Chapter 2

Talking about Tobacco

IN THIS CHAPTER

Bullet Understanding why you smoke

Bullet Plowing through tobacco

Bullet Looking back at tobacco through time

Do you remember your first cigarette? If you’re like most people, you were probably a teenager hanging out with one or more friends — no adults to be found. You may remember a fit of coughing as you awkwardly struggled to inhale. You and your friends may have nervously choked and giggled while hoping not to be caught. It may have seemed delightfully rebellious.

Perhaps you wonder how you, as well as millions of others, took that first irritating, disgusting drag and continued to smoke. And, amazingly, you kept doing it despite the revolting smell, filthy cigarette butts, money, and risks to your health. You didn’t fear addiction because you’d never get addicted to something so vile as smoking. However, if you ask most long-term smokers whether they’d take that first cigarette again, most would say never, no way, no how.

Yet, over time, that disgusting smell morphed into a smoker’s perfume. The cigarette butts became mere nuisances. The money seemed justifiable. And health risks appeared to lie in the distant future.

In this chapter, we report on the numerous physical, emotional, and social causes of smoking addiction. We give you a tool for helping you understand just to what extent you’re “hooked” on smoking. We also review the various ways people manage to get their tobacco fix and note how tobacco has created so much pleasure, pain, profit, and problems.

Tip Although this chapter focuses on addiction to cigarettes, this information applies to all addictions to tobacco products whether they’re smoked, chewed, vaped, or snuffed.

Analyzing Addiction

Most smokers want to know why they smoke. No one starts smoking wanting to become addicted, and most new tobacco users think it won’t happen to them. But for those who continue to smoke after those first early packs, addiction powerfully contributes to why they keep smoking.

Experts don’t have a universally agreed upon definition of addiction. That’s because it’s a complex concept that defies easy explanations. Nevertheless, most people have notions as to what they think it is. And perhaps you’ll find it helpful if we describe our way of looking at the phenomenon.

An addiction involves powerful feelings that come about from ingesting certain types of drugs or substances. The hallmark of an addiction is using a substance chronically despite harmful effects on a person’s life now and in the future. Using addictive substances generally feels good, and bad feelings abate for a while. Unfortunately, negative feelings return, and the craving for positive feelings increases, culminating in a vicious cycle of addiction.

Technical stuff Tolerance is another important aspect of addiction. Tolerance occurs when a substance is used over and over again, and it begins to have a reduced impact. More is, therefore, needed to get the same effects. Tolerance develops quickly for most regular smokers — 1 or 2 cigarettes a day quickly turns into 10, 20, or more. Of course, at some point, smokers usually reach a stable level of intake (after all, there are only so many hours in a day!).

There are many myths and misconceptions about what an addiction is and isn’t. The following points explain some of these myths:

  • Myth: Addiction is unfixable. Actually, considerable data suggests that many people ultimately are able to break their addiction, whether it’s tobacco, drugs, or alcohol.
  • Myth: All addicts must reach rock bottom before they can break their addiction. Rock bottom is hard to define — it varies from person to person. However, lots of people stop using addictive substances well before hitting anything like a true rock bottom.
  • Myth: Willpower is all you need. Psychologists don’t even fully agree on what exactly willpower is. If you think of yourself as lacking something fundamentally necessary, such as willpower, you’ll never succeed. If you want to quit, it’s worth taking a shot, no matter how much willpower you think you do or don’t have.
  • Myth: Addicts are weak people. People become addicted for a variety of reasons as we explain in the following sections on biological, psychological, and social factors. Being strong or weak has nothing to do with it.
  • Myth: Addiction is simply a choice. Sure, there’s an aspect of choice involved with starting to smoke. However, most addicts would truly not choose to be addicted.
  • Myth: I could never become addicted. Thinking like that could make you more vulnerable to becoming addicted. No one is immune.
  • Myth: Addicts always suffer considerably when they try to quit. Surprisingly, there are a few, lucky people who manage to quit a substance like cigarettes without struggle. But for most people, the more they develop a plan and garner support and help from others, the easier they’ll find quitting.
  • Myth: After you’re detoxed, you’re done with your addiction. Your system clears itself of nicotine in a few days, but cravings are another matter. Those may continue for weeks, months, or sometimes forever (though almost always they lessen over time).
  • Myth: Taking medication to help with addiction is cheating by substituting one drug for another: Medications used to treat addiction (see Chapter 9), are always safer than the original substance. Even nicotine replacement therapy avoids tars and toxic chemicals that come from burning cigarettes. Furthermore, most people use these medications as a bridge to quit entirely at some point. Does it help to call it cheating? No.
  • Myth: Addicts are bad people. We can’t deny that those who are addicted to almost anything are often shamed and stigmatized by others. But so-called addicts are people just like everyone else. They start out using substances as recreation, response to pressure, or a variety of other reasons. What they don’t do is start out with the intention of becoming addicted.

