How many Americans will be killed this year by tobacco use? And how does the societal burden of addiction to smoking cigarettes compare to, say, our national opioid epidemic? Readers who have worked in public health for a long time may well know the tobacco death toll by heart: 480,000 annually.[1] How about the death toll of alcohol use compared to, again, opioid-related deaths in America? It happens that alcohol use is the third leading cause of death with 88,000 lives lost every year.[2] And opioids? The death toll from heroin, fentanyl and prescription opioids combined was 42,000 in 2016.[3],[4] That’s comparable to the 41,000 lives lost due to secondhand exposure to cigarette smoke. Every year, almost as many people are dying by incidentally being near smokers as are dying by accidentally overdosing. Our opioid epidemic has been declared a national public health emergency though the annual death toll from tobacco is ten times greater. How should we reconcile this?

Per the statistics above, we can’t reconcile why we now read daily about the opioid crisis with nary a whisper in the press about smoking deaths. Perplexing as it is, it’s a fool’s errand to reason whether deaths from one cause are more or less worthy of attention. All unintended, premature deaths take their toll in full measure. John Donne’s famous poem ending with “it tolls for thee” is thought by some as a mere reminder of our mortality. I align with the more mystical interpretation that any deaths, especially the wrongful kind, somehow diminish me.[5]

Rock star Tom Petty and Minnesota’s beloved Prince had deaths we can’t fathom. How could bad hips lead to accidental overdoses? We are mortified by the loss of a brilliant talent like Phillip Seymour Hoffman to pain pills, but that Jesse Owens and Lou Rawls died from heavy smoking seems less of a mystery. When did we come to accept that dying ten years prematurely due to smoking is not too hard to grasp? What gets our attention as a nation, and, yes, as health professionals seeking funding for prevention, is what’s trending. So is it because opioid deaths are increasing so surprisingly fast that we must shift inordinate attention to the latest epidemic? Well, actually, alcohol-related deaths also rose dramatically, from 26,000 to 33,000 since 2015[6], and every day over 2000 youth and young adults who have been occasional smokers become daily smokers.[7] What’s more, it appears that e-cigarettes may be the tobacco addiction feeder that we’ve been worried about.[8]

I’d venture two differences affect our psyches when comparing the demise of Lou Rawls to that of Prince. First, tobacco causes a slow death. That opioid abuse is lowering America’s life expectancy has more to do with its killing our youth than to the incidence of fentanyl overdoses compared to cirrhosis of the liver. Second, and the one that makes me reflect more intentionally on Donne’s mortality tome, is the argument that opioid addiction is a “disease of despair.”[9] I agree, but I wonder still: If tobacco and opioids were on a spectrum relative to the relief they provide from social, emotional, financial and other sources of pain in the lives of the disenfranchised, could it be that they are indeed two sides of the same coin? For individuals in despair, pain relief is a complicit actor in what will become pleasure seeking and, for smokers, vice versa. Donne’s poem edifies my thoughts on the similarities rather than the differences between these diseases, mostly because I am drawn to the poem’s anticipative title, “No man is an island,” rather than to the poem’s grim ending. To paraphrase Donne, we’re all in this together so when anyone of us is “washed away,” it can feel as if it is happening to me or my friends. Any addiction produces despair that will eventually be experienced by us all. As health educators, we reside alongside these vulnerable life experiences more than those in other professions and we’re the better for it.

Being a “part of the main.”

When I was a college undergraduate, there were two main factions in the psychology department faculty. About half were behaviorists who taught me about operant conditioning and how to shape the behaviors of rats (and their galvanic skin responses, a measure of emotional arousal) and half were humanists who were into love and humanity and didn’t think rats and humans had much in common.

And as much as the factions were warring over our minds during the most impressionable time in our professional development, in retrospect, their competing for our beliefs led to too many helpings of false dichotomies. Both camps had vital knowledge to share relative to addressing diseases of despair. The humanists taught theories of motivation ala Abraham Maslow who wrote: “The fact is people are good. Give people affection and security and they will give affection and be secure in their feelings and behavior.”[10] B.F. Skinner wrote that “the ideal of behaviorism is to eliminate coercion: to apply controls by changing the environment in such a way as to reinforce the kind of behavior that benefits everyone.”[11] These contrasting, but not all that incompatible, views proved to be a wonderful bell-weather of the waxing and waning of principles in and out of favor over the years in the field of health promotion. “Motivational Interviewing” with its quest for intrinsic motivation and higher purpose has a humanistic tilt to be sure. “Choice architecture” and other behavioral economics principles relating to our predictably irrational decision-making certainly smack of Skinnerian operant conditioning. And don’t get me started on the calculating genius behind our addiction to smart technology. Variable interval schedules anyone?

Where the humanists and behaviorists may diverge the most relates to the premise that extinguishing a maladaptive behavior is simply a function of substituting in healthy behaviors.[12] I taught my first smoking cessation class in 1985, and dealing with cravings, changing routines, planning avoidance tactics and, of course, lots of carrots were replacement staples. Having recertified as a health coach just a few years ago, I’m mindful that some of the basics of distraction and avoidance haven’t changed much, and now I’m skeptical that carrots were ever much help.

