Surgeon General C. Everett Koop's 1988 report on the health consequences of smoking compared nicotine addiction to a heroin habit. "Recognizing tobacco use as an addiction is critical…for understanding why people continue to smoke despite known health risks," the report says. "Tobacco use is a disorder which can be remedied through medical attention."
There are good reasons to call smoking an addiction. Many smokers have a strong desire for nicotine, develop tolerance for its effects, and suffer withdrawal symptoms without it. In several surveys, addicts and alcoholics in treatment have said that cigarettes were tougher to give up than crack, cocaine hydrochloride, or alcohol. But the evidence does not support the idea that smoking is a disease with a medical cure. Not only is that approach misleading, stressing nicotine's addictive power and the need for expert assistance undermines efforts to quit.
While some 46.5 million Americans smoke the Centers for Disease Control report that nearly as many—44 million—have kicked the habit. Furthermore, over 90 percent did so on their own, without any formal treatment program. Now if we could only learn how more than 40 million Americans gave up cigarettes, we would know the most successful method ever used for quitting addiction. It turns out that good information, social forces, and concern for one's health work better than any kind of treatment.
To begin with, the government, the news media, and national health organizations publicized accumulating evidence that smoking is toxic. At the same time, individuals and employers began to disapprove of smoking and smokers. In many companies, smoking actually impaired one's chances for promotion. Employees sometimes had to hide their smoking or restrict it so dramatically that they went through most of the work day without a cigarette.
Meanwhile, smokers' friends and families began indicating that smoking was abhorrent to them. They expressed concern about smokers' self-destructive behavior and complained that tobacco smoke was annoying and disgusting. (As techniques for quitting, try having your small daughter cry every time you come home, "Daddy/Mommy, I hate that you're killing yourself," or having your spouse refuse sex until you stop.)
Of course, these efforts at personal persuasion haven't made everyone quit. Advising and pressuring people to quit smoking works (in the long run) only about half the time. Why doesn't social pressure work better? For one thing, the pressure is felt unevenly. In many groups, such as working-class adolescents, smoking retains its cachet. Smoking is more accepted in some occupations than in others. When I looked for a new car last year, every salesman I saw smoked cigarettes. According to one survey, almost half of all waitresses smoke, compared with fewer than one in 10 doctors.
Epidemiological data from the CDC and other sources support these impressions. The pattern resembles that of cocaine use: After much publicity about the negative effects of cocaine, middle-class experimentation has declined dramatically, while inner city addiction has remained high and even intensified in some areas. Similarly, the percentage of former smokers among those who ever smoked is highest for college graduates (60 percent). While about 16 percent of college graduates continue to smoke, the smoking rate for those without a high school diploma is 36 percent.
One way to think about these discrepancies is to imagine the function smoking serves; many people use it as a way of rewarding themselves during the day. If you are relatively affluent, you can substitute other rewards: "I'm having a tough time today, but I'll go out for dinner with my wife or play tennis tonight to make up for it." If you're poor, smoking may seem the most ready alternative. Many smokers accept the risks of their behavior in exchange for the benefits they receive.
But for those who want to quit, some methods clearly work better than others. A recent national survey by the CDC found that, of smokers who had tried to stop in the previous decade, "47.5% of persons who tried to quit on their own were successful whereas only 23.6% of persons who used cessation programs succeeded." I hear skeptics saying, "I bet the ones who entered the programs were more addicted, heavier smokers." Wrong. According to the researchers, "Daily cigarette consumption…did not predict whether persons would succeed or fail during their attempts to quit."
Overall, smokers attending treatment programs were twice as likely to fail as those who did it on their own. These programs included Smokenders, which relies on group exhortation combined with some behavior-modification techniques. Nicotine gum was the least effective method. Ironically, this is also the most heavily advertised method. Merrell Dow, maker of Nicorette, has bombarded the media with ads explaining that nicotine addiction is a form of chemical dependence. Because of the "physical dependence of nicotine," the ads say, "your chances of quitting successfully are greater with a program that provides an alternative source of nicotine."
A clinical study published in The Journal of the American Medical Association in 1989 tested this proposition. At the end of a year, smokers given Nicorette were not significantly more likely to be off cigarettes than those given a placebo gum. A Merrell Dow spokesperson immediately declared that calling the gum ineffective because people were smoking a year after taking it was "like blaming an antidepressant [medication] if a person gets depressed again a year after discontinuing the drug." The manufacturer seems to expect "patients" to continue taking nicotine in gum form forever. While this might help them stay off cigarettes, it wouldn't be a cure for nicotine addiction.
How do smokers succeed in quitting on their own? Surveys reveal that most ex-smokers say something like, "I decided I had had enough, so I threw my last pack of cigarettes away." Many begin smoking again. But over the long run, half of those who have smoked—including many who relapse one or more times—eventually achieve their goal of a nicotine-free existence. When psychologists ask people what cognitive techniques they used—what mind games they played—they find ex-smokers employ just about every trick under the sun. Only one such method didn't work well for at least some smokers: negative and self-punitive thoughts (for example, "I'm a self-destructive wimp who is a slave to nicotine").
One reason crutches such as Nicorette are so unsuccessful may be that they reinforce people's beliefs that they can't succeed on their own. Along with a desire to stop smoking, the most important ingredient in quitting seems to be the belief that you can succeed, that you can live and function without cigarettes. When a program strives to convince you how overwhelming your addiction is and tells you that you'll never be able to overcome it on your own, it isn't surprising that the results are so dismal.
Contributing Editor Stanton Peele is a psychologist and health-care researcher.
This article originally appeared in print under the headline "Smoking: Cold Turkey".
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