I won't bother to repeat the usual statistics on how addictive cigarettes are or the fact that nicotine is one of the most addictive drugs. Cigarettes have a special place in the hearts of psychiatrists in my generation because when we first started practicing they enjoyed significantly more status in terms of public opinion than they do now. I can recall running a therapy group at a VA Medical Center where at least half of the group was smoking during the session. The cigarette smoke was so thick that the ceiling panels turned from white to bright orange over the course of a year. I asked one of the staff what kind of paint they use to make them look so good and he said: "Oh they don't paint them. They just replace them and throw the old ones away." Too bad you can't do that with lungs. As activist attorney generals took over and got more and more smoking regulations, the last bastion of smoking in hospitals was inpatient psychiatric units.
They were two schools of thought on inpatient units that pertained to smoking. The most benign was also the most paternalistic and condescending. It went something like this: "Cigarettes are all that some of our patients have. Taking them away will deprive them of their only sense of enjoyment." Really? The second was the theory that without cigarettes or access to cigarettes it was guaranteed to trigger increased anger and aggression if access to cigarettes was denied. Some of the patients in question were compulsive 2+ pack per day smokers. The politics of smoking on inpatient units was even more complex. Battle lines were naturally drawn between staff who were smokers and nonsmokers. That was complicated by what each faction wanted you to believe. For example, the nonsmokers doubted that depriving a smoker of his or her heaters would have any effect at all. People with acute mental illnesses would willingly stop smoking for days or weeks in the interest of everyone's health. The pro-smoking faction of the other hand knew what going cold turkey was like and they predicted many more incidents of uncontrolled behavior. I attended conferences where both parties produced data. The data presented was consistent with the political orientation of the researchers. The smoking cessation folks always posted data showing that people could acutely stop smoking without any major problems.
Reality always seems to produce a much different result than research. I won't post any war stories, but I will say that the reactions covered the expected range of quiet resignation to rage. The proliferation of nicotine substitutes, nicotine substitute polypharmacy, and "smoking passes" led to fewer problems. Eventually hospitals banned smoking in any area of their campus forcing patients and staff to cross the street for a cigarette. As the tide began to shift against Big Tobacco they sustained a number of setbacks. In 1998, there was a record $246 billion settlement with state attorney generals. Smoking rates began to drop and suddenly smoking in public places including bars and restaurants was the order of the day. In 2010, the Family Smoking Prevention and Tobacco Control Act was passed. This Act set standards for labeling tobacco products and also rules about flavoring cigarettes and marketing them to minors. It also established some limits in terms of what the FDA could do in their regulatory role with tobacco. At the clinical level it is known that some psychiatric populations absorb nicotine per cigarette amounts on the higher end of the typical 1-3 mg per cigarette due to more puffs per cigarette and a shorter interval between puffs. They also take a shorter time to resume smoking another cigarette. Psychiatric populations are at much higher risk for smoking and increased cardiovascular mortality (Reference 1) and nicotine exposure potentially increase the risk of exposure to other addictive drugs (Reference 2).
With all of the tightening in the area of tobacco regulation it was quite shocking to learn that these regulations not only do not apply outside the US, but in some cases where countries are trying to develop similar regulations, tobacco companies are fighting back. In a number of these countries like Australia, Uruguay, and even the United Kingdom, tobacco companies are suing against the use of graphic health warnings and restrictions on advertising. This legal action has led Bill Gates and Michael Bloomberg to set up a $4 million "anti-tobacco trade litigation" fund to assist with some of the legal costs. That is not a lot of money but the fund also seeks to set up a network of attorneys, many of whom are going to work pro bono on this issue. Tobacco companies argue that they are protecting their investments and intellectual property rights. Gates and Bloomberg argue that it is the sovereign rights of nations to pass laws that protect the health of their citizens and believe it is necessary to support countries defending these rights against tobacco companies.
My take on this is a little different. There has been a growing movement to liberalize the use of intoxicating and addicting drugs in this country. The growing legalization and commercialization of marijuana is certainly the best example. There is also more in the press about how benign hallucinogens are and how cognitive enhancement from stimulants may be a legitimate activity of students at all levels. There tends to be less debate about opiates in the midst of an epidemic of excessive accidental drug overdoses, but I think it is important to recall that the epidemic started with a call to prescribe more opiates and diagnose more Americans with chronic pain syndromes. It is one thing to talk about a person with a chronic medical illness smoking marijuana in a contained manner. It is quite another to think about how the commercialization of addictive drugs works and how a business responds to regulation when there is clear evidence that their product has adverse effects and needs tighter regulation. Elected officials also frequently get into the act and declare that tax revenues from the commercialization of addictive compounds will be a windfall for taxpayers without a careful analysis of the attendant costs.
The motivation of tobacco companies could not be clearer - use proven marketing techniques to get people into smoking, all the while knowing that it will be difficult for them to stop. The lesson here is that addictive drugs are good for business and marketing restrictions are not. I would not be shocked to find that as marijuana and (possibly) other street drugs are legalized and commercialized that they would get some of the same early regulatory leniency that cigarettes had before there was overwhelming evidence that tobacco should be avoided rather than encouraged.
George Dawson, MD, DFAPA
References:
1: Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. JAMA. 2007 Oct 17;298(15):1794-6. PubMed PMID: 17940236.
2: Kandel DB, Kandel ER. A molecular basis for nicotine as a gateway drug. N Engl J Med. 2014 Nov 20;371(21):2038-9. doi: 10.1056/NEJMc1411785. PubMed PMID: 25409384.
Supplementary 1: Image is in the public domain courtesy of the CDC and Deborah Cartagena at the CDC Public Health Image Library. Image #14541 accessed on March 20, 2015.
Supplementary 1: Image is in the public domain courtesy of the CDC and Deborah Cartagena at the CDC Public Health Image Library. Image #14541 accessed on March 20, 2015.
