Nicotine dependence is the most common substance use disorder in the United States. Approximately 60% to 80% of current smokers fulfill classic criteria for drug dependence; e.g., they have difficulty stopping have withdrawal when they stop, are tolerant and continue despite knowledge of personal harm. Nicotine appears to have a dependence potential at least equal to that of other drugs. For example, among persons who experiment with alcohol, 10% to 15% will meet criteria for alcohol dependence at some point in their life. Among persons who experiment with cigarettes, 20% to 30% will meet criteria for nicotine dependence in their lifetime.

Among smokers, nicotine dependence should be viewed as the primary problem and health-related diseases as consequences of nicotine dependence. Psychiatrists, other mental health professionals, and physicians of other specialties are aware that nicotine dependence is harmful, but they often underestimate the magnitude of the risks that it poses to patients. For example, tobacco use is the largest and most preventable cause of mortality in the United States. Smoking causes more than 430,000 premature deaths annually among U.S. smokers alone. In addition, over 50,000 deaths per year among U.S. nonsmokers are associated with environmental tobacco smoke exposure.

Nicotine dependence is especially prevalent in alcohol/drug abusers (e.g., over 80% of alcoholics are current smokers). The notion that nicotine dependence is best left untreated during the treatment of alcohol/drug use disorders lacks empirical support. Over half of alcohol/drug abuse patients want help to stop smoking but do not receive such help. There is no scientific evidence that smoking cessation threatens sobriety. In addition, addiction psychiatrists are often unaware of the influence of smoking on the diagnosis and treatment of alcohol/drug abuse disorders. For example, symptoms of nicotine withdrawal (e.g., restlessness and insomnia) can be confused with or exacerbate alcohol withdrawal; i.e., both produce irritability, restlessness, difficulty concentrating, anxiety, depression, and insomnia. Finally, since alcohol/drug abusers are especially heavy smokers, they are especially likely to die of smoking-related diseases.

Nicotine dependence is highly treatable using pharmacological, behavioral, and/or psychosocial treatments and such treatment can substantially reduce the widespread complications of nicotine dependence. Many of the basic skills and knowledge that addiction psychiatrists possess are readily applicable to helping smokers stop.

In view of the above, the AAAP advocates and supports the development of policies and programs which promote prevention, treatment, and research activities in the area of nicotine dependence. These include, but are not limited to, the following:

1. Addiction psychiatrists should take an active role in treatment, research, prevention, and advocacy activities.

2. The prevention and treatment of nicotine dependence should receive attention comparable to other drug dependencies in the training of psychiatrists. There should be greater teaching about the nature of nicotine dependence and its treatment in medical schools, psychiatry residency training programs, and continuing professional education programs. This teaching should occur in units on alcohol/drug abuse.

3. Since prevention is crucial to reducing the prevalence of smoking and since patients with alcohol/drug problems are especially vulnerable to developing nicotine dependence, addiction psychiatrists should be actively involved in prevention activities.

4. Addiction psychiatrists should support the development of smoke-free policies in all health-care facilities including alcohol/drug abuse units.

5. Psychiatrists and the AAAP should work to change governmental policies regarding tobacco in the following ways:

Control the availability of tobacco products to young persons through the establishment of a national minimum age of 21 years for purchase of all tobacco products, prohibit the unsupervised sale of tobacco products through vending machines, and enhance enforcement of existing laws regulating the sale of tobacco products.

Eliminate subsidies and all other forms of governmental assistance which encourages the production or exportation of tobacco and tobacco products and, concomitant with this, encourage funding of transition programs for those with tobacco-related jobs.

Substantially increase state and federal taxes on tobacco products with the proceeds of such taxes invested in the prevention, treatment, and research of nicotine dependence.

Change the warning labels of tobacco products to include the high likelihood of developing dependence on nicotine.

6. Several aspects of public education should be promoted:

Early teaching in schools should inform young people about the high risk of developing nicotine dependence after experimentation with tobacco and the health hazards consequent to nicotine dependence.

Countermarketing measures, including public service announcements and anti-tobacco marketing programs, should be designed to counter the seduction of tobacco advertising imagery and to educate the public about the hazards of smoking, to discourage experimentation with smoking, and to promote smoking cessation.

7. Addiction psychiatrists should work to convince third party payors, including government-supported health insurance programs (Medicaid, Medicare, Champs), to reimburse qualified health professionals using clinically recognized methods for the treatment of nicotine dependence. Reimbursement for nicotine dependence should be included in alcohol/drug abuse benefits.

8. Although smoking is clearly recognized as the most preventable cause of early death and disability, only about one percent of the federal research budget concerns smoking and of that amount, only a small proportion is slated for research on behavioral and psychiatric aspects of nicotine dependence. Increased research efforts by government, universities, and other institutions into the causes, prevention, and treatment of nicotine dependence is long overdue. Among the many areas of research needed, the following are especially relevant to addiction psychiatry:

a) The comorbidity of nicotine dependence with other alcohol/drug abuse and psychiatric disorders.

b) The positive and negative effect of smoke-free inpatient units on the diagnosis and treatment of alcohol/drug abuse problems.

c) The advisability and time of treatment of smoking cessation in those with alcohol/drug abuse disorders.

d) Recognition of nicotine withdrawal as affecting human laboratory experiments with psychological, self report, and behavioral endpoints.

In summary, nicotine dependence takes an enormous toll on the health of our nation. The AAAP urges all of its members to work toward the goals outlined in this policy statement.

Footnote: Sections of the above policy statement were adopted from and are consistent with the policy statements on nicotine dependence of the American Psychiatric Association, the American Society of Addiction Medicine, and the American Medical Association.

Approved by AAAP Board of Directors: October 1995