A.10 TOBACCO

INTRODUCTION

In a relatively short time tobacco has become one of the most commonly used drugs in the world. Tobacco is prepared by drying and curing the leaves of Nicotiana tabacum or, less commonly, Nicotiana rustica, plants indigenous to the Western Hemisphere, and more recently grown in moderate climates around the world. The earliest documented use of tobacco occurred with American Indians, in what is now Arizona, a few centuries after the birth of Christ. Even earlier cultivation and use probably occurred in South America.12, 91

Jacques Cartier encountered the use of tobacco in Canada in 1535 and Samuel de -Champlain recorded his experience with it in 1615. A major component of the history of tobacco in Canada involves two Indian nations, the Petuns and the Attawandarons, who lived on the north shores of Lake Erie and Lake Huron (Georgian Bay). The word Petun was often used as a name for tobacco in parts of North and South America, and later in England and France. The Petun Indians produced tobacco for trade and domestic consumption. Tobacco had a sacred as well as social character for the Indians and was used in ceremonial rites, in the treatment of diseases, and to ward off evil. Smoking the tobacco pipe was associated with peace and contentment, and was part of the ceremony in any tribal business.90
The Petuns were defeated in a war with the Hurons in 12649, and in 1661 the Attawandarons suffered the same fate by the Iroquois. These once prosperous and strong nations were later dispersed by the white colonialists and finally confined to reservations. The land they farmed was deserted for over 100 years until the British Crown bought it in 1784, surveyed it, and settled it by 1800. During the 19th century the tobacco industry began to grow and large plantations flourished in the areas where tobacco was formerly grown by the Indians."

Tobacco use spread rapidly to Europe and beyond, soon after communication and trade was established with the New World, and within a few centuries tobacco became popular in most parts of the world. The rapid assimilation of tobacco smoking by societies with no previous acceptance or common experience with the intentional inhalation of smoke has few parallels, and is possibly the most dramatic 'epidemic' spread of drug use in history.12, 13, 29

The widespread use of tobacco did not occur without opposition. In 1604, not long after Sir Walter Raleigh and others popularized the smoking of tobacco in England, King James I published a now famous treatise entitled Counterblaste To Tobacco, in which he identified smoking as:

A custome lothsome to the eye, hatefull to the Nose, harmefull to the braine, dangerous to the Lungs, and in the blacke stinking fume thereof, neerest resembling the horrible Stigian smoke of the pit that is bottomelesse."

In other countries, tobacco users were threatened with imprisonment, fines, excommunication, torture, disfigurement, and, in China in 1638, beheading.12 The sale of tobacco was prohibited in many parts of the United States. The use of tobacco was opposed in many areas of Canada and prohibition was considered in the early part of this century.28

As recently as January, 1884, the New York Times issued the following warning about the spread of tobacco use:

A grown man has no possible excuse for thus imitating the small boy .... The decadence of Spain began when the Spaniards adopted cigarettes and if this pernicious practice obtains among adult Americans the ruin of the Republic is close at hand."

None of these policies or warnings seem to have had much effect in the long run.

Today about 40% of Canadians over the age of 15 smoke tobacco regularly,20, 27, 65 and Canada is now fifth in world production of flue-cured tobacco.23 Tobacco is second only to wheat in agricultural exports.23a About 95% of the crop comes from Ontario in areas where it was originally grown by the Indians." (See also Appendix B.9 Sources and Distribution of Tobacco and Appendix C Extent and Patterns of Drug Use.)

Restrictions on tobacco advertising have been implemented in parts of Canada and the United States. In 1971 an American government survey indicated that over one third of the general public favoured a complete ban on the sale of cigarettes.93

The main chemical constituent of tobacco possessing pharmacological properties is nicotine. The percentage of nicotine in tobacco varies considerably, but averages about 1.5% in cigarettes today. Even those cigarettes which are claimed to be `denicotinized' still contain substantial amounts of the drug. In addition, more than 500 other compounds, many of which have some physiological effects, have been isolated from tobacco smoke. Tarry and phenolic substances, for example, contribute significantly to the irritation of respiratory mucosa.1, 4, 87, 101, 102

Concentrated nicotine is a highly toxic poison and was once widely used in North America as a pesticide (e.g., Black Leaf 40®), but such use has decreased, partly due to nicotine's hazardous nature and the availability of less dangerous substances. Nicotine insecticides are still available at garden supply stores.

The practice of smoking tobacco is responsible for a significant proportion of the property damage and loss of life resulting from urban and forest fires. This must be included in any overall consideration of the consequences and costs to society of this drug use.

The characteristics of illicit tobacco in Canada are discussed in Appendix B.9 Sources and Distribution of Tobacco.

MEDICAL USE

Although tobacco was used in various folk remedies and medicines in the past, neither tobacco nor nicotine have any established medical or therapeutic value and are no longer used for any medical purpose. Nicotine has been important in neurophysiology as a tool for studying nerve transmission. Although the B vitamins niacin (nicotinic acid) and niacinamide (nicotinamide) can be made from nicotine, this is not the usual mode of production, and these vitamins have none of the pharmacological properties of nicotine.

ADMINISTRATION, ABSORPTION, DISTRIBUTION AND PHYSIOLOGICAL FATE

Today tobacco is mainly administered by inhalation. The amount of tobacco smoke inhaled by cigar and pipe smokers tends to be lower than that of cigarette smokers. In addition to being smoked, tobacco is also chewed and sniffed (as snuff). Nicotine is never injected, except in experimental situations.

