsmok-
  ers and ex-smokers, 422
withdrawal symptom, 199, 201, 204
withdrawal symptom, with nicotine
  polacrilex gum, 208, 210

ARBCOLINE
discriminative stimulus, 172, 175
hippocampal theta activity, 109

ATROPINE
discrimination, nicotine-trained ani-
  mals, 174
effects on desynchronixation, 109
effects on radioligand binding, 90

620

ATROPINB-Contd.
low dependence potential, 285

AUDITION
amplitude decreases, withdrawal
  symptom, 204
auditory evoked response during
  smoking abstinence, 202
information task, smoking effects,
   385
psychological enhancement and
  sensory gratification, 413
vigilance tasks, smoking effects,
   383

AUTONOMIC NERVOUS SYSTEM
myenteric plexus, 96
peripheral cholinergic neuron stim-
  ulation, 79
phasic increases, emotional stimula-
  tion, 411

AVERSIVE THERAPY
contingency contracting, 494-495
covert sensitization, 488
directed smoking, 488
less severe techniques, 492-493
rapid smoking, 501
relaxation training, 49W94
unpleasant conditions, 501

BEHAVIOR, ANIMAL
associated stimuli, 309
drug seeking, 309
food intake and body weight, nic-
  otine administration, 434
negative-affect-reducing properties
  of nicotine, 407
physical activity, nicotine adminis-
  tration and cessation, 435
place preference or aversion, 194-
   195
reinforcing drug effects, 279
self-administration of drugs, 279

BEHAVIOR, HUMAN
classically conditioned, 307
cocaine deprivation, 310
compulsive drug use, 250
counseling, 502-503
drug seeking, 310
nicotine self-administration, nega-
  tive reinforcement, 193-194
nicotine self-administration, re
  sponse rates, 192
operant, 307


INDEX

BEHAVIOR, HUMAN-ConM.
repetitive and stereotypic drug use,
   8
respondent, 367
treatment strategies, 487-503

BELGIUM
body weight, smokers vs. nonsmok-
  ers and ex-smokers, 419, 420

BIOASSAYS
cotinine and nicotine, 4243
enzyme-linked immunosorbent as-
  my, 43
gas chromatography, 43
mass spectrometry, 43
radioimmunoassay, 43

BIOCHEMICAL MARKERS
blood cotinine, 38, 42
blood nicotine, 42
carboxyhemoglobin, 42, 514
cotinine, 515
metabolism of nicotine, 41
salivary cotinine levels, 42
thiocyanate, 514-515
urinary cotinine levels, 42

BLACK AMERICANS
(See also ETHNIC GROUPS)
cessation motivation and success,
   510
cessation of smoking, 508-509
church and fraternal roles, 511512
coronary risk trial, 511
health care access, 569
physician influence, 511
quit-smoking treatments, 511512
smoking and quitting patterns, 510
social norms and advertising, 509-
   510
sociodemographic factors, 509

BLOCKADE THERAPY
mecamylamine, 484-485
opioid dependence, 484
tobacco dependence, 484-485

BLOOD

carboxyhemoglobin, 39
cotinine, 38
nicotine, 30-33, 38-39
pH and nicotine measures, 41
wound healing, 600

BLOOD PRESSURE
changes during abstinence or re-
  lapse, 202, 205

BLOOD PRBSSURE-Contd.
hypertension relationship to smok-
  ing, 600-601

stress and nicotine, 409

BODY HEIGHT
smokers vs. nonsmokers and ex-
  smokers, 416, 418

BODY TEMPERATURE
changes, withdrawal symptom, 202
skin, changes during abstinence or
  relapse, 202, 205

BODY WEIGHT
adipose tissue, relative nicotine lev-
  el, 32

carbohydrate metabolism and smok-
ing, 107

changes during abstinence or re
lapse, 205

control, smoking and nicotine ef-
fects, 381

gains after nicotine cessation, ani-
mals, 432

hypothalamic consummatory drive
model, nicotine, 412-413
nicotine administration, animals,
with food intake, 434
nicotine polacrilex gum, effects, 432
smokers vs. nonsmokers and ex-
smokers, 414-441
smoking cessation effects, 199, 202,
439
weight loss and nicotine, animals,
432

BRAIN
alpha, beta, and theta power, with
  smoking, Ill-112
anteroventral thalamic nucleus, 86,
   94
blood-brain barrier, nicotine isome
  thonium penetration, 57
caudate nucleus, 94
central grey matter, 86-87
cerebellum, 94
cerebral cortex, 94
chemical mediation of nicotine, 8
cortical arousal, withdrawal symp
  tom, 202, 204
cortical electric potentials, with-
  drawal symptom, 206
cortical evoked potentials, with-
  drawal symptoms with nicotine
  polacrilex gum, 208

621


INDEX

BRAINAontd.
dentate gyrus, 94
electrocortical effects of nicotine,
   107-l 12
expectancy and orienting waves,
   115
frontoparietal cortex, 86-87
glucose utilization, nicotine stimula
  tion, 81, 86-88
hippocampus, 94, 99-100, 109
homovanillic acid levels after nic-
  otine exposure, 110
hypothalamus, 94, 97
interanteromedial thalamic nucleus,
   86
interpeduncular nucleus, 86, 94, 95
interpeduncular nucleus and medi-
  al habenula, SH-labeled nicotine,
   81
lateral geniculate body, 86
lateral habenulae, 86
lateralized affective processors mod-
  el, stressful conditions, 412
locus coeruleus, 95
medial habenulae, 86, 94, 95
metabolism, binding sites, 85-86
nerve cells, nicotine concentrations,
   85
nicotine concentrations, animals,
   82-85
nicotine levels, discrimination stim-
  ulus, 174
nicotine polacrilex gum, 111-112
nicotine-induced desynchronization,
   109
physiological effects of nicotine in-
  jections, 9697
presubiculum, 94
putamen, 94
rapid nicotine uptake, 32-33
rat cerebellum, nicotine effects, 92-
  93
relative nicotine level, 32
retrosplenial cortex, 86
substantia nigra pars compacta, 94
superior colliculus, 86, 94
ventral tegmental area, 86-88, 94

BUNGAROTOXIN
binding sites, 47
binding studies, mammalian brain,
   91-94
nicotinic choline@ receptors, 88-
   89

622

BUNGAROTOXIN-ConM.
receptor measurement, 53

CAFFBINE
cigarette consumption effects, 167
nonreinforcer, 281

CANADA
body weight, smokers vs. nonsmok-
  ers and ex-smokers, 417

CARBON MONOXIDE
carboxyhemoglobin content, 59
smoking behavior, 154
toxicity, 59
visual information processing task,
  smoking effects, 384

CARBOXYHBMOGLOBIN
carbon monoxide exposure, 59
concentration, 39

CARCINOGENBSIS
benzofa)pyrene-tetradecanoyl phor-
  bol acetate, 604
bladder, 604
respiratory tract, 664
tobacco cigarettes vs. nicotine pola-
  crilex gum, 215

