(PBN file photo)
Name: David B. Abrams, PhD
Age: 49
Position: Director of the Centers for Behavioral and Preventive Medicine
at The Miriam Hospital and professor of psychiatry and human behavior at Brown
Medical School.
Background: Abrams has spent more than 25 years studying smoking addiction
and other addictive behaviors. Since 1978, he has been conducting research at
The Miriam Hospital, which was the first hospital in New England to start a behavioral
medicine program. Abrams was the program’s first research director and became
director of the centers in 1988. He is a member of the Board of Scientific Advisors
for the National Cancer Institute
Education: PhD in clinical psychology from Rutgers University, 1981.
Family: Married; three children
Residence: Providence
PBN: Tell me a little about The Miriam’s smoking-cessation program.
ABRAMS: We see ourselves as the specialists to treat the toughest smokers
who have tried everything else and have not succeeded. So it’s a very intensive
program that includes medical evaluation as well as psychological evaluation.
From a treatment point of view, we believe that smoking is a serious addiction,
on the same level as heroin, cocaine and alcoholism. We have a clinic that has
the capacity to treat the most addicted smokers and we also have a range of treatments
that are less intense that reach out to the community. A lot of what we offer
is tied to evaluating combined behavioral and pharmacological therapy. We offer
the next generation of experimental drugs that are being developed to try to help
smokers quit. So we do a lot of clinical trials with pharmaceutical companies
and we receive funding from the National Cancer Institute. Often people can get
into fairly intense programs at no cost or minimal cost because it’s tied to research.
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I’ve heard the theory that smokers are either addicted to the nicotine or the physical habit of smoking. Is that true?
That’s exactly our philosophy, that it’s a combined physical addiction and
learned addiction. It depends on why they smoke. The addiction could be psychological
as well as physiological. If you’re smoking because it helps you manage your moods,
then you’re more addicted because you don’t have any other way to control your
anxiety, frustration or boredom. An example would be blue-collar workers who may
have very monotonous jobs may literally not be able to get through the day without
cigarettes because it’s so boring and repetitive. Nicotine is known to be a stimulant
that keeps your attention and kind of jacks up your reflexes and speed of information
processing. So you could be addicted to those parts of nicotine if you’re in a
certain kind of job. Like people in high-stress jobs tend to smoke more. In fact
the military is very concerned that if they ban smoking in high-performance aircraft
pilots or tank operators, [they don’t smoke when they’re operating the equipment,
but many do before and afterwards] it could decrease their performance. It can
be a very powerful, positive drug, if you get rid of the fact that it causes cancer
and heart disease.
Is nicotine itself bad for you?
Because nicotine in and of itself is not a very dangerous drug, we now have
a very interesting dilemma. You’ve got nicotine in a pure form with the patch
or the gum. In fact, I read that people at Duke University just invented a nicotine
liquid, so you’ll be able to drink soda to get your nicotine. They’re starting
to test market it. Is that now just like caffeine? It’s interesting: We’ve got
the good guys, like the food industry and drug companies, saying ‘We could give
you pure, healthy nicotine for fun.’ And you’ve got the bad guys, the tobacco
companies, saying, ‘But the biggest hit still comes from sucking on a cigarette.’
Right now the total market for permission to deliver nicotine to the human brain
is like $60 billion. All but about half a billion of it is currently controlled
by tobacco. But I’ve heard a health economist say that maybe 10 years from now
it will be switched. Maybe $40 billion will go to the pharmaceutical industry
for so-called “good, healthy nicotine.”
Are there any recent breakthroughs in smoking-cessation research?
In the last five years we’ve come to understand what we call the brain-reward
circuitry, which is a set of centers deep in the brain that control the four basic
human drives that are genetically hard-wired into our brains. What we now understand
is that these drugs like Zyban (a smoking-cessation medicine sold by Glaxo-SmithKline)
sort of hijack that natural reward circuit. The way I put it is, once your brain
has tasted the best chocolate cake you’ve ever had, it’s actually programmed never
to forget it, and to seek it again. So once a person learns to suck on a cigarette
to trigger that same sort of reward, it becomes programmed. Your brain says ‘I
want to keep seeking that until I get it again.’ You’re literally driven by a
primitive brain function that was never designed to be switched off. So addiction
is not just the chemical in the brain, but it’s the memory of the chemical that
can reverberate for many years afterward. The research being done with brain imaging
and brain chemistry has taught us so much about how that works and it is leading
to designer, breakthrough drugs. The next generation of drugs that are being tested
now that might work a whole lot better than just nicotine-replacement therapy
to help people get off it. But the best way is stopping kids from exposing their
brains.
