Gary Bolden calls his decades-long addiction a "horrible nightmare."
"I had to have it every time I sat down and watched TV, anytime I went to the bathroom, anytime I was nervous. I had to have it. The cravings were so bad," Mr. Bolden said.
It's not alcohol, heroin, or cocaine Mr. Bolden, 47, is referring to. It's nicotine.
Nonsmokers may scoff at the notion that a cigarette can be so powerfully addictive, and even many smokers will deny nicotine's addictive power. But counselors and scientists who study addiction marvel at the iron grip the drug has on many of its users.
"I have had numerous clients in recovery for substance abuse. They've quit the illegal drugs, but can't quit smoking," said Kathy Gilley, a Toledo respiratory therapist and addiction counselor.
Dr. Richard Hurt knows the power of nicotine firsthand. He's now director of the Nicotine Dependence Center at the Mayo Clinic in Rochester, Minn., but as a young physician he was a heavy smoker.
"One test of addiction we use is how long is the time until the first cigarette in the morning, and if it's less than 30 minutes, that's considered [a sign of addiction]," he said. "Well, my routine in the morning was I'd wake up, wheel my legs over the bed, and I'd be smoking before my feet hit the floor. The only place I never smoked was in the shower."
Dr. Hurt said the reason nicotine is so addictive is the way it's delivered. He said smoking a cigarette is the most effective drug delivery system ever developed, with nicotine reaching a smoker's brain within five heart beats after inhalation. Smoking is even more effective than injecting nicotine intravenously, he said.
"If you could inhale alcohol it would be just as addicting," he said. "It's all in the delivery system."
Only a small fraction of those who drink become alcoholics, but because smoking delivers nicotine in such an efficient way, "the vast majority of regular smokers are addicted," Dr. Hurt said.
Dr. Hurt has since managed to quit smoking - which statistically speaking is quite an achievement. Only two percent of smokers who try quitting cold turkey successfully quit, and the average quit rate for smokers who use counseling, nicotine patches, or other therapies averages from 20 to 40 percent. Most smokers need repeated attempts before they're able to quit, he said.
Dr. Hurt said most nonsmokers have no idea just how powerful nicotine can be, which often causes hurt feelings between smokers and nonsmokers.
"Nicotine addiction is a biological phenomenon. This is not somebody's weak will," he said. "It has nothing to do with intelligence, some of the smartest people on Earth are smokers."
What Dr. Hurt didn't know as a young physician, but knows now is that nicotine physically changes the brains of smokers. Everyone's brain, even nonsmokers, has nicotine receptors. But after steady exposure to nicotine in cigarette smoke, the brain begins to change by increasing the number of nicotine receptors. That's one reason it can be so difficult to quit: Those extra receptors demand to be satisfied, placing enormous pressure and cravings on the smoker.
"Once you bathe the brain cells with these very high concentrations of nicotine, the receptors in the brain change. You end up with more of them, then it's a matter of feeding the little critters," Dr. Hurt said.
Dr. Neal Benowitz, leader of the Tobacco Control Program at the University of California, San Francisco, said addiction is either amplified or weakened by genetics. Some people are more prone to become addicted to nicotine, he said, with studies of identical twins bearing this out.
But what affects all smokers beside just the physical addiction are the cues that go along with smoking: Having a drink while smoking, having a cigarette after eating, smoking and driving.
"These situations are paired thousands of times with smoking and after awhile it becomes very strong," Dr. Benowitz said.
Dr. Hurt said when smokers who are trying to quit are presented with cues like this, it can trigger cravings months, even years, later.
"Often, they'll go to a party and say, 'I'll just have one,'" Dr. Hurt said. "Then the brain says, 'Whoa, we've been missing you a lot, let's have another one.'"
That's why he reminds smokers and former smokers never to underestimate nicotine.
"Patients must understand they've been biologically altered," he said. "It's not that they're a bad person. Their brains have changed, and they've been changed forever."
Dr. Hurt said just one relapse can almost instantly re-activate the plentiful, yet dormant, nicotine receptors in the brain.
Ms. Gilley has seen examples of this. One of her patients was a school superintendent who once smoked but had quit 17 years ago. Out for a drink with co-workers, she mentioned she used to smoke and they didn't believe her. They asked her to prove it so she had one cigarette.
"On the way home, she bought a pack. She smoked again for six more years," Ms. Gilley said.
Seeing and hearing stories like that prompted Ms. Gilley to switch from a career as respiratory therapist to addiction counselor.
"I was watching my patients die for 35 years and it was driving me crazy," she said.
Today, she tries to get smokers to quit before they've already passed the point of no return - lung cancer or other deadly diseases. She admits it's a challenge.
"I work with people on oxygen," she said. "And those are the people who've cut back from four packs to two packs a day. These are drug addicts. They hate hearing that, but that's what they are."
And many of them start young.
I have one young man who started smoking at the age of 4," she said. "He stole his father's lit cigarettes out of an ash tray, and he's smoked a pack a day since the fourth grade."
Dr. Benowitz said cigarette companies have long known that more than 80 percent of all smokers start before the age of 18. He and others point to once-secret tobacco industry documents that have surfaced in lawsuits against the companies over the last decade. Some records speak of young teen-agers as "tomorrow's potential regular smokers."
Dr. Benowitz said mixing nicotine addiction and teens is dangerous.
"Teen-agers under-estimate the addictiveness of nicotine," he said. "Kids today are well-educated about the risks of smoking, and if you ask them what they intend to do they say, 'Well, I just want to smoke with my friends, but I can quit.' But if you interview those same kids six years later, most are smoking much more."
Dr. Hurt said tobacco companies have long known how powerful nicotine is, and he also pointed to the once-secret tobacco industry documents. One from the 1960s notes that: "we can't defend smoking as a free choice if the person is addicted." Others outline how company scientists had discovered that by adding ammonia to tobacco it would increase the rate at which nicotine is absorbed by the brain, thus making cigarettes more addictive.
Dr. Hurt, as well as Dr. Benowitz and Ms. Gilley, said though nicotine is difficult to kick once addicted, it can be done. Repeated attempts are common, and smokers shouldn't get discouraged.
Just ask Mr. Bolden. The Toledo man, after seeking help from Ms. Gilley, hasn't smoked a cigarette in almost two years. He said if he can do it, anyone can. He smoked three packs a day and couldn't walk with his grandchildren because he'd get out of breath.
"Now I can walk the whole [Toledo] Zoo with my grandkids without stopping," he said. "As a matter of fact, the kids were sitting down tired and I wanted to walk some more. I feel like a young man again. I got another chance."
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