U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE • Public Health Service • Alcohol, Drug Abuse, and Mental Health Administration Research on Smoking Behavior Editors: Murray E. Jarvik, M.D., Ph.D. Joseph W. Cullen, Ph.D. Ellen R. Gritz, Ph.D. Thomas M. Vogt, M.D., M.P.H. Louis Jolyon West, M.D. NIDA Research Monograph 17 December 1977 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute on Drug Abuse Division of Research 5600 Fishers Lane Rockville, Maryland 20857 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 Stock Number 017-024-00694-7 The NIDA Research Monograph series is prepared by the Division of Research of the National Institute on Drug Abuse. Its primary objective is to provide critical re views of research problem areas and techniques, the content of state-of-the-art conferences, integrative research reviews and significant original research. Its dual publication emphasis is rapid and targeted dissemination to the scientific and professional community. Editorial Advisory Board Avram Goldstein, M.D. Addiction Research Foundation Palo Alto, California Jerome Jaffe, M.D. College of Physicians and Surgeons Columbia University New York Reese T. Jones, M.D. Langley Porter Neuropsychiatric Institute University of California San Francisco California William McGlothlin, Ph.D. Department of Psychology. UCLA Los Angeles, California Jack Mendelson, M.D. Alcohol and Drug Abuse Research Center Harvard Medical School McLean Hospital Belmont, Massachusetts Helen Nowlis, Ph.D. Office of Drug Education. DHEW Washington, D.C. Lee Robins, Ph.D. Washington University School of Medicine St. Louis. Missouri NIDA Research Monograph series Robert DuPont, M.D. DIRECTOR, NIDA William Pollin, M.D. DIRECTOR, DIVISION OF RESEARCH, NIDA Robert C. Petersen, Ph.D. EDITOR-IN-CHIEF Eunice L. Corfman, MA. EDITOR Eleanor W. Waldrop MANAGING EDITOR Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857 Research on Smoking Behavior ACKNOWLEDGEMENT This monograph is derived from papers presented at a conference on smoking behavior convened at the University of California at Los Angeles, June 24 and 25, 1977. (An indication of their impact is that the editor of the NIDA Research Monograph series has stopped smoking .) Ms. Toby-Ann Cronin played a critical role in the coordination of the conference and in the development of this publication, under NINA contract #271-77-3422 with UCLA. Library of Congress catalog number 77-090890 DHEW Publication No. (ADM) 78-581 Printed 1978 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of Biosciences Information Service, Chemical Abstracts, Psychological Abstracts, and Psychopharmacalogy Abstracts. iv Foreword In the 14 years since the 1964 Advisory Committee’s Report to the Surgeon General on smoking, awareness of the important effect of this widespread behavior on the nation’s health has moved in op- posite and paradoxical directions. On the one hand, the Report triggered significant changes. A distinct drop in cigarette con- sumption occurred in that year, and since then consumption has de- creased for adult males from 52 per cent to 39 per cent and for adult females from 32 per cent to 29 per cent. A 1975 study shows the number of physicians still smoking has decreased from 30 per cent in 1967 to 21 per cent, dentists from 34 per cent to 23 per cent, and pharmacists from 35 per cent to 28 per cent. On the other hand, the knowledge has become trite and the magnitude of the dam- age lost sight of. Fifty million Americans still smoke. Ominously, smoking by girls between 12 and 18 nearly doubled between 1968 and 1974, eliminating the difference in smoking behavior between the two sexes. The age at which many children begin regular smoking is down to 11 to 12 years. Not only is early onset of a drug habit often predictive of heaviness of use and difficulty of cessation, but cigarette smoking is often a precursor or gateway substance to use of stronger drugs. Most people, including health officials, are startled when the fig- ures on smoking damage are put into perspective. For example, the number of people who annually die prematurely from smoking is es- timated at 300,000. For comparison, annual automobile fatalities are estimated at about 55,000, overdose deaths attributed to bar- biturates are estimated at about 1,400, and to heroin at about 1,750. Over 37 million people (one of every six Americans alive today) will die from cigarette smoking years before they otherwise would. If tobacco-related deaths were eliminated, there would be: 300,000 Americans each year who would not die prematurely 1/3 fewer male deaths from 35 to 59 85 per cent fewer deaths from bronchitis or emphysema 1/3 fewer deaths from arteriosclerosis 1/3 fewer deaths from heart disease 90 per cent fewer deaths from cancer of the trachea and lungs 50 per cent fewer deaths from cancer of the bladder Given the extent of the problem, a