ADDICTION AND PHILOSOPHY
In one sense it is perhaps curious that a symposium on addiction
should include a paper by a philosopher. Addiction, as we are constantly told, is, after
all, a medical, indeed a scientific issue for which the tools of the philosopher might
seem ill-suited or out of place. But to allow that addiction is a medical problem, a
disease to use the vocabulary favoured by some, is to concede precisely the point which is
at issue, namely, what should we mean when we use the word `addiction', or more
importantly, do we mean anything at all when we use the word. And if the question is
genuinely one of the meaning of or the appropriate employment of a word, the philosopher
might well have something useful to say.
The philosopher has legitimate business here, however, not simply
because the problem of addiction is a problem about meaning: he has a role in the debate
because the problem of addiction goes to the heart of our conception of what human beings
are like - what philosophers like to call the free will problem. What the proponents of
the concept of addiction as disease assert is that addiction is a condition wherein a
subject's actions are caused by something over which he literally has no control.
In the grip of an addiction his actions cease to be voluntary in any
meaningful sense so it is correct for him to say `I can't help myself'. Such
claims are certainly not trivial for those things over which I have no control are those
things for which I cannot reasonably be held accountable. Nor, it should be added, are
such claims normal. One of the most important things to note about the addiction as
disease model is how radically at odds it is with our normal, everyday concepts about
ourselves and others. Most of the time both individually and as a society we believe
exactly the opposite of what the disease model claims: we believe that individuals can
choose, can do otherwise, and can be held responsible for their actions.
Now the concept of addiction is both too vast and too complicated to
be dealt with as a generality. I want to focus my attention on one particular way in which
the idea is used - in the claim that smoking tobacco is addictive. More specifically, I
want to argue that the claim (1) smoking is addictive is an ideological as opposed to a
properly scientific claim and that (2) as an ideological claim it suffers from several
irremediable weaknesses that make it inappropriate as a basis for public policy on
smoking.
ADDICTION AS IDEOLOGY
Let us begin with addiction as ideology. What does it mean to call
addiction an ideology? What I do not mean is that the concept of addiction is without
meaning or that it is necessarily untrue. What I do mean is that in calling smoking an
addiction one is making an ideological as opposed to a scientific claim. By ideology I
mean an unchallenged, unexamined set of beliefs, ideas, and claims that are formulated and
advanced by a group of people both to explain something and to shape the behaviour of
others, but which are open to serious challenge. The ideologue is thus the 'true
believer', the creator of a social truth that is beyond inquiry and doubt.
The claim that smoking is addictive is ideological in two senses:
one in terms simply of the debate about addiction and second in terms of what one might
call the ideology of smoking. In the first sense, the claim smoking is addictive is
ideological in that it is an explicit attempt to change how it is that we both conceive
and regulate smoking. It is an attempt to move the explanatory framework for smoking from
'I smoke because I choose to' to 'I smoke because I have no choice but to'. It is, in
short, an attempt to explain smoking not as the product of reasons but as the product of
causes that lie beyond the volition of the smoker. Smoking is to be understood not as a
decision on the part of the smoker but as an irresistible pharmacological property of a
drug. People smoke, the ideology suggests, because they are addicted: smoking is never a
choice, only a disease. Despite the fact that such a claim is advanced as scientific it is
really ideological. It is ideological because the concept of addiction is not itself a
scientific definition. It is ideological because the criteria for addiction has been
created and consistently manipulated not by science but by politics, or more precisely by
politicized science designed to serve ideological as opposed to scientific ends. It is
ideological because once advanced it is unquestionable: anyone who raises a question or
dissent is accused of being a puppet of the tobacco industry. It is ideological because in
the end its purpose is to control behaviour and manipulate public policy -- not to arrive
at the truth.
But the claim that smoking is addictive is ideological in a second
and larger sense that it is the last piece that completes the carefully constructed
ideology of smoking. The ideology is founded on the claim that smoking is morally
illegitimate, both with respect to what it does to smokers and what it does to
non-smokers. Only if it can be demonstrated that smoking is morally illegitimate can
smoking be criminalized. At first glance it would appear that the chances of convincing
society that smoking was morally illegitimate, as opposed to merely silly or even unwise,
were minimal. After all, smokers possessed what were thought to be two impregnable
defences. In the first case, while the decision to smoke might be seen as in some sense
irrational, it was nevertheless the smoker's own choice. And in a democracy this aspect of
personal autonomy counted significantly against the legitimacy of any legal sanctions
against smoking. In the second case, the smoker's actions, even if posing risks to
himself, did not pose risks to others. The smoker's harms were harms confined to himself.
Despite the seeming strength of this position, the success of the
smoking ideology over the last 25 years is directly attributable to its ability to
undermine both of these claims about smoking. Using carefully selected physical and social
science evidence, the advocates of the smoking ideology have managed to obtain significant
public and government support for the following:
- (1) Smoking poses significant risks to the health of non-smokers;
- (2) smoking imposes significant social costs on non-smokers;
- (3) smoking is precipitated not by personal choice but by careful
advertising;
- (4) smoking is best understood as a disease explained and treated by
medical science.
Together these claims significantly undermine the claim that smoking
is a rational choice made by the smoker and the claim that smoking does not pose a risk to
others. But what is needed for the ideology of smoking to triumph conclusively, that is to
show without equivocation that smoking is morally illegitimate, is clear evidence that
smoking is involuntary. Hence the crucial importance of addiction. With addiction, smoking
loses both its crucial rational and moral defences. It is not a rational, free choice,
instance of autonomy, but rather an instance of pharmacological compulsion.
