Five tricks bars use to keep you drinking their alcohol

Christopher Russell

With alcoholic drink sales in the UK estimated at around £37 billion ($58.6 billion) each year, bars, clubs, and drinks companies need to fight hard, think ahead, and sometimes get down and dirty with the competition to win their piece of this lucrative pie. BBC Newsbeat reporter, Jim Reed, asked industry insiders about the top five tricks bars use to keep their customers drinking alcohol for longer and buying the drinks they want to sell. Here is what they said.

(1)   The ‘three second’ rule

“Most punters just focus on the products right in front of them”, said one former bar manager. Three seconds is the amount of time the customer has to make a decision after staff ask for his order. The key to his choice is visibility; the drinks which are easiest to see behind the bar are more likely to be chosen. As a result, drinks companies strike deals with bars to ensure their drinks get ‘profitable placement’ behind the bar. This isn’t all that different from the famous “sugary cereal placement” issue common in American Supermarkets and includes alcopops being placed on the top shelf of the fridges, draft beers with oversized, illuminated pumps, and a row of spirit optics hanging right behind the bar. The latest eye-catching marketing gimmick – the “extra cold” beer pump covered in condensation – will be in your bar soon.

(2)   Turn up the volume and heating and pack people in

People drink more alcohol when the music is louder and the room is hotter. Results from a recent field study of the effect of music volume and beer consumption showed that louder music led to an increase in beer consumption and a decrease in time customers took to drink their glass. Clubs want people on the dance floor, but not all night. Some DJs told the reporter that they are often asked to drop in a couple of dodgy tunes to push people towards the bar, known as ‘persuaded drink breaks’. Some bar staff also said that they are told to turn up the heating, even in summer, to get people to drink faster and head back up for more. Door staff are also encouraged to fill the club to capacity and sometimes, over capacity. A packed club means long queues at the bar, and so people tend to buy more than they actually want in one visit to avoid having to wait later on. Having bought two to three rounds worth of drinks, the customer then feels obligated to drink them, even if he has to force them down.

(3)   Cocktails – Making alcohol sexier

Alcoholic cocktails are that “something a bit different” on the menu. First, cocktail names are memorable, often sexually suggestive, evocative, and often humorous. Usually involving an elaborate creative process in full view of the customer, cocktail making is as much a treat for the eyes as it is for the tongue. Infusing the flavours of gins, vodkas, whiskeys, tequilas or rums with fruit juices, liqueurs, and soft drinks and garnishing the glass with pieces of fresh fruit, mint leaves, cream, sugar, coconut milk and other fancy touches to produce a unique blended taste and exotic colouring all explain why cocktails are a staple of the alcoholic drinks menu in bars and clubs. The often lengthy time taken to make cocktails also gives bars the excuse to sell cocktail pitchers as well as single glasses, meaning more is sold to the same number of customers. And for this grandiose procedure, customers are willing to pay a premium price.

The customer pays, in part, for the image, the back-story, the ‘show’ which preceded the cocktail; they are not buying the ingredients, they are buying the cocktail experience, or at least this is the marketing intention to justify hiking up prices for a combination of ingredients which on their own would cost significantly less than the price of a cocktail. Some bar managers reported being more than happy to repackage a £3 rum-and-coke as a £8 Cuba Libre. While vodka, peach schnapps, cranberry juice and orange juice may be tasty drink, a “Sex on the Beach” with a straw umbrella and sugar-rimmed glass is a ‘product’ which commands an exponentially higher price. Cosmopolitans and French martinis say “class”; mojito’s say “cool”;  mai tai’s say “relax”. One trainer of cocktail makers said “Are the drinks made using fresh fruit? Does the bar tender look technically confident? All those are signs that you are getting value for money”. In much the same way that clothes, cars, and colognes are sold as  “more than just these things”, the cocktail is the bars’ opportunity to repackage ordinary ingerdients as an extraordinary product for which an extraordinary price is justified.

(4)   Skilled, attractive staff

The best bar staff are those who can get you to buy more than you wanted. You ask for a vodka and coke, the barman might offer to make it a double. You ask for a glass of wine, the barman might suggest you buy a bottle because it works out cheaper than buying individual glasses all night, pre-empting your decision to actually drink more than one glass. The downside of upselling is that customers drink more than they had intended to when they arrived at the bar. It is also well-known that the most popular bars and the bars with the highest turnovers generally employ the most attractive bar staff. Attractive, flirtatious male and female bar staff can ensure customers choose their bar for their next night out and ensure that customers visit the bar more regularly throughout the night.

(5)   In-venue alcohol marketing

According to a former marketing executive, eight out of ten drinkers walk through the door of a pub without knowing what they want, so “if you can put a brand name in their head they are very likely to remember it when they get to the bar”. Strategically placed posters, beer mats, printed glasses and illuminated signage all serve to keep the name of a drink at the front of the mind and the tip of the tongue. Bars and clubs receive incentives, discounts, and promotional products from drinks companies for the right to preferential placement of their marketing materials throughout a venue. The idea again is that an effective advertising can make the choice for the undecided customer, that he can be persuaded to buy a drink he either didn’t want or doesn’t even like.

