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.

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

  1. Pingback: The more complete response to “…but they are still addicted!”: a dialog tree (part 1) | Anti-THR Lie of the Day

  2. Hi Carl, this is an excellent series of posts.

    I just wanted to add another component of addiction, one that I believe essential in any good definition of the term: namely the chronic relapsing nature of addictive behaviors (not that this alters the substance of your posts in any way).

    I think most smokers would recognize that there is immense individual variation in the ability to tolerate tobacco withdrawal, just as there is a large difference in the quantities of nicotine individual smokers consume. But the relapsing nature of tobacco smoking appears to be universal, when one considers the evidence from NRT trials, as well as a huge body of anecdotal evidence.

    Some neuroscientists view the relapsing component of addiction as relating to “sensitization” – a neuronal process that exists in opposition to tolerance, whereby the pathways responsible for orienting an individual towards rewarding stimuli become overactive in the presence of drug-related cues. Phenomenologically, sensitization is the ‘craving’ component of addiction.

    This sensitization process operates differentially according to a drug’s method of action, its method of delivery and its potency, although the final common pathway is always the mesocorticolimbic system. In particular, the faster the complement of a drug dose is delivered to the CNS, the more sensitizing that drug is, and this is true regardless of the specific pharmacological method of action.

    The process also appears to be highly dependent on the context of the drug’s use – the classic example being hospitalized patients who are given long-term morphine treatment, developing both tolerance and withdrawal symptoms, but who do not go out afterwards and attempt to purchase black market opiates (although there are a minority who do).

    Why have I brought this up? Well, it seems to me to be highly relevant in two ways to electronic cigarettes. In the first instance, relating to the degree to which tobacco-naive people are likely to become sensitized to nicotine as provided by electronic cigarettes. Nicotine as provided by tobacco smoke is known to be highly sensitizing, in some susceptible individuals possibly after as little as one cigarette. It is highly unlikely that electronic cigarettes have this effect, as the method of delivery is slow; equivalent, I believe, to that of NRT. Additionally, nicotine is (with standard ingredients) provided in the absence of other compounds known to act in a synergistic fashion with nicotine. Secondly, this probably explains why pharmaceutical products are viewed by most smokers as being unpleasant and ineffective: they lack the sensory cues that smokers are accustomed to – the sight of the smoke, the sensation of “throat hit”, the flavoring component – all taken care of by electronic cigarettes.

    As to the terminology: I’m not so sure that Addiction is so lacking in scientific utility. Yes, it’s certainly a term that is misunderstood and often used in imprecise ways, but there are workable definitions and there is clearly a range of behaviors that fall under the “addiction” appellation . This is a widespread problem in brain/behavior science – the vocabulary available often is insufficient to describe observed phenomena sufficiently, meaning that terms must be defined each time they are used (not necessarily a bad thing, by the way, despite the labor intensiveness of such enterprise). The Churchlands have argued convincingly for a new vocabulary, but I suppose the fear of appearing jargonistic has put most researchers off doing so.

    Of course, this wouldn’t have been the case even 100 years ago, where new nomenclatures were constantly arising to describe phenomena in the natural sciences…..but I digress.

    Many thanks for starting this blog. I’m a little late to it, but I’m really enjoying reading your posts.

  3. I echo Oliver’s sentiment on the good thinking your doing in this series Carl! :)

    Oliver I’d like to add a bit to what you said though. You wrote, “I just wanted to add another component of addiction, one that I believe essential in any good definition of the term: namely the chronic relapsing nature of addictive behaviors ”

    I think the term “chronic relapsing nature of addictive behaviors” is misleading in some ways, since it implies a continuing physical addictive force at work rather than a simple knowledge of a strong benefit from re-indulgence. Smokers know from experience that the most enjoyable time of smoking is after having not smoked for a while. So, if it’s been a day, a week, a month, or a year since a regular smoker last smoked, they’re strongly tempted to “have just one” because they strongly believe it will be intensely enjoyable. The problem that sets in after that “just one” may be partly physical, but it’s also strongly psychological: the “record” (as in “How long have I stayed dry?” from the alcoholism model) has been broken, so there’s far less motivation to “keep it going.” Plus there’s the newly recent memory of just how nice it felt to actually smoke again. Put those two together and there’s a very significant psychological benefit to convincing oneself that “Well, maybe I’ll just smoke two or three a day…” and usually ending up back at a pack a day instead out of habit and physical “addiction” tendencies.