Between them, advertising and addiction now provide a complete
explanation as to why anyone smokes. As Robert Goodin puts it:
'People begin smoking before they are responsible adults: by the
time they are responsible adults their nicotine addiction will have rendered their
continued smoking largely involuntary. Policies justified as aids in preventing harms to
oneself are bound to be opposed as paternalistic. But helping addicts who want to break
the habit is not offensively paternalistic... '. (Goodin, 1989)
Addiction thus provides the crucial piece of missing evidence and
argument against smoking. With addiction, public policy interventions to prevent smoking,
even to the extent of criminalization are morally justified in that they are reasonable
actions designed to save the vulnerable from irreversibly bad decisions. Indeed, they are
justified by the principle of autonomy itself in that they are designed to preserve and
enhance, not erode autonomy. With addiction public policy is allowed to turn its attention
as well to the truly wicked - those who make and market tobacco all the while showing
compassion to the helpless smoker. In one sense addiction is an ideal ideology: it allows
one to prescribe something immoral whilst offering solace and compassion rather than
condemnation for those caught in the immorality.
However attractive as an ideology, addiction is insupportable as
public policy for five reasons:
- (1) it is an instance of corrupted science;
- (2) it exhibits faulty logic;
- (3) it is confused in its claims;
- (4) it cannot deal with counter-examples; and
- (5) it is non-falsifiable.
CORRUPTED SCIENCE
Without question the most disturbing aspect of the smoking is
addictive claim, and the one that characterizes it most indisputably as ideology is its
dubious scientific character. In effect, the smoking is addictive claim is not science but
what we have called elsewhere corrupted science - science that serves the ends of politics
rather than the ends of truth (see Luik, 1994).
In a sense the centrality of `science' in the ideology of addiction
should not be a surprise, for `science' is perhaps the most important component of the
late 20th century campaign against tobacco.
Whether with respect to the dangers of smoking to smokers, the
alleged risks of Environmental Tobacco Smoke to non-smokers, the alleged effects of
tobacco advertising on tobacco consumption, or the alleged addictive qualities of
nicotine, in each instance it is science - whether natural or social science - that
provides the case against tobacco. Indeed, if the government and the anti-smoking movement
are to make their case against smoking it is imperative that they establish that smoking
poses a range of dangers that are demonstrated, compelling, unequivocal and significant.
And it is only science that can deliver dangers with the requisite pedigree. Without
science, or more precisely, without scientifically credible dangers, the case against
smoking collapses. Everything depends upon science. And with so much at stake the pressure
to adjust, shave, create, ignore, reevaluate, even manipulate, is enormous.
What emerges from these pressures is corrupted science, science that
is not merely incompetent or flawed, but characterized by a cluster of pathologies. First,
corrupt science is science that moves not from hypothesis and data to conclusion but from
mandated/acceptable conclusion to selected data back to mandated/acceptable conclusion.
That is to say it is science that uses selected data to reach the `right' conclusion, a
conclusion that by the very nature of the data necessarily misrepresents reality. Second,
corrupt science is science that misrepresents not just reality, but its own process in
arriving at its conclusions. Rather than acknowledging the selectivity of its process and
the official necessity of demonstrating the right conclusion, and rather thanadmitting the
complexity of the issue and the limits of its evidence, it invests both its process and
its conclusions with a mantle of indubitability. Third, and perhaps most importantly,
whereas normal science deals with dissent on the basis of the quality of its evidence and
argument and considers ad hominem argument as inappropriate in science, corrupt science
seeks to create formidable institutional barriers to dissent through excluding dissenters
from the process of review and contrives to silence dissent not by challenging its quality
but by questioning its character and motivation. In effect then, corrupt science is
science that is flawed in both its substance and its process and that seeks to conceal
these essential flaws. It is essentially science that wishes to claim the policy
advantages of genuine science without doing the work of real science.
The history of the smoking as addictive claim exemplifies the
process of corrupted science in three ways. First, the concept of addiction is itself not
a scientific term. In fact, it is a term that is specifically excluded from the scientific
and medical vocabulary. Neither the Diagnostic and Statistical Manual of the American
Psychiatric Association nor the World Health Organization use the term addiction. Indeed,
it would appear that the only scientific body recommending the use of the word is the
Royal Society of Canada in a 1989 report prepared at the request of the Government of
Canada. We will return to this report later as its process and conclusion provide an ideal
case study in the workings of corrupted science in the addiction and smoking debate.
Addiction, of course, does have a popular meaning, a meaning that
carries a tone of moral reproach suggesting weakness or absence of the will and lack of
discipline. The result of labelling smoking as addictive is thus a very potent combination
of `science' and morality: the use of the term appears to be scientifically legitimate and
compelling because it appears to issue from the scientific community and is backed by
Government while at the same time the term casts a moral stigma either on smokers or on
those who produce tobacco.
Addiction is allowed to do the partisan work of morality while
appearing under the neutral banner of science. In this sense it summarizes the entire
anti-tobacco strategy which is designed to cover a paternalistic moral campaign of
imposing certain people's values on others with the patina of scientific objectivity. It
is instructive to return to the only public policy question which has any weight in this
debate: `What is wrong with smoking?' The answer to that question offered by science, not
science and morality, but science is that smoking is a risk factor for certain diseases
which may shorten some smokers' lives. The assumption that the possibility of a slightly
longer non-smoking life is preferable to the possibility of a slightly shorter smoking
life is not the assumption of science, but of morality, indeed a particular version of
morality.