Summary

These are just some of the tricks which bars and clubs use to persuade the customer to spend more money and time in their premises. However, it must be remembered that no one and nothing can literally make you drink. People drink when it makes sense for them to drink, and the tricks described here are intended to make the customer see drinking as something which makes sense at that moment. Effective marketing is that which presents ‘good’ reasons to drink, but these should be tempered with your own reasons for why you should or should not keep drinking.

By being aware of some of the tricks bar owners and bar staff are using to make more drinking seem like a good idea, you can keep in mind a quantity and speed of drinking which you consider sensible and so make sensible decisions about when you should call it a day.

References:

Gueguen, N., Jacob, C., Le Guellec, H., Morineau, T., Lourel, M. (2008). Sound level of environmental music and drinking behavior: a field experiment with beer drinkers. Alcoholism: Clinical and Experimental Research, 32(10), 1795-1798.

Reed, J. (2011). Five tricks to make you buy more booze. Accessed 28/01/11 at http://www.bbc.co.uk/newsbeat/12299877

Tobacco smoking alone isn’t enough: More than smoking important in lung cancer death

Christopher Russell and Adi Jaffe

The tobacco epidemic already kills 5.4 million people a year from lung cancer, heart disease and other illnesses. By 2030, the death toll will exceed eight million a year. Unless urgent action is taken tobacco could kill one billion people during this century. (The World Health Organization Report on the Global Tobacco Epidemic, 2008)

These are some scary numbers, right? Cigarette smoking, according to the WHO, is the single most preventable cause of death in the world today, and in conveying these deadly statistics to the general public, cigarettes have come to be alternatively referred to by smokers and non-smokers as “cancer sticks”, “nicotine bullets”, and “coffin nails”.

But does smoking really ‘kill’ anybody in the literal sense with which we use this word?  To an epidemiologist, tobacco smoking (nor many other drugs of abuse for that matter) does not “kill” a person or “cause” illness or death in the way the words “kill” and “cause” are typically understood by the media and general public. For example, if I shoot someone in the head, stab another in the heart, and strangle a third till he stops breathing, it is reasonable to say that my actions were the direct, sole, and sufficient causes of death – I would have killed them. Smoking, however, is often neither a sole nor sufficient ‘cause’ of lung cancer, coronary heart disease, or myocardial infarction because non-smokers die from these diseases, and for example, because only 1 in 10 heavy smokers die from lung cancer when one looks at the overall numbers. Continue reading “Tobacco smoking alone isn’t enough: More than smoking important in lung cancer death”

Quitting smoking ‘on the spot’ is more likely to succeed than a quit attempt planned in advance

Christopher Russell

Readers who are smokers will likely have heard that if you approach stopping smoking like any other major life change, with careful preparation and planning, you can succeed, and that quitting depends first on putting together a plan that will work for you. These beliefs stem from the prevailing model of how people stop smoking which states that smokers moves through a succession of motivational stages involving contemplating stopping, preparing to stop, and then subsequently trying to stop (Prochasksa & Velicer, 1997). Consequently, physicians, GPs and smoking cessation therapists have been charged with using the model’s ‘four As’ – ask, advise, assist, and arrange – to guide smokers through these stages of change (Royal College of Physicians, 2000). This typically involves assisting smokers to anticipate potential difficulties in the early stages of quitting (e.g. identify the people, places, and things which stimulate craving), make plans to avoid/resolve these difficulties, set a date on which they plan to have stopped smoking completely, and plan rewards for maintaining abstinence between now and the quit date.

Based on this philosophy of “fail to prepare, prepare to fail”, the overarching goals of current cessation guidelines are to identify the smoker’s current stage, make recommendations appropriate for this stage, and guide the smoker sequentially through to the final stage of putting the quit attempt into action. However this model has been criticised on many grounds, the most notable being the lack of evidence that most smokers actually plan their quit attempts in advance and that doing so increases their chance of success. Indeed, this model conflicts with the accounts of many ex-smokers who say they just decided to stop smoking one day and have not looked back since.  In response to this gap in the literature, two relatively recent studies – one each in Canada and England – investigated the extent to which smokers plan their quit attempts and the extent to which planning increased the  success of quit attempts.

 The benefit of deciding to stop smoking immediately

Larabie (2005) found that while the majority of smokers (63%) planned their quit attempts in advance, the interesting finding was that the 67% of ex-smokers (i.e. successful quitters, defined as those who had not smoked in the past six months) had not planned their successful quit attempt in advance compared to 33% of ex-smokers who planned their successful quit attempt in advance. The three most commonly reported types of planning were (1) planning to quit on a significant date (e.g. birthday, New Year’s Day); (2) planning to obtain nicotine replacement medication in the near future); and (3) planning to quit once they had smoked all the cigarettes in their current carton.

