…or so goes the refrain of the addict. I was going to put up a more substantive, well-researched post, but I wanted to give you a few weekend thoughts to chew on.
I deal with addictions a lot, but the most common and deadly one is tobacco. Tobacco is responsible for millions of serious illness and deaths every year in the U.S., all of which are preventable. But, like other substance use disorders, we don’t really know how to talk about tobacco addiction (which is more properly “nicotine addiction”). There is no doubt that nicotine is powerfully addictive, and the health and social consequences of cigarettes are huge. Clearly, almost any rational person would quit smoking once they were told the consequences.
But of course, they don’t.
If I have a patient with coronary heart disease, the medical regimen that they need to be on costs about $16.00 per month (aspirin, beta blocker, ACE-inhibitor, statin). Often, patients tell me they can’t afford these life-saving medications, but they may still have a $120.00/month smoking habit. Even if they have symptomatic lung disease and peripheral artery disease, they still won’t quit. Clearly their behavior is not entirely rational. It often seems like smokers are just not exercising any will-power.
But this is where the “dualism” problem comes in (as DrugMonkey has pointed out in several conversations). Where does will-power come in when discussing addiction? Does it have something to do with the “psychological” rather than the “physical” addiction? Since “mind” is an epiphenomenon of brain, it can be argued that this is an invalid division. All addiction is a “brain” problem. Drugs that cause physical dependence—such as nicotine, alcohol, heroin—cause profound changes to the brain and other parts of the body. Wherever receptors for the drug are present, or where affected brain exerts an effect, these areas are affected by drug dependence. What sense is there in creating a division of the mind and body when referring to addiction?
Part of the reason for doing this is the treatments we have available—support groups and counseling are often thought of as part of the psychological treatment, but of course these interventions cause changes in the brain just as medications do.
Just as important, we are much more comfortable laying blame on people for their inability to control the psychological symptoms rather than the physical symptoms—the physical is seen is being “more” outside the control of the individual.
Does creating sanctions help the addict? Will creating financial penalties (such as higher insurance rates for smokers) help people to quit? Isn’t feeling like hell already a sanction that isn’t working?
Clearly (to me, at least) since nicotine addiction causes so much suffering and financial loss, we need to treat it comprehensively, based on the evidence when evidence exists. There should be subsidies for anti-smoking programs, including medications such as Chantix. Behavioral treatments—support groups, limiting smoking areas—should be implemented.
There is no easy way to tell which smokers do it “by choice” and which are truly addicted. We need to have a national program to help people quit—and scary statements on the package do very little. This will cost money, but it’s a helluva lot cheaper than a cardiac cath or ICU stay for everyone.