By 1974 however, both of these terms had been replaced by the
concept of `dependence' which was itself further modified in 1993 to be:
`A cluster of physiological, behavioral and cognitive phenomena
of variable intensity, in which the use of a psychoactive drug (or drugs) takes on a high
priority. The necessary descriptive characteristics are a preoccupation with a desire to
obtain and take the drug and persistent drug-seeking behaviour. . . The existence of a
state of dependence is not necessarily harmful initself, but may lead to self
administration of the drug at dosage levels that produce deleterious physical or
behavioral changes . . . ' (WHO, 1993). What emerges from the evolution of WHO's
definitional work is that while the 1957 definition of addiction would not include tobacco
smoking, WHO then abandoned the use of the concept of addiction in favour of the arguably
much less precise term dependence, a concept that would include smoking.
| |
| WHO 1957 |
Addiction |
|
| Smoking |
Yes_______
|
No___ ____
|
| WHO 1993 |
Dependence |
|
| Smoking |
Yes_______ |
No_______ |
The fact that the 1957 WHO addiction definition would not support a
determination of smoking as addictive was recognized in the US Surgeon General's 1963
report.
`The tobacco habit should be characterized as an habituation
rather than an addiction, in conformity with accepted World Health Organization
definitions, since once established there is little tendency to increase the dose; psychic
but not physical dependence is developed ... No characteristic abstinence syndrome is
developed upon withdrawal ... Discontinuation of smoking ... is accomplished best by
reinforcing factors which interrupt the psychogenic drives. Nicotine substitutes or
supplementary medication have not been proven of major benefit in breaking the habit'
(USSG, 1964, p. 354). `The overwhelming evidence points to the conclusion that smoking -
its beginning, habituation, and occasional discontinuation - is to a large extent
psychologically and socially determined' (USSG,1964 p. 40).
The crucial point here is that under the only internationally agreed
definition of addiction, smoking was not an addiction. Even more disturbing, the concept
of addiction was no longer available for use after 1974 having been abandoned in favour of
dependence. How then, it might be asked, could one justify a public policy in which
smoking is labelled `scientifically' as an addiction?
The answer is to be found by recalling what corrupted science is. It
is not constrained by the normal definitional and evidentiary considerations: it begins
with the mandated policy conclusion and works backward to create the requisite
definitional and evidentiary support.
The players in this process were three: the US Surgeon General, The
Royal Society of Canada and the Government of Canada, and the US Food and Drug
Administration. In 1988 the US Surgeon General concluded that `cigarettes and other
forms of tobacco are addicting' (US DHHS, 1988, p. 9).
But notice how very peculiar is this conclusion. Since 1974 there
had been no scientifically or medically recognized concept of addiction and even when
there was such a conception the Surgeon General had concluded (1964) that smoking was not
addictive.
| |
| USSG 1964 |
Addiction |
|
| Smoking |
Yes_______
|
No_______
|
| USSG 1993 |
Addiction |
|
| Smoking |
Yes_______ |
No_______ |
Are we to conclude that the Surgeon General had good scientific
reasons for reintroducing the concept of addiction or that he had new and compelling
evidence that tobacco qualified as a drug of addiction? The answer to both questions is
no. Tobacco was labelled as addicting in 1988 in order to reintroduce, under the guise of
science, the morally pejorative concept of addiction.
Second, the policy decision to label smoking as addictive was made,
both in Canada and in the United States, in the absence of any compelling scientific
support, and then the `evidence' to support the policy decision was created. The process
was not one in which the question `What does the evidence suggest?' preceded the
policy question `What should we do about the evidence?'. Instead, the policy
needs - destroying the claim that smoking is an adult choice through portraying smokers as
individuals who are addicted, who have no choice but to smoke - determined the direction
interpretation of the scientific `evidence'.
The persistent problem with addiction, from the perspective of those
who favour defining smoking as addictive is twofold. First, but using the traditional
definition of addiction - coined in 1957 by WHO - tobacco use is not addictive. Second,
since 1957 WHO has moved to abandon the use of the term addiction. But smoking must be
addictive, hence the pressure both to create a definition of addiction that encompassed
smoking and to `re-think' the evidence about addiction.
Let us begin with the original WHO definition of addiction.
`Drug addiction is a state of periodic or chronic intoxication
produced by repeated consumption of a drug (natural or synthetic).
Its characteristics include:
- (1) an overwhelming desire or need (compulsion) to continue taking
the drug and to obtain it by any means;
- (2) a tendency to increase the dose;
- (3) a psychic (Psychological) and generally a physical dependence on
the effects of the drug;
- (4) detrimental effect on the individual and on society'
(WHO,1957).
In addition to the definition of addiction, WHO also defined what it
termed `drug habituation'.
`Drug Habituation (habit) is a condition resulting from the
repeated consumption of a drug. Its characteristics include:
- (1) a desire (but not a compulsion) to continue taking the drug for
the sense of well-being it engenders;
- (2) little or no tendency to increase the dose;
- (3) some degree of psychic dependence on the effect of the drug, but
absence of physical dependence and hence of an abstinence syndrome;
- (4) detrimental effect, if any, primarily on the individual'
(WHO,1957).
In order that smoking be labelled addictive and notwithstanding the
scientific basis for dependence, science was pressed to `recreate' the notion of
addiction.
The second player was the Royal Society of Canada acting at the
request of the Health Protection Branch of the Government of Canada. The Royal Society was
asked to convene a panel of experts to determine which term - addiction, dependence or
habit formation was the most appropriate term to characterize the risk from tobacco
smoking.
