Monthly Archives: February 2013

Book Review – “Electronic Cigarettes; what the experts say” James Dunworth and Paul Bergen eds.

by Carl V Phillips

This new short electronic book (available for a nominal purchase price at Amazon USA and UK, with free reader software available for all typical platforms) collects interviews that the editors conducted from 2009 to 2012.  Most, though not all, are indeed experts on the topic.  Four (myself included) are researchers who had published research on e-cigarettes at the time of their interviews, and the remaining 13 are researchers in related fields, political operatives, commentators, and community leaders including CASAA’s own Elaine Keller and ECCA’s Chris Price.

(A few disclosures about relationships: I brought Paul into THR work and he worked in my THR research group at University of Alberta School of Public Health for about five years, longer than anyone else, and we did numerous projects together.  I have also coauthored with James (he collected the first survey data about e-cigarette users and I volunteered my group at UASPH to analyze it).  The proceeds from sales will be split between CASAA and ECCA, though given the low sale price, this is probably less a source of bias for me than the choice to feature me as the first interview in the book.  James is an e-cigarette merchant.  Paul has done paid work for James, presumably including this book, and now works for an e-cigarette trade association.)

The interviews – mostly written exchanges apparently, though mine and a few others are transcripts of oral interviews – are a mixed collection of snapshots.  Some provide in-depth views of the subjects, while others are broad overviews.

Some of the older interviews provide interesting historical perspective.  In 2009, I expressed worry about a contaminated batch of e-cigarettes (or, more precisely of e-cigarette liquid) causing acute poisonings.  I am genuinely surprised that over three years have passed with no such incident, and I think it is still a possibility.  As noted by the editors in a comment, there are self-regulation systems in place to reduce this risk, but there are still far too many wild cards in the market.  It is a good reminder that the authorities whose duty it is to try to ensure quality of what people buy, and thus prevent such an incident, have already wasted years pursuing bans rather than doing their jobs – something else I noted in 2009.  If such an incident does occur now, there will be no denying their guilt in letting years pass without attempting to provide any regulatory guidance.

The time capsule provided by the 2009 interviews is also a good reminder about how little historical memory the e-cigarette community has, a good reason for producing a book like this.  The best response to the FDA anti-e-cigarette propaganda has not changed from what I and others observed in the interviews, and yet we need to keep re-writing this same information.  Of course any frustration from that pales in comparison to what comes from trying to get the information beyond our community.  The interviews are a reminder that if the current incarnation of CASAA (and ECCA) had been active in 2009, we might have had a better shot at capping the damage done by the US government’s lies.

The 2009 interview with Adrian Payne, formerly of British American Tobacco, has a similar feel to my interview from the same year.  At that time, for example, it was generally recognized that most of what we know about the risk from e-cigarettes is extrapolated from our knowledge of smokeless tobacco.  That is barely less true now, and so it is an interesting reminder of how quickly this was forgotten as the e-cigarette community emerged over the last four years.  Nowadays, the belief that e-cigarettes are low risk mainly traces to the fact that this was believed in 2012, and that belief in turn is an echo of what was believed in 2011.  There is remarkably little awareness that this recursion traces back to 20 year of research on Swedish and American smokeless tobacco, and my calculation that it is roughly 1/100th that of smoking, coupled with our best guess – which has stood the test of a few years – that there was nothing about e-cigarettes that would make them substantially more harmful than smokeless tobacco.  Overly precise claims that suggest we know more than this about the risk from e-cigarettes, claims which are basically just made up based on nothing and repeated, can be found in several of the more recent interviews.

The 2011 interview with Scott Ballin focused on his optimism about finding common ground between real public health advocates, the ANTZ (a term that he would presumably not use, and indeed that had not been coined yet), and other factions.  He specifically was optimistic about the FDA Center for Tobacco Products serving as an honest broker.  Two years is not a long time, and things could change, but the trend definitely does not support his optimism.

The elegant gem in the book, in my view, is the interview with David Sweanor, which ranged across general observations about the past and future, making it a somewhat better fit for a collection like this than some of the other chapters.  I disagree with several of the specific points Dave made, but the broad sweep was insightful and well crafted as a whole.  Sadly, if that interview were simply reposted today without a date, the reader would be hard pressed to notice any clues that it is almost four years old.  A lot of details have changed in that time, but the overview narrative has seen limited progress.

The recent Clive Bates interview provides another nice overview of the arguments for THR.  Once again, the historical observation from this is that the same observations could have been made at the time of the earliest interview in the book (though Bates was not working in this area at the time), and are basically what I and others (including Bates, during his previous incarnation in the field) have been writing for more than a decade.

Other interviews focus on the details and are basically current.  These were conducted in greater depth, and so offer somewhat different value compared to the historical snapshots.  Konstantinos Farsalinos offers interesting observations about the situation in Greece and his view about optimal research strategies.  The Riccardo Polosa interview is more of a typical journalist exploration of a single study and its results, as well as some details about the situation in Italy.  Elaine Keller provides a great discussion of the recent US politics of THR, as well as her compelling personal story.

The story of Chris Price and ECCA and ECF is interesting, and much of it was news to me.  His biting insight (in what is really more of an authored essay than an interview) makes it valuable reading even for an expert on the topic, though the reader should be cautioned that even I think he is perhaps he is a bit too cynical in some of his observations (yes, it is possible to be too cynical, even when observing opposition to THR, though I think it does lead to exactly the right conclusions about what we should be doing).

