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J Richard Eiser

University of Exeter. UK

Smoking, addiction and decisionmaking

There can be few, if any, forms of behavior both as widespread and


as damaging to health as is cigarette smoking, yet behavioral
medicine research has so far produced only very partial im-
provements in our understanding of such behavior or of techniques
for its modification. When one considers the contributions which
psychologists have made, one is by and large looking at specific ap-
plications of specific approaches, and the goal of an integration of
behavioral and biomedical science knowledge (cf. Gentry, 1981)
still seems a long way off. In short, the field still lacks a coherent
conceptual framework, and as a result there is a multiplicity of
views on which research questions should be given the highest
priority. This multiplicity is not in itself a matter for regret, but it
makes it difficult for any single paper to represent fairly all current
areas of research activity. This paper claims no such represen-
tativeness. I shall not consider directly the potential applications of
techniques of behavior modification in smokers’ clinics and similar
person-to-person encounters between therapists and individual
smokers (cf. Raw, 1978). Nor shall I deal here with the extremely
important area of prevention of smoking among adolescents (cf.
Evans, 1981). The immediate effects of nicotine or deprivation on
attention, mood and task performance likewise will not be describ-
ed specifically.
Instead, I shall concentrate on what seems to me to be one of the
most critical conceptual contrasts in current research. This contrast
is that which arises from two divergent approaches. The first ap-
proach, with a strong reliance on physiological evidence concerning
smokers’ attempts to regulate their intake of nicotine, emphasizes

International Review of Applied Psychology (SAGE, London, Beverly Hills and


New Delhi), Vol. 32 (1983). 11-28
12 J Richard Eiser

the addictive nature of cigarette smoking. The second approach,


relying more on measures of attitudes and behavioral intentions,
emphasizes smokers’ beliefs and decisions as predictors of their
behavior. In the context of a broader consideration of the relevance
of cognitive social psychology to this field, I shall argue that there
is no necessary contradiction between these approaches. To under-
stand how physical dependence affects smokers’ behavior, one
must also consider how it affects smokers’ decisions, and if one can
understand the decision processes of dependent smokers, this must
help our understanding of the concept of addiction itself.

Why do people smoke?

To ask why people smoke cigarettes is not to ask a single question.


One could concentrate on a variety of more specific questions, all
worthy of study in their own right - why do people take up smok-
ing, why do they find it difficult to give up, why do they often
relapse after periods of abstinence, why do they smoke the par-
ticular brands they do, why do they inhale (or not), why do they
keep to a fairly regular level of consumption, why do particular
situations make them want to smoke more than others, what are
the factors which contribute most to the effectiveness of any cessa-
tion treatment? The list could go on and on. The point is simply
that smoking is not a single behavior or a single behavioral problem
and that approaches which may provide insights in the context of
one type of question may be much less relevant to another. To take
just one example, the addictive nature of nicotine hardly seems the
most obvious starting-point for an explanation of teenagers or
younger children accepting their first cigarette.
Contrasting sharply with the specificity required by any
behavioral analysis is the generality of much of the information
communicated to the public in the form of government health
warnings, anti-smoking advertisements and the like. Here ‘smok-
ing’ is typically treated as an undifferentiated whole. The degree of
effectiveness of most such attempts at dissuasion can be most
charitably described as undetectable by the crude evaluation techni-
ques typically employed, and in the light of such disappointments,
the question, ‘Why do people smoke?’ often takes on a more plain-
tive form ‘Why do people carry on smoking when they’ve been told
they shouldn’t?’
Smoking, addiction and decision-making 13

The answer I shall suggest to this form of the question is a simple


one: ‘Because they decide to’. Clearly, such an answer requires fur-
ther explanation of what kinds of decisions may be involved. Yet it
is no mere truism. The admissibility of any concept of decision-
making in this context implies that one is dealing with behavior at
least in some sense under volitional control. However, to suggest
that smoking is in some sense voluntary runs directly counter to
what might seem to be implied by describing smoking as an addic-
tion. Before looking at how the notion of decision-making has been
treated in cognitive social psychology, and how this might apply to
smoking, it is therefore important to look briefly at the argument
that smoking is addictive, and what this means.

