Michael Shaw, a 40-year-old from Brooklyn who has smoked cigarettes for 24 years, says he really wants to quit. And I do not doubt his sincerity. He has tried to give up cigarettes many times. But after several days or weeks of not smoking, something happens — an evening out with friends, an emotional upset or just plain boredom — and he relapses.
His sole weapon so far in battling his addiction, he says, has been willpower. But what scores of experts on nicotine addiction have come to learn is that willpower is rarely enough. Most diehard smokers need methods far stronger — and usually a combination of stop-smoking aids — to help quit in the first place and, more important, remain former smokers.
There are exceptions. I was amazed when my husband, who had smoked for 50 years, quit cold turkey in 1994 after one session with a hypnotist and a few sticks of nicotine gum.
Survey statistics from the US Centers for Disease Control and Prevention show that 70 percent of smokers say they want to quit and that 40 percent try to quit each year. But 80 percent of smokers who try to quit on their own relapse within a month, the data show, and only 3 percent remain former smokers at six months.
Though long called a lifestyle choice or pernicious habit, smoking is now widely recognized as an addictive disease comparable to alcoholism or heroin addiction.
“Tobacco addiction is best considered a chronic disease, with most smokers requiring repeated interventions over time before achieving permanent abstinence,” Neal L. Benowitz of the University of California, San Francisco, said last month in The American Journal of Medicine.
BIOLOGICAL BASIS OF ADDICTION
Like other addicting substances, nicotine produces pleasurable effects that prompt smokers to keep up the habit and, ultimately, lose control over smoking, often even when dire consequences like a heart attack, cancer or emphysema result.
Among the addiction-maintaining effects of nicotine are arousal, relaxation, improved mood, reduced anxiety and stress, better concentration and faster reaction time. When deprived, smokers report withdrawal symptoms that include irritability, depression, restlessness, anxiety, difficulty concentrating, increased hunger, insomnia, a craving for tobacco, difficulty getting along with others and a feeling that life lacks pleasure.
These effects have a biological basis. Nicotine easily crosses the blood-brain barrier, where it binds to nicotine-specific receptors in the brain. This results in the release of a host of neurotransmitters, primarily dopamine, that “signals a pleasurable experience and is critical to the reinforcing effects of nicotine and other drugs of abuse,” Benowitz explained.
Repeated exposure to nicotine increases the receptors and induces tolerance to and dependence on nicotine. Smokers typically take in the amount of nicotine needed to bind to the receptors. When the drug is withdrawn, in a night’s sleep, for example, or in an effort to quit, the falloff in nicotine rewards becomes a barrier to lasting abstinence.
Changes also occur in brain function as measured on an electroencephalogram, especially in the so-called reward center of the brain.
In addition to the biological effects of nicotine, conditioned behaviors reinforce its continued use. Smokers quickly learn to associate nicotine intake with certain moods, situations or environmental circumstances, both pleasant and unpleasant. As Shaw of Brooklyn has found, those circumstances become powerful cues for the urge to smoke.