CARDIOVASCULAR SYSTEM
(See also CORONARY HEART DIS-
  EASE)
acute tolerance, 48, 49
atherosclerosis, 596598
body weight, smokers vs. nonsmok-
  ers and ex-smokers, 417, 422,
   427
carbon monoxide effects, 596
cardiomyopathy, 599-666
contribution of nicotine, 56
coronary artery disease, 598
lowdensity lipoproteins, 596
nicotine and carbon monoxide, 116-
   117
nicotine effects, 596601
stress and smoking, 118
Surgeon General's Report, 12
thrombosis, 597-598
very low-density lipoproteins, 596

CATECHOLAMINBS
amniotic fluid, 603
nicotine effects on central neurons,
   100
release from extra-adrenal chromaf-
  iin tissues, 97-98


INDEX

CELLS
nerve, nicotine concentrations, 85

CENTRAL NERVOUS SYSTEM
nicotine concentrations, 83-84
nicotine isomethonium, 57
nicotinic cholinergic receptors, 89
pre or postsynaptic release of ace-
  tylcholine, 95
psychoactive drugs, 267
tranquilization effects of nicotine,
   409

CESSATION OF SMOKING
f&e also ABSTINENCE; DEPRIVA-
  TION; WITHDRAWAL SYMP-
  TOMS; WITHDRAWAL SYN-
  DROME)
blacks vs. whites, 572
criteria, 516
heavy vs. light smokers, success
   rates, 577
males vs. females, 580, 581
measurements, 576, 580
men, neuroticism, 402
physical activity changes, 435
program development, nicotine ad-
  diction, 6
quit attempts, 150
quit difficulty and daily consump
  tion, 206
quit ratios by age and sax, 1965 to
  1985, 531
relapse and psychophysiological re
  activity, 120
spontaneous remission, 255-259
stages, 518
Surgeon General's Report, 12
trials, 489-496
weight gain, 414, 416, 422, 423,
  424, 425, 431, 439-440

CESSATION OF SMOKING,
METHODS
(See also NICOTINE DELIVERY,
  ALTERNATE; NICOTINE POLA-
  CRILEX GUM; NICOTINE RE
  PLACEMENT; TREATMENT)
acupuncture, 564
contingency contracting, 494-495
hypnosis, 504
nicotine addiction, 8-9
nicotine fading, 497-499
nicotine vapor inhaler, 212
selfefflcacy, 497

CESSATION OF SMOKING,
MEI'HODS-ConM.
similarity to methods for other
  drugs, 467
stimulus control, 497

CHEMICAL DETECTION
biological samples, 256, 259
interpretation, 259
sensitivity, 259
specificity, 259

CHEMICAL STRUCTURE
nicotine, 27
nicotine metabolites, 35
tobacco alkaloids, minor, 27

CHEWING TOBACCO
nicotine absorption, 29, 31
nicotine levels, 38

CHILDREN
negative- and positive-affect regula-
  tion, smoking, 399
smoking and body weight beliefs,
   438

CHOLINERGIC AGENTS
acetylcholine release, 81
interaction with biogenic amine
  pathways, 98
nicotine effects on central and pe
  ripheral nervous systems, 96-97

CIGAR SMOKING
body weight, smokers vs. nonsmok-
  ers, 417, 419
nicotine levels, 38
prevalence, men, 1964 to 1986, 580,
   582
Surgeon General's Report, 12

CIGARIWlXS, HIGH-NICOTINE
affect modulation, 405
blood nicotine levels, 39
brand loyalty, 567
carboxyhemoglobin levels, 39
effects on recall, 389
emphysema, 604
knee-jerk reflex, 45
visual information processing task,
  smoking effects, 384
yields of nicotine, 26

CIGARETTES, HIGH-TAR
brand loyalty, 567
visual information processing task,
  smoking effects, 384

623


INDEX

CIGARETTES, HIGH-YIELD
carbon monoxide, 59
heart rate, partial tolerance, 55-56
smoking behavior, 163

CIGARETTES, LOW-NICOTINE
affect modulation, 405
effects on recall, 389
emphysema, 604
knee-jerk reflex, 45
Surgeon General's Report, 12
visual information processing task,
  smoking effects. 3,84

CIGARETTES, LOW-TAR
Surgeon General's Report, 12
visual information processing task,
  smoking effects, 364

CIGARETTES, LOW-YIELD
carbon monoxide, 59
consumption. health risks, 566
heart rate, partial tolerance, 5.%56
vented, smoke concentration, 159-
   161

COCAINE
cost, 283-284
crack, 281
increase in use, 305306
multidrug use, 261-264
place conditioning, 285
starter drug, 278

COFFEE CONSUMPTION
smokers vs. nonsmokers, 437

COGNITION
concentration difficulty, withdrawal
  symptom  199 201, 204. 205.
          1 1
  208, 210
euphoria and dysphoria. 117
oral contraceptive use, response to
   stress, 118-119
stressor response among women,
   118
task performance, 394

CONDITIONING
behavioral tolerance, 269
cues to smoke, 465
drug use as learned behavior, 307-
   309
drug-opposite response, 289
nicotine addiction 465
pharmacologic and psychological
   factors, 465
physiological reactions, 466

624

CONDITIONING-Contd.
place preference and aversion, 194,
   284

placebo effects, 309
taste aversion, 194

CONSUMPTION
adolescents, 260
adolescents, stress factor, 400
adults, effects of stress, 401
body weight effects, 415, 416, 417,
  419, 420, 423, 426, 431
children, smoking and body weight
  beliefs, 438

frequency and multiple drugs, 263-
264

heavy smokers, stress, 403
heavy vs. light smokers, smoking
cessation success, 577
high-yield cigarettes, 163
multiple drugs, 260
occasional tobacco use, 253-254
prediction, 262-263
progression of drug use, 261-263
race, age, and gender factors, 579
severity of withdrawal symptoms,
206
United States, 1973 to 1987, 567
United States, estimation through
taxes, 565
United States, per capita decline,
565-566

CONTROLLED SMOKING
compensatory behavior, 499-500
outcomes, 499-500
parameters, 499
prospects for abstinence, 500

COPING STRATEGIES
cognitive versus behavioral tech-
  niques, 530-531
retrospective bias, 531
self-punitive cognitions, 531
short- and long-term effects, 496
skill-based treatment, 532
skills training, 496
stimulus control, 530-531
stress and smoking habit, 402
willpower, 531

CORONARY HEART DISEASE
!See also CARDIOVASCULAR SYS
  TEM!
ischemia, mortality
myocardial infarct, 598-599