More generally, the reader should realize that this is definitely not a reference book, and is not designed to be a primer on the topic for someone just learning about THR or e-cigarettes.  There are some statements by interviewees that are out-and-out wrong and at least one of the interviews would make many readers decidedly less knowledgeable if all the content were believed.  Many other statements are defensible but debatable, and the reader will not be aware of that debate without extensive outside knowledge.  Thus, the book functions best as a “reader” – a collection of thoughts for someone who already has a general understanding of the topic and is able to bring some critical thinking.

The fact that the book consists of interviews that were intended to be free-standing short overviews that emphasized the hot topics of the month creates several limitations.  The questions asked in the interviews were somewhat random, with most interviews tending toward a general overview rather than a focus on the particular individual’s expertise.  Non-scientists were asked about as many scientific questions as the scientists, for example.

The interviewers do not seek to illustrate differing views and do not probe points of controversy.  Some contrasts are immediately apparent, such as Price vs. Ballin (and points in between) on whether there is any value in we genuine advocates for consumers and health trying to work with the “public health” power brokers.  But there are few questions, other than general overviews, that were put to more than one interviewee, and thus extensive background knowledge is required to observe the evolution of thinking and points of disagreement (and to sort out one from the other).  It is there, and it is interesting reading when put side-by-side, but it does require some thinking beyond the content of the text.  Most interviews include some general statement about harm reduction being a good idea and the politics arrayed against it being deplorable, but only one or two include any further details, offering the reader limited opportunity to explore nuances of those views.

A knowledgeable or very careful reader will notice a few other contrasts.  Some interviewees have worked in tobacco harm reduction for a long time, while others became interested in e-cigarettes specifically, usually as a result of personal or family experience.  Some have done key research while others are pundits and activists who have made use of that research.  But those divisions do not correspond to the outline of the book and are not highlighted, and so even careful readers may remain unaware.  Similarly, ethical or ideological differences – those who support consumer freedom versus those who grudgingly accept THR as merely a poor substitute for abstinence, for example – are somewhat apparent, but are not probed in the interviews.

The evolution of the thinking of the interviewers themselves is apparent.  The questions posed in the later interviews definitely make the content more useful for a collected volume.  Presumably at some point during their process, the editors started to envision creating this collection, and there are rumors that they will continue this process in another volume.

A few paragraphs of context about each interviewee and some background on the subject matter covered in the chapter would have aided most readers.  This would have dramatically changed the feel of the book, though, and so presumably it was intentional on the part of the editors to let the interviews stand on their own with only a few sentences of biosketch as an introduction.  I probably would have made a different choice if I were the editor, but no one ever accused me of having a light touch.  (Indeed, I suppose this review provides some of the additional observations that I might have added, had I been writing introductions to the chapters.)

With the cautions in mind, I would suggest that anyone who regularly reads my work or otherwise has an interest and some background in the topic will want to throw a few pennies to CASAA and ECCA and get this book.

From my archives – Tobacco Candy research “study”

by Carl V Phillips

I do not have enough spare cycles this week to write any new Lies posts, I’m afraid, and the rest of the CASAA leadership is equally buried with legislation and such so I cannot draft them.  But it has become increasingly apparent that many readers of this blog are not familiar with the huge collection that comprised my older THR work, and by “older” I mean everything from early 2012 and going back more than ten years before that.

So I will take this opportunity to outsource to a “research paper” I wrote in early 2012, which I think is one of the best, or at least funniest things I have ever written.  It would have been a good post for this blog, but this blog did not exist yet.

It is interesting to note how much things have changed in a year.  That post was inspired by the flurry of ANTZ junk “research” on the dangers of dissolveable smokeless tobacco products (though it has an e-cigarette component too).  Some of that is reviewed in the post, for those not familiar.  A year later, dissolveables have pretty much disappeared from the market (for the moment — they will be back) and, of course the ANTZ have stopped writing anything about the topic.  It is further evidence that, as noted in the last post here, they are not actually interested in learning anything or assessing whether a product is good or bad for the world.  They just do their pseudo-science to bolster their political attacks on THR, and when they think they have won a battle they lose interest in the topic.

ANTZ and the mirror-image delusion

by Carl V Phillips

Last week there was a flurry of discussion about a call by UCSF’s ANTZ queen, Ruth Malone (and endorsed by that institutions chief ANTZ liar, Stanton Glantz), for a boycott of FDA proceedings that involved a dialog with tobacco companies.  The demand that actual stakeholders be excluded from policy, in favor of just leaving it to the self-appointed busybodies, is so utterly insane that I am not even going to bother to respond to it.  Others have done so.  And I certainly do not want to try to talk them out of the boycott like others have — if they want to let their megalomania and obsessions lead them to stay out of the discussion, but all means let them.

But the discussion surrounding this has starkly illustrated one particular delusion that seems endemic among the ANTZ, something that is common among non-thinking fanatics, and can be observed in various areas where people let their ideology determine their “facts”:  the belief that the one’s opponents are just like oneself, only in support of an opposing ideology, the mirror image delusion.  As a genuine delusion, this is not actually a lie, though it is the cause of numerous lies.  (Recall the position of this blog that actively affirming a false claim out of ignorance is still a lie if there is an explicit or implicit claim of expertise; even if you view inexcusable ignorance as different from a lie, there is still the lie about the expertise.  But this does not represent a claim of expertise.)