Nicotine is readily absorbed from the entire respiratory tract, from oral and nasal mucosa, the entire gastrointestinal tract, and even from the skin. In fact, cases of severe poisoning have been reported after only skin contact with concentrated nicotine used as an insecticide. Approximately 15-35% of the nicotine in a tobacco cigarette is delivered to the smoker in the mainstream smoke.", 10° Deep lung inhalation provides the fastest and most complete absorption and is generally preferred by chronic users. Up to 90 per cent of an inhaled dose of nicotine is absorbed in the lungs, compared to 25 to 50% in smoke drawn only into the mouth.10. 07 Depending on the cigarette and various smoking conditions, a smoker may absorb several milligrams of nicotine per cigarette (typically containing about one gram of tobacco) .

In animals, nicotine or its metabolites concentrate initially in the central nervous system (CNS). After 30 minutes to one hour, nicotine concentration is higher in other organs such as liver, stomach, intestines, salivary glands and kidneys.8° Nicotine crosses the placental barrier in pregnant females and a reaction to the drug can be measured in the fetus soon after the mother begins to smoke.

Approximately 80 to 90 per cent of a given dose of nicotine is metabolized in the body, mostly in the liver but also in the kidneys and lungs. Nicotine and its major metabolites are rapidly and completely eliminated in the urine. The milk of lactating mothers contains nicotine in concentrations proportional to their rate of smoking. As much as .5 mg of nicotine can be contained in each millilitre of milk of a heavy smoker.97 Nicotine and its metabolites can be readily detected in body fluids and tissues using standard chemical techniques.26, 89

PHYSIOLOGICAL EFFECTS

Acute effects
The effects of nicotine on the body are complex and often unpredictable due to the fact that nicotine has mixed stimulant and depressant actions. Thus the ultimate effect of the drug on a specific organ or system reflects a summation of various different and often opposing simultaneous effects. Nicotine is known to mimic certain effects of the neurotransmitter acetylcholine and is considered the prototype of a pharmacological class of compounds which stimulate certain basic neural functions.41 Nicotine generally produces CNS arousal, as indicated by a flattening and speeding up of the EEG pattern, while higher doses may depress activity.32, 70 Low doses of tobacco produce increased respiration, heart rate and blood pressure, and can decrease appetite. Constriction of the small blood vessels in the skin also results.18, 18, 75 Nicotine produces increased tone and motor activity in the gastrointestinal tract, occasionally resulting in diarrhea. A state of reduced gastric motility usually follows the initial stimulation phase. Increased salivary and bronchial secretions also result from nicotine administration, although the possibility exists that the increased secretion is due in part to the irritating properties of the smoke rather than the pharmacological properties of nicotine alone. Nausea and vomiting may occur in inexperienced users.83, 97 In some cultures when tobacco was introduced, smokers intentionally inhaled as deeply and rapidly as possible, producing unconsciousness by the combined effects of hyperventilation and nicotine intoxication.'2

Nicotine is one of the most toxic drugs known and its speed of action can be comparable to that of cyanide. The onset of symptoms of severe nicotine poisoning is rapid, and death can occur within a few minutes. The initial symptoms are nausea and excessive salivation, followed by abdominal pain, vomiting and severe diarrhea. In advanced cases, headache, dizziness, disturbances of vision and hearing, as well as mental confusion occur. If treatment is not administered at this stage, general collapse may ensue, followed by terminal convulsions and death, usually resulting from respiratory arrest. The lethal single dose of pure nicotine for an adult is approximately 60 mg, although, as with other drugs, great individual differences exist. While overdose fatalities due to the acute use of tobacco are very rare, nicotine poisoning deaths have been reported following the accidental ingestion of insecticides containing nicotine, as well as after rectal infusions (enemas) of tobacco to combat intestinal parasites.97
In spite of the fact that a cigarette or cigar may contain more than the lethal nicotine dose for children, few deaths have occurred following the ingestion of tobacco. This is presumably because gastric absorption of nicotine from tobacco is relatively slow, and a significant amount initially absorbed usually triggers vomiting, which removes the remaining tobacco from the stomach. Tobacco is one of the more common causes of poisoning among children. According to the Federal Poison Control Program Statistics, toxic reactions attributed to tobacco products in Canada numbered 547 in 1969, 474 in 1970 and 478 in 1971.21• [n More than 90 per cent of these cases involved children under five years of age.

Chronic effects

While the main acute poisoning effects of tobacco can be attributed almost exclusively to nicotine action, the chronic, long-term health consequences of tobacco consumption are also a function of the tars and many other irritants which are present in tobacco and tobacco smoke. For example, nicotine itself is probably not the causal factor in cancer.58 Cigarette smoke contains a number of carcinogenic substances including phenols, acids, aldehydes, and ketones, as well as irritant gases like carbon monoxide, acetaldehyde, acrolein, and hydrogen cyanide.22, 101, 102 The clearest relation between cigarette smoking and health is that smokers have an increased overall mortality rate—an observation made in numerous studies in different parts of the world, independent of variations in diagnosis.22, 46' 77' 94

The 1969 Report of the United States Department of Health, Education, and Welfare indicated that the life expectancy of young men who smoke over two packs of cigarettes a day is reduced by a mean of eight years, while the life expectancy of those who smoke less than half a pack per day is reduced by a mean of four years." After reviewing a massive amount of evidence, the authors concluded that significant correlations exist between cigarette smoking and general mortality, cardiovascular diseases, chronic obstructive bronchopulmonary diseases, cancer, several non-cancerous oral diseases, and reduction in birth weight of infants born to mothers who smoke during pregnancy. The 1972 report" added gastrointestinal disorders and allergies to this list. In addition, a public health problem is created by air pollution caused by tobacco smoke. The level of carbon monoxide in a smoke-filled room may exceed the legal limits for maximum air pollution allowed in some localities. Such conditions can adversely affect both smokers and non-smokers, in addition to often being decidedly unpleasant to the nonusers present.

