Smoking

CHAPTER 1
Why Do People Do That?
I have known Spaniards, on the island of Hispaniola, who were accustomed to taking [cigars] and who, being reproved and told that this was a vice, replied that they were not able to stop ... . I do not know what pleasure or advantage they firrd in them.
--BARTOLOME DE LAS CASAS, 15271






ONE OF WESTERN culture's longest running bewilderments may have been stated first by de Las Casas, the great humanitarian of the period when the Old World was conquering the New. What, he wondered, is the attraction of these smouldering weeds, that people should covet their smoke as if it were the breath of life itself?
Five hundred years after the tobacco genie was let out of the bottle and into Western life, there still is a bafflement about smoking, one that spills over occasionally into derision or even anger. (The 19th-century American Horace Greeley once defined a cigar as "a fire at one end and a fool at the other.")2
When he was first doing stand-up comedy, Bob Newhart would begin one of his best bits by noting that "It seems to me that the uses of tobacco aren't obvious right off the bat." He then imagined a 17th-century phone call between Sir Walter Raleigh and the head of the "WestIndies Company" in London, with Raleigh explaining this newfound substance to his boss. You could take this tobacco, the boss was told, shred it up, put it on a piece of paper, and:
Then what do you do to it, Walt? (Laughs) You set fire to it, Walt? (Laughs) Then what do you do, Walt? You inhale the smoke. You know, Walt, it seems, off-hand, like you could stand in front of your fireplace and have the same thing going for you ... . I think you're going to have a tough time, ahh, selling people on sticking burning leaves in their mouths.3
Not so tough a time at all, as it turns out. Even today, however, with centuries of cultural tradition behind it, tobacco still puzzles. The vast majority of nonsmokers think that smoking has the dubious distinction of not providing much pleasure but being addictive all the same.4
Smokers themselves, understandably, tend to see the habit in less negative terms. Only about half of them regard themselves as addicted, and they're apt to describe smoking in terms of pleasure5-usually as a matter of smoking "calming" them. Yet even smokers seem to have fairly hazy notions of what benefits smoking provides. Britain's M. A. H. Russell, who has spent a good part of his working life trying to understand the smoking habit, puts it this way:
To seek the solution to the question, why do people smoke?, the obvious way to begin would seem to be simply to ask; but if we do this we soon discover that many smokers are at a loss for a satisfactory answer ... . When confronted with this question they hesitate, smile foolishly, shrug their shoulders and say something like, "Habit I suppose," or "I don't know." ... The simple answer is that they enjoy it, but the simple pleasure principle does not always operate with smoking. There are few who positively enjoy every cigarette and some smokers experience no positive pleasure at all. 6
So what does tobacco do? With its use, there's none of heroin's ecstasy, alcohol's sudden brightening of personality, marijuana's giddiness, LSD's visions. The urge to get high is understandable, even to those who disdain it. But what's to be made of tobacco smoking? To thecasual, nonsmoking observer, it's as if smokers have gotten the worst of both worlds: drug addiction without drug euphoria.
Yet smoking's nebulous benefits come attached to a habit of amazing power. Ninety percent of all drinkers drink alcohol when they feel like it but leave it alone when they don't, which leaves about 10 percent drinking out of compulsion. These percentages are almost exactly reversed with smoking: only about 10 percent of the smoking population are thought to be "chippers," who can take smoking or leave it as they please. The Smoking Nag must be served at regular intervals for 90 percent of the smoking population, and this population amounts to better than one in four adult Americans. Since smokers take about 10 drags per cigarette, a pack-a-day habit, which is about the average, adds up to 200 "hits" of tobacco per day-or about 70,000 hits annually. The number is easy to calculate because there are no vacations from the practice.
