Smokers, Death Benefit Arguments, and Poly-behavioral Addiction

This was the conclusion of a report, commissioned by Philip Morris, who looked at the cost of smoking in the Czech Republic in 1999. They concluded that tobacco can save a government millions of dollars in health care and pensions because many smokers die earlier. They reported that the government had benefited from savings on health care, pensions and housing for the elderly that totaled $30 million - the "indirect positive effects" of early deaths (Arthur D. Little International, 2000).

I was shocked to hear this death benefit argument for the first time, after making a presentation to a group of professionals informing them that tobacco use is the chief avoidable cause of illness and premature death for over 430,000 Americans each year. It reminded me of the dialog in the movie, Traffic, when Michael Douglas playing a congressman/ drug czar asked a Mexican general (played by Tomas Milian), How do you treat your drug addicts? And the general responded by saying, We let our drug addicts treat themselves. They overdose and die, and then there is one less drug addict to worry about.

Although the argument is immoral, unjustifiable, and factually inaccurate (National Center for Tobacco-Free Kids, 2001), it would appear that 46 States in the United States are indirectly supporting this dreadful argument as only 5% of the tobacco-settlement funds (of the $206 billion settlement for tobacco-related health costs that went to 46 States according to a National Conference of State Legislators study), are being spent on tobacco prevention and treatment programs.

Federal taxpayers are directly paying more than $340 million to tobacco farmers to make up for lost income because of low prices and tobacco litigation settlements. These direct payments are in addition to subsidies in the form of tobacco crop insurance, administrative costs for price supports, and non-recourse loans. This subsidy supports expanded tobacco production at the same time that the federal government is spending millions actively discouraging the use of tobacco for public health and safety reasons (Green Scissors, 2006).

These subsidies also occur at the same time that our political candidates accept millions of dollars in contributions from the tobacco industry. Tobacco companies are heavily invested in politics, contributing $36.8 million to federal candidates and political parties since 1989, the Winston-Salem Journal reported Oct.23, 2004.Observer, June 25, 2000.

Federal law does not allow retailers to sell cigarettes, tobacco, or smokeless tobacco to anyone under the age of 18. Laws regarding the possession of tobacco are left up to the individual states. I wonder why it is legal for minors to smoke cigarettes in most States, but illegal for minors to buy cigarettes when there are approximately 1.23 million new smokers under the age of 18 each year (Gilpin, et al., 1999), and more than 6,000 children and adolescents try their first cigarette each day (CDC, 1998).

More than 90% of first-time use of tobacco occurs before high school graduation. Because the average age at first use is 14.5 years, smoking prevention must start early.

Approximately 40% of teenagers who smoke eventually become addicted to nicotine.

Hawaii presently has a bill before the Legislature that would prohibit the use of tobacco products by minors, with penalties including tobacco education, community service, fines and drivers license suspension (Honolulu Advertizer, March 12, 2006). Why has it taken the 50th State - 50-plus years to propose this bill? And what are the other States doing with the other 95% of their settlement, if their not attempting to educate and treat smokers?

Children smoke 1.1 billion packs of cigarettes yearly. This accounts for more than $200 billion in future health care costs. The health consequences of this addiction are enormous. Tobacco smoking is responsible for 1 of every 5 deaths and is the most common cause of cancer-related deaths in the United States.

Proponents of the death benefit argument would say that tobacco victims (46.5 million American smokers, CDC, 1997) deserve to die, because they have chosen to smoke and risk the consequences. Does this also include the 70% of smokers who want to quit (Health Education Authority, 1995), but find themselves physiologically, psychologically, and socially addicted to nicotine? In fact, less than 25% of smokers who try to quit succeed as long as a year (Stolerman, I.P. & Jarvis, M.J., 1995).

It does not appear that Governments are actively supporting treatment for smokers. In 2001, a survey of the federal-state Medicaid coverage for tobacco-dependence in the United States was conducted, and only 1 State in 50 (Oregon) provided for all the tobacco-dependence counseling and pharmacotherapy treatments recommended by the 2000 Public Health Service (PHS) guideline. Only 10 States in 2001, offered some form of tobacco-cessation counseling services to the 11.5 million federal-state Medicaid program patients that smoke (CDC, 2003). A lack of reimbursement for tobacco-cessation counseling services is also the most common complaint for private health insurance companies when inquiring about treatment for smokers.

