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Against Nicotine Abstinence:

Hunter College epidemiologist Philip Alcabes has an op-ed in the Washington Post arguing against an "abstinence only" approach to nicotine. "Like other abstinence campaigns (alcohol prohibition, sexual abstinence before marriage, just saying 'no' to drugs), this one is both moralistic and ineffective," he argues. Instead Alcabes suggests public health advocates should be willing to promote alternative, less-harmful means for people to get their nicotine fix.

Obviously, nicotine use is a popular and tenacious habit. Equally obviously, tobacco policy is a failure. Surveys show that a majority of current smokers would like good alternatives to smoking as ways of getting nicotine. But we will not tell nicotine users that there are safe ways to continue to use the legal drug they crave. Apparently, our policymakers would rather see those people get sick and die.
Smokeless tobacco is hardly a "safe" alternative to cigarettes, but it is "safer," in that it poses a lesser risk of cancer and other health problems. (Nicotine patches and gum work for some, but not for all.)

If the aim is to reduce tobacco-related deaths, why not inform smokers of this fact? One possible argument is that this knowledge could encourage some people to use smokeless tobacco who otherwise would have given up tobacco use altogether. Perhaps, but given the enormous death toll from cigarettes, I find this argument unconvincing. To the contrary, if smokeless tobacco companies had the guts to promote the comparative health "benefits" of their products over cigarettes, I am inclined to think the net public health benefit would be quite substantial.

Perhaps even more provocatively, Alcbes suggests public health professionals should take a second look at so-called "social smoking":

And then there's what many smokers nowadays really do: Mix periods of abstinence (encouraged by smoke-free workplaces and restaurants) with periods of light smoking. Mixing light or occasional smoking with other nicotine-delivery products might be even safer -- but it can't be studied as a possible alternative because current funding goes only to research on how to quit smoking, not on finding a safe level of smoking.
If the aim is to improve public health, this mindset should change.

Related Posts (on one page):

  1. Big Tobacco Goes Smokeless:
  2. Against Nicotine Abstinence:
humbert (mail):
"To the contrary, if smokeless tobacco companies had the guts to promote the comparative health "benefits" of their products over cigarettes, I am inclined to think the net public health benefit would be quite substantial."

I was under the impression (possibly erroneous) that smokeless tobacco companies like skoal or kodiak (my favorite) were prohibited from advertising their products as safer alternatives to cigarettes. Doesn't it say right on the tin that this is not a safer alternative to cigarettes or something to that effect?

Also, I think Norway or Sweden tried out a pro-smokeless tobacco program a few years ago and it actually turnded out to be pretty successful.
5.30.2006 11:47pm
Barbara Skolaut (mail):
The "aim" is not to improve public health, but to extort get as much money as possible out of the tobacco companies.

The government could ban smoking - or at least ban making cigarettes - but they never will. They like the tax money way too much to ever give it up.
5.30.2006 11:49pm
frankcross (mail):
I would just like to express my disapproval of any sort of abstinence.
5.31.2006 12:12am
therut:
Here is one physician that agress with this guy. I have often wondered why many physicians did not do that. I have told my patients that smokeless tobacco is not as dangerous. But believe me there are anti-smoking zealots everywhere. Some would litterally shoot you if they saw you smoke. Like everything else in this country there is always some nanny govermental group that wants to demand you follow their orders. Sorry to say many in the Medical Profession are the same NO GUNS, NO TOBACCO and NO FREEDOM FOR YOU.
5.31.2006 12:38am
Lorenzo (mail):
To frankcross: There's nothing to fear from abstinence, as long as you do it in moderation.
5.31.2006 12:54am
JT Wenting (mail):
Does this guy also advocate the government makes opium derivatives freely available for purchase at the supermarket without prescription as an alternative to heroine and cocaine?
5.31.2006 1:31am
Dave Hardy (mail) (www):
I suggest we treat all diseases related to voluntary lifestyle choices in the same way.

So I suppose the question is whether we withdraw all funding aimed at reducing AIDS, followed by outlawing or publicly deriding activity that can spread it, or on the other hand spend millions on creating safe ways to smoke.
5.31.2006 1:36am
M. Simon (mail) (www):
Tobacco is an anti-depressant.

Which is why it tends to improve the productivity of those who use it.

BTW pot is an anti-depressant.

Chronic drug use may not be voluntary.

Is Addiction Real?

==================================================

This is all so depressing. I think I'll have a smoke.
5.31.2006 2:17am
JB:
Doesn't smokeless tobacco give you mouth cancer?
5.31.2006 2:53am
Ship Erect (mail) (www):
The premises of this post and the accompanying op-ed are truly bizarre. Unlike sex/drug/alcohol abstinence that is taught in schools, the "abstinence" mentioned does not seem to concern keeping people from smoking, but, instead, stopping people who already smoke. So what's the problem here? The few people for whom methods like cold turkey, nicotine gum, etc. don't work probably need counseling.

In these cases, why would anyone be pro-chewing tobacco instead? Tobacco of any sort causes lots of health problems; holes in the jaw and eventual removal are among the worst effects of dipping. And can you honestly say that you want to be around someone who not only can barely speak with a wad of dip in their mouth but also has to spit brown saliva every two minutes?
5.31.2006 3:23am
Steve Reuland (mail) (www):
I fail to see how smoking is analogous to sex or alcohol consumption. The latter two are not only safe, but measurably healthy in moderation. Society would not be missing anything if everyone quit using tobacco.

That being said, I agree that smokeless tobacco shouldn't be discouraged for those who want to quit smoking. And as far as I can see, it's not. Unlike methadone, you can get your Red Man or Copenhagen over the counter. In my experience though, it's an extremely ineffective way to quit. The vast majority of people go the other way -- they use smokeless tobacco first and then graduate to cigarettes.

What I really don't get though is how Alcabes seems to think that not being a huge fan of smokless tobacco somehow translates into encouraging people to smoke cigarettes:

The human cost of the nicotine-abstinence policy is doleful. More than 430,000 U.S. deaths each year -- one out of every five -- can be attributed to smoking.


