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.