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TWO. Diagnosis

What is addiction ?

The American Society of Addiction Medicine (ASAM) defines addiction as follows:

"Addiction is a disease characterized by continuous or periodic impaired control over the use of drugs or alcohol, preoccupation with drugs or alcohol, continued use of these substances despite adverse consequences related to their use, and distortions in thinking, most notably denial."

This definition of addiction as a disease means that it has a fairly predictable course and a constellation of signs and symptoms, associated with a relatively defined pathophysiology and a scientifically validated treatment. With respect to the course of the disease, addicts typically begin by experimentation, evolve into regular but controlled use, and ultimately find themselves in periodic episodes of out of control use that causes impairment in various areas of their lives, either physically or socially. Despite these negative consequences, they continue to use.

Preoccupation with obtaining and using tobacco refers to the fact that the addictive substance plays a central part in their inner and/or outer lives, whether or not they are actively using it. Thus, maintaining abstinence is only one element in one's treatment, as the major struggle continues. Distortion in thinking includes, but is not limited to, denial. Also included are the litany of excuses for continued use, the blaming of others, particularly family members and caregivers, for one's failure to maintain abstinence, and the frequently cited identification with some other emotional problem that really needs to be addressed rather than the drug itself. The negative consequences play little if any role in modifying the continued use, which is the final aspect of addiction. From the ASAM's perspective, addiction and dependence can be used interchangeably.

Addictive behaviors may include gambling, sex, drugs, and all of the variations on those themes, which recently include the use of the Internet and involvement with pornography. From that simple definition, it appears that no biological or pathophysiological process must be invoked. The addiction may result from the involvement or the pursuit of an activity rather than on what effect the pursuit of the activity may have on the brain. How can gambling or the Internet have the same effects on the brain as nicotine or alcohol? There is no receptor specific for gambling or the Internet like there is for nicotine or alcohol. Somehow the behavior and the pursuit of an activity take on a life of their own, to the exclusion of all other activities.

Why has there been so much controversy regarding cigarette smoking as being addictive?

Obviously, from the perspective of tobacco companies, the financial implications regarding smoking's addictive potential were enormous. Addiction conjures up a set of images that is at best negative, at worst grossly disturbing. To associate tobacco use with heroin or cocaine addiction is neither a good marketing ploy nor generally an accurate depiction of a smoker. Smokers hold jobs, obey the law, and have normal relationships. A lesser term, such as a bad habit seems more appropriate and easier to swallow. After all, we all have bad habits, but a chronic smoker is hardly a person associated with the seedier elements of society portrayed on Miami Vice. A bad habit is a behavior that is acquired by frequent repetition. Although not easily broken, with a conscious effort it can be broken without withdrawal symptoms and without adverse consequences. Smoking, on the surface, seems more like this than an addiction. With increasing scientific information and greater scrutiny of tobacco companies' research into the issue and their attempt to prevent access to that research, the issue became highly politicized, eventually leading to the enormous class action lawsuits and government fines.

Joseph's comment:

Through the past couple of years, I started to feel my self-esteem was being affected by the public controversy around smoking. I tried hiding my smoking and covering my tobacco breath. I felt non- smokers looked down on me (in many respects, I agreed with them). I wasn't a bad person but an addicted person needing help.

Lisa's comment:

I attended a smoking cessation program in the early 1980s. The leader read through a virtual tirade against smokers that made the group feel like failures, people who just would not cooperate, people who simply were too lazy to perform their duty to quit smoking, and so on and so forth. The group '"performed" so poorly that eventually the co-leader of the group began smoking again. Then the whole program fell apart. I was afraid to attempt another smoking cessation program for many years after that for fear of failing again.

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