The clearest example of the mirror image delusion is that the ANTZ do not hesitate to corrupt scientific inquiry, lie about scientific results, and otherwise produce stinking pools of junk- and pseudo-science, and so they assume that their opponents have the same lack of concern about good science and ethics.  The calls by Malone and company to forbid stakeholder involvement are obviously transparent attempts to keep everyone but their fanatical minority out of the policy process.  But they attempt to justify the claim with something they seem to actually believe:  that the tobacco companies, and even the consumers (see, e.g., the previous posts about Glantz trying to censor consumers’ own testimonials about their success with THR), are liars.

The reality, of course, is that both the tobacco industry and THR consumer advocates conduct high-quality scientific research which is basically never challenged by the ANTZ.  Despite how glaringly clear this is, and despite the fact that the ANTZ surly must be aware that they never, in fact, find any evidence of lying or even aggressive spinning by the tobacco industry and other serious researchers and commentators, for many ANTZ these claims seem to be more than a mere tactic.  They seem to really believe them.  The only apparent explanation is that the ANTZ’s delusion leads them to assume that the people they are attacking must be as dishonest as they are, despite no evidence to support that claim.

One of the reasons the ANTZ never challenge the accuracy and honesty of their opponent’s research and analysis is that they would lose.  They have no ground to stand on.  As far as I am aware, no ANTZ has ever even tried to refute the arguments presented in this blog, and that is perfectly typical of their behavior.  However, I believe that another explanation is that they really do not think there is any point in disputing a claim because they do not pay any attention when someone disproves one of their claims, and they (falsely) assume their opponents act the same way.  I, and most of us in THR, would withdraw a claim (whether it be a scientific claim, an analysis that shows someone is a liar, or anything else) if it were shown to be wrong or even merely seriously disputable.

But the ANTZ basically never withdraw anything they have ever said, no matter how obviously false, and their mirror image delusion means that they are incapable of understanding that others act differently.  That is, they do not fail to debate merely because they would lose the debate (they would, but they often clearly are so clueless that they do not realize that), but because they live in an echo chamber and ignore everyone else, and so think that is true of everyone else also.

Another example relates specifically to their attempts to censor the stories of ex-smokers who have successfully used THR.  They claim that somehow all of the consumers reporting this evidence are corrupt and are only doing it on behalf of “industry”.  This seems to reflect several different bits of mirror image delusion.  Most of the ANTZ would never take the time to do anything they were not being paid for, and are themselves often doing the bidding of their paymasters.  For many, their delusions make them incapable of understanding that consumers and the rest of us who are genuinely concerned with public health do not behave that way.  Even more important, they know that most of the “public health” people who repeat the ANTZ lies are unthinking useful idiots who are acting entirely due to the manipulation by others (i.e., by the ANTZ leaders), and so they assume it must be true of the consumers too.

Perhaps most important, returning to the topic of junk science, the ANTZ do not actually care what information their “research” provides, and so they assume the same is true for their opponents.  They do not care whether or not a study shows some genuine reason to be concerned about a health effect; they just want to cook up results that seem to show a bad effect in order to support their ideology.  Their mirror image delusion prevents them from understanding that actual stakeholders — the people who have some real stake in THR, as opposed to the busybodies who have no stake and so are happy to sit on the outside and lob bombs at it — care quite a lot about the science.  Their failure to grasp this obvious non-similarity means that they assume that our scientific analysis must be like theirs — an attempt to support an ideology, rather than an attempt to understand and perhaps improve people’s health.

I suspect there are other good examples.  If any come to mind, I welcome them in the comments.

CASAA launches Research Fund – please donate

A quick aside for anyone who follows this blog but not other CASAA communications.  This week we launched a Research Fund which we will use to support targeted scientific THR research that we have determined is needed but missing.  Further information appears at those links, so I will not duplicate it here.  But please go check them out and if you like this blog, please contribute to help with what it stands for.

(Note: the content of those two links is the same at the time of this writing.  The second will be updated on an ongoing basis as we have more to report about the Fund and the research it is supporting.  The first is the permalink for the launch announcement.)

Second-order preferences as addiction, cont. (part 4 of “what is addiction” dialog tree)

by Carl V Phillips

This post continues immediately from the previous one, which you will need to read to make sense of this.  That, in turn, is part of the “dialog tree” of how to talk to someone about what they think addiction is (starting here), which in turn follows from this post.  Got all that?

In the previous post, I pointed out that one thing that people often mean when they say “addiction” is that someone chooses smoking over not smoking, but “wants to quit”.  I pointed out that this almost certainly means they have a second-order preference for wanting to prefer not smoking over smoking, but that is not their actual preference.

I emphasized one critical point that is often overlooked when this concept is implicitly invoked as an excuse for torturing smokers into quitting:  Most everyone has been tricked into believing that every smoker who manages to quit will find himself just as happy/alert/clear-headed/etc. when he abstinent as he was when he smoked.  While this will be true for some people who give up tobacco/nicotine, it is definitely not true for many.  In particular, it is almost certainly not true for those who “want to quit” but start again after a period of abstinence.

