Transcript of "Is Addiction a Choice?," Voice of America's Talk to America, broadcast May 31, 2001
Voice of America's Talk to America
May 31, 2001, 1:00 PM EST
Studio 18/Control 49
Via satellite, Washington, DC.
"Our guests will debate whether or not there is such a thing as 'addiction', a deliberate and conscious course of action which people literally cannot stop doing."
Host (Carol Pearson): It's seventeen hours, universal time, and this is Talk to America.
. . . Today is "World No-Tobacco Day," and, if you didn't do it today, tomorrow, try using no tobacco. Let me quote a famous American writer, Mark Twain once said: "Quitting smoking is easy, I've done it a thousand times." Maybe you've tried to quit too, and if you've tried it once, you've probably tried it more than once, like Mark Twain. But why is quitting so hard for so many people? Is it the nicotine or is it more than that? I'm Carol Pearson. On today's Talk to America we'll discuss whether addiction to tobacco is a choice, and, if you smoke, what you're options are for quitting. That's next on Talk to America. . . First, the news . . .
Announcer: Live, from Washington, this is Talk to America, with Carol Pearson.
Pearson: It's "World "No-Tobacco Day," so on today's Talk to America, we're going to be talking about smoking and whether addiction to tobacco is a choice.
Announcer: To participate in today's Talk to America place your telephone calls now. The number is 202-619-3111, and the U.S. country code is "1." Call your operator and reverse the charges. Again, that's 202-619-3111. We want to hear from you on Talk to America.
Pearson: We're talking about addiction, tobacco, and smoking, with Dr. Jeffrey Schaler. He's a psychologist and a professor at American University. He's written a book called Addiction Is a Choice.
On the phone with us is Dr. Elizabeth Whelan. She's President of the American Council on Science and Health, and her doctoral degree is in public health.
And, getting to the whole issue, you, Dr. Schaler, believe that addiction is a choice, that we make?
Schaler: Yes, it most certainly is. I think it is important to frame our discussion though, by differentiating between what tobacco, nicotine, does to the body and how tobacco, smoke, nicotine, gets into the body. Now, clearly people put it there. Smoking is a choice. Common sense tells us that, and the scientific evidence also supports the idea that people choose to smoke for reasons that are important to them. I think what the scientific research clearly shows is that the best predictors or explanations for why people smoke have to do with psychology, and environment, and their values. And many of us have been misled to believe, as part of this worldwide anti-tobacco campaign, that the best predictors are the tobacco itself, physiology, and biology, which I just don't think is true.
Pearson: Dr. Whelan, there's been some news lately about whether there's a gene that could predict whether you'll become addicted to a certain substance or not.
Whelan: Well, that remains to be seen, whether indeed that will be predictive of the people being unable to give up smoking. But I think the reality is, whether you use the word "addictive" or "highly-habit forming," the bottom line is that 90 percent of people who currently smoke tell interviewers that they would, basically, give their right arm to give it up. And that would pretty much meet my definition of addiction and lack of actual freedom of choice. And indeed, even when a youngster starts smoking, I would not call that a totally-informed choice, by any means. It's done as a lark. They see advertising. And they have no idea of the staying power of the cigarette smoking habit.
I definitely agree with your other guest that the addiction, and the hold that cigarettes has on smokers, is far more than physiological. You know, a lot of people talk about nicotine being addictive, and they believe that, gee, if we could only get rid of the nicotine in cigarettes we'd have a safer one, and people wouldn't be addicted. Well, that's really nonsensical. Because, indeed, the real hazard from smoking does not come from the nicotine, it comes from all the products of combustion or burning that you get when you inhale the cigarettes. So reducing nicotine could make it a more dangerous cigarette, as people inhaled more. But beyond that, smoking, whether it's the smoke screen that the exhaled smoke puts between you and other people, or whether it's the actual physical sensation of the smoke going down your esophagus, one writer referred to that as "esophageal eroticism," as a positive feedback that some smokers get, it's very, very complex, but I think that we can all agree that once you start smoking it can be extremely difficult to give it up.
Pearson: And in fact the rates of success are dismally low, aren't they?
Schaler: Sure. . .