Some examples of the unplanned quit attempts reported are given below, and more are available at the link in the references:

“I found out I was pregnant and I just quit” (LV, age 36).

 “I just felt like I had had enough and it was not going to kill me” (CB, age 36).

“I got ‘the scare’. I went out from work to have a cigarette and got a severe dizzy spell and had difficulty walking for 20 minutes. I quit on the spot. I still had cigarettes left in my pack” (LF, age 40).

Just as interesting was Larabie’s finding that 79% of successful quit attempts were made unassisted (defined as no use of Bupropion, nicotine patches, nicotine gums, tapering, or hypnosis). Larabie’s findings therefore argue against the prevailing model that successful smoking cessation depends on receiving assistance to quit (from medications, counselling etc) and planning quit attempts in advance. Rather, the most effective quit attempts were found to be those done without prior planning and without assistance! The paradox in this, noted by Larabie, is that health care providers may actually be hindering smokers’ chances of quitting by dissuading unassisted quitting (and promoting the uptake of formal treatment programmes) and by discouraging sudden, unplanned quit attempts. These assumptions deserve testing in their own right.

 A similar story in England

West and Sohal (2006) observed a similar success of unplanned quitting in their survey sample of 918 smokers and 996 ex-smokers in England. Almost half of all quit attempts (48.6%) were made without prior planning. Of the 611 quit attempts made between six months and five years previously, 65.4% of unplanned attempts lasted at least six months without smoking compared with 42.3% of planned attempts. This means that smokers who made unplanned quit attempts were 2.6 times more likely to still be not smoking six months later than those who made planned quit attempts. Likewise, smokers who made an attempt to stop smoking between six and twelve months previously were 2.5 times more likely to still be not smoking six months later than smokers who planned their quit attempts.

 Conclusion

A sudden decision to not smoke any more cigarettes was both common and more likely to be successful than were quit attempts made after a period of planning. While this does not necessarily suggest that planning and forethought and promoting treatment options are counterproductive, it does provide a strong case for health care providers going against current guidelines to encourage smokers, particularly those on the cusp of wanting to quit, to recognise and act upon opportunities to quit on the spot. In challenge to the prevailing ‘stages of change’ model, findings from these two studies should encourage smokers to consider the benefits of not thinking ahead, not waiting until Monday or the New Year, not waiting till the carton is empty, but instead, quitting now, without warning, or a running start, or a few days to prepare. West and Sohal state that even small changes in a smoker’s motivation to quit can trigger big changes in his/her behaviour and so smokers should be encouraged to capitalise on any desire to stop smoking. For those readers who are thinking about stopping smoking, planning may help, but consider the larger benefit of quitting today, right now.

Please write your comments in the box below.

 Just for fun

The questions asked of smokers and ex-smokers in West and Sohal’s study are provided below. If you have tried to stop smoking or are an ex-smoker and feel comfortable answering, how would you answer?

Q1. Which of these statements best describes how your most recent quit attempt started?

(a)    I did not plan the quit attempt in advance; I just did it.

(b)   I planned the quit attempt for later the same day

(c)    I planned the quit attempt the day beforehand

(d)   I planned the quit attempt a few days beforehand

(e)    I planned the quit attempt a few weeks beforehand

(f)    I planned the quit attempt a few months beforehand

(g)   Other

(h)   Cannot remember.

Q2. How long did your most recent quit attempt last?

References:

Larabie, L. (2005). To what extent do smokers plan quit attempts? Tobacco Control, 14, 425 – 428.

Larabie, L. (2005). To what extent do smokers plan quit attempts? Appendix A: Examples of responses. Accessible at:

http://tobaccocontrol.bmj.com/content/suppl/2005/11/23/14.6.425.DC1/146425_datasupplement_appendix.pdf

Prochaska, J. O. & Velicer, W. F. (1997). The transtheoretical model of health behaviour change. American Journal of Health Promotion, 12, 38 – 48.

Royal College of Physicians (2000). Nicotine addiction in Britain. London: RCP.

West, R. & Sohal, T. (2006). “Catastrophic” pathways to smoking cessation: findings from national survey. BMJ, 332, 458 – 460.

Should all drugs be decriminalized? A UK debate

Christopher Russell

In a recent UK parliamentary debate, Bob Ainsworth MP, a former Home Office minister in charge of drugs policy, called for the decriminalization of all drugs. Ainsworth, the most senior UK politician to publicly endorse a system of decriminalization, joins respected figures from the medical and research communities in recent months in suggesting that the decriminalization of drugs would significantly improve public health and reduce crime further than is being achieved under the current system of criminalization. Ainsworth argues that that the past 50 years of the War on Drugs has been counter-productive to its intended goals of reducing the availability of drugs and improving public health. Furthermore, he claims that billions of pounds had been spent without preventing the wide availability of drugs, reducing the wide use of drugs, or weakening the illicit drug market. Consequently, Ainsworth proposes that the drug market be taken out of the hands of organized criminals and be placed into the hands of medical professionals and licensed vendors. Such a change in policy would mark a return to UK drug policy prior to the mid-1960’s in which drug use was treated as a health issue, not a criminal issue.