In a hundred different ways, this lie permeates discussions about use and cessation (“all you need is just a little help getting over that hurdle”).  The lie dooms countless smokers — literally millions of them — to a repeated cycle of temporary abstinence, expecting to find that they no longer want to smoke after being abstinent for a while, followed by starting to smoke again because they still prefer smoking to abstinence.  But it is also one of the fundamental anti-THR lies that I have written about before:  Everyone would be happy being abstinent, and so they just need to get there; thus, we do not need THR.  (Actually, this claim is wrong for other reasons too, actually, but I will stick to the one theme.)

Circling back to the dialog tree of what to say to a non-ANTZ who invokes the old “…but they are still addicted” claim as a reason for opposing THR, when someone defines “addiction” with answer #6, how should we respond?  I took so long getting to this because I think it is necessary to really understand the implications of second-order preferences in order to answer well.  With the background in mind, the script for responding should begin with:

If someone says they want to quit but never does, or they quit for a while and start again, it shows that they actually prefer smoking to abstinence when those are the only two choices.  But there is a good chance they would act on their stated desire to quit, and stick with it, if given a way to make non-smoking better — that is, to keep some of the advantages of smoking.  That makes such a smoker the perfect candidate for THR.  Indeed, it is difficult to think of any more compelling reason to support THR than this notion of “addiction”.

If you can get to this point in a conversation with any thinking and feeling person (i.e., most any non-ANTZ), I venture to say that you will almost certainly win them over.

This argument renders the point about whether someone is “still addicted” rather moot.  But should the conversation continue to focus on addiction, the argument only becomes stronger:

Not only is THR a good way, and perhaps the only way, to help such an individual fulfill their stated desire to quit smoking, but it is the only way to actually overcome the addiction.  The abstinent ex-smoker whose preferences fit this pattern is still addicted by this definition, because his preferences have not changed — he still would prefer to smoke even though he is forcing himself to act like someone who prefers to not smoke.  However, if he is satisfied with THR, then not only is he no longer a smoker, but he is no longer “addicted”.

Just pause for a moment and let that sink in, because I think that these points might well be the strongest arguments for THR that are almost never made.

Having let it sink in, I have to finish with one caveat.  Arguably it is necessary to add something about the impact of past use to answer #6, since some reference to past use is part of most notions of what addiction might mean (recall definition #5 in particular, and also #4).  Thus it might be that the full version needs to be something like:

6a. Someone is addicted when he prefers taking particular action even though he would prefer to prefer to quit, and the reason he prefers the action is because of past consumption.

That is, someone is “addicted” to smoking if he has that pattern of preference and second-order preference, and because he ended up with that pattern because of past smoking.  It should be immediately apparent that this is of no practical consequence if we are talking about someone who already fits this description.  There is no changing the past.  The only change required is to add the phrase “since he is already in that situation” to the above arguments.

However, if this describes someone’s belief about tobacco/nicotine use (which I believe is the case for many who are anti-tobacco but not ANTZ, and who are thoughtful enough to figure out what they are really claiming), and they believe that the creation of the second-order preference disconnect is truly a terrible thing in itself, then this concept of “addiction” remains an argument for preventing anyone from initiating use of even a low-risk product.  I do not actually think that this is a good argument, but I will acknowledge that it could be defended because, unlike the ANTZ, I am not just spewing propaganda, but am seeking honest understanding of these issues.

The reasons I think it is a very weak argument start with the observation that, as noted in the previous post, there is nothing inherently terrible or unusual about having a second-order preference to have a different preference about some choice.  I used to drink orange juice that I mixed from those little cans of frozen concentrate, but then I got in the habit of buying the jugs of “premium, never frozen” juice, and now strongly prefer that.  But I would prefer to still like the frozen concentrate just as much, since it is cheaper and easier to carry and store, but my experience changed my tastes.  But that experience also left me happier, since the premium stuff really is better.  My indulgence caused a second-order preference disconnect, but did not make me worse off.

The typical response to that observation would be that tobacco use is different because it causes not merely the discovery you like something and an evolution of tastes, but rather it causes some strange massive reprogramming of your brain.  It is not clear why that even matters, though, and moreover  I am not entirely convinced by these claims.  Most of them come out of the notoriously dishonest ANTZ “research” literature or the brain porn research in neurochemistry that is currently in vogue but is widely derided for not actually supporting the claims that are made.  Yes, tobacco/nicotine use changes our brains, but so does acquiring a taste for orange juice or reading a book (if you remember what you read, it changed your brain).  The bottom line is that there is a possible argument against tobacco to be found here, but even the factual claims are far from definitive, and the ethical and economic conclusions are much shakier still.  After all, there is also a valid case to be made that someone’s exposure to tobacco/nicotine can improve their life by making them susceptible to the benefits, so long as they can get those benefits without the high cost of smoking.  So perhaps I should complain that I was denied that opportunity to reprogram my brain at an early age, just as I wish I had learned to speak Mandarin when I was still young enough to do it easily.

But I digress.  That is a topic for another day.  At the end of this day I will sum up the thread by saying that if you can get an open-minded person to discuss their concerns about “addiction”, and you can offer the responses presented in this series, there is a very good chance that you can show them that the concept  of addiction offers much stronger arguments in favor of THR than it does against it.

Second-order preferences as addiction (part 3 of “what is addiction” dialog tree)

This post continues the series (started here) on “addiction”.  While the discussion of second-order preferences mostly stands on its own as an independent point, some bits will make more sense if you have read the series.