Whelan: Well, if you look at the cessation programs, even using modern technology, in terms of patches and nicotine gum and other aids, it doesn't get much above 28 percent or 30 percent, having, being off cigarettes at the end of the year. And indeed, many of us now are encouraging our smoking friends to actually hospitalize themselves. There's one very prominent clinic, out at Mayo Clinic, in Minnesota, that actually hospitalizes, and they have a success rate of about 50 percent after one year, cessation.
Schaler: Well, Dr. Whelan is looking at this from a medical point of view and I tend to look at it from a psychological and moral point of view. Not that smokers are good or bad, but that they choose to smoke for reasons that are important to them. It's important to keep in mind, too, that addiction can be positive or negative. We all engage in positive addictions, to activities, to substances, etc., and negative ones. We also have what we refer to as socially-acceptable risky behaviors and socially-unacceptable ones. There are many, many behaviors that we call "entertainment," really, on television, that put the participant at very high risk for injury, if not death, and we wouldn't say that they are "addicted" to playing football or race-car driving, etc., requiring treatment. These are lifestyle choices that people make. And certainly if they want help in changing their behavior, I support that. But ultimately, when anyone stops an "addictive" behavior, or changes it, it's due to a choice. The person makes a decision. And that's not a medical issue, that's a moral issue.
Whelan: Well, I strongly disagree with this assessment. Indeed, to equate cigarette smoking with any other lifestyle factor I believe is really out of the ballpark. Smoking kills, in the United States alone, over 500,000 people every year. And, I do not believe, if you did a survey of large numbers of cigarette smokers, they would argue with you that they are choosing to smoke. They are desperate people. They are very unhappy. They deserve our compassion and our concerns to help them get away from this life-threatening habit. Certainly people who enjoy exercising every day, as I do, I swim every day, maybe your guest would say I'm addicted to swimming, well, if I stopped swimming I would not go into sweats, lose my appetite, and have every physiological function in my body turn off.
Schaler: That's a good point, except one of the strongest withdrawal reactions that people experience is the ceasing of a love relationship, which is often characterized by all the symptoms and signs that you mentioned, if not depression and even suicide. . .
Pearson: . . . But back to smoking. . .
Schaler: . . . So there are all kinds of addictions . . .
Pearson: . . . But back to smoking, isn't it true, Dr. Whelan, that most, at least most Americans, who start smoking, do so when they're under the age of 18?
Whelan: Absolutely, I mean, that is really the market for the replacement smoker, the replaced ones who, over 1300 die every day so the cigarette companies really need to go out there recruiting, and they recruit, in the definitely, the young teen years. The average age of initial smoking is actually, really, startling low. I mean, you're seeing kids now, and they're nine, ten years old, beginning. I cannot accept the fact that these kids have any concept of what this is going to do their life.
Pearson: They may not have that concept, but do they make, in a sense, kind of a lifestyle choice? Smoking looks cool, therefore, I'm going to do it. Or, maybe just curiosity?
Whelan: I could probably go with they're making a choice, but I would say it is simply not an informed choice. And that's really what we need to get at. What the kids see are the glamorous ads, and the sexiness of the smoker, the svelte ladies, and smoking to keep their weight down, purportedly, and this attracts them. At that point, you know, after a year or so, they may not have any, not only are they not informed, but they are also not making a choice any more, because they are, however you define it, addicted to the cigarette smoking. By the way, I want to emphasize that they're not addicted . . .
Pearson: . . . We've got to take a short break, so why don't we get back to this, after the break. I'm Carol Pearson, and this is Talk to America.
[News break . . . email us at email@example.com]
Announcer: We're back with more of Talk to America. It's easy to take part in our show. Just call collect at 202-619-3111 and the U.S. country code is "1." Again, here's Carol Pearson.
Pearson: We're talking about smoking, tobacco, health, and addiction. Our guests are Dr. Jeffrey Schaler, he's a psychologist and a professor at American University. And Dr. Elizabeth Whelan, she's President of the American Council on Science and Health. And, it seems like there's one key and that is you've got to prevent children from starting, to begin with.