“It is time to replace our failed war on drugs with a strict system of legal regulation, to make the world a safer, healthier place, especially for our children. This (policy of criminalization) has been going on for 50 years now and it isn’t getting better. The drugs trade is as big, as powerful as it ever was across the world. Prohibition isn’t the answer to this problem” he said.

It is important to understand that Ainsworth is not arguing that drugs like heroin and cocaine should be freely available to buy in the same way that adults can buy alcoholic drinks and tobacco products. Rather, he argues that drugs be decriminalized, which is different from legalized. Decriminalizing would likely mean the government would control all aspects of the manufacture, quality, purity, distribution, and trade of drugs, including who will be licensed to provide drugs. Legalization would mean drugs could be traded in the free market, a position which Ainsworth is explicitly against. “I’m not proposing the liberalization and the legalization of heroin so we can all get zonked out on the street corner” Ainsworth said in an interview with BBC’s Radio 4.

Why decriminalize drugs?

The argument for decriminalization is based on the hypothesis that the legal regulated supply of drugs will draw trade away from the illicit market and so reduce crime related to the illicit sale and purchase of drugs; improve the health of users by providing quality-controlled drugs under the guidance and supervision of licensed individuals; increase the uptake of addiction treatment; allow treatment providers to reconnect with a group of drug users who do not typically seek or know about treatment options or have distanced themselves from treatment providers for fear of criminal prosecution; and improve drug education for current and would-be drug users.

If decriminalizing does shift the drug market toward legal vendors, a major benefit could be the medical and addiction research communities’ sudden widespread access to a population of drug users who are notoriously difficult to reach. This access would allow medical professionals and researchers obtain rich first-hand information as to why these people started using drugs and why they use drugs today, to provide drug education, to provide assistance with any problems relating to employment, housing, relationships or physical and mental health. Decriminalizing drugs may therefore better place treatment providers to support those who want help and to minimise harm in those who continue to use. Paradoxically then, while many people believe decriminalization will send a message to the youth that drug use is acceptable as well as maintaining use in current users, proponents of decriminalization argue that, by reconnecting drug users to the health community, legal regulation of drugs will actually increase in the number of people quitting drugs and provide earlier opportunities to deliver educational interventions to ‘would-be’ drug users.

What might decriminalization look like?

While Ainsworth did not describe in detail how drugs should be regulated, Steve Rolles, Head of Research for the Transform Drug Policy Foundation, which campaigns for the decriminalization of drugs, released a ‘blueprint for regulation’ in December, 2009 which described how models of regulation for different types of drug would improve health and decrease crime. The report proposes that cannabis and opium could be sold and consumed on membership-based “coffee shop-style” licensed premises and would likely be subjected to similar trade laws as those currently applied to tobacco products; cocaine, ecstasy and amphetamines could be sold by licensed pharmacists or named purchasers; and psychedelic drugs, including hallucinogens such as LSD or Salvia could be used only under supervision in licensed “drug clubs” or similar venues. Rolles said: “Drugs are here to stay, so we have a choice – either criminals control them, or governments do. By the cautious implementation of a legally regulated regime, we can control products, prices, vendors, outlets, availability and using environments through a range of regulatory models, depending on the nature of the drug, and evidence of what works”.

Rolles also echoed Ainsworth’s sentiments about the futility and counter-productiveness of prohibition in a recent BBC radio interview: “It hasn’t reduced drug use, it hasn’t prevented the availability of drugs, but it has created a whole raft of secondary problems associated with the illegal market, including making drugs more dangerous than they already are and undermining public health and fuelling crime”.

Rolles called on the UK government to consider evidence about the effectiveness of the prohibition policy both in the UK and other countries and health and crime projections under a decriminalized system. Craig McClure, foreword author on the Transform Drug Policy Foundation report and former executive director of the International Aids Society states that several Latin American governments have already realised how their war on drugs have undermined public health goals and fueled crime and have already moved, or are moving, towards decriminalization and a public health model targeting the prevention and treatment of drug misuse.

What next for the decriminalization deabte?

Knowing that drug decriminalization is a sensitive, emotion-laden, divisive idea, and therefore public support from fellow MPs will initially be largely absent, Ainsworth has called for an impact assessment to be conducted on the Misuse of Drugs Act, 1971 – the legislation which introduced drug classification in the UK – rather than calling for drugs to be decriminalized outright.

