Three of the DSM-IV Criteria (5, 6, and 7) focus on the “costs” of smoking or other drug use. Continuing the behavior despite costs may reflect how compulsive the behavior is. But the costs assessed by the DSM criteria will vary significantly according to the person’s life context, and the extent to which they might normally limit tobacco use; e.g., diagnosis is more likely for those who cannot afford tobacco, who are engaged in employment that prohibits smoking, or who have a tobacco related disease. While continuing to smoke in the face of such costs does make dependence more evident, dependence surely exists even absent such costs, or awareness of such costs. Thus, focusing on costs makes the diagnosis too highly bound to an individual’s social and health context. Was tobacco dependence nonexistent in the 1940’s when tobacco use was thought to be innocuous, when it little disturbed the fabric of life, and when quit attempts were rare (why quit?). Are low-income smokers more dependent because the costs of purchasing tobacco weigh more heavily on them? Would smoking become any less addictive if it were somehow rendered harmless?