According to the 1971 report of the Royal College of Physicians of London, cigarette smokers are about twice as likely to die in middle age as non-smokers.77 Those who quit smoking run a steadily diminishing risk of dying from its effects. The diseases to which smokers are most vulnerable are not only often fatal, but can otherwise cause illness and disability and decrease the smoker's chances of enjoying a healthy retirement.

The 1969 Canadian Report of the Standing Committee on Health, Welfare and Social Affairs on Tobacco and Cigarette Smoking accepted the findings of studies which showed that cigarette smokers have increased risks of lung cancer, chronic bronchitis and emphysema, and coronary heart disease, and that cigarette, pipe and cigar smoking have been linked to less common diseases like cancers of the mouth, esophagus, and larynx.22 They also noted a positive relationship between cigarette smoking by pregnant women and the incidence of premature birth, spontaneous abortion, still birth, and neonatal death. They stated that:

. . . It is impossible to escape the conclusion reached by the overwhelming majority of health authorities and organizations throughout the world that cigarette smoking is one of the most important preventable causes of disease, disability and death in countries like Canada."

They concluded that the avoidance of cigarette smoking is the most effective way to prevent most cases of lung cancer, chronic bronchitis and emphysema, and that it is probably the most practical step to reduce the risk of a heart attack in cases of coronary heart disease. Furthermore, they noted that:

There can be no question that if cigarettes were a food or drug [sic] or being newly marketed, their sale would have to be prohibited or strongly regulated on the basis of evidence now available, the known constituents of the smoke and the express purpose for which they are sold.'

The vasoconstrictive effect of smoking can have an especially detrimental effect on persons suffering from certain cardiovascular diseases such as arteriosclerosis, and, under some circumstances, may be a contributing factor in the development of gangrene."• 53 Furthermore, chronic heavy smoking has been associated with increased wrinkling of facial skin.3°

In Canada, the Department of National Health and Welfare attributed approximately 13,800 deaths in the year 1966 to chronic tobacco smoking.22 It is clear that tobacco and alcohol are the leading causes of drug-related morbidity and death in our society. No other drugs are significant factors in comparison.

PSYCHOLOGICAL EFFECTS

No clear, concise picture of the effects of tobacco smoking or administration of nicotine upon psychological functioning exists. Tobacco effects may be very different for experienced users as compared to novices. Nicotine is usually classified as a stimulant, yet paradoxically, regular users most often report that they use tobacco because of its pleasurable relaxing or tranquilizing effects.51 Since the physiological response to nicotine, as described above, is quite complex, it is not surprising that confusion exists about psychological effects. It should also be noted that the psychological and physiological effects of pure nicotine may not be exactly the same as those produced by crude tobacco.

As a test of the proposed stimulant effect of nicotine upon human intellectual and motor performance, Heimstra and associates compared the performance of smokers, non-smokers and deprived smokers in the operation of a simulated driving device.48 They found no significant differences between smokers and non-smokers on the various measures involved. The smokers going through withdrawal, however, showed significantly more tracking and vigilance errors than the other two groups. Other findings may also be related to driving safety. Of possible relevance to night driving is a reported decrease in light sensitivity in the dark adapted eyes of subjects after smoking standard cigarettes.82 In addition, carbon monoxide alone in levels typically absorbed by heavy cigarette smokers may have detrimental effects on certain psychomotor abilities.11• 81, 98 It has been shown that smokers have higher crash rates than non-smokers, although such a correlation does not necessarily demonstrate a causal relationship.2

Both common experience and laboratory studies indicate that nicotine and tobacco smoke possess strong reinforcing properties, in that they will be repeatedly self-administered by both humans and laboratory animals.42. 59 Monkeys prepared with chronic intravenous catheters will spontaneously begin to self-administer nicotine.31, In addition, some monkeys will learn to puff on lighted cigarettes. It is interesting to note that in one study pretreatment with oral doses of nicotine did not dramatically reduce the number of cigarettes smoked by experienced human subjects," although, in other experiments, intravenous nicotine lowered cigarette consumption.", 79 Varying the nicotine content of cigarettes sometimes, but not always, produces predictable changes in the rate of smoking.3, 36, 39' 43' 79 Some heavy smokers reportedly crave the sensation of deep lung inhalation. Much data suggest that although the maintenance of tobacco smoking is primarily due to the effects of nicotine, there is a large learned component to cigarette smoking by humans which is to some extent independent of the pharmacological properties of nicotine. This effect may be analogous to the reinforcing or reward characteristics of the hypodermic syringe which often develops in chronic intravenous users of heroin, amphetamines or barbiturates, as discussed elsewhere in this report.

Much has been written in the psychiatric literature on the oral gratification involved in most tobacco use. In an extensive study of the use of heroin and other dependence-producing drugs in Canada, Stevenson and associates summarized the psychoanalytic position as follows:

Psychoanalysis has emphasized that the mouth, tongue and lips are highly erogenous zones, not only for love-making in its various forms, but from earliest infancy in the taking of food. The crying infant ceases to cry the moment his lips encircle the mother's nipple, his whole body relaxes, he obviously gets great contentment long before the nourishment actually relieves his hunger. This close oral relationship between the lips and relief from distress carries over from the infantile nursery period to adult years. At any age, something between the lips and the mouth tends to relieve tension and anxiety, whether it be solid food and drink . . . (or) chewing gum, a toothpick, a cigarette, cigar or pipe."

