07 May 2011

Unhealthful News 127 - What passed for smoking policy analysis this week

Three random observations, which seemed worth making but did not fit in anything else I was writing.  Only the second was actually in the press, but the fact that the press ignores the others, despite this being the first or second most burning topic in public health, is commentary enough.

A new article in the anti-tobacco periodical (Tobacco Control really does not deserve the title "journal") reported study methods:
A content analysis was conducted of reader commentary posted on Australian online news items about the plain packaging announcement [i.e., the plan to ban all color, illustrations, etc., on cigarette packaging]. Reader opinion polls on the plain packaging were also recorded. All arguments opposed to plain packaging contained within reader comments were categorised into 11 debating frames.
So, do we think that the author is interested in figuring out if there are any concerns that need to be addressed in making policy?  Of course not.  In tobacco control studying concerns with proposals is like entomologists studying the preferences of bugs in order to better kill them.  The conclusion was:
The results of this study can be used by tobacco control advocates to anticipate opposition and assist in reframing and counteracting arguments opposed to plain packaging.
When everyone who disagrees with your worldly goal just needs to be hunted down and defeated, it sure must be easy to do "research".

Second, the March of Dimes charity in New Hampshire claimed in a local newspaper that a proposed ten-cent drop in the cigarette tax will reduce revenue.  This might be true, though the motivation for the reduction is the standard New Hampshire revenue practice of keeping prices low to increase revenues, at the expense of larger neighboring states.  New Hampshire makes a lot of money by encouraging purchases by those from other states (illegally in the case of cigarettes, and I believe for most goods unless the consumer voluntarily pays their home-state tax and pigs fly), and I would tend to believe the state government's clever reasoning about such things is more accurate than that of a birth defects charity.  A little closer to the charity's area, but still apparently not a matter of scientific expertise, is the claim that this will result in a huge increase in the number of neonates damaged by smoking mothers.  Really?  If a dime-a-pack is all that stands between droves of pregnant women and smoking, then the New Hampshire March of Dimes must be the worst educators in the world.

Finally, and rather more involved, the following is the current draft of the "Tobacco Use Disorder" entry for the next edition of the American Psychiatric Association's document, Diagnostic and Statistical Manual of Mental Disorders (DSM-5).  The DSM is interpreted by far too many people as determining what does and does not constitute mental illness despite a history that included defining homosexuality as a mental illness through the 1970s.  The following (quoted in full because I suspect there will be revisions and they might try to send this version down a memory hole) is what someone thinks is a sensible enough proposal for how to think about tobacco use that they put it on a public website as a draft under consideration.
Tobacco Use Disorder
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
4. tolerance, as defined by either of the following:
     a.   a need for markedly increased amounts of the substance to achieve intoxication or desired effect
     b.   markedly diminished effect with continued use of the same amount of the substance
(Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
5. withdrawal, as manifested by either of the following:
     a.   the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
    b.   the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
6. the substance is often taken in larger amounts or over a longer period than was intended
7. there is a persistent desire or unsuccessful efforts to cut down or control substance use
8. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
9. important social, occupational, or recreational activities are given up or reduced because of substance use
10. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
11. Craving or a strong desire or urge to use a specific substance. 
Severity specifiers:
Moderate: 2-3 criteria positive
Severe: 4 or more criteria positive
This gives the APA's declaration that being gay is a disease a good run for its money in terms of stupidity.  That would probably even still be true if points 1-3 were not copied and pasted from the entry for some entirely different type of drug, like alcohol or meth, that is debilitating and actually causes psychological problems (as opposed to being performance enhancing and usually beneficial to mental functioning, as nicotine is).  Item 2 suggests that if you smoke while driving you have one strike, halfway to having a disorder (it does not quite say that, because it phrases it as conditional upon this being dangerous, which it is is not – but still, it does specifically mention driving; is this someone trying to sneak in an excuse for banning tobacco use while driving?).

But let's set aside 1-3, as well as 8, as having nothing to do with tobacco, and thus presumably just an extended typo that the APA decided to publish because they do not have anyone to help with proofreading (I can sympathize – I often miss an incorrect word or two in this blog).  Just think about what 4-7 and 9-11 mean.  Tolerance (4), is pretty inevitable for most drugs, including nicotine and negative withdrawal effects (5) are common for nicotine users.  Point 6 says that if you started smoking figuring you would just do it occasionally but ended up doing it daily, you have a strike.  Point 11 just says you really like to use it.  These four alone pretty much make "severe tobacco use disorder" synonymous with "daily tobacco use".

Points 9 and 10 might be the result of some nasty compulsion, but they also represent rational choices, to making choices in life that facilitate use (i.e., not going to pubs anymore) and deciding that the benefits warrant the costs. 

