Quitting smoking without help is hard: Effects of motivation and other personality factors

Quitting smoking is hard, but that suggestion probably isn’t terribly exciting all on its own since most of our readers probably knew it already. Still, while we’ve talked about quitting smoking using nicotine replacement and medication, we haven’t really touched the subject of all those people out there who just decide to give quitting smoking a try one day without those patches, gums, or pills.

Since something like 95% of those who try their hand at quitting smoking relapse within one year, and most of these people try to quit unaided, I think this is an important topic to touch on. Fortunately, recent research conducted in the U.K. tried to assess the personality and cognitive aspects that end up predicting who will succeed, or fail, in their quit attempt.

The effects of expectation, motivation, and impulsivity when quitting smoking

Quite a bit of research has already shown that when smokers are trying to quit (so we’re talking early on during abstinence), their brains react differently to stimuli in the environment depending on the relationship between those stimuli and nicotine. Stimuli that aren’t associated with smoking (or some other form of nicotine intake) get less attention and show overall less activation of important brain circuits while nicotine associated cues light up the brain just as if nicotine was on board (even though participants were drug free at the time). Essentially, if a stimulus predicts getting a hit, the brain gets smokers to pay attention to it so that they can do whatever is necessary and get a little drug in. Throw in some of that reduced ability to control behavior that we talk about so much (like impulsivity), and which is common not only in smokers but in users of almost every other drug (heroin might be the exception) and you have a recipe for disaster, or at least for a good bit of smoking relapse. And yet if we want to fight the horrible health consequences of cigarettes, then quitting smoking has to be made easier, which nicotine replacement and medications like bupropion have done to some extent.

As part of this equation, knowing the specific predictors of early relapse in people who are quitting smoking may be useful so that professionals planning smoking interventions can do a better job of targeting the most important factors. The study recently published the journal Psychopharmacology tried to assess the relationship between the severity of smoking, the above-mentioned personality factors, and the success of the quitting attempt.

The cool thing about this study is that the 141 people who participated were assessed on a whole set of these cognitive tests twice – once after a smoking free night and a nicotine lozenge and another time after a smoking free night followed by a nicotine-free lozenge. While they couldn’t tell which was which, the procedure gave the researchers an assessment off how different participants’ reactions were with or without nicotine on board. Following the assessments participants were directed to begin their attempt at quitting smoking. While they were asked not to use nicotine replacement options or other medications, they were allowed to use any other resource available and were given a set of information pamphlets that explained expected side effects and likely difficulties during the quit attempt. They were then followed up after 1 week, 1 month, and 3 months. Quitting was identified as minimal smoking (less than 2 cigarettes per week) and was verified both by self report and cotinine testing. There was a small financial incentive to quitting, with people who relapsed after a week getting only £40 (about $60) and those who made it through month 3 getting £150 (about $250), though I’m pretty sure that if $200 was enough to make people quit we’d have just paid up already…

The first thing to note in the results was that 24% of the participants were still not smoking at the 33 month followup. This seems to be about on par with the usually low success rates at 1 year though I’m sure this research group will try to continue following these participants at least up to the 1 year mark and hopefully produce another paper.

The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interfering with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After the 1-week follow-up, at the 1 and 3 month assessment, the odds of quitting had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.

The take-home: Quitting smoking is hard for different reasons in the first week and later on

If you’ve ever tried to quit you’ve been told you that the first week is the hardest and that once you make it through that the rest is a piece of cake. While this research doesn’t necessarily support that notion, since about 25% of the sample relapsed between each of the followups, it does seem to indicate that the reasons for relapse change after that first week.

It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking seems to be associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward.

Overall, these findings suggest that the cognitive function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.

Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can reduce relapse numbers at 1 week we can have a more gradual fall-off for the following month resulting in significantly higher quit rates.

Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medications like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?

Citation:

Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.

 

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The first thing to  note in the results was the 24% of the participants were still not smoking at the 33 month followup. This seems to be about on track for the normally low success rates at 1 year though I’m sure this group will try to follow these individuals up at that point and hopefully produce another paper. The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interruption with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After that point, at the 1 and 3 month follow-ups, had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.