The concept of addiction

The labeling of a behavior as an addiction is not simply a matter of


drawing conclusions from pharmacological evidence. It is to take a
position which can have a number of repercussions - political,
legal, commercial, ethical - which extend well beyond any purely
scientific debate. It also places the behavior, in this case cigarette
smoking, within a particular medical category - that of
dependence disorders (Russell, 1971) - which is itself a subspecial-
ty of psychiatry. Thus Jaffe (1977) has felt entitled to classify
cigarette smoking as a ‘mental disorder’. From such a definition, it
is potentially a short step to saying that smokers smoke because
they are mentally ill, and not responsible for their behavior.
Cruder definitions are not uncommon in the context of addic-
tion, and philosophers are fond of quoting the old idea that opium
sends one to sleep because of its virtus dormitiva. It is therefore
vital to treat the behavioral and pharmacological criteria of addic-
tion separately from questions of harmful consequeqces, if any,
and more tendentious notions of diminished choice, responsibility
and rationality.
On behavioral and pharmacological grounds, there now seems
every reason to view cigarette smoking as at least as addictive as the
use of many other licit and illicit substances, such as alcohol and
opiates. Some of the strongest evidence in support of this position
is that which shows that the smoking patterns of established smokers
function in such a way as to regulate the level of nicotine in their
bloodstream, for example in response to changes in the nicotine
14 J Richard Eiser

yield of cigarettes (Russell, 1977) or to changes in their urinary (and


salivary) pH which affects absorption and excretion of nicotine
(Schachter et al., 1977). Russell (1977) also points out the extreme
efficiency of the manufactured cigarette as a device for self-
administering nicotine: the nicotine from an inhaled puff hits the
brain in about seven seconds - faster than the heroin from an
intravenous injection. Nicotine itself has been identified as having
the properties of a central nervous system stimulant, but, depen-
ding on dose and other factors, can also act as a relaxant. There is
evidence of the development of tolerance to its effects, as well as of
withdrawal symptoms when it is made unavailable. The success
rates of smokers who come to clinics for help in giving up are unim-
pressive (Hunt and Matarazzo, 1973; Raw, 1978) as with other
drugs.
Cigarette smoking, then, clearly is an addiction. Of course, not
all smokers will be addicted to the same extent, and some perhaps
not at all, but the same might be said of any drug. For most adult
smokers, smoking is not a ‘take it or leave it’ activity. Compared
with how most people use alcohol, for example, smokers will feel
deprived if they cannot smoke regularly, every day, and throughout
the day.
To call smoking ar, addiction might seem to imply that smoking
is a behavior quite beyond volitional control and hence one to
which an analysis of decision processes is irrelevant. This implica-
tion is based on an image of the addict as someone completely
helpless in the face of his craving and in constant terror of
withdrawal. Is this image correct? Even in the archetypical case of
heroin, there is reason to suppose it is not. Robins, Davis and
Goodwin (1974) conducted an important study of opiate use among
US servicemen returning from Vietnam. Included in their sample
were 495 whose urines were positive for opiates when they left Viet-
nam. When interviewed 8-12 months later, only 7 per cent of this
sample still showed signs of opiate dependence. Other data from a
sample chosen to be representative of the general army population
showed that almost half had tried heroin or opium in Vietnam, but
less than 1 per cent were addicted to opiates by the time of the
follow-up. The myth of life-long addiction as an inevitable con-
sequence of opiate use (at least in the absence of medical interven-
tion) is simply unsupported by such evidence, which suggests rather
that one is dealing with a learned response to a more or less specific
situation. One factor that might distinguish the street addict from
Smoking, addiction and decision-making 1:

the addicted serviceman, however, may be the lack of any prospect


of ever leaving the situation in which drug use has been learned and
may at first have been felt to be adaptive.
If addictive behaviors may be less than totally involuntary, is
there also a sense in which they may be less than totally irrational?
Like many other terms that permeate discussions in this area, ‘ir-
rational’ carries clear value connotations. There is a temptation to
think that anyone who engages in behavior which has foreseeably
potentially terrible consequences must be acting irrationally. As
Aronson (1972, p. 9) has put it, however, ‘People who do crazy
things are not necessarily crazy’. Rather than dismiss some 40 per
cent of the adult population as insane or imbecilic, we should ask
ourselves whether the relative unmodifiability of smoking behavior
may not be a more predictable outcome of the ways in which
human beings make decisions.

Social cognition and the question of rationality

Of the many streams of research in cognitive social psychology in


recent years two deserve special mention for this discussion. The
first is concerned particularly with individuals’ subjective explana-
tions for events and has been organiLed around the various for-
mulations of attribution theory (e.g. Kelley and Michela, 1980).
The second is concerned with questions of how individuals make
predictions and inferences under conditions of uncertainty, and
places particular emphasis on notions such as ‘cognitive heuristics’
(Tversky and Kahneman, 1974; Nisbett and Ross, 1980). Both
streams of research share a common interest in the fundamental
questions of how individuals simplify complex information about
social events to the point where these events become interpretable.
In both areas, however, researchers have tended to be rather coy
about predicting the behavioral consequences of particular
cognitive processes. Kelley and Michela distinguish ‘attribution
theories’, which are concerned with how people interpret the causes
of events, from ‘attributional theories’ which deal with the conse-
quences of such causal attributions. In a somewhat more apologetic
tone, Nisbett and Ross (1980, p. 11) write: ‘we share our field’s in-
ability to bridge the gap between cognition and behavior, a gap that
in our opinion is the most serious failing of modern cognitive
16 J Richard Eiser

psychology’.
Both of these areas may be distinguished from another tradition,
derived from normative models of economic decision-making,
which does attempt to relate cognitions and values to behavior, but
arguably fails to give an accurate representation of the processes in-
volved at an individual level. It is this tradition which has most in-
fluenced psychological definitions of rationality. At its simplest, a
decision may be defined as ‘rational’ if it is seen, on balance, as
more likely to have good consequences than bad, in comparison to
other available options. In other words, the maximization of ex-
pected profit is the measure of rationality. Adopting this approach,
one can calculate the subjective expected utility (SEU) of any op-
tion by taking each identifiable possible consequence of the option,
obtaining an evaluation of its desirability to the individual (utility),
multiplying this evaluation by its perceived probability, and summ-
ing the products over the set of identified consequences. The
greater the SEU of a given option, the more likely it should be to be
chosen, and in many situations researchers have found support for
this prediction.
Is cigarette smoking ‘rational’ according to any such definition?
Bearing in mind that the SEU approach defines rationality in terms
of subjective probabilities and evaluations of outcomes, the fact
that some people smoke and others do not might simply be at-
tributable to smokers assigning lower importance and/or pro-
babilities to the risks involved. Mausner and Platt (1971) calculated
smokers’ SEUs for stopping smoking and continuing and indeed
found some evidence that smokers who had higher SEUs for stopp-
ing as compared with continuing were more likely to try to stop.
More troublesome for the SEU approach, however, was the finding
that smokers’ SEUs for stopping were reliably greater than their
SEUs for continuing. In other words, these smokers were prepared
to acknowledge that smoking was bad for them, on balance (given
a particular way of calculating this ‘balance’), but just seeing it as
‘bad on balance’ was not enough to make them decide to stop. This
is consistent with other evidence (e.g. Eiser, Sutton and Wober,
1979) which suggests that, even though smokers may be more scep-
tical of the health hazards of smoking than non-smokers, they still
d o not deny them entirely.
Attempts to make sense of such findings whilst preserving the
main assumptions of the SEU approach have taken the line that
one must be far more specific about the particular kind of decision
Smoking, addiction and decision-making 17