Oh, right. Every smoking death is the fault of not begging people to chew tobacco like cowboys and baseball players. It's the new "personal responsiblity".
5.31.2006 3:40am
logicnazi (mail) (www):

I fail to see how smoking is analogous to sex or alcohol consumption. The latter two are not only safe, but measurably healthy in moderation. Society would not be missing anything if everyone quit using tobacco.


I simply don't see how this is true. I've never taken up smoking because I've never found it very enjoyable but some people certainly get pleasure from smoking.

The overall problem seems to be an attitude which equates unhealthy with bad rather than admitting there is often a trade off between health and enjoyment. Sure, smoking may fall further along that tradeoff than alcohol (though marijuanna from recent studies seems to fall the other way) but the important point is that it is all a matter of degree and different people will find the right tradeoff at different levels.

The idea that there is a one sized fits all smoking solution (no one should smoke) is just absurd. Clearly some people get some pleasure from smoking and at the very least if you have a terminal illness or otherwise have reason to place little value on long term health smoking might make sense. Alternatively if you get a great benefit out of smoking socially and can do so without taking up the regular habit (as many people I know have done) smoking then may also make sense (there is little reason to suspect that very infrequent smoking would be particularly harmful).
5.31.2006 3:53am
DiversityHire:
Kodiak Wintergreen and Copenhagen Long Cut are exquisite. All smokers should consider switching to smokeless tobacco. Contra Ship Erect, a pinch between cheek and gum does not impede speech and spitting can be done discretely. These godlike products aren't safe, but they're safer than smoking and deliver the nicotine you need along with the delicious, peaty flavor you gotta have.

Kodiak or Copenhagen might be appropriate for chronic smokers confined to a mental hospital. Either will boost the productivity of smokers imprisoned in a modern smoke-free office. Smokeless users do not need to leave their task to indulge and smokeless use will maintain a more consistent nicotine level throughout the workday. Perhaps the government could provide tax credits to workers, businesses, and schools that undertake gingoval nicotine productivity improvement programmes?

Skoal is filthy, disgusting compost. The government should ban it.
5.31.2006 4:07am
Steve Reuland (mail) (www):
I simply don't see how this is true. I've never taken up smoking because I've never found it very enjoyable but some people certainly get pleasure from smoking.


Some people get pleasure from sex, but this doesn't make sex and tobacco the same thing. People will have sex regardless of what they're taught or exposed to, and this has been the case for as long as humans have existed. Large-scale tobacco addiction is a mostly 20th century phenomenon.

"Abstinence only" sex education fails largely because it expects people to behave against their nature. There is nothing in our nature that compels people to use tobacco.

If people don't want to quit smoking, well, they are free not to. But it's not like we should tell people that it's a-okay to chew tobacco and that this will solve their problem.
5.31.2006 4:16am
DiversityHire:

Unlike methadone, you can get your Red Man or Copenhagen over the counter. In my experience though, it's an extremely ineffective way to quit. The vast majority of people go the other way -- they use smokeless tobacco first and then graduate to cigarettes.


Thanks, Mr. Reuland, for reminding me of another of god's wonderous creations: Red Man Golden Blend. A delicious treat guaranteed to enhance one's morning commute.

I don't believe smokeless tobacco is a gateway to cigarettes. Snus users have a higher average nicotine level so why light-up? Especially since you can't smoke 14 hours a day.

Regardless, for those that can't or won't quit smoking, dipping is a great substitute. For those that wish to indulge occassionally, the quantity required to get a good buzz-on is so small that a single tin could serve a bar-full without producing all that mythically poisonous second-hand smoke.

It's good for obesity, too. A chronically overweight individual can use snuff or snus to reduce appetite or to soothe hunger pangs. You can dip while you exercise, too, cycling, hiking, swimming, and skiing all combine well with both Kodiak and Copenhagen.
5.31.2006 4:31am
Paul doson (mail) (www):
Very well said. I just wanna say that in any case smoking should be avoided because it is harmful for your body and health.
5.31.2006 7:09am
PatHMV (mail) (www):
I went to school in a rural area where many people chewed tobacco. Ick. Ever seen a platic bottle filled with tobacco juice spit?

More seriously, I know at least one person who no longer has a jaw because of the cancer of the mouth given him by several years of "chaw". Go here and see if you remain enamored of this "safe" alternative.
5.31.2006 9:44am
Andy Freeman (mail):
> There is nothing in our nature that compels people to use tobacco.

Don't know many people do you? Human nature compels folks to do lots of strange things.

Moreover, nature compels folks to do things that we should discourage. (I had to stop one of my co-workers from telling us at lunch yesterday about his weekend spent trying to toilet train his twins.)

"Nature" is basically code for "I don't really have an argument and am looking for an authority that won't contradict me".
5.31.2006 9:49am
Preferred Customer:
There are people out there, god bless them, that can be "social smokers," and can smoke the occasional cigarette without spiraling down into addiction and over-consumption. There are, unfortunately, a lot of people out there who can't do this.

I would wager that the majority of serious smokers fall into the latter camp. Suggesting that people who have spent years heavily addicted to smoking can suddenly transform themselves into "social smokers" is unrealistic, and is a recipe for failure in attempts to quit using nicotine. This is anecdotal, but in my experience (and the experience of many heavy smokers I know) the easiest way to relapse and fail at quitting is to convince yourself that you can just smoke socially, or can just smoke when drinking.
5.31.2006 10:18am
Tflan (mail):
Smokeless Tobacco is to Cigarettes what Needle Exchanges are to:

A - Knitting Clubs
B - LP (vinyl discs that play music) clubs
C - Air pumps
D - Heroin use

I wonder what the ratio is of people that support needle exhanges to those that disapprove of safer tobacco use? Granted, it's not completely safe, but then again, what is?
5.31.2006 10:28am
frankcross (mail):

Society would not be missing anything if everyone quit using tobacco.


