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The Psychology Behind Addiction

Addiction Psychology

Addiction is such a complicated issue, that the question of what causes it and what defines it remains somewhat unsettled, even after a century of debate and advancement in science and medicine. The psychology behind addiction covers many bases: whether it is a disease or a personal failing; the effect of lifestyle and childhood; family history and socioeconomic demographics; and the dozens of other factors that cannot be accounted for or measured.

What’s behind Addiction?

Delving into the psychology of addiction entails understanding what the basics of addiction are. Psychology Today makes it quite simple: When a person engages in an activity that is pleasurable but cannot stop doing it, even to the detriment of everyday living (such as work, hobbies, family time, finances, etc.), and health and wellbeing suffer as a result, this behavior would be considered an addiction.[1] A person who drinks to the point of alienating friends and family and losing a job, and continues to drink in spite of all this, is likely addicted to alcohol. Similarly, a person who has an uncontrollable need to gamble, even dipping into life savings to play, and wants to do nothing else but gamble is probably addicted to the risk (and illusion of control) of gambling.

At the root of addictive behavior is some form of emotional stress, an issue that is so deeply buried within the person’s subconscious mind that addressing it is too overwhelming or unfathomable a challenge. To ease the stress, to make it go away, pleasure is found in excess; the fun of a drunken night out or the thrill of making an expensive bet. Ceasing the behavior threatens to return thoughts to whatever that source of emotional stress is; the presence of addictive behavior suggests that there are no healthy coping mechanisms for that problem. The only mechanisms in place are distracting and unhealthy ones, like substance abuse or problem behavior. As Psychology Today says, “the focus of the addiction isn’t what matters”; what matters is the need to do something when that emotional stress makes itself felt. Some people are able to stop their drinking or compulsive behavior cold turkey because their emotional stress doesn’t manifest itself as one of those addictive behaviors; for many others, however, their drug or alcohol problem is a sign of a problem they may not even be aware that they have, and this requires long-term therapy and counseling.2

Associative Learning

To that point, the Association for Psychological Science writes that only between 20 percent and 30 percent of people who use drugs actually develop an addiction.3 Reviewing a study published in the European Journal of Neuroscience on “neural and psychological mechanisms underlying compulsive drug seeking habits,” the association explained that the want for drugs begins as a goal-directed behavior: A person finds and takes drugs (the action), and gets high (the outcome of the action).4 This is a form of associative learning – the simple process of learning to do something based on a new stimulus. Ivan Pavlov’s famous experiment, of ringing a bell to summon his dog and then rewarding the dog with food, is a classic example of associative learning.5 There is a particular area of the brain that regulates associative learning, which it does through the use of a neurotransmitter called dopamine.

Percentage of People Who Develope Addiction

Dopamine is naturally produced by the brain when a person does something pleasurable and rewarding. Evolutionarily, this is a survival technique; eating and drinking feels good, but it also ensures the continuation of the person’s life, family, and the species on the whole. Dopamine production is one of the main drivers behind sex because as much as sex is a pleasurable and rewarding act, it is also necessary for survival.One of the effects of dopamine production is that it creates a memory of the experience, which compels us to seek out the experience again. If presented with our favorite food, we recall past exposures to that food (which are positive and reaffirming), so we continue the cycle.

The Brain on Drugs

Dopamine is secreted by the brain during healthy activities, but drugs like cocaine or heroin (or compulsive behaviors, like gambling, shopping, or eating) will force the brain to release massive amounts of dopamine, and then prevent the brain from reabsorbing the dopamine, making the pleasurable experience last unnaturally longer. In many cases of chronic or severe substance abuse, this actually changes the brain’s chemistry to the point where normal activities (e.g., one’s favorite food, sex, etc.) don’t produce the same amounts of dopamine that they used to. In the context of associative learning, the brain has been reprogrammed to associate the blast of euphoria from drugs or compulsive behavior with only feelings of pleasure, reward, and the anticipation of more pleasure and reward. Healthy activities don’t register on the radar anymore, so they are discarded and eventually forgotten.