one is considering. In one application of this approach, Eiser and


Sutton (1977) looked at variables influencing whether adult
smokers would accept or decline the offer of free treatment at a
smokers’ clinic, and Sutton (1979) has argued more fully that the
choice confronting smokers in such situations is not only whether
to continue or to stop smoking, but whether to continue or to try to
stop. In other words, the expected benefits of actually stopping
have an indirect influence on such decisions; what matters is the ex-
pected benefit or cost of trying to stop. Someone who ‘knows for
sure’ that he is bound to fail in any attempt at giving up, and also
expects any such attempt to involve a great deal of discomfort,
would be acting quite ‘rationally’, in terms of SEU theory, if he
made no attempt to stop, even though he might acknowledge that
the benefits of successfully stopping would be tremendous.
When one tries to take account of smokers’ own expectations of
success at giving up, the concept of addiction reasserts itself, but
under a new guise. Those who feel they are addicted will have a low
expectation of success at giving up, and, according to the above line
of reasoning, would be less likely to try. What matters here,
though, is not addiction as an identifiable physiological state, but
addiction as an attribution which people make for their own
behavior. It is here that the popular stereotype of the addict, as
someone incapable of desisting from drug-taking without the help
of medical intervention, can profoundly influence behavior even if
it is profoundly inaccurate. If believed, it can be self-fulfilling.
Robinson (1972) has discussed some of the paradoxical implica-
tions of this concept of the addict or ‘sick role’ (Parsons, 1951) for
the treatment of alcoholism. He points to the tendency of practi-
tioners treating alcoholics to demand ‘motivation’ from their
clients, in spite of the view that people defined as ‘sick’ are not
usually held personally responsible if they fail to make themselves
better. In a series of studies, we have investigated some of the fac-
tors associated with whether smokers do or do not see themselves as
addicted to cigarettes (Eiser, Sutton and Wober, 1977; 1978). Most
importantly, those who see themselves as addicted are more likely
to think that they would fail if they tried to give up, and are thus
less likely to try. They are also more likely to fall into the category
which McKennell and Thomas (1967) call ‘dissonant smokers’ -
specifically those who say that they would like to give up smoking
‘if they could do so easily’. McKennell and Thomas claimed that
such individuals would be in a state of ‘cognitive dissonance’ with
18 J Richard Eiser

respect to their smoking, but I have argued elsewhere (Eiser, 1978,


1981), that such a self-attribution of addiction may function as a
way of reducing dissonance, in that dissonance, according to
theory, should not occur in the absence of perceived freedom of
choice. Besides, the image of this large proportion of smokers all
desperate to give up but unable to do so is not altogether in tune
with their endorsement of the statement ‘I don’t think I’m really
prepared to give up smoking if it proves too difficult or distressing’
(Eiser, 1981).
Related to the SEU approach is the Fishbein and Ajzen (1975)
model of attitudes and behavioral intentions. A central part of this
model is the notion that attitudes toward an act are predictable
from the salient ’evaluative beliefs’ about that act. As in the SEU
model this involves a quasi-economic calculation of expected
benefit based on a summation of products of evaluations (utilities)
and beliefs (subjective likelihood ratings). A person’s intention to
perform the act is then predicted from the person’s attitude toward
the act and also from what is termed the ‘subjective norm’ - the
person’s impressions of how performance of the act would be
evaluated by other people, weighted by how much the person is
motivated to comply with such evaluations (again the score is
calculated as a summation of products). The actual performance of
a behavior - provided the behavior is defined at the appropriate
level of specificity - then is typically quite predictable from the
measure of intention.
Fishbein (1981) describes a number of applications of this model
to the issue of smoking behavior. An understanding of a smoker’s
subjective norms can contribute considerably to making sense of
behavior which might seem ‘irrational’ in terms of expected utilities
alone. Fishbein also makes clear that he views his approach not
merely as a predictive model, but more generally as a ‘theory of
reasoned action’. Applied to smoking, Fishbein argues that smok-
ing can be seen as a behavior under volitional control in that smok-
ing intentions can be quite good predictors of smoking behavior.