Blasphemy! I'll give up my cigars only when you pry them from my cold dead hands.
Addiction, in the form of chain smoking cigarettes, is plainly a bad thing. But there's nothing intrinsically terrible about occasional use of tobacco. It's not that recent a phenomenon, unless you only count white people, and if it were, so what? Airplanes are recent phenomena but that doesn't make them less valuable than horses.
5.31.2006 11:06am
byomtov (mail):
Who says smoking abstinence campaigns are ineffective?

The absolute number of adult smokers has declined since 1965, and the percentage of adults who smoke has dropped from 42% to 21%.

And classing smoking with sex as natural human activities is utterly ridiculous. Humanity survived many thousands of years without tobacco.
5.31.2006 11:21am
CJColucci:
I smoked for about a year three decades ago and stopped, so I never got hooked, (pipe smoking takes a while to become addictive, especially if you don't inhale), but as I understand it, it's the nicotine that hooks you and the other agents in tobacco that kill you. Does anyone out there know what the health effects, if any, are from shooting up nicotine?
5.31.2006 11:27am
spencere (mail):
After smoking over a pack a day for over 45 years I switched to the COMMIT lozenge some two years ago for
my nicotine fix. It has worked fine. There are now other sources of ncicotine on the market to replace tobacco products.
5.31.2006 11:47am
JosephSlater (mail):
Ditto Bymotov's point. The premise that anti-smoking campaigns have been "ineffective" is flatly wrong: the decline of smoking in my lifetime has been dramatic and significant, both in terms of the percentage of smokers and in terms of the places in which smoking is allowed (I still remember "smoking sections" on U.S. domestic flights, with all the related health risks -- thanks to the Flight Attendents Union for getting rid of those).

Since the article starts with a faulty premise, whether the rest follows is less interesting. But I'll join those who worry about how easy it is to be merely a "social smoker," given the addictive nature of the drug. That's the big contrast with alchohol: the overwhelming majority of people who drink alchohol can be and are "social" drinkers; most cigarette smokers soon go beyond the "social" stage. And smokeless tobacco may be relatively safe compared to cigarettes, but that's a far cry from "safe" in the normal use of that term.
5.31.2006 11:57am
Medis:
Two idle thoughts:

(1) I'm always interested to see how certain intrinsic goods (eg, the simple pleasure derived from doing something one finds enjoyable) are discounted or denigrated by some people during "public health" or "social welfare" discussions. Of course, perhaps that is because at least some moral systems--usually religiously-based moral systems--have an underlying anti-wordly-pleasure (ascetic) theme.

(2) One interesting analogy for nicotine might be caffeine. Many of us, at least, think of caffeine as something that can justifiably used in moderation, and we also regulate caffeine accordingly (eg, by not making its use illegal, but by doing things like limiting the amount of caffeine a single pill can contain).
5.31.2006 12:17pm
Clayton E. Cramer (mail) (www):
Was this perhaps a parody of criticism of "abstinence only" sex education, and Professor Adler didn't recognize it as such? My first reaction on reading it was to laugh. Indeed, the substantial effort that both public and private organizations have put into discouraging smoking has been one of the great success stories in social engineering (and social engineers need a success story or two to counter all their failures).


And classing smoking with sex as natural human activities is utterly ridiculous. Humanity survived many thousands of years without tobacco.
Complete agreement. Smoking tobacco for most of the world is a very recent innovation. King James I correctly identified cigars "as a fire at one end, and a fool at the other."

I find it significant that most people that smoke have to work their way up to it, because their initial reaction is somewhat negative--which is why one traditional method by which parents discouraged a kid who they caught smoking a cigarette was to force him to finish the pack, right then and there. The results were so repulsive that it sometimes ended the experiment with being "cool."
5.31.2006 12:21pm
Medis:
Oh, and one last thought on "social smoking":

I recall reading once that people who begin smoking during their youth are far more likely to become seriously addicted to smoking than people who take up smoking as adults. If my recollection is correct, then that may suggest both the possibilities and limits of a "social smoking" campaign.
5.31.2006 12:22pm
Joel B. (mail):
bytotov and Joseph are absolutely correct "abstinence campaigns" with reference to tobacco have been wildly successful, of course part of this is because the abstinence campaign has been appropriately paired with a public mentality that it is appropriate to shame those who choose not to abstain.

I would also bet that a teenage or abstinence till marriage would be far more successful if people took the same approach to premarital sexual relationships. Which is the main reason I think sexual abstinence is harder, is because the rest of society instead of supporting traditional morality mocks and attacks it, so we shouldn't be surprised then when adolescents take up that behavior.

Lastly, what the parents allow in moderation, the children take to excess. Which is always important to remember when society decides to "encourage" any behavior.

As an aside, I find smoking a far less revolting habit the chewing tobacco, neither appears to be particularly healthy, but can we at least agree that ashtrays are far less disgusting than spitoons, (ick, I feel my stomach turning at the thought.) As a result, I suggest that Alder and Alcabes on this point are greatly mistaken at the "benefit" to society and individuals.
5.31.2006 12:27pm
MDJD2B (mail):
...as I understand it, it's the nicotine that hooks you and the other agents in tobacco that kill you. Does anyone out there know what the health effects, if any, are from shooting up nicotine?\

The cardiovascular effects (heart disease, Reyneaud's phenomenon, etc.) are due to nicotine . The lung effects (emphysema) and carcinogenic effects (lung, oral cavity, larynx, cervix) are due to other components.
5.31.2006 12:28pm
JosephSlater (mail):
Along the lines Medis was mentioning, who actually takes up smoking as an adult these days? Maybe a few folks got into the cigar thing when that industry figured out how to market its product as sophisticated and upscale, but seriously, what person past college age decides that he wants to take up smoking cigarettes? Of the smokers I know, all started as teenagers.
5.31.2006 12:29pm
Medis:
Yet another thought:

It seems unquestionable that the popularity of cigarette smoking in particular has declined over the years, but to claim that abstinence-oriented anti-smoking campaigns caused this trend seems to be engaging in a bit of post hoc ergo propter hoc reasoning. For example, it seems likely to me that simply doing a better job of informing people about the risks associated with cigarette smoking may well have been a major factor driving this trend.
5.31.2006 12:33pm
Medis:
Joseph,

Anecdotally, I know of a few adults who took up smoking one or two cigarettes periodically (eg, when they go out to a bar). In fact, I have smoked a few cigarettes myself as an adult without first doing so as a youth, although most of my "social smoking" has in fact been with cigars and pipes.