    And a second point: you wrote, “the method of delivery is slow; equivalent, I believe, to that of NRT. ” I would disagree. I’ve experimented with NicoGummy things, just to see how they worked, and I’ve recently begun sampling the e-cigarette world to see how it works as well. The gums *are* slow in terms of any effect felt. When you haven’t smoked for a few hours and you take two or three puffs in the first minute or so after lighting up it *feels* really good. Immediately. The gum doesn’t do that at all. You have to chew it for at least several minutes before feeling anything at all, and the feeling, while similar to what you get from a few puffs of a cigarette, isn’t close to being the same thing. The e-cigs are quite different: you “feel” the “good effect” pretty much immediately upon inhalation… in much the same way that you feel it when taking a puff from a cigarette. I’m guessing, all else being equal, that the immediate gratification from the e-cig makes it more likely to be a long term success for a smoker who isn’t actually self-motivated to stop smoking.

    – MJM

  4. Michael, thanks for your reply.

    You wrote that the chronic relapsing nature of addiction “implies a continuing physical addictive force at work”. And indeed it does – but this

    is my point: The available and growing evidence, from a variety of sources, is that neurological sensitization does indeed render individuals

    susceptible to relapse for many years, if not permanently.

    The logical fallacy you’ve stepped into here is that “psychological” is anything other than a manifestation of brain chemistry. It’s not, of

    course, and behaviors (and cognitions) can be observed as a result of specfic changes to neurological functioning.

    The point that needs to be made is that the “higher-level” cognitive appraisal of “have just one” comes as a result of the sensitization towards

    the cues (exposure to cigarettes, in this case). In other words, a strong feeling of desire to smoke preceeds the cognition “I’ll have just one”.

    And the desire (caused by sensitization) is so strong that the rational modifier of “but I probably shouldn’t, because the chances are that i’ll

    be back on the slippery slope towards full time smoking again” is either absent or faint and ignored.

    By way of illustration, consider this analogy: If you had narrowly escaped a car accident, you might later describe yourself as thinking “I

    thought I was going to die”. However, it’s highly unlikely that you did indeed have this cognition – instead you would likely have been absent of

    any cognition, but entirely focussed on avoiding the collision – the cognitive appraisal would have been secondary to the reactions. This analogy is no different in substance to that of having a desire to smoke, followed by a cognition of “I’ll have just one – and it’s this “desire” component that is higher in individuals sensitized to a drug than drug-naieve individuals.

    On your second point – you’re not actually disagreeing with anything I claimed, although it might seem that way. It’s perfectly possible to have

    a strong “satiation” reaction to e-cigarettes despite the slow delievery of nicotine, precisely because the sensory cues (inhalation, vapor,

    throat hit, etc) are satisfied. Again, this is due to the sensitization of the mesocorticolimbic system to these cues – nicotine gum does not

    have this effect in you – but nicotine lozenges do in me (I’m a long term lozenge user, as well as a vaper); I get a mild “satiation” effect from

    a lozenge as soon as I place it in my mouth, despite knowing full well that the nicotine will not be at peak levels for another 10 minutes. I

    have this effect because I’m sensitized to them after using them for many years.

    “I’m guessing, all else being equal, that the immediate gratification from the e-cig makes it more likely to be a long term success for a smoker who isn’t actually self-motivated to stop smoking.” I couldn’t agree with you more, but it’s probably not because of the specific method of nicotine delivery.

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