Who can comprehend the effect of a habit this constant? Smoking is the familiar tug on the sleeve: at the office, at the dinner table, in the car, in front of the television. Observe smokers at the intermission of a play, rushing to light up as the crowd files out or hungrily taking a last drag before Act II begins. Kept from their normal smoking cycle--about one cigarette every 40 minutes--they need a quick infusion of smoke to keep the Nag at bay. This goes on in less noticeable form all day, every day, for the vast majority of smokers. Smoking may be pleasurable in some instances, but certainly is a necessity in others. In these latter cases, smoking has first call on the smoker's activities. Neither work nor play can go forward unhindered until the Nag is served. So deeply does smoking work itself into the warp and weft of human behavior that one can seriously begin to ask to what degree lifestyle creates occasions for smoking or smoking creates lifestyle.
How amazing, then, that smokers have so little idea of why they do it. Smoking seems to sit, fat and laughing, on one of our cherished assumptions: that we have reasons for doing what we do; that we are purposeful even in our indulgences. People often do things they don't understand, but what comes close to smoking in terms of an ongoing act that is motivated by forces that are within us, and yet unknown to us? At the conference table of the self, smoking speaks another language; it takes up our time and energy, but is unable to tell us why. Ifsmoking's consequences were benign, its constancy--hour after hour, day after day--would be noteworthy enough. That its consequences are deadly, but its purpose unknown, should make us very curious about what is at work here.
The landmark Surgeon General's report of 1964--the first one on tobacco--said that smoking was "habituating" but not "addicting." Tobacco's use, the report said, was related primarily to "psychological and social drives" that were reinforced by the effects of nicotine. In retrospect, we can see that the 1964 report lies near the beginning of modern scientific research into why people smoke. (This is natural enough, since the report itself brought urgency to the issue.) Since that time, there have been thousands of scientific investigations into the subject, with research going, in a general way, from a "softer," psychological approach to a "harder" approach that places more emphasis on biological processes and pharmacology. This work has borne considerable fruit, particularly in the 1980s, and not just on theoretical issues. In the words of Jerome Jaffe of the National Institute on Drug Abuse, smoking research has "shipped."7 It has delivered a product--nicotine gum--that seems to be of real value, at least in helping people get over early withdrawal symptoms when they quit smoking.
The gum could stand, however, both as a symbol of how far smoking research has come and how far it has to go. Despite its value, nicotine gum is not the magic bullet against smoking that we all might hope for: the substance that, once ingested, would allow anyone to quit smoking quickly and painlessly. Even with it, quitting frequently is so difficult that it makes smokers ask the question of the infirm: How long must I feel this bad?
Smoking research is definitely work in progress. There are a multitude of unanswered questions in the field, and the research results that are obtained often are maddeningly contradictory. Nevertheless, a clearer picture of why people smoke has emerged in recent years, and this work, as we will see, provides some insight into the question of drug use in general.
The central finding of contemporary scientific research on smoking is straightforward, stands in contradiction to the 1964 Surgeon General's report, and pretty much confirms what generations of preachers and grandmothers have suspected: people smoke primarily toget nicotine into their bodies. There are other reasons for smoking, as we'll see, but alone or together it's unlikely that they could motivate millions of people to regularly draw a somewhat bitter pollutant into their lungs. M. A. H. Russell puts it this way:
There is little doubt that if it were not for the nicotine in tobacco smoke, people would be little more inclined to smoke than they are to blow bubbles or to light sparklers.8
Readers may be inclined at this point to say that they knew this all along and to ask why the government has spent so much of their money trying to confirm it. Let me quickly point out, then, that there is a universe of meaning in the phrase "primarily to get nicotine into their bodies," and that, therefore, some serious misunderstanding may result.
The likely confusion is that people are apt to think that this explanation of smoking means nothing more than that people are addicted to nicotine. To further compound the trouble, the average person is likely to have a misguided notion of what "addiction" means.
The common understanding of addiction is of a one-dimensional craving for a drug: a mental and physical discomfort--perhaps even anguish--that must be endured until more of the drug is taken or the addiction is shaken off. We might call this a "monkey addiction," since it could just as well be monkeys we're talking about, there being no human quality to the act under this view. Give drug X to an organism for long enough and the organism will become addicted to it, after which it will have to have a certain amount of the drug running around in its system or suffer the consequences.