The chemical effects of drugs in the brain have been revealed through the use of brain imaging techniques, such as magnetic resonance imaging and positron emission tomography scans, which show the extent to which the pleasure/reward regions in an addict’s brain are corrupted by long-term or severe exposure to drugs.7, 8 Such insights have largely dispelled outdated notions that addiction is a moral failing or a sign of a weak character, or even that there is a religiously punitive element to substance abuse and compulsive behavior. The rise of the 12-Step movement and peer groups like Alcoholics Anonymous had set the stage for the so-called “moral model of addiction” to be cast aside, evolving the conversation to think of addiction in terms of a disease; high-resolution optical imaging technology showing the brains of people who had some form of mental health disorder that presented itself as substance abuse seemed to seal the deal.

Emotional Stress

When talking about the psychology behind addiction, understanding the full context of “emotional stress” becomes very important. Emotional stress can take on many forms and have many causes. In the home, for example, domestic violence (whether physical, sexual, verbal, or emotional) can have a lasting impact on vulnerable and helpless family members and witnesses, especially children and women. The American Psychiatric Association explains that partner abuse can cause a number of mental health conditions in the victims, as well as those who see the abuse taking place. These conditions include:

  • Depression
  • Anxiety
  • Panic attacks
  • Post-traumatic stress disorder
  • Suicidal thoughts9

The emotional stress falls under the category of trauma, which the American Psychological Association says is an emotional response that takes place when a person is deeply afraid for their life or wellbeing. A woman being assaulted by her partner and a child witnessing the event could be so scared that their brains are unable to fully process the experience, a process that fundamentally alters the brain’s functioning and chemistry (not dissimilar to what happens to a soldier’s brain after a traumatic event).10 The fallout from this shock could manifest as one of the conditions listed above. Left untreated, the emotional stress grows and festers, and only unhealthy behaviors (like substance abuse or compulsive shopping, gambling, sex, etc.) can calm the inner storm.11

Women, Children, and Trauma

According to TIME magazine, “the vast majority of people with addiction have suffered significant previous trauma.”12 Many of those people are women, who tend to be the most frequently victimized in households where domestic violence is prevalent.13 The Journal of Psychiatric Research writes that women have a “heightened fear response,” so they are twice as likely to develop post-traumatic stress disorder in the aftermath of a traumatic event than men.14, 15 In addition to substance abuse, girls who suffer or witness domestic violence tend to act out in other risky and uncontrollable ways, such as being sexually promiscuous (which itself may lead to the development of compulsive sexual behavior) or engaging in self-harm, like cutting the skin; it is not meant as a suicidal action, but the intense pain provides a distraction from the emotional stress of domestic abuse.16, 17

For children, the emotional stress caused by witnessing domestic violence can be particularly debilitating. Children are typically unable to understand what they are seeing when their parents yell and fight with one another, which leaves a lasting impact on their brains, usually in the form of an anxiety or stress disorder. The Center for Nonviolence and Social Justice writes that the differences continue into adulthood, so children who grow up in stable and positive households have markedly different brains than children who grow up in a household of domestic abuse.18

Childhood Trauma and Lifelong Addiction

The journal of Neuropsychopharmacology explained that the difference is in “connectivity problems” in the areas of the brain that associate emotions to thought; another affected area is responsible for planning actions and responses to events. Teenagers who lived through domestic violence as children have brains that cannot regulate their emotions and their actions based on those emotions. Left untreated, the brains are unable to process the sights and sounds of abuse and instead find relief in compulsive behaviors or substance abuse.19 Children tend to internalize their problems, some even blaming themselves and feeling guilty for their parents’ abuse.

 The children grow up with hatred and resentment toward their parents and low self-esteem, for which they lack the tools and skills to repair. Instead, they find relief in problem behaviors and substance abuse.