In order to preclude the possibility of any dissenting voices the
majority of the committee members were affiliated in some fashion with the Ontario
Addiction Research Foundation, a foundation which is committed to the view that addiction
is a disease. The committee, in marked contrast to the work of WHO, which proceeded over
the course of almost 40 years, arrived at their conclusion over a 3-month period in 1989.
Not surprisingly, they provided uncritical support to the work of the US Surgeon General,
concluding that `cigarette smoking can, and frequently does, meet the criteria for the
definition of drug addiction' (RSC,1989, p. 23). This conclusion, which like the
Surgeon General's was unsupported by any new scientific evidence, was justified by the
fact that the WHO definition was `ambiguous and ... not as satisfactory for general
public and professional use'. What this means is that the WHO definition does not
include the key ideological claim of the smoking as addictive proponents', namely, that
smoking is a compulsive activity brought about by the pharmacological property of
nicotine. It was necessary therefore to create a scientific definition that included the
alleged addictive characteristics of smoking.
The process then is instructive.
- (1) Create a committee whose members are professionally committed to
the existence of something called the disease of existence.
- (2) Insure that a majority of the committee is associated with a
research institution that is already committed to a particular view of the question under
discussion (should smoking be called addictive?)
- (3) Allow the committee to reject the agreed term of dependence in
favour of the concept of addiction.
- (4) Encourage the committee to re-define addiction to its own liking
without compelling justification.
- (5) Encourage the committee to conclude that smoking fits - again
without any compelling - its contrived definition of addiction.
The final player in the addiction as corrupted science process is
the Food and Drug Administration whose advisory committee concluded in 1994 that
cigarettes and other forms of tobacco are addicting. In one sense their conclusion, given
the work of the Surgeon General (1988) and the views of the current head of the FDA were
hardly unexpected. But in another sense their work is surprising for it emphasizes the
particularly brazen nature of the process of corrupted science. Rather than creating a new
criteria of addiction, the FDA simply took the existing criteria for drug dependence from
the WHO and DSM-III and claimed that they now defined nicotine addiction. Quite aside from
any scientific justification for such a procedure, its commitment to official
misrepresentation is startling. What the FDA has in effect done is to take nine criteria
which define drug dependence and present these as nine criteria that define addiction. The
work of the FDA completes a process in which the concept of addiction -- a concept that
was never used scientifically to define smoking -- was systematically reintroduced without
any compelling justification in order to replace the word dependence. What one has are the
characteristics of dependence -- whatever these might mean -- under the label of
addiction. Inasmuch as the criteria for dependence are much vaguer than those of
addiction, it is, of course, much easier for smoking to meet them. The strategy of
reducing the precision of dependence whilst hijacking its criteria for addiction thus
serves the ends of the smoking as addictive activists wonderfully well. In the end,
addiction, a hard word, is allowed to be used on the basis of an easy criterion.
None of this, of course, is obvious to the public or to the media
who assume that the smoking is addictive claim has proceeded from a scientific as opposed
to an ideological process. Both aspects of the process are misrepresentations of reality.
On the one hand the scientific evidence adduced by the process does not support the label
of addiction. On the other hand the nature of the process itself does not support the
label scientific.
The third way in which the smoking as addictive claim exemplifies
the process of corrupted science is that it seeks to stifle dissent about both the process
and its claims. Both the process of producing corrupted science and of utilizing it as the
basis for public policy demand a fundamental intolerance of dissent, both scientific and
otherwise. The imperatives of the smoking ideology are such that the ambiguities and
uncertainties that form a legitimate part of science and most importantly the questions
about the quality of the evidence and whether it justifies the proposed public policy
measures cannot be tolerated. This means that scientific and public policy dissent must be
suppressed through portraying dissenters as either in the pay of the tobacco industry or
at the margins of the scientific establishment. Whatever the cost, `science' must be seen
to provide a conclusive and unified answer to the question of addiction. The irony is that
the smoking as addiction proponents seek to silence dissent in the interests of protecting
not the truth, but its misrepresentation of the truth. It is not merely with its enemies
that the process of ignoring dissent occurs. Awkward conclusions by friends are just as
troublesome. Thus, to take but one example, the Royal Society of Canada Report on Tobacco,
Nicotine and Addiction is replete with references to the work of Jack Henningfield, one of
the architects of the Surgeon General's report. But one searches in vain for a single
reference to Henningfield's 1984 paper in which he concluded that:
- (1) the tobacco withdrawal syndrome was limited by `constraints
and inconsistencies' and
- (2) `there is little evidence that nicotine produces physiologic
dependence . . . '.
FAULTY LOGIC
The second family of problems that beset the ideological claim that
smoking is addictive is logical, that is, the claim when subjected to close examination is
either incoherent or internally inconsistent. These incoherences and inconsistencies occur
in four sorts of areas. First, there is what might be termed the methodological
inconsistency which occurs with respect to the degree of reliability that one accords to
the self reports offered by smokers. It should be remembered that the self reports of
smokers are all that we have to establish such crucial addiction criteria as `persistent
desire' or `craving' (APA and WHO), and these terms themselves admit of
enormous imprecision not to say questionable relevance for defining addiction. (It might
be asked, for instance, how craving usefully defines something as addictive when it might
describe a quite large range of human attachments). But to return to the methodological
problem, the inconsistency occurs in that the self reports of smokers who report that they
are:
- (1) rational and
- (2) choose to smoke
because they like to smoke are universally discounted as false
whilst the self reports of other smokers who report that they wish to stop smoking, having
tried to stop smoking but have been unable to stop smoking are accepted as true. Clearly
there is nothing in the methodology or the logic of self reports that allows one to decide
a priori which self reports of which subjects are true and which are false. And there is
certainly nothing in the methodology or the logic of self reports that allows one to
decide a priori that an entire class of self reports is true or false. Yet this is what
drives the entire process of `making sense' of addiction. The purpose of addiction
research is, after all, `to find the most appropriate term to designate or describe
the attributes of tobacco smoking that are responsible for the strength and persistence of
this behaviour, despite its well-documented noxious consequences' (RSC, 1989).