INDEX

CORONARY HEART DISEASE+
  Contd.
myocardial infarct, weight gain af-
   ter smoking cessation or continu-
   ation, 426
pharmacodynamic aspects, nicotine,
   56
risk, 598
stress and smoking, 118
Surgeon General's Report, 11
CORTICOSTEROIDS
corticosterone and tolerance, 52
plasma corticosterone levels, 100-
   101, 103
plasma levels and cigarette smok-
   ing, 104-106
COST
alternate nicotine delivery systems,
   214
individual and social, 252
positive and negative incentives,
   284
required work, 2KJ-284
time, 283
COTINmE
bioassay comparison, -0
biochemical detection, 515
blood levels with nicotine polacri-
  lex gum, withdrawal symptoms,
   209
content, 28
daily cigarette consumption, 160
discrimination, nicotine-trained ani-
   mals, 172
levels and severity of withdrawal
  symptoms, 206-207
metabolites, 34
nicotine metabolite, 34-36
structure, 27
tobacco-use marker, 36, 40
CRAVING
abstinence, 205
definitions, 295
gender difference, 523
measurement problems, 211
mecamylamine effects, 485
nicotine polacrilex gum, -209,
  210, 475
plasma nicotine levels, 211
precipitating factors, 211
recurrent and persistent, absti-
  nence, 8
relapse, 205, 523

CRAVING-ConM.
sensory stimuli, 211
smokeless tobacco withdrawal
  symptom, 207
withdrawal symptom, 199, 201, 204

CYTISINE
discrimination, nicotine-trained ani-
  mals, 172-173
respiratory and cardiovascular ef-
  fects, 57

DEMOGRAPHIC FACTORS
6'eg~) SOCIOECONOMIC FAG
cigarettes and smokeless tobacco,
   306
marital status, 571
smoking prevalence, 569, 571
women and youth, 396

DENMARK
body weight, smokers vs. nonsmok-
  ers and ex-smokers, 418

DEPENDENCE
aversive limits, 266
behavioral effects, 286
cross-tolerance, 292
definitions, 7, 198, 247-246, 245-
   250
drug use, 12
interoceptive drug effects, 266
levels, 253
neuroadaptation, 266
physiological effects, 286
positive reinforcement, 266
potential testing, 269-270, 285-286
progression, 253
unconditioned stimuli, 266

DEPRESSION
Navy men, cigarette consumption,
   404
nicotine polacrilex gum, 208-210
withdrawal symptom, 201

DEPRIVATION
(See also ABSTINENCE; CRSSA-
  TION OF SMOKING; WITH-
  DRAWAL SYMPTOMS; WITH-
  DRAWAL SYNDROME)
attention span of smokers, 366
effects on memory, 336
negative affect, 405, 406
smoking rates and behavior, 164
stress, relapse, 402

625


INDEX

DIAZEPAM
nicotine-induced antagonism, 175
withdrawal syndrome, 297

DIET
alkaline, smoking behavior, 163-
   164
changes during abstinence or re-
  lapse, 205, 206, 433-434
changes, smokeless tobacco with-
  drawal symptom, 207
food intake and appetite, withdraw-
  al symptom, 202
food intake and smoking-related
  energy imbalance, 434
hunger, hypothalamic consummate
  ry drive model, nicotine, 412-413
hunger, withdrawal symptom with
  nicotine polacrilex gum, 209, 210
sweet food intake and weight gain
  after smoking cessation, 433-434

DISCRIMINATION
behavior, 274
drug similarity, 274
generalization. 274
intravenous nicotine administration,
   humans, 176177
metrazol, animals, 175
nicotine, administration method,
  animals, 171-172
nicotine, humans, 176-177
nicotine, pentolinium pretreatment.
   176-177
nicotine vs. 3-methyl-pyridylpyrolli-
  dine, 173
specificity, 275276
testing, 274-277

DIZZINESS
acute sensitivity, 45, 47
tobacco poisoning, 595

DOPAMINE
control over acetylcholine turnover,
   98
cue properties of nicotine, 97
nicotine agonists, 54
stimulation by nicotine, 54
turnover and release, 100-101

DOSE CONTROL
brand switching, 162
consistent nicotine intake, 158
function of time, 164
nicotine reinforcement, animals,
   189-190

626

DOSE CONTROWonM.
ventilated cigarette holders, 159

DOSE-RESPONSE
amphetamines, 282
aversive limits, 282
biphasic effects, 44
compensatory nicotine intake, 283
heart rate changes, 56
psychoactivity, 272
self-administration and reinforce-
  ment, 282
self-reported effects, 274
titration-studies, nicotine, 282-283
tobacco smoke, 282
withdrawal reactions, 293

DRUG ABUSE
adolescents, smoking as risk factor,
   400-401

liability factors, 304

DYSPHORIA

nicotine dose increases, 178

EDUCATION

high school dropouts, smoking
prevalence, 574
smoking prevalence, 1985, 571

ELECTROENCEPHALOGRAPHY
activating effects of nicotine, 81-82
activity in rats, 52
changes during abstinence or re-
  lapse, 205, 206
distinct central nervous system ef-
  fects, 108-109

history of nicotine studies, 108-109
nicotine-induced desynchronization,
112

parallels with self-reports, 274
power spectral analysis, 110
withdrawal symptoms with nicotine
polacrilex gum, 208

ELIMINATION
acid loading, 40-41
alkaline loading, 4041
kinetics, 38
measurement of smoke intake, 152
renal nicotine, 4Wl
tolerance measure, 289
urinary tract, 33, 34, 36, 37

EMPHYSEMA
Surgeon General's Report, 11
weight gain, smokers vs. nonsmok-
   ers. 426


INDEX

ENDOCRINE
adrenal cortex, 104-106
follicle-stimulating hormone, 100-
   102
growth hormone, 101
luteinizing hormone, 100-102
nicotine effects, 96
prolactin, 100-102
thyroid, 104
thyroid-stimulating hormone, 100-
   102

ENVIRONMENTAL FACTORS
conditioned responses, 306
contingent reinforcement, 306
drug costs, 306
economic factors, 266
individual reactions, 529
negative affect, 530
other smokers, 529-530
parental drug use, 266
peer smoking, 526
place conditioning, 284-285
relationship to direct drug effects,
  308, 309
smoking cues, 526, 529-530
spousal smoking, 526-527
stimulus control, 497
stress, 536
withdrawal effects, 204, 310-311

EF'INEPHRINE
levels during abstinence or relapse,
  204, 205

serum concentrations, 97

JWI-INIC GROUPS
(see also BLACK AMERICANS;
  HISPANIC AMERICANS)
black Americans, 508-512
black vs. white males, smoking
  prevalence, 569
black vs. white pregnant smokers
  vs. nonsmokers, body weight,
  418, 424

blacks, smokers vs. nonsmokers
and ex-smokers, body weight,
419
blacks vs. whites, cigarette con-
sumption, 577
blacks vs. whites, smoking preva-
lence, 572, 579
Hispanic Americans, 512-513
Hispanic, smoking prevalence, 569-
570
Oriental alcoholism, 290

ETHNIC GROUPS-Contd.
Oriental aversion to alcohol, 290

=-SMOKERS
body weight, vs. smokers and non-
  smokers, 416430
spontaneous remission, 466
withdrawal symptoms, 199-200

EYES
nicotine concentrations, 83
pupil enlargement after nicotine
  use, 274
pupillary constriction from opioids,
   291
visual evoked response during
  smoking abstinence, 202