Put everything together and “childhood trauma creates lifelong addicts,” says The Fix. Enduring abuse damages a child’s psyche to such an extent, that they grow up with a massive risk of acting out in dangerous and unhealthy ways with the freedoms of adulthood.20 Researchers writing in the journal of Depression and Anxiety surveyed 587 participants and found a strong statistical connection between abuse (whether sexual, emotional, or physical) during childhood and substance abuse as a symptom of post-traumatic stress disorder:

  • 39 percent of respondents abused alcohol
  • 2 percent abused heroin or other opioids, including prescription painkillers
  • 1 percent abused cocaine
  • 8 percent abused marijuana21

Beyond childhood and domestic violence, the psychology of addiction can be influenced by profession. Athletes who are exposed to head injuries in sports like football, boxing, wrestling, and ice hockey risk traumatic brain injury when the head is impacted so forcefully that the brain bumps against the side of the skull, tearing nerve fibers.22 One of the many effects of this kind of injury is that the pathways in the brain that transmit signals of pleasure and reward are disrupted in a very similar way to how those pathways are disrupted when a person abuses drugs and alcohol. According to the Journal of Neurotrauma, this means that traumatic brain injuries can increase the chances of the athlete developing a substance abuse problem because of how the “incentive motivation neurocircuitry” is damaged.23 On the topic of “Substance Abuse and Traumatic Brain Injury,” Brainline.org wrote of research that indicated upwards of 20 percent of people who receive TBIs go on to develop an addiction in the aftermath of the event.24

In addition to head injuries that affect the brain’s functioning, athletes have to live with chronic pain and fatigue, often competing when they are neither physically nor psychologically ready to perform out of fear of losing lucrative contracts or disappointing their teams and fans. The pressure is immense and compels many to abuse painkillers and steroids to play through the pain, often becoming addicted to the drugs as they do so.25

A world away from the field of play, veterans who return home from the battlefield come back with increased rates of substance abuse. Soldiers are similarly at risk of receiving a traumatic brain injury as part of their vocation, as well as enduring constant and long-term pain and fatigue; the sights and experiences of war also increase their risk for developing post-traumatic stress disorder. Each condition can individually contribute to the development of an addiction; in combination, they almost guarantee it.26

Law enforcement officials have it no easier. Corrections officers do jobs that are exhausting, traumatizing, and often dehumanizing, leaving the industry with PTSD rates that are more than two times those of military veterans. A clinical researcher who specializes in working with police reported that the specific signs of PTSD (hypervigilance, flashbacks, suicidal thoughts, depression) were found in 34 percent of corrections officers; among military veterans, that number was 14 percent. Retired officers confess to self-medicating with drugs and alcohol as the only way to cope with the emotional stress of what they experience on the job.27

Emotional Stress and Addiction

In 2016, author Maia Szalavitz’s Unbroken Brain: A Revolutionary New Way of Understanding Addiction explained that for addicted people, their emotional stress drove them beyond the point of controlling their compulsions (whether to seek out and use drugs, or gamble, overeat, shop, etc.). As the Washington Post puts it, the brains of people who are driven to addictive behavior are unable to resist the temptation to indulge in that behavior – not because they are corrupt and weak but because their psyche is in a constant state of pressure and tension.28 Framed that way, the moral model’s theories of addicts being greedy and hedonistic do not hold; instead, addicts have anxiety, depression, or trauma caused by (or the result of) a repressed, buried event or series of events in their past. Giving in to compulsive gambling or drinking is an escape mechanism, a powerful source of pleasure to counter a powerful cause for emotional stress.29

But the more that research has been conducted into the psychology behind addiction, the more complex the question becomes. Addiction isn’t about willpower, says Pacific Standard, as the magazine presents five different studies that claim success in treating addiction as a disease, based on “the genetic and physiological roots of addiction.” But Frontiers in Psychology writes that it is possible to “conceptualize addiction as a choice,” even while accepting the standard model of addiction as a disease.30, 31 Indeed, the American Journal of Medicinestudied the neural basis of addiction and concluded that it is a “pathology of motivation and choice.”32

Choice vs. Disease

This new school of thought – one that Maia Szalavitz herself puts forward in Unbroken Brain – presents addiction as being part of both the disease and moral models, with enough additional and unique characteristics to even create a third model. This, say proponents, is the best way to treat the individual psychologies behind addiction, and not to wall off one side of the vast and diverse spectrum of substance abuse. For many in the medical community, the shift in the paradigm is long overdue; casting addiction as a personal flaw was wrong, but presenting it as a medical disease was a mistake.