Smoking, in other words, cannot be rational, so we must find some pharmacological basis
for what can only be compulsive, irrational behaviour. This means that the self reports of
those who describe smoking as volitional must be wrong and the self reports of those who
describe themselves as unable to stop smoking must be right.
The second logical problem with the smoking is addictive claim
centres on the meaning of the terms craving and withdrawal as criteria of addiction. It is
these two criteria that perform the bulk of the work in understanding as addictive in that
they drive the move to describe smoking as involuntary; problems with these notions are
threefold.
First, the evidence for the existence of craving is confined to self
reports: it derives from smokers who are asked a particular question. Craving is a
difficult concept precisely because there is no objectively observable behaviour that can
establish it. It is established only on the basis of self reports.
Second, even if we allow persistent desire or craving, as vague and
unscientific as they are, to define addiction, craving and persistent desire do not equal
involuntary behaviour. There is a substantial common-sense and moral difference between a
craving making something difficult to stop and a craving making something impossible to
stop.
Difficulty to stop does not impugn moral capacity nor eliminate
individual responsibility. Third, whilst there might be withdrawal symptoms, the logic of
using this for defining addiction is dubious. Consider the diagnostic criteria for
withdrawal suggested by the APA's DSM:
- (1) craving for nicotine;
- (2) irritability, frustration, or anger;
- (3) anxiety;
- (4) difficulty concentrating;
- (5) decreased heart rate;
- (7) increased appetite or weight gain.
Are any of these uniquely associated with tobacco use and do any of
them support the notion of smoking as addictive? For example suppose instead of describing
the symptoms of nicotine withdrawal we are describing the symptoms of profound mourning on
the death of a beloved spouse, say Susan, of 50 years. Thus we could redescribe 1 as
craving for Susan and then quite reasonably, supported in each instance by the literature
of grief, proceed to plausibly attribute each of the other criteria to mourning as well.
Is our new illness and symptomatology -- spousal withdrawal -- to be described as evidence
of addiction to Susan? More importantly, are any of the seven criteria so irresistible
that it makes sense to say that individually or jointly they make it impossible to stop
smoking? In other words when the vagueness associated with such notions as difficult
withdrawal symptoms is given some semantic if not scientific precision, it becomes obvious
that the symptoms do not support the characterization of smoking as involuntary. There are
any number of behaviours that I might choose to stop and which in stopping might make me
angry, frustrated, or anxious. Indeed these characteristics might be said to describe any
significant behavioral change. What they do not do, however, is justify, either in common
sense or in scientific usage, the conclusion that I am unable to stop. If irritability,
frustration or anger counted as evidence of or justifications for inability, then the
majority of human behaviour would have to be described as involuntary. It should also be
noted that, logical consistency aside, the evidence for the existence of the above
criteria is limited. As even a champion of the smoking cause, Jack Henningfield, has
noted:
`The following constraints and inconsistencies should be noted
when considering the evidence for a tobacco withdrawal syndrome. First, a syndrome of
reliable physiologic signs has not been described. With the exception of the desire to
smoke other phenomena typically occur only in a fraction of all subjects abstinent from
cigarettes ... For instance ... weight gain, gastrointestinal disturbances, or anxiety may
each occur in less than one-third of all subjects, and up to one-half of abstinent
subjects may report no symptoms at all' (Henningfield,1984, p.147).
A third source of logical difficulty occurs with how one understands
the logic of certain smokers who claim that they wish to stop smoking but are unable to do
so. Given, as we have noted above, that we have no compelling reason to take these self
reports at face value, then the only other way in which to make some sense of them is to
assess their logic. And it is this process that yields an interesting outcome. From a
logical point of view it surely makes as much sense to explain the behaviour of someone
who says that they wish to stop doing X but continues to do X by concluding that they did
not really wish to stop doing X as it does to say that they were compelled to do X. In
other words the class of smokers who claim that they are unable to stop smoking, that they
are addicted to smoking, might in fact be the class of smokers who do not wish to stop
smoking. How else, after all, is one to explain one's failure to do something that one
professes to want to do? One is either confused about one's intentions or without the
will-power to act upon them and neither explanation is particularly flattering to one's
self esteem. Addiction provides an extraordinary convenient solution to this problem in
that it allows a third way to explain the inability to achieve something that one
professes to truly want. It is not that thesmoker does not wish to stop smoking nor is it
that he cannot bring himself to stop: it is instead that his volition is no longer within
his control. In short, he is addicted.
This sort of explanation, of course, would be considered ludicrous
in any other context but the ideology of smoking. As Viscusi (Viscusi,1992) has noted: `Almost
half of the residents of Los Angeles indicate a desire to move out of the city, but do not
do so. Almost one-third of all blue collar workers would like to leave their jobs but do
not' (p. 120)
Does this mean that we should describe certain residents as addicted
to Los Angeles or blue collar workers as addicted to their jobs? Our normal, non-smoking
related pattern of explanation would suggest that:
- (1) the residents and blue collar workers do not mean what they say;
- (2) they mean that there are certain things about their city or their
jobs that they are dissatisfied with but these are not sufficient to compel them to leave
or quit their jobs or
- (3) they mean what they say but are unable to leave or quit their
jobs.
