Tag Archives: addiction

Is “ecigs are a gateway” the new “addiction”? (i.e., fiercely debated in the absence of defining the term)

by Carl V Phillips

Just a quick note to vent my amusement about the never-ending war of commentaries about whether e-cigarettes are a gateway to smoking. That war apes a scientific debate, but it is not one for several reasons. Most notably, no one (on either side) ever explains what they would mean by “there is a gateway effect.” There are also serious problems about what would constitute useful evidence.

I suppose you don’t vent amusement, do you? You vent frustration. And it is frustrating that I recently spelled most of this out and yet even the ostensible scientists in the debate do not seem to have bothered to read that or any of the other serious scientific analysis on the topic. And they won’t read this either, so it does not seem to merely be a matter of tl;dr. I blame social media and the motivations it creates to write without doing the reading. And the thirty-second news cycle. And blogs. And Twitter. Also, would you kids please be so kind as to get off my lawn. Continue reading

More on the FDA ecig workshop

by Carl V Phillips

Those of you who watched my contribution to the workshop (which you can do by following the link in yesterday’s post) probably found the most memorable observation to be the one about San Francisco. But I am rather prouder of not missing a beat regarding a later question. Leading into that, there was a rambling multi-part question to the panel, which a couple of others responded to bits of. I took the mic last to respond to the phrase “renormalizing smoking” in the question. Continue reading

U.S. government declares that vaping is not addictive (nor is smoking)

by Carl V Phillips

Sorry for the blog silence. I have been immersed in working on papers, with some interruptions to give testimony and interviews. I happened to stumble across this page from the U.S. National Institute on Drug Abuse (NIDA) that addresses the question, “Is there a difference between physical dependence and addiction?” As my readers know, I have pointed out that the use of the word “addiction” in scientific analysis is completely inappropriate, given that the word has no accepted scientific definition and, indeed, it appears that no one can even propose a viable candidate for such a definition. Similarly, no policy debate — at least about tobacco products — should ever be allowed to depend on claims about “addiction” since those making such claims are usually implying they have scientific meaning, and even if not, there is not a shared interpretation of the term even in clinical or common language. Continue reading

MD Anderson Cancer Center lies about and e-cigarettes and other tobacco products

by Elaine Keller

In a press release dated November 7, 2013, the University of Texas MD Anderson Cancer Center purported to debunk myths about tobacco. However, the end result was to perpetuate some myths and to introduce a few new ones.

The first heading is Tobacco Myth #1: Almost no one smokes any more. Lewis Foxhall, M.D., vice president for health policy at MD Anderson makes a good point that although the prevalence rate has been reduced from 42% of adults in 1964 to 19% of adults in 2011, the number of adults who smoke is still too high.

The details tell a more interesting story, though.  Most of that decrease happened a long time ago, and the number of smokers hovered around 46 million from 1990 through 2009, with the small reductions in the percentage of the population who smokes matched by increases in the size of the population.  It turns out that the decrease in the percentage roughly matched the increase in the popularity of smokeless tobacco as a substitute for many years, though it was difficult to conclude with confidence that THR was responsible for the progress. This changed when use of e-cigarettes began rising, and the number of adult smokers began dropping in 2010 (to 45.3 million) and continued into 2011 (to 43.8 million). (Source)

Continuing under the first heading, long-time ANTZ Ellen R. Gritz proceeds to perpetuate the myth that “the exorbitant and seemingly unlimited advertising dollars spent by tobacco companies” is the driving force behind youth initiation of smoking.  The obviously-false premise that no one actually likes to use tobacco, forces the ANTZ to concoct the tired myth that advertising must exert some magical power over people.

The basic claim is silly on its face, and the details make it worse.  Tobacco advertising is one of the most highly regulated forms of marketing. Cigarette ads were banned from television on April 1, 1970, which was a huge gift to the tobacco companies, who could save the cost of advertising without losing customers to their rivals who were also forbidden from spending much.  It is not clear that total sales were reduced much at all.  But having a large enough advertising budget became pretty easy, since without buying television ads, but far the most expensive advertising, and later not being able to buy many other types of ads, there was not all that much to spend on.