Although such arguments are often ridiculed, there exists some scientific evidence supporting the oral-erotic hypothesis, and, for example, linking severity of cigarette use with infantile weaning experiences." Many heavy smokers, in a simpler fashion, merely say they smoke because they need `something to do with their hands'.

In the past, psychological damage due to tobacco use has been the subject of much controversy. In summarizing the Canadian 'tobacco debate' which took place in the first decade of this century, Cook quoted the following different statements made in the House of Commons and the Senate regarding the physiological, psychological and social effects of tobacco:

There is scarcely a town or city in Canada where you will not find boys, the sons of respectable parents, who have not dwarfed their bodies, ruined their intellect and damaged their moral perceptions to such an extent that they do not know the difference between right and wrong, and consequently many of them have had to be sent to reformatories.
It is found that 9/10 of those [in the elementary schools] who lag behind, are cigarette smokers, and many of these are brilliant youths who otherwise would be ahead in their classes. In our high schools it is even worse, and the boys who make the failures there are most certainly those who are addicted to the use of cigarettes.
These young people became 'moral and physical wrecks'.... A Quebec judge was quoted to the effect that 'all children that he was obliged to condemn to gaol, or the reformatory school had their fingers stained by smoking so many cigarettes'.'

Over the years, no permanent psychological damage has been scientifically demonstrated to result from the use of tobacco, although an association between chronic use and poor academic performance, anti-social tendencies, and various other personal and social disabilities has been frequently documented.6, 7' 63, 74, 85, 99 It would appear that in certain populations, delinquents and various maladjusted individuals are more apt to use tobacco (and other drugs), although no causal relationship between tobacco use and anti-social behaviour is now considered likely.

TOLERANCE AND DEPENDENCE
Some tolerance to nicotine develops in regular tobacco smokers. These individuals seem to be unaffected by quantities of the drug which would produce marked toxic reactions in the novice.97 Regular use usually results in a tendency to increase dose. Some heavy users have been known to 'chain smoke', and deeply inhale several packs of cigarettes a day and, consequently, except when asleep, are never without significant quantities of nicotine in their tissues.54 Spiralling increases in dose do not always occur, however, and many chronic users are able to stabilize their consumption of the drug at some intermediate level. Most persons who smoke at all use tobacco daily.20, 27

There is a consensus among experts that psychological dependence does develop to tobacco.16, 49* 56' 58 In fact, in the sense that it produces cravings, repeated and compulsive self-administration, and preoccupation with obtaining the drug, it is probably the most clear-cut and common example of `psychic dependence' as the term is defined by the World Health Organization.33 The nature of the physical dependence component in chronic tobacco use is less clear.62 Although no severe physiological withdrawal symptoms have been described, restlessness, nervousness, sleep disturbance, sweating, gastrointestinal changes, fall in heart rate and blood pressure, irritability, headache, EEG changes, inability to concentrate, tremors and weight gain have been reported in early abstinence. Furthermore, as mentioned earlier, impaired psychomotor performance during tobacco withdrawal has been demonstrated.", 49. 79, 92

The strength or persistence of tobacco dependence is well known. The recent Consumers Union Report makes a strong case that tobacco should be considered an "addicting drug", and that tobacco dependence is almost exclusively a chronic condition." The majority of those who smoke more than a few cigarettes become regular users, and very few people who have ever become daily smokers are able to quit tobacco permanently. The pattern of relapse displayed by heavy users attempting to stop smoking, is quite similar to that seen with persons dependent on opiate narcotics and alcohol.° Because of the high frequency of relapse among cigarette smokers after withdrawal, it would appear that positive reward aspects, as well as the avoidance of unpleasant withdrawal symptoms, are important in motivating continued use. Most ex-smokers claim that they are never really free from the desire to use the drug—even after years of abstinence, the smell of burning tobacco reportedly can produce strong cravings in some individuals. Relapse during periods of psychological stress commonly occurs.

As with other drugs, tolerance and dependence seem to develop most rapidly and strongly when the frequency and quantity of use is high. In addition, the longer tobacco is used the more difficult it is to break the habit.12 In an English report, it was noted that only 15% of adolescents who smoked more than one cigarette avoided becoming regular users, and only 15% of smokers stopped permanently before the age of 60.79 Intermittent or occasional cigarette use only occurred in about 2% of smokers.

The difficulty some smokers experience in giving up tobacco can be illustrated by the experience at Synanon, the therapeutic community primarily concerned with heroin dependents. In 1970, when tobacco smoking was banned at Snyanon, many members of the community reported depression and irritability lasting several months. During the six-month period following the ban, about 100 people left Synanon rather than give up cigarettes. The opinion was voiced that it was easier to quit heroin than tobacco."

In Germany, following World War II, tobacco was rationed to two packs per month for men and one pack per month for women. Many smokers traded their food rations for tobacco, bought tobacco on the black market, begged for tobacco (but not for other restricted items), and picked up cigarette butts from the street, rather than give up smoking.8

A small study of regular daily users of both tobacco and marijuana suggests some differences in the type of dependence which can develop with these two drugs—at least with the present North American conditions." Subjects were asked which one drug they would prefer to use if they had to abstain from either marijuana or tobacco for different periods of time. In the long run, all subjects preferred marijuana, and would choose to quit tobacco; when the required 'abstinent time' was reduced to a day or less, almost all chose to use tobacco, since they felt it would be easier to do without marijuana for short periods than to go through the acute discomfort of tobacco withdrawal. Generally similar results were obtained in a Commission study of adult users of cannabis, tobacco and alcohol.45 Whether or not behaviour would actually coincide with these attitudes was not demonstrated. In addition, if marijuana were as freely available as tobacco, the patterns of preference or dependence might be altered.