“I call on those on all sides of the debate to support an independent, evidence-based review, exploring all policy options, including: further resourcing the war on drugs, decriminalizing the possession of drugs, and legally regulating their production and supply” he said. As influential political, medical and scientific forces join to pressure a review of the efficacy of current drug policy, there is a sense in the UK that drug decriminalization is slowly moving from an ideological conviction to an evidence-based alternative to a failing system of prohibition.

Please write your comments about the prospect of drug decriminalization in the box below.

References:

Bob Ainsworth BBC 1 television interview, 16th December, 2010. Accessible at http://www.bbc.co.uk/news/uk-12005824

Bob Ainsworth BBC Radio 4 interview, 16th December, 2010. Accessible at http://www.bbc.co.uk/news/uk-12005824

Transform Drug Policy Foundation (2009). After the war on drugs: Blueprint for regulation. Accessible at http://www.tdpf.org.uk/Transform_Drugs_Blueprint.pdf

Medical and political support for the Transform Drug Policy Foundation’s ‘blueprint for regulation’ (2009) report. Accessible at http://www.tdpf.org.uk/blueprint%20download.htm

The Myth Of “Loss of Control” As A Scientific Truth Of Addiction

All About Addiction aims to be a place where an open conversation about issues relevant to addiction can be discussed. To that end, the following is a piece from Christopher Russell that challenges the notion that people in some way lose control over their behavior suggesting instead that their seemingly compulsive behavior is actually volitional. Look for an upcoming post featuring Dr. Jaffe’s views on some of the points made by Christopher.

The Myth of “Loss of Control” – By Christopher Russell

Popular wisdom among addiction neuroscientists states that while initial drug use is voluntary, with repeated drug consumption the consumer moves closer to a critical, tipping point separating non-addicted from addicted drug use (e.g. Leshner, 1997). At the passing of this critical point, believed to reside in drug-induced changes to one or more brain sites and gene expression, the individual is argued to lose his ability to control his use of drugs thereafter. Beyond this point, drug use is now something which happens to the individual, compelled by pharmacological causes, not something the individual does for phenomenological reasons.

This notion of a physical “loss of control” as an explanation for why some people continue to use drugs has prevailed as the core hypothesis of the view of addiction as a progressive disease for the past 200 years (Levine, 1978) and today remains largely accepted by the general public as a taken-for-granted, scientifically-proven truth of addiction. Furthermore, the primary use of the word addiction has come to describe a particular set of behaviours which have a causal basis operating irrespective of the will of the individual (Davies, 1996), with “addicts” used as the term to distinguish those who are no longer able to control their drug use from those who are still able to control their drug use.

But why has this belief become so ubiquitous among the general public when the neuroscience community has produced no evidence which is sufficient to warrant the conclusion that certain individuals are physically unable to stop using their drug? Additionally, no evidence has been provided which warrants the conclusion that a critical, tipping point exists in the brain at which a person shifts from non-addicted to addicted drug use, the point at which the “loss of control” is assumed to occur. Both beliefs remain hypotheses for which there is as yet no evidence, however, the public  understanding tends to be that these arguments have been long since proven as basic truths of addiction. What we do know and can show today is that some people find quitting a drug to be easy, a bit hard, quite hard, or extremely difficult. But evidence of the difficulty to exercise control should not be confused with an inability to exercise control, no matter how much the evaluation “I can’t stop” feels like a literal truth about our capabilities. This 3-part blog describes what we can and cannot show about the nature of drug use today and why the “loss of control” myth has prevailed as a “fact” of addiction for many people.

What we can and cannot show about addiction today

What we can and cannot show about the nature of addiction today is summed up by Akers (1991), a sociologist:

“The problem is that there is no independent way to confirm that the “addict” cannot help himself and therefore the label is often used as a tautological explanation of the addiction. The habit is called an addiction because it is not under control but there is no way to distinguish a habit that is uncontrollable from one which is simply not controlled”.

In other words, we have only shown that some people do not stop using drugs, not that they cannot stop using drugs. The belief that some people cannot control their drug use will soon be shown to be a scientific fact, which comes from the moral judgment that people who do not stop when they say they really want to stop and who continue to use even to the detriment of other important things in life like work and relationships must be doing so not of their own will, but rather, their behaviour must be being compelled by a force outside of their will. In other words, the value-laden judgment is that no person in their right mind would voluntarily pursue this life; therefore, it fits with our view of a moral society to think that a drug “addict” is not a morally reprehensible person, but rather, must be using drugs against his will. But we must remember that to say “for why else would this poor person continue to use drugs?” is a value-laden statement about how we believe morally decent humans should behave. We should not infer that people cannot stop using drugs simply because we observe them not stopping. This may be useful information in itself, but is not evidence of a loss of control.