If the death benefit argument was applied across the board to all areas, then these proponents would end all medical research directed at preventing and finding treatments for illnesses and diseases, and promote euthanasia for all unproductive people in society including the elderly, severely retarded, mentally ill, and physically handicapped. The answer is not in condemning victims of diseases, disorders, and addictions, but in providing effective prevention, education, assessment/ diagnosis, treatment, and aftercare programs for those in need.

Nicotine addiction is classified as a nicotine use disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV TR, 2000). The criteria for the diagnosis of 305.1 - Nicotine Dependence - include any 3 of the following within a 1-year time span:

o Tolerance to nicotine with decreased effect and increasing dose to obtain same effect

o Smoking more than usual o Persistent desire to smoke despite efforts to decrease intake

Screening tools are available to assist counselors and therapists with diagnosing this condition - such as the Fagerstrom Tolerance Questionnaire (FTQ). Two items in the FTQ that are considered the key questions are as follows:

1. Do you smoke within 5 minutes of awakening? 2. Do you smoke greater than 25 cigarettes per day?

Individuals that answer Yes to both questions are highly dependent on nicotine (Prochazka, 2000).

Note: If after reading the above, you started rationalizing to yourself, Well it usually takes me 6-minutes to light-up after I get out of bed or I never smoke more than 20 cigarettes per day, (As my old graduate professor use to say) STOP BULL-SH#%ting yourself and go see a therapist.

Addictions such as nicotine dependence and other addictions as a rule do not develop in isolation. Individuals can shift from one addiction to another or sustain multiple addictions at different times. The National Co-morbidity Survey (NCS) that sampled the entire U.S. population in 1994, found that among non-institutionalized American male and female adolescents and adults (ages 15-54), roughly 50% had a diagnosable Axis I mental disorder at some time in their lives. This surveys results indicated that 35% of males will at some time in their lives have abused substances to the point of qualifying for a mental disorder diagnosis, and nearly 25% of women will have qualified for a serious mood disorder (mostly major depression). A significant finding of note from the NCS study was the widespread occurrence of co-morbidity among diagnosed disorders. It specifically found that 56% of the respondents with a history of at least one disorder also had two or more additional disorders. These persons with a history of three or more co-morbid disorders were estimated to be one-sixth of the U.S. population, or some 43 million people (Kessler, 1994).

Psychiatric disorders are more common among tobacco users than in the general population. Among patients seeking tobacco cessation services, as many as 30% of them may have a history of depression (Anda, et al, 1990) and 20% or more may have a history of dependence (Brandon, 1994). Most descriptive studies of alcohol abusers published in the past 20 years have reported tobacco use rates of at least 90%. (Bobo, 2000). More research and information is needed on the co-morbidity of nicotine dependence and behavioral addictions such as pathological gambling, eating disorders, and sexual addictions.

We have come to realize today more than any other time in history that the treatment of lifestyle diseases and addictions are often a difficult and frustrating task for all concerned. As already noted, less than 25% of smokers who try to quit succeed as long as a year (Stolerman, I.P. & Jarvis, M.J., 1995). Repeated failures abound with all of the addictions, even with utilizing the most effective treatment strategies. But why do 47% of patients treated in private treatment programs (for example) relapse within the first year following treatment (Gorski,T., 2001)? Have addiction specialists become conditioned to accept failure as the norm? There are many reasons for this poor prognosis. Some would proclaim that addictions are psychosomatically- induced and maintained in a semi-balanced force field of driving and restraining multidimensional forces. Others would say that failures are due simply to a lack of self-motivation or will power. Most would agree that lifestyle behavioral addictions are serious health risks that deserve our attention, but could it possibly be that patients with multiple addictions are being under diagnosed (with a single dependence) simply due to a lack of diagnostic tools and resources that are incapable of resolving the complexity of assessing and treating a patient with multiple addictions?

Since successful treatment outcomes are dependent on thorough assessments, accurate diagnoses, and comprehensive individualized treatment planning, it is no wonder that repeated rehabilitation failures and low success rates are the norm instead of the exception in the addictions field. Treatment clinics need to have a treatment planning system and referral network that is equipped to thoroughly assess multiple addictive and mental health disorders and related treatment needs and comprehensively provide education/ awareness, prevention strategy groups, and/ or specific addictions treatment services for individuals diagnosed with multiple addictions. Written treatment goals and objectives should be specified for each separate addiction and dimension of an individuals life, and the desired performance outcome or completion criteria should be specifically stated, behaviorally based (a visible activity), and measurable.

