In the 1950s, if you asked a smoker why he or she smoked, they would not have replied, “because I am hopelessly addicted.” More likely, they would have told you about the pleasure they experienced from smoking.

Today, we know something they did not. Smoking kills. Worldwide, 1.1 billion people smoke, causing more than 7 million deaths each year. Almost every smoker now knows that smoking kills. The Foundation’s Worldwide State of Smoking Survey found that up to 96% of the smokers interviewed understand that their habit is bad for their health.

Most smokers today want to quit. And with good reason. So why are they still smoking?

The most common answer to this question is “smoking is addictive.” I believe this is a true statement. But what does it actually mean? Surprisingly, there is no universally accepted definition for “addictive” (a word that carries very negative connotations). For this post, I will adopt a simplistic taxonomy based on common sense and usefulness (consistent with official definitions). This is not rocket science.

So, what are smokers addicted to? It is time to admit what every smoker has known for centuries: They derive pleasure from smoking.

That pleasure comes from a complex mixture of ritual hand-to-mouth behaviors; oral, olfactory, and visual stimuli; the “throat hit”; monoamine oxidase inhibitors (MAOIs are powerful antidepressants); and nicotine. Unfortunately, these “goodies” come with a rogue’s gallery of “baddies” including carbon monoxide, solid particulates (tar) and high levels of at least 70 known carcinogens – a lethal mix that makes smoking the number one cause of preventable cancer, heart and lung disease in the world.

Enter reductionist thinking

Since the 1960s, a narrative has emerged that ignores the whole complex pleasure-package of smoking, and instead points its finger at one culprit: nicotine. The landmark 1988 US Surgeon General report on The Health Consequences of Smoking: Nicotine Addiction stated: “Pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine” (now widely misquoted as “nicotine is as addictive as heroin and cocaine”).

According to most health authorities today, nicotine is “the primary addicting chemical in tobacco products.” However, the US Food and Drug Administration (FDA) now says that nicotine replacement therapies (NRTs) – available over-the-counter for smoking cessation – “do not appear to have significant potential for abuse or dependence.” And most smokers who try NRTs still struggle to quit (averaging 30 attempts before succeeding). NRTs can increase quit rates by 50% to 60%, but that’s not saying much given that only 4%-7% who try to quit cold turkey succeed. Why aren’t NRTs more effective?

Thanks to decades of research on nicotine, we know more about the biological effects of this molecule than almost any other. Nicotine’s actions are mediated by activation of nicotinic acetylcholine receptors (nAChRs) on mesolimbic dopaminergic neurons that originate in the midbrain and innervate the nucleus accumbens (often called the pleasure center of the brain). Dopamine, the “feel good hormone,” is released upon activation of dopaminergic neurons to mediate good feelings. It is also released when you win the “boss battle” in a video game, or when you have even more pleasurable experiences (let your imagination run wild).

These effects may be especially relevant for people with mental illnesses. Smoking prevalence is extraordinarily high among people with schizophrenia (62%), bipolar disorder (31.2%-66%) and depression (34%-60%), with predictable and unfortunate consequences for smoking-related disease and death. By one estimate, Americans with psychiatric conditions smoke 44% of all the cigarettes in the country. Many mental illnesses are associated with low dopamine levels. While this idea remains controversial, it is plausible that many persons with mental illness are “self-medicating” with nicotine to help alleviate their psychiatric symptoms.

For all people, nicotine is known to have positive effects on fine motor skills, attention-accuracy, response time, “orienting attention-response time,” and short-term and working memory. It seems reasonable to assume that these cognitive benefits are pleasurable.

Is pleasure OK?

Imagine a mythical product that provides almost all the pleasure-package “goodies” of smoking without any of the “baddies.” Imagine that this mythical product is as safe as breathing pristine mountain air. By my definition (above), this product may be dependence-forming (like coffee) but cannot be called addictive (see End Note, below).

Unfortunately, this mythical product does not yet exist. E-cigarettes are a close approximation, but they remain controversial. The number and level of toxins in e-cigarette vapor are much lower than in combustible tobacco, but not zero. Potential harms – especially long-term harms – may be implausible and theoretical, but they are not zero. This fact raises an important question: At what level of reduced harm does “addiction” shift to “dependence”?

E-cigarettes are not perfect. However, there is room for optimism based on our experience with almost every consumer product ever invented. For example, deaths per mile traveled by air and road have declined steadily since the 1920s and continue to fall due to incremental technological innovation. Research and development will almost certainly increase e-cigarette safety over time . . . if regulators allow and encourage such innovation.

The overarching question, however, is whether we can bring ourselves to accept a clean – or cleaner – nicotine product wrapped up in a pleasure-package appealing enough to help smokers quit by switching. In a 2018 paper Mitch Zeller, Director of the FDA’s Center for Tobacco Products, asked this very question: “How comfortable are we with long-term, or possibly permanent, use of less harmful nicotine delivery mechanisms by adults, if they help keep currently addicted smokers from relapsing to combustible tobacco products?”

Conclusion

As an ex-smoker who quit by vaping, I may be biased by my personal experience. I am definitely biased by the recent death of my father, a lifelong smoker, from chronic obstructive pulmonary disease (COPD). But I believe that safer nicotine products including e-cigarettes (and others, e.g., snus) could hasten the end of the age of smoking. Embracing harm reduction as a complementary addition to traditional tobacco control measures (taxes, bans, etc.) has the potential to save millions of lives by preventing horrible deaths from cancer, heart disease and COPD.

Some claim that safer nicotine products just trade one addiction for another. But consider this analogy: Very few people wake up in the morning and take a caffeine pill. A pill could deliver caffeine (which, by the way, is known to affect developing brains not unlike nicotine). But a cold caffeine pill just can’t deliver the whole hot java pleasure-package that I love. I am dependent on coffee, not the caffeine alone. By my definition, benign dependence is not addiction. Pleasure is OK if it is safe.

If we could travel back in time to the 1950s and hand an e-cigarette to that smoker who once innocently enjoyed the pleasure of smoking, her initial response might be “I don’t like this new-fangled gizmo.” Indeed, some smokers initially find e-cigarettes less enjoyable than smoking. But many others say they “quit by accident” after trying their first e-cigarette. Every smoker is different. Most who want to quit do so “cold turkey.” For some, counseling, NRTs, or other pharmacotherapies can help. For others, a safer pleasure-package could be a lifesaver.