The last of the likely answers to your question “what do you mean by addiction” invokes the concept of second-order preferences (though presumably without using that jargon):

6. Someone is addicted when he keeps choosing to take a particular action even though he wants to quit.

I have thought and written quite a bit about the concept of second-order preferences as it relates to smoking and THR, much of it in collaboration with my THR.o colleague, Catherine Nissen.  The concept is that someone may prefer a particular choice (their preference), but would prefer to not prefer that choice (their preference about preferences, aka a second-order preference).

It is commonly claimed that most smokers want to quit.  The surveys that support this are actually quite suspect, since smokers know that they are supposed to say that, and thus often just give that answer as cheap talk.  But while this explains a large portion of the responses, there are definitely some people who sincerely assert that they want to not smoke, even as their actions show that they are choosing to smoke.  But what can this obvious contradiction possibly mean?  It almost certainly means, in most cases, that their second-order preference is to be someone who wants to not smoke, even though the reality is that they are someone who really wants to smoke.

This, unlike most of the previous notions of what “addiction” means, is a very real and common phenomenon with practical implications.  But those implications are not what those who use “addiction” as a negative epithet might think.

There is nothing horrible, or even the slightest bit unusual, about this second-order preference pattern.  We all have countless preferences for different preferences.  I would prefer to like going to the gym as much as I like playing computer games, and I would prefer to like unsweetened iced tea as much as I like Coke.

It is sometimes perfectly ethical and otherwise reasonable to implement public policies that help people achieve their second-order preferences in spite of their actual preferences.  But justifying this is complicated.  It clearly cannot just be taken as a given that such policies are good, as is sometimes implied.  In particular, there is no obvious reason why we (as a society) should favor someone’s second-order preferences over their actual preferences, let alone an obvious justification for policies that inflict costs in order to push that choice.

Most people who support such policies have clearly never thought through the ethical questions, and frankly appear mostly to be lying about their stated motives.  There are those who argue that such policies help make everyone “better” people, but that is only by their own measure.  These are usually busybodies who would push the particular choice even if it were not someone’s second-order preference.  How many active supporters of anti-smoking efforts ever say, “if someone does not want to quit, then we should avoid interfering with that choice”?  Their real motives are wanting to force particular actions, not to help people fulfill their own second-order preferences.

A particular clear justification for some types of interventions can be found in how I phrased my personal second-order preferences.  Notice that I do not want diminish my enjoyment of computer games to the point that I prefer the gym; I want to raise my enjoyment of gym-going to that of computer games.  If there were an action that accomplished that, making gym attendance better without diminishing the value of any alternative, there would be no question that this was an improvement in the world.  But, of course, for most actions, particularly those where there is profit to be had by improving quality, there is no such magical cost-free improvement that no one has bothered to implement.  You can sweeten and flavor the iced tea, but only at the cost of making it nutritionally about the same as Coke.  My gym options are much nicer than the university weight rooms I frequented for a few decades, thanks to the wonders of the free market, but those wonders are still not enough to change the fact that staying home is nicer still, and there is no reason to expect magical further improvement.

Many anti-smoking efforts can be characterized as attempts to cause people’s preferences to align with their second-order preferences.  But this is done by lowering the net benefits of smoking until quitting is the preferred option.  That is ethically justified if (and those of us who believe in individual liberty would argue, only if) those who are affected genuinely want an external actor to do that to them, and they understand that the action is not going to make being abstinent as good as smoking, but is going to make smoking as bad as being abstinent.  So, a drug like Chantix that makes someone not want to smoke is fine (ignoring, in this analysis, the side effects), so long as someone understands that it probably will not make the experience during long-term abstinence as enjoyable/productive/etc. as life when they smoked, but is merely going to lower the benefits of smoking in the short run to help achieve a new habit of abstinence that is in line with the second-order preference that the individual cannot bring herself to act upon.

Yes, there are a lot of conditionals and caveats in that ethical analysis.  Notice that those conditions are clearly not met for policies that try to make smokers miserable through punitive taxation, forcing them out of pubs, and otherwise increasing the costs of smoking.  Many of those who suffer the inflicted costs do not actually want to quit, and the rest have not consented to someone making one of their choices less pleasant in order to try to try to align their preferences.  Moreover, even many of those who would consent to have their preferences forced into alignment, as they do with voluntary drug therapy, have been tricked into believing that the result will be that they will be just as happy or happier once they are abstinent.

This last bit is critical and rather more subtle than the other conditions that are more often discussed.  Most people (smokers and nonsmokers alike) have been tricked into believing that every smoker will be just as happy as a nonsmoker, once they get over some hurdle (which is often called “addiction”, but is really better labeled “dependence” or even just “withdrawal” — see the discussion under #4 in the previous post).  Some ex-smokers are happier, certainly, but these are probably the ones who just decide to quit and end up staying abstinent.  Those who are seeking extra help because just deciding to quit does not work are typically misled into believing that once those tools cause them to quit, they will be happy about being abstinent, but that is often just not so.

When the ANTZ defend policies that make smoking more costly and less pleasant with language like “helping smokers quit”, a standard response is that this is utter crap:  Intentionally inflicting pain on someone to try to modify their behavior is called “torture”, not “help”, and it violates all accepted modern Western rules of ethical behavior.  But while this response is solid, and the ANTZ position is indeed crap, there is a bit more to it.  The missing nuance is important not just for getting the argument completely right, but for understanding why non-ANTZ might buy into the ANTZ position (and thus, coming back to the theme of this series, how to respond).

