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6.1 Defining nicotine as a drug of addiction

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Note: the terms 'addiction' and 'dependence' are used interchangeably in this and the following sections to refer 'to a situation in which a drug or stimulus has unreasonably come to control behaviour'.1

The most widely used criteria for assessing drug dependence2 are those from the International Classification of Diseases (ICD) of the World Health Organization, and the Diagnostic and Statistical Manual of Mental Disorders (DSM), compiled by the American Psychiatric Association. Both of these classification schemes undergo major periodical revision, the most recent versions being ICD-10 (1990),2 and DSM-IV (1994).3 The main features from the DSM-IV and ICD-10 are summarised in Table 6.1.1, and include:

  • a strong desire to take the drug
  • taking the substance in larger amounts or for longer than intended
  • difficulty in controlling use
  • spending a great deal of time in obtaining, using or recovering from the effects of the substance
  • giving a higher priority to drug use than to other activities and obligations
  • continued use despite harmful consequences
  • tolerance
  • withdrawal symptoms.

Table 6.1.1
Summary of diagnostic criteria for drug dependency from classifications developed by the American Psychiatric Association (DSM-IV) and the World Health Organization (ICD-10)

DSM-IV

ICD-10

At least three of:

A cluster of behavioural, cognitive and physiological phenomena that develop after repeated use and that typically include:

Substance often taken in larger amounts or over a longer period than intended

A strong desire to take the drug

Persistent desire or unsuccessful efforts to cut down or control use

Difficulty in controlling use

A great deal of time spent in activities necessary to obtain the substance, use the substance or recover from its effects

Important social, occupational or recreational activities given up or reduced because of substance use

A higher priority given to drug use than to other activities and obligations

Continued substance use despite knowledge of having a persistent or recurrent social, physiological or physical problem that is caused or exacerbated by the use of the substance

Persisting in use despite harmful consequences

Tolerance: need for markedly increased amounts of the substance to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount

Increased tolerance

Withdrawal: the characteristic withdrawal syndrome or the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

Sometimes, a physical withdrawal state

Source: Derived from Table 4.1 in Royal College of Physicians1

The criteria in these systems apply to legal and illicit substances. Because tobacco products are legal to use, easily obtained, comparatively inexpensive, and may be readily used while engaged in other activities, some of the criteria listed above are less applicable to tobacco than other drugs of addiction. For instance, the average smoker does not need to devote a great deal of time to obtaining cigarettes, and only in countries where smoking restrictions have been introduced do smokers need to forego important activities to smoke a cigarette. Otherwise, nicotine use easily meets the criteria listed in Table 6.1.1; nicotine is, in fact, among the most addictive of substances known.1, 4 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 their pharmacological classification. In terms of addictiveness, nicotine delivered in tobacco smoke is a "hard" drug on a par with heroin and cocaine' (p184).1

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 capture rate than for users of heroin (23%), cocaine (17%), alcohol (15%) or cannabis (9%).5, 6 Tobacco's status as a legal, and until recently, a socially acceptable product, with a long history of high-profile marketing and promotion, has contributed to much higher levels of tobacco than illicit drug dependence in the community.

References

1. Royal College of Physicians of London. Nicotine addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London: Royal College of Physicians of London, 2000. Available from: http://www.rcplondon.ac.uk/resources

2. World Health Organization. Nomenclature and classification of drug- and alcohol-related problems: a WHO memorandum. Bulletin of the World Health Organization 1964;59(2):225–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/6972816

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition – Text Revision (DSM-IV–TR). 4th edn. Washington DC: American Psychiatric Association, 1994. Available from: http://allpsych.com/disorders/dsm.html

4. Benowitz N. Nicotine addiction. New England Journal of Medicine 2010;362(24):2295–303. Available from: http://content.nejm.org/cgi/content/full/362/24/2295

5. Anthony J, Warner L and Kessler R. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances and inhalants: basic findings from the National Comorbidity Survey. Experimental & Clinical Psychopharmacology 1994;2(3):244–68. Available from: http://www.umbrellasociety.ca/web/files/u1/Comp_epidemiology_addiction.pdf

6. Upadhyaya H, Deas D, Brady K and Kruesi M. Cigarette smoking and psychiatric comorbidity in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry 2002;41(11):1294–1305. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12410071

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