Note that what's implied here is a kind of thermostat for an addictive drug: for smokers a nic-o-stat, regulating nicotine; for, say, heroin users a morphine-o-stat. When the amount of the drug in the system gets low, the stat kicks in, distress follows, and more of the drug must be taken.
Now, monkey addiction requires only that the nicotine tank be kept full to a certain level. Smokers trying to quit will soon go below this level. (They will reach the "dose-needed" stage.) Thereafter, their need should be a simple function of "drug-supplied or drug-denied." Given this, their propensity to relapse shouldn't change depending on thecircumstances they find themselves in. But this is precisely what we do not find with cigarettes. We have no reason to believe that smokers relapse in accordance with some chemical clock. They relapse when they get bad news, when they're stressed, or when they're at a party. They relapse after they've had a good dinner.9
If a monkey addiction theory is true, why should a smoker's internal state or external surroundings prompt relapse? If we stretch the theory, we might be able to accommodate depressive states. ("The need was constant, but I only gave into it when work got me down.") But what about relaxing or exuberant states, which also are a minefield for people trying to quit? Moreover, with monkey addiction, we would presume that withdrawal symptoms--irritability, confusion, and so forth--would be the thing that would prompt an ex-smoker to light up again. But Saul Shiffman, who is one of the nation's leading experts in this area, has studied a large number of relapse crises in ex-smokers and reported that a majority of these episodes occur in the absence of withdrawal symptoms. 10
Finally, consider the role of nicotine gum. Presumably, it should take care of the nic-o-stat. If monkey addiction were a correct model, we would expect this oral replenishment of the drug to eliminate cigarette withdrawal symptoms. In high enough doses, the gum does this to a large extent--irritability, anxiety, and difficulty in concentrating, for example, all are lessened with it. But one symptom remains that is so overriding, it seems to make a mockery of the gum's good effects. What the gum doesn't wipe out is the urge to smoke. If monkey addiction were true, shouldn't this urge simply be the sum total of all the other withdrawal symptoms? If we take care of them with the gum, what is this thing that remains?
The problem with the common understanding of cigarette addiction is that it doesn't begin to tell us enough about why people engage in a behavior that they know stands a good chance of sending them to an early grave. Cigarette smoking does have an element of monkey addiction in it--something that we might do better to call "physical dependence," as scientists do. But that's not all there is to it. In the broadest of terms, what's wrong with this view of smoking is that it sees the cigarette habit as a purely pharmacological process. That in itself is off the mark, but there's a compound error in monkey addiction: it positsa chemical habit that is all stick and no carrot; it says that smokers who try to quit are physically punished--and that's why they keep smoking.
As we will see, however, there are abundant reasons to believe that cigarettes do things for smokers as well as to them. This duality exists with all addictive drugs, but may be somewhat harder to see with cigarettes. With, say, cocaine or alcohol, we have no problem perceiving their apparent reward: users get high from them. What about smoking? The problem in seeing the commonality between cigarettes and other drugs comes because of our preconceived notions of what addictive drugs do.
We need to grasp the fact that a drug can be desirable to people without making them euphoric. It can be rewarding without getting us "high" as that term is commonly understood. Most of the addictive drugs we know about other than cigarettes have an apparent element of euphoria to their use. What's important to recognize, however, is that being blissed-out is only one of many ways in which drugs can be rewarding. Being mildly stimulated or tranquilized is another. Nicotine seems to be able to do both things, and these are a couple of the reasons it's attractive.
Indeed, subtle effects of this sort may be very great attractions. We recognize this with alcohol: it's the soothing reward of having just one drink. Might not there be the same, or even greater, value in a drug that is taken strictly for subtle effects? If we think about it for a second, why should we assume that being dramatically altered by a drug would be more attractive to the average person than being slightly altered? Most people assume, I think, that the more dramatic a drug's effect, the more attractive it would be to anyone; that if any of us encountered heroin, for example, we would find it so overwhelmingly attractive we would want to continue with it forever.