When the ANTZ claim that torture is help, they are invoking the implicit (and clearly false) claim that everyone affected by the torture has second-order preferences for quitting, and also invoking the implicit (and clearly false) claim that they want someone to use force to align their preferences with their second-order preferences by inflicting torture until quitting is preferable to smoking.  In addition, the ANTZ are making the implicit (and clearly false) claim that all of these smokers who want to be forced really understand that when they are abstinent they are likely to be less happy/productive/etc. compared to when they were smoking.

If all three of those implicit claims were actually true, then there would be a legitimate argument that the current anti-smoking approaches are ethical, and perhaps even an argument that anti-THR is justified (though anti-THR lies are never justified).  To be sure, under those conditions the position would be defensible, but there would still be some strong ethical arguments against it (which I will not address in this series).  But a lot of people, having never thought seriously about the ethics, have a gut notion of ethics that says that under those three conditions, that position is Right.  The biggest problem is that they have been tricked into believing that those conditions are met, and that is optimal point of response.

And with that, I have to leave the issue of how to try to un-trick them until the next post, having already passed our “no post longer than…” limit.

The more complete response to “…but they are still addicted!”: a dialog tree (part 2)

This post picks up where the previous one ended, continuing a series that started two posts ago.

Continuing the dialog tree of responses to “what do you mean by addiction?”, the following are the responses that you might get initially, or that you might get after your conversation partner realizes that answers #1 and #2 do not work because smoking is not all-consuming and rapidly destructive and “cannot quit” is never really true.

3. It means that it is bad for one’s health, but people still do not quit (because the benefits still exceed the costs).

The response will not include the “benefit-cost” language, of course, but it is helpful to add that yourself when someone gives an answer like, “they know it is bad for them, but they keep doing it anyway.”  Once the absurdity of the “cannot quit” myth is pointed out, it must be that if they are still doing it, they are choosing to do it.  This means that the benefits exceed the costs, even though the physical health impact is probably negative.

With that in mind, the obvious response is that this cannot really be what addiction means because it describes many — perhaps most — choices that people make.  You can start your reply with, “People choose to do lots of things that create health risk – are all of these addictions?”, and continue on to “If people are choosing to do it because the benefits exceed the costs, doesn’t that make it good, not bad?”  The latter of these presents an opening to point out that if someone currently chooses to smoke and is offered an alternative with only a small fraction of the health costs, then the net result can only be positive.  Not only is this an argument for THR in itself, but it points out that #3 must be flawed since it implies this would be a bad thing.

For any sensible respondent, the response will reset the conversation.  It will be apparent that this approach to defining some bad force known as “addiction” makes no sense, leading to another answer (or perhaps to the realization that there is no real answer).

You might get the response that people should avoid anything that is bad for their health and is “unnecessary”.  If you encounter such a claim at this stage in the conversation or any other, it means that you are actually talking to someone who has been brainwashed by “public health”, and you probably should have stuck with the short-and-simple answer rather than attempting an intelligent conversation.  No one other than “public health” people actually believes that physical health risk is all that matters in the world.  But, too late.

Your temptation will be to point out how ridiculous that position is, since it precludes such activities as holiday travel, eating anything other than the healthiest foods, bicycling, going to the movies, etc., and no one actually acts that way.  But if you do that, the conversation about addiction is over.  I recommend trying to force the conversation to stay on topic instead by pointing out that if “addiction” is meaningful, it cannot include everything that causes some risk, and so a different answer is needed.  However, if you do decide to take on that argument, you might consider pointing out that psychological health is officially part of health by most measures, and tobacco/nicotine is very beneficial for many people’s psychological health.  This risks buying into the “health trumps everything else” argument (if people like it, who cares whether this is because of some official “psychological health” benefit), but keep it in mind.

4. It means that people need to use more and more to get the same effect. -or- They suffer negative withdrawal effects when they go too long without (or quit entirely).

One final category of common answers is someone using “addiction” to just mean one of the well-defined characteristics of tobacco/nicotine use (as well as use of many other drugs, ranging from caffeine to headache remedies, and depending on the exact wording, exercise, socializing, and all manner of habit-forming activities people engage in).  Those concepts have more precise names (“tolerance” for needing more to get the same effect; “dependence” or, better still, “short-term dependence” for suffering withdrawal effects).  But if someone chooses one or a combination of these as their personal definition of “addiction” (and remember that because there are no scientific or broadly accepted definitions, all definitions are personal), at least it is a well-defined and accurate description.  It might be worth pointing out that there are better words for these particular concepts, but the real response here is “so what?”

So what if someone needs more than they once did to get the same effect, so long as what they are using is low risk?  So what if someone still faces the prospect of withdrawal effects?  If that is the case, what possible advantage is there to making them suffer these sooner rather than to put off that suffering — possibly forever — with minimal risk.  In short, who cares?  Yes these characterize what many users experience, and thus identifies something that might be different if the gods truly loved us, but these characteristics do not support the original conclusion at issue, “…and therefore we should not encourage THR.”