That leaves Point 7, trying to quit but not doing so, as the only one that really seems to represent a disorder.  Withdrawal symptoms are unfortunate, but hardly a mental illness.  Tolerance and most of the others are just a description of consumption patterns and preferences. 

What does this imply about who among us has a mental illness?  Feel free to suggest your own in the comments, but what comes to mind for me are the following:  I am an occasional causal nicotine user (in low-risk smoke-free forms, with the exceptions of a few hookahs at the Lebanon harm reduction meetings – ironic, huh).   I thoughtfully and intentionally use it to control my mental functioning in positive ways.  I can take it or leave it.  According to the above, my careful sensible use of this drug to improve my functioning and mental health solidly fits the definition of having a moderate "disorder", and might even qualify as severe (and that does not even include that driving thing). 

What else?  Using pain medicine for a long-term problem of any sort probably ticks boxes 5,6,10,11, potentially 2 (though you can avoid that) and also 4.  Oh, wait, the authors cleverly say that if you pay their fee while using then 4 and 5 do not count; however, if you endure the medicalization, you then have to add 8 to your list.  If you remove the specific references to it being a "substance" then all sorts of behaviors qualify.  Anyone who becomes religious as an adult likely must tick boxes 6,8,9,11, as does most everyone who uses at Facebook or Twitter.  If you take up jogging or some other athletic activity you can likely add 10 and 4 to the list. 

It might be reasonable to say that if you want to quit one of these but fail to do so (7) then there is a problem, and if 8 and 9 go too far that might be a problem too.  But there are genuine psychological disorders that capture doing an otherwise not-unhealthy activity to too great an extent (by someone's judgment).  Listing these as a specific disorder with regard to tobacco use is just a political act and financial ploy (insurance covers "treatment" for "disorders"), to say nothing of the ease with which the definition of disorder is met. 

Since that is what they are doing, it would be more honest to just say the mere act of using tobacco is a mental illness.  As it stands, this proposed entry in the DSM makes a joke of the APA, of real mental illness, and of the genuine major health concerns associated with some (not all) forms of tobacco use.


  1. I didn't realize that "intoxication" was caused by nicotine. I use nicotine products (cigars, Swedish snus, and electronic cigarettes) but I've never felt "intoxication" in the normal meaning of the word. According to the free legal dictionary(.com) intoxication is "[g]enerally, an intoxicated person is incapable of acting as an ordinary prudent and cautious person would act under similar conditions." I'm not nice to deal with if I don't have nicotine. Yes, I am addicted, and I also have (diagnosed) AHDH. Nicotine helps some with my ADHD, thus why I choose to use nicotine products. When I don't have nicotine I feel 'lost' or as if I am 'daydreaming' constantly. So, by definition, when I am nicotine-free I'm "incapable of acting as an ordinary prudent." Using nicotine would cure me of my own disorder(s).

    Also, it is interesting to read through this draft of "Tobacco Use Disorder" and substitute "caffeine" for the word "tobacco" and then read through the draft. Hell, I just found another disorder to add to the DSM. "Caffeine Use Disorder"

  2. I forgot to thank whoever it was that sent out a link to that DMS entry via twitter or facebook -- I cannot give proper credit, though, because I forget who it was.

    Re the previous comment:
    Somehow I managed to forget caffeine in my examples -- it is pretty much the perfect analogy. I must have been too tired to think about it. If only there were some way to be more mentally alert when you needed to be.

    The intoxication bit was clearly copied from some other completely different drug because apparently no one at APA knows anything about the experience of using nicotine. I suspect your experience is more common than not. Out of the many absurdities of this whole concept, the greatest may be that people who are using nicotine are somehow worse off for it psychologically. The whole thing is a money-grab and a really awkward kludge for what the well-meaning among them (I know there are some) are presumably searching for: If APA wants to try to create some definition of "unwanted addiction to a physically or socially harmful behavior", that would be a great contribution. But I suspect it is a little bit beyond the capability of committees who write simplistic manuals like DSM.

  3. This is seriously scary stuff. Die-hard core smokers who refuse to give up are by the medical fuhrers' definition mentally ill. We will eventually be forcibly injected with anti-nicotine medication that will block our nicotine receptors. And zen ve vill conform.

  4. Yes, I agree. It is (mostly) a money grab nowadays, trying to push their product (ie Varenicline, Bupropion, Nortriptyline, or Clonidine). While at the same time society, with the help of governments and anti-smoking groups, have tried to (and sucessfully) denormailze(d) the behaviour of tobacco use. I cannot begin to count the number of times I've received scoffs and/or dirty looks from people when they: A) see me using a tobacco product or B) hear me talk about it and defend the personal use of the product. Its absurd to believe that a person is subhuman just because he or she uses a legal product, even if the product is somewhat harmful to health. It is not the government's business to determine behaviour (or social norms). We still see the effects of prohibition and the denormalization of alcohol use almost 100 years later.


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