Technical stuff When we use the term addiction in this book, we’re referring only to the response people have to certain substances such as opioids, alcohol, and nicotine. This approach avoids applying the term addiction to behavioral issues such as aberrant sexuality, Internet addiction, and kleptomania, which may actually belong in another category of mental dysfunction that lies beyond the scope of this book.

Remember To further understand addiction to tobacco, it’s important to appreciate how an addictive substance affects the body. In addition, it’s useful to recognize that addiction interacts with powerful feelings and emotions. Finally, addiction affects relationships while relationships simultaneously impact addiction. In other words, addiction is driven by biological, psychological, and social forces as explained in the following sections.

Burrowing briefly into biology

Imagine taking a drag on a cigarette. Smoke pours into your lungs while dumping a stew of chemicals into your bloodstream. These chemicals quickly breach the blood–brain barrier and deliver a jolt to the brain, most of which comes from nicotine. It takes less than ten seconds to go from drawing in that first puff of smoke to the brain starting to respond.

Nicotine stimulates the effects of dopamine, a brain chemical that increases feelings of pleasure. Dopamine levels also rise after ingesting cocaine, eating a favorite food, and having sex; in other words, stuff that feels good.

Nicotine also increases adrenaline, a neurochemical that stimulates the body to increase blood pressure, increase heart rate, and restrict blood flow to the heart. Adrenaline prepares the body for threat — the well-known fight-or-flight syndrome that prepares you to either stand and fight or flee from danger. It also increases focus and causes calories to burn at a faster rate.

In addition, nicotine causes the body to dump more glucose (blood sugar) into the blood stream. Normally, when blood sugar rises, insulin is secreted, which enables blood sugar levels to come back to normal. However, nicotine inhibits that process, which leads to higher levels of blood sugar and decreased appetite.

So, in ten seconds or less, nicotine delivers pleasurable feelings, increases focus, decreases appetite, and increases energy. What could possibly go wrong?

Well, within a few minutes, nicotine levels begin to decline rapidly. Lower nicotine levels elicit feelings of reduced pleasure, increased nervousness and anxiety, diminished energy, a lack of focus, and the emergence of cravings. That’s why most long-term smokers report immediate decreases of anxiety and a sense of great relief when they light the next cigarette. No wonder, the pattern continues throughout the day.

But oddly, not through the night. Very few smokers wake up every hour to have another cigarette. And most smokers manage to get through work, movies, and airplane flights without intense distress. So, something more than mere biology must be contributing to the addiction of smoking.

Technical stuff Some experts contend that any addiction is a disease of the brain. Although biological factors clearly form part of the picture, that’s not the whole story. Thinking of smoking as a disease minimizes the importance of psychological and social contributors to the problem.

Inspecting psychological factors

We now turn to psychology to further clarify smoking addiction. People struggle with how to explain why they do things that they know are not in their best interests — smokers are no exception. The following three sections explain. First, a popular metaphor reveals how the mind works. Next, we show you how distorted thinking contributes to difficulty quitting smoking. Finally, we help you see how common associations become triggers for turning to tobacco.

