Tag Archives: addiction

by Carl V Phillips

A random science lesson, because I have not written a good “the conventional wisdom — how everyone looks at this and thinks is self-evidently true — is not the only plausible explanation” lesson in a while (other than tweet storms), and just want to. I was triggered on the topic by some chatter I saw about a recent paper, though neither of those is particularly important (so no links).

Consider an example from another realm: A large portion of significant original contributions in theoretical mathematics are figured out, or at least the seeds are completed, when the author is under 25-years-old, or even under 20. The conventional wisdom is — or was (I have been out of that field for a long time) — that people’s sheer physical brainpower in this area declines with age, and that this is the only time someone has the ability to outperform all who have come before them. It is like being a professional athlete. You can be a perfectly solid athlete or science geek at 60 if you have the natural skills and keep at it, but to be among the absolute best — among the 0.001% who can be a performance-level jock or breakthrough mathematician — you have to have both the natural skills and be at your lifecycle physical peak.

But there is a plausible alternative theory that was pointedly ignored in that conventional wisdom: Generations of mathematicians have already worked out everything, within the bounds of what occurs to them to work on, that can be done by just plugging away at it. Therefore, new breakthroughs only come when someone is wired enough differently to see something beyond that, either in terms of recognizing something outside the existing bounds to pursue or some striking insight into a within-bounds problem. That is, they need to not just be solid in the skills of the field, but have one little cognitive quirk that no one else had. Either they have that when they are 16 or they don’t. If they do, they make their breakthrough early because they can. It is not about age — if one was somehow prevented from making the breakthrough for a couple of decades (but managed to keep up his skills in the field and was not scooped), he would have made it later.

Perhaps the relative contributions of those two factors has been largely resolved — as I said, I have been out of that area a long time. In contrast with the tobacco realm, most everyone who is aware of that debate is a smart clear thinker, so they may have long since worked out how much each of the stories explains the association of age and breakthroughs. But the point is that the naive explanation for something being associated with age — that it must have been entirely caused by age itself — was not so obviously correct as the conventional wisdom had it.

This is a metaphor, of course, for all the claims about tobacco use initiation, habituation, “addiction”, and such that are attributed to age because they are associated with age. This is a fail for exactly the reason found in the alternative theory of math prodigies: If something were able/likely to happen sometime in someone’s life, but not in most people’s, the fact that it happened early among the former (because it could) is not informative.

So we have the conventional wisdom that because smokers (etc.) mostly start fairly early in life, if you stop them from starting early, they never will. This is undoubtedly true to some extent. Everyone gets more set in their ways about what they do and do not do after adolescence. For smoking specifically, having adult-level judgment and a more forward-looking mindset makes it much less appealing (though this is not true for low-risk and potentially net beneficial smoke-free products). But it is obviously not nearly as true as is generally claimed. Someone who would have used a product at 16, but is somehow kept from doing so for two years does not magically revert to having the average lack of interest (which means being below the line for inclination to use the product) at 18. The same is true if you substitute age pairings 18…21 or even 16…40.

My goal here is to just immunize readers against the common naive error by planting the idea, so I am not going to delve deeply into the data. But just notice that transitioning to “smoker” status has gone down sharply among 14-year-olds in the US population, but not 18-year-olds. It is down overall, of course, but it is impossible to not notice that some of the “success” at earlier ages consists of delay rather than elimination. If the conventional wisdom were true, we should not have seen the sharp rise in the average age for that transition; the conventional wisdom says that the people who are pulling that average up do not exist.

The issue is clearer still for claims about early-initiating smokers (etc.) being more habituated (usually called “addicted” of course, but my readers will understand why that is bullshit rhetoric). If there is any variation within the population in terms of who is inclined to become strongly habituated — and obviously there is, due to both biological and social factors — then of course we see this. Those who are most inclined quickly become regular consumers upon first trialing at, say, 13. Those eventual-smokers (etc.) who ramp up more slowly were not so enamored, and so waited until it was easier to do. The former group are undoubtedly less likely to quit, have higher “dependence” scores, etc. The rhetoric attributes all of this obvious confounding to causation.

This does not means that there is no biological effect of early smoking (etc.) that causes greater inclination later in life, of course. But it does mean that the main body of evidence deployed in support of that claim is worthless. My readers presumably understand that the evidence deployed in support of “gateway” claims is bullshit because it merely observes the inevitable association across individuals choosing to use very similar products. Any association that is inevitable due to confounding cannot be said to be evidence of any causation without further serious analysis, analysis that tobacco control “researchers” never do. The present case is a bit more subtle than the gateway case, but it is exactly the same problem.

Similarly, these observations do not mean that somehow preventing an incidence of initiation at 16 is always just be a delay rather than permanent prevention. There is some probability of each. There is ample reason to believe that the probability of mere delay is fairly high. Yet the claims based on the observed association almost always bake-in the unstated and unexamined assumption that the probability of it being mere delay is approximately zero.

I did not become a regular drinker until my 30s, or a regular user of nicotine products and sometimes [redacted because we live in a fucked-up anti-liberty police state when it comes to stuff like this] until later still. But I trialed all of these before I was 20 and did a bit during my 20s. Those who want to say “it is all about ‘youth’ initiation!!!” will spin this into supporting their claims. Look closely at their claims and you will see that most of them would attribute my later behavior to those largely forgotten moments from adolescence. I can tell you there was no causal continuity between the trailing and later period of ongoing use, except via the confounding pathways. Granted I am a bit unusual — I have taken up quite a few things at time in my odd life that very few people ever do if they do not start at a much younger age: professional popular writing, various sports, farming, having babies. But the oddity there just illustrates the point that acting upon willingness or interest gets mistaken for causation, because willingness and interest are usually not kept latent for so long.

Consider one more metaphor that illustrates a different angle on this: adults who choose to visit Disney World (i.e., because they like to, not just because they are roped into taking their kids). There is undoubtedly a huge association between this and having visited as a child. Undoubtedly it is causal to some extent, but it would be obviously stupid to assume the association is all causal. Among those negative for both traits are those with a religious or semi-religious objection to visiting, those who disdained the idea as children (often due to their particular subculture think of it as belonging to Others), and those for whom making the trip is unaffordable. Those traits tend to be fairly persistent through the lifecycle, and this alone creates an association. Among those positive for both traits are those who just love stuff like that, and so pushed their parents to taken them and later choose to go again when they could. This increases the association with no causation in sight yet. Finally, among those positive for both are those who go back because they remember how much they enjoyed it as kids, the causal group. The “logic” of the tobacco control literature and rhetoric would be to claim that the association is caused entirely by the latter group.

I would assume that the marketing people at DisneyCorp — who are presumably much better at their jobs than most tobacco researchers and pundits are — have this all worked out and make extensive use of that knowledge. It would undoubtedly be possible to form honest estimates that separate the contributions of causation-by-age and mere temporality in the tobacco space also. But few in that space even recognize this is an issue, and most of them want to pretend it is not, and few of them have the skills to do the (actually pretty simple) analysis to try to sort it out.

It is one more persistent set of lies (partially intentional, partially due to Dunning-Kruger) to be aware of when analyzing tobacco control claims.

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.