The take-home: Quitting smoking is hard for different reasons in the first week and later on

If you’ve ever tried to quit you’ve heard someone telling you that the first week is the hardest and once you make it through that the rest is a piece of cake. Well, this research doesn’t really support that notion since about 25% of the sample relapsed between each of the followups, but it does seem to indicate that the reasons for relapse change after that first week. It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking was associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward. Overall, these findings suggest that the brain function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.

Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can bring the relapse numbers down at 1 week we can have a more gradual fall-out for the following month resulting in significantly higher quit rates. Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medication like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power that nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?

Citation:

Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.

Time to Act: Helping parents deal with teens and drugs

Parents are always looking for help on how to parent when it comes to teens and drugs. Well, the new tool from drugfree.org, called Time To Act, may provide just the help parents want.

The tool has separate sections for parents who fear their kids may be trying drugs or for those who know for sure.

Check it out, it’s a great tool that can help a lot in terms of educating, guiding, and informing parents who are having trouble with teens, drugs, and parenting. NIDA also has a new tool called Family Checkup, developed by the Child and Family Center at the University of Oregon, that is aimed at helping parents communicate effectively with their kids when it comes to drugs.

More than anything, research has shown us that communication around the topic of teens and drugs and even more generally communication between parents and their kids about taboo topics, can be effective for reducing problems and for finding help sooner (see here for smoking related research).

How I stopped drinking, again – Entry 2

Okay, I’m not in as good a mood about the whole “Psychology Board-quitting drinking alcohol” experience this time… The not drinking alcohol part has not proven to be an issue until now although it has certainly come up a few times, especially around my upcoming anniversary and the question of whether I can sip champagne or not (obviously the answer is no). It certainly brings up the fact that so many of our social ceremonies involve alcohol and whether I like it or not, those notions are part of my view of social interaction. But that is seriously not the part that pisses me off the most.

Here it is – I am going into a helping profession, meant to support those in our society that need help. I myself have belonged to that group and still see someone on occasion, but I think I’ve come a long way in the last 12 years or so. But not only am I now forced to call in every morning (an ordeal for someone with ADHD anyway) and report for testing during work hours, but the payment for these things is absurd! Each test is going to cost between $50-$75 and I will initially be tested 4-5 times per month for a total of $200-$375 per month or $2400-$4500 per year! and that doesn’t include the $1000 per year in probation costs! That means that for a crime I committed 12 years ago, spent time in jail for and served 5 years of probation time, the CA Board of Psychology will now ask me to spend another $10,000-$14,000. Now, I should be able to afford the cost (barely) but here’s the rub the way I see it: These sorts of limitations and expenses are an endlessly  difficult and probably nearly impossible hoop for a whole slew of people to jump through. By placing these sorts of demands on people with a past, no matter how distant, the California Board of Psychology is essentially squeezing out possible clinicians who may have dealt with drug and alcohol issues in the past. Even my Board-assigned probation monitor told me that she thinks this is excessive, but as usual there “isn’t much [she] can do about it.”

Money is the instrument by which we control people in this society, and that issue comes up again and again for me when I listen to rich politicians (yes, Romney) telling us that if we all just paid less taxes and if government just spent less money than we would all be better off. But that’s a lie – government provides services specifically for those of us who can’t afford to provide them for ourselves. Romney may be able to build a private road to any of his many houses but the rest of us need the government to build that road otherwise we’d only be able to drive where the rich allow us to… and they wouldn’t let us drive on their private roads anyway. So government helps the rest of us with education, transportation, food, and health care because its job is to equalize the playing field a little bit. That might seem like a digression, but here:

If people with an addiction or criminal past are made to pay $10,000-$15,000 in addition to satisfying every other requirement to become lawyers, psychologists, physicians, therapists, and more then aren’t we in essence saying to them that we don’t want them in these jobs? Aren’t we telling them that due to their past they are now damaged goods and aren’t really welcome where the rest of society lives? And if we’re telling them that when they try to become part of the helping professions aren’t we also saying that they are either unable to help or that we simply don’t want their help?