Decision-making and cognitive simplification

It seems, then, that various theoretical approaches - SEU theory,


attribution theory, and Fishbein’s theory - can all be applied
reasonably successfully to aspects of smoking behavior. Even if one
Srnokinn, addiction and decision-rnakir7.g 19

grants that there are rarely hard-and-fast criteria for interpreting


one’s subjects’ responses as evidence of rationality rather than ra-
tionalization, at least one is not forced to abandon entirely one’s
search for an adequate decision-making analysis. There is a dif-
ference, though, between showing, on the one hand, that smokers’
decisions are predictable from their evaluations and expectations of
certain perceived consequences and, on the other hand, being able
to say why some perceived consequences appear more desirable
and/or important than others, and why they are seen as more or
less probable.
This is not simply an empirical matter of determining the values
in a specific instance of weights and variables in a formal model -
it is a question of the adequacy of the formal model itself as a
description of the decision process rather than as a prediction of the
outcome of that process. Viewed as descriptions of process, both
SEU theory and Fishbein’s model may be seen to make rather
stringent assumptions about people’s abilities to combine pro-
babilistic and evaluative judgments in ways compatible with nor-
mative principles. Do individuals really sum the products of expec-
tancies and utilities in their heads to come up with an overall
preference for each behavioral option before deciding on a course
of action? Do they combine their judgments of different conse-
quences together as SEU theory and Fishbein’s model suggest?
In fact, in laboratory tests involving choices between
hypothetical gambles and similar kinds of stimuli, the basic axioms
of SEU/expected value theory have been continually violated
(Coombs and Huang, 1976; Kahneman and Tversky, 1979). The
focus of this research has been on decision-making involving risk
- that is, uncertain outcomes involving possible loss or reduction
of profit - and this focus on uncertainty is clearly relevant to deci-
sions involving dangers to health on the one side, and imperfectly
effective strategems for changing behavior on the other. In spite of
the success of the SEU/expected value approach at making global
predictions in many instances, therefore, such predictions may turn
out right for the wrong reasons. If we want to describe how
smokers arrive at their decisions, a different kind of model may be
required.
One of the key themes in attempts at finding an alternative model
of decision-making is the idea that individuals may rely on
simplificatory cognitive strategies - what Tversky and Kahneman
(1 974) call ‘heuristics’ - so as to make decisions, as it were, by rule
20 J Richard Eiser

of thumb rather than by working through some kind of internal


representation of an economic balance sheet or a statistical equa-
tion. Such heuristics can relate to the handling of probabilities and
the impact of particular kinds of information on decisions.
One line of research relates to people’s tendency to neglect infor-
mation about base-rate probabilities, when assigning an object to a
particular category or assessing the likelihood of an event. In other
words, people’s subjective inferences do not typically accord with
normative principles such as Bayes’ theorem (Nisbett and Ross,
1980). This has important practical implications when one is
presenting probabilistic information about health risks, as, for in-
stance, in the form of mortality statistics, where ordinary people
may have only the haziest idea of how many people annually die
from any given cause, or from all causes combined (Harding, Eiser
and Kristiansen, 1981). Contrasting with this tendency to neglect
statistical information is a tendency to rely more heavily on con-
crete instances, or individual cases (Nisbett and Ross, 1980). Thus
the smoker who queries the smoking-cancer link on the grounds
that he personally knows one (or more) heavy smokers who have
survived to a ripe old age is exhibiting a familiar cognitive strategy
used both by smokers and non-smokers across many situations. To
label such a cognitive process as irrational or maladaptive in
general on the grounds that it can lead to errors in specific instances
is to beg many important questions about how far abstract
statistical information is to be trusted over more concrete, im-
mediate and (for all one knows) replicable, personal experiences.
The question of what kinds of information have most effect on
judgment may be narrowed down to the question of what kinds of
expected consequences have most effect on decision-making. If in-
dividuals are selective in terms of their attention to probabilities,
they surely are likely to be selective in terms of their attention to
different kinds of outcomes. This might appear to be purely an em-
pirical matter of determining for each decision after it has made the
relative importance of different possible criteria. Indeed, pro-
cedures have been developed, based on multiple regression, for
calculating the relative weights of different attributes of alternative
options as predictors of preference on an ad hoc basis (Hammond,
Stewart, Brehmer, and Steinmann, 1975). But are we completely in
a theoretical vacuum here, without any guidelines from either
research or intuition regarding the kinds of consequences which in
general will be more influential?
Smoking, addiction and decision-making 21