“The drug’s chemical grip on our brains is nestled up alongside our search for happiness, our economic status and our sense of fulfillment or emptiness. In this context, the quest for a “replacement behavior” seems crazy-making.”

For some, beating tobacco addiction may well be a contest of willpower where angels, demons and self-talk flail away and the addict finally catches a break with the right mix of Skinnerian contingencies of reinforcement. But for most, a disease of despair is rooted in a humanistic milieu of that which makes us who we are. The drug’s chemical grip on our brains is nestled up alongside our search for happiness, our economic status and our sense of fulfillment or emptiness. In this context, the quest for a “replacement behavior” seems crazy-making. As Johnson argued about replacement behaviors and alternative tactics: “… when a problem behavior is targeted for removal from a repertoire, an objective that is probably infrequently attained in any complete sense, there is no hole in the repertoire that then needs to be filled. Time that previously was spent engaging in the problem behavior will now be spent engaging in other behavior that is most likely already in the repertoire.”[13] My Skinnerian’s take on Johnson’s point is that my life better have some decent secondary reinforcements in queue if I’m about to forfeit a primary source of pleasure. Carrots probably won’t cut it. So I’m relieved that my humanistic side reminds me that no man is an island.

‘No Man is an Island’ by John Donne
No man is an island entire of itself; every man
is a piece of the continent, a part of the main;
if a clod be washed away by the sea, Europe
is the less, as well as if a promontory were, as
well as any manner of thy friends or of thine
own were; any man’s death diminishes me,
because I am involved in mankind.
And therefore never send to know for whom
the bell tolls; it tolls for thee.

MEDITATION XVII
Devotions upon Emergent Occasions

As much as disease prevention can feel like a Sisyphean job, I take my inspiration from leaders like Harry Lando. When it comes to pushing a boulder up hill, Lando defines the word tireless. Read on for a full version of this editorial which includes an interview with Harry Lando as part of a special issue of the American Journal of Health Promotion dedicated to the science of smoking control. From what’s working via Quit-Lines for adults to using nicotine replacement therapy (NRT) with kids and from an examination of e-cigarettes to the application of the socio-ecological framework, this issue reflects remarkable creativity, a commitment to continuous improvement and some edifying success stories in tackling tobacco addiction.

 

References

[1] CDC Fact Sheet, Centers for Disease Control and Prevention. Feb. 20th, 2018. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm (accessed 2/23/18)

[2] Fact Sheets, Alcohol Use and your Health. Centers for Disease Control and Prevention. Jan 3rd, 2018. https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm (accessed)

[3] Understanding the Epidemic, Centers for Disease Control and Prevention, Opioid Overdose. August 30th, 2017. https://www.cdc.gov/drugoverdose/epidemic/index.html (accessed, 2/23/18)

[4] Opioid Overdose, Centers for Disease Control and Prevention. Feb. 20th, 2018. https://www.cdc.gov/drugoverdose/ (accessed 2/23/18)

[5] “No Man is an Island.” John Donne. https://web.cs.dal.ca/~johnston/poetry/island.html (accessed 2/27/18)

[6] Drug Overdose in the United States, National Center for Health Statistics, NCHS Data Brief No. 294, December 2017. https://www.cdc.gov/nchs/products/databriefs/db294.htm (accessed, 2.23.18)

[7] Trends in Current Cigarette Smoking Among High School Students and Adults, United States, 1965–2014, March 30, 2016. Smoking and Tobacco Use, Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/ (accessed, 2/23/18)

[8] Primack, B., Shensa, A., Sidani, J., et.al., “Initiation of Traditional Cigarette Smoking after Electronic Cigarette Use Among Tobacco-Naïve US Young Adults” The American Journal of Medicine. Article in Press: http://www.amjmed.com/article/S0002-9343(17)31185-3/fulltext (accessed 3/13/18)

[9] Trust for America’s Health and the Well Being Trust, “Pain in the Nation Update: Deaths from Alcohol, Drugs and Suicide reach the highest level ever recorded.” 1730 M Street, NW, Suite 900, Washington, DC 20036. http://healthyamericans.org/assets/files/TFAH-2018-PainNationUpdateBrief-FINAL.pdf (accessed, 2/23/18)

[10] Maslow, A., “A Theory of Motivation.” Classics in the history of Psychology, Web site: http://psychclassics.yorku.ca/Maslow/motivation.htm (2/26/18)

[11] Skinner, B.F., “Are Theories of Learning Necessary?” Classics in the history of Psychology, Web site: http://psychclassics.yorku.ca/Skinner/Theories/ (accessed 2/25/18)

[12] Dwyer, K., Rozewski, D., Simonsen, B., “A Comparison of Function-Based Replacement Behaviors for Escape-Motivated Students.” Journal of Emotional and Behavioral Disorders, First Published October 13, 2011. http://journals.sagepub.com/doi/abs/10.1177/1063426610387432?journalCode=ebxa (accessed 2/26/18)

[13] Johnston, J., “Replacing” Problem Behavior: An Analysis of Tactical Alternatives.” Behav Anal. Spring, 29 (1): 1-11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223178/ (accessed 2/26/18)

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