But I'm not sure I know of anyone who regularly smokes cigarettes (ie, several a day, every day) and who first took up cigarette smoking as an adult.
5.31.2006 12:38pm
JosephSlater (mail):
Medis:

I'm confused as to how/why "abstinence-oriented anti-smoking campaigns" are something entirely different from "doing a better job of informing people about the risks associated with cigarette smoking." Isn't there at least a significant overlap?

If we're looking at causal factors, we might also look at restrictions on advertising (I'm old enough to remember cigarette ads on TV), and pressures on TV and movie makers to stop using cigarettes as symbols of glamor, sexiness, toughness, etc. (to combat previous decades of cigarette companies pressuing TV and movie makers to do the opposite). Watching TV and movies from the 50s and 60s as compared to now, the difference in smoking rates is really striking.
5.31.2006 12:42pm
JosephSlater (mail):
Joel B.:

I think sex and smoking are different. First, there is a huge biological imperative to want to have sex, even if you've never had it, and there's no equivalent natural lust for cigarettes. Second, cigarettes are almost always going to be bad for your health, because the addiction makes it hard to do in any sort of moderation, and the product is simply unhealthy. In contrast, while there are certainly risks of pregnancy and disease, sex can usually be done safely, even by teenagers.

Further, the reports on the outcomes of "abstinence only" programs for kids are not encouraging for proponents of such programs, even though I would guess their parents were supportive of such programs. In fact, I would guess that most parents would still be more upset if they caught their teenager in bed having sex than if they caught them smoking.
5.31.2006 12:49pm
Medis:
Joseph,

I certainly think that in practice, information about the risks associated with habitual smoking is often coupled with the proposed remedy of complete abstinence in anti-smoking campaigns. Indeed, my point is basically just that we do not know what role the abstinence portion of such a campaign is playing with respect to reducing the popularity of cigarette smoking in light of the fact that there are other possible factors in this mix.

Similarly, I agree that differences in how cigarette smoking is portrayed in mass media likely has contributed to this trend. Again, to me that just suggests that we cannot be sure how much of this trend can be attributed specifically to abstinence-oriented messages.
5.31.2006 12:52pm
Joel B. (mail):
Joseph,

No doubt sex and smoking are different, but the affect that social acceptability or shame makes a difference in the actual rates of abstinence I think for both items. Of course, one particular difference, is that no one is expecting adolescents to remain abstinent forever, but until they are older/married (take your pick).

Which, is certainly a sacrifice, but it's not the same thing smoking abstinence is asking for.

More or less, I agree they are different, BUT, that doesn't mean that the same factors in success wouldn't be applicable. Social shaming is a very powerful tool. That has been leveled at smoking, but not teenage sexual activity.
5.31.2006 1:28pm
Clayton E. Cramer (mail) (www):
Medis writes:


It seems unquestionable that the popularity of cigarette smoking in particular has declined over the years, but to claim that abstinence-oriented anti-smoking campaigns caused this trend seems to be engaging in a bit of post hoc ergo propter hoc reasoning. For example, it seems likely to me that simply doing a better job of informing people about the risks associated with cigarette smoking may well have been a major factor driving this trend.
And what do you think abstinence programs do? They emphasize the substantial physical and emotional risks of premature and immature sex. One big difference, however: sex abstinence programs don't encourage life-long abstinence (for which there is no significant support), but waiting until at least adulthood, and ideally, until marriage.

Tobacco abstinence programs, on the other hand, encourage never taking up this disgusting habit (and I will say that chewing tobacco making smoking seem positively debonair).

Tobacco abstinence has clearly worked. I suspect that sexual abstinence programs will be less effective, simply because you don't have to encourage or teach adolescents to be interested in sex. Still, if the mass media went along with encouraging minors to wait--instead of actively mocking it--abstinence programs would likely be more effective. (I'm skeptical of abstinence-only programs; I think abstinence is safest programs are more realistic.)
5.31.2006 1:47pm
Medis:
Joel B.,

As an aside, it seems to me that "social shaming" has in fact been "leveled at . . . teengage sexual activity" at least to some extent. Girls in particular have long been subject to "shaming" for actually engaging in sexual activity, and it seems to me there is still a great deal of societal hand-wringing about girls having sex.

Of course, part of the problem may be that boys have often been treated differently when it comes to sexual activity. And even with respect to girls, the message is pretty mixed--it often seems to me that we are basically telling girls that it is very important that they be sexually attractive to boys/men, but also very important that they not actually let any boys/men have sex with them.

Anyway, with respect to smoking, my point would be that insofar as we conciously try to use social mechanisms to affect behavior, we have to think about how we structure those mechanisms. In particular, we do have to take into account the reasons why people might do something like smoke in the first place, and also make sure that we try to communicate a plausible, coherent, and non-hypocritical message about smoking.
5.31.2006 1:47pm
Joel B. (mail):
I will agree that in the past social shaming on youthful sexual activity was much greater, I think the difference we would have, is that I see the aspect of shaming on teenage sexual activity has faded greatly since the 1950's. Now, was there teenage sexual activity in the 1950s? Yes, but the way it was treated was much not nearly as glowingly.

Girls were and are treated unfairly in this area, and I think we are in agreement, however, some believe the appropriate response is to remove the shame from girls, I disagree, and think that the appropriate response would be to shame boys as well.

