The tendency to see addiction in everything from smoking to shopping is a morbid social symptom, argues Dr Michael Fitzpatrick
'Most smokers do not continue to smoke out of choice, but because they are addicted to nicotine.' This statement appeared in the latest edition of Smoking and Health, the report by the Royal College of Physicians (RCP) that launched the public campaign against smoking in the early 1960s. Whereas earlier editions had characterised smoking as a bad habit, the February 2000 version, bluntly titled Nicotine Addiction in Britain, claims that smokers are in the grip of a chemical dependency. The turnaround reflects a significant shift in the war against tobacco, and a confirmation of the current status of the concept of addiction.
According to the RCP report, its recognition of the addictive character of nicotine was a result of new researches in psychopharmacology, involving biochemical and behavioural studies in animals and humans. It seems probable that a greater influence was the growing popularity of notions of addiction in society more generally. The report conducted a detailed comparison of nicotine with heroin, cocaine, alcohol and caffeine, and concluded that nicotine was a 'highly addictive drug' - by some criteria more so than some of these notorious drugs of abuse. Though this comparison was designed to reinforce the pernicious character of nicotine, it also implicitly undermined the wider concept of addiction. After all, if millions of people have managed to quit smoking and overcome the demon nicotine, perhaps the grip of heroin and cocaine is not quite the overwhelming compulsion it is often made out to be.
For anti-smoking campaigners, labelling nicotine as addictive is crucial to their challenge to the tobacco industry's insistence on 'consumer sovereignty' - the freedom of the individual to choose whether or not to buy cigarettes. As the RCP put it, 'if smoking and nicotine are addictive, the argument that the individual adult consumer has the right to choose to purchase and use tobacco products, and that the tobacco industry has the right to continue to supply them, is difficult to sustain'. If the smoker is the victim of a chemical dependency, and cigarettes are delivery systems for this chemical, then the government should regulate the supply and distribution of cigarettes as it would any other dangerous drug.
But though the anti-smoking lobby plays up its offensive against the tobacco industry, its real threat is to the status of the individual and to civil liberties. If people who smoke - more than a quarter of the adult population - are defined as being in a state of drug addiction and are considered, as a result, to be incapable of making rational decisions, then the state is justified in taking ever-greater control over their behaviour.
Over the past decade a sense of heightened individual vulnerability has fostered a climate in which people are more and more inclined to attribute responsibility for their behaviour to somebody - or something - outside themselves. Thus adults attribute their difficulties in relationships to emotional traumas inflicted on them in early childhood by their parents, students blame their teachers for their poor performance in exams, and everybody seeks compensation from somebody else for their misfortunes. In this climate, the concept of addiction - the idea that a substance or activity can produce a compulsion to act that is beyond the individual's self-control - has a powerful resonance. The notion of the individual as an independent person who decides his or her destiny has given way to a more diminished interpretation of autonomy, as the pathology of addiction provides a new standard for determining behaviour.
Alcoholism provides the model of a disease defined by uncontrollable behaviour, which can readily be adapted to other activities deemed to be compulsive. The American critic of addiction Stanton Peele observes that 'there are an awful lot of things that people do that they know they shouldn't, or that they regret doing more of than they want to'. However, 'once this pattern has been defined as a disease, almost anything can be treated as a medical problem'. Whereas the struggle to medicalise alcoholism raged for more than a century, the extension of the disease model of addiction, first from alcohol to heroin and tobacco, and then to gambling, shopping and sex, has taken place over only a few years.
Though there were attempts to advance a disease theory of alcoholism from the end of the eighteenth century, the medical model made little headway against the powerful forces of religion and temperance until after the Second World War. During this period the conception of excessive drinking as a moral problem, as a vice demanding punishment, remained ascendant over the notion of alcoholism as a disease requiring treatment. It was not until the 1950s and 60s, as the influence of religion declined and that of medicine increased, that the 'disease concept of alcoholism' gradually gained acceptance. In 1977 the World Health Organisation adopted the term 'alcohol dependence syndrome', reflecting the new emphasis on 'chemical dependency' as the underlying pathology. By the 1980s, programmes of 'detoxification' and 'rehabilitation' under the control of the medical and psychiatric professions became the established forms of treating the problems of alcoholism.
The establishment of medical jurisdiction over opiate, specifically heroin, addiction was more straightforward, for a number of reasons. First, until the 1960s it was a marginal problem: according to one account, 'there were so few heroin addicts in Britain that nearly all of them were known personally to the Home Office Drugs Branch Inspectorate'. Second, most of these were 'anxious middle-aged professional people' (indeed many were doctors or nurses) who were not regarded as a threat to society. Third, heroin, a synthetic opiate first introduced (for its non-addictive qualities!) in 1895, was a prescription drug, with a 'medical' means of administration, the hypodermic syringe. Thus in 1926 the Rolleston report firmly defined heroin addiction as a disease and inaugurated the 'British system' of medical supervision. In the USA a more prohibitionist approach continued to criminalise heroin, with the effect, as in the sphere of alcohol, of encouraging illicit supply networks.
