White Coat Underground

I can quit anytime…

…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.

Comments

  1. #1 Blake Stacey
    January 24, 2009

    Since “mind” is an epiphenomenon of brain, it can be argued that this is an invalid division. All addiction is a “brain” problem.

    Well, yeah, but. . .

    When I get called over to fix somebody’s broken computer, I don’t start by writing a many-body Schrödinger Equation for the electrons flowing through its transistors. Knowing the dopant density as a function of position in the silicon chip is irrelevant to fixing the problem, as the real issue is that they’re running Windows Vista.

    Consider the state of my laptop right now: “Evolution and Firefox are running on Ubuntu. Firefox is pointed to such-and-such a page on White Coat Underground. . .” As far as I the user am concerned, this “state of being” could be realized by many mutually equivalent sequences of bytes in RAM; the blocks of memory allocated to various programs could start at different addresses, for example. Software written in higher-level languages doesn’t have to care about the bit-bashing details, either: the GreaseMonkey scripts I have customizing the appearances of the websites I view are indifferent to the hexadecimal addresses of memory sites.

    Furthermore, many different flows of electrons map to the same state of processor and memory. (That’s the familiar situation of statistical physics: oodles of microstates mapping to the same macrostate.)

    So, even in a system we understand pretty well — an engineered system — many levels of emergence intervene between the brusquely physical description of atoms and electrons and the description we actually employ in solving typical problems.

    I’m sure the brain is much simpler.

  2. #2 leigh
    January 24, 2009

    i don’t think comparing computer hardware vs software to brain vs mind is quite the legit comparison. after all, you can remove software and replace it with a few clicks. try doing that with memories and habits, among other things. your brain’s “hardware” is in constant physical flux due ot adaptations, responding to the environment, what you put into it, creating memories/associations, etc. computer hardware presumably does not change in that manner.

    at any rate, i came here to point out that i find it funny that people are willing to spend $160/mo on smokes, but a temporary $120/mo for chantix [no insurance] is a bad deal. the high relapse rate i think will always be an issue, as with many other addictions. [i share my life with an ex-smoker who has relapsed 3 or 4 times, so i'm not being flippant.]

    and not to sound too conspiracy-theorist here, but wouldn’t the tobacco lobby be pissed off if we had a national quit-smoking subsidy…

    i, however, think it’s a good idea.

  3. #3 Stephanie Z
    January 24, 2009

    Ooh, Blake, you came this close to touching off the “why computers are a bad analogy for brains and why most of us do not want a computer organized like a brain” rant. But other things must be written today instead. Some other time.

    For now, I’ll just note the bit most relevant to addiction: while programs run on a computer may change the information stored in memory, they don’t change the organization and operation of the processor. This is not true of drugs’ effects on the brain (or the effect of anything else, really). Brains reorganize themselves constantly based on what they process–in ways that affect their ability to process the next thing.

  4. #4 Stephanie Z
    January 24, 2009

    Or, you know, what leigh said. :)

  5. #5 Michael Burke
    January 24, 2009

    I specialize in treating tobacco addiction and find it helpful to look at individual differences and concepts of choice and addiction as a multi-layered phenomenon.

    Different people who smoke vary greatly in the severity of withdrawal symptoms and the intensity of cravings they experience when they are nicotine abstinent. This in part stems from number and placement of type/s of nicotinic acetylcholine receptors which in large part results from phenotypic expression after exposure to nicotine. So, differences in difficulty in quitting smoking can in large part be attributed to genetic predisposition.
    (as an aside – I use the term tobacco addiction and talk about cigarettes because the cigarette is a very effective drug delivery device (better than intravenous). The manner in which the cigarette delivers a rapid high dose of ‘free-based’ nicotine is much more potent and reinforcing than any of the medicinal nicotine delivery system.)

    Motivation for quitting smoking can waver according to the intensity of discomfort from abstinence, the salience of the reasons a person wants to stop, availability of cigarettes, a person’s confidence and skills for successfully stopping, and a person’s overall resources available for making difficult changes in their life. Many of these factors can change moment to moment and will vary according to a person’s environment.