Schaler: Right, well, the best way of preventing children from starting is through the example set by parents, and through the relationships that parents have with their children. I think, from a public policy point of view, this massive anti-tobacco campaign is having the opposite effect that its sponsors have intended. We know, common sense tells us, that "a don't is a do." The more taboo, the more evil, the more "bad" you say smoking is, the more inclined children are to try to do it. I think that has much more of an effect, of an influence, than the marketing techniques of the tobacco corporations.
Pearson: Dr. Whelan?
Whelan: Well then, the logical interpretation of the flip side of that is that we should tell the kids the cigarettes are good for them, and that they're healthy, and that they should eat them with their broccoli . . .
Schaler: . . . No, I don't think that government has any role in telling children how they should lead their lives. I think that's the proper domain of parents . . .
Pearson: . . . Government makes children go to school until their sixteen . . .
Schaler: . . . That's true, but that's not the same thing as regulating their lifestyle . . .
Whelan: . . . We're not regulating lifestyle, we're simply trying to get information out there, and the cigarette companies, now for over 50 years, have been blocking the flow of that information, to get to people. I have written now for 30 years, for women's magazines, and every time I put in a manuscript that mentions the dangers of smoking, because of the cigarette ads, they will cut out all references of a pejorative nature. We're not talking about telling people how to live their life. I totally embrace libertarian lifestyle myself. And I believe people should be allowed to do what they want as long as they don't harm others. But in the case of smoking, they do not have the facts. People do not understand, for example, that cigarette smoking is now the leading cause of blindness in the United States, the number one cause, preventable cause, of hearing loss . . .
Schaler: I support your interest and your intention in provide accurate information. Too often, though, the information is more hyperbole. It's not accurate information. I don't have any objection to people providing education programs. What I object to is government, the [US] Public Health Association, interfering in the relationship between children and their parents. That's a private and really sacred domain. But you know you mentioned something about choice, how many smokers said they couldn't stop smoking, but the flip side of that is if you ask anyone who has stopped smoking they all say the same thing. When you asked them how they stopped, they said "I made a decision. It's a choice." Now that may be difficult. But we accept as fact that there are many difficult things in life. Going to work is difficult, being married, raising children, enduring all kinds of hardships, are difficult and accepted facts in life . . .
Pearson: . . . But they're not detrimental, necessarily, to your health . . .
Schaler: . . . Well, sure, they're all kinds of activities that are detrimental. Working too hard can be very detrimental. Being in a bad relationship can be detrimental. Many parents say that their kids drive them crazy. There are all kinds of outcomes. Life is difficult. Life is hard. And we shouldn't make an exception and say, well, just because this person enjoys the sensation from smoking, my God, it's much too difficult for them. You know, this really flies in the face too of many traditions and principles of the world's major religions, they say, if something is difficult, well, you have to learn to resist the temptation to smoke.
Pearson: Dr. Whelan I know that you have to go soon, so let's hear your remarks.
Whelan: Again, I'd like to emphasize that cigarettes are a highly-unique product in our society. We're talking about one in every four deaths that occurs every day being directly caused by smoking. And one in two of the deaths that occur prior to the age 75. So, I cannot sit here and accept the hypothesis that people choose to end their life in an agonizing manner, and an early age, and that the pleasures of smoking are worth all of that. I think we also have to go back to the idea of choice and look at the people who go into smoking-cessation programs, and these are highly-motivated people, they really, really want to quit. They accepted that the anti-smoking technology, the patches, and the gums, the injections, and the pills, and hypnosis, and everything, and even those people, less than one third of them, actually succeed. I think that is testimony to the absolute staying power, addiction if you will, of the cigarettes.
Schaler: The way you describe smoking, in this sense, it's very similar to an epileptic seizure, or a convulsion. Now those are not choices. But these are intentional behaviors-people search out their cigarettes, they light them, they enjoy them, these are all choices that people make. It's not a hypothesis, it's a fact.
Pearson: But are they making this choice because their body is telling them that it doesn't have enough nicotine in it?
Schaler: Well, but you could look at that from any number of points of view. If someone feels some kind of sexual attraction towards someone does that mean that they should assault that person? I mean there are biological correlates associated with everything we feel and do. But, we are expected, as adults, to be responsible for our behaviors, and smoking is no exception.
Pearson: But that isn't working.
Schaler: Well, it doesn't work only because people don't want to stop smoking.
Whelan: They do want to stop smoking.