To assist with resolving this problem a multidimensional diagnosis of Poly-behavioral Addiction, is proposed for more accurate diagnosis leading to more effective treatment planning. This diagnosis encompasses the broadest category of addictive disorders that would include an individual manifesting a combination of substance abuse addictions, and other obsessively-compulsive behavioral addictive behavioral patterns to pathological gambling, religion, and/ or sex / pornography, etc.). Behavioral addictions are just as damaging - psychologically and socially as alcohol and drug abuse. They are comparative to other life-style diseases such as diabetes, hypertension, and heart disease in their behavioral manifestations, their etiologies, and their resistance to treatments. They are progressive disorders that involve obsessive thinking and compulsive behaviors. They are also characterized by a preoccupation with a continuous or periodic loss of control, and continuous irrational behavior in spite of adverse consequences.

Poly-behavioral addiction would be described as a state of periodic or chronic physical, mental, emotional, cultural, sexual and/ or spiritual/ religious intoxication. These various types of intoxication are produced by repeated obsessive thoughts and compulsive practices involved in pathological relationships to any mood-altering substance, person, organization, belief system, and/ or activity. The individual has an overpowering desire, need or compulsion with the presence of a tendency to intensify their adherence to these practices, and evidence of phenomena of tolerance, abstinence and withdrawal, in which there is always physical and/ or psychic dependence on the effects of this pathological relationship. In addition, there is a 12 - month period in which an individual is pathologically involved with three or more behavioral and/ or substance use addictions simultaneously, but the criteria are not met for dependence for any one addiction in particular (Slobodzien, J., 2005). In essence, Poly-behavioral addiction is the synergistically integrated chronic dependence on multiple physiologically addictive substances and behaviors (e.g., using/ abusing substances - nicotine, alcohol, & drugs, and/or acting impulsively or obsessively compulsive in regards to gambling, food binging, sex, and/ or religion, etc.) simultaneously.

The Addictions Recovery Measurement Systems (ARMS) theory is a nonlinear, dynamical, non-hierarchical model that focuses on interactions between multiple risk factors and situational determinants similar to catastrophe and chaos theories in predicting and explaining addictive behaviors and relapse. Multiple influences trigger and operate within high-risk situations and influence the global multidimensional functioning of an individual. The process of relapse incorporates the interaction between background factors (e.g., family history, social support, years of possible dependence, and co-morbid psychopathology), physiological states (e.g., physical withdrawal), cognitive processes (e.g., self-efficacy, cravings, motivation, the abstinence violation effect, outcome expectancies), and coping skills (Brownell et al., 1986; Marlatt & Gordon, 1985). To put it simply, small changes in an individuals behavior can result in large qualitative changes at the global level and patterns at the global level of a system emerge solely from numerous little interactions.

The ARMS hypothesis purports that there is a multidimensional synergistically negative resistance that individuals develop to any one form of treatment to a single dimension of their lives, because the effects of an individuals addiction have dynamically interacted multi-dimensionally. Having the primary focus on one dimension is insufficient. Traditionally, addiction treatment programs have failed to accommodate for the multidimensional synergistically negative effects of an individual having multiple addictions, (e.g. nicotine, alcohol, and obesity, etc.). Behavioral addictions interact negatively with each other and with strategies to improve overall functioning. They tend to encourage the use of tobacco, alcohol and other drugs, help increase violence, decrease functional capacity, and promote social isolation. Most treatment theories today involve assessing other dimensions to identify dual diagnosis or co-morbidity diagnoses, or to assess contributing factors that may play a role in the individuals primary addiction. The ARMS theory proclaims that a multidimensional treatment plan must be devised addressing the possible multiple addictions identified for each one of an individuals life dimensions in addition to developing specific goals and objectives for each dimension.

The ARMS acknowledges the complexity and unpredictable nature of lifestyle addictions following the commitment of an individual to accept assistance with changing their lifestyles. The Stages of Change model (Prochaska & DiClemente, 1984) is supported as a model of motivation, incorporating five stages of readiness to change: pre-contemplation, contemplation, preparation, action, and maintenance. The ARMS theory supports the constructs of self-efficacy and social networking as outcome predictors of future behavior across a wide variety of lifestyle risk factors (Bandura, 1977). The Relapse Prevention cognitive-behavioral approach (Marlatt, 1985) with the goal of identifying and preventing high-risk situations for relapse is also supported within the ARMS theory.