Note that at this point the conversation could turn to doubt about the “low risk” claim: “But that is still a problem if it is not low risk!”  (Something similar could happen down other branches of the tree also.)  Be ready to offer the reminder that this conversation is a response to the original claim that THR is bad because it leaves people “still addicted”.  You should offer to clear up the lack of knowledge about the health risks, which is frankly much easier than arguing about addiction.  But before going in that direction, point out (nicely, assuming you are talking with someone you hope to persuade) that this suggests they are really worried about the risks of the alternative products and not really about “addiction”.

One answer that you will almost certainly not get, unless you are talking to someone educated in economics, is the semi-formal economic definition that I alluded to before (I include this for completeness and you can skip this wonkish bit and jump to the next post without losing the thread if you want):

5. Addiction exists when someone has increasing marginal utility from consumption (use), but  accumulated past consumption lowers baseline utility.

To translate that:  For most things, the more you have or have consumed recently the less you want the (e.g., if you own only one pair of shoes, you could benefit a lot from a second, but if you own 11, the 12th has less additional value; if you eat Indian food every day for a week, your desire to eat Indian food is much lower than it was a week ago).  But when something is addictive, by this definition, the more you consume the more you want more because your net benefit from consuming the next bit increases (“marginal” is economist-speak for “the next bit”).

This is often treated as bad, and it certainly if we are talking about something that is rapidly leading to personal destruction, as per definition #1.  But when that is not the case, it is clearly advantageous (more benefit is good).  But the downside is the second bit of this definition, which says that the more you have consumed in the past the less happy you are if you do not consume any today.  That is, a lot of that increased benefit of consumption is used up digging yourself out of the hole you are in to get back to what would be normal.

(A more wonkish aside:  Sometimes that second condition — about the negative effect of past consumption — is considered to define “negative addiction”.  The counterpart can be called “positive addiction”, where the accumulated history has no effect or is actually beneficial.  For example, the first time someone picks up a musical instrument or goes bowling, they might not have much fun.  But as they accumulate skill and it becomes a regular activity, they will find their benefits from it increasing.  Those who are familiar with some of the various scales for evaluating whether someone is dependent or addicted might recognize that this accumulation of positive appreciation for something often qualifies as “addictive”.)

(One more even more wonkish aside:  The reason that this is only a semi-formal definition and it is not fully scientific is that the marginal benefits are not always increasing, so more detail is needed.  To explain:  Consider eating one bite of a yummy dessert, which makes you really want another bite (your marginal benefits increased, fitting the definition of addiction), but you are satisfied after four bites and do not really care for any more (the marginal benefits resumed their normal decrease, so this was clearly not an addiction).  Consider also that someone who just finished smoking a cigarette does not want another one right away (so the marginal benefits decreased), even though smoking for the last year increases the desire to smoke today.   A complete definition would need to sort out when, exactly, the increasing marginal benefits occur, and this has not been done.)

With apologies for the wonkishness of this, I would venture to say that #5 picks up on what many well-intended people come up with if they really try.  But since these are not the people who are likely to say “but they are still addicted”, you are not likely to get a version of this as an answer in this particular conversation.  If the response is something equivalent to #5, though, the response would be the same “so what?” from #4.  This does not sound like such a terrible characteristic of a consumer choice, certainly not enough to demand that something be categorically avoided.  And even if it might be a reason for avoiding starting down that path, it is certainly not an argument against harm reduction.  Indeed it is a strong argument in favor of THR because of the increased benefit of continuing to consume the product or a substitute (i.e., it is better to let someone who is addicted keep consuming, so long as you can reduce the health costs).

I have one final point to make in one last post in this thread, and it may be the only cogent response to “what is addiction?” that offers an argument for why allowing it to continue is bad in itself.

The more complete response to “…but they are still addicted!”: a dialog tree (part 1)

by Carl V Phillips

In the previous post I addressed the common anti-THR statement that a smoker who switches to a smoke-free alternative is “still addicted”, and that whatever that means, somehow it should be considered both bad and important.  I observed that this sentiment, unlike many anti-THR claims which are pretty much always dishonest rationalizations by ANTZ, often comes from people who are genuinely concerned and open-minded, but have just not thought the matter through.  Thus, it is useful to be ready to respond.  I further noted that the easy and quick responses, which are most often what is needed, turn out to be quite different from the more scientific discussion.

The more I think about it, the more I think that the simple and quick response, though a bit cheap and easy, is actually the place to start even if you are inclined to have a more precise conversation.  That is, we should probably always lead with the previous post’s points, which can neatly summarized in the sentence, “Isn’t it better to almost eliminate the health risk the easy way, without having the damage continue to accumulate until the addiction is ended, and then deal with the addiction after that?”

But one goal of this blog is to help readers understand what constitutes good science and legitimate arguments, so I cannot just leave it with that response.  I pointed out that if you want to have a serious conversation, you have to start to address what “addiction” even means in the conversation, which is why I pointed out that a deeper and complete response has to begin with the question:

What do you mean by addiction?

Where to proceed with the conversation depends on the answer to that question.  The reason that we need to ask the question is that there is no such thing as “addiction”.  I am being slightly glib when I say that, but saying there is no such thing is much closer to accurate than to suggest that addiction has an accepted definition that is useful in scientific, health, or serious policy discussions.  “Addiction” does not have a definition in the health sciences and the only scientific definition of it is found in economics, as is appropriate since it is an economic phenomenon, but few using the term are even aware of that, and it is undoubtedly not what they mean.  There is not even a medical definition.

