In a recently published piece in the New York Times on April 30, 2012, the artist David Kramer offers a self-portrait as a smoker. He says: "Of all the vices I have overindulged in, smoking is the only one I will admit has an addictive spell over me."
He also makes the following rare admission:
I have always used substances to cope with my anxiety ... Sometimes it seemed that survival would have been impossible without them. But after five years in therapy I can now admit that I probably would have been fine without the substances. What really makes my anxiety go away is time and distance. But here's the thing: Part of me doesn't want it to go away. I actually thrive on and revel in the heart pounding and discomfort, and I enjoy it even more when I am dumping booze or cigarettes on the fire that is burning in my heart and brain.
What is the clinician interested in the vexing and notorious problem of smoking to make of this vivid description of the spell that smoking can cast? The author depicts a theme sometimes found in the complex disease of tobacco dependence: the compelling attraction of cigarettes when freedom from their sway is already palpable and at hand.
What can good psychotherapy or good smoking cessation treatment accomplish in the face of the hypnotic spell of addiction? At its best, it makes choices possible. The choice to make decisions which lead to more health, psychologically and physically, and less suffering. But, as Mr. Kramer points out, the psychotherapy patient or the smoking cessation patient can still choose to suffer or smoke. It's possible to make the case that smoking itself is a model for understanding the intensity of what used to be called "masochistic," and is now, less judgmentally, called self-defeating behavior. Through chemical dependence, cigarettes create the unpleasure of withdrawal. This includes depressed mood; insomnia; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; and increased appetite or weight gain, according to the psychiatric manual DSM-IV (1994).
Once dependence sets in, the smoker finds the social and other pleasures of smoking are now accompanied by the non-pleasure of withdrawal when the smoker is away from the cigarette for a while. At this point, the cigarette presents itself as the agent of pleasure by eliminating the pain that is part and parcel of chemical addiction. Who doesn't like to come in out of the freezing cold and sit by a warm and cozy fire? But what if the same person putting you out in the cold is also the one inviting you in by the fire? This is similar to an abusive relationship where the dominant party controls the submissive party by causing them pain, insecurity, and anxiety and convincing the submissive party that only they will be there to help them. The smoker, interestingly also comes to believe they can't make it without the cigarette. As Mr. Kramer says, "When I am overwhelmed with work, I find it almost impossible to not light up." This is the same argument Sigmund Freud made for smoking over a century ago when he called his cigars "the stuff of work."
Addicts under the addictive spell of smoking always have a reason or an excuse to smoke, whether these make sense or not. The real question is whether they truly believe their lives will be better, more functional if less intense, if they free themselves from the familiar thrall that smoking reliably provides them.
Dr. Daniel Seidman is director of smoking cessation services at Columbia University Medical Center, and author of Smoke-Free in 30 Days: The Pain-Free, Permanent Way to Quit, with a foreward by Dr. Mehmet Oz (Simon & Schuster 2010). For more details about the book, go to www.danielfseidman.com
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