Discovering elephants and their riders

Think of yourself as having two minds. The first you can think of as your elephant mind, and the second, as the elephant rider part of your mind. To a casual observer, the rider is in charge. The rider directs the elephant to go right, and the elephant usually obeys. However, if a hungry elephant spots its favorite meal on the left (consisting of luscious tree bark dripping with sap), who do you think will win?

Think of addiction as the elephant part of your mind, commanded by intense feelings of pleasure, pain, and/or fear. Yet the elephant isn’t that smart and mostly responds to what’s right in front of its trunk. The elephant does a poor job of forecasting the future or learning from the past. Immediate pleasures, temptations, and fears dominate the elephant’s decisions.

By contrast, the rider “knows” exactly what to do and is controlled by logic, reasoning, and critical thinking. The rider is no match for the brute strength of the elephant. The elephant part of the mind wants what it wants when it wants it. And the elephant truly does not like to feel one bit of discomfort.

So, how do the elephant and the rider parts of your mind dictate whether you’ll smoke? The elephant just wants to have fun. It can’t process and reason about long-term threats to health such as lung and cardiovascular diseases (see Chapter 3 for more information). The rider knows better but can’t seem to control the elephant. The rider tries reasoning, bribes, and persuasion, but the elephant feels bad when it doesn’t smoke and feels better when it does. It’s that simple.

Your rider mind can slowly but surely train the elephant to obey commands more often, but the training involves considerable skill, persistence, and patience. See Parts 4 and 5 for ideas about how to gain greater control over your elephant mind.

Remember If you’re trying to quit smoking or vaping and you experience a relapse (see Chapter 19), remember that you’re dealing with a very, very large elephant. It takes time to train the elephant. Be patient with your elephant, and yourself!

Adding up addictive thoughts

From a psychological standpoint, one of the most problematic factors driving both addiction and emotional distress can be found in the realm of distorted thinking. Distorted thinking causes you to make unwarranted assumptions and inaccurately portrays reality, usually in negative ways. Such thinking can be seen in these examples related to smoking:

  • “I smoke because I’m so nervous. If I quit, I’d be a wreck and never be able to do my job. I’d get fired, for sure.”
  • “I’ll probably gain a hundred pounds if I quit smoking.”
  • If I want another cigarette this badly, I must need it.”
  • “I smoked when I shouldn’t have today. Might as well give up.”
  • “My grandfather smoked two packs a day and died in his sleep at 92. It worked for him; it should work for me.”
  • “Just because countless others have learned to quit smoking, doesn’t mean I can do it.”
  • “I can’t function without a cigarette.”
  • “I’ve tried to quit before and failed, so I might as well give up and enjoy smoking.”

These thoughts all contain distortions of reality. And they wreak havoc on people’s attempts to quit. They sabotage quitting efforts by making mountains out of mole hills, ignoring positive evidence, increasing feelings of helplessness, and decreasing confidence. Not exactly a recipe for success. See Chapter 10 for help with problematic, distorted thinking.

Behavioral associations turn into smoking triggers

Do you remember getting thoroughly sick to your stomach after eating something? If so, you probably felt queasy or disgusted when you next encountered that food. Maybe you avoided that food for years or never ate it again. That’s because your mind connected the food with getting sick. The food became a potent trigger for nausea. However, that food might be both tasty and nutritious. You might spend a lifetime not eating a perfectly good, healthy food because of one association.

Associations are also formed to protect us. For example, when you smell badly spoiled food, you probably also feel nauseous. That’s a good thing, because the feelings prevent you from eating food that might make you sick.

On the other hand, the smell of freshly baked peanut butter cookies might take you back to a pleasant childhood memory. And if it doesn’t lead to binge-eating peanut butter cookies, that’s great. The brain tries to connect experiences that way so that it knows how to make you feel good and avoid feeling bad. And that can be a good or a bad thing.

With addictions, these brain connections or associations can work against you. They make you anticipate something very pleasant (we’re talking tobacco here) when thinking about or encountering certain settings, people, activities, or events. Associations can also bring on unpleasant emotions that make you want to smoke in order to feel better. These associations become triggers for smoking. Here’s a list of particularly common triggers that push many smokers to smoke.

