Habitually smoking a certain number of cigarettes is a condition referred to by different terms, which do not have the same meaning: tobacco dependence, nicotine dependence, or simply being a “smoker” or a “heavy smoker.” Tobacco smoking, through the nicotine it contains and which is inhaled in the smoke, is a behavior that can induce dependence. Dependence simply means remaining tied to the repeated, cyclical performance of that behavior, which becomes an important and frequent action and serves as the starting point for a whole series of circumstances: smoking to start the day, to end it before going to sleep, to calm down at night and go back to bed, to think more quickly, to quiet one’s thoughts, to control anxiety, to give oneself confidence, to get through an interview, to vent, and so on. When the reasons become “a thousand,” this essentially means that the brain identifies smoking—that is, getting some nicotine—as a first step before being able to proceed with any activity. Some of these activities are in fact affected by a “hit” of nicotine, especially when it has been a long time since the person last smoked (for example, in the morning after a night’s sleep), whereas in other cases the difference is presumably negligible. Nevertheless, the brain still signals that a cigarette “fits,” “is needed,” or “must be smoked.”
Smoking does not necessarily mean being dependent. Habitual smoking means that there is a certain probability of dependence, especially in “heavy” smokers. However, diagnosing dependence requires a contradiction between the person’s belief that smoking is harmful and undesirable, together with the intention to eliminate or reduce it, and the inability to achieve this despite various attempts. In other words, as with all addictions, being dependent means no longer wanting something while still being unable to stop wanting it.
A typical “short-circuit” thought that pits intention against desire occurs when a dependent smoker thinks that they will stop smoking “after I smoke the last one.” Another sign of a conflict between the intention to quit and the inability to do so is when the person begins to think that they cannot smoke less or less often, but must stop smoking altogether. This is a sign that controlled use of the substance is no longer possible. If the substance is available, consumption will return to its previous level; the alternative, therefore, is for it not to be available at all. The problem is that this can only be achieved for periods of time, or for a few days, and therefore does not reflect the actual capacity of the dependent person.
Dependence is not withdrawal
The smoker is not tied to smoking simply because they feel unwell when they stop. This is a complication in breaking away from smoking, but it is not even a necessary stage in the treatment of nicotine dependence.
Simply put, when people realize that they cannot smoke less, but that the only controlled level of smoking is absolute zero, they try to quit. At that point, they have to deal with withdrawal, which usually discourages them or at least makes detachment from smoking more difficult.
In any case, even when a person manages to break away from smoking, the underlying nicotine dependence remains unchanged and can lead to relapse.
The term most commonly associated with the idea of a smoker receiving treatment for dependence is “smoking cessation.” The concern, however, should not be limited to this, which is often only a temporary achievement, but should focus on whether there is a way to ensure long-term control.
Quitting smoking is always beneficial to general health, but it is not, by itself, a way of curing nicotine dependence. Ultimately, if relapses erase the apparent results, it is clear that “quitting” is something a dependent smoker may manage to do dozens of times, but it is merely an interval in a long history of nicotine dependence.
Two different diagnostic and therapeutic pathways must therefore be distinguished:
a) The non-dependent smoker
The non-dependent smoker may wish to address their chronic nicotine exposure and decide either to quit or to reduce smoking.
There are treatments that can facilitate breaking away from this behavior when it is understood as a habit or vice. If the habit also contained an element of self-medication for certain conditions, such as anxiety or depression, available treatments may replace nicotine in a healthier way for achieving similar effects, for example through antidepressant or anti-anxiety treatments.
The goal of this treatment is smoking abstinence, whether or not it is complicated by more significant psychological symptoms.
b) The dependent smoker
The dependent smoker may want to change the course of their dependence, with two possible outcomes: complete or partial reduction in consumption.
Complete abstinence may be achieved, as desired, or the person may remain an irregular smoker or smoke substantially smaller amounts without succeeding in stopping completely.
This occurs because the severity of dependence varies, and especially during the first few months, results do not necessarily have to be complete in order to show that treatment is working.
Moreover, treatments for dependence make the person freer to follow their own intentions, and those intentions are not necessarily directed toward abstinence, especially in non-dependent smokers.
Many people who have achieved “miraculous” results through a wide variety of techniques are simply between two relapses, or are not dependent at all. They were therefore able to stop because nothing had compromised their ability to control their behavior once they decided not to smoke anymore.
A particular category consists of smokers who are already receiving psychiatric treatment for an unrelated reason. It is known that some treatments, such as antipsychotic treatment, are associated with increased tobacco smoking. At times, smoking can also interfere with the treatments themselves, but it is nevertheless interpreted as an automatic attempt to compensate for certain side effects of those treatments.
These people may benefit from an adjustment of their treatment or from switching to medications that are less likely to induce reliance on “compensatory” substances.
Appendix: DSM-IV diagnostic criteria
For a diagnosis of nicotine dependence, at least three of the following criteria must be present over a period of 12 months:
Development of tolerance.
Withdrawal symptoms.
The substance is taken in larger amounts or for a longer period than originally intended.
Persistent desire or unsuccessful attempts to reduce or control substance use.
A great deal of time is spent obtaining the substance, using it, or recovering from its effects.
Substance abuse causes the person to give up or reduce social, occupational, or recreational activities.
Continued use of the substance despite recognition that it is causing psychological or physical harm.
ICD-10
At least three of the following criteria must be present, and they must have occurred together for at least one month:
A strong or compulsive desire to consume tobacco.
Reduced ability to control tobacco use; unsuccessful attempts or a persistent desire to reduce or control its use.
A physical withdrawal syndrome when the amount of tobacco is reduced or consumption is stopped.
Development of tolerance.
Increasing priority given to tobacco use: loss of interest in other activities, and a great deal of time spent obtaining the substance, using it, and recovering from its effects.
Continued use despite clear evidence of harmful consequences.
As can be seen, both sets of criteria have the limitation of confusing habitual smoking—for example, withdrawal, tolerance, and physical consequences—with dependence, which is better represented by social impairment, excessive use, and unsuccessful attempts to reduce consumption, even in the absence of tolerance or withdrawal.
In the DSM criteria, the requirement that the condition persist for at least one year provides greater specificity.