Speak softly and carry a big stickIf that is what we’re saying then I think our system is fucked up. If we’re telling a portion of our society that even if they achieve everything someone else has they are not worthy of the same recognition then I think we need to take a long hard look at ourselves. Society survives and thrives because its members play together and help each other out – when we start drawing lines around what people are worth and what they’re allowed to strive for we disenfranchise exactly the portion of society we pretend to want to rehabilitate.

So I’m going to walk through this, proudly and successfully. I am going to stop drinking and I am going to pay the fees. But I am also going to speak my mind and make sure that the injustice and absurdity of the whole thing is heard, even if only by a few thousand dedicated readers. I’ve worked too hard to just turn the other cheek and say thank you. This is my life, I’ve earned the respect they can’t seem to find, and I’m going to claim it.

How I stopped drinking, again – Entry 1

Those of you not following All About Addiction on Facebook (you should) or paying attention to our updates on Twitter and such might not have known that I was recently informed that in order to become a psychologist in California (actually, to get registered as a Psychological Assistant, which allows someone to get experience towards becoming a fully licensed psychologist) I was going to have to submit to a 3-year probationary period of drug and alcohol testing. I was completely sober for almost 3 years between January 2002 and about September 2004 following an arrest and jail stint for drug possession and sales (see here for part of the story). In the summer of 2004 I decided to take on the classic “AA Experiment,” meaning that I wanted to see if having an alcoholic drink would bring me back to drug use as so many in my 12-step groups told me it would. I am happy to report, that 8 years later the answer is still no – I’ve been drug free since 2002 but have been drinking alcohol socially since 2004.

Aside from staying drug and crime free, I also received my PhD, published dozens of articles, set up All About Addiction, started writing for Psychology Today, and had my convictions set aside by my judge after completing 5 years of probation without a single dirty drug test or violation of any sort. But the California Board of Psychology wanted more, so they told me I had to test if I wanted to move forward. I was offended, consulted with many other professionals I know about what I should do, and threatened to request additional hearings before eventually succumbing. The bottom line is that the Board is almost all powerful and can ask me to do anything they want. Besides, I am a 9-felony ex-convict asking to become a psychologist – maybe I’ll never live down my past no matter what I do (for my take on stigma, read here). So I have a probation officer again and I have to stop drinking.

Last Wednesday I stopped drinking alcohol – having a final glass of wine with my wife who is being nice and joining me (for now) in not drinking. Ironically, I stopped last week because I thought my meeting with my probation representative was in two days – I was a week off. And apparently I was so concerned about not drinking any more that I only drank half of my glass (my wife didn’t actually touch hers). Still, I have been drinking a drink or two 3-4 times every week for a while now and had gotten used to my glass of wine as post-work stress relief. So I’m wondering what the experience will feel like having to give up my coping tool for at least 2 years.

I talk to addicts and alcoholics on a regular basis and my own social drinking has come up as an issue many times before. I always said it wasn’t a problem and many others have told me I’m wrong – that I am either in the midst of a relapse or that I was never really an addict. The latter point is moot and I can’t prove that at all, but I know that this little experience might be an interesting experiment (the reverse of the initial one if you will) to see if returning to drinking was indeed a cop-out.

Having this website and all, I decided I am going to write about it. I’ll be giving weekly (probably summaries) of my not-drinking experiences and how quitting drinking has affected me in my daily life. If something comes up in between updates I might write an impromptu post to talk about it. I’d love to hear your thoughts as comments here or on our Facebook page.

Week #1 – September 1th-15th (short week since I stopped on Tuesday)

As I mentioned, we never finished those last glasses of wine. Still, Thursday and Friday were stressful workdays (I am now up to about 65 hours of work per week) and I have to say that realizing I won’t be able to have my nightly alcohol serving was a bummer. I had that thought a few times throughout those workdays and on the way home. I know full and well that for me stress is a trigger for alcohol use. Thankfully, I was not actually tempted to open up anything and drink once I got home. This is still early on in the process, so obviously it does not mean that I won’t be tempted soon, but I was happy to find that resisting a drink was not a difficult task even when I would have usually had one.

