Tag Archives: addiction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

by Carl V Phillips

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

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

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

What do you mean by addiction?

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

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

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

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

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

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

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

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

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

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

2. It means people can’t quit.

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

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

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

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

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

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

Responding to, “but they are still *addicted*!!!”

by Carl V Phillips

Sorry for the blog absence.  I was spending that same niche of time and energy in a mass email conversation that consisted mainly of some of the “establishment” researchers and political operatives.  But most of them do not much care for we populists who try to represent the actual stakeholders, to say nothing of their feelings about the criticism and scrutiny that are considered necessary parts of science by those of us who come from real sciences, but are avoided in the cozy uncritical confines of “public health”.  So I was basically told to shut up.

That clear message of “we have the insider influence and your inconvenient observations are not welcome in our cozy little club” was a reminder that we (as in We The People) need to lead the fight for THR.  Even our closest allies among those in institutionalized tobacco policy are not really very close allies.  So I return to the series I started on how best to communicate our arguments to the vast majority of people (and, thus, lawmakers) who would be pro-THR if they heard and understood the truth.  (Click on the category “truths” in the sidebar to see the previous ones.)

Many anti-THR arguments are voiced exclusively by people with hidden agendas and who are just saying anything that comes to mind to try to muddy the waters.  But it is my impression that a lot of people who say “but this is just another addiction”, or something similar, are honestly concerned and thus can be honestly persuaded that they are drawing the wrong conclusions.

So how to respond?

This is an interesting one, because it is one of the few cases where I think the simplest response (that we need to use when the target audience is either not able to understand anything complicated, or when we only have a few seconds to make the point) is not a dumbed-down version of the complete and more precise response.  So, for example, the one-sentence answer to “how hazardous are e-cigarettes?” is a highly simplified version of the more complete and scientifically correct version of the answer.  But on the topic of “addiction”, the simple response is quite different from the more complete and correct discussion that I will come back to.

I will start with the simple response, because that is what most of us need to use most of the time.  If someone argues that THR should not be endorsed because it is just replacing one addiction with another, the one-sentences response should usually be:

If some people are addicted, then isn’t it better than they use a product with very low risk instead of smoking?

Boom!  This response, all by itself, is remarkably effective at winning over many people who have been tricked by anti-THR lies and have not really given the topic any serious thought.  Should this response steer the conversation in the direction of, “but it is better if they just quit entirely”, as it often does, then the next response is equally easy (though it does require a bit of scientific knowledge, which I presented in a previous post):

Smoking for just a couple of more months creates more health risk, on average, than a lifetime of using a smoke-free alternative.  Do you really think that everyone who would switch is going to quit entirely within two or three months?

This can also be supplemented with:

Once someone has switched, if you still think it is best for them to quit entirely, then you can try to get them to that point.  But shouldn’t we go ahead and almost eliminate the health risk in the meantime?

Admittedly, this is potentially slightly disingenuous depending on your beliefs, because it takes advantage of the other side’s rhetoric (making it fair and downright enjoyable, but also a bit cynical).  Many of us believe that if someone is using a low-risk product that makes their lives happier, then the powers that be have no business trying to push them to stop, but we can still quite legitimately say “go ahead and give abstinence promotion your best shot, but do so after the risk has been removed.”  However, we also know that — contrary to ANTZ rhetoric — most support for abstinence campaigns will probably collapse once most people are using low-risk products.

But, as I said, this is the simplified version.  Also that slight bit of disingenuity is a great legitimate way to corner the ANTZ and the lie-based disingenuous motive many of them have.  They pretend to care about health while actually trying to keep the risk high to support their abstinence-only approach.  Thus, their honest response to the previous argument is, “but most people are not going to want to quit once they have found they like a smoke-free alternative and they understand how low the risks are.”  But let us just see what happens when they offer that response.  We have a tough fight, so we deserve the joy that comes from seeing the anti-THR liars trapped by their own hidden motives.

There are some more complicated directions that this conversation can be taken, if it continues.  We can point out that the evidence shows that many smokers who never managed to just quit entirely seem to have an easier time quitting entirely once they have switched to an alternative product.  There is also the observation that long-term smoke-free use of tobacco/nicotine is so similar to long-term use of coffee that it is difficult to see much of a difference.  However, be aware that while the coffee argument seems to be persuasive to some people who are already sympathetic, but it does not seem to have much traction for changing people’s minds.

The last observation does bring up a question that leads us into the rather different response to this issue that can be pursued when we are not limited to soundbites:

What do you mean by “addiction”?

That is not a path to go down unless you have a bit of time and a receptive listener rather than a mob scene.  (It is way too easy for dishonest opponents to ridicule this very legitimate question.)  In the next post (and two after it), I will suggest some thoughts of how to travel that more complicated path if you so choose.