FINLAND
body weight, smokers vs. nonsmok-
  ers and ex-smokers, 429

FRANCE
body weight, smokers vs. nonsmok-
   ers and ex-smokers, 422

GANGLIA
localization of nicotine, animals, 85
peripheral cholinergic neuron stim-
  ulation, 79
GASTROINTWTiNAL SYSTEM
heartburn, 607
peptic ulcer, 605607
relative nicotine level, 32
small bowel, nicotine reabsorption,
   33
stomach, nicotine concentrations,
   82-83

GENETIC PREDISPOSITION
adolescent drug use, 266267
vulnerability factors, 266

HAIR
nicotine recovery, 33

HEADACHE
acute sensitivity, 45, 47
tobacco poisoning, 595
HEART
acute nicotine tolerance, 48, 49
arrhythmia, 599
nicotine concentrations, animals, 84
relative nicotine level, 32

HEART RATE
abstinence or relapse, 122-123. 202,
  204. 205, 206

627


INDEX

HEART RATE-Co&d.
acute tolerance, 48, 49
drug and environmental effects,
   308
nicotine-induced tachycardia, 291
smokeless tobacco withdrawal
  symptom, 207
stress and nicotine, 409
stress and smoking, 118
tachycardia, 492-493
withdrawal symptom, 199, 201
withdrawal symptom with nicotine
  polacrilex gum, 210

HEROIN
cigarette consumption effects, 167
methadone effect, 236

HEXAMETHONIUM
acetylcholine release blocked, 81
attenuated amine release, 98
discrimination, nicotine-trained ani-
  mals, 174
inhibiting effects on nicotine, 88,
   92-93
smoke-induced edema, 179

HISPANIC AMERICANS
(See also ETHNIC GROUPS)
gender difference, 512
physician influence, 513
prevalence of smoking, 512
smoking cessation, 512-513
smoking correlates, 512-513

HISTORICAL PERSPECTIVE
addictive behavior, 269
discovery of nicotine, 10
medicinal vs. harmful effects, 9-10
nicotine addiction, 16-11
nicotine pharmacology, 10-11
tobacco use, 9

HORMONES
adrenocorticotropic, acetylcholine
  effects, 97
adrenocorticotropic, nicotine effects,
  100-103, 105-106
androgen, testosterone levels, and
  smoking, 106
    .
argmme vasopressin, nicotine-
  induced release, 102-103
estrogen production and metabo-
  lism, smoking effects, 106
pro-opiomelanocortin, acetylcholine
  effects, 97

628

HORMONES--Contd.
pro-opiomelanocortin, factors influ-
  encing release, 103-104
prolactin, luteinizing, and follicle
  stimulating, 52

HYPOTHALAMUS
consummatory drive model, nic-
  otine, 412-413
neuroendocrine function, 52

HYPOXEMIA
fetal development, 603
subsequent behavioral abnormali-
  ties, 603

IMPATIENCE
nicotine polacrilex gum, 210
withdrawal symptom, 199, 201

INHALATION PARAMETERS
measurement techniques, 152
published values, 156-157

INITIATION
aversive reactions, 264-265
dependence, cigarettes vs. nicotine
  polacrilex gum, 215
drug classes, 259, 261-265
environmental motivations, 278
experimental use, 265
smokeless tobacco, 265, 564
social and pharmacologic factors,
   264-265
stress and early smoking onset, 399
Surgeon General's Report, 12
weight control and smoking, 436
women, neuroticism, 402

INTEROCEPTIVE EFFECTS
definition, 170
dependence potential testing, 270-
   271

mood and feeling, 270
morning withdrawal cues, 307-306
perception, smoke and nicotine, 179
subjective pleasure, 308
taste, airway irritation, 179

IRRITABILITY
changes during abstinence or re-
  lapse, 205, 206
nicotine polacrilex gum, 208, 210
withdrawal symptom, 199, 201

JAPAN

body weight, smokers vs. nonsmok-
ers and ex-smokers, 420


INDEX

KIDNEYS
nicotine concentrations, 82-84
nicotine elimination, 33, 37
relative nicotine level, 32

MAINTENANCE OF SMOKINWntd.
weight control, 438

LEARNING
behavioral tolerance, 289
letter-digit substitution task, smok-
  ing effects, 386-387
nicotine and smoking effects, hu-
  mans and animals, 386
paired-associated, smoking effects,
  387, 388
serial, retention, smoking effects,
   388
state-dependent, definition, 389
verbal rote, smoking effects, 387-
   388

MARIJUANA SMOKING
cigarette consumption effects, 168
multidrug use, 261-264
smoking as risk factor, 401

LIVER
drug detoxification and tolerance,
   290
nicotine concentrations, 83-84
nicotine metabolism, 37
relative nicotine level, 32

LOBELINE
discrimination, nicotine-trained ani-
  mals, 173
respiratory and cardiovascular ef-
  fects, 57

LOCOMOTOR ACTIVITY
decreases with nicotine, 49, 51
nicotine induced, 53

MECAMYLAMINE
brain and spinal cord effects, 89
discrimination, nicotine-trained ani-
  mals, 173-174
dose-response, 93
effects on desynchronization, 109
local cerebral glucose utilization,
   86-88
nicotine conditioning taste aversion,
   196
nicotine-induced antagonism, 175
nicotinic receptors blocked, 81
place preference, nicotine effects,
   195
pretreatment, effect on conditioned
  reinforcer, 191
pretreatment, harshness ratings of
  smoke, 179
pretreatment, negative nicotine re-
  inforcement, 193
pretreatment, nicotine discrimina-
  tion, 176-177
pretreatment, nicotine polacrilex
  gum, discrimination, 178
pretreatment, smoke intake, 166

LUNG DISEASES
bronchoconstriction, 664
cancer, Surgeon General's Report,
   11
chronic bronchial wall inflamma-
  tion, 663
emphysema, 663
nicotine toxicity, 603604
pulmonary epithelial permeability,
   604
Surgeon General's Report, 12

MEMORY

(See also RECALL)
delayed, smoking effects, 388
immediate, smoking effects, 388
nicotine and smoking effects, hu-
mans and animals, 386
recognition study, state-dependent,
390

task performance, 394
verbal, smoking and nicotine ef-
fects, 389

LUNGS
afferent neuron stimulation, 116
nicotine concentrations, animals, 84
relative nicotine level, 32
LYSERGIC ACID DIETHYLAMIDE
(LSD)
nonreinforcer, 281, 282, 285
MAINTENANCE OF SMOKING
Surgeon General's Report, 12

words and order, smoking effects,
389

METABOLISM
(See also PHYSICAL ACTIVITY)
animal, body weight, smoke expo-
  sure or nicotine administration,
   436

body weight and smoking, 434,
435437

629


INDEX

METABOLISM-Contd.
decreased, withdrawal symptom,
   263
nicotine clearance, 40
nicotine metabolites, 34, 35, 36
rate, 37
smokers vs. nonsmokers, 53
smoking cessation effects, 433, 436