Just as concrete information may have more influence on deci-


sions than abstract information, so might consequences which are
immediate be more influential than consequences which are more
remote. In crude terms, this is a reappearance in cognitive terms of
the idea that reinforcements are more effective when they are con-
tiguous with the response.

Smoking and its perceived consequences

Let us return now to our main question ‘Why do people carry on


smoking when they’ve been told they shouldn’t?’ Before writing
off such behavior as an example of perversity, stupidity or mental
illness, we should ask what impact the familiar health warnings
might have at the level of individual decision-making. Let us make
a further assumption - that often, if not always, when people are
given general information about the effects of particular behavior,
they are likely to check out this information for plausibility in the
light of other knowledge and personal experience. What form
might this checking-out take?
The first step might be for smokers to ask themselves the ques-
tion ‘What is the observable relationship between any stopping or
continuing smoking and the occurrence of dire consequences to my
health?’ The answer they might give themselves might run like this:
‘Well, honestly, I can’t see that it has very much effect. Maybe my
cough is worse when I’ve been smoking heavily, and I get a bit
short of breath; but I can’t ever really say “this cigarette’s the one
that’s going to kill me - if I smoke this cigarette, it’s going to
make me less healthy than if I don’t”. Anyway, everyone has to die
of something and you can get killed crossing the road’.
Then they might ask themselves ‘What would I expect to happen
if I tried to stop?’ The answer might then be: ‘Well, I’ve tried
before, remember? It was pretty rotten, wasn’t it? I felt irritable
and couldn’t work properly, and I kept nibbling things and putting
on weight (which couldn’t have been too good for my health). Sure,
if I actually managed to give up for good, that would be great, but
that’s a bit irrelevant really as I know I’d start again. Perhaps I’ll
feel differently in a few years’ time. Right now, 1 feel I’d be
punishing myself if I tried to give up’.
I am not attempting to give the above caricature any quasi-
universal status, but hopefully it should serve to illustrate the
22 J Richard Eiser

