Written by Adam O. Goldstein, MD, MPH
Like many before him, President Obama has struggled to quit smoking for many years. Reports say he has “quit” now for good, and we wish him well now and in the future, but success in any addiction is rarely black and white. Rather, it is the shades of gray where most of us reside in our addictions, whether it is cigarettes, alcohol, gambling, eating, or even ‘Angry Birds’.
When we say quitting, we must also say relapse and relapse prevention. We talk about success as much more nuanced and in many colors. With tobacco addictions, success for many can be a day, a week or a month without a cigarette. Success can be a quit attempt, a decision to cut back, a decision to eliminate smoke exposure to others in the home or car.
We avoid terms like failure. If President Obama had another cigarette, he has not failed. Rather, that is the expected course, as addictions for most people are chronic illnesses, diseases that are often controlled but sometimes never cured.
What makes cigarettes so addictive and difficult to quit? When someone smokes a cigarette, it’s not the cigarette they’re hooked on, but the chemical within- Nicotine. Nicotine rapidly (within seconds) enters the brain and triggers the release of a chemical messenger (aka neurotransmitter) called dopamine. Dopamine then stimulates the “Reward” center of the brain, called the nucleus accumbens which is responsible for feelings of pleasure and happiness. This stimulation of the nucleus accumbens is what makes nicotine so addicting. Also, psychological cues everywhere, such as seeing another smoker, seeing a movie where someone is smoking, or just being in an environment that you associate with smoking, such as when alcohol is served, triggers intense cravings and interactions with the dopamine system.
Here is where it gets really tricky. The more the brain of a smoker is stimulated by dopamine (via nicotine), the less it typically responds to other rewards. For example, a person who smokes a few cigarettes a day, or has smoked for a few years may find activities such as hiking or biking less rewarding than they did before they started smoking. In turn, smoking a cigarette becomes all the more satisfying. The more you smoke, the more your brain changes, and the harder it is to quit. That is why nicotine addiction, and most addictions that have similar causal pathways, are called “brain diseases”. Over time, your brain does start to reorganize itself, but because it will never fully return to “normal,” quitting becomes a lifelong battle.
So is President Obama’s “relationship with nicotine really over?” No. It never will be. But we applaud his success in controlling if not curing this addiction, a process that can help over 40 million other Americans who face similar addiction problems.
UNC Nicotine Dependence Program