But really, I'm more curious about the chewing vs. smoking point...we would as a society really rather have people chew? Like I said I think that's far more disgusting.
5.31.2006 1:55pm
Medis:
Clayton,

Again, it seems to me you are conflating two different elements of abstinence-oriented anti-smoking campaigns (or, for that matter, abstinence-oriented anti-sex campaigns, or abstinence-oriented anti-anything campaigns). Again, I understand that abstinence-oriented campaigns will often include information about the risks associated with the behavior in question. But providing information about the risks is a separable factor from advocating a particular remedy (abstinence). And that is one of the reasons why you can't be sure that insofar as such an anti-something campaign has an effect, it is because of the abstinence portion of the campaign.
5.31.2006 1:56pm
Medis:
Joel B.,

I agree that pointing out any inconsistencies in our social messages about childhood sexual activity does not tell you which way those inconsistencies should be resolved. I might note that I am personally convinced that an effective and responsible message on childhood sexual activity would focus on what is age-appropriate, meaning that the question is not whether childhood sex is good or bad, but rather what sorts of sexual activity are appropriate and healthy at any given stage of childhood development.

And I think a similar tactic might be a good idea for childhood use of legal drugs (alcohol, nicotine, caffeine, etc.). Indeed, if it is true that children are particularly susceptible to lifelong addiction to something like smoking, I see no reason not to share that information with children as part of an age-appropriate message.
5.31.2006 2:09pm
Andrew J. Lazarus (mail):
One of the many effective anti-smoking ads done here in California showed a drooping cigarette, a teenage boy smoking, and a clear implication that smoking cause erectile difficulties.

Unfortunately, I can't see a sexual-abstinence campaign with similarly punchy advertising.
5.31.2006 2:11pm
Medis:
Joel,

Oh, and I have no particular stance on chewing versus smoking from a societal standpoint. Obviously, though, insofar as the former does in fact present less of a public health problem--a problem whose costs often end up being exported to the rest of us--then I might be willing to accept a greater "ick-factor" in exchange for lower health care costs.
5.31.2006 2:13pm
Ken Arromdee:
Indeed, my point is basically just that we do not know what role the abstinence portion of such a campaign is playing with respect to reducing the popularity of cigarette smoking in light of the fact that there are other possible factors in this mix.

The original article claims that we *do* know, and that what we know is that it has no effect.

Claiming that we don't know is just as good for negating the original argument as claiming that the effect is positive.
5.31.2006 2:45pm
Medis:
Ken,

Sure, I don't take myself to be proving Alcabes's claims, nor in general to be providing a comprehensive defense of his op-ed.
5.31.2006 2:54pm
DiversityHire:

But providing information about the risks is a separable factor from advocating a particular remedy (abstinence).


California's anti-tobacco crusade is four-pronged: (1) educate folks about the risks, (2) advocate a pure abstinence position, (3) increase the actual cost of tobacco use through massive taxes, and (4) coerce tobacco consumers to quit by making use as inconvenient as possible. (It's illegal to smoke in Calabasas and Palo Alto.)

The first factor amount to an "...over-representation of factual presentations on how dangerous it is, as a predicate for opening up the audience to listen to what the solutions are..." I'm reminded of the PSA that claimed smoking was as difficult to quit as heroin. The over-representation makes abstinence the only acceptable alternative. Once you're on board that train, it doesn't stop at any convenient stations, it just barrels-on to Police State City where the fundamentalists decide what's good (needle exchange, medical marijuana, condoms) and what's bad (smoking, a glass of wine with dinner, fatty foods, soda pop, dogs) and write it into law.
5.31.2006 3:06pm
Dave Hardy (mail) (www):
The lung effects (emphysema) and carcinogenic effects (lung, oral cavity, larynx, cervix) are due to other components.

Cervix? What are they doing with those stogies? Even for Monica, it was a one-time thing, not a carton of Te Amos a week.
5.31.2006 3:42pm
Bob Loblaw (www):

(It's illegal to smoke in Calabasas and Palo Alto.)

Uh - no.
5.31.2006 3:47pm
DiversityHire:

(It's illegal to smoke in Calabasas and Palo Alto.)


That's just my over-representation of factual presentations, Mr. Loblaw. It's not really illegal to smoke in Palo Alto, just hard to find a place where it's legal to smoke.
5.31.2006 4:30pm
Tom952 (mail):
"Like other abstinence campaigns (alcohol prohibition, sexual abstinence before marriage, just saying 'no' to drugs), this one is both moralistic and ineffective,"
This strikes me as an odd grouping for generalization. Advocacy for abstienence from heroin and cocaine is not to be derided as "moralistic and ineffective". It is factually the only effective way to avoid becoming an addict.

I do not understand why this made it to the op-ed section in one of our two major newspapers.
5.31.2006 4:31pm
Medis:
Tom952,

Are you suggesting that it is impossible to use heroin and cocaine at all without becoming an addict?
5.31.2006 4:50pm
Joshua (www):
Tom952: It occurs to me that there is one critical difference between the tobacco-abstinence campaign and other abstinence campaigns: the Christianist factor (to borrow Andrew Sullivan's term). To make a long diatribe short, the sexual-abstinence crowd (and to a lesser degree the alcohol-temperance and "just say no to drugs" crowds) has long had the weight of Christianism behind it, politically and culturally, in a way that the tobacco-abstinence crowd never has.
5.31.2006 5:45pm
Andy Freeman (mail):
> One of the many effective anti-smoking ads done here in California showed a drooping cigarette, a teenage boy smoking, and a clear implication that smoking cause erectile difficulties.

Effective, or popular among the smarmy set?
5.31.2006 5:48pm
Medis:
Joshua,

Although I wonder if that would be the case if tobacco grew best in northern climes.
5.31.2006 5:59pm
Tom952 (mail):
Medis: Correct - Brains repeatedly exposed to heroin and cocaine change and become addicted.

Joshua: Yes, sexual abstinence is tangled up with Christian morality, and many other factors as well.

My point is that proscriptions against sex based on morality aren't comparable to recommendations against heroin or cocaine - toxic chemicals that are unfortunately seductive in their short-term effect.