  • The first cup of coffee in the morning
  • The sound and smell of someone opening a fresh pack of cigarettes
  • Coffee after dinner
  • Boredom
  • Driving to work
  • After lunch
  • Eating out
  • Driving in traffic
  • Before a job interview
  • After a job interview
  • Break time at work
  • Having a drink
  • After sex
  • Playing cards
  • Getting in trouble
  • After an argument
  • At a party
  • Talking on the phone
  • With certain friends

Good grief. What’s a smoker to do? Avoid everything in life? No. But you can see how powerful associations can lead you straight to the next cigarette. Whether it’s to feel good or avoid feeling bad, the influence can be hard to escape. See Chapters 10 and 15 for ideas on how to deal with triggers.

Searching for social contributors to addiction

Kids who hang out with smokers are more likely to smoke. Research suggests that adolescents are influenced to smoke by their friends or family who smoke, including parents, siblings, and extended family. That influence happens for three reasons:

  • Modeling: Modeling is referred to as observational learning or imitation. People readily pick up on behaviors demonstrated by important people they relate with. See the nearby sidebar, “Monkey see, monkey do,” for an example.
  • Predisposition: Secondhand smoke from household members may create a biological predisposition for acquiring an addiction to nicotine. Animal studies support that connection. See the nearby sidebar, “Secondhand smoke: Priming kids to smoke,” for an example.
  • Peer pressure: Peers not only model smoking behavior, but also sometimes exert pressure on their friends to do the same. The pressured friends cave in so that they can fit in better and be liked. Adolescents are particularly vulnerable to peer pressure. See the nearby sidebar, “All the cool kids are doing it … ,” for an example.

The degree to which these influences impact any given person varies greatly. And for some people, all three influences come into play. The following three stories illustrate how modeling, addiction vulnerability due to secondhand smoke, and peer pressure lead to trouble.

Tip If you’re a smoker, try to remember your earliest cigarettes. Ask yourself if modeling, secondhand smoke, or peer pressure may have played a role in your becoming hooked on cigarettes.

Tip According to the U.S. Surgeon General, the younger you start, the more likely you are to become addicted. Out of every four high school smokers, three will become adult smokers. Sadly, out of those three, only one will quit and another will die early from the health consequences of smoking.

On the other hand, not every person with biological, psychological, and social risk factors becomes addicted to tobacco or nicotine. See the nearby sidebar, “The exception to the rule,” for an example.

Assessing your tobacco addiction

It’s easy to deny the idea that you’re addicted or teetering on the edge of addiction to something like cigarettes. If you deny it, you’re likely to fool yourself into minimizing the damage it’s causing in your life. We have a quiz for you that may help you decide if your smoking really is a problematic addiction.

How bad is your addiction or how hooked are you? Ponder the following list of questions (our dirty dozen) to help you know.

  • Do you smoke every day?
  • Do you smoke to feel better?
  • Do you have physical withdrawal symptoms such as agitation, restlessness, and increased appetite when you’re not smoking?
  • Do you have emotional symptoms of withdrawal such as depressed mood, anxiety, lack of concentration, or stress when you’re not smoking?
  • Would you buy cigarettes even if you couldn’t afford them?
  • Do you avoid places that don’t allow smoking?
  • Have you tried and failed to quit smoking numerous times?
  • Do you have health problems from smoking?
  • Do you crave a cigarette immediately after waking up in the morning?
  • Do you plan for your next cigarette?
  • Do you sometimes smoke instead of doing something else you need or want to do?
  • Do you continue to smoke even though you know you’re harming others (your kids, spouse, or friends) through secondhand smoke?
  • Do you worry when you’re about to run out of cigarettes?

There is no specific cutoff score for this quiz. But obviously, the more questions that apply to you, the more you’re hooked. Even answering yes to two or three of these questions suggests you have significant trouble with smoking. At the end of the day, it doesn’t matter to what extent your addiction is based on biological, psychological, or social factors. Either way, smoking kills, and it’s tough to quit.