    For example a person who has moderately intense cravings, has just had a heart attack, has previously quit smoking for a long period of time,is provided effective nicotine replacement, and has a supportive and non-smoking home and work environtment will be much more able to quit than a person who has very intense craving, no current salient health concerns about smoking, lives with people who smoke, has never been more than 2 days without smoking since age 18, cannot affort nicotine replacement, bupropion or varenicline and is suffering from moderate depression.

    Treatment for smokers consists of a combination of medication and supportive and problem solving counseling and it is clearly effective. However, some people need higher intensity or multiple treatments and health care providers can help by being sensitive and without judgement regarding individual difference and the need to help paitents recycle into treatment when needed.

  6. #6 The Perky Skeptic
    January 24, 2009

    I know what you mean about being baffled that, to a nicotine addict, $16 per month to increase one’s heart health seems like SO MUCH EXTRA, while $120 per month for the rest of one’s life for smokes seems like simple cost o’ living. It just goes to support the notion that addiction causes the addict to think irrationally about their addiction, which makes it that much harder to treat. Gah. I have no solution; I’m just grateful for whatever made me think cigs were disgusting when I was at risk for picking up the habit.

  7. #7 The Perky Skeptic
    January 24, 2009

    Michael Burke said:
    Different people who smoke vary greatly in the severity of withdrawal symptoms and the intensity of cravings they experience when they are nicotine abstinent. This in part stems from number and placement of type/s of nicotinic acetylcholine receptors which in large part results from phenotypic expression after exposure to nicotine. So, differences in difficulty in quitting smoking can in large part be attributed to genetic predisposition.

    Right, I had read about the genetic component but hadn’t heard about the acetylcholine receptor # and placement being a factor.

    Does anyone know whether any “gene therapy” research is being done in the area of treating nicotine withdrawal? It’s certainly an area of great concern to public health.

  8. #8 D. C. Sessions
    January 24, 2009

    For now, I’ll just note the bit most relevant to addiction: while programs run on a computer may change the information stored in memory, they don’t change the organization and operation of the processor.

    Actually, they can. However, that’s really beside the point that there are appropriate levels of abstraction (or simplification) for any discussion. It’s really not useful to discuss potty training in terms of neurochemistry, for instance; while valid, it’s so general to the subject of learning that it’s not helpful for a specific set of behavior modifications.

    And that’s exactly the point here. People learn things via various routes. Some are fairly direct pleasure stimulus/response (e.g. sex.) Others are more indirect, layering self-reward on top of prior associations.

    The behaviors that are relatively direct may be susceptible to equally direct biochemical interventions (e.g. methadone) but that only addresses the mechanism that taught the behavior. We’re complex enough that we don’t require continuous retraining in acquired behavior; elsewise we’d all need potty-training refreshers.

    Which means that simply stopping the “training” for addictive behavior is not going to solve the problem. It also means that shotgun approaches to the biochemistry of learned behavior is far too imprecise to be useful; we could as readily cause someone to forget how to drive as to forget smoking.

    That’s not dualism, it’s just a recognition that we’re dealing with a really complex system here. Going back to the admittedly-flawed analogy, you’re not going to fix an Internet Explorer security problem by fiddling with the system voltages.

  9. #9 Blake Stacey
    January 24, 2009

    Ooh, Blake, you came this close to touching off the “why computers are a bad analogy for brains and why most of us do not want a computer organized like a brain” rant. But other things must be written today instead. Some other time.

    I also have other stuff that needs to be done today, but I have a little time here while my cellphone charges a bit, so I’ll briefly note that most such rants I’ve seen are founded on unsupported assumptions of how computers work (fetishizing von Neumann architecture, for example).

    If it helps, don’t think of a program running on a single computer; instead, consider the state of all the software running on all the computers connected to the Internet. It’s a massively parallel mess — which only makes the issue of successive levels of emergent phenomena more important.

