Alcohol, Tobacco, and Other Drugs
Alcohol, Tobacco, and Other Drugs
The spread of tobacco usage in the late-sixteenth and seventeenth centuries was part of the global drug confluence resulting from the European voyages of discovery, expanded trade, and the colonial plantation system. As tobacco gained in popularity, users learned to combine it with more familiar substances, often smoking or chewing them together. Drinkers chased their spirits with a pipe full of tobacco, then bought another round. Critics thought tobacco users likelier to consume intoxicants and to come to grief. They were right. Tobacco did interact with other drugs in ways that magnified psychoactive and toxic effects. Scientific research has confirmed early intuitions about tobacco, mainly that it was a gateway drug and that combined use multiplied its charms as well as its harms.
By the early 1600s tobacco was established in western Europe as both a medical and recreational drug. People bought and consumed tobacco in apothecaries, alehouses, and, later, cafés, all places where other psychoactive substances, from chocolate to liqueurs, were available. It would have been natural to use them while using tobacco. Soldiers and sailors, those most responsible for spreading the use of tobacco within and beyond Europe, took their leisure in brothels and taverns. The sailor in port, with a drink in one hand and a pipe in the other, puffing away to the amazement of the natives, unconsciously broadcast a cultural message about smoking behavior, that this strange thing should be done with alcohol.
By whatever emulative means, two customs of male conviviality had been established throughout Europe by 1700. They were smoking while drinking alcohol and smoking while drinking caffeinated beverages. The latter practice was also popular in Islamic coffeehouses, where garrulous men kept the hookahs bubbling. The more tobacco they smoked, the more coffee they drank, for smokers metabolized caffeine half again as fast as nonsmokers.
Though not a drug per se, sugar figured in the emerging tobacco–alcohol–caffeine complex. Merchants used sugar or molasses to coat smoking and chewing tobacco; distillers used it to make distilled beverages; and coffee and tea drinkers used it to sweeten their bitter infusions. Someone enjoying an after-dinner smoke over a cup of sweet coffee with a shot of rum consumed three forms of sugar as well as three distinct drugs. All came to market through the toil of unfree laborers. What made possible the mass consumption of popular drugs and their sweeteners was the steadily declining price of these commodities. What brought down the price was expanded plantation agriculture using indentured and slave labor, the economic common denominator of the early modern drug revolution.
The spread of tobacco usage outside Europe and the Middle East led to other joint practices. Chewing betel quid—the seed of the areca palm wrapped in a betel leaf with lime—was an ancient practice in south and south east Asia. Depending on local custom, betel users sweetened and flavored their quid with sugar and spices like fennel. The spread of tobacco cultivation in Asia during the seventeenth century let them add tobacco leaves, mingling two potent stimulants, nicotine and arecaidine. Subsequent migrations introduced the betel–tobacco combination to Africa and Europe. It even became common in such places as London's Bangladeshi neighborhoods, which were also hot spots for oral cancer.
Arab traders brought opium to China in the eighth century, though it was not until after the introduction of tobacco that the Chinese had a ready means to smoke the drug. The mixture, called madak, consisted of shredded tobacco leaves and semi-refined opium. Around 1760 the Chinese learned to smoke purified opium in a separate pipe, a practice that spread from the wealthy to all classes over the next century. Tobacco remained a frequent companion, though no longer taken in the same draw. The mastermind of China's twentieth-century cigarette revolution, the American tobacco baron James B. Duke, said he hoped to lure the Chinese from their opium pipes. Charles B. Towns, who treated thousands of addicts in both America and China, thought Duke's cigarettes were simply a means to get the Chinese to spend even more on tobacco than they did on opium.
Cannabis was another Old World plant that became intertwined with New World tobacco. The consumption of cannabis folk medicines, such as liquid bhang mixtures, seems not to have been particularly tied to tobacco. However, recreational smokers, mostly men, learned to mingle the two drugs in the same pipe, cigarette, or cigar. In Morocco kif smokers added ground-up tobacco leaves to locally grown cannabis. If tobacco were missing from the mix, the smoker would complain that his kif "didn't have salt." In hindsight, it also lacked the nicotine necessary to forestall withdrawal symptoms.
Guilt by Association
Tobacco's links to other drugs did not go unnoticed. In the West, the most controversial association was with drinking. The American physician and educator Benjamin Rush, an early critic of alcohol and tobacco, was appalled to see groups of boys, some as young as six, strolling through the streets and smoking cigars. The habit annoyed others, wasted time, and encouraged idleness, the font of vice. However consumed, tobacco gave rise to a thirst which, Rush wrote, could not be slaked with water. "A desire of course is excited for strong drinks, and these when taken between meals soon lead to intemperance and drunkenness" (Rush 1798).
