What a Breakthrough E-Cigarette Study Illustrates About Addiction

    The first large, systematic study of whether e-cigarettes help people to quit smoking was published January 30 in the New England Journal of Medicine, and covered by the New York Times, the BBC and many other major outlets.

    The study, conducted among almost 900 smokers in England, compared e-cigs and nicotine replacement therapy (patches, gum, etc.) to discover whether vaping is helpful for cigarette cessation. The answer, unequivocally, was yes. The study found e-cigs to be roughly twice as likely to help cigarette smokers to quit as NRT.

    The figures were still relatively low—with 18 percent of smokers who switched to e-cigs remaining smoke-free after one year, versus 10 percent for NRT. But, given that 18 percent would extrapolate to almost 7 million people if applied across the population of US smokers, that is not something to sneeze at.

    These results actually affirm everything we know, or should know, about addiction. (In this article, I’ll use the term “addiction” in the popular sense, to describe compulsive use, with or without harmsalthough there are persuasive arguments to define addiction as necessarily including serious negative consequences, which align with current American Psychiatric Association criteria for diagnosing substance use disorders.)

    Inhalation and involving your hands are crucial elements in cigarette addiction for some.

    E-cigs work better than NRT for preventing cigarette smoking because smokers can still follow familiar and pleasurable patterns of behavior. A crucial ingredient in the overall drug experience to which a person becomes addicted are the favored rituals involved in administering a drug. Thus some people addicted to injecting heroin don’t accept non-injectable opioid replacements (like methadone and buprenorphine), which is one rationale for heroin-assisted treatment.

    Likewise, inhalation and involving your hands are crucial elements in cigarette addiction for some. The new study, in showing that many smokers will succeed better by vaping than by wearing a nicotine patch or chewing gum, suggested that replacing cigarettes without continuing these elements doesn’t work for roughly half of addicted smokers who are able to switch to other nicotine products.

    The worried observation, published in a separate editorial in NEJM, that 80 percent of the study participants who had quit by using e-cigarettes were still vaping at one year, while only nine percent of the NRT group were still using NRT, misses the point—the fact that smokers find e-cigs preferable is the whole advantage of that treatment.

    The fact that people who switch to other nicotine products may keep using them compulsively is not necessarily a bad thing.

    Neither e-cigs nor NRT cure, or even halt, “addiction,” used in the sense I described. In both cases, the person remains dependent on the chemical effects of nicotine, only delivered in much safer form. Replacing something that is potentially lethal (like adulterated street heroin, or shared syringes) with something that is not (like safely administered heroin, or sterile syringes) is the very essence of harm reduction.

    The fact that people who switch to other nicotine products may keep using them compulsively, however, is not necessarily a bad thing. Addictive experience can be essential for a person’s functioning, in either the short or the long run. In The Meaning of Addiction I explain how addiction is not an inherent property of drugs (as in, “heroin is chemically addictive”). People instead become addicted to the experience that the drug—or other addictive involvement—provides. That is, the “drug”—be it heroin, nicotine, alcohol, sex or gamblingprovides feelings and sensations that are so welcome as to feel essential for the person.The benefits these experiences provide may be long-term, as heroin may be for sexual assault survivors, or shorter-termas opiates were for caged rodents, but not when they were removed to Rat Park; or for soldiers in Vietnam, but not when they returned home.

    Rather than recognize this, we too often confuse addiction with directly induced medical problems. Addiction is not per se medically harmful, though some kinds of addiction are. But our culture’s view of compulsive use means that we too readily combine the ideas of “harmfulness” and dependence.

    People who vape obviously haven’t quit nicotine. For some critics, this makes vaping a useless exercise: “Vaping may help some people quit cigarettes, but what about the nicotine?” When survival is at stake, this, again, misses the point.

    If there is a way to continue nicotine use without killing yourself, anyone ought to consider that a positive outcome. Death is bad. And among the many reasons for death’s badness is that it prevents people from outgrowing addiction—as Maia Szalavitz, Gene Heyman and I show that most people do. Giving people the space and time—even a lifetime—to overcome addiction is an incalculable existential gift. And the realization that addiction is typically outgrown ought to somewhat reassure those who are concerned about youth vaping.

    As a backdrop to the regularity of natural recovery, keep in mind, however, that cigarette-smoking is the most resilient of substance addictions. NESARC, a massive survey (43,000 subjects) of Americans’ lifetime drug and alcohol use, shows that while most people overcome drug addictions over their lifetimes, smokers are the least likely to do so (84 percent of smokers do, versus 91 percent for alcohol, 97 percent for cannabis, and 99 percent for cocaine).

    Moreover, the half-life (the point at which half of those who were ever dependent remitted) for each form of addiction was 26 years for tobacco, 14 for alcohol, six for cannabis and five for cocaine. (This, however, constitutes an additional argument for tobacco harm reduction, rather than one against it.)

    For smokers, getting beyond the peak early period for relapsing is a significant landmark to achieve. In another analysis from NESARC, the risk of relapse for those who had quit smoking for a year or less was above 50 percent; for smokers who had quit for over a year, the risk of relapse rapidly decreased, stabilizing at around 10 percent after 30 years.

    Providing replacement therapies can be life-preserving. Convincing people in the process that they have a lifelong disease is not.  

    Addiction replacement therapies can sometimes have negative effects, but this depends on how they are presented. In one remarkable study that followed people who quit smoking with and without NRT for several years, the most dependent smokers were two-to-three times as likely to relapse if they relied on NRT.

    Putting our common-sense hats on, why would this be? Because, if you believe your quitting depends only on using a replacement, then ceasing to use that replacement will likely lead to relapse. Concluding that you were able to overcome addiction on your own is less likely to lead you down this road; belief that your addiction is a disease over which you are powerless increases the chances of relapse.

    We should therefore ask ourselves how to maximize the benefits of replacement therapies, while minimizing potential drawbacks. As Zach Rhoads described in Filter, providing replacement therapies like buprenorphine and methadone can be life-preserving. Convincing people in the process that they have a lifelong disease is not.  

    Concomitant addiction therapy—that is, therapy that assists, encourages and inspires people to overcome addiction—provides guideposts, goals and resources for people to permanently leave addiction behind, even while welcoming their safer addictive alternative.

    Dependence is not always harmful, and it is useful and good to switch people from harmful to less harmful addictions. While embracing such lifesaving switches, we can continue, through help and our own agency, to seek the purpose and fulfilment that can give us the choice of abandoning addiction. Praying for some sort of miracle cure for addiction only sidetracks us from what is genuinely helpful.

    In the meantime, let’s welcome the good news about e-cigarettes. Whether or not addiction may be harmful, death always is.

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