    For now, I’ll just note the bit most relevant to addiction: while programs run on a computer may change the information stored in memory, they don’t change the organization and operation of the processor. This is not true of drugs’ effects on the brain (or the effect of anything else, really).

    But a hit of acid doesn’t change the laws of physics, the electronegativity of chemical elements, the pair-binding choices of nucleotides. . . . And even if you do know some of the biochemical consequences of a drug (say, it competes with serotonin for the attentions of monoamine oxidase, while also binding to 5HT-2A receptors) that’s only the first step to understanding its cognitive effects and alterations of behaviour.

    Brains reorganize themselves constantly based on what they process–in ways that affect their ability to process the next thing.

    So does a Bayesian spam filter.

    I’m not aiming for an exact analogy (doing so would be pointless and counterproductive). Rather, I’m trying to make the point that in practical terms, there’s a distinction between psychological and physiological phenomena.

  10. #10 Russell
    January 24, 2009

    “Often, patients tell me they can’t afford these life-saving medications, but they may still have a $120.00/month smoking habit.”

    That’s what makes me think Philip Morris International has a safe revenue stream.

  11. #11 The Perky Skeptic
    January 24, 2009

    Blake Stacey wrote:
    I also have other stuff that needs to be done today, but I have a little time here while my cellphone charges a bit, so I’ll briefly note that most such rants I’ve seen are founded on unsupported assumptions of how computers work (fetishizing von Neumann architecture, for example).

    Oooh, baby, I’m fetishizing von Neumann architecture RIGHT NOW…!

    …Yeah, I’ll get my coat.

  12. #12 PalMD
    January 24, 2009

    This conversation has taught me three things:

    1) i need to write about smoking more often

    2) mind-body dualism is complicated

    3) blake is a lot smarter than me

  13. #13 whatever
    January 24, 2009

    I remember you writing about smoking earlier – and this topic always sparks my interest. One of the most common excuses I hear is “I’m going to die anyway, better die when I’m young and not in an old person’s home, trying to remember who my kids were…”

    Interesting how addiction can make people think.

  14. #14 leigh
    January 24, 2009

    blake, so where does the magic kick in that separates the mind from the brain?

    i’m not a computer expert, i’m just into neuropharmacology. but i have yet to see a mental process that is not mediated by, you know, the presence and activity of the brain.

    addiction is a lot of learned behavior and a lot of neuroadaptation on the receptor and downstream signaling level, plus a lot of dendritic remodeling and other things i’m not getting to here. learning occurs via concerted, synchronous firing of specific groups of neurons in a specific pattern. disrupt that, learning gets screwed up. it is a direct correlate. (my drug of interest does just that.)

    just sayin’…

  15. #15 Stephanie Z
    January 24, 2009

    …I’ll briefly note that most such rants I’ve seen are founded on unsupported assumptions of how computers work (fetishizing von Neumann architecture, for example).

    Okay, Blake, point. It really is more of a rant about how people use computers to make really bad analogies regarding the brain, because the analogies I’ve seen tend to have the very same problems as the rants you’ve seen. I think people’s reactions to the “vagaries” of Bayesian spam filters supports my point about what people (in general) want from a computer though.

    And I’m not sure it would be practical to make a distinction between, say, memory and processing functions if people had decided that faulty processing was something a computer should fix all by itself. There is practical at the level of analyzing the processing to its fullest extent and practical at the level of things getting accomplished to make it work again.

  16. #16 D. C. Sessions
    January 24, 2009

    blake, so where does the magic kick in that separates the mind from the brain?

    You must be thinking of someone else. What Blake and I are discussing isn’t anything other than “mind as an epiphenomenon of neurophysiology” — but we’re also pointing out that neurophysiology itself is a horrible oversimplification of quantum mechanics. The reason that we (humans) use generalized abstractions such as neurophysiology or psychology is that it’s impossible to discuss everything at the lowest level of detail — there just isn’t time to do the wave equations for a single neuron firing, much less the process of learning a complex behavior.