In none of these explanations are we likely to accept addiction,
that is literal incapacity to do something that one genuinely wishes to do as an
explanation for a particular behaviour. Even in the case of someone who says that they
genuinely want to leave Los Angeles or quit their job but cannot our response is likely to
be why not? Thus when Peter tells us that he desperately wants to quit his factory job but
cannot because he has to support his family, we do not believe that Peter literally cannot
quit his factory job because of his family. `Because of his family' functions as
a reason for Peter not to quit his factory job, it does not function as an addiction that
prevents him from choosing to act otherwise. Our normal logic of explanation is built
around reasons for doing or not doing a particular thing not around compulsions. Addiction
thus replaces this paradigm of explaining actions by one in which involuntary external
causes are the source of one's behaviour. The answer to the question `Why did you do
that?' Becomes `because I couldn't help myself'.
The fourth logical problem with the smoking is addictive claim is
that it postulates addiction as a disease despite the fact that addiction cannot fit the
disease model. The normal model of disease is built on two defining characteristics. The
first is that disease is disorder -- it is something that destroys the accustomed pattern
of order and function. The second characteristic of disease is that it has symptoms over
which one has no control -- e.g. having a rash or high temperature. But addiction in
general and smoking as an addiction in particular cannot logically fit this model of
disease. For one thing there is no evidence that smoking is un-patterned or disordered. It
may be a different pattern of behaviour but it is not by definition disordered behaviour.
Equally important, the symptoms of this disease -- smoking addiction -- are not
involuntary in anything like the sense of having a high temperature. We cannot plausibly
speak of lighting a cigarette as being just like having a high temperature. As Davies
(1992) has noted:
`Whatever we mean by the word "voluntary" (i.e.
whether we take it to imply a metaphysical exercise of the power of "free will",
or a particular mode of cerebellar functioning) it is clear that going into a pub is
voluntary in a sense that having a high temperature is not. For these reasons, the
inclusion of acts of drugs or alcohol-directed appetitive behaviour as parts of the
disease symptomatology, alongside involuntary bodily changes, lumps together two sets of
phenomena which require different levels of explanation'.
CONFUSION
The third type of problem that besets the smoking is addictive
ideology is the problem of confusion and clarity. The problem being, of course, with the
definition of what addiction actually is. As a close study of the term reveals, there is
an enormous variety of meanings attached to the term and the definitional history of
addiction suggests a deliberate movement from precision to vagueness. Thus where the
original 1957 WHO definition spoke in fairly precise terms of drug addiction as a state of
`periodic or chronic intoxication produced by repeated consumption of a drug (natural
or synthetic) . . . ' by 1993 this relative precision had been replaced by the
extraordinary vagueness of dependence, defined as `[A] cluster of physiological,
behavioral and cognitive phenomena of variable intensity, in which the use of a
psychoactive drug (or drugs) takes on a high priority . . . ' The best way to
characterize the concept addiction is a boundary- less concept, this is one that appears
to have no hard definitional edges that mark out the appropriate from the inappropriate
stages. Boundary-less concepts are so elastic that they can mean like Humpty Dumpty
whatever those that employ them wish them to mean. While ideologies might flourish with
boundary-less concepts, both science and public policy suffer from such conceptual
imprecision since they are both activities that derive their character from rule-bounded
activity. At the end of the day, concepts that are so fluid, that have no objective,
accepted rules of employment finally come to have no meaning whatsoever. Because they can
mean anything they ultimately mean nothing.
But confusion is not simply confined to the meaning of addiction
itself, it extends to how the pharmacological evidence is to be understood in the smoking
as addiction debate. One of the most obvious aspects of the controversy is how very
unclear it is what precisely the pharmacology of nicotine actually shows. Even one of the
principal advocates of the smoking as addictive label, Jack Henningfield, noted that `there
is little evidence that nicotine produces physiologic dependence . . . '.
`Administration of nicotine-receptor antagonists ... has not
been shown to evoke a withdrawal syndrome .. [P]roviding abstinent smokers with a
nicotine-containing chewing gum only partially attenuates physical complaints ... [and] in
animal studies, abrupt abstinence is not followed by ... a withdrawal syndrome. These
inconsistencies ... impose constraints on the comparisons ... of tobacco withdrawal with
that of withdrawal from opioids, sedatives and ethanol ... The relevance of this point
goes beyond semantic issues of classification ... [be]cause when withdrawal is considered
in the context of drug dependence it generally connotes a more narrowly specified set of
conditions (viz. a reliable syndrome of behavioral and physiologic changes)'
(Henningfield,1984, pp. 147-148).
Nevertheless, it is quite obvious what the evidence does not show:
it does not show that smokers are under a compulsion to smoke; it does not show that their
behaviour is involuntary. And for addiction to have any moral or public policy
implications in the smoking debate, it must establish that smoking is an involuntary
behaviour. Whilst it may well be true that there is evidence from a variety of sources
that demonstrates that nicotine acts on the central nervous system to produce psychoactive
effects this is not equivalent to saying that it acts in such a fashion as to compel
smokers to smoke against their will.
