“Hey, Doc, you can’t be serious!” I had simply suggested that he come to my smoking cessation group and think about quitting smoking while he was in treatment for his alcoholism and drug addiction. He unleashed a torrent of rationalizations and excuses:
“One addiction at a time, Doc.”
“My sponsor said I shouldn’t make any major changes in my first year of recovery.”
“A guy in the program said I should wait six months or a year before I try to quit smoking.”
“There’s nothing else to do around this place except smoke.”
“Hey, there’s so much smoke around those A.A. meetings, I might as well be smoking.”
“If you make me quit smoking, Doc, I’ll probably start drinking again.”
Protests like these once made me feel defensive, frustrated, and angry. However, when I recognized that they are essentially the same as the ones we have heard for years from alcoholics and drug addicts, I realized that we can understand both the excuses and the patients when we view their smoking as an addiction.
Nicotine is a mind and mood altering drug which produces all the effects required to satisfy even the most stringent definition of addiction:
tolerance: More is required over time.
withdrawal: Symptoms and signs characteristically develop when the drug is discontinued.
drug-seeking behavior: Compulsive use of nicotine is exhibited.
Tobacco is unique among addicting drugs, combining potent addicting chemicals with nurturing social rituals, at a modest price, and with social acceptance. No other chemical, no other object, no other person, can do for an addicted smoker what cigarettes can do.
As a smoker: When you are sleepy and you are having trouble paying attention, do you feel like having a cigarette? After you smoke one, do you feel more alert? When you are tense and anxious, do you feel like having a cigarette? After you smoke one, do you feel relieved? These are the effects of the chemicals in tobacco smoke.
Tobacco contains the addicting stimulant nicotine, which has properties similar to those of cocaine and amphetamine. It increases alertness and alleviates depressed moods. Acetaldehyde is also present in cigarette smoke. It is the first metabolic product of alcohol but is far more potent than alcohol. It shares sedative properties with alcohol.
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Thus, among the 4000 or so chemicals that have been identified in tobacco smoke is an addicting stimulant (nicotine) and an addicting sedative (acetaldehyde). Imagine a compound that can wake you up, and calm you down — at the same time. No wonder no other chemical can take the place of tobacco.
What about the behaviors? Tobacco can be used just about anywhere (although restrictions are increasing), at any time. A two-pack-a-day smoker feeds his/her addiction 40 times a day, eventually associating a cigarette with just about every human activity. Over time, smokers develop rituals around their cigarette use. They carry the pack in the same place; they open the pack and extract a cigarette in the same way; they light the cigarette and hold it in the same way; they inhale and exhale the smoke in the same way; they tap off the ash in the same way; and they put out the cigarette in the same way.
These little rituals provide a sense of security to otherwise insecure lives. Even if the world is out of control, a cigarette is something the smoker can control. People and places change, but cigarettes remain the same.
Cigarettes also help a smoker project an image and participate in a private fantasy. Think for a moment about how the advertising for cigarettes portrays the people who smoke their brands. The Marlboro Man is independent, secure, and healthy; the Virginia Slims woman is liberated, empowered, and athletic; the Benson and Hedges smoker is sophisticated and aloof.
Smokers use cigarettes to manage feelings: cigarettes help restrain anger and calm resentments, allay fears and assuage grief, fill up the loneliness and manage the boredom. Cigarettes become not just a friend but also a confidante, a buddy, and a lover. When the world becomes overwhelming, a smoker can retreat into isolation with a cigarette, and avoid reality for a while.
So here we have a product that provides a stimulant to the weary and a tranquilizer to the anxious, a ritual to rely on and a fantasy to enjoy. Cigarettes become a smoker’s very best friend. Other friends may come and go, but cigarettes are always there. Other friends may be inconsistent, but cigarettes never vary. Other friends may not keep their promises, but cigarettes are always reliable.
Is it any wonder, then, that a person addicted to this potent compound will seek to protect it? Just as any addicted individual will do whatever it takes to maintain access to their drug, addicted smokers will defend their smoking. They are protecting their addiction. They aren’t stupid, misinformed, deluded or misguided; they aren’t being obstructive or antisocial; they are safeguarding their best friend, their addiction. And who would you expect them to listen to — their best friend or some therapist?
The tragic irony is that while believing cigarettes to be their friend and companion, their playmate and co-star, their lover and rescuer, the smoker has insidiously become addicted. No longer is the cigarette an object to control — it is the object which controls. Smokers suddenly discover that this cunning, baffling, and powerful chemical now controls their lives, telling them how to spend their time, whom to have as friends, where to sit on a plane or in a restaurant, how long to sit in a meeting, and how to spend their money. And all the while, smokers continue to protect their false friend.
And, as well all know, this false friend produces desperate consequences. At least 325,000 Americans die each year as the result of smoking-related illnesses. There is no longer any question that smoking causes heart disease, emplhysema, and cancer. But as with other addictions, the threat of death or disability does not stop addicts from using their chemicals.
All addicts fortify their defenses when they sense their addiction is being attacked. Smokers have had more practice than most.
“One addiction at a time, Doc . . .”
‘If you make me quit smoking, I’ll probably start drinking again.”
They attack me because I run the smoking cessation groups in our chemical dependency treatment program. None of the patients are eager to join the group. “Just come and listen,” I tell them. “You don’t have to quit smoking today. Or tomorrow, or next week or next month. But everyone quits eventually, and I’d like you to know how to do it when you’re ready. It’s not so important when you quit, as it is that when you do quit, you stay quit. if you try to quit prematurely and relapse, you may not be willing or able to make the effort again.”
I don’t ask smokers to admit that they are powerless over tobacco and that their lives have become unmanageable — I show them. We work first on reasons for quitting, seeking to get past “other people’s reasons.” We work on “times I want a cigarette,” discovering how cigarettes have become an integral part of their lives. We work on how they use cigarettes to deal with feelings, such as anxiety and anger, and work on developing alternatives. Through this program, “Quit and Stay Quit,” smokers come to understand the nature of their addiction, and discover a 12 Step alternative to smoking.
One day — perhaps in as little as five years — well will expect our patients who smoke to recover from tobacco addiction along with their addictions to alcohol and other drugs. We will look back to the Eighties and wonder why we ever permitted such a destructive addiction to continue. And we will have learned that recovery is possible — even from nicotine addiction.