Schaler: I don't believe that because if they did want to stop smoking they would stop smoking.
Whelan: I think all of us know people who are desperate. I'm dealing, personally, with a friend right now, who desperately wants to give up cigarettes and has tried absolutely everything and is now considering going into a hospital. This person is highly motivated and the physical consequences that he experiences when he does not smoke are so overwhelming that, in your language, he chooses to go back to cigarettes. Well, that is now what I would call freedom of choice.
Pearson: Now, have either of you ever smoked?
Schaler: I have, yeah, when I was a teenager. Sure.
Pearson: And how much of it? Were you a heavy smoker?
Schaler: Well, in college, maybe a pack a day for a short time. But most college kids experiment with smoking. There's nothing particularly unusual about that. I don't buy the idea that anyone who starts smoking at a young age is locked into smoking behavior. People mature out of it, just like, in college, you see all the drinking in college, kids mature out of drinking behavior.
Pearson: And some don't. But Dr. Schaler, do you think that, the fact that you were able to stop, assuming you don't smoke now, do you?
Schaler: No, I do not.
Pearson: OK, that that might color your view of whether other people can do the same thing?
Schaler: No, because I think all behaviors are choices, and we're talking about a behavior. Smoking is a behavior. It's not an epileptic seizure. It's not a physiological process. Sure there are physiological processes correlated with smoking. But the act of smoking is a behavior and by definition a choice. There's no such thing as a behavior that's not a choice.
Pearson: Dr. Whelan, do you have to go?
Whelan: I'm going to have to leave, but as mentioned, my colleague, medical director, Dr. Gilbert Ross, will be on at your next break.
Pearson: OK. And I want to thank you very much for joining us.
Whelan: Thank you very much.
Schaler: Thank you.
Pearson: Dr. Schaler, since you're with us now, do people come to you and say I really would like to stop smoking, what can I do?
Schaler: People don't come to me for that, they come to me for lots of different reasons. Drinking problems, some of them may smoke. What I have found though, in helping them change their behaviors, and this again is supported by the research on smoking and addiction in particular, whether it's heroin addiction, cocaine addiction, tobacco addiction, alcohol, by focusing on what's going on in the person's life, what we often find is that the use of some substance like tobacco, or alcohol, or heroin, or whatever it is, is a way of avoiding coping with some other problem that the person has. And when you address those other problems, they often give up their negative addiction, without much pressure at all. I think that our approaches to helping people change their addictive behaviors are wrong. By focusing just on the act of smoking, you're not addressing the underlying reason why they may smoke. When you address that underlying reason, they often give up the addiction with no problem.
Pearson: Well, let's go to the phones, Dr. Gilbert Ross has joined us, and he is with the American Council on Science and Health. Ivan in Croatia. Hello!
Caller from Croatia: Hi Carol!
Pearson: Hello Ivan. Do you smoke?
Caller from Croatia: No, and I will never start to do this.
Pearson: Well, good for you!
Caller from Croatia: I am one hundred percent against people who are smokers.
Pearson: And what's your question then?
Caller from Croatia: As we go as far to the east, some mental, er, something mental, of those people, especially here in Croatia, unfortunately, recent studies show, that usually children, children are starting to smoke at age of eleven, as they are in primary school. Here in Croatia, the alcohol is also big problem. Young people don't know what to do with themselves. They don't know to have some hobby, etc. They are just sitting in coffee bars, drinking coffee, drinking beer, wine, stuff, joints, etc. and smoking, smoking, smoking, smoking. You can't even find a little percent of clean air there. So what is it? In the West people is smart. They know we must stop smoking if we want to have a job.
Pearson: Well, I don't know if we're so smart, but, however, let's let Dr. Ross comment on that. About 20 percent of Americans overall smoke, and I think it's 30 percent of Europeans.
Ross: That was my impression as well. And it's not a question of being smart or dumb. It's a question of the enticements to smoke, that the tobacco industry presents, and are all over the place, although it's slight better now than it was some years ago. There is still a pervasive marketing campaign by the tobacco industry to entice young people to smoke. And it's not people who have a character flaw or people who are stupid. Kids are normally susceptible to these kinds of messages. It's kids, overwhelmingly, who begin to smoke. And as we now know, and it is quite well proven physiologically and psychologically that smoking cigarettes is one of the most addictive behaviors known to man. Both the physiological addiction of nicotine and the body, and the behavioral addiction of the activity of smoking, and the socialization of smoking . . .