This idea—boys smoke, boys drink, boys go to hell—became a commonplace in nineteenth-century temperance literature. Of all forms of tobacco, cigarettes offered the surest road to ruin. The Keeley Institute, an American addiction-treatment franchise, would not accept cigarette smokers. Experience taught that they had slipped into the use of alcohol and narcotics easily, and that, while they smoked cigarettes, they could not abstain from other drugs. Prohibitionists sought laws against cigarettes for the same preventive reason. It seems not to have occurred to them that boys who were impulsive, defiant, and prone to keep bad company might have used intoxicants anyway. Reformers like the Illinois school teacher Lucy Gaston insisted on blaming the cigarette.
Charles Towns, a lay addiction specialist, offered a more sophisticated critique. Except for a few women, Towns wrote, every alcoholic and addict he had treated had a history of excessive tobacco use. Smoking magnified any personal predisposition toward inebriety "because the action of tobacco makes it normal . . . to feel the need of stimulation." Its irritating effects could be blunted by alcohol, on which the smoker in turn became dependent. Then came narcotics to allay hangovers and other unpleasant effects of drinking. "Cigarettes, drink, opium is the logical and regular series" (Towns 1915).
Towns saw that smoking was socially as well as physiologically conducive to addiction. Boys sought out the back rooms of pool halls and saloons to smoke in secrecy and there learned to gamble and drink. Better-educated men who refrained from smoking until they entered college found themselves "out of it" if they did not light up. Sociability was tobacco's most seductive attraction, and its social utility made it that much harder to quit. Worse, tobacco's use scandalized others, tempting them to follow the same path to intoxication. The very openness and permissibility of the vice, Towns decided, made tobacco the worst of the drug habits.
The notion of biosocial linkages between tobacco and other drugs had an uneven history during the mid-twentieth century. It persisted in otherwise disparate groups—Nazis, Mormons, Evangelical Protestants—that shared an unremitting hostility toward tobacco. But, as millions of ordinary men and women took up cigarettes, the idea that smoking led, or caused relapse, to harder drugs faded. Pamphlets at the Lexington Narcotic Hospital told new patients where to buy their cigarettes; clouds of smoke hung over Alcoholics Anonymous meetings. Researchers shifted their attention toward alcoholism as a separate, phased disease. They tended to ignore nonalcoholic drinking, let alone tobacco products that might encourage it.
The paradigm shifted again in the last quarter of the twentieth century and in the direction that the early critics of tobacco had anticipated. Epidemiologists found strong statistical support for the anecdotal evidence linking tobacco to other drugs. For example, U.S. adolescents aged twelve to seventeen who reported smoking in the past month were 16 times more likely to drink heavily and 11.4 times more likely to use illicit drugs than their nonsmoking peers. The more they smoked, the higher the likelihood of other drug use. Adolescents who smoked fifteen or more cigarettes a day were twice as likely to use illicit drugs than those who smoked less frequently. These associations were not limited to smoking. High school students who regularly used spit tobacco, when compared to nontobacco users, were 16 times more likely to concurrently use alcohol, 4 times more likely to concurrently use marijuana, 3 times more likely to have ever used cocaine, and 3 times more likely to have ever used inhalants.
The relationship between tobacco and alcohol turned out to be more complex than that between tobacco and illicit drugs. U.S. data indicate that more individuals began their drug use with alcohol than with tobacco, but only a minority of these drinkers went on to smoke (Substance Abuse and Mental Health Services Administration 1999). By contrast, the majority of those who started with cigarettes went on to drink alcohol. Smokers over the age of twelve who reported using cigarettes in the previous month were 3 times more likely to binge drink (have five or more drinks in a row) than nonsmokers. Pack-a-day smokers were also 14 times more likely to binge drink than nonsmokers.
In the 1970s epidemiologists began describing tobacco as a gateway drug, an early step in a drug-use progression that begins with licit substances and advances to illicit ones like marijuana, cocaine, amphetamines, and heroin. In order to qualify as a gateway, a drug has to precede the use of another drug with which it is statistically associated. So, while 86 percent of smokers consumed coffee as compared to 77 percent of nonsmokers, tobacco was not a gateway for caffeine because smokers did not move from tobacco to coffee in a regular progression. The gateway hypothesis was probabilistic. It did not imply that all smokers would move on to illicit drug use, or that all nonsmokers would refrain. But the odds of progressing clearly lay with those who smoked.
Other studies have found gateway effects in different ethnic groups in countries outside the United States, including France, Israel, and Japan. The major sequence—alcohol/cigarettes to marijuana to cocaine to heroin—recurs throughout the literature, with heavier use of a particular class of drugs often preceding movement to the next level. More men than women reach the so-called higher stages, but there is no significant difference in route between the sexes.
The gateway hypothesis remains a statistical description rather than an explanation. The actual process by which tobacco users move on to other drugs involves at least three types of causes—social, learning, and neurochemical. None is necessary or sufficient to induce other drug use, but they all work to increase its likelihood. The social category, or "enabling factors," refers to the sort of bad influences Towns had in mind when he described boys lighting up in the pool hall. Adolescent smokers are more likely to be part of peer groups in which alcohol and other drugs are accessible, to become curious about them, to be able to observe how they are used, and to receive praise if they try them.