Limited cross-tolerance and perhaps cross-dependence between nicotine and related drugs develops. Tablets containing a nicotine-like alkaloid, lobeline (Nikoban®), are sold in Canada to help block the craving for tobacco in persons who are attempting to quit. Although the efficacy of such chemotherapy has not been confirmed, lobeline is commonly used by itself and to supplement other treatments in tobacco withdrawal clinics." These practices are analogous to the chemotherapy maintenance programs used in the management of other forms of drug dependence. Many former heavy cigarette smokers have compromised and have settled for non-inhalation use of a pipe or cigars.

TOBACCO AND OTHER DRUGS

Tobacco has apparently been closely linked with the use of other drugs in most societies over the past few centuries. In many cultures soon after tobacco was introduced, other substances, including henbane, datura, mulberry, sumac and a variety of other leaves, hashish, and even coals and woodchips were commonly smoked when the preferred tobacco was not available.12. 81 Blum has presented considerable evidence that before the world-wide 'epidemic' spread of tobacco use, the intentional inhaling of the smoke from burning substances, as a mode of drug administration, was not popular in most parts of the world.'2 The smoking of opium in China and India, for example, was common only after tobacco was introduced to the Orient, and for some time opium was smoked in conjunction with tobacco. Cannabis, even today, is rarely smoked alone in Eastern countries. In India, hashish and marijuana are invariably mixed with tobacco for smoking.25, 52 The smoking of cannabis was not common before tobacco was introduced.

It would appear then, that although these drugs were previously taken orally, the past and present practices of smoking cannabis and opium in most cultures is directly and causally linked with the assimilation of tobacco smoking practices from the Western Hemisphere.

A direct causal relationship between tobacco smoking and marijuana use in North America was suggested sometime ago by Rowell, who worked closely with the United States Bureau of Narcotics in the 1930s:

Slowly, insidiously, for over three hundred years, Lady Nicotine was setting the stage for a grand climax. The long years of tobacco using were but as introduction and training for marijuana use. Tobacco, which was first smoked in a pipe, then as a cigar, and at last as a cigarette, demanded more and more of itself until its supposed pleasures palled, and some of the tobacco victims looked about for something stronger. Tobacco was no longer potent enough."

In North America, marijuana use has traditionally been closely tied to tobacco use and there seem to be relatively few regular cannabis smokers who did not initially learn the technique of inhaling smoke from prior experience with tobacco cigarettes. While the smoking of tobacco leaf does not necessarily precede or lead to the similar use of cannabis leaf, the temporal sequence is commonly observed and must be considered in any serious investigation of the proliferation of drug use today. A pharmacological `progression' is not considered likely, however, since there is no scientific evidence that one drug creates a need for the other.

Because the inhalation of smoke is initially difficult and unpleasant for the novice, and usually requires considerable practice and control of natural reflexes, the problems of learning the technique of smoking might be considered a general barrier against this mode of drug administration. Many observers feel that after one has acquired the seemingly unnatural and originally offensive practice of smoke inhalation, and learned that the effects can be rewarding or pleasurable, the general 'smoking barrier' is removed and the smoker is then more likely to try smoking other drugs than is a non-smoker.12, 39 The drug smoking associations discussed above tend to support such an hypothesis.

Stevenson and associates found considerably more heavy tobacco use among heroin dependents than in other members of a prison population in British Columbia." In addition, heroin users claimed that cigarettes became more desirable after they began the use of heroin. A British report summarized data indicating that 92% of alcoholics and 99% of heroin addicts were tobacco smokers compared to 58% of the general population.79 Heavy alcohol use is usually linked with similar patterns of tobacco consumption and the interaction of chronic alcohol and cigarette use has been linked with certain physical disorders." In addition, the smoking of cigarettes may enhance the detrimental effects of alcohol on psychomotor coordination.55. 73

The common morning routine of coffee and a cigarette suggests that there is some rewarding interaction between nicotine and caffeine. It has also been noted that persons who do not use tobacco are also more likely to abstain from caffeine.67 In general, tobacco users are more likely to take a wide variety of other licit and illicit drugs than are non-users.44, 78, 86, 99 (See also Appendix C Extent and Patterns of Drug Use.)