The power of smoking addiction can’t be overstated. Ask any hospital nurse about patients’ desperate attempts to smoke while hospitalized. You’re likely to hear stories of people suffering from end-stage lung cancer still craving the very thing that’s killing them. One nurse we spoke to remembered a lung cancer patient, too weak to walk, who wanted to be wheeled outside to smoke. When the nurse turned down the request, the patient called 911 to report that he was being abused by the uncaring staff. After the patient’s third phone call to the police, an officer was dispatched to the hospital. Upon hearing his complaint, the officer was less than sympathetic to the patient. No charges were filed. To be clear, we have no intent to disparage this patient. Consider the anguish he must have been feeling over his overwhelming compulsion to smoke. Under such circumstances, all reasoning and common sense are drowned by the intense cravings for a cigarette.

Tip About half of all smokers try to quit each year, but only a very few do it without help. See Parts 3 and 4 for more information about quitting successfully.

Dissecting Tobacco

Tobacco is a plant found across the world. Tobacco leaves are cultivated and then cured before conversion into products like cigarettes, cigars, snuff, and such. Like any plant, tobacco contains a variety of ingredients. Nicotine is the most addictive constituent.

Before it’s burned, tobacco contains about 4,000 chemicals, dozens of which have been demonstrated to have carcinogenic effects. (See Chapter 3 for additional, specific health effects of these and other chemicals.) Just a few of the ingredients in this toxic stew include

  • Formaldehyde (also used in embalming)
  • Acetone (used in nail polish remover and dissolving Super Glue)
  • Arsenic (need we say more?)
  • Cadmium (a poisonous metal used in batteries)
  • Lead (a highly toxic metal that causes damage to the entire body, especially the nervous system)
  • Hydrogen cyanide (used in chemical warfare, it blocks the body’s ability to use oxygen)
  • Radioactive elements (which over time can deposit in the lungs)

Warning No matter how you ingest tobacco, these chemicals come along for the ride. Don’t be fooled by promises of “safety” because the tobacco is consumed orally or not inhaled as is generally the case with cigar or pipe smoking.

Different tobacco delivery systems (for example, cigarettes, snuff, pipes, and so on) have different combinations of these and other toxic chemicals. However, in a nutshell, burning makes everything even worse, and that’s what happens when you smoke cigarettes.

Delivering Tobacco to the Body

Humans have shown considerable creativity when figuring out ways to ingest tobacco. Choices abound. In this section, we review some of the most common methods of tobacco consumption. New strategies come out all the time. Various tobacco delivery systems have different health implications (see Chapter 3 for a discussion of effects of tobacco on health).

Burning tobacco

Burning does more than heat tobacco prior to inhaling. It also changes the chemical composition and adds new toxins to the mix. Here are some of the popular ways of burning tobacco:

  • Cigarettes: About 34 million adults in the United States smoke cigarettes, which represents a new low of about 14 percent of the adult population. Most cigarettes are commercially manufactured, although a few people roll their own. Manufactured cigarettes include filtered, nonfiltered, low tar, all natural, menthol, and so-called “light” versions. See Chapter 3 for information about the health risks associated with various types of cigarettes.
  • Cigars and cigarillos: These products come in a variety of sizes. Cigars and cigarillos are wrapped in either leaf tobacco or another material that contains tobacco, which contrasts with cigarettes (which are wrapped in paper). Cigarillos differ from cigars in that the former are generally smaller and thinner than cigars. Fewer than 10 million adults in the United States smoke cigars or cigarillos. Alarmingly, cigars may be becoming more popular with adolescents because they can be sold individually and now have desirable flavorings available.
  • Pipes: Pipe smokers generally place loose tobacco in a bowl with an attached stem for inhaling the smoke produced by burning the tobacco. Although pipes are considered a symbol of affluence and sophistication in some circles, tobacco smoke from pipes is also toxic. Pipe tobacco flavors appeal to teens and young adults. Who wouldn’t want to try Grandpa’s, Cherry Smash, Cupcake, Vanilla Cream, or Log Cabin pipe tobacco? However, very few people (about 1 percent in the United States) smoke pipes frequently.
  • Waterpipe tobacco (similar products include hookah, bong, shisha, maassel, and so on): Waterpipes are used as a way of filtering and/or cooling burning tobacco by running the smoke through water prior to inhaling. Well under 1 percent of American adults smoke tobacco with some type of water pipe. Of note, hookah lounges are popular with adolescents and young adults. These lounges are often seen as particularly enticing due to their use of flavored tobaccos.