And where are kids seeing these ads?  According to Ad Age Media News, R.J. Reynolds states that “the company will only advertise in magazines where at least 85% of readers are 18 and older when data are available on readers older than 12. For magazines that offer only data on readers 18 and older, the company buys ads if the median age of the audience is 23 or older. Lorillard, the third largest maker of cigarettes, has similar restrictions on its magazine advertising. The largest tobacco company in the U.S., Philip Morris USA, a subsidiary of Altria, does not advertise tobacco in print, according to spokesperson.” (Source)

The next heading, Tobacco Myth #2: e-Cigarettes, cigars and hookahs are safe alternatives implies that smoking tobacco cigarettes is no more hazardous than using any of the three named alternatives. The press release continues, “Fact: All tobacco products, including e-cigarettes and hookahs, have nicotine. And it’s nicotine’s highly addictive properties that make these products harmful.”

False: Nicotine is not what makes smoking harmful. What makes smoking harmful is the tar (solid particles in the smoke), carbon monoxide, and other chemicals of combustion that cause the lung disease, heart attacks, strokes, and cancers linked to smoking. Nicotine does not cause any of these diseases. In addition, this blog has repeatedly explained the several reasons why the “highly addictive” is also nonsense.

Nicotine is not 100% safe — it poses basically the same risks as caffeine and other mild stimulants. It does cause a temporary increase in heart rate and blood pressure, but it does not cause hypertension. Nicotine is probably harmful to a developing fetus (though the research on the effects of nicotine ex-smoking is limited) and it is claimed to have detrimental effects on the adolescent brain, but the support for this is quite thin.

Cigars and pipes are intended to be smoked without inhaling. Research shows that smoking-caused disease risks are lower by about half among cigar and pipe smokers who don’t inhale than they are among cigarette smokers. E-cigarettes do not produce smoke at all, and as far as we can tell are close to harmless for a non-pregnant adult.  Moreover, nicotine also has beneficial effects. (Source)

Under the same heading, Alexander Prokhorov, director of the Tobacco Outreach Education Program at MD Anderson tells some whoppers. “The tobacco industry comes up with these new products to recruit new, younger smokers, and, they advertise them as less harmful than conventional cigarettes.”

First of all, e-cigarettes were invented (multiple times) as anti-smoking efforts by people outside the tobacco industry, most recently by a Chinese pharmacist  who wanted to quit smoking, but was unable to tolerate nicotine abstinence, even after watching his father die of lung cancer. It is even more absurd to make that claim about cigars and pipes, which predate cigarettes by centuries.

And if Prokhorov does not know that e-cigarette (and cigar and pipe tobacco) companies cannot advertise their products as less harmful than conventional cigarettes, I have to wonder: On what planet has he been living? If an e-cigarette company makes health claims, the FDA can order their products to be removed from the market until after they undergo the lengthy and costly New Drug Approval process. What company would not simply comply with the request to remove the health claims?

Prokhorov’s last statement, “But once a young person gets acquainted with nicotine, it’s more likely he or she will try other tobacco products,” is the classic argument of someone who knows there is nothing wrong with the drug he is attacking. There is no basis for the belief that e-cigarette use leads to smoking conventional cigarettes. The same fear was expressed when the FDA was considering approval of nicotine replacement therapy products. Despite the fact that nicotine patches, gum, and lozenges were not only approved, but became available over the counter, there are no known cases of new nicotine addictions attributed to their use. Researchers looked at the issue as it relates to e-cigarette use and determined that due to the slower elevation of nicotine in the blood stream from e-cigarettes, they are unlikely to hook new users. (Source)

“At this time, it’s far too early to tell whether or not e-cigarettes can be used effectively as a smoking cessation device,” lied Paul Cinciripini, professor and deputy chair of behavioral science and director of the Tobacco Treatment Program at MD Anderson. That will come as surprising news to the hundreds of thousands of smokers who have effectively used e-cigarettes for smoking cessation, many of whom were very interested in quitting but found that other options all failed them.