distinction between the immediate contingencies of the act of


smoking any single cigarette and the long-term consequences of
continuing or giving up smoking as a habit. The immediate con-
sequences are certain and familiar. The long-term benefits of stop-
ping are based on hearsay, and may be both unreliable and un-
attainable. This distinction also brings out the question of the dif-
ference in urgency between the kind of decisions involved in saying
‘I want a cigarette’ and ‘I want to stop smoking’. This difference is
such that the two statements can be made together without any real
inconsistency. What is more, the problem is not one of merely
delaying gratification - of doing without a small reward now for a
large reward later. One does not knowforsure that there will be a
large reward in the long term. Essentially, the smoker who gives up
is buying an ‘insurance’ against the risks of continued smoking, at
the ‘price’ of certain discomfort and expenditure of effort in the
short and medium term. The question of how high a ‘price’ a
smoker will or should be prepared to pay for such ‘insurance’ is not
at all obvious, and depends very much on how relative risks are
perceived - although most lung cancer victims are smokers, most
smokers do not get lung cancer. The point then is that the im-
mediate and even medium-term reinforcement contingencies all
point to the smoker smoking another cigarette (and another, and
another.. .). To decide to give up smoking is to decide to act in
spite of such contingencies, and this, although not impossible, is
very difficult indeed to do.
This problem of being trapped by immediate contingencies is an
extremely general one. It has parallels in such unlikely areas as in-
terpersonal conflict, and experimental games such as the Prisoner’s
Dilemma (Eiser, 1980), where, because of problems of interpersonal
trust, individuals have to run risks of short-term loss - and indeed
reject a strategy of minimizing loss and maximizing profit on any
given trial - in order to achieve the goal of mutual cooperation
which is more profitable in the long term. Pruitt and Kimmel(l977)
have argued that the achievement of mutual cooperation requires a
cognitive change from short to long-range thinking. Broader im-
plications have been discussed by Platt (1973) in his paper on
‘social traps’. Both in applied and laboratory contexts, this
literature shows that this longer term goal is very difficult to
achieve, even when its ultimate desirability is acknowledged.
Considering decisions in this way, one may begin to gain some
better idea of the sense in which an addictive behavior may still be
Smoking, addiction and decision-making 23

under volitional control. A smoker may want to give up cigarettes,


but the fact that he wants to and has not done so, would seem to
imply that it is not the only thing he wants. He also wants a
cigarette, and at frequent and regular intervals this want is likely to
be the more pressing.
What then of the concept of addiction? Too often the concept
has been wheeled in to account for nothing more substantial than
verbal expressions of regret. To understand addiction, however, it is
more important to understand why a smoker says ‘I want a
cigarette’ than to try and unravel the epistemological tangles in
statements such as ‘I wish I didn’t want cigarettes’. If it were not
for the urgent short-term reinforcement contingencies, there would
be no need for expressions of regret. Clearly we do not want to get
trapped into saying that a heavy smoker is never addicted until he
wishes he wasn’t. Regret, or ‘dissonance’ in the McKennell and
Thomas (1967) sense, therefore, cannot be a criterion of addiction,
even though it may be an effect.

Addiction and reinforcement

The concept of addiction here proposed is very simple - in learn-


ing theory terms, an addictive behavior is one which is associated
with strong short-term positive reinforcement contingencies. In
other words, it is something that, at the time a person very much
wants to do, and/or very much does not want to do without,
whatever the longer-term consequences may be. To say a person
needs a great deal of determination and/or help to overcome an ad-
diction is to say no more and no less than that it is extremely dif-
ficult to act deliberately, or be made to act, in a way that runs
counter to overlearned reinforcement contingencies.
Does this mean that any reinforcing activity can be addictive,
whether or not it is drug-related? In principle, there is no reason
why not. Over-eating in the case of obese people may be one exam-
ple. Compulsive gamblers may talk about their gambling much like
alcoholics talk about their drinking. Television watching, computer
games such as ‘Space Invaders’, and a variety of recreational ac-
tivities might appear to take on a similarly obsessional character for
some people at 1east.To try to confine one’s concept of addiction to
activities which produce psychological effects of certain kinds does
not help very much when so little is known about the
24 J Richard Eiser