Also, I realized that my weekly (or so) friendly get-togethers with a couple of guy friends are either going to have to change venues or I’m going to be the only guy not drinking at a Happy Hour. We’ll see. I’m sure they won’t mind but I’m not sure how I will feel. Lord knows some of my clients frequent bars without issue while others are triggered constantly… If I’m right about my lack of alcoholic drinking issues, it shouldn’t be a problem.

More to come!

About Addiction: non-addictive pills, internet addiction, marijuana and alcohol

You want to know more about addiction and we want to tell you, so here is this week’s wrap up of exciting news (well, some of it. ) A lot of news about addiction comes up every week and we want you to be informed!

The End of Opioid Addiction?According to a joint international study by the University of Adelaide and the University of Colorado, published in the Journal of Neuroscience, the scientists have discovered an essential receptor in the brain that can cause opioid addiction, and there is a drug that can block this receptor without interfering with pain relief! The drug is called (+)-naloxone and it works by binding to the specific receptors in the immune system that ordinarily trigger the drug’s addictive properties and preventing the opioids from interacting with them, thus reducing the body’s addictive response to the opioid drug. This new drug is a variant of the drug naloxone, which has been used for many years to treat overdoses. However, this study is the first clear link to its effect on preventing addiction. According to the leaders of the study, clinical trials may even begin within the next 18 months!

Scientists discover internet-addiction gene?Internet addiction is defined as someone who obsessively thinks about the internet and whose sense of well-being is negatively impacted if they can not get access to the internet. According to the findings of German scientists, published in the September issue of Journal of Addiction Medicine, problematic users more often carried a variation of the CHRNA4 gene, which is typically linked to nicotine addiction. While this receptor in the brain has been known to be essential in nicotine addiction, this is the first neurological link to internet addiction that has been discovered. The study’s lead author, Christian Montag, acknowledged that more large-scale studies need to be done to further examine this connection between internet addiction and the CHRNA4 gene, however he insists that there is enough clear evidence to support a genetic predisposition to internet addiction.

Your childhood’s effect on your adult life It has long been accepted that traumatic experiences in one’s childhood can have long-lasting effects on a person well into their adult life. According to new research at Cambridge University, suffering a traumatic experience in childhood may increase one’s risk of drug addiction. The compulsivity and impulsiveness linked to addicts are also found in people as a result of a traumatic childhood. While having a traumatic experience in one’s childhood does not mean they will automatically become an addict, just as not having a traumatic experience does not make one immune to addiction, coming from this kind of background does make one more at-risk of becoming an addict.

Is Marijuana Addictive?There has long been a debate on whether or not marijuana is an addictive drug. Recently, it has been ranked number one on a list of the top five most commonly abused prescription drugs used by post-50 year olds. According to a 2011 report from The National Survey on Drug Use and Health, 3 million adults older than 50 have illegally used the drug and “out of 4.8 million older adults who used illicit drugs, marijuana use was more common than non-medical use of prescription medicines among the 50-to-59 age range.” All of this evidence leads to a need to differentiate between addiction and dependency. In this article, Robert DuPont, M.D. and Laurel Dewey debate the addictiveness of marijuana by arguing their point of view. As evidence of its addictiveness, DuPont points out that, since 2000, admission for treatment of marijuana abuse ranks higher than that of heroin, methamphetamine, cocaine and prescription painkillers. Of 7.1 million people with dependence or abuse of drugs other than alcohol or tobacco in 2010, 4.5 million had marijuana dependence. That’s 63 percent of everyone with illicit drug dependence or abuse! Contrarily, Dewey uses many personal experiences to show her side of the argument. She points to a 1974 study, conducted at Virginia Commonwealth University, that proved that the cannabinoids in the marijuana plant shrunk cancerous tumors and killed cancer cells, leaving healthy cells alone. She adds that, in the thousand years of its use, no one has ever died of marijuana use. Both authors use much more evidence for their side, which you can read about by clicking the link above. Read both views and form your own opinion!