Under Tobacco Myth #3: Infrequent, social smoking is harmless, David Wetter, Ph.D., chair of health disparities research at MD Anderson states, “If you are a former smoker, data suggests that having just a single puff can send you back to smoking.” If this overblown claim were true, it stands as a great argument for switching to e-cigarettes. Among those who totally switch to e-cigarettes, the desire to take that one puff is low, and indeed, those who use e-cigarettes that do not remind them of smoking (particularly by using non-tobacco flavors) find that when they try that single puff on a cigarettes, it is terribly unappealing.

Now if the anti-nicotine crowd manages to convince a gullible public and captured regulators that all those shelves of yummy-sounding flavors exist for the sole purpose of addicting non-smoking youth to e-cigarettes, such flavors will be banned. In that case, it is possible that former smokers will be more vulnerable to this relapse scenario because they will be stuck with e-liquid that tastes like tobacco and reminds them of smoking.

But the press release saved the biggest whopper for last: Tobacco Myth #4: Smoking outside eliminates the dangers of secondhand smoke. “Even brief secondhand smoke exposure can cause harm.”  First, if they really believed this, they would be pushing hard in favor of e-cigarettes, which do eliminate the dangers of secondhand smoke. But, of course, they know this is not really true. The reduction in air quality from outdoor smoking is far less than the reduction in air quality from being inside, where the concentration of toxins (entirely apart from smoking) is many times as high as it is outside, even if there is a whiff of cigarette smoke in the air.

William Saletan wrote about the topic in a Slate article, having looked at two studies of outdoor smoke exposure recommended by former EPA scientist James Repace as proof of the dangers of outdoor cigarette smoke exposure:  “Again, the data confirm common sense. The more open the space and the farther away you are, the lower your smoke exposure. To get the kind of exposure you’d suffer indoors, you have to stand within two feet of the smoker.  Move seven feet away, and you’re “close to background,” i.e., breathing normal air. I recommend greater distance than that, just to be safe. But you don’t need to ban smoking throughout Central Park.” If people at MD Anderson make a habit of keeping their face within two feet of others when standing outdoors (assuming they are not planning to kiss them), it might be an even more anti-social habit than their habit of lying to people about THR.

Does ANYONE have a valid definition of “addiction”?

by Carl V Phillips

Sorry for the radio silence.  Was traveling, and then exhausted and sick.  During my travels, I had a few interesting debates about the concept of addiction, and promised to write the following, which I finally have completed.  The funny thing about all debates about addiction that I have ever participated in is that whenever someone defending the use of that term (pretty much always in the context of nicotine, since those are the conversations I am in) is challenged to explain what it means, they cannot.  Quite often – in a bit of rather patent irony – they also get mad at me for daring to suggest that it is not well defined, even as they fail to offer any useful suggestion about how to define it.

Addiction exists in the same sense that happiness or beauty exists:  It is a “know it when I see it” concept we are familiar with, and most people use the common language (i.e., informal) term.  But it does not have a scientific or even medical definition.  If words like “beauty” are used in a scientific context, the author needs to define how he is using the word, because the common language notion is not precise enough.  Those who use “addiction” in a scientific context, without explaining what they mean by it, are creating confusion (intentionally, in most cases, I would guess).

For example, in the debate about THR, it is often claimed that those who quit smoking by switching to a low-risk product are still addicted.  But are they?  That depends on what the word means.  But even when concrete claims like that are being made – so the word is not an aside, but the crux of the discussion – no one actually explains what they mean by the word.  (Aside:  Note that usually the most effective quick response to the silly “but they are still addicted!!!!” rhetoric is not to attempt the actual thoughtful discourse presented in this post, but to just say something like, “So what? They are addicted to something that is almost harmless” or the snarkier, “So you would rather someone die from lung cancer than stay addicted?”)

It is definitely possible to create a valid definition of addiction.  Most everyone agrees that there is such a thing, though not necessarily that it covers vaping or even smoking.  Consider the following (labeling it Scenario 1 to refer back to it):  A person uses meth.  He knows he needs to go to work today (sober), or he will lose his job, which is his only means of support, paying not only for his food and housing, but also his meth.  If he smokes meth now he will have no money in a week.  Yet he fails to resist the urge to smoke now, in spite of the dire immediate consequences.