Pearson: . . . Which gets us back to the point, because, I think that it's been proven that tobacco ads aimed at children, to try to lure them into smoking, so how do you prevent them from smoking to begin with?
Ross: It's very, very difficult.
Schaler: Well, I think that this is the proper role of parents. It's not the proper role of the public health movement or government. This is the relationship between parents and children. And it's not our place to intervene there. Now . . .
Ross: . . . That's the most ridiculous thing I've ever heard in my life!
Schaler: No, it's not ridiculous at all.
Ross: . . . parents have a role in the behavior of children. But to say that the public health community has no role is ridiculous . . .
Schaler: . . . No, I disagree, because what's happening with the public health movement is . . .
Ross: . . . Parents can't control their children's behavior . . .
Pearson: . . . Please, one at a time . . .
Ross: . . . they try, but they're up against a multimillion dollar marketing machine.
Schaler: . . . I refuse to scapegoat the tobacco industry.
Ross: . . . Oh, poor little tobacco industry . . .
Schaler: . . . I do not believe that it is the proper role for the public health people to dictate morality and lifestyle.
Ross: . . . It doesn't have anything to do with morality.
Schaler: . . . It has everything to do with morality. The public health people are . . .
Ross: . . . What are you talking about? Nobody is talking about . . .
Pearson: . . . We're going to come back after a short break for the news . . .
Schaler: . . .You're misunderstanding the use of the term morality . . .
Pearson: . . . What I would like, Dr. Schaler, . . . If you're talking about the public health role in terms of tobacco, what would you say, is there a public health role in terms of preventing AIDS?
Schaler: Yes, because that's a real disease . . .
Pearson: And I want to talk about that after the break, because we have to take a short break for the news. The phone number is 202-619-3111. The U.S. country code is "1." Tomorrow, we're going to talk about whether homosexuality is a choice or not. We're continuing a conversation we had last week. And we're looking for your calls on that. I'm Carol Pearson, and this is Talk to America . . . .
Announcer: Welcome back to Talk to America. Call us collect at 202-619-3111. Our country code is "1." Here again is Carol Pearson.
Pearson: Today is "World No-Tobacco Day," and so we're talking about cigarettes, addiction, and whether addiction to tobacco, and nicotine, is a choice or not. My guests are Dr. Jeffrey Schaler, he's a psychologist and a professor at the American University. On the phone we have Dr. Gilbert Ross. He's with the American Council on Science and Health. And we're going to take up the issue of where public health policies are supposed to intervene, I guess, in private life. But first let's here from Foley in The Gambia. Hello Foley!
Caller from The Gambia: Hello!
Pearson: Yes, Foley. Now Foley, how long have you smoked?
Caller from The Gambia: Well, I've been smoking for over twenty years.
Pearson: And, are you still smoking?
Caller from The Gambia: No. Right now I am not smoking. For the past ten years, every year, I have to quit for about three months, four months, then I have to go back. I was given reference to one of the local herbalists here in our country. They went to produce some kind of a concoction, a mixture of hops and these things. And I tell you if you drink it, you will never think about cigarettes. So I think I beg to differ with the doctor, that cigarette is a behavior. I don't think it's a behavior. I think there is something there. Whether it is the nicotine or something, that keeps you, or keeps your mind on it. If you don't use it, you start getting uneasy, you know? So right now, if I am using the medicine, I don't think about cigarettes. When the herb is finished, then my mind starts to go back, something is haunting me to smoke again. What does he have to say on that?
Pearson: Let's hear first from Dr. Ross.
Ross: The addictive power of cigarette smoking is caused by both the physiological addiction of the body to the drug, nicotine, and the behavioral aspects of it, involving the action of hand-to-mouth, and the habituation of taking a cigarette at a particular time of the day with food, or at a party, etc. So it's both of these effects are powerful. Most people that have been smoking cigarettes for a period of time find it extremely hard to quit. Even with medical assistance the best rates of quitting that have been reported to occur are under ten percent without the addition of help such as counseling, and nicotine replacement, and other modalities, which are now available.