Equally disturbing in the ideology of smoking addiction is the
confusion between the regular or the habitual and the involuntary. It is possible, of
course, given the evolution of the concept addiction, that this confusion is in fact
deliberate. Recall, for instance, that in its initial attempt at defining addiction in
1957, WHO carefully distinguished between an addiction and a habit. But with the movement
toward the concept of dependence, the habitual has tended to be conflated with the
compulsive so that the fact that someone engages in a behaviour on a regular or repeated
basis, or to use the language of WHO a `continuous ... basis' becomes evidence
that the behaviour is in some sense determined or involuntary. Clearly there is a
difference between the habitual and the unfree. I might have a good many habits, some
good, some bad, that precisely because they are habits occur regularly. I tend, for
instance, to habitually shave each morning without in any respect feeling compelled to
shave each morning. The regularity of my habits might provide a wealth of interesting
information about my character and mode of living, but it cannot reveal anything about
whether those habits are voluntary or involuntary.
Closely related to this confusion as another which runs throughout
the smoking is addiction ideology: the confusion between reasons and causes. The reasons
which we provide to ourselves and to others serve as explanations for actions that we have
chosen to perform. The language of causes, on the other hand, generally describes the
mechanisms that make things happen.
The language of reasons is the language of volition while the
language of causes is the language of compulsion. Those who describe smoking as an
addiction tend to ignore these distinctions: they tend to use the language of reasons as
if it were the same as the language of causes. But because people describe addiction as a
reason why people smoke does not mean that addiction is the involuntary cause of my
smoking.
EMBARRASSING EVIDENCE
The problems of demonstrating that smoking is an addiction are not
all problems of logic, clarity, or inconclusive pharmacology. They are also the problems
of dealing with millions of counter examples in the form of former smokers. In one sense
the most compelling argument against nicotine as addictive is the roughly 43 million
former smokers in the United States. It is curious how the existence of these ex-smokers
functions in the ideology of smoking. In one sense these ex-smokers are routinely
portrayed as a brilliant advertisement for the success of the last 30 years of smoking
control policies. It is these policies, we are told, that are responsible for these
ex-smokers making the decision to stop smoking. But these same ex-smokers are
conspicuously absent when the discussion of smoking as addictive arises.
What is a policy triumph in the one context appears as nothing less
than persistent embarrassment in the other context. For however one massages the data it
is clear that huge numbers of long-time ex-smokers, those who are allegedly most addicted,
have stopped smoking. (The entire `logic' of the smoking ideology flounders upon a curious
inconsistency with respect to its policy recommendations. If smoking is addictive in the
sense in which it is portrayed, then the policy measures aimed at getting smokers to quit
smoking cannot possibly succeed in the vast majority of instances. Such policies are not
only ineffective, they are a cruel hoax).
The advocates of smoking as addictive are left with an uncomfortable
conundrum: every former smoker is by definition an addicted smoker who, if the addiction
theory is correct, most likely cannot become a former smoker. The addiction theory of
smoking has no way to account for how it is that one moves from the class of current
smoker to ex-smoker: it cannot account for not hundreds but millions of counter-examples
to its claim. The only way in which the claim can be salvaged is either by suggesting that
there is an enormous class of former smokers who were never truly addicted or by arguing
that what addiction really means is nothing more than that stopping smoking is something
with which some people will find some difficulty. But then such an admission removes the
strategic usefulness of smoking as addictive since it leaves intact the claim that smoking
is a freely chosen behaviour.
The claim that smoking is addictive also suffers from another sort
of empirical embarrassment: the fact that the demand for tobacco products is elastic
rather than inelastic. If tobacco products were addictive in the sense that the ideology
of addiction claims then `tobacco addicts' should be willing to pay any price for tobacco
products: they should be completely insensitive to price increases because they have no
choice but to smoke. But this is clearly not the case, as the anti-smoking lobby itself
points out. (This is another curious anomaly in the `logic' of tobacco control policy:
price increases for tobacco products are justified as one tool to encourage `addicted'
smokers to stop smoking.) While estimates of price elasticity vary from 0.4 to 0.6, what
is inescapable is the fact that tobacco products are like other non-addictive goods, price
elastic. A price elasticity of 0.6 would mean that for every 10 per cent increase in the
price of tobacco products the purchase of tobacco products will decline by 6 per cent.
NON-FALSIFIABLE
One sign of the reasonableness of any sort of belief is the degree
of tenacity with which it is held. A belief is a reasonable one if it specifies in
principle at least those things that might serve to undermine or to refute it. The deeper
assumption at work here is that all our empirical beliefs about the world are contingent:
they rest upon the currently best available information. There is nothing necessary about
these beliefs -- they are subject to revision when better evidence presents itself.
In one sense falsifiability is part of what distinguishes ideology
from science in that for science, all beliefs are open to falsification by new evidence,
whereas for ideology truth is fixed by the boundary of what the ideology deems acceptable.
Whereas science is an open-process in which evidentiary inputs from a variety of sources
can undermine even the most sacrosanct belief, ideology is a closed-process in which the
truth is by definition non-falsifiable regardless of the nature of non-confirming
evidence.
Not surprisingly the smoking as addiction ideology regards its views
as unfalsifiable. That is, it refuses to specify what in principle might count as
falsifying the claim that smoking is addictive, what might refute the claim that smoking
is a pharmacologically-induced compulsive activity. There are three pieces of evidence
that demonstrate the non-falsifiable character of the smoking is addictive claim.