It was not until the 1970s and 80s that heroin abuse became identified as a significant social problem, now associated with an 'underclass' of alienated and marginalised youth. This resulted in some tension between the medical profession and the criminal justice system as the civil authorities insisted on tighter methods of regulation, as well as imposing harsher penalties on users and dealers. The penal and medical approaches subsequently converged in the methadone maintenance programmes of the 1990s.
The key factor in enabling the concept of addiction to extend beyond dependence on chemical substances was the emergence in the USA of the 'co-dependency' movement. The roots of this movement (the subject of a penetrating study by John Steadman Rice) lie in the 'Twelve Step' recovery programme popularised by Alcoholics Anonymous. (Founded in Ohio in 1935, AA became widely established in the USA and internationally in the postwar period.) Though groups concerned with the special problems of the spouses and families of alcoholics had long run in parallel with the mainstream AA meetings, in the 1980s there was a dramatic proliferation of such groups. They now rapidly expanded to include 'survivors' of other forms of victimisation (domestic violence, sexual abuse) and victims of other forms of addiction, such as gambling, shopping and sex. The central claim of this movement was that 'co-dependency' was a disease, an addiction, characterised by dependence on a pathological relationship with another person, a substance, or any 'processes external to the individual'.
Co-dependants are believed to experience 'a pattern of painful dependence on compulsive behaviours and on approval from others in an attempt to find safety, self-worth and identity'. As Steadman Rice observes in A Disease of One's Own, this is a concept of 'virtually limitless applicability' and it was not surprising to find it extending to cover, not only familiar bad habits, but even fads about novelties such as the internet, mobile phones and the national lottery (all of which were linked with media scare stories about new forms of addiction in the late 1990s). The inevitable result was inflated estimates of the numbers of victims of various addictions: one (US) estimate reckoned that co-dependency afflicted 'approximately 96 percent of the population'. The British advocacy group Action on Addiction claims that 'almost every one of us has either experienced some form of addiction or knows someone who has'. With typically British modesty it settles for the assertion that 'in fact, one in three adults suffers from some form of addiction'.
While co-dependency expanded the concept of addiction to cover diverse personal and social problems, there was also a surge in the popularity of biological theories of addiction. Developments in genetics (not only a 'gene for alcoholism', but also a 'promiscuity gene'), advances in the study of neurotransmitters (endorphins, serotonin, dopamine) and the speculations of evolutionary psychologists have all been recruited to explain the remarkable grip of compulsions and addictions on individuals in modern society. The crude biological determinism apparent in such attempts to establish a direct link of causality that extends from embryonic DNA, through the structure and function of the brain to the individual personality and social behaviour, reflects the profoundly fatalistic outlook that underlies the concept of addiction. If human behaviour is 'hard wired' into our genes and hormones, then the scope for individual autonomy and self-control is drastically curtailed.
Nowadays, the drug which has played a key role in the popularisation of the concept of addiction is one which was not considered addictive at all before the 1980s - tobacco. In a chapter devoted to 'the smoking habit', the second edition of the RCP report on Smoking and Health in 1971 acknowledged discussion of 'pharmacological dependence' on nicotine. Its general tone was dismissive: 'evidence that the difficulty that many smokers find in giving up the habit is due to habituation to nicotine is scanty.' The view that smoking was a habit which could be broken was confirmed by the subsequent decline in smoking. However, a hard core of smokers remained and studies of various techniques to encourage them to quit, using everything from behavioural and psychodynamic therapies to hypnotism and acupuncture, showed disappointing results. In the course of the 1980s, the recognition of nicotine addiction offered an explanation of the difficulty experienced by some in breaking the smoking habit. It also allowed the convergence of different forms of dependence in the concept of 'substance abuse'.
If smokers were addicted to nicotine, then they needed treatment. Indeed they needed 'nicotine replacement therapy', a formulation paying ironic homage to the use of hormone replacement therapy in post-menopausal women. However, it was not until 1998 that an editorial in the British Medical Journal called for 'nicotine replacement therapy for a healthier nation' - and proposed that it should be made available on prescription. This demand was issued with the full authority of a 'systematic review' claiming to demonstrate its efficacy. But patients were only followed up for 6-12 months, so whether the effect is sustained remains unknown - as does whether this approach would also be effective when extended to a wider, and inevitably less motivated, population. Nevertheless, the nicotine replacement bandwagon was on the roll that brought it to the recent endorsement of the Royal College of Physicians, having overcome its scepticism of 30 years earlier.
Whether the discussion is about tobacco or drugs, sex or shopping, the inflation of addiction is a morbid social symptom, assiduously promoted by the therapeutic entrepreneurs of the worlds of counselling and therapy and by the cults of self-help, personal growth and victim support. It encourages people to regard themselves as passive victims of external forces, of demonised 'substances' or 'toxic' relationships, even of their own biology. The widespread acceptance of this outlook is all the more remarkable if you consider the extent to which it contradicts most people's experience. As Stanton Peele writes, 'people regularly quit smoking, cut back drinking, lose weight, improve their health, create healthy love relationships, raise strong and happy children and contribute to communities and combat wrong - all without expert intervention'.
Reproduced from LM issue 129, April 2000