Pearson: Now Dr. Schaler, I've always understood that it takes about six weeks to break or make a habit. And here Foley says that every year he gives up smoking for three months, but at the end of three months he's always been compelled to go back. So, how is this habit of smoking different for him, than it is for other habits.
Schaler: I don't think it is any different than any other habit. He smokes because he wants to smoke. He finds some pleasure in it. And the fact that he moderates his smoking again supports the idea that this is not something that a person cannot control. But I think that . . . what Dr. Ross is saying concerns me because, despite his intention, which I believe is a good one, he's regarding the human being as if he's a thing, something that is reflex-oriented in its action, and not a person as a moral agent who makes choices. When I say that this is a moral issue, I don't mean to say that people who smoke are good people or bad people. What I mean to say is that they smoke for reasons that are important to them.
Pearson: Well, let's find out why Foley . . . Foley, why do you go back to smoking after three months of stopping?
Caller from The Gambia: No, this is what I don't know Carol . . .What is happening? . . . It's not any brand of cigarettes. There would be no point to go back to smoke . . . . Aston . . . and these things. . . . Any brand will do . . . I've been smoking all brands of cigarettes. So, there is something.
Pearson: Dr. Ross?
Ross: The reason he goes back to smoking is because cigarette smoking is highly addictive. When I refer to the less than ten percent quit rate, I was referring to people who will remain off cigarettes for one year. Addictive behaviors are not something that you can just flush out of your system in a few weeks. People who have been addicted to drugs are well aware of this . . .
Schaler: . . . But you see the research . . .
Ross: . . . Please, let me finish. Cocaine addiction or heroin addiction, for instance. Addicts well know that just because they're abstinent for a few weeks or a few months, addicts are often incarcerated for periods of months and for years, and yet when they come out, they're still addicts. It's not a question of just getting the substance out of your system. It's an entire mental mind set.
Pearson: Dr. Schaler, it's been said that in order to successfully stop smoking you have to both address the physical effects that the nicotine has on your body and how long it stays in it, and your dependence on nicotine, but you also have to change your behavior because there are psychological aspects to it. So what kind of suggestions can you give Foley to at least change his behavior.
Schaler: There is no one reason why someone might smoke. People who smoke, like people who use any number of drugs, are a heterogeneous population. It means that there are diverse reasons why they do this. Now, what I would ask him to consider is what's going on in his environment, in his life, that makes him feel anxious, that he uses smoking to reduce his stress for. That's the type of thing that I would look at. Now, I don't know what else to say in terms of what might be the reason for why he does this, other than there's some lifestyle issue. And the research on addiction, contrary to what Dr. Ross is saying, and as the research I present in my book shows, people who engage in addictive behaviors, for example, the Vietnam Veterans in 1973 who were studied, who used heroin in South Viet Nam, 87 percent of them gave up heroin when they came back to this country just by a change of environment. Now, those findings are consistently true for alcohol users, for cocaine users, for heroin users, and for tobacco users. The best predictors are not physiology and nicotine, but environment, expectancy, psychology, and lifestyle.
Ross: I'm not familiar with the Viet Nam veterans . . .
Schaler: . . . I'm amazed that you're not familiar with it . . .
Ross: . . . How did you just lump cigarette smokers into the group with alcohol users? Is that what you said? . . . They have a change in their environment, and then they're able to quit smoking, what does that mean?
Pearson: No, no, no. And he was talking about different addictions: Addictions to alcohol, addictions to smoking, addictions to heroin use, and when the environment is changed . . .
Ross: . . . and you related those groups to the Viet Nam study, in which the veterans who returned from Viet Nam who had been using heroin, a large percentage of them stopped using heroin, and then he said similar to alcohol abusers and cigarette smokers. What cigarette smokers is he referring to?
Schaler: What's amazing to me is that you can speak with authority about addiction and you're not familiar with these studies, which the research has . . .
Ross: . . . I'm familiar with all of the studies about tobacco addiction, sir, and I can assure you that that study you're referring to has nothing to do with cigarette smokers.
Schaler: . . . We're talking about tobacco addiction as a drug addiction. We're talking about an allegedly physiological addiction which . . .