New working paper by Philips, Nissen and Rodu - Must read.

[Oliver]

I'm not going to comment on this just yet, save to say it requires careful and thorough reading and, I believe, the level of analysis they've engaged in will be music to many posters' ears.

It's a very important piece of work.

Working Paper: Phillips-Nissen-Rodu, Understanding the evidence about the comparative success of smoking cessation methods: choice, second-order preferences, tobacco harm reduction, and other neglected considerations | EP-ology

 

[DrMA]

Indeed a very interesting paper. I find that it brings together and summarizes a lot of ideas that have been floating around THR circles, but were never connected with such clarity and a coherence. The slides linked in that blog post are also very interesting, in particular I found the pie-chart graphics quite illuminating.

 

[Kent C]

Glad you started a new thread SJ!

"At the simplest level, the misinterpretations are a case of not understanding what “better” [for cessation/cessartion attempts]
even means in the presence of heterogeneities and the resulting confounding and
selection bias."

While this is a simple level, it is almost never questioned in any cases of the use of 'better' or 'good'. There is a 'meta' level question, that always needs asked - "Better (or Good) by what standard?" So when Zeller says 'regulating ecigs is for the greatest good' - one must ask "'good' by what standard?" And frankly he'd be stumped for an answer that didn't end up in some circular answer of 'public health' or the 'public good'.

And Phillips/Nissen/Rodu differentiate between 'disease' and 'personal preference'. We've seen (and many do believe) that the health community has made 'alcoholism' into a 'disease' (just to pick one obvious example). There are many reasons for this - 1. Some people actually believe this; 2. If it is a disease, then the person isn't as responsible for their behavior and this plays into the 'it's not your fault' crowd of false self-esteem - which, btw, kills self-esteem; 3. Medical insurance covers diseases; 4. It can be considered a chronic disease - one you can never get rid of and this plays into the hands of certain 'societies'. (I'm not saying that they don't make a situation better, btw - they can and do).

And P/N/R makes this point very well:

"This (the 'disease' theory) contrasts with a preference-and-choice situation. In that situation, there is clear
heterogeneity of individuals, and those individuals typically know – or could be guided to
understand – what their relevant individual characteristics are."

and:

"relevant to smoking cessation: For a particular person at a particular time, a particular
method will either succeed or fail. It is useful to try to figure out which will succeed for
the particular individual and offer advice; it is not useful to figure out which would work
better, on average, if prescribed to everyone."

This last (bold) goes against the collectivist solutions that ARE prescribed to everyone as if there are no individuals who do things for different reasons. OR at least justifies any bans, restrictions and/or regulations.

What struck me is that this forum (thanks to the OP does exactly what P/N/R describe - the 'non-bold' above, and later in the paper:

"Moreover, the success of THR is strongly dependent on the social support of those who have already done it, and who are often the motivators for realworld switching attempts."

Those vets or quick studies who are knowledgeable can 'prescribe' solutions to newbies and others having problems but according to their own behavior. What is good for a 'weekend smoker' isn't the same for a 3 pad smoker. There are so many other examples of peculiarity of behavior that we've all seen and experienced but good 'solutions' are given out here appropriately. And some 'adjustments' are needed sometimes.

As P/N/R point out - "what food tastes better?" ... we get this all the time on flavors. There is no good answer (because of the subjectivity of taste), but I found and have put this out as a 'solution' that IF you can find someone who likes the same flavor you do (for me it was JustJulie and Elendil - to name a few) - then what OTHER flavors do they like is a good hint to what you may like as well. It isn't 100% but I'd say it's well above 50%.

... just to illustrate how 'objective' some usually 'subjective' aspects of vaping can be. And this points to the comments made by some of the panel in the Summit and SJ on another thread says about how hard (near impossible) it is to make any 'collectivist' judgments about both smoking and vaping as far as cessation solutions are involved.

This 'difficulty' likely not fully appreciated by ANTZ on a rational level but probably is the basis at a more rudimentary level as to why they do the 'broad stroke' of fear mongering and demonization to get people to quit - their orientation is 'public health' not 'individual health', so they have to either scare you to death or to get 'public opinion' on their side, to make you into a leper. (with no intent to offend those with Hansen's disease).