Heating tobacco without burning

Touted by merchants of tobacco as far safer than burning tobacco, some devices vaporize tobacco by heating it without actually burning it. Also known as heated tobacco products (HTPs) or heat not burn (HNB), proponents of this delivery method claim that the subjective experience closely resembles that derived from smoking cigarettes.

Technical stuff HTPs contain nicotine (which is highly addictive), additives, and flavors. They are not considered e-cigarettes because they heat tobacco whereas e-cigarettes heat liquid nicotine. See Chapter 3 for a discussion about the relative safety (or lack thereof) of heated tobacco products.

HTPs were around in the 1980s but failed to catch on. They were reintroduced around 2013 and have been heavily marketed by major tobacco companies since then. In 2016, sales totaled about $2.1 billion and are expected to reach $18 billion by 2021. HTPs are far more profitable than traditional cigarettes.

Technical stuff Facing a decline in cigarette sales, it’s no wonder that the largest tobacco company in the world sought an alternative, profitable product. They developed a type of HTP that their marketing team branded as an IQOS device. Urban legend has it that IQOS cleverly stands for “I Quit Ordinary Smoking.” The manufacturer of the IQOS denies this suggestion and contends that IQOS is meaningless.

Ingesting tobacco without burning or heating

Smokeless tobacco can be sucked, chewed, sniffed through the nostrils, or dissolved in the mouth. Smokeless tobacco usage pales in comparison to cigarettes, but it’s significant and it has been increasing. Smokeless tobacco is fairly popular among American males, of whom, about 7 percent indulge in the practice (which compares to only about 0.5 percent of American women).

Around a million American high school students and a quarter million middle school students report current use of smokeless tobacco. Manufacturers have been incorporating kid-friendly flavorings to many of these products. Here are the most common forms of smokeless tobacco:

  • Chewing tobacco: This product comes in the form of loose leaves, leaves pressed into a plug form, or leaves twisted together like a rope. Frequent spitting is required, thereby limiting where you can consume it. On the other hand, there are those who don’t seem to care where or when they spit. Chewing tobacco comes in a variety of teen-friendly flavors such as berry blend, citrus blend, cinnamon, peach blend, wintergreen, apple blend, and grape.
  • Snuff: Snuff can be moist or dry tobacco and comes finely ground. Moist snuff is placed in the mouth on the gums and requires spitting. Dry snuff is either put in the mouth or inhaled through the nose. Snuff has enjoyed increased popularity around the world as more locations have been designated as nonsmoking areas.
  • Snus: This product originated in Sweden. It’s advertised as safer than other forms of smokeless tobacco because the manufacturing process appears to involve lower toxic levels of chemicals in the curing process. The tobacco comes in a teabag-like container, which is held in the mouth and easily disposed of. In fact, the U.S. Food and Drug Administration (FDA) has recently allowed a Swedish tobacco company to advertise snus as safer than smoking regular tobacco cigarettes.
  • Dissolvable tobacco: This product is highly desirable to kids because it looks like candy or mints and often comes in interesting flavors. The tobacco is sometimes made into lozenges or a toothpick-like stick or thin sheets that look like dissolvable breath strips. No spitting required.

Tip To spit or not to spit? To sniff or not to sniff? Those are the questions. Dipping, chewing, snuffing, or snussing. The language of smokeless tobacco can be confusing. One reason is that different countries have different terminology for similar products. For example, snus is Swedish for a type of snuff. But the bottom line is that, however you ingest, it’s all smokeless tobacco. The choice is yours.

Remember The best choice of all is to quit consuming all forms of tobacco. See Chapter 3 for information about the health risks of various types of tobacco, including the smokeless variety.