The first is that the proponents of the claim refuse a priori to
admit that there is any other explanation for why people smoke aside from the fact that
they are attracted by advertising, after which they are addicted by the pharmacology of
tobacco. Other types of explanation for smoking, beginning with the most obvious one that
smoking provides substantial pleasure to those who smoke are dismissed as impossible. For
instance, the Royal Society of Canada, in its report on addiction begins with the premise
that it is the pharmacology of tobacco smoking that can alone provide a reasonable
explanation for the repeated use of tobacco. Of course to speak of pharmacology as
providing a `reasonable' explanation of smoking is itself inaccurate since what
pharmacology provides is strictly a causal explanation of tobacco use -- nicotine is the
cause of repeated tobacco use. In effect the non-falsifiable character of the smoking as
addiction ideology is seen clearly in the fact that reasons and choices -- voluntary
behaviour are by definition excluded as explanations as to why people smoke. The ideology
of smoking as addictive refuses to countenance the notion that smokers are rational and
that the smoking decision can be a sound decision.
But if there were compelling evidence that, as Davies (1992, p. xi)
suggests, `most people who use drugs do so for their own reasons, on purpose, because they
like it, and because they find no adequate reason for not doing so, rather than because
they fall prey to some addictive illness which removes their capacity for voluntary
behaviour', then such evidence would constitute an example of what in principle would
count as refuting the claim that smoking is addictive.
The second piece of evidence of the non-falsifiable character of the
smoking is addictive claim is that the proponents of the claim speak only to themselves
and refuse to accept the legitimacy of any non-confirming smoking data.
As we have noted the process of corrupt science is a closed loop
process in which the circle of inquiry is never opened up to divergent, dissenting views,
views that challenge the orthodox conclusion. It is not simply that such views are
discounted, it is rather that they are treated as if they do not exist. Consider once
again the Royal Society of Canada's report on addiction. The only voices that were heard
were those that supported a pre-established conclusion. Thus, for example there were no
committee members who disagreed with the smoking as addiction view, even though such
internationally recognized addiction experts as David Warburton hold dissenting
perspectives. Warburton, not surprisingly, makes it into the bibliography only in the form
of a reference to a short 1989 paper, despite his substantial publications in this area.
The third piece of evidence of non-falsifiability is the fact that
the proponents of the smoking is addictive ideology refuse to even consider an alternative
of addiction in general, an account that would falsify the characterization of addiction
as inescapable compulsion. The smoking is addictive claim, it will be remembered, derives
support for its claim of pharmacological compulsion only from the self reports of smokers
who claim that they are compelled to smoke. The pharmacology model of addiction is based
on nothing more than accepting the self reports of smokers as facts, as opposed to
functional hypotheses put forward to explain their behaviour both to themselves and
others.
`If we observe that, with great regularity, we overindulge in
some activity to the detriment of our health, family, friends and economic functioning, we
require a linguistic formula that enables us to explain these circumstances in an
acceptable fashion. The statement that "I cannot stop" is not a statement of
fact, but an inference based on the self observation that I reliably fail to do so'
(Davies, 1992, p. 62).
This alternative account of addiction is predicted on the assumption
that when confronted by the claim that someone cannot do other than what they do, there is
no scientific way in which to determine whether this is true as opposed to their not
wishing to do other than what they do. Put slightly differently: there is no scientific
way to determine whether what we call an addiction is something that is uncontrollable or
simply uncontrolled. The alternative account of addiction would argue then that, rather
than addiction being explained through a substance that causes behaviour, it should be
explained through a functional hypothesis that does three things:
- (1) justifies my behaviour in a morally satisfactory manner --
namely, I am not responsible for my actions;
- (2) provides the justification for my actions that is appropriate in
a particular social context, since addiction is given meaning only in a social context
(addiction is the right explanation for explaining smoking in North American society); and
- (3) makes sense to both myself and others of my behaviour pattern,
e.g. `I've tried to stop but I couldn't'.
CONCLUSION
What emerges then from a careful examination of the case for smoking
as addictive is not the incontestable mass of scientific fact that its proponents describe
but instead an ideology founded on corrupted science and plagued by problems of logic,
clarity, and embarrassing counter-examples. Rather than providing the justification for a
new series of public policies designed to control smoking, it provides fresh evidence of
how pervasively public policy can be subverted when it adopts what appears to be the
working maxim of the anti-smoking movement, `Yes, it's rotten science, but it's in a
worthy cause. It will help us to get rid of cigarettes and to become a smoke-free
society'.
_______________________
REFERENCES
Davies. J. B. (1992). The Myth of
Addiction. Harwood, UK.
Goodin, R. (1989). No Smoking. University of Chicago Press, Chicago.
Henningfield, J. E. (1984). Behavioral pharmacology of cigarette smoking. In: Advances
in Behavioral Pharmacology, Thompson, T., Dews, P. B. and Barnett, J. F. (Eds),
Academic Press, New York.
Luik, J. (1994). Pandora's Box: The dangers of corrupted science for public policy. Bostonia,
Winter.
Royal Society of Canada (1989). Tobacco, Nicotine and Addiction. Ottawa.
US Surgeon General (1964). Smoking and Health. US Dept. of Health, Education and
Welfare, Public Health Service Publication No. 1103, Washington.
US Surgeon General (1988). The Health Consequences of Smoking: Nicotine Addiction.
US Dept. of Health Services Publication No. 88-8406, Washington.
Viscusi, W. K. (1992). Smoking: Making the Risky Decision. Oxford University
Press, New York.
World Health Organization (1957). Expert Committee on Addiction-Producing Drugs.
Seventh Report. World Health Organization, Geneva.
World Health Organization (1993). Expert Committee on Drug Dependence. 28th
Report. World Health Organization, Geneva. |