The author is taking a broad swipe at abstinence, trying to convince the reader dismiss all calls for abstinence as trite ("just say no") or simple Christian moralizing. It is not a valid generalization.
5.31.2006 6:39pm
Medis:
Tom952,

But now you are talking about the brain-chemistry effects of "repeated exposure". I'm not sure what you mean by that, but insofar as there is a gap between the sort of habitual use that is likely to lead to addiction and complete abstinence, one cannot say that complete abstinence is the only way to avoid addiction.
5.31.2006 6:45pm
Tom952 (mail):
Medis,
In response to any habitual exposure to heroin or cocaine, all brains become addicted. It is not a character issue. Perhaps you are intimating the fact that some people are able to dabble with these chemicals without becoming hopeless, helpless addicts.
5.31.2006 7:26pm
Frank Drackmann (mail):
Such as our current president, and probably the former president also.
5.31.2006 7:38pm
Clayton E. Cramer (mail) (www):
Andrew J. Lazarus writes:


One of the many effective anti-smoking ads done here in California showed a drooping cigarette, a teenage boy smoking, and a clear implication that smoking cause erectile difficulties.

Unfortunately, I can't see a sexual-abstinence campaign with similarly punchy advertising.
That's only because the television stations wouldn't run ads showing chancred penises. They could, however, show a woman or a man in pain from a herpes outbreak, and explain that this decision he or she made at 16 is going to be with them--for life.

Or they could show a woman crying because she has just found out that the HPV-induced cervical cancer now means that the baby that she had planned to have...someday...isn't an option.

Or they could show a guy or a gal in the final stages of AIDS caught as a result of a condom failure--or failure to insist that her boyfriend use a condom.

But there's not much interest in liberal circles in discouraging sex, even when the risks are pretty substantial, because it might imply, you know, that there's some good arguments for self-restraint. We can't have that!
5.31.2006 7:42pm
Clayton E. Cramer (mail) (www):

Medis,
In response to any habitual exposure to heroin or cocaine, all brains become addicted. It is not a character issue. Perhaps you are intimating the fact that some people are able to dabble with these chemicals without becoming hopeless, helpless addicts.
There are people who dabble with these drugs without becoming hopeless, helpless addicts. The same is true for tobacco. There are some people who get addicted rapidly and hopelessly. There are others who do not. There are people who become addicted to opiates in the hospital, but are weaned off them, and don't become a problem later.

The problem is that it is often quite difficult to figure out if you are going to become an addict or not. I have no idea whether I might become an addict to any of these drugs, so I have kept my distance from alcohol, tobacco, marijuana, opiates, and cocaine. (With the exception of cocaine in alcohol suspension administered by a doctor on several occasions as part of clearing out my sinuses.) I think there are some biochemical reasons for this--and there's probably some character reasons as well.
5.31.2006 7:46pm
Tom952 (mail):
Surveys show that a majority of current smokers would like good alternatives to smoking as ways of getting nicotine

What survey? Anyone can go out and buy a box of Nicorettes gum anytime they want, and ingest safe measured doses of nicotine. But it isn't catching on.
5.31.2006 7:49pm
Clayton E. Cramer (mail) (www):
Joshua writes:


To make a long diatribe short, the sexual-abstinence crowd (and to a lesser degree the alcohol-temperance and "just say no to drugs" crowds) has long had the weight of Christianism behind it, politically and culturally, in a way that the tobacco-abstinence crowd never has.
Huh? Tobacco usage has been discouraged strongly by most Protestant churches for decades. Indeed, back in the 1930s, the use of tobacco was one of the ways that people demonstrated that they were liberated from narrow-minded reactionary Christian thinking. They were called "coffin nails" back then for a reason.

I will agree that most Christian churches don't emphasize tobacco abstinence as strongly as they do chastity before marriage. This is partly because chastity before marriage is clearly mandated by the New Testament, where the Bible is silent about tobacco use. But I can tell you that I don't think there's a church that I have ever attended that would not have looked with disapproval on someone who attended church, and lit up a cigarette afterwards. Many Protestant denominations have a policy that they will not invest retirement funds in companies that make or distribute alcohol or tobacco.

You are correct that at least part of what drives the hostility towards tobacco abstinence is the general liberal hatred of anything that smacks of Christian morality.
5.31.2006 7:52pm
Tom952 (mail):
The problem is that it is often quite difficult to figure out if you are going to become an addict or not.

Please excuse me for adding, it is impossible to predict who will and who won't, and that is a key fact in determining public policy.
5.31.2006 7:52pm
Medis:
Tom952,

Again, insofar as there is a gap between "habitual exposure" and complete abstinence (call it "nonhabitual exposure"), then complete absistence is not the only way to avoid addiction.

I understand Clayton's point about the difficulty of knowing in advance one's particular susceptibility to addiction. But unless a substantial percentage of people would become addicted as a result of a particular nonhabitual exposure to the drug in question, your a priori risk of becoming addicted through such a nonhabitual exposure will not be substantial.
5.31.2006 10:04pm
Tom952 (mail):
Medis,

I cannot find a study establishing a safe level of habitual exposure to cocaine. A quick check did turn up numerous credible studies documenting the physiological changes to the brain upon repeated exposure to cocaine, without qualification.

Certainly there are anecdotes of people who dabble with cocaine and do not appear to have an addiction problem, but anecdotes are not useful for policy determination because we do not have all the facts for those cases.

One also must weigh the consequences to those who do become addicted. The changes to the brain caused by habitual cocaine use are irreversible, and there is no known cure.

To argue against abstinence is to suggest it is permissible to try to use cocaine occasionally and hope that you will not become one of the inevitable addicts. Of those who do become addicted, many will die as a result. Knowing that a significant portion of users will become addicted, this is equivalent to advocating Russian roulette.
6.1.2006 1:20am
Medis:
Tom952,

But that is just my point--you haven't shown that any use of cocaine whatsoever leads "inevitably" to some people becoming addicts. So, you haven't shown that ANY cocaine use is equivalent to Russian roulette, just that SOME cocaine use (what you are calling "habitual exposure") is equivalent to Russian roulette.

