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Table 6.1
Summary of diagnostic criteria for drug dependency from classifications developed by the American Psychiatric Association (DSM-IV) and the World Health Organization (ICD-10)
6.1 Defining nicotine as a drug of addiction
Note: the terms 'addiction' and 'dependence' are used interchangeably in this and the following sections. Although, strictly speaking, they have different definitions, their meanings have evolved over time and substantially merged within the public perception to the point where there is little purpose in distinguishing between the terms. Here, both words refer 'to a situation in which a drug or stimulus has unreasonably come to control behaviour.' 2 p 83
The most widely used criteria for assessing drug dependence2 are the International Classification of Diseases (ICD), which is the international standard diagnostic classification maintained by the World Health Organisation, and the Diagnostic and Statistical Manual of Mental Disorders (DSM), compiled by the American Psychiatric Association. Both of these systems undergo major periodical revision, the most recent versions being ICD-10 (1990),9 and DSM-IV (1994).10 The main features from the DSM-IV and ICD-10 are summarised in Table 6.1, and include:
|
DSM-IV |
ICD-10 |
|
At least three of: |
A cluster of behavioural, cognitive |
|
Substance often taken in larger amounts or over |
A strong desire to take the drug |
|
Persistent desire or unsuccessful efforts to cut |
Difficulty in controlling use |
|
A great deal of time spent in activities necessary |
|
|
Important social, occupational or recreational |
A higher priority given to drug use than to other |
|
Continued substance use despite knowledge |
Persisting in use despite harmful consequences |
|
Tolerance: need for markedly increased amounts |
Increased tolerance |
|
Withdrawal: the characteristic withdrawal |
Sometimes, a physical withdrawal state |
Source:Derived from Table 4.1 in Nicotine Addiction in Britain, Royal College of Physicians, 20002
The criteria adopted by these systems are designed to apply to substance abuse in general, including legal and illicit substances. Because tobacco products are legal to use, easily obtained, comparatively inexpensive, and to some extent may be used while engaging in other activities, some of the criteria listed above apply less strongly to tobacco use than to other substances of addiction. For instance the average smoker would not need to devote a great deal of time to the task of obtaining cigarettes, nor to forgo important activities rather than miss out on having a cigarette, except where smoking restrictions have been introduced over the past two decades. Otherwise, nicotine use easily meets the criteria listed in Table 6.1, and is, in fact, among the most addictive of substances known.2 According to the Royal College of Physicians, 'although nicotine in the form of tobacco is a legal drug, it should not be regarded as pharmacologically benign. The classification of drugs as 'legal', 'soft' or 'hard' reflects public perceptions and current law enforcement practice, rather than constituting a useful pharmacological classification. In terms of addictiveness, nicotine delivered in tobacco smoke is a 'hard' drug on a par with heroin and cocaine.'2 p 184
Research on the epidemiology of drug dependence has shown that of all people who initiate tobacco use, almost one third (32%) become addicted smokers. This is a much higher addiction rate than for users of heroin (23%), cocaine (17%), alcohol (15%) or cannabis (9%).11, 12 It is likely that tobacco's status as a legal, relatively socially acceptable product with a long history of high profile marketing and promotion has also contributed to higher levels of dependence in the community, compared to levels of illicit drug use.
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