METHADONE
cigarette consumption effects, 167
effect on heroin use, 266
efficacy, 296

MOOD
changes during abstinence or re-
  lapee, 205-206
hedonic systems model, negative af-
  fect, 411
regulation, smoking and drug use,
   401
regulation, subjective well-being,
  smoking effects, 394-399

MORPHINE
discrimination, 275-276
euphoria and self-administration,
   277
physical dependence, withdrawal,
   294
place conditioning, 265

MOTIVATION
behavioral tolerance, 239
gender differences, 506
self-perceived reasons for smoking,
   398
treatment enhancement, 332-334

MOTOR BEHAVIOR
alcohol-induced muscle relaxation,
   291
smoking and nicotine effects, 392
   393
task performance, 394

MUCOUS MEMBRANES
cardiovascular effects of nicotine,
   596

MUSCLES
alcohol-induced relaxation, 291
N-methylnicotinium ion, pressor
  and neuromuscular effects, 57
relative nicotine level, 32
tonic and phasic muscular activity,
  nicotine effects, 410

630

MUTAGENESIS
Salmonella typhimurium assays,
   605

NALOXONE
cigarette consumption effects, 168
opioid withdrawal, 297

NAUSEA
acute sensitivity, 45, 47
tobacco poisoning, 595

TI-IE NETHERLANDS
body weight, smokers vs. nonsmok-
  ers and ex-smokers, 430

NEUROENDOCRINE FUNCTION
nicotine effects, 95-96

NEW YORK
smokeless tobacco use, 1966, 561

NEW ZEALAND
body weight, smokers vs. nonsmok-
  ers and ex-smokers, 421

NICOTINE
content, different tobaccoa, 26
intake, 40
place conditioning, 285
sensitivity, ti7
structure, 27

MCOTINE AEROSOLS
respiratory sensations, plasma nic-
  otine levels, 179-180
tobacco-like sensations, cessation
  method, 166

NICOTINE CONTENT
cigarettes vs. chewing tobacco,
  snuff, 26
high-yield cigarettes, 26
low-yield cigarettes, 26

NICOTINE DELIVERY, ALTER-
NATE

Bee also CESSATION OF SMOK-
ING, METHODS; NICOTINE
POLACRILEX GUM; NICOTINE
REPLACEMENT; TREATMEN'I'l
chewable product, FDA ruling,
212-213

dependence potential, 214
nicotine polacrilex gum, depen-
dence and withdrawal, 20'7-206
potential for abuse with concurrent
tobacco use, 213-214
tobacco cigarettes vs. nicotine pola-
crilex gum, 215


INDEX

NICOTINE DELIVERY,
ALTERNATE-Contd.
tolerance, physical dependence,
  withdrawal symptom alleviation,
   212
toothpaste-like formulation, FDA
  review, 212
toxic effects, convenience, depen-
  dence potential, 213

NICOTINE FADING
combination with self-monitoring,
   498
definition, 497
low-tar and -nicotine brands, 497-
   498
outcomes, 49S.499

NICOTINE MEX'ABOLISM
nicotine-l'-N-oxide, 36
pathways, 34-37
tachyphylaxis, 50

NICOTINE PHARMACOLOGY
addictive properties, 6
discrimination effecta, 272
pharmacokinetics, 25, 32
stimulant and depressant effects,
   79
tobacco cigarettes vs. nicotine pola-
  crilex gum, 215

NICOTINE POLACRILEX GUM
(See also CESSATION OF SMOK-
  ING, METHODS; NICOTINE
  DELIVERY, ALTERNATE; NIC-
  OTINE REPLACEMENT;
  TREATMENT)
absorption, 29, 31
affect modulation, 405
blood levels of nicotine, 472
body weight effects, 432
combined with behavioral therapy,
   476
coronary heart disease, 599
craving reduction, 475
dose-patient relationship, 478-479
duration of use, 478
efficacy trials, 473-474, 475-478,
   486
fetal development, 60243
followup, 477
mood regulation during smoking
  cessation, 406
physical dependence, 210
physician trials, 476-477
poststimulus components, 115

NICOTINE POLACRILEX GUM-
Gmtd.
pretreatment, smoking behavior,
   165
relapse, 477478
safety vs. cigarettes, 214-215
stimulus effects, 178
temporary treatment aid, 214
toxicity, 213
weight gain, 423
withdrawal symptom alleviation,
  207, 208, 472

NICOTINE REPLACEMENT
(See also CESSATION OF SMOK-
  ING, METHODS; NICOTINE
  DELIVERY, ALTERNATE; NIC-
  OTINE POLACRILEX GUM;
  TREATMENT)
addiction treatment, 7
aerosols, 480
comparisons of preparations, 46O-
   481
dependence, 481
forms and rationale, 471
nasal solutions, 479
polacrilex gum, 471-479
side effects, 480
transdermal patches, 479-480

NITROSAMINES
American snuff, 605
chemical structure, 606
mainstream tobacco smoke, 605

NOREPINEPHRINE
levels during abstinence or relapse,
   205
neuroendocrine activity, 101
nicotine effects, 100-101
release in hypothalamus, 97

NORNICOTINE
content, 28
discrimination, nicotine-trained ani-
  mals, 172
structure, 27

NORWAY

body weight, smokers vs. nonsmok-
ers and ex-smokers, 417, 418,
421, 426

OCCUPATIONS
asbestos workers, 422
civil servants, 422
factory workers, 419
farm workers, 594

631


INDEX

OCCUPATIONS-Contd.
government workers, 418
insurance company employees, 416
manufacturing company employees,
   419
nurses, 439
physicians, 438
steei workers, 419
telephone company employees,
  420, 423
OPIOIDS
addiction, 247
addictive patterns, 282
chipping, 253
discriminative effects, 272
fetal syndrome, 251-252
physical dependence potential, 286-
   287
protracted withdrawal, 253
tolerance, 287
withdrawal, 291-294

OXOTREMORINE
discrimination, nicotine-trained ani-
   mals, 172
muscarinic cholinergic agonist, 52
PANCREAS
body weight and smoking, 107
PASSIVE SMOKING
Surgeon General's Report, 12
PEER GROUPS
relapse, 321-322
treatment, 334

PENTOBARBITAL
depressant, cigarette consumption
  effects, 167
discrimination, 275-276
PERFORMANCE
impairment, withdrawal symptom,
   204, 205, 206
nicotine polacrilex gum, 203, 208
problem solving, attention, and
  memory, 391
PERIPHERAL EFFECTS OF NIC-
  OTINE
discriminative stimulus, 173
overview, 79
PHARMACODYNAMICS
cardiovascular changes, 55-56
daily smoking patterns, 55
definition, 25
dose-response, 44

632

PHARMACODYNAMICS-Contd.
tolerance, 44-46

PHARMACOLOGIC TREATMENT
alprazolam, 482
blockade therapy, 328
clonidine, 328329, 482-483
deterrents, 329
drug replacement therapy, 326-328
mood changes, 483-484
relief from withdrawal symptoms,
   327
symptomatic treatment, 328, 481-
   483

