The Root of the Problem: Nicotine Addiction

A 1994 investigative report developed by Cliff Douglas, director of the U-M Tobacco Research Network, and broadcast by ABC News, provided the first public disclosure that the tobacco industry had long been manipulating the content and delivery of nicotine to cause and perpetuate widespread addiction in tobacco users. That report triggered a series of investigations, hearings, and litigation, culminating in the 2009 enactment of the Family Smoking Prevention and Tobacco Control Act, giving the Food and Drug Administration regulatory authority over tobacco products.

And yet, says Douglas, tobacco companies continue to carefully engineer their products to have the greatest addictive impact. Nicotine's powers were laid out in a 1988 Surgeon General's Report comparing it to heroin and cocaine in its ability to hook users. Nicotine is both a stimulant and a relaxant, and tobacco use is physically as well as psychologically addictive. The report concluded that:

  • Cigarettes and other forms of tobacco are addicting;
  • Nicotine is the drug in tobacco that causes addiction;
  • The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.

An Insider Speaks Out on Menthol

Jeffrey Wigand, whose story inspired the 1999 movie The Insider (starring Russell Crowe as Wigand), is the highest-ranking former executive ever to speak out against the tobacco industry. A former vice president of research and development for Brown & Williamson, Wigand turned whistleblower in 1995 when, on the CBS news program 60 Minutes, he revealed that Brown & Williamson had intentionally manipulated its tobacco blend to increase the amount of nicotine.

Today Wigand travels the world as an expert on tobacco issues and works to reduce teen tobacco use through his nonprofit organization, Smoke-Free Kids, Inc. In December, Wigand spoke by webcast to students in HMP 618: Tobacco: From Seedling to Social Policy, taught by SPH's Cliff Douglas. Discussion topics ranged from e-cigarettes (about which Wigand is skeptical) to tobacco marketing and what Wigand describes as the "menthol problem."

"Tobacco products contain approximately 616 additives, most of which are designed to ameliorate the harshness of tobacco and to increase the potency and addictive potential of nicotine," Wigand told the students. "Additives like menthol make it easier to take up smoking and easier to continue the habit. Industry officials like to say, 'If you can hook 'em young, you can hook 'em for life.' The best way to shut the industry down is to stop its new users—children—so I'm a proponent of eliminating menthol. Menthol also keeps the mentally ill addicted. In fact, Merit ads target schizophrenics."

The E-Cigarette Debate

The electronic cigarette industry and its proponents claim e-cigarettes can help smokers quit and also reduce their exposure to the harmful substances found in conventional tobacco smoke. Public health officials are concerned that e-cigarettes may perpetuate nicotine addiction, "re-normalize" the act of smoking, and have not been proven to aid in cessation or to reduce harm. SPH experts have this to say:

"It's no coincidence that Big Tobacco, the leading expert in mass marketing nicotine addiction, has moved aggressively into the e-cigarette business. Lorillard, which makes Newport cigarettes, owns about half of the e-cigarette market, and Philip Morris, Reynolds-American, and other major cigarette manufacturers are rapidly increasing their stake in the market. Currently, e-cigarettes are marketed freely without regulation, with manufacturers spending millions on ad campaigns that closely resemble the aggressive cigarette ads of decades ago. In the meantime, an increasing number of states and municipalities are taking steps to prohibit their sale to minors and include e-cigarettes in their smoke-free restaurant, bar, and workplace laws."

Cliff Douglas, Director, U-M Tobacco Research Network

"With kids thus far, as with adults, it appears that e-cigarettes are being used by cigarette smokers. Some are doing so with the desire to substitute e-cigarettes for regular cigarettes. Others are using e-cigarettes as a bridge between the times they can smoke. The question is how many vapers (as e-cigarette users are called) will quit and how many will sustain their smoking. To date, the data simply can't answer that question.

Several factors will play into the future of e-cigarettes, most notably the fact that they will evolve into better products. The important question is when and how the FDA will use its new authority to regulate cigarettes and smokeless tobacco products. Done properly, regulation could dramatically discourage cigarette smoking, while making more attractive e-cigarettes (and equivalent products) available to help people get off of cigarettes. The 50th-anniversary Surgeon General's report on smoking and health, released this February, calls for the elimination of the use of cigarettes and other combustible tobacco products. It is unlikely that we will see a more important public health goal this century."

Kenneth Warner, Avedis Donabedian Distinguished University Professor of Public Health

The Addicted Brain

Our minds cannot exist without our brains. And addiction changes both by altering not only the physiology of the brain but also the behaviors and decisions we make with our minds. All drugs of abuse—drugs that get people addicted—change the prefrontal cortex, that part of our brain that determines what we believe is important. The nucleus accumbens—the part of the brain where we feel pleasure—is another area that is changed by repeated drug use.

There are two main reasons people take drugs. The first is that they're curious. The second is that they are in an unpleasant state of mind and take drugs to self-medicate. When they take a drug over and over again, it causes changes in the brain that overwhelm the brain's ability to function normally, and they become compulsive users.

The good news is that the change in brain physiology caused by the sustained use of an addictive drug is often reversible. The affected brain cells are not killed by the vast majority of drugs of abuse, but simply become skinnier and less functional. The goal of therapy or recovery is to allow time and space for those cells to revert to normal, taking advantage of the brain's plasticity. Medication and/or psychotherapy—or other interventions, such as 12-step programs—reverse the change more quickly.

It's important to understand that people will always be addicted, they will always look for mind-altering things. Researchers tend not to think in terms of an "addictive personality" but rather in terms of a person who is at "risk for addiction." Public health can help reduce that risk by working to change attitudes, especially among the vulnerable young. If kids understand how drugs will affect—and potentially harm—them, they are much less likely to use them.

Don Vereen, Director, U-M Substance Abuse Research Center; Director, Community-Academic Engagement, Prevention Research Center of Michigan; previously Special Assistant to the Director, National Institute on Drug Abuse; Deputy Director, White House Office of National Drug Control Policy