    So we ignore the low-level details and discuss “chemistry” or “software” or “physiology” or “psychology.” Each a useful model [1] of reality in its own context, with enough detail to be useful and not so much as to bog down.

    i’m not a computer expert, i’m just into neuropharmacology. but i have yet to see a mental process that is not mediated by, you know, the presence and activity of the brain.

    And none of us has seen a computer program that isn’t mediated by the presence and activity of transistors [1]. However, it’s not productive to analyze software at the transistor level and I daresay that you don’t get very far discussing human behavior at the neurochemical level. The details are too overwhelming.

    The reason we use the computer analogy isn’t because the human brain is all that much like a computer, except for one thing: they’re both horribly complex, and as a result they can only be productively approached by abstracting away details that are unnecessary to the immediate discussion.

    [1] Trying to remember that a model is just that.
    [2] Not strictly true — Ada Lovelace used mechanical systems. However, the same principle applies; we could substitute “logic hardware” if you want to get picky.

  17. #17 llewelly
    January 24, 2009

    The architecture of the computers(1) almost all of us are familiar with is in part determined by many organizational choices that were made to make them easier for other (well-trained) humans to understand (although some of these choices were made poorly) . Address space is typically divided into different regions with specific purposes – some of it for traditional ram, some for i/o, etc. Files have formats. Most programs are written in high-level languages like lisp, C, C++, Java, Perl, Python, etc. Furthermore – systems that are difficult to program for (e.g. Sega Saturn) often fail to survive when they must compete with other systems that fulfill similar purposes, but are easier to program for. (It’s not the most important advantage – but it’s an important advantage.) People need to understand these machines in order to use them, to repair them, to debug them, and to build them.

    Brains are Turing machines(2), like computers, but they’re organized by the historical contingencies of their evolution and development. Until very recently, no animal could gain any advantage from having a brain whose function was easier for a human to understand. Further, most brains develop in environments not designed to encourage comprehensible organization. Nor is there any evidence that brains are organized analogously to typical computers.

    It’s not just lay people that are confused by brain-to-computer analogies. Marvin Minsky, a fine computer scientist of some well-deserved note, made many famously wrong predictions about the future of AI, which were rooted in brain-to-computer analogies.

    ‘Turing machines’ is a broad category of devices, and the computers most of us are familiar with are a tiny slice of it.

    (1) By this term I mean only typical digital electronic desktop, server, and workstation computers, as well as the computers that exist in typical home electronics devices, such as cell phones and dvd players. Most people do not have enough experience with other sorts of non-animal-brain computers to usefully inform their their understanding of brain-to-computer analogies. If Blake has such experience, I don’t think it helps him communicate with people who don’t. To the pedants who claim brains are computers, I will claim only pedants use ‘computer’ to mean ‘all conceivable sorts of Turing machines’. (Computer scientists only use ‘computer’ that way when they are in pedant mode, or doing math, where pedant mode is required.)

    (2) Ignoring the ‘tape which is as large as necessary’ bit for the moment here …

  18. #18 Matt Heath
    January 25, 2009

    blake, so where does the magic kick in that separates the mind from the brain?

    Is there another post by Blake that has been deleted, where he defends any sort of metaphysical dualism? I only see the one where he is arguing against the sort of greedy reductionism that says if we can reduce a phenomenon to a more fundamental level, that we should then act as though the higher level phenomenon isn’t worth considering.

  19. #19 Gray Gaffer
    January 25, 2009

    Perhaps in inside view of the problem, and one person’s solution, might be of interest here.

    I worked on quitting for some 20 years. I started when I was 14, peer pressure of course, had to look ‘cool’ for my buddies (who all already smoked). I finally quit at the ripe age of 57, some four years ago. I did not get any physical/chemical withdrawal symptoms from any of the methods, and I tried all of them, multiple times each just to be sure. It did not take many to come to the conclusion that smoking was more of a behavioral issue than chemical dependence, at least for me. Yet it was equally clear that it has a chemical origin. And I was not blind to the medical reasons for quitting. It was just that neither reason nor will would have any practical effect. Each quitting method led to some small interval – weeks to maybe a couple of months – of not smoking but yearning after the odor trail of those who did, followed by renewing the habit.