References

A.10 TOBACCO
1. Abdallah, F. Can tobacco quality be measured? New York: Lockwood, 1970.
2. Adams, J. R. Oral habits and traffic accidents: Over-dependency as an explanatory construct. In Alcohol and traffic safety. Unpublished manuscript, Department of Police Administration, Indiana University, Bloomington, Indiana, 1966.
3. Ague, C. Nicotine content of cigarettes and the smoking habit: Their relevance to subjective ratings of preferences in smokers. Psychopharmacologia, 1972, 24: 326330.
4. Akehurst, B. C. Tobacco. London: Longmans, Green, 1968.
5. Amit, Z., & Corcoran, M. Tobacco. Unpublished Commission research paper, 1971.
6. Andrews, D. A., Wake, F. R., & MacLean, J. A working document on smoking. Unpublished Commission research paper, 1971.
7. Annis, H. M., Klug, R., & Blackwell, D. Drug use among high school students in Timmins. Unpublished manuscript. Project J-183, Sub-study 1-38 & 39 & B1-71, Addiction Research Foundation, Toronto, 1971.
8. Arntzen, F. I. Some psychological aspects of nicotinism. American Journal of Psychology, 1948, 61: 424-425.
9. Aviado, D. M. Ganglionic stimulant and blocking drugs. In J. R. DiPalma (Ed.), Drill's pharmacology in medicine. (3rd ed.) Toronto: McGraw-Hill, 1965. Pp. 524-544.
10. Baumberger, J. P. The nicotine content of tobacco smoke. Journal of Pharmacology and Experimental Therapeutics, 1923, 21: 35-46.
11. Beard, R. R., & Werthein, G. Behavioral impairment associated with small doses of carbon monoxide. American Journal of Public Health, 1967, 57: 2012-2022.
12. Blum, R. H., & Associates. Society and drugs. San Francisco: Jossey-Bass, 1969.
13. Borgatta, E. F. Some notes on the history of tobacco use. In E. F. Borgatta & R. R. Evans (Eds.), Smoking, health, and behavior. Chicago: Aldine, 1968.
14. Borgatta, E. F., & Evans, R. R., (Eds.) Smoking, health, and behavior. Chicago: Aldine, 1968.
15. Boyle, M. N., Wegria, R., Cathcart, R. T., Nickerson, J. L., & Levy, R. L. Effects of intravenous injection of nicotine on the circulation. American Heart Journal, 1947, 34: 65.
16. Brecher, E. M., & the Editors of Consumer Reports. Licit and illicit drugs: The Consumers Union report on narcotics, stimulants, depressants, inhalants, hallucinogens and marijuana-including caffeine, nicotine and alcohol. Boston: Little, Brown, 1972.
17. British Medical Journal. Smoking and vascular disease. British Medical Journal, 1972, 2: 3-4.
18. Burn, J. H., Leach, E. H., Rand, M. J., & Thompson, J. W. Peripheral effects of nicotine and acetylcholine resembling those of sympathetic stimulation. Journal of Physiology, 1959, 148: 332.
19. Canada, Department of National Health and Welfare. Smoking habits of Canadians, 1964: Report of a survey carried out by the Dominion Bureau of Statistics. Unpublished manuscript, Department of National Health and Welfare Information Services, Ottawa, 1965.
20. Canada, Department of National Health and Welfare. Trends in cigarette consumption, 1920-1970. Unpublished manuscript, Canadian Smoking and Health Program, Ottawa, 1970.
21. Canada, Department of National Health and Welfare, Biostatistics Division. Poison control program statistics. Ottawa, 1969, 1970, 1971.
22. Canada, House of Commons. Report of the Standing Committee on Health, Welfare and Social Affairs on tobacco and cigarette smoking. Ottawa: Queen's Printer, 1969.
23. Canada, Statistics Canada. Tobacco and tobacco products statistics quarterly: March 1972. Ottawa: Information Canada, 1972.
23a. Canada, Statistics Canada. Exports by Commodities: December, 1971. Ottawa: Information Canada, 1972.
24. Canadian Tobacco Industry (Ad Hoc Committee). Smoking and Health. Presented to the House of Commons Standing Committee on Health, Welfare and Social Affairs, Ottawa, 1969.
25. Chopra, R. N., & Chopra, G. S. The present position of hemp-drug addiction in India. Indian Medical Research Memoirs, July, 1939, Memoir 31.
26. Clarke, E. G. C. (Ed.) Isolation and identification of drugs. London: Pharmaceutical, 1969.
27. CoIbum, H. N. (Director of Tobacco Program, Department of National Health and Welfare) Unpublished information communicated to the Commission, February 22, 1973.
28. Cook, S. J. Ideology and Canadian narcotics legislation, 1908-1923. Unpublished manuscript, University of Toronto, Toronto, 1964.
29. Corti, C. A history of smoking. New York: Har.murt, Brace, 1932. 554
30. Daniell, H. W. Smokers' wrinkles-A study in the epidemiology of "crow's feet". Annals of Internal Medicine, 1971, 75: 873-880.
31. Deneau, G. A., & Inoki, R. Nicotine self-administration in monkeys. Annals of the New York Academy of Sciences, 1967, 142: 277-279.
32. Domino, E. F. Electroencephalographic and behavioral arousal effects of small doses of nicotine: A neuropsychopharmacological study. Annals of the New York Academy of Sciences, 1967, 142: 216.
33. Eddy, N. B., Halbach, H., Isbell, H., & Seevers, M. H. Drug dependence: Its significance and characteristics. Bulletin of the World Health Organization, 1965, 32: 721-733.
34. Ejrup, B. E. V. Report on withdrawal clinics. In H. A. Goodman (Ed.), World Conference on Smoking and Health: A summary of the proceedings. New York: American Cancer Society, 1967. Pp. 198-207.
35. Fairholt, F. W. Tobacco: Its history and associations. London: Chapman and Hall, 1859.
36. Finnegan, J. K., Larson, P. S., & Haag, H. B. The role of nicotine in the cigarette habit. Science, 1945, 102: 94-96.