What medications do and do not do

Of course I do not deny that the use of medications like naltrexone, acamprosate and buprenorphine make it easier to forego certain drug use by blocking parts of the brain which motivate drug use. I would encourage people to use these medications if they find it helps them to not use other drugs. However, reducing the difficulty of quitting should not be confused with restoring the individual’s ability to quit as if this ability was at any point lost. Medications can help people quit using drugs and great strides are being made to manufacture medications which make the process of quitting easier to do and tolerate. However, these medications are not necessary for controlling drug use in the way heart medicines, radiation therapy, and insulin is necessary to stave off the mortal threats of heart conditions, cancers, and diabetes respectively.  These groups of people do not have agency over their conditions in the way drug users have over their behaviour.

No medication has yet been shown to restore a drug user’s free will to reject drugs. Additionally, manufacturing medications has long been considered by addiction researchers such as Bruce Alexander, Stanton Peele, and John Davies to be focusing on the thin edge of the wedge; too much focus on the uses of medication, they would argue, restricts the need for drug users and treatment providers to consider a broad social analysis of why drug use is so prevalent in our societies.

The paradox of “behaving responsibly” after control is lost

The paradox inherent to the belief that some drugs erode free will and others can restore free will is that a drug user is expected to exercise his control and his will to sign up for and attend treatment and take medication like a “responsible” person should do precisely when we believe he has been robbed of his control and will to make choices about drugs. This paradox is also seen in the myth that an “addict can only quit after he hits rock bottom” which is promulgated by the 12-step movement; we expect people to show free will to quit precisely when they are thought to be least free to make choices about drugs. In other words, we expect so much self-control from those we believe are no longer capable of self-control!

The defence of this paradox has tended to be along the line of “he has not lost his free will to control all parts of his life, only the parts which involve drugs”. In one of his early speeches in San Diego, June 6th, 1989, William Bennett, former National Drug Policy Director and drugs czar appointed by President George H. W. Bush, defined an “addict as a man or a woman whose power to exercise rational volition has been seriously eroded by drugs, and whose life is organised largely – even exclusively – around the pursuit and satisfaction of his addiction”. Bennett’s statement reflects a common logical contradiction. Organisation of one’s life around anything is a rational skill, a wilful act, often requiring complex cognitive operations to be performed such as planning for an event which is two and three moves ahead. As Schaler (1991: 237) notes, “If an addict’s power to exercise rational volition is seriously eroded, on what basis does the addict organise life?” Interestingly another curious medical-moral contradiction by Bennett was noted by Massing in his book The Fix. Massing said “Addicts were in his (Bennett’s) view irresponsible individuals lacking basic levels of self-control” (p195). If these people do lack the capacity for self-control, how can they be responsible for not showing self-control? If they were irresponsible, it is their irresponsibility which causes drug taking; self-control is irrelevant. Bennett appears to be of the view that addiction is a moral failing which the addict is helpless to prevent, which is logically impossible.

Instead, what we do observe is that drug users are actually very good at putting in place the conditions by which drugs can be obtained, and that many people who are diagnosed as drug addicts do show a great capacity for self-control of behaviours except for those involving drugs. So addiction neuroscience is not pursuing a neurobiological basis of free will, per se, just the basis of our free will to control drug use, which is an even harder premise to swallow.

Stay tuned for Dr Jaffe’s reponse and part 2 coming soon.

References:

Akers, R. L. (1991). Addiction; the troublesome concept. The Journal of Drug Issues, 21(4). 777-793. (only available in print form at present).

Davies, J. B. (1996). Reasons and causes: Understanding substance users’ explanations for their behaviour. Human Psychopharmacology, 11, 39-48.

Leshner, A. I. (1997). Addiction is a brain disease, and it matters. Science, 278,45−47.

Levine, H. (1978). The discovery of addiction: Changing conceptions of habitual drunkenness in America. Journal of Studies on Alcohol, 39, 143−174.

Massing, M. (1998). The Fix. University of California Press Ltd; London England.

Schaler, J. A. (1991). Drugs and free will. Society, 28(6), 235-248.

Does current smoking among health care providers limit their ability to dissuade smoking to the general public?

By Christopher Russell

In 2003, the US Department of Health and Human Services (USDHHS) set a goal of reducing cigarette smoking among US adults (18 years +) to 12% by 2010, which if achieved would halve the adult smoking prevalence rate reported in 1998 (24%). Achieving this current smoking reduction may depend on the extent to which health care providers (doctors, nurses, and such), who are charged with promoting smoking cessation and dissuading the uptake of smoking among to the general public, are themselves current smokers. For example, health care providers’ anti-smoking and pro-quit messages will likely be more persuasive and credible to the smoking public when the messengers practice what they preach about smoking. Such messages may also better motivate quit efforts if the health care providers have had personal success in quitting smoking using the methods and information they are now endorsing. Conversely, smokers may intuit that when health care providers advise quitting but continue to smoke themselves despite enjoying ready access to all the resources, information, and tools which should facilitate quitting, then smokers, without this luxury of access to education and resources, will be even less likely to successfully stop smoking.