    So I started to see what I could learn about the mechanism of the addiction. Something about the training one undergoes when starting induces a very low level behavioral pattern, something that produces a neurological reinforcement associating the ritual of smoking with its physiological after-effects combined with the immediate social approval. Something that thereafter remains immune to frontal-lobe reasoning. From other life experiences I already had a pretty good working hypothesis that laying down or changing any enduring habit takes between 6 months to a year to become autonomous. An independent hypothesis, but one that I finally recognized as germane to the smoking problem, was that negatives in verbal instructions to ones’ subconscious (or others) are lost in translation. “do not think of Pink Elephants” is the exemplar phrase. The not is dropped and the associated concept activated.

    And I had to find something that recognized that basis with which to attack smoking.

    Reading Dr. Jeffrey M. Schwartz’s books on his OCD research gave me an underlying theory, and the regularity and acceptance of weekly Nicotine Anonymous meetings gave me the framework on which to build the habit change (forget the 12 step nonsense, all I needed was an ongoing community with a smoking focus. There are no alternatives). Rather than working on “not smoking’, the idea became to just pay attention without critique to my inner thoughts when ‘smoking’ became activated, and simply let them pass. No negatives involved. One year later I smoked my last cigarette.

    I am still a smoker. I just forgot to smoke today.

  20. #20 scicurious
    January 26, 2009

    As a note, probably part of the reason that people who “can’t afford” a $16 per month treatment still have a $120 per month smoking habit is partly the way tobacco is bought. It’s kind of like my coffee and bagel fix in the morning. I go a lot more often than I should, and I know that I spend too much money on it, but it’s often hard to tell HOW much, because it’s a few dollars here and a few dollars there. If you’re like me and used to paying cash, that money pretty much goes unaccounted for until you’re wondering why you have no money.

    I’m sure that tobacco works the same way. You’re buying a few dollars worth here, a few there, in the daily scheme of things it doesn’t seem like that much. If you told them how much it cost, they probably wouldn’t believe you, or try to cut back here and there, and then vastly overestimate how much money they’re saving. All they know is that they keep running out of money, and aren’t really sure where it’s going. You’d probably have to get them to do the math themselves to really face up to how much they’re spending, and that doesn’t factor in all the denial and other psychological and physical mechanisms going on in addiction.

  21. #21 Shannon
    January 26, 2009

    I quit smoking on 1/19, the article and comments have been very helpful in understanding why I’m irritable, restless, etc and have given me some ideas on how to deal with it. Thanks to everyone.

  22. #22 PalMd
    January 26, 2009

    Your family and friends may just have to deal with a “bitchy shannon” for a while—it’s the least they can do to help you regain good health.

  23. #23 Danimal
    January 26, 2009

    Tobacco is responsible for millions of serious illness and deaths every year in the U.S., all of which are preventable.

    So you are saying you can prevent my death. Great to know! Can you prevent non-smokers deaths also? My guess is you meant premature death. However, coming from a family where everyone smoked, most lived longer then normal life expectancy. I do not deny smoking causes premature death. I do have a problem with the claim of second hand smoke (SHS) and now third hand smoke is harmful. However, my time is limited that I cannot currently address that issue. Luv your new digs though.

  24. #24 DuWayne
    January 26, 2009

    Blake -

    Rather, I’m trying to make the point that in practical terms, there’s a distinction between psychological and physiological phenomena.

    Yes, there is a distinction to be made, but I think you’re making it more simple than it is.