In other words, we know that Russian roulette is dangerous because we know that one of only a few chambers contains a bullet, creating a substantial chance of death each time the trigger is pulled, including the first time. But if, counterfactually, it took many pulls of the trigger before the gun could even possibly fire, then pulling the trigger a couple times wouldn't be dangerous. And you really haven't shown that, say, taking cocaine once could possibly lead to the brain changes associated with cocaine addiction.

And although you seem to be suggesting that any unmeasured and purely conjectural risk is worth avoiding as soon as it is suggested, I think you are overlooking the costs to such a policy. For example, you lose credibility if you state things that people can observe to be false. So, if people observe others taking cocaine or heroin a couple times without becoming addicted, and they never observe the addiction you are claiming is an "inevitable" byproduct of any cocaine or heroin use whatsoever, then this "anecdotal" evidence will still lead such people to question your credibility, and tune out your entire message.

In short, I think it is important not to misrepresent what we know to be true. And it appears to me that while we know that "habitual exposure" to cocaine and heroin presents a substantial risk of addiction, we do not in fact know that ANY use of cocaine and heroin presents a substantial risk of addiction.
6.1.2006 2:17am
Steve in CA (mail):
Medis has it right. I've used all the drugs on the list of stuff that scares Clatyon Cramer, and I'm not addicted to any of them, though I am quite addicted to caffeine. I've known dozens of people who smoke, drink, and do various drugs socially/occasionally, and very few who have become addicts. Sure, that's anecdotal evidence, but it does disprove the notion that addiction is inevitabley if you use The Very Bad Substances.
6.1.2006 2:32am
Tom952 (mail):
Medis,

you haven't shown that any use of cocaine whatsoever leads "inevitably" to some people becoming addicts.

Among people why try cocaine, some become addicted. There are no cocaine addicts who did not first try it. Everyone who tries it does so believing they are special, and therefore will not become addicted like those other people.

The threshold of use that leads to addiction is not defined or predictable. The outcome for addicts varies greatly between those who shake it off and those who suffer premature death.

The illusion of safety reinforced by the public and seemingly, harmless use of cocaine by influential people is a big problem. When George Carlin was out cracking jokes about his cocaine use, appearing happy and rich, it had an influence. When George sank into addiction and fell off the public stage, the rest of his story was not given the same public exposure, so the public was left without the whole story.

seem to be suggesting that any unmeasured and purely conjectural risk is worth avoiding as soon as it is suggested,

I am discussing cocaine and heroin in particular. The risk of addiction is not conjecture. I do not generalize these observations to apply to all risky behavior.

Take a step back and try this: You are the head of the FDA reviewing ABC, a food product that has been consumed for years. New data shows that over the long term, 2-20% of consumers will develop fatal cancer. Very long term data not yet available is needed to better define the risk. Everyone can use ABC for a short while without ill effect. People do not need to consume ABC to live full, healthy lives. Would you permit the sale of ABC?
6.1.2006 2:29pm
Clayton E. Cramer (mail) (www):

I've used all the drugs on the list of stuff that scares Clatyon Cramer, and I'm not addicted to any of them, though I am quite addicted to caffeine.
"Scare" isn't the right word. I have a healthy respect for the dangers of addictive drugs, because I've seen the damage that they do for those who become addicted.
I've known dozens of people who smoke, drink, and do various drugs socially/occasionally, and very few who have become addicts. Sure, that's anecdotal evidence, but it does disprove the notion that addiction is inevitabley if you use The Very Bad Substances.
I agree that there are people who use various addictive drugs without becoming addicted. But it has been my experience is that many addicts don't recognize that they are addicts--and have a tendency to engage in this same sort of denial when they see others with addiction problems.

I don't know what percentage of those who start recreationally using meth become addicts. It might be fairly low. But the damage that it does to those who become addicted--completely separate from the damage caused by its illegality--is substantial. Alcohol, meth, cocaine, are all associated with serious violent crime because these drugs act as disinhibitors, reducing or sometimes completely wiping out the inhibitions that keep most people reasonably well-behaved. Caffeine, as addictive as it is, doesn't seem to have this disinhibiting effect.
6.1.2006 2:35pm
Medis:
Tom952,

You say: "There are no cocaine addicts who did not first try it."

But that is really besides the point. The actual question is whether there are any cocaine addicts who ONLY tried it, or who in general only used it "nonhabitually". Again, all the evidence you have presented so far suggests that people can become addicted after "habitual exposure". The fact that habitual exposure necessarily starts with the first use does not mean that the first use alone constitutes habitual exposure and can lead to addiction.

As for your FDA example: I don't really have enough information yet. You say: "New data shows that over the long term, 2-20% of consumers will develop fatal cancer." But it appears unlikely to me that such a propensity is independent of how much and how frequently "ABC" is being consumed, and it may not be independent of the form and processing of ABC. Accordingly, there is a range of possible remedies: a complete ban on ABC, an attempt to moderate consumption of ABC to a safe level, an attempt to identify and eliminate the carcinogenic factor(s) in ABC through differences in form or processing, and so on.

And the most cautious approach--a complete ban--is not necessarily going to be the most effective approach. If, say, people can still get ABC despite my ban, and if people are likely to do so, then it is not at all clear that a complete ban will have the best overall effect. Instead, one of the less stringent regulations may have a better overall effect insofar as it allows people to consume ABC, but in lower amounts or in a less dangerous form.

Finally, I suspect that the dearth of public information on something like the amount and frequency of cocaine or heroin use that is not likely to produce addiction is at least in part a product of the very policies we are discussing. The very idea seems to be that if we inform people that some amount of drug use might be safe, it undermines our complete abstinence message, and for some people that might lead to excessive use and addiction.

But my point is that there is a cost to this policy which might outweigh its benefits: maintaining that any use at all inevitably leads to addiction may ruin our credibility, and failing to provide accurate information about safer uses may hinder the ability of people to self-moderate. This in turn could be causing people to become addicts when they otherwise (with full and accurate information) would not.