Alcohol and Drug Use in SchoolsWith kids going back to school across the country, there have been many different studies on alcohol and drug use amongst the youth. In a survey led by SAFE Inc. (Substance Abuse Free Environment), there were mixed results. While the number of students who have tried alcohol has actually decreased, marijuana and amphetamine use have both increased. The survey targeted eight-, tenth-, and twelfth-graders, and showed that those tenth-graders who reported using alcohol in the last month dropped from 31 percent in 2010 to just 22.7 percent this year. It also decreased slightly in the eight- and twelfth-graders. Of the troubling findings, the most troubling may have been the increase in prescription stimulant abuse, such as Adderall and Ritalin. The most dramatic increase was among twelfth-graders, more than doubling from 3.8 to 8.5 percent. Marijuana use also showed increase both in the last month and in lifetime use amongst eighth- and twelfth-graders, although there was a slight drop by tenth-graders. 

Death in rehab- What is wrong with California’s addiction treatment?

We at A3 have long been saying that there is something seriously wrong with the way addiction treatment is being regulated and with the addiction treatment system that has sprouted up as a result. Now, a government report created for the California Senate Rules Committee called “Rogue Rehabs: State failed to police drug and alcohol homes, with deadly results” (see here) supports our notion and extends them in alarming ways. Among the major findings:

  1. Over the past decade, the California department in charge of regulating residential drug and alcohol programs consistently failed to catch life threatening problems [with addiction treatment facilities].
  2. Many addiction treatment facilities in California are providing medical care in clear violation of their licenses and often by under-trained staff.
  3. Addiction treatment providers are accepting patients that are far too impaired (as in sick) for them to handle because they would rather take the money than turn away a patient.
  4. These problems have led to several deaths within the California addiction treatment system in the last decade.

Obviously these findings are extremely disturbing and cases like the one studies in the report of Brandon Jacques, a patient who died while under the care of MorningSide Recovery’s care,  could have been prevented with more attention and transparency in our system. The idea that addiction treatment facilities that are not equipped to handle severe cases are taking them just for the money is sickening and antithetical to the reason for their existence. As far as I’m concerned, such unethical flouting of patient care should lead to an immediate revocation of their license and a ban for the management from the field.

The most distrubing factor to my mind is the fact that many of these providers know that what they are doing is wrong. But they also know that more than 50% of people who are looking for addiction treatment are doing so for the first time and have no idea what to ask, what addiction services they need, or how to assess whether a facility is appropriate. That means they can take advantage of them with fancy websites and the use of terms like “holistic treatment” that mean little and promise much. It’s disgusting and flies in the face of everything our field is supposed to stand for. It’s also the main reason I worked so hard to develop our Rehab-Finder, which while far from perfect and in need of serious work that I can’t afford to put into it, tries to fix these problems by recommending treatment that is appropriate given the specific issues a client is dealing with. We are currently conducting a study with UCLA on the effectiveness of tools like this and I am committed to figuring out a safer way to help those in need find the right addiction treatment for them.

Importantly, the report also makes a number of recommendations:

  1. Allow for medical service provision at addiction treatment facilities but legislate strict oversight and accountability paid for by agency fees.
  2. Medical detox facilities should be required to have medical directors.
  3. Establishing requirements and procedures for death investigations at addiction facilities.
  4. Strict oversight of programs found to admit clients it is not fit to treat including immediate license suspension.
  5. Information sharing between addiction treatment licensing boards and medical boards.

We think it’s time that addiction treatment providers be held to the same standard that other medical facilities are held to. It might help finally close the gap in terms of recovery outcomes. Running as a relatively unregulated industry does not help patients, it does not help move the field forward, and although they can’t see it it does not even help the treatment providers who are behaving unethically since many of them are eventually forced to close and face lawsuits. It’s time to move forward on this.

Teens and drugs: Drug use statistics and treatment that works

Here are some drug use statistics:

  • Over 80% of teens engage in some form of deviant behavior (1).
  • Over 50% of high-school seniors admit to having used drugs (2).
  • Only 10%-15% of the population develop drug addiction problems related to their drug use (1).

The question is:

If the majority of teens experiment with drug use, and so few eventually develop drug addiction problems, should we be focusing on something other than stopping kids from trying drugs? Continue reading “Teens and drugs: Drug use statistics and treatment that works”