PHYSICAL ACTIVITY
(See also METABOLISM)
body weight differences, smokers
  vs. nonsmokers, 434
body weight, smoking cessation,
   435
decreased energy expenditure, with-
  drawal symptom, 203
exercise tolerance, 600
smokers vs. nonsmokers, 435

PIPE SMOKING
body weight, smokers vs. nonsmok-
  ers, 417, 419
coronary heart disease, 598
nicotine levels, 38
prevalence, men, 1964 to 1986, 580,
   582
Surgeon General's Report, 12

POLAND
body weight, smokers vs. nonsmok-
  ers and ex-smokers, 420

POLYDRUG DEPENDENCE
adolescents, 259-260
frequency of use, 263-264
initiation of cigarette and other
  drug use, 259-260
prediction, 262-263
preference tests, 272-273
progression of use, 261-263
tobacco-opioids-alcohol-stimulants,
   254

POTENTIALS, SENSORY EVENT-
RELATED

auditory function and nicotine,
112-113

contingent negative variation, 114-
115


INDEX

POTENTIALS, SENSORY EVENT-
RELATED--Co&d.
visual function and nicotine, 11%
   114

PREGNANCY

amniotic fluid, nicotine recovery,
33

body weight, smokers vs. nonsmok-
ers, 416, 418, 424, 426, 429
breast-milk fluid, nicotine levels, 33
low birth weight, 602
nicotine effects on animals. 602
perinatal mortality, 602
placenta, carbon monoxide and nic-
otine, 602

placenta, nicotine penetration, 33
prematurity, 602
spontaneous abortion, 602

PRETREATMENT
lidocaine, airway sensations, 169
nicotine, smoking behavior, 165-166
pentolinium, nicotine discrimina-
  tion, 176-177
pimozide, taste aversion, 196

PREVENTION OF SMOKING
aversive smoking, 501-502
program development, nicotine ad-
  diction, 6
skills training, 501

PSEUDOOXYNICOTINE
structure, 27

PSYCHIATRIC DISORDERS
multiple diagnosis, 254
negative affect of smoking, 403
neuroticism, 401-402
tobacco-nicotine dependence and
  withdrawal, 12

PSYCHOACTIVITY
drug classification, 269-270
interoceptive effects, 270
mood and feeling, 270-271
tobacco cigarettes vs. nicotine pola-
  crilex gum, 215

PSYCHOMOTOR PERFORMANCE
letter crossing tests, smoking ef-
  fects, 384

smoking abstinence vs. nicotine po-
lacrilex gum, 203
smoking and nicotine effects, 381
smoking effects, methodological lim-
itations, 382

PSYCHOMOTOR PERFORMANCE-
Contd.
Stroop test, nicotine effects, 385-
   386
sustained attention tasks, defini-
  tion, 382

PUFFING PARAMETERS
definitions, 153
frequency, duration, volume, inter-
  puff interval, 153-154
interdependent relationships among
  measures, 153
measurement techniques. 151-152
published values, 156-157
visual information processing,
  smoking effects, 384
within-cigarette changes, nicotine
  dose, 155158

RAPID SMOKING
aversive smoking cessation therapy,
   196-197
cardiovascular and pulmonary
  risks, 493
comparison with other techniques,
   492493
conditioned aversive response, 492
rapid puffing, 501-503
single and multicomponent proce-
  dures, 491492
stress, 494
tachycardia, 492-493

REACTION TIME
simple and complex, smoking ef-
  fects, 392-393
smoking abstinence vs. nicotine
  polacrilex gum, 203
visual and auditory, smoking ef-
  fects, 385

visual information processing,
smoking effects, 384
visual, smoking effects, 383

RECALL

(See also MEMORY)
immediate, nicotine effects, 388
short- and long-term, nicotine tab-
lets, 390

state-dependent, smoking vs. no-
smoking conditions, 390
verbal rote learning, smoking ef-
fects, 387-388

RECEPTORS
adaption to drug, 289
binding sites. minor alkaloids. 56

633


INDEX

RECEPTORS-Contd.
constitutional tolerance, 290
dihydro-beta-erythroidine, rat brain,
   91
disuifoton, 3H-nicotine binding, 54
functional or pharmacodynamic tol-
  erance, 289

RECEPTORS, CHOLINERGIC
distribution of `H-acetylcholine and
  3H-nicotine, 80
neuron stimulation, 79
regulation of 3H-nicotine sites in
  mice, 80

RECEPTORS, NICOTINIC
aversive effects of nicotine injec-
  tions, 193
binding sites, 53
chronic tolerance, 53
ganglionic and neuromuscular
  types, a-439
high-affinity sites, 90, 92-94
locomotor activity, 53
low-affinity sites, 90-91
peripheral nervous system, 88-89
primary and secondary binding
  sites, 86
radioligand binding studies, 89-92
tolerance, 54

REINFORCEMENT
evaluation, 279-281
negative, behavior modification, 193
negative, nicotine injection, 193
nicotine addiction, 6
positive, continuous, intravenous
  nicotine, 182
positive, intermittent, intravenous
  nicotine, 189, 190-191
positive, nicotine, review, 183-168
potential of various drugs, 305
self-administration, 276-279
stimulus effects, 268
tobacco cigarettes vs. nicotine pola-
  crilex gum, 215

REINFORCERS
cocaine vs. nicotine, 189-190
definition, 170
positive, biobehavioral mechanism,
  dependence-producing drugs,
   181-182
psychoactive drugs, 8

634

RELAPSE
Gee also SPONTANEOUS REMIS
   SION)
abstinence violation effect, 532
age factors, 316
alcohol and opioid dependencies,
   316
attribution theory, 525-526
biochemical detection, 313
correlates, 315, 317-319
definition, 312, 518
demographics, 520
drug dependence severity, 315-316
drug use, 8
family support, 321, 324
frequency of smoking, 521
gender differences, 520
high-risk factors, 519, 529-530
long-term abstinence difficulties,
   311
measurement, 313
negative emotions, 322-324
peer drug use, 321-322
prevention skills, 330-331
psychiatric impairment, 316
quitting history, 312, 522
rates by drug class, 313-314
self-efficacy, 524-525
sensory cues, 121-123
smoking history, 521
social learning theory, 519
treatment effectiveness, 315, 320-
   321
treatment modalities, 312-313
typologies, 521-522
weight gain, risk factor, 440, 523-
   524
withdrawal and dependence, 522-
   523
withdrawal symptom alleviation,
  205
work and leisure activities, 322,
   324

RESEARCH METHODS
biochemical markers, 514-515
carbon monoxide, 514
carboxyhemoglobin, 514
confounding design factors, 119-120
cotinine assays, 515
nicotine dosage control, 119
self-reports, 515
study design, 513-514
suspect data, 514


R-NESS
changes during abstinence or re-
  lapse, 205
nicotine polacrilex gum, 208, 210
withdrawal symptom, 199, 201