consensus is growing that the national effort to cope with it has been defective. Not qualita- tively, since good people have done substantial and important work, and many lives have been saved. But quantitatively the effort has v been too little and its priority insufficiently urgent. Cigarette smoking is the largest preventable cause of premature death, ill- ness, and disability we have. These smoking damage figures are so large because of heavy promotion, governmental protection and sub- sidy,. a health industry largely preoccupied with other things, and an entrenched and overlearned addictive behavior that has proven extraordinarily hard to reduce or extinguish, But what should we think of ourselves, individually or collectively as a nation, if we concede, therefore, that we are helpless to change this toll and must learn to tolerate it? The NIDA Division of Research has given increased priority to this issue during the past few years for several reasons: the increasing identification of smoking as a prototypic addiction, the status of smoking as a gateway drug to use of stronger or illicit drugs, and our focus on substance abuse as a generic phenomenon that includes tobacco. The Royal College of Physicians 1977 report on Smoking and Health says of the habit, " . tobacco smoking is a form of drug dependence different from but no less strong than that on other drugs of addiction.. " The current International Classification of Diseases (ICD) now lists tobacco smoking disorder as a drug prob- lem, and, as Dr. Jerome Jaffe tellingly recounts in this monograph, so, at last, does the new psychiatric Diagnostic and Statistical Manual (DsM)III draft revision. Public health policy on smoking should probably recognize that ex- tinction of the habit is an unrealistic goal and even undesirable, given the adjunctive coercion such a goal would require. But we should take care to devote a degree of concern and excellence to understanding and dealing with the problem that is’ commensurate with its size. The idea of control appears central, whether this is ex- ercised in brain and CNS responses, by genetic or psychological pre- disposition, through learning or reinforcing factors in the cultural and institutional environment. Cur research agenda needs to address all these levels. Correspondingly, one measure of the usefulness of the papers in this monograph is their scope, from the basic opponent process theory formulated by Dr. Joseph Ternes to the activist prevention policy presented by Dr. Ellen Gritz; from the differently impressive syn- optic views of Drs. Russell and Van Lancker to the valuable particu- lar cost figures calculated by Drs. Lute and Schweitzer. To have put between two covers a set of papers of such high caliber, time- liness, and utility is a welcome achievement. William Pollin, M.D. Director Division of Research National Institute on Drug Abuse vi Preface The National Institute on Drug Abuse has been given the lead role in the Federal Government to carry out and support research on tobacco smoking behavior. Unlike other Federal efforts in this area of public health, NIDA will focus its effort on the dependence pro- cess associated with tobacco smoking. Tobacco smoking can be viewed as a prototype dependence ‘process which has a significant impact on the public health. The morbidity and premature mortality figures associated with this habitual behavior ark high. It is estimated, for example, that some 250,000-300,000 premature deaths can be di- rectly or indirectly related to tobacco smoking. While much re- search has been devoted to the biomedical and pathological conse- quences of smoking (early onset of cardiovascular and pulmonary di- sease and lung cancer), relatively little Federal research support has been provided for understanding the biological, behavioral, psychological, and societal factors which may be substantial in the etiology and maintenance of this habitual behavior. Little, if any, research has been focused on elucidating withdrawal phenomena associated with cessation of smoking or factors leading to relapse and recidivism. Other areas of research which are ripe for develop- ment are innovative treatment procedures for teaching people how to stop smoking and pharmaco-therapeutic techniques for maintaining abstinence. Development of biological assays to detect tobacco, nicotine, and its metabolites is essential. Such technology would afford researchers a way to validate self report data in follow-up studies and epidemiological surveys of smokers. NIDA is currently developing an extra-mural funding program targeted for research on tobacco smoking as a dependence process. Part of our effort in this area of smoking research is exemplified by this conference. Norman A. Krasnegor, Ph.D. Division of Research National Institute on Drug Abuse vii Monograph Contributors Ransom J. Arthur, M.D. Jerome H. Jaffe, M.D.