That seems to be addiction according to any typical understanding of the term.  But smoking cigarettes does not produce any experience similar to that story.  Indeed, using a term that evokes the image of Scenario 1 to describe tobacco use is misleading in itself, and that evocation is often intentionally used to make smoking seem worse than it is.  Still “addiction” might be defined to include smoking also.  Perhaps not.  And if so, does it include e-cigarette use too?  To address these points, we need an actual definition.

I have thought a lot about this over the years.  I have a pretty good idea of what the definition must include and what it must exclude.  So here is the challenge to those of you who are sure there is a defensible definition:  Can you provide one that fits the following parameters, or argue that some parameters are not reasonable expectations for the definition?   Note that the list is really a lot shorter than it looks, as summarized at the end.

Requirement 1:  The definition has to cover a situation like Scenario 1.  If anything fits this definition, it has got to be that.  This probably goes without saying, but it is included for completeness.

Requirement 2:  The definition cannot be so broad as to cover such behaviors as breathing and eating, or spending time with your family and trying to get your work done.  If the term is to be useful, it cannot be so broad.  Yet I would estimate that half of the definitions someone offers for the term include behaviors that are biologically necessary or are the most positive behaviors people engage in.  Note that taking refuge in the caveat “but it not biologically necessary” does not address the second of these (and anyone who offers a definition and then realizes they need that caveat has clearly not really given their definition any serious thought).

Put another way, the definition cannot be equivalent to saying “the benefits of the activity outweigh the costs by such a huge amount that the actor will not stop doing it.”  This is the definition of “highly beneficial” not “addictive”, and yet many proposed definitions of addiction do not make any distinction between those.

Requirement 3:  The definition cannot be so broad as to include eating dessert, driving, travel, or mountain climbing.  I am thinking of proposed definitions like “they keep engaging in a behavior even though it is bad for their health”.  (Note that this is not to say that once you had a definition, it cannot be found to apply to climbing or eating for some people; it just means that if the proposed definition includes all those activities for everyone, it is clearly a fail.)  Roughly half of the activities we habitually engage in are bad for our health on net, and we clearly would not call them addictive just because of that.  Setting a minimum risk level (to try to include cigarettes and meth but exclude burgers) is no solution, since there are not-necessarily-addictive activities that are riskier than smoking.  Also, imagine medical breakthroughs that lowered the risk of smoking to below the proposed threshold:  Any proposed definition of addiction that would be changed by finding a magic cure for lung diseases, even though the behavior did not change, is a fail.

Note, however, that the harmfulness of the behavior seems to be part of the common language notion of addiction.  The way the word is used, it obviously refers to something substantially bad happening to the addicted person (see Requirement 5).  If so, this suggests that the use of snus cannot be addictive, whatever the behaviors and urges involved, because it is close enough to harmless that the risk is not measurable.

Requirement 4:  The definition cannot just be “uses a drug” or something similar.  Often in political rhetoric (some of which pretends to be science), “addiction” is just used as an inappropriate substitute for “use”.  It is a political trick:  Take a word with nefarious implications and use it to refer to mere existence, and thereby tar a population with it without ever actually making any substantive claim.  It reminds me of my days in Berkeley at the dawn of what would come to be disparaged as “political correctness”, when the chatterers tried to declare “racist” to mean something like “gets any benefit from the fact that there are racial disparities” or merely “is white”.  Obviously a word misused like this becomes so broad that it loses all real meaning – except that it does not lose innuendo because the nasty implications of the word linger, even though the new definition has no nasty implications.  Cute, huh?

But regardless of whether it is intentional rhetoric or just the sloppy language of non-thinkers, it is clear that addiction does not just mean use.  We already have a word for that.

Requirement 5: It must necessarily be a bad thing that someone is addicted.  That is, if all you know is that a person is addicted to X and nothing more (including what X is), you know that this is a circumstance that is substantially worse than if it were not true.  To be consistent with the common language usage, it must be that “addicted to X” is bad independent of whether “does X” is bad (which relates closely to Requirement 4).  The way the word is typically used, it implies something bad in itself, beyond any badness of the activity.  Witness the common anti-THR refrain “but they are still addicted”, meaning “something is still bad when of ex-smokers are using a low-risk alternative, even though the activity itself has no substantial downsides.”