The impact of nicotine dependence and poly-behavioral addictions is of course financially devastating. The estimated smoking attributable cost for medical care in the US in 1998 was more than $75 billion and the cost of lost productivity due to smoking-related disability was estimated at over 80 billion per year (CDC, 2003). But making life and death decisions based on a cost analysis is putting a price on life itself, which I believe no mortal man has the authority to do. Considering that addictions involve unbalanced life-styles operating within semi-stable equilibrium force fields, the ARMS philosophy promotes positive treatment effectiveness and successful outcomes that are the result of a synergistic relationship with The Higher Power, that spiritually elevates and connects an individuals multiple life functioning dimensions by reducing chaos and increasing resilience to bring an individual harmony, wellness, and productivity.

Partnerships and coordination among all service providers, government departments, and health insurance organizations in providing treatment programs are a necessity in addressing the multi-task solution to Nicotine Dependence and Poly-behavioral addictions. I encourage you to support the addiction programs in America, and hope that the (ARMS) resources can assist you to personally fight the War on nicotine dependence within poly-behavioral addiction.

Poly-Behavioral Addiction and the Addictions Recovery Measurement System, By James Slobodzien, Psy.D., CSAC at:

James Slobodzien, Psy.D., CSAC, is a Hawaii licensed psychologist and certified substance abuse counselor who earned his doctorate in Clinical Psychology. The National Registry of Health Service Providers in Psychology credentials Dr. Slobodzien. He has over 20-years of mental health experience primarily working in the fields of alcohol/ substance abuse and behavioral addictions in medical, correctional, and judicial settings. He is an adjunct professor of Psychology and also maintains a private practice as a mental health consultant.

References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000, p. 787 & p. 731. American Society of Addiction Medicines (2003), Patient Placement Criteria for the Treatment of Substance-Related Disorders, 3rd Edition,. Retrieved, June 18, 2005, from:

http://www.asam.org/ Arthur D. Little International, Inc., Report to Phillip Morris, Public Finance Balance of Smoking in the Czech Republic, November 28, 2000, Http://tobaccofreekids.org/reports/phillipmorris. Bandura, A. (1977), Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215. Bobo, J.K., Sociocultural influences on smoking and drinking. Alcohol Res Health. 2000;24(4):225-32. Review. PMID: 15986717 [PubMed - indexed for MEDLINE] Brownell, K. D., Marlatt, G. A., Lichtenstein, E., & Wilson, G. T. (1986). Understanding and preventing relapse. American Psychologist, 41, 765-782. Centers for Disease Control and Prevention (CDC). Retrieved June 18, 2005, from: http://www.cdc.gov/nccdphp/dnpa/obesity/ Gorski, T. (2001), Relapse Prevention In The Managed Care Environment. GORSKI-CENAPS Web Greenscissors.org/news, Up in Smoke Tobacco Program 840 Million, 2006. Healthy People 2010. Retrieved June 20, 2005, from: http://www.healthypeople.gov/ Publications. Retrieved June 20, 2005, from: www.tgorski.com Lienard, J. & Vamecq, J. (2004), Presse Med, Oct 23;33(18 Suppl):33-40. Marlatt, G. A. (1985). Relapse prevention: Theoretical rationale and overview of the model. In G. A. Marlatt & J. R. Gordon (Eds.), Relapse prevention (pp. 250-280). New York: Guilford Press. McGinnis JM, Foege WH (1994). Actual causes of death in the United States. US Department of Health and Human Services, Washington, DC 20201 Humphreys, K.; Mankowski, E.S.; Moos, R.H.; and Finney, J.W (1999). Do enhanced friendship networks and active coping mediate the effect of self-help groups on substance abuse? Ann Behav Med 21(1):54-60. Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H. H,-U, & Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the national co morbidity survey. Arch. Gen. Psychiat., 51, 8-19. Legislative Bills, Honolulu Advertizer, March 12, 2006. Morgenstern, J.; Labouvie, E.; McCrady, B.S.; Kahler, C.W.; and Frey, R.M (1997). Affiliation with National Center for Tobacco-Free Kids, 2001 Alcoholics Anonymous after treatment: A study of its therapeutic effects and mechanisms of action. J Consult Clin Psychol 65(5):768-777. Nicotine Addiction, emedicine.com. 2004. Orford, J. (1985). Excessive appetites: A psychological view of addiction. New York: Wiley. Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing the boundaries of therapy. Malabar, FL: Krieger. Slobodzien, J. (2005). Poly-behavioral Addiction and the Addictions Recovery Measurement System (ARMS), Booklocker.com, Inc., p. 5. Whitlock, E.P. (1996). Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach. Am J Prev Med 2002;22(4): 267-84.Williams & Wilkins. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Alexandria, VA. U.S. Department of Health and Human Services. Healthy People 2010 (Conference Edition). Washington, DC: U.S. Government Printing Office; 2000.

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