Last month, the U.S. Food and Drug Administration announced its intention to lower the nicotine content of cigarettes to, ideally, “minimally or nonaddictive” levels. Public health advocates celebrated the decision; on the other hand, Big Tobacco investors began dumping shares at the prospect of supplying an ever-more-elastic demand.
Cigarette critics and capitalists alike belong to what Richard DeGrandpre calls the “cult of pharmacology,” a system of belief that dominates American drug discourse. Rooted in modernist faith in understanding the world through scientific approach, by the early twentieth century many considered drug experience to be a straightforward process of brain and body chemistry, without regard for concepts we might recognize today as set and setting. Historically contingent forces divide drugs into “angel” and “demon” categories, but their effects are similarly reduced to biological mechanism: “‘soul’ was reinterpreted as ‘mind,’ and ‘spirit’ was reinterpreted as ‘biochemistry.’”
But cults are given to blind faith, so it is worth considering the extent to which substances are to blame for problem use.
When it comes to tobacco, FDA commissioner Dr. Scott Gottileb is confident in a scientific capacity to manage addiction: “The science of nicotine regulation, and understanding what the addictive level is, is well established,” he said. “There is a threshold level below which cigarettes probably wouldn’t be addictive.” However, chemistry alone does not an addict make. As I documented in Part I of this series, cigarette and nicotine cravings are triggered circumstantially by situations smokers associate with their tobacco use. Furthermore, DeGrandpre noted that while tobacco companies have for decades calibrated nicotine for optimum satisfaction, by the end of the twentieth century almost half of self-identified smokers were able to quit for a year or more. Studies also suggest other components of cigarettes affect withdrawal symptoms, independent of nicotine – a key stage in most addiction models.
Still, there is no doubt that nicotine plays an integral role in cigarette addiction. Inhaling it in any form releases pleasurable dopamine into the brain, so targeting that mechanism is a surefire way to slow down reward circuits that reinforce smoking. But we should remember that cigarette addiction is a more holistic process than nicotine dependence.
Is the cult of pharmacology on firmer ground with “harder” drugs? Tobacco is hardly cocaine, as a variety of animals have eagerly surmised in decades of research on drug self-administration. But DeGrandpre reminds us that even monkeys who repeatedly and often fatally mainline the drug in lab settings do not necessarily imply it is inherently addictive: experimental conditions often provide subjects with unlimited access to the stimulant and few distractions from it. The World Health Organization conducted the largest-ever human study on cocaine use across nineteen countries in 1992-1994. “One of the main conclusions of the study is that there is no ‘average cocaine user,’” the study found. There is an enormous variety in the types of people who use cocaine, the amount of drug used, the frequency of use, the duration and intensity of use, the reasons for using cocaine and any associated problems users experience.”
The ongoing rise in contemporary opioid use can further illustrate that a minority – a significant minority, but a minority nonetheless – of people who use supposedly highly addictive drugs ever become dependent or develop use disorders. Up to around 34% of opioid users fit diagnostic criteria; though, considering one study found physicians prescribed opioids in more than half of 1.14 million nonsurgical hospital visits from 2009 to 2010, that number is still considerable.
The cult of pharmacology has shepherded its flock to an evidently false idol, but its theology is complex enough to resist crises of faith. The reigning addiction paradigm is defined by the U.S. National Institute on Drug Abuse as a “chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a disease because drugs change the brain; they change its structure and how it works.” Not all addicts relapse, nor do all addictions produce harmful consequences, nor do drugs always permanently change the brain, but enough patients and research subjects fit the mold to buoy its appeal among experts and ordinary people alike.
Nancy Campbell famously characterized the brain disease theory as a “unifying framework for a problem-based field in conceptual disarray.” In other words, the model got researchers on the same page and, through popular imagery like “hijacking” brain functions, invited everyone to understand the concept.
A criticism of this paradigm is that it reduces people with drug problems to slaves subject to chemical overseers, with two powerful implications. One is dismissing the process of quitting or moderating problem use, either through established recovery institutions or independently (as the vast majority of people who develop use disorders do). Another is implicit support for punitive, supply-side approaches to drug use, which have yet to generate a net social good.
I’m reminded of another insight by Campbell, one that cautions historians against “wholesale adoption” of historical, or for that matter contemporary metaphors: they bind our “analysis to [their] historical moment in somewhat limiting ways.” The cult of pharmacology is styled as thoroughly modern, and, with the dressing of neuroscience and to a lesser extent social science, it is – particularly vis-à-vis the decidedly anti-modern, irrational characteristics of addiction, but it is also the latest paradigm to take hold in a long intellectual history of addiction studies.
FDA’s effort to reduce nicotine content may amount to an offering by the pharmacologic faithful, even if Big Tobacco fails to resist these changes, but the likely reduction in aggregate craving may also tamp down the influence of non-nicotine influences on smoking. Stay tuned for Points commentary on this developing initiative.