I also applaud the emphasis on 'benefits' of nicotine. Were it not for that, virtually no one would smoke or would have smoked since whomever discovered the plant. Or perhaps we should get CVP's 'demon' a provari and some good eliquid, so that he'd leave us alone! I also encourage more studies along this line and would be a bit more generous than the 10-20% stated but even that is significant if one has 20% more focus/concentration, or 20% more memory retention or is 20% more relaxed.

More comments after a 2nd reading.

On 'benefits' - perhaps it's the nature of the publication, I saw no mention of the role of 'smoke/vapor/aerosol' and this is something for obvious reasons, imo, that should be considered in any study for individual preferences. Patches and gum don't emit aerosol - ecigs do.

 

[Kent C]

"It is difficult to reconcile claims like “surveys show that the vast majority of smokers want
to quit” with the reality that the vast majority of smokers continue to smoke. But the
apparent contradiction can be easily explained by interpreting the survey responses as the
voicing of second-order preferences. That is, a large portion of smokers would prefer to
not prefer to smoke, even though the reality is that they prefer to smoke, which is why
they continue to do it."

If one puts the first-order of preference in terms of 'preferring nicotine' and the second-order of preference as, the same - preferring not to smoke cigarettes, then it becomes obvious why someone might take up ecigarettes as doing so carries out both the first and second order of preferences.

This is something that Zeller misses entirely and most ANTZ, I would presume, who make this same argument as I posted a while back.

Zeller stated in the HELP committee in attempting to explain why dual use leads to continued smoking...

Me: "And the true fallacy of the idea that dual use will lead back to smoking is shown in his own understanding of the people in the 'larger group' (ie his 'net population): those "who are concerned about their health and who are interested in quitting." But those who are 'concerned about their health' would be those who already know that they should be concerned and about what, they are concerned."

and...

"If they've found their way to ecigarettes and choose that as an alternative, they do that for the very reason why they are 'concerned about their health!' and have likely done a bit of research on it.

But Zeller ignores the obviousness of the above and of the implications of what he says. He invalidates his own premise: of 'those who are concerned' and concludes by saying they will go back to smoking and what? forget about what they were concerned about?

The "syllogism" would look something like this:

A large group is very concerned about their health.
Quitting smoking would eliminate that concern.

Therefore: The will continue to smoke."
----

There's another 'implied minor premise' in there: "They found ecigarettes."

So he first misunderstands a second order preference for a first, which ecigs actually 'solves', but concludes that dual use will lead back to the actual first order preference of smoking, which totally abandons what he thinks the 'first order preference' is - quitting smoking.

From the paper:

"It is sometimes argued that THR is an inferior choice for someone in Category 1 or 2 who
genuinely prefers abstinence. Implicitly claiming this, with the ancillary implicit claim
that most smokers are in those categories, seems to be the basis for a lot of anti-THR
advocacy. (“Seems to be” because the arguments are typically vague, and those making
them have seldom thought through the premises their claims are based upon (27).)"

 

[WharfRat1976]

I'm not going to comment on this just yet, save to say it requires careful and thorough reading and, I believe, the level of analysis they've engaged in will be music to many posters' ears.

It's a very important piece of work.

Working Paper: Phillips-Nissen-Rodu, Understanding the evidence about the comparative success of smoking cessation methods: choice, second-order preferences, tobacco harm reduction, and other neglected considerations | EP-ology

The Choir preaching to the Choir

 

[sofarsogood]

To take the pressure off I decided I would vape but have a cig whenever I wanted one. The day I started vaping my cigs declined from 30 to 5 with no apparent effort. That day I redefined the goal from "quitting" to gaining control of my smoking. The first day I had 80% control. After 6 weeks of adjusting the devices, liquids and habits I was smoking 4 cigarettes a day and suspecting the only reason I was smoking those was because I had them. So I allowed myself to run out of cigarettes to see if I went out to buy more and haven't done that after a week.

Vaping gives me control. When I figured I probably had 100% control I decided to test that and turned out to be correct. I was enjoying a few of my daily cigs but not most of them. Once I eliminated the ones I didn't enjoy it made sense to eliminate the rest and wasn't difficult. So far so good.

Smoking caused me anxiety which I medicated by smoking which encouraged more anxiety which encouraged more smoking, etc. Nothing enjoyable about that. I interfered with that cycle and eliminated the anxiety caused by smoking by not smoking.

 

[Oliver]

The Choir preaching to the Choir

Explain?

 

[Kent C]

Explain?

Really! It's more like the Pope preaching to the choir (no offense to you or to the Pope

 

[Lessifer]

Posting so I remember to come back and read the linked paper.