But we have good reason to believe that this is not the case at all. As Jack Henningfield of the National Institute on Drug Abuse says: "If we tested heroin and we just picked 50 people up off the street, and gave them doses of heroin, most of them would get sick and they wouldn't like it."11 What matters is not so much whether people get smashed on a drug; what matters is whether they find the drug useful: for relaxing, for remaining alert, for working, for imagining--or for getting blissed-out.
Now if people find a mildly tranquilizing drug useful and take it for long enough, and then that drug isn't available to them anymore, there'sa possibility that in their "withdrawal" from the drug there will be an element of physical dependence--manifested as an unpleasant physical state.
But isn't there likely to be something else, too, something a little less exotic, but perhaps important in its own way? Won't they simply miss not having that mild tranquilizer around whenever they want it? This is not something we can measure in terms of heart beats per minute or brain-wave states. But isn't it likely to affect our behavior?
A person raised in coastal Maine but now living in Kansas may miss the ocean--may miss it to the point of returning to Maine even though he or she has a better job in Kansas. We can't describe that person as being "addicted" to the ocean, unless the term is to lose all its meaning. Yet this person's attachment to the sea has caused him to act, in one sense, against his own best interests. There is surely some of this with cigarettes, or for that matter with any addictive drug we know about. We are attached to their effects as well as addicted to them; we feel an absence when these effects are no longer at our disposal. In this sense, drug use--commonly cordoned off in our minds to a separate, dark underworld--is not so much different from any number of other things in our lives.
If it's possible to miss having a mild tranquilizer, is it not possible to miss something simply connected to having it--say, holding a cigarette? Pack-a-day smokers hold them 140 times a week. And they hold them on many of these occasions at very specified times--after a meal, while filling out reports at work, while doing the crossword puzzle. After a time, wouldn't manipulating the cigarette while doing the crossword become nearly as reflexive as shifting in the chair while working on it?
Readers may be able to see where I'm going with all this. We have seen the reasons for smoking start with physical punishment for not smoking; then we added pharmacological rewards for smoking; then we speculated on the personal, almost emotional, nature of missing a pharmacological effect; then we talked about missing a smoking-related behavior that has nothing directly to do with pharmacology at all.
If all these things are motivations for smoking, then the seemingly simple act of drawing tobacco smoke into the lungs--this nothing activity, so slight it's hardly there--begins to be seen for what it is: a habit of deep roots and great complexity. As we will see, addiction andattachment; pharmacology and behavior; personality, culture, and genetics all chase each other around like a cat after its own tail when we start to consider the issue of why people smoke.
That said, we should remember how this discussion started: with the assertion that the main reason people smoke is to get nicotine into their bodies. This is true not only because of the direct effects nicotine has, but because of its indirect effects. Think of the four reasons I set forth for smoking. The first two--being physically rewarded for smoking or physically punished for not smoking--clearly are pharmacological effects. But what about the other two reasons? (Chosen almost at random, by the way; many others could have been selected.) Well, missing having a mild tranquilizer around is not a matter of physical dependence, but it is based on the pharmacological effects of nicotine. The fourth reason follows this pattern as well. The reason people get used to holding cigarettes is not that this act is pleasurable in itself. We have no instances of people taking up tobacco holding. They take up tobacco smoking (and only later, when they're trying to quit, do we find them regularly holding unlit cigarettes). It is the pairing of nicotine's effects with holding that gives the latter act its power.
The point here is that nicotine is like a stone dropped in a pond: it has direct effects and indirect effects. A water strider might be sunk by such a stone or buffeted by the ripples that its splash creates. But ultimately, there is one cause for all the effects.
This analogy is not exact. There are reasons for smoking that lie completely outside the effects of nicotine. Some of these may be strong motivating forces. But science increasingly points to nicotine as the strongest force of all in motivating smoking. Before turning to its role in the smoking habit, however, we might benefit from taking a look at some motivations for smoking that are related only weakly, if at all, to this subtle yet powerful drug in tobacco.
Copyright © 1991 by W. H. Freeman and Company