SEROTONIN
intemeuronal communication sys-
   tern, 98

pharmacological effects of nicotine,
99-100

ROLLYOUR-OWN
prevalence, men, 1964 to 1986, 580,
   562

SEX RATIO

adolescents, weight control and
smoking, 438

SALIVA
nicotine secretion, 33
tobacco poisoning, 595

body weight, smokers vs. nonamok-
em, 415, 417, 421, 431
cessation and relapse rates, 505-
508

SATIATION
comparison with comprehensive
  procedure, 501-502
single and multicomponent proce-
  dures, 488, 491

education, 506507
heavy vs. light smokers, 577
high school seniors, smoking preva-
lence, 574-576
Hispanics, smoking prevalence,
569-570

SELF-ADMINISTRATION
abstinence symptoms, 310
adjunctive, schedule-induced behav-
  ior, 278-279
alcohol, 278, 281
amphetamine, 278, 281
animal research methods, 27%Z%O
behavioral process, 158
cocaine, 278-281
compulsive use, 149
drive state, 277
drug substitution, 278
environmental pressure, 278
free sampling, 277
graduation, 277-278
human and animal studies, 276
   277
human research methods, LB&281
initiation, 277
intravenous nicotine, response
  rates, humans, 192
morphine, 278, 281
nicotine, 278-281
pentobarbiti, 278, 281
positive reinforcement, 276-277,
   279
reinforcing effects, 279-280
reinitiation of drug use, 310
voluntary conditions, 279

motivation to quit, 506
neuroticism and adult smoking
habit, 402

smokeless tobacco use, 1970 to
1986, 580, 583
smoking cessation rates, 580, 581
smoking prevalence, 569, 572, 573,
579

social support, 508
social values and beliefs, 507
stress and smoking, 118, 508
weight gain after smoking cessa-
tion, 416, 433, 507-506

SENSATION
environmental stimulus, condi-
  tioned reinforcers, 191
place conditioning, 284
psychological enhancement and
  sensory gratification, 413

INDEX

SLEEP
disturbances, nicotine polacrilex
  gum, 208, 210
disturbances, smokeless tobacco
  withdrawal symptom, 207
disturbances, withdrawal symptom,
  202, 204, 205, 206

SMELL
aversion to alcohol, 230
environmental stimulus, condi-
  tioned reinforcers, 191
receptors, 58-59
tobacco grade and type, 53-59
tobacco smoke, place conditioning,
   285

SMOKE CONSTITUENTS
acetaldehyde effects, 60
benxo(a)pyrene, 604
brand switching, 162
nonnicotine, tracheobronchial sensa-
  tions, 168-169

635


INDEX

SMOKE INHALATION, ANIMAL
lungs, spleen, intestine, and brain,
  nicotine concentrations, 84

SMOKELESS TOBACCO
(See also SNUFF)
addiction, with nicotine, 13
demographic changes, 306
nicotine dependence, 214
starter products, 265
withdrawal symptoms, 207

SMOKELESS TOBACCO USE
gum and mouth diseases and neo-
  plasms, 213
prevalence, 1970 to 1986, 580, 583

SMOKING ANTECEDENTS
anxious, aggressive, and neurotic
  personality traits, 402
personality measures, 402
stress, adolescents, 400

SMOKING ARTICLES
ventilated cigarette holders, 159

SMOKING BEHAVIOR
biochemical and behavioral mea-
  sures, 154
carbon monoxide intake, 154
cigarette length, 161
consistent patterns, 155
measurement techniques, 150-152
perceived functions of smoking, 397
Surgeon General's Report, 12
switching cigarette brands, 161-162
taste and smell, 58-59

SMOKING CONTROL PROGRAMS
multicomponent, smoking cessation,
   501-503
Surgeon General's Report, 12
SMOKING HABIT
negative- and positive-affect regula-
   tion, 399
smoking-related disease diagnosis,
   150
United States, adults, prevalence,
   565-567
young adults, prevalence and con-
  sumption, 578
SMOKING SURVEYS
adolescents, 573-577
Adult Use of Tobacco Survey, 572
Behavioral Risk Factor Surveil-
  lance System, 573
Current Population Survey, 573

636

SMOKING SURVEYS-Contd.
Hispanic Health and Nutrition Ex-
  amination Survey, 569-570
National Health Interview Surveys,
  56.%566, 568569, 572
self-reported smoking status, un-
  derreporting, 567-568
tobacco use trends, 9

SNUFF
(See also SMOKELESS TOBACCO)
angina pectoris, 600
dipping prevalence, 1970 to 1986,
  580, 583
nicotine absorption, 29-31
nicotine levels, 38
paroxysmal hypertension, 600

SOCIAL SUPPORT
buddy system, 495
gender differences, 508
global support, 527
partner support, 527-528
smoking cessation. 526-527
spouse, 495

SOCIOECONOMIC FACTORS
(See also DEMOGRAPHIC FAG
  TORS)
body weight, smokers vs. nonsmok-
  em, 420, 428
ethnic, class, gender differences,
   505
smoking prevalence, 1985, 571
treatment and prevalence, 467

SPONTANEOUS REMISSION
(See also RELAPSE)
comparison by drug class, 255-259
contributing factors, 255-259
studies, 257-258

STATEDEPENDENT LEARNING
abstinence vs. smoking, 393-394
definition, nicotine, humans, 181,
   389
nicotine effects, 387

STATISTICAL ANALYSIS
Addiction Research Center Invento-
  ry, 271-272
discrimination procedures, 271
Morphine Benzedrine Group scale,
   271-273
overlap of drug classes, 271

STIMULANTS
addiction, 247


INDEX

STIMULAmnM.
addictive patterns, 282
discriminative effects, 272
nicotine, 177

STRESS
abstaining and coping, 528-529
adult cigarette consumption, 401
affect modulation, smoking and nic-
  otine effects, 405-408
affect regulation, smoking, 395-399
consumption increases, 404
elimination of nicotine, 41
Hassles Scale, 528
hedonic systems model, negative af-
  fect, 411
initiation and consumption risk,
   413-414
lateralized affective processors mod-
  el, 412
low- vs. high-nicotine cigarettes,
   405
management skills, 332
Navy men, smoking habit, 403-404
nicotine polacrilex gum, 405
nicotine withdrawal, conditioned re-
  sponses, 408
nurses, smoking habit, 403
perceived stress, 528
perceptual and painendurance
  thresholds, nicotine effects, 410
psychophysiological reactivity, 117-
  122
reduction, gender differences, 508,
   528
reduction, neurochemical role of
  nicotine, 408-409
reduction, smokers vs. nonsmokers,
  407
relationship to relapse, 528529
risk factor for adolescent smokjng,
  399-401
smoking and nicotine effects, 381
smoking cessation relapse, 402, 528
subjective well-being, smoking ef-
  fects, 394-395

STUDENTS

high school boys, body weight and
smoking, 438

high school seniors, smoking preva-
lence, 574-576
junior and senior high school,
stress and smoking initiation,
400