What are some of the ways you can do that?
Frankly we don’t have really effective prevention programs and some of that
is because the tobacco industry is ahead of us. It’s a losing battle. They’ve
put $8 billion into advertising this year, whereas even before the massive tobacco
settlement, it was only $6 billion. The counter-advertising doesn’t come on often
enough, and those ads are overwhelmed by the tobacco ads (elsewhere, not on TV)
that produce a positive association with tobacco and smoking. They wouldn’t have
settled if they didn’t have something in their pockets to counteract everything.
What they’ve been doing very effectively is going into bars and nightclubs and
offering all sorts of inducements to bar owners, like giving out ashtrays and
things. So they’re doing much more targeted marketing to 18-to-25 year-olds, because
they took so much heat for marketing to younger kids. But my biggest beef is that
our society is economically addicted to taxes and the benefits that governments
get from selling tobacco products that we are reluctant to do effective policy
and really shut down (the tobacco industry’s) capacity to hook the next generation.
What do you think should be done with the tobacco settlement money?
To me, all of it should be used for health-related issues and most of it should
be used for tobacco-specific prevention, treatment and policy change. I’m outraged
that we got a settlement on behalf of the victims of tobacco – that was the purpose
of the settlement money, was to repay the victims. And to use it for any other
purpose I think is immoral, unethical and just plain wrong. Rhode Island is in
the bottom three or four states in the country in terms of the percent of the
settlement that is going to prevent and treat tobacco addiction. I think that’s
pretty embarrassing.
Are there any dramatic statistics that would correlate to a reduction in smoking to improved health or reductions in health-care costs?
The one statistic I find really powerful is that if there were absolutely
no smoking, 30 percent of all cancer in the United States would disappear overnight.
In other words, about 30 percent of all cancers are caused directly by cigarettes
and would disappear, including 90 percent of lung cancer.
I take it you blame the tobacco companies for the prevalence of tobacco addiction.
The part of it that I have a problem with is the documentation that has come
out as a result of the settlement. It shows that the tobacco industry knew in
the ’60s and ’70s that they had an addictive product and that they were manipulating
the chemistry to make sure the addiction locks every smoker in. I’m going to make
a bit of a leap here, but in my mind that’s sort of the equivalent to a bunch
of chemists sitting in a factory designing a death instrument. It’s a product
whose only known use is to get people so hooked that they can’t quit on their
own, so it’s not voluntary anymore. And of course (the tobacco industry) is still
saying that it’s an adult choice, not an addiction. But we now know it’s addictive,
and they’re still sitting there designing and marketing something that just basically
kills people. To me it’s not much different than the chemists in the Second World
War in Germany who were asked by the Nazi government to invent a cheap, fast,
better way to kill people. They came up with the gas ch ambers and the rest is
history. I don’t see much of a difference, except that nicotine hooks you so you’re
now trapped like you’re in a personal little gas chamber, because you can’t switch
off that switch in your brain. The only difference is it takes 25 years to give
you lung cancer instead of 5 minutes to kill you in the gas chamber.
What about the people who say we’ve known for decades how bad smoking is and that smokers should have known better?
I don’t buy that at all, because they didn’t know the extent of the addiction.
It was hidden. The advertising so overwhelmingly focuses on the positive benefits
and the good things about tobacco and the warning labels are intentionally designed
to be very ineffective. And marketing to underage kids is still where they get
their best customers, whether they admit to it or not. When you’re hooking a 16-year-old
on this stuff for life, you’re doing it at a time where they don’t have the capacity
to completely understand. So I blame the industry for making it available when
they know that all cigarettes do is make the companies money and kill people.