Learning also plays an obvious role. Smoking is an acquired skill. By learning to inhale smoke into their lungs, individuals acquire the behavior necessary for consuming marijuana and crack cocaine. Because underage smoking is illegal, adolescent tobacco users also learn to develop a set of masking behaviors that can serve to hide later illicit drug use.
Finally, there is the effect of tobacco itself. Smokers have significantly lower levels of monoamine oxidase-B, the enzyme responsible for breaking down dopamine in the brain. As a result, they are able to sustain higher levels of dopamine for longer periods of time, particularly if they continue smoking. Elevated dopamine means elevated pleasure; tobacco works synergistically with alcohol, cannabis, cocaine, and narcotics to provide a sustained high. Hence alcohol and other drug users tend to smoke more heavily. The reverse is also true. Alcohol, a depressant, mitigates some of the adverse effects smokers experience, such as an increased heart rate. And alcohol activates nicotine-metabolizing enzymes, which makes it necessary to consume more tobacco to achieve the accustomed effect.
The relationship between nicotine and caffeine is complex, but researchers have shown that rats chronically exposed to caffeine self-administer nicotine at higher-than-control levels. Compared to nonsmokers, heavy smokers also prefer more heavily caffeinated beverages, such as coffee rather than tea. In addition to caffeine, other drugs shown to increase nicotine consumption in animals include pentobarbital, amphetamines, methadone, and heroin.
While the combined use of tobacco and other drugs can increase their pleasurable effects, it can also have grave health consequences. Individuals who smoke and drink heavily are 38 times more likely to develop oropharyngeal (mouth–throat) cancer. By comparison, those who just drink have 6 times the risk, those who just smoke, 7 times. The risk of combined use is closer to being multiplicative than merely additive. One clue lies in studies showing that long-term alcohol consumption increases levels of cytochrome P450, a metabolic enzyme responsible for converting the tar in cigarettes to cancer-causing chemicals.
Smokers who regularly use tobacco in combination with marijuana or crack cocaine likewise run an increased risk of cancer when compared to single-substance users. Many of the carcinogenic chemicals present in tobacco are found in marijuana, some at substantially higher levels. Individuals who smoke both drugs receive double doses of carcinogens.
Not all combinatory effects are unhealthful. By normalizing levels of vasopressin, a neurochemical messenger, nicotine can help counteract alcohol-induced memory impairment. Nicotine can also mitigate alcohol-related motor and coordination difficulties—hence the drinker who lights up to "steady his nerves." On balance, though, the use of tobacco with other drugs is plainly unhealthful, both because of the tendency to consume more of the combined substances and because of specific interactive effects like multiplied cancer risk.
▌ ANDREW M. COURTWRIGHT
▌ DAVID T. COURTWRIGHT
Bedi, R., and P. Jones, eds. Betel-Quid and Tobacco Chewing among the Bangladeshi Community in the United Kingdom. London: Center for Transcultural Oral Health, 1995.
Courtwright, David T. Forces of Habit: Drugs and the Making of the Modern World. Cambridge: Harvard University Press, 2001.
Joseph, Roger. "The Economic Significance of Cannabis Sativa in the Moroccan Rif." In Cannabis and Culture. Edited by Vera Rubin. The Hague: Mouton, 1975.
Kandel, Denise B., ed. Stages and Pathways of Drug Involvement: Examining the Gateway Hypothesis. Cambridge, U.K.: Cambridge University Press, 2002.
National Center on Addiction and Substance Abuse at Columbia University. Cigarettes, Alcohol, Marijuana: Gateways to Illicit Drug Use, October 1994.
National Institute on Alcohol Abuse and Alcoholism. Alcohol Alerts: Alcohol and Tobacco, no. 39, 1998. Quarterly bulletin published by the NIAAA.
Rush, Benjamin. "Observations upon the Influence of the Habitual Use of Tobacco upon Health, Morals, and Prosperity." In Essays, Literary, Moral and Philosophical. Philadelphia: Thomas and Samuel F. Branford, 1798.
Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Summary of Findings from the 1998 National Household Survey on Drug Abuse, August 1999.
Towns, Charles B. Habits That Handicap. New York: Century, 1915.
psychoactive having an effect on the mind of the user.
opium an addictive narcotic drug produced from poppies. Derivatives include heroin, morphine, and codeine.
cannabis hemp-derived intoxicants such as marijuana and hashish.
dopamine a chemical in the brain associated with pleasure and well-being. Nicotine raises dopamine levels and intensifies addiction to cigarette smoking.
depressant a substance that depresses the central nervous system. The most common depressant is alcohol.
tar a residue of tobacco smoke, composed of many chemical substances that are collectively known by this term.