This is a rather more complex condition than it might seem at first blush.  It subsumes Requirements 2, 3, and 4.  This makes those redundant, but I went ahead and included 2, 3, and 4 as separate points to emphasize their implications which might be a bit too subtle if they were just subsumed under 5.

Separating those more undeniable specifics also allows for some aspects of Requirement 5 to be relaxed if anyone wants to argue that the proposed scientific definition need not be a negative epithet like the common language usage.  If that is one’s approach, it is important to keep in mind the political uses of the term (and the analogy to “racism” noted above), and to make clear when using the term that it is not necessarily a bad thing.  For example, the Chicago School economic definition of addiction by Becker et al. – which is the only candidate for a real scientific definition of addiction I recall ever having read in literally decades of interest in the subject – was proposed in the context of how it can be beneficial and a rational choice to become addicted.

Requirement 6:  The definition cannot appeal to untestable claims, let alone absolute claims that are clearly false.  In particular, any definition that includes a phrase like “cannot stop” is a fail.  First, it is probably not true: if you could credibly tell someone that, say, you would torture his mother or child to death if he smoked another puff, he would stop.  No doubt there are a handful of highly dysfunctional cases where even this consequence would not stop someone, but so few that the term would be almost vacuous.  Second, even without such extreme scenarios, it is impossible to know how someone would react under every possible realistic circumstance, and thus a universal such as “cannot” can never be shown to be true, and so any proposed definition that uses it actually includes nothing.

Requirement 7:  The definition must be based on behavior.  The phenomena that are referred to as “addiction” have to do with the actions and volitions of the actor, not the object of those actions (a drug or whatever) itself.  This is not to say that the implications of the object cannot be included in the definition (e.g., “addiction means that someone does X, and X has property Y” where Y might refer to a health hazard), but the characteristics of the actor (“does X”) are primary and any “property Y” is secondary.

In particular, this requirement excludes an appeal to “brain porn”.  (That term refers to the recent quasi-science of measuring people’s brain activity under particular circumstances and drawing worldly conclusions, ignoring that there is no basis whatsoever for relating the images to reality – hey, it makes cool pictures and uses fancy equipment, so it must be science, right?).  It is easy to make the case that a definition of addiction cannot refer to dopamine receptors, PET scans, and the like:  Recall Scenario 1.  Now consider some proposed definition of addiction that is based on brain chemistry, and imagine that you measured the brain activity of the person in the Scenario and found that none of the conditions were met.  Would you say “oh, I guess he was not addicted after all”?  Of course not.  Similarly, if someone had all the brain activity in a proposed definition, but could easily take-or-leave the behavior, we would agree that is not addiction.  So while brain porn might (might!) offer a prediction about whether addiction is present, it cannot be a defining characteristic.

Additionally, this requirement excludes defining addiction in terms of merely facing withdrawal symptoms (often called “dependence”) or having an acquired tolerance.  Those experiences might be part of the reason why someone is addicted, but they are clearly separate phenomena.  If someone has these but can take or leave the behavior nonetheless (which is a fairly common pattern for, say, caffeine) that cannot be addiction.

Requirement 8:  The definition cannot just beg the question but using other ill-defined terms.  If “addiction” is partially defined by “having a compulsion”, it is necessary to define “compulsion”.  (Also, if someone “has a compulsion” but does not act on it, is that still addiction?  You can go either way on this, but need to be clear about it.)

 

So, that is a very long list, but it also can be almost completely summarized as this short version:  A definition of addiction must be based on behavior and must not be so broad as to include every strongly desired behavior nor every behavior that creates health risks nor all use of drugs; meeting the definition must either be inherently bad or a case must be made that addiction is not necessarily a bad thing.  And, of course, it actually has to be a definition.

As I suggested, I have some candidate ideas.  But before offering those I would like to see if those who insist that there is a clear and obvious definition can tell me what they think it is.  I await your replies.  But based on my experience of the universal failure to actually answer the question, I will not hold my breath.

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.