37. Fletcher, C. M., & Home, D. Smoking and health. WHO Chronicle, 1970, 24: 345-370.
38. Fort, J. (The Center for Solving Special Social and Health Problems, Fort Help, San Francisco) Information communicated to the Commission, 1971.
39. Frith, C. D. The effect of varying nicotine content of cigarettes on human smoking behaviour. Psychopharmacologia, 1971, 19: 188-192.
40. Garner, W. W. The production of tobacco. Toronto: Blakiston, 1946.
41. Ginzel, K. H. Introduction to the effects of nicotine on the central nervous system. Annals of the New York Academy of Sciences, 1967, 142: 101.
42. Glick, S. D., Jarvik, M. E., & Nakamura, R. K. Inhibition by drugs of smoking behaviour in monkeys. Nature, 1970, 227: 969.
43. Goldfarb, T. L., Jarvik, M. E., & Glick, S. D. Cigarette nicotine content as a determinant of human smoking behaviour. Psychopharmacologia, 1970, 17: 80-93.
44. Goode, E. Cigarette smoking and drug use on a college campus. International Journal of the Addictions, 1972, 7: 133-140.
45. Green, M., & Leathers, B. Adult drug users study. Unpublished Commission research project, 1971.
46. Hammond, E. C. World costs of cigarette smoking in disease, disability and death. In H. A. Goodman (Ed.), World Conference on Smoking and Health: A summary of the proceedings. New York: American Cancer Society, 1967. Pp. 15-44.
47. Hammond, E. C., & Horn, D. Smoking and death rates-report on forty-four months of follow-up of 187,783 men. II. Death rates by cause. Journal of the American Medical Association, 1958, 166: 1294.
48. Heimstra, N. W., Bancroft, N. R., & DeKock, A. R. Effects of smoking upon sustained performance in a simulated driving task. Annals of the New York Academy of Sciences, 1967, 14: 295-307.
49. Hunt, W. A. Tobacco: Habit and addiction. In H. A. Goodman (Ed.), World Conference on Smoking and Health: A summary of the proceedings. New York: American Cancer Society, 1967. Pp. 140-141.
50. Hunt, W. A., & Matarazzo, J. D. Habit mechanisms in smoking. In W. A. Hunt (Ed.), Learning mechanisms in smoking. Chicago: Aldine, 1970. P. 76.
51. Ikard, F. F., Green, D. E., & Horn, D. A scale to differentiate between types of smoking as related to the management of affect. International Journal of the Addictions, 1969, 4: 649-659.
52. Indian Hemp Drugs Commission, 1893-1894. Report on Indian Hemp. Vol. 1-7. Simla: Government Central Printing Office, 1894. (Primary Volume reprinted Silver Spring, Md.: Thos. Jefferson, 1969).
53. Inglis, A. E. Lysergic acid diethylamide (LSD) and gangrene of the hand. Review of the Hospital for Special Surgery, 1972, 1: 22-26.
54. Isaac, P. F., & Rand, M. J. Cigarette smoking and plasma levels of nicotine. Nature, 1972, 236: 308-310.
55. Jackson, R. J., & Murphree, H. B. Effects of cigarette smoking on motor and perceptual responses in alcohol-intoxicated men. Unpublished manuscript, Rutgers University, Center of Alcohol Studies, New Brunswick, N.J., 1972.
56. Jaffe, J. H. Drug addiction and drug abuse. In L. S. Goodman & A. Gilman (Eds.), The pharmacological basis of therapeutics. (4th ed.) New York: Macmillan, 1970.
57. [James I]. A counterblaste to tobacco (1604). English Reprints, 1966, 5: 112.
58. Jarvik, M. E. The pharmacological basis of addiction to tobacco: Nicotine. In H. A. Goodman (Ed.), World Conference on Smoking and Health: A summary of the proceedings. New York: American Cancer Society, 1967. P. 142.
59. Jarvik, M. E. Tobacco smoking in monkeys. Annals of the New York Academy of Sciences, 1967, 142: 280.
60. Jarvik, M. E., Glick, S. D., & Nakamura, R. K. Inhibition of cigarette smoking by orally administered nicotine. Clinical Pharmacology and Therapeutics, 1970, 11: 574-576.
61. Koslowski, W. The habit of tobacco smoking. London: Staples, 1955. Cited by B. Holmstedt & 0. Wallen, Drug administration by means of cigarettes. Archives Internationales de Pharmacodynamie et de Therapie, 1959, 119: 275-293.
62. Knapp, P. H., Bliss, C. M., & Wells, H. Addictive aspects of heavy cigarette smoking. American Journal of Psychiatry, 1963, 119: 966.
63. Larson, P. S., & Silvette, H. Tobacco-Experimental and clinical studies. Baltimore; Williams & Wilkins, 1968. P. 270.
64. Laforest, L. La ,,consomrnation de drogues chez les etudiants du secondaire et du collegial de l'Ile de Montreal. Unpublished manuscript, Office de la Prevention et du Traitement de l'Alcoolisme et des Autres Toxicomanies, Quebec, 1969.
65. Lanphier, C. M., & Phillips, S. B. The non-medical use of drugs and associated attitudes: A national household survey. Unpublished Commission research project, 1971.
66. Lucchesi, B. R., Schuster, C. R., & Emley, G. S. The role of nicotine as a determinant of cigarette smoking habit frequency in man with observations of certain cardiovascular effects associated with the tobacco alkaloid. Clinical Pharmacology and Therapeutics, 1967, 8: 789-796.
67. McArthur, C., Waldron, E., & Dickinson, J. The psychology of smoking. Journal of Abnormal Psychology, 1958, 56: 267-275.
68. Miller, R. D. Some principles of psychopharmacology: Implications for the social control of drug abuse: Paper presented at the Sir George Williams Symposium on Drug Abuse, Montreal, February, 1969.
69. Miller, R. D., & Hemmings, B. Drug induced poisonings and deaths in Canada. Unpublished Commission research project, 1973.