psychophysiological effects of these other activities. Likewise, to


reserve the concept for activities which are clearly damaging to
health may be misleading, since even within the fields of drugs,
some substances might be damaging without being addictive and
others addictive without being damaging. In fact, it could be
argued that cigarettes illustrate this point - put crudely, the
nicotine is what makes cigarettes addictive, but the tar is what leads
to lung cancer (though the nicotine may be associated with other
health risks).
On the other hand if no bounds are set on the applicability of the
concept, it ceases to explain anything at all. As I argued earlier,
calling something an addiction has a variety of political and other
implications, for example for legislative control or prohibition
designed to ‘protect people from themselves’. Addiction is not a
label which should be lightly attached to any activity one regards as
a problem. I personally would be happy with a definition according
to which drug-related compulsive behaviors were considered as ad-
dictions in a literal sense and other compulsions as addictions only
in a metaphorical sense. This is still arbitrary, since, from a
psychological point of view, what matters is the pattern of rein-
forcement contingencies associated with the behavior, rather than
the particular kind of substance involved. Of course, without an
understanding of the psychopharmacological effects of different
substances one could never, for instance, explain why smoking
tobacco can be a pleasure but smoking lettuce leaves is at best a
penance. Such reinforcement contingencies rely largely (though
maybe not totally) on the psychopharmacological effects. Although
in principle any behavior might be addictive in either the literal or
metaphorical sense, in fact there may be very definite constraints
on what behaviors can become so. Little, if anything, is known about
such constraints, but the literature on biological constraints on
learning (Hinde and Stevenson-Hinde, 1973; Seligman and Hager,
1972) points to definite limitations to the kinds of behaviors that
may be learned with particular kinds of reinforcements. It would be
the height of naikety to assert, on the basis of current knowledge,
that there is nothing special about drugs as reinforcers or about
drug-taking as learned behavior.
Smoking, addiction and decision-making 25

Conclusions

Cigarette smoking thus provides both an important and instructive


example of where a behavioral medicine approach can achieve an
integration of biomedical and behavioral science perspectives. For
too long, biomedically oriented research has investigated addic-
tions to specific substances as specific physical conditions, and an
impression may have been created that, by describing the phar-
macological (and even pathological) effects of a drug, one has said
all that needs to be said about the psychological and behavioral ef-
fects. This emphasis has contributed to a view of addiction as a
physical state in which the individual is completely unable to help
himself - a view which may not only be at variance with the facts
but damaging to prospects of prevention or treatment.
The argument put forward in this paper - that smoking is still,
in a particular sense, under volition control and the product of a
kind of decision-making, hopefully may provide some counter-
balance. For this argument to be informative, however, it has been
necessary to examine what kind of decision-making may be
involved, and how various cognitive processes and biases may lead
smokers to make the decisions which they do. Also, to say that
smokers decide to smoke is not to say that they could easily decide
to do otherwise. On the contrary, it would seem to be extremely dif-
ficult for people to escape from the trap of short-term reinforce-
ment contingencies - to avoid letting their decisions be dominated
by immediate appetites, cravings or anxieties, and to start to aim
for a long-term goal with little certainty of success. Escape from
addiction is not simply a matter of detoxification or endurance of
withdrawal symptoms - it requires a cognitive shift from short to
long-range thinking, even if the ‘long-range’ goal is no more than
merely abstinence for one day at a time.
Such a cognitive view, however, may itself lead to misconcep-
tions if the biomedical evidence is ignored. It is simply untrue that
any kind of cognitive or attitudinal manipulation, designed, say, to
change people’s perceptions of the consequences of smoking will be
as effective as any other in producing behavior change. Quite apart
from questions of credibility, individuals may be highly selective in
the kinds of factors they take into consideration when making deci-
sions, and this selectivity is not always taken full account of even in
some of the more successful psychological models of attitudes and
decisions. Just as the biomedical approach cannot afford to ignore
26 J Richard Eiser

similarities between addictions and other learned behaviors, so too


must the cognitive approach avoid the pitfall of denying that drugs
may have special effects, and these effects may have special im-
plications for decision-making.

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Furner, depmdance et prise de dkision

Le comportement des fumeurs est examine a la lumiere des recher-


ches faites en psychologie sociale cognitive. L’idte difendue est que
les fumeurs adultes continuent B fumer probablement parce que
c’est la conskquence d’un processus de dtcision plut6t qu’un fait in-
dtpendant de tout contr6le volontaire de I’individu. Les implica-
tions du concept de dtpendance sont discuttes ici particulittrement
en relation avec les concepts de rationalitt et de renforcement. La
conclusion est la suivante: pour comprendre le comportement de
fumeur, i! faut inttgrer les approches biomtdicales et psychologi-
ques.