Therefore, significant strides in increasing the number of quit smokers and never smokers in the general population may somewhat depend on reducing current smoking among the health care providers who act as both educators and trusted role models to the general public. It is therefore important to know how the prevalence of smoking among health care providers compares to the prevalence of smoking in the general population, which health care providers are charged to reduce.

Current smoking among health care providers

Using US population survey data, a recent study published in Nicotine and Tobacco Research reports estimated changes in the prevalence of current smokers, former smokers, and never smokers among eight groups of health care provider  – physician, physicians assistant, registered nurse (RN), licensed practical nurse (LPN), pharmacist, respiratory therapist, dentist, and dental hygienist – between 2003 and 2006/07. While the majority of these health care providers have never smoked a single cigarette, the authors report that, in 2006/07, approximately one in every five licensed practical nurse (20.55%) and respiratory therapist (19.28%) was a current smoker. Current smoking rates among LPNs and respiratory therapists were marginally higher than the rate of current smoking in the general population (18.01%) and near double the Healthy People 2010 goal of 12% current smoking in the general population. Four groups of health care provider – physicians (2.31%), dentists (3.01%), pharmacists (3.25%), and registered nurses (RNs) (10.73%) were all on course to be below the 12% prevalence goal. Furthermore, seven of these eight health care groups in 2006/07 showed higher quit rates than was found in the general population (52%) – only LPNs had a lower quit rate (46%). However, the concern from a public health perspective, is that while current smoking rates among these health care groups and in the general population have dropped considerably when compared to data reported in a similar cohort study in 1990/91, these decreases in current smoking appear to have leveled off in recent years; current smoking did not significantly decrease in any health care profession or in the general population between 2003 and 2006/07.

An important methodological note about this study is that results reflect weighted population estimates (WPE), not actual data. WPEs allow researchers to make inferences about an entire population group given only some data for that group simply by scaling up the actual data, (i.e. data reported by around 4000 health care providers in each collection year were used to estimate smoking statuses for over 2 million actual individuals). Of course, this technique likely overgeneralizes behavior in the sampling group, but is nonetheless a standard, valuable tool of health epidemiologists when they want to make inferences about how entire populations are behaving. Indeed, many of our health policies have derived from WPEs.

Current smoking among licensed practical nurses

Among the most important findings of this study is that one in five licensed practical nurses in the US is currently smoking. Of the estimated 754,000 LPNs in the US, this equates to roughly 155,000 current smokers in this profession, illustrating that health campaigns designed to depict smoking as socially unacceptable, readily available access to education and empirical research on the health consequences of smoking, working in smoke-free health care campuses, and being charged with task of persuading clients to stop smoking, all appear insufficient to reduce current smoking among LPNs and respiratory therapists to below the rate of current smoking in the general population.

In contrast, 10.73% of registered nurses are current smokers. The discrepancy between LPNs and RNs begs two questions: why are LPNs nearly twice as likely as RNs to be current smokers, and should we expect RNs will be better able than LPNs to persuade current smokers to quit and dissuade smoking to would-be smokers? Certainly, researchers should now ask whether a health care provider’s smoking status is related to his ability to produce cessation in health care recipients. If we assume that health care workers have a central role to play in producing mass behaviour change of whatever kind, then it is plausible to reason that reducing smoking prevalence at the national level will significantly depend on first reducing smoking prevalence among health care providers, our first responders to public health concerns. Testing this hypothesis seems the logical extension to capitalise on these smoking prevalence data.

Why are licensed practical nurses twice as likely as registered nurses to be currently smoking?

If one’s smoking status is important for persuading change in others, we need to know why smoking is more prevalent among LPNs than RNs, why LPNs have a lower quit ratio than the general population, and so, which factors should be addressed to reduce current smoking among LPNs to below the 12% level. The authors of this study suggested that LPNs’ fewer years in education and lower annual income may be associated with their current smoking status since they mirror socioeconomic factors known to associate with higher smoking rates. Comparably large proportions of LPNs and RNs are female, thus ruling out an important effect of gender. In my opinion, given that nicotine produces positively reinforcing psychoactive effects and that smokers commonly report smoking to alleviate affective distress, another consideration may be that LPNs and RNs differ in their exposure to stressful work events and environments, and/or differ in their emotional reactivity and sensitivity to these events, and/or differ in their bias to perceive work events as stressful. Furthermore, as smoking staus is known to be associated with socioeconomic status and socioeconomic status is known to be associated with many health and wellbeing factors including stress, then stress may be important both as a direct influence on smoking behavior and indirectly as a mediator of the effects of socioeconomic variables on smoking behavior. A good start to exploring these hypotheses would be to simply ask LPNs and RNs of their main reasons for smoking in short open-ended interviews; if reliable differences in smoking attributions emerge then we may begin the harder task of counseling LPNs to think of smoking in ways which alter their reasons to smoke, the reasons which may currently be maintaining smoking in one in five LPNs.