    With smoking (or most any addiction/dependency) we are dealing with multiple tiers of problems. First, we have the overt nicotine dependence. That is, the specific mechanism that causes dependence on nicotine, that is unique to nicotine. This is the only absolute you will find in this discussion. And how people deal with that dependence, how their bodies deal with it isn’t standardized. For practical purposes, I think it is helpful to separate overt dependence from addiction altogether. As I am fond of saying, while such a person is rare, there are people who use heroin (for example) long enough to become dependent, who after detoxing, will never want to use it again. Can it really be said that this person is an addict? (I have gone into this in far more detail on my own blog)

    So now we get to addiction, which is really two realms of discussion. Because there are mechanisms for addiction, that are very likely standard for every addiction, whether it be cigarettes or shopping. Again, how people deal with them can vary greatly, but the mechanisms are quite likely the same. And I would suspect that it is this aspect of addiction that makes most people a life long addict. It’s why an alcoholic who hasn’t had a drink in twenty years, can lose it entirely, after just one drink.

    And finally, you have what I would call situational addiction. For example, I have a serious problem with tobacco that transcends the overt dependence and the common addiction traits. For more detail, I discuss it in a couple recent blog posts about drugs. Short version, I had several years of a rather “Bohemian” lifestyle. I had absolutely no consistency in my life for nearly eight years, in which time I slept outdoors nearly as much as I slept inside. I lost everything I owned on multiple occasions. The only consistency in my life was my cigarettes. They’re the only thread carrying me from around fourteen years old, to now (32).

    Or one of my best friends, who’s favorite childhood memories are sitting on his dad’s lap after dad got home from work. Dad smoked like a chimney. My friend’s smoked for a total of twenty eight years. He managed to quit for six years in there, then his dad died. He’s been smoking since.

    Point being, that addiction in general and smoking in particular, is not even a simple dichotomy between overt dependence and addiction. It is a multi-pronged beast and demands a complex approach. Fundamentally, our social and political addiction paradigm is fatally flawed. In part, I think that we have this inane notion that addiction is rarer than it is and necessarily bad. It’s not rare and it’s not inherently bad, it’s just that a great many addiction outlets tend to be inherently destructive.

    Ultimately, I think that I’m really glad to be getting into school now. I am focused and really know where I want to go – addiction research. Starting out in a basic clinical psych program, heading for neuropsych.

  25. #25 The Perky Skeptic
    January 27, 2009

    Yay, DuWayne! Good for you!!!

  26. #26 Blake Stacey
    January 28, 2009

    By this term I mean only typical digital electronic desktop, server, and workstation computers, as well as the computers that exist in typical home electronics devices, such as cell phones and dvd players. Most people do not have enough experience with other sorts of non-animal-brain computers to usefully inform their their understanding of brain-to-computer analogies.

    Ah, but people do have experience with the Internet. And people have more experience with consumer electronics in general than they do with, say, statistical physics, where issues of “emergence” and such can be explored with somewhat more rigour (say, in the kinetic theory of gases).

    Sometimes, I find myself stuck with the choice between a bad analogy and none at all. . . .

    The reason we use the computer analogy isn’t because the human brain is all that much like a computer, except for one thing: they’re both horribly complex, and as a result they can only be productively approached by abstracting away details that are unnecessary to the immediate discussion.

    For example.

  27. #27 Blake Stacey
    January 28, 2009

    DuWayne:

    Point being, that addiction in general and smoking in particular, is not even a simple dichotomy between overt dependence and addiction. It is a multi-pronged beast and demands a complex approach.

    You argue your point well. Perhaps I could better phrase my earlier contention if I expressed it something like this: For all practical purposes, some phenomena are best discussed at a higher level of abstraction, while others can be described and predicted in lower-level terms. A complicated mess like addiction is likely to require concurrent understanding at multiple levels of this (vaguely defined) hierarchy. In some circumstances, you’ll be designing drugs which act on neurotransmitter receptors (e.g., naltrexone), but in others, you’ll be trying to manipulate a social environment without regard to details of biochemistry.

    Ultimately, I think that I’m really glad to be getting into school now. I am focused and really know where I want to go – addiction research. Starting out in a basic clinical psych program, heading for neuropsych.

    As The Perky Skeptic said, good for you!