SWEDEN
body weight, smokers vs. nonsmok-
  ers and ex-smokers, 426

SYMPATHETIC NERVOUS SYS-
TEM
arousal regulation with nicotine,
   409

TAR CONTENT
sales-weighted average yield, 566
smoking maintenance, 58
tobacco taste characteristics, 58

TASTE
environmental stimulus, condi-
  tioned reinforcers, 191
iirst cigarette of day, 47
menthol popularity among black
  Americans, 510
receptors, 58
tobacco cigarettes vs. nicotine pola-
  crilex gum, 215
tobacco grade and type, 58
tobacco smoke, place conditioning,
   285

TASTE AVERSION
alcohol, 280
apomorphine vs. nicotine, 196
chlorisondomine, 196
nicotine conditioning, animals, 196
   196

TAXATION
reflection of cigarette consumption,
   565

TERATOGBNICITY
animals, 601
humans, 601-602

THERAPY
approved drug uses, 298
deterrent, silver acetate, 485A86
replacement, 326323
symptomatic, 328
TOBACCO CONSTITUENTS
beta-carbolines, pharmacologic ef-
  fects, 60

TOBACCO SUBSTITUTES
smoke condensate, sensory effects,
   169

TOLERANCE
acquired reaction, 289
acute, tachyphylaxis, 44, 47-50
animal and human studies, 251

637


INDEX

TOLERANCE-4ont.d.
behavioral, 44
behavioral and physiological re-
  sponses to nicotine, 197
chronic, 44, 50-54
constitutional reaction, 290
cross-tolerance, 288, 292
dependence potential testing, 286
dose escalation, 50, 51
intoxication, 251
limits on escalation, 286-287
measures, 288
mechanisms, 288-290
nicotine addiction, 6
nicotine uptake, 8
pharmacodynamic, functional, 44
pharmacokinetic. dispositional, 44
toxic effects, 45

TOXICITY
acute, 593-596
acute sensitivity, 45, 46
children, 595
chronic, 596
nicotine polacrilex gum, 595-596
physiological and psychological, 252

TREATMENT
(See dso CESSATION OF SMOK-
  ING, METHODS; NICOTINE
  DELIVERY, ALTERNATE; NIC
  OTINE PGLACRILEX GUM;
  NICOTINE REPLACEMENT)
abstinence maintenance, 503
behavioral strategies, 329-334
blockade therapy, 328
clonidine, 328-329
family support, 333
goals, 325
leisure activity skills, 331-332
loss of control, 325
methodology, 513-516
motivation enhancement, 332-334
nicotine polacrilex gum, maintain-
  ing physical dependence, 210
overview, 465470
peer suppcrt, 334
pharmacologic approaches, 326-329
professional contact, 333
relapse prevention skills, 330-331
relief from withdrawal symptoms,
   327
replacement therapy, 326328
stress management skills, 332
symptomatic therapy, 328

638

TREMOR
hand, changes during abstinence or
  relapse, 205
smoking effects, 392

TWINS
body weight, smokers vs. nonsmok-
  ers, 417

TYROSINE HYDROXYLASE IN-
HIBITOR
histofluorescence studies, 100

UNITED KINGDOM
Wales, body weight, smokers vs.
  nonsmokers and ex-smokers, 416

URINE
acidification and cigarette consump
  tion, 163
cotinine, 36, 37
nicotine isomethonium, 57
nicotine-N-oxide, 36, 37
pH and stress, 41
unchanged nicotine content, 33

VISION
conditioned reinforcer, nicotine de
  livery, 191
environmental stimulus, 191
information processing tank, smok-
  ing effects, 384
peripheral vision monitoring, smok-
  ing effects, 385
place conditioning, tobacco smoke,
   285
psychological enhancement and
  sensory gratification, 413
rapid visual information task,
  smoking effects, 385
vigilance tasks, nicotine tablet ef-
  fects, 383
vigilance tasks, smoking effecta,
   383

WEST VIRGINL4
smokeless tobacco use, 1986, 581

WITHDRAWAL SYMPTOMS
(See also ABSTINENCE; CESSA-
  TION OF SMOKING; DEPRIVA-
  TION; WITHDRAWAL SYN-
  DROME)
aggression, 203
anxiety, 199, 201, 204, 208, 210
behavioral and physiological seque-
  lae, 251
biting, animals, 204-205


INDEX

WITHDRAWAL SYMPTOMS-Contd
body temperature changes, 202
concentration difficulty, 199, 201,
  204, 205, 208, 210
conditioned drug seeking, 310
craving, 199, 201, 204, 208-209, 210
depression, 201, 208-210
electroencephalography changes,
   208

environmental and pharmacologic
factors, 198

environmental stimuli, 310
fatigue, 201, 202, 205
further drug intake, 8
hearing amplitude decreases, 204
hunger, food intake, 202, 207, 209,
210, 412-413, 434
hypothalamic consummatory drive
model, nicotine, 412413
identified, 198-199
increased heart rate, 210
irritability, impatience, 199, 201,
208, 210

measurements and techniques, 199-
200

metabolism changes, 203, 433, 436
negative affect reduction, nicotine,
408

nervousness, 199, 201
nicotine blood levels with nicotine
polacrilex gum, 209
nicotine polacrilex gum, 207, 208,
472

opioids, 291, 292
performance, 208
physical complaints, 199, 201, 208
plasma nicotine levels and symp

tom severity, 206207
rebound phenomena, 204
respiration rate decrease, 202
restlessness, 199, 201, 208, 210
sleep disturbances, 202, 204, 205,
206, 207, 208

stress, 402, 408, 528, 529

WITHDRAWAL SYMPTOMSXontd.
tobacco cigarettes vs. nicotine pola-
  crilex gum, 215
weight gain, 414, 416, 422, 423,
  424, 425, 431, 438, 439-440, 523

WITHDRAWAL SYNDROME
(See also ABSTINENCE; CESSA-
  TION OF SMOKING; DEPRIVA-
  TION; WITHDRAWAL SYMP-
  TOMS)
American Psychiatric Association,
  recognition, 295
autonomic measures, 291
behavioral, 291
dependence potential testing, 286
distinctive signs, 296-297
evidence of addiction, 6, 294295
precipitated responses, 293
protracted, 253
somatomotor measures, 291
spontaneous reactions, opioids and
  depressants, 292
variability, 294-295

WOMEN
black, smoking prevalence, 569
body weight, smokers vs. nonsmok-
   ers, 420
education, 506507
electroencephalograms of neonates
  from smokers, 112
prolactin and breast feeding, smok-
  ing effects, 102
smoking prevalence, 569
social factors, 507508
stress and smoking, 400, 508
Surgeon General's Report, 12
treatment programs, 467
weight control, 439, 507-508
weight gain, 523

WORKPLACE
Surgeon General's Report, 12
YUGOSLAVIA
body weight, smokers vs. nonsmok-
  ers and ex-smokers, 425

639

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