Questions for the reader; please give your comments below

1)      Why do you think current smoking is more prevalent among licensed practical nurses than in the general population?

2)      Does a health care provider’s status as a current smoker make him/her more or less able to persuade smoking cessation in others?

3)      Will reducing current smoking nationally depend on reducing current smoking among health care providers?

References:

U.S. Department of Health and Human Services. (2003). Healthy People 2010, Retrieved from http://www.healthypeople.gov/

This report is free to download at: http://www.healthypeople.gov/document/pdf/uih/2010uih.pdf

Sarna, L., Bialous, S. A., Sinha, K., Yang, Q., & Wewers, M. E. (in press). Are health care providers still smoking? Data from the 2003 and 2006/2007 Tobacco Use Supplement-Current Population Surveys. Nicotine and Tobacco Research.

Understanding addiction research will require us to argue our corner but be flexible to change corners.

Hello everyone,

My name is Christopher Russell, I am a doctoral student in psychology at the University of Strathclyde in Glasgow, UK. My addiction research interests are wide and varied, but my core interests are in addiction theory (“why people do what they do”), the issue of freedom to control when using drugs, interpretations of addiction research evidence, and the use of licit and illicit drugs in the law.

Respect and rational debate of addiction research

Dr Adi Jaffe has very generously asked me to become a contributor to A3 and after reading about what A3 stood for (the mission and the abbreviation) and what Dr Jaffe is trying to achieve through A3, I am delighted to be a part of A3. Adi noted in a previous post that we do hold some different opinions about the nature and course of addiction. Above our differences, however, I respect that Dr Jaffe and I are able to debate addiction research rationally, respectfully, and vigorously without either of us resorting to ideological proclamations, disrespect for the alternative view, claiming a moral high ground or attacking each other’s moral character, or worst of all, name calling! Such people are hard to find in the academic world! The truth is that I, like Dr Jaffe, am still learning about addiction, and I’m not foolish enough to believe that my way is the way! If addiction research over the past 100 years has shown anything it is that a researcher would be foolish to hang his hat on any interpretation and proclaim it as fact – for example, for the past 200 years, masturbation was considered the most prevalent psychiatric disorder until it was replaced by drug use, and up until 1973, homosexuality was still diagnosed and treated as a form of mental illness! We must be willing to bend with the wind, to accept when addiction research evidence invalidates our beliefs, and to respond to falsifications by constructing models which stand up to our efforts to falsify them.

A3 and the fluid landscape of addiction research

The landscape of addiction research changes by about 50% each decade, as do many scientific ideas, so it is important that we all hold our beliefs about addiction lightly and be willing to consider that some dearly held addiction “truths” may not be as truthful as we had thought, perhaps hoped. Scientists are constantly revising what they thought they knew, changing their approach to measuring and conceptualising the problem, disseminating the latest findings to the public; like any good scientist, those who are involved with addiction, either personally or professionally, should always try to update their model, and sometimes, evidence can arise which causes us to question everything we thought we knew about the nature of a problem. Such evidence may require us to not merely adapt our exisitng models of the problem, but if called for, to abandon them in favour of more potent models which need not necessarily be liked or fully understood.

Hearing what addiction research is telling us, not what we want to hear

However, despite our pledges to be good scientists, our basic ways of thinking tend to get in the way of building better models of a problem. For example, a classic contribution of psychology research has been the finding that people prefer to try to discredit a new piece of evidence about a concept which doesn’t fit with their existing understanding of that concept rather than assimilate the new evidence into our understanding because it is cognitively easier to leave our belief structure as it is. This phenomenon is quite common in the addiction research community; some people just refuse to believe that addiction could be something other than what they had long thought it to be, and no amount of validated, replicable evidence to the contrary will move them to revise their beliefs. It is regrettably common that, for some, beliefs about addiction are based on an unwavering ideology rather than a science-grounded conclusion. Addiction researchers cannot afford to be this pompous, lazy, or inflexible; too many people are counting us to get the right answers to them, no matter who they come from or what form they come in. I know that my contributions to A3 are only useful to the extent to which they help get people from where they are to where they want to be. To achieve this, I must argue my corner but be willing to bend when the wind blows. We all must.

In the hope that I can be both teacher and student of A3, I believe that the value of my arguments will be measured by how well they hold up in the face of your most passionate, insightful criticism. Therefore, I invite all those who read my contributions to criticize, refute or support any of my arguments when you feel it is warranted. I will always try to give an intelligent answer and I swear to never resort to clichéd answers, bumper sticker answers, or the “it just is because it is” answer, which is in effect, no answer. And I will never resort to name calling (except when you really deserve it!).

I look forward to providing you with thought pieces, philosophical contributions, reviews of evidence, and most of all, interacting with you the readers, the lifeblood of A3.

Christopher