All of which is not to say I know for sure which is the right policy. But I am generally skeptical of policies that depend on manipulating information, because I think the information we try to hide has a tendency of coming out--and often in a distorted and even more damaging form.
6.1.2006 5:43pm
Medis:
Oh, and I forgot to mention a point I made above: I think our policy decision about ABC should also take into account whatever enjoyment people derive from consuming ABC. In short, rational people frequently choose to accept some risk of harm in exchange for some amount of enjoyment, and government regulators should respect such choices.
6.1.2006 6:06pm
Tom952 (mail):
Medis,
But that is just my point--you haven't shown that any use of cocaine whatsoever leads "inevitably" to some people becoming addicts

Getting back to that statement, perhaps I do not understand your meaning. I assert a) every user begins using cocaine intending to be an occasional user (we can disregard any others here), and b) some of them become addicted after they first use it despite their intentions.

For any particular individual, no one can say what will happen after his or her first use. Some crack addicts acknowledge addiction at that point. For a group, all experience shows a subset will become addicted. Doesn't that qualify as inevitable?

Further, regardless of individual tendencies, every brain repeatedly exposed to cocaine experiences irreversible changes. It is an inevitable consequence of cocaine exposure. Do you know of a study that states some brains do not react?

Regarding manipulated information: Is that an accusation? I don't believe in it for the reasons given.
6.1.2006 6:23pm
Tom952 (mail):
Medis,

Re the "ABC" food example. Assume the information given is all than is known. As the example says, more long-term data is needed to answer your questions but a study has revealed that users of ABC are contracting a particular cancer later in life, and the stats hold up. Also assume it is just a food, and that a substitute product is available, although perhaps at a higher cost, or perhaps not quite so palatable as ABC. In this example, there is no dramatic benefit to the consumer of ABC beyond perhaps that associated with consuming a tasty treat.
6.1.2006 6:54pm
Medis:
Tom952,

First, (a) is not necessarily true. I'm not sure what intentions people have, but I see no reason to believe that all people specifically intend to be only occasional users. They may not intend to be addicts, but they might entertain the possibility of being "habitual" or "repeated" or "regular" users, or simply have no firm intentions at all.

Second, the meaning of (b) seems to depend on an ambiguity in your use of the word "after". Again, my point is that you haven't shown that people become addicted immediately after they first use it. And if it is true that more steps are required before a person can become addicted, then it is misleading at best for you to claim that some people become addicted "after" their first use.

Third, you say, "For any particular individual, no one can say what will happen after his or her first use." Supposing that is true, then you should stop saying that addiction inevitably follows from using cocaine.

Fourth, you say, "Some crack addicts acknowledge addiction at that point." Before you disparaged anecdotal evidence. I wonder if you have any proof that the brain changes you have referenced can occur after a single use of crack.

Fifth, you say, "For a group, all experience shows a subset will become addicted. Doesn't that qualify as inevitable?" I'd say that is the exact opposite of "inevitable", since apparently a different subset of this group will not become addicted.

Sixth, you say, "every brain repeatedly exposed to cocaine experiences irreversible changes." Again, my precise point is that this statement doesn't tell you what happens if the brain is NOT repeatedly exposed to cocaine.

So, you are still just making a case involving what we have variously called habitual use, habitual exposure, repeated exposure, and so on. And when you try to extend this claim to all use, and then claim that all use inevitably leads to addiction--yes, I think that is a manipulative statement in light of the evidence that you have presented.
6.1.2006 7:07pm
Medis:
Tom952,

On the ABC example: you still haven't shown me that attempting to ban ABC would be a proportionate and effective response. I'd favor government regulators not interfering until they have a better idea of the problem and a better idea of the consequences of what they would be doing than you have described. In the meantime, I might support informing people about the risks associated with ABC insofar as we have ascertained them so far.

And I would again note that your desire to consume "a tasty treat", particularly a treat that is particularly to your tastes, is worthy of a government regulator's respect. Again, we all ultimately take small risks in the pursuit of small pleasures, so pointing out the only benefit is a small pleasure does not mean that this small pleasure should have no weight in our regulator's decisions.
6.1.2006 7:17pm
Tom952 (mail):
Medis,

Cocaine addiction undeniably occurs. No one can predetermine who will or will not become an addict if they use cocaine. No certain treatment exists to cure addicts. The only way to be certain that a person will not become a cocaine addict is for that person to never take cocaine. To abstain.

Public education advocating abstinence from cocaine is a rational response to a real public health issue.

(BTW - In controlled experiments, exposure to cocaine for as little as 4 days has produced measurable changes in subject's brains - See A.M. Graybiel.)

But as I mentioned before cocaine and heroin are very different issues from sex or nicotine, and I think a generalization that includes all these issues is too broad to support a policy proposal.


"Manipulating information" means distorting facts. Knowingly issuing untrue statements or omitting relevant facts, for example.

A "manipulative statement" is a statement that manipulates, i.e. influences or controls. Effective oratory and compelling arguments are manipulative speech. Some people who disagree with you may make compelling arguments. When that occurs, it is worth your consideration.
6.1.2006 10:02pm
mary (mail):
Just a brief correction to those claiming abstinence education on tobacco use has been successful. You are simply wrong. The precipitous declines in smoking over the last 50 years can be traced most directly to the very discovery of new scientific information about tobacco's dangers, not the use of that information in any sort of organized way. You can see in the annual data, for example, clear declines in use in the years following the release of the various surgeon general's reports and other such health disclosures, but to suggest that those disclosures amount to an abstinence campaign is simply not true.

True abstinence campaigns on tobacco are relatively new monsters, and their effectiveness has been minimal at best. Over the last ten years, for example, the smoking rate has hovered in the 22-25% range. The evidence suggests that use has leveled out, and that the remaining population of smokers are those on whom abstinence campaigns will be ineffective.
6.3.2006 6:14pm