 

[Oliver]

Well, I should say - there's some things I disagree with. But that doesn't preclude me from believing this to be a unique and important new way of conceptualising tobacco cessation behavior.

Not sure where "preaching" comes into this.

 

[carlvphillips]

Indeed a very interesting paper. I find that it brings together and summarizes a lot of ideas that have been floating around THR circles, but were never connected with such clarity and a coherence. The slides linked in that blog post are also very interesting, in particular I found the pie-chart graphics quite illuminating.

Just to put it out there, one of the reasons that these ideas were floating around THR circles for years is that the authors of the paper (along with a handful of our collaborators) pretty much created THR circles and we have been putting out versions of these ideas for many years. Just sayin'. On the other hand, it took us many years to pull together our thoughts on this, so no awards for efficiency. (Note that I am not implying that many of the points have not been independently derived many many times, of course. But there are actually sources of much of the conventional wisdom in this space, and many of them date back to before e-cigarettes even "happened".)

Anyway, thanks for the thread, Oliver. I will try to monitor it for comments on the paper. It really is a working paper. I am not one of these pseudo-scholars who just writes something and throws it straight into a journal without ever letting it be debated and reviewed, and improved based on that.

 

[Tache]

Explain?

I can't speak for WharfRat1976, but my interpretation of that comment is a magnification of the expression "preaching to the choir". In other words the message is so true or self evident to those of us that have incorporated vaping into our lives that it is telling us what we already know and are in complete agreement with (whether we had thought of it in those terms before or not).

 

[Oliver]

Carl, thanks for responding.

A quick one from me, then. I differ from your perspective insofar as I do believe the "craving" component to be a definitive neuropsychological phenomena that exists as distinct and separate from withdrawals and is caused by the drug(s) as opposed to habituation to its (or their) use.

That said, I don't claim that everyone who smokes suffers it, and suspect that it might be more-or-less a typology, or at least that the degree to which it is experienced affects where someone sits on a continuum of dependence - and that this will affect the ranked preferences you describe.

Let me offer up a phenomenological example: Recently I underwent some reasonably invasive surgery, for which I was presribed opiate painkillers to take for 3 weeks post-operatively. On ceasing them, I suffered withdrawal effects - lethargy, irritableness, some, ahem, digestive disruption. What I did not experience was any desire to get more of these drugs, except in the sense that I "mused" that taking more would make me feel less of the withdrawals - but there was no compelling motivation. This is puzzling, since the side-effects of these drugs are quite pleasant, and withdrawals nasty, and 3 weeks solidly taking a drug is not an inconsiderable amount of time. So, there's a (weak, admittedly) dissociation between withdrawal and craving as regards opiates, in my case at least.

Contrasting this with nicotine: Both the withdrawals and euphoric effects are, for me, much milder that those I experienced with opiates (although they do last longer), but the most insidious part of abstinence for me is the craving. This is strong, relentless and without parallel with anything else I do behaviourally. It is both cue dependent and spontaneous, and I've never been able to remain abstinent long enough for it to diminish (6 months being the longest I've been nicotine free).

You could suggest that this is simply because I smoked for a long time, and had "habituated" or some such - but I'm certain that's not the case. I remember having this precise "sensation" of craving (and it is a sensation, quite different to any other experience of desire or longing) from the month I started smoking as a 14 year-old.

Now, without wanting to pre-empt your response, you and I can agree to differ on this. What I want to know is, were you to accept this notion of strong-craving as a drug-specific drug-caused phenomenon (in this case, nicotine), would this fundamentally alter the premise of your model? And, if not - why refer to it at all?

 

[Oliver]

I can't speak for WharfRat1976, but my interpretation of that comment is a magnification of the expression "preaching to the choir". In other words the message is so true or self evident to those of us that have incorporated vaping into our lives that it is telling us what we already know and are in complete agreement with (whether we had thought of it in those terms before or not).

Hmmn, perhaps that is what he meant. But I don't think we're all in a "choir", so to speak

 

[CES]

SJ, that makes sense to me. Aren't the mechanisms for withdrawal and craving somewhat 'biologically' distinct?

I'm oversimplifying, but my understanding is that withdrawals are due to conditioning/homeostatic mechanisms that counter the effect of the drug over time, so that loss of the drug results in effects opposite of the drug (for example, the body increases heart rate when someone is in a setting associated with use of a drug that reduces heart rate. If the drug is not administered, then the heart rate remains high).