  28. #28 JLK
    March 22, 2009

    As a smoker who is about to embark on quitting (and who has done so before), and as a budding social psychologist, I’d like to add to the psychological element of this discussion. (Late to the party, I know.)

    The biggest problem for me and most of my friends when it comes to quitting smoking is a social psych concept known as “reactance.” It is a behavioral response to real or perceived attempts at restricting a person’s individual freedoms.

    In other words, my friends and I believe that we have the right to be smokers. It is our bodies, our health, etc. We know the consequences of smoking and we choose to do it anyway. When the price of cigarettes gets jacked up to astronomical prices (over $7/pk where I live right now) in an attempt to get us to quit, we get angry. It basically turns into a “You can’t make me quit smoking if I don’t want to!” mentality.

    Those of us who smoke regularly consider being a smoker to be part of our identity, as stupid as that sounds. We were The Smokers in high school, The Smokers in college, The Smokers at work. When there began to be a heavy anti-smoking movement in this country, an us-versus-them mentality that developed.

    The difference is that most of us smokers are willing to compromise with the anti-smokers, but they want to beat us into submission. And that pisses us off.

    For example, even though the actual studies on the effects of second-hand smoke are largely inconclusive, when smoking was banned in restaurants we were like “Okay, I respect that at the very least you think it’s disgusting. That’s fine.” But then they added $1/pk price to our cigarettes to pay for whatever pet program the state wanted to do but didn’t have funds for.

    Then they banned smoking in bars. We all really, really hated that because most places will not allow you to take your drink outside with you to smoke. So we mostly stopped going out to bars that didn’t have a patio, even though we all thought to ourselves “These people are coming here to ingest poison and WE’RE targeted as being unhealthy? Not to mention the argument about the bartenders’ health – the people who have a problem with smoke in bars can go work somewhere else.” But we kept silent and went along with it. Then they added another $1/pk in taxes.

    The pattern continues. Smokers have been villified while at the same time the state takes advantage of our addiction by taxing the shit out of our smokes. They know how difficult it is to quit, and they know that many of us will keep paying no matter how high the prices go. That makes us angry. Hence the reactance.

    When I started smoking, cigarettes were about $2 a pack. Now they’re over $7. Philip Morris hasn’t raised their prices – I paid $1.96/pack in Mexico. Everything else is taxes. Even the federal duty to bring them from Mexico into the US was only $4/carton.

    And all of us smokers know this. We find websites that sell cheap cigarettes. I used to buy mine from Switzerland until the ATF found out what was going on and seized my shit at the airport. We drive to New Hampshire to buy tax-free cigarettes. When we travel to states with lower prices, we stock up.

    I took wellbutrin to quit smoking a few years ago, and it worked for 8 months until I stopped taking it and started a new job that required me to do a lot of driving. When I tried to get an Rx from a new doctor, they told me they wouldn’t prescribe it because it’s not designed for quitting smoking. (BULLSHIT, heard of Zyban???)

    He then tried to get me to take Chantix, but guess what – my insurance company didn’t cover it. In fact, I think my insurance company STILL doesn’t cover it. Chantix is NOT CHEAP.

    So how screwed up is that? My insurance company will charge me a higher premium for being a smoker, but not cover anti-smoking medication. My doctor won’t prescribe another medication that I have a history of success with because it’s considered an anti-depressant. And if you’ve ever looked at the prices of nicotine replacement products, you’ll understand why more of us don’t use them. $40 for a pack of gum?? Really?

    Smokers get mixed messages – y’all say you want us to quit, but take advantage of our addiction by making it just as hard to quit as it is to smoke, and use the difficulty of quitting to pay for whatever state program is in financial need.

    I’ll be quitting because my husband is being forced to quit by the military, and if he comes back and I’m still smoking he’ll start up again. In the meantime I have to find a physician who is willing to prescribe wellbutrin for that purpose. But I will still have sympathy for the rest of The Smokers out there who are getting hosed. Because I’ll still be one of Them, even if I don’t smoke anymore.