“Addiction” is one of those “I know it when I see it” concepts, like “beauty” or “pornography”.  To the extent that there are proposed definitions they are both idiosyncratic (i.e., everyone has their own, and a word that everyone has their own definition for is obviously not well-defined) and question-begging (i.e., they just replace a single “know it when I see it” concept with a list of characteristics, many of which are themselves merely “know it when I see it” characterization).

So, lacking either an accepted scientific or medical definition, the word has no place in scientific or other serious discussions.

There are medical definitions of the related concept of tolerance and withdrawal symptoms, and these can be defined scientifically too.  There is also a muddled concept known as “dependence”, which is slightly more scientific than “addiction”, but not much.  (It basically is scientific only to the extent that we are ok with circularity:  if “dependence” is simply defined to be “whatever someone scores on this arbitrary measurement instrument”, then that instrument will indeed measure it.)

“Addiction” evokes visions of people who are suffer a compulsion to taking an action even as it is obviously rapidly destroying their life.  Creating the image of this specter is presumably the goal of many people who apply the word to nicotine/tobacco.  But while this may describe many users of meth, crack, and other drugs, as well as some gamblers, and some online computer game players, it is impossible to reconcile that image with the deliberate and calm use of tobacco, day after day, for decades.  Smoking might eventually result in the loss of some years of someone’s life, but that is hardly the same as compulsively gambling or (non-tobacco) smoking away your life over a matter of months.

To be clear, I do not recommend volunteering the observation that “addiction” is not scientific and is barely meaningful except in very rare environments – when you are having very serious conversations with seriously interested people or, if you happen to ever find yourself in the situation when you can control the discussion and keep going (without being heckled) until you make your point, such as when being cross-examined or teaching a class.  Instead, kick it back to the person who used the term.  It was their word after all!  If necessary, say push them to make the next move with, “it means different things to different people, so since you brought it up, what does it mean when you use it?”

With that, the dialog tree begins.  What do they answer?

1. It means that they do it compulsively even though it is rapidly destroying their lives.

Unless the conversation has recently steered through what “addiction” means in the context of meth or gambling, no one is going to say that or anything equivalent.  So it is probably not necessary to rehearse the answer, “seriously? you do know we are talking about tobacco and not meth, right?”  But I lead with this possible answer because it is often what people have been tricked into subconsciously associating with smoking, via the use of the word.  This means that if they are foundering about, looking for an answer, then they are probably realizing that this gut feeling is clearly absurd when they actually think about it.  They might even concede the point right there.

But if you sense someone is foundering but offering no concession, you can always put voice to their struggle.  Assure them that it is not an easy question because the word is mostly used to confuse people rather than inform them.  And when they finally do offer an answer other than this one (and they will — it is a natural human tendency to make up an answer that justifies your gut feeling, even if that answer does not really explain the gut feeling), be ready with a remark like “well that does not sound like such a terrible thing to worry about compared to the health costs of smoking, does it?”

2. It means people can’t quit.

This is probably the most common answer, and one that people seem to make sense right up until the time they say it.  It is also the easiest to respond to.  Just return to the previous post’s simple approach:  If a smoker cannot quit tobacco/nicotine, it is clearly better that they use it in a way that poses very low risk rather than being forced to continue to smoke, right?

I would, however, urge you to not stop with that if you are in a conversation that can handle greater nuance.  If we just leave unchallenged the absurd claim that smokers or other tobacco/nicotine users cannot quit, it opens the door for all sorts of terrible analysis and policy.  Obviously everyone can quit.  Anyone would quit if, say, they were told (and believed) that they would die tomorrow if they smoked another cigarette, or that they would be tortured at Guantanamo, or a close relative would be executed.  Many people do not quit because the costs of quitting are too high, but it is not impossible even for them.  (I suppose there are a few seriously troubled or mentally disabled people who would not respond to these incentives, but for them smoking is hardly their worst problem.)

This is not merely picky semantics.  If we do not resist the claim that tobacco/nicotine users “cannot” quit – or that something close to this is true – then we concede a particularly pernicious set of ANTZ lies.  Only this concept of “addiction” allows them to get away with the obviously absurd claim that tobacco/nicotine has no benefits (why would someone keep doing something with no benefits? because they “cannot quit).  But if all of the effects of tobacco/nicotine are negative, and every user is entirely an involuntary victim, then any effort to eliminate tobacco is justified.  This notion is the bedrock of the worst ANTZ lies and abuses.

Moreover, this “no benefits” claim means that the only reason anyone chooses THR over abstinence is because they cannot quit entirely, which must be what they would really rather do.  If that is conceded then it is easy for ANTZ to argue that THR products should be tightly controlled as prescription-only products that are merely appealing enough to keep people off of cigarettes.  (Sound familiar?)

So, when conversing with someone who is genuinely interested in learning and understanding, or when talking to an ANTZ but with others listening, there is some value in pulling out the above challenge to “cannot”:  “Are you saying that a substantial number of smokers would refuse to quit even if they were credibly told that if they kept smoking they would be killed tomorrow [or whatever]?” “…um, no…”  “Ah, so it is not that they cannot quit, but that given the actual costs and benefits, they are choosing to not quit.  How is this ‘addiction’ any different from any other consumer choice?”

In the next post, I will continue with more branches of the dialog tree.