Craving is the drive for more, and there are some suggestions that anticipation of/seeking the reward is actually (part of) the effect driven by the dopaminergic reward system.

Characterizing the two as distinct might go some way toward explaining how people can be abstinent from any substance long after the physiological withdrawals are complete (to whatever extent the body can be reset to pre-drug functioning levels - which definitely differs by drug) yet still experience the cravings for a very, very long time.

..."preaching to the choir" led me to wonder about how can we get the people who need to read this paper to actually read it.

 

[Oliver]

CES - nice to see you on this thread.

Certainly that's my understanding of the neurobiological explanations. There's lots of competing claims at different levels of analysis, but there seems to be a broad agreement that craving, withdrawal and pleasure components are dissociable and drug-specific.

 

[carlvphillips]

A quick one from me, then. I differ from your perspective insofar as I do believe the "craving" component to be a definitive neuropsychological phenomena that exists as distinct and separate from withdrawals and is caused by the drug(s) as opposed to habituation to its (or their) use.

I do not disagree that there is such a phenomenon, certainly. But it does not seem to affect my economic analysis.

To expand on that, there is definitely some acquired feeling of hunger (I prefer that to "craving" because of the judgmental connotations of the latter), which occurs to varying degrees. It is quite distinct from disease withdrawal effects, as you note. However, it is not clear to me there is any reason this should not just be subsumed into preferences as one of the many sources of preferences.

That said, it does affect how people think about this and about themselves. It probably causes far more tendency toward having and focusing on second-order preferences than most sources of preferences do. That is certainly worth mentioning. Also, it is worth mentioning that it exists and ultimately is part of -- rather than distinct from -- the source of preferences as analyzed. That is implicit but is worth making explicit. I will make those changes.

Aside: One point of confusion here is that so much of the rhetoric about tobacco use seems to be about a violent opposition to someone acquiring this hunger. It comes from the same ilk of people who oppose other hungers -- other drugs, sex, gluttony, etc. -- perhaps because it deeply distresses them that humans are ultimately animals not godlike higher spirits. But that is a theme for literature. What is most relevant here is that if the hunger is already extant, then it looks just like any other preference for practical purposes. If it does not exist in someone, however, there could be an argument for not allowing it to happen. But what is generally not recognized is that this is a quantitative matter, not a qualitative one. Most every new experience holds the risk of creating some acquired taste to engage in something that results in either cost or unfulfilled longing. At the extreme are "...... madness" level captivating drugs that overwhelm someone's other preferences and priorities and devastate their lives. At the other end are such things as taking a nice vacation, which might leave you wanting to do so more often, or checking out a new band, which might leave you wanting to acquire all their works. It is hard to see tobacco use as being very far from the latter end of that spectrum. Smoking itself might tend somewhat in the former direction due to the health cost, but frankly the health cost is not all that great compared to quite a few other lifestyle choices. Once that is eliminated, it is hard to see how it is much different from countless other experiences.

 

[Kent C]

Well, I should say - there's some things I disagree with. But that doesn't preclude me from believing this to be a unique and important new way of conceptualising tobacco cessation behavior.

Not sure where "preaching" comes into this.

I don't see any 'preaching' either - just taking some poetic license on the 'analogy'

 

[Oliver]

Thanks for the clarification, Carl.

Elsewhere I've noted (doubtlessly following others), that the dependence is potentially qualitatively different from, say, really wanting to go on holiday if it creates distressing levels of burden such as, say, an intolerable financial cost (which, in the case of NRT, say, primarily arises from market restrictions), or from accessibility (varies, but often also due to market restrictions) - in other words, they're not burdens that are necessary or are inherent to being dependent on a drug, but ones which arise due to wider socio-cultural phenomena. Arguably, these are burdens the market should be able to satisfy cheaply and easily.

That said, I suspect there is a qualitative difference between the nicotine "craving" and other hungers and desires, insofar as it does (to me at least) feel different to them. Whether that means anything objectively is a tricky one which I'm not really up to thinking about on a cold, wet Tuesday afternoon.

 

[Oliver]

Also - I agree on the pejorative nature of 'craving' - and I really like this critique of it by Lynn Kozlowski, old though it may be: Use and Misuse of the Concept of Craving by Alcohol, Tobacco, and Drug Researchers - KOZLOWSKI - 2006 - British Journal of Addiction - Wiley Online Library