70. Murphree, H. B., Pfeiffer, C. C., & Price, L. M. Electroencephalographic changes in man following smoking. Annals of the New York Academy of Sciences, 1967, 142: 245.
71. New York Times, January 29, 1884. Cited by N. Taylor, Narcotics: Nature's dangerous gifts. New York: Dell, 1966. P. 104.
72. New York Times, May 23, 1971. Cited by E. M. Brecher, Licit and illicit drugs. Boston: Little, Brown, 1972. P. 216.
73. Nichols, J. L. Drug use and highway safety: A review of the literature. Report DOT-HS-012-1-019. Unpublished manuscript, 'U.S. Department of Transportation, National Highway Traffic Safety Administration, Washington, D.C., July, 1971.
74. Pawan, G. L. S. (Senior Lecturer in Metabolism, Middlesex Hospital, London) Personal communication to the Commission, 1972.
75. Roth, G. M., MacDonald, J. B., & Sheard, C. The effect of smoking cigarettes and of intravenous administration of nicotine on the electrocardiogram, basal metabolic rate, cutaneous temperature, blood pressure and pulse rate of normal persons. Journal of the American Medical Association, 1944, 125: 761.
76. Rowell, E. A., & Rowell, R. On the trail of marihuana, the weed of madness. Mountain View, Calif.: Pacific, 1939.
77. Royal College of Physicians of London. Smoking and health now. London: Pitman, 1971.
78. Russell, J. Survey of drug use in selected British Columbia schools. Vancouver: Narcotic Addiction Foundation of British Columbia, 1970.
79. Russell, M. A. H. Cigarette dependence: Part I-Nature and classification, British Medical Journal, 1971, 2: 330-331.
80. Schmiterlow, C. G., Hansson, E., Andersson, G., Appelgren, L.-E., & Hoffman, P. C. Distribution of nicotine in the central nervous system. Annals of the New York Academy of Sciences, 1967, 142: 2.
81. Schulte, J. H. Effects of mild carbon monoxide intoxication. Archives of Environmental Health, 1963, 7: 524-530.
82. Sheard, C. The effects of smoking on the dark adaptation of rods and cones. Proceedings of Federation of the American Societies of Experimental Biology, 1946, 5: 94.
83. Silvette, H., Hoff, E. C., Larson, P. S., & Haag, H. B. The action of nicotine on central nervous system function. Pharmacological Reviews, 1962, 14: 137.
84. Smart, R. G., Fejer, D., & Alexander, E. Drug use among high school students and their parents in Lincoln and Welland Counties. In P. H. Blachly (Ed.), Progress in drug abuse. Springfield, Ill.: C. C. Thomas, 1972. Pp. 62-103.
85. Smart, R. G., Fejer, D., & White, J. Drug use trends among metropolitan Toronto students: A study of changes from 1968 to 1972. Unpublished manuscript, Project J-183, Sub-study 512, Addiction Research Foundation, Toronto, 1972.
86. Smart, R. G., Fejer, D., & White, J. The extent of drug use in metropolitan Toronto schools: A study of changes from 1968 to 1970. Addictions, 1971, 18: 3-19.
87. Stedman, R. L. Nicotine reduction in tobacco and tobacco smoke: Toward a less harmful cigarette. Monograph 28, National Cancer Institute, U.S. Department of Health, Education and Welfare, Washington, D.C., 1968.
88. Stevenson, G. H., Lingley, L. R. A., Trasov, G. E., & Stansfield, H. Drug addiction in British Columbia. Unpublished manuscript, University of British Columbia, Vancouver, 1956.
89. Sunshine, I. (Ed.) Handbook of analytical toxicology. Cleveland, Ohio: Chemical Rubber Publishing, 1969.
90. Tait, L. Tobacco in Canada. Tillsonburg, Ontario: Ontario Flue-Cured Tobacco Growers' Marketing Board, 1968.
91. Taylor, N. Narcotics: Nature's dangerous gifts. New York: Dell, 1966.
92. Ulett, J. A., & Itil, T. M. Quantitative electroencephalogram in smoking and smoking deprivation. Science, 1969, 164: 969-970.
93. United Press International. 38% want ban on cigarettes U.S. poll shows. Toronto Star, April 7, 1971: 2.
94. United States, Department of Health, Education and Welfare, Public Health Service. The health consequences of smoking. (A report of the Surgeon General) Washington, D.C.: U.S. Government Printing Office, 1969. (1969 Supplement to the 1967 Public Health Service Review)
95. United States, Department of Health, Education and Welfare, Public Health Service. The health consequences of smoking. (A report of the Surgeon General: 1971) Washington, D.C.: U.S. Government Printing Office, 1971.
96. United States, Department of Health, Education and Welfare, Public Health Service. The health consequences of smoking. (A report of the Surgeon General: 1972) Washington, D.C.: U.S. Government Printing Office, 1972.
97. Voile, R. L., & Koelle, G. B. Ganglionic stimulating and blocking agents. In L. S. Goodman & A. Gilman (Eds.), The pharmacological basis of therapeutics. (4th ed.) New York: Macmillan, 1970. Pp. 585-600.
98. Waller, J. A., & Thomas, K. Carbon monoxide, smoking, and fatal highway crashes. Paper presented at the Fifteenth Conference of the American Association for Automotive Medicine, Colorado Springs, Colorado, October, 1971.
99. Whitehead, P. C. Head or brain? Drug use and academic performance. Unpublished manuscript, Department of Sociology, Dalhousie University, Halifax, 1969.
100. Wynder, E. L. The biologic effects of tobacco. Boston: Little, Brown, 1955.
101. Wynder, E. L., & Hoffman, D. Tobacco and tobacco smoke. New York: Academic, 1967.
102. Van Duuren, B. L., & Schmitt, F. L. Isolation and identification of some components of cigarette smoke condensate. Journal of Organic Chemistry, 1958, 23: 473.