But as a sign of how complicated the psychology behind addiction is, not all the medical voices are unanimous. ABC News talked with a number of psychologists, doctors, and researchers, some of whom called for a new model of addiction and some who ardently defended the school of thought of addiction as a disease.[33]

According to Dr. Jeffrey A. Schaler, a psychologist who wrote a book entitled Addiction is a Choice, “people have more control over their behavior than they think.” On the other hand, “many scientists say addicts have literally lost control,” and that the loss of control is a characteristic of the addiction disease. Speaking to ABC, a doctor said that addicts “actually lose their free will” because of what the drugs do to them.
Official government policy is that addiction is a disease that wastes the brain, born in part by a genetic predisposition toward substance abuse and compulsive behavior. This is the stance of both the National Institute on Drug Abuse and the Surgeon General of the United States.34

What Addiction Is Not

But Sally Satel, a psychiatry lecturer at Yale University, argues that even though drug addiction is an “intense biological process,” it is not a disease of the brain. She is one of many who warn that as tempting as it may be to consider addiction as purely a disease, doing so runs the risk of forcing addiction into a category that it does not belong to. In asking if addiction is really a disease, Psychology Today argues that as much as the battle is fought in the brain, substance addiction is not Alzheimer’s disease; as much as the patient’s body changes and symptoms are beyond control, addiction is not cancer.

Addiction may be a disease (in that it needs treatment), but it is a disease unlike any other in the “disease” category. Instead, says Psychology Today, addiction is a group of behaviors, activated by emotionally stressful events or memories. Moving away from the moral model of addiction was beneficial, but going too far with the disease model misrepresents what addiction is, what it does to a person, and how it can be treated.35

A “psychological model” of addiction effectively addresses the limitations of the preceding models. Understanding addiction as a compulsive disorder – not a failing of character and not a “disease” – elevates the victims of addiction above simple dynamics of weakness and sickness. Patients are no longer trapped in the rubric of “once an addict, always an addict,” and neither are they forced into the position of powerlessness that critics of the 12-Step method object to.36

A Problem of the Person

This line of thinking is a notable shift from the conventional wisdom of the past few decades, and many doctors and researchers are critical of how strongly the disease model has been (and still is) pushed. In The Conversation, Sally Satel argued that addiction is “a problem of the person,” and that for rehabilitation to be effective and successful, the choices made by an addicted person have to be factored into treatment. Erasing culpability and responsibility by attributing consequences to the “disease” creates an unrealistic approach to solving the problem of addiction; instead, treating the problem will actually treat the person, even if it means acknowledging that the patient had an active role to play in their addiction.37

Sally Satel also coauthored a study in the Frontiers of Psychiatry journal entitled “Addiction and the Brain-Disease Fallacy,” where she wrote that the theory of addiction being a disease of the brain “over-medicalizes” addiction (while still granting that there is a “legitimate place” for treating addiction with medication) and ignores “the dimension of choice in addiction.” The limitation of the brain-disease model is shown when patients are able to get clean but still struggle to thrive in their newly abstinent lives. Logically, if addiction was purely a disease of the brain (the conventional wisdom of the past few decades), choice shouldn’t be an issue; but, Satel wrote in the journal, “addicts can choose to recover,” a statement that might have been considered heretical by many addiction researchers just a few years ago.38

A Consequence of Social Ills

Indeed, The Guardian writes that the idea of addiction being a disease is “entrenched” in popular culture, the media, the justice system, and even within the scientific, medical and treatment communities. But while victims of substance abuse respond positively to counseling and therapy, a change of environment, mindfulness therapy, and emotional growth, the sufferers of cancer, malaria, diabetes, and pneumonia (to name some other diseases) will benefit only marginally from such measures.

Social Context and Addiction

Hence, says The Guardian, it is wrong to call addiction a disease; neither is it a result of individual flaws. It is, instead, “a consequence of social ills,” such as emotional stress, environmental pressure, and unhealthy lifestyle. Choices are part of this equation, but they are choices made in adversity and poor mental health. Those are what needs to be addressed, not the illusion that addiction is a disease and needs to be treated the same way other diseases are. The Guardian writes that the disease model has helped our understanding of addiction, but it has run its course; addiction is a complex and vast condition, and the disease label simplifies it to the point of inaccuracy.39

Similarly, the New York Post held no punches when it wrote that “addiction is not a disease,” and that current methods of treatment are incorrect. The Post argued that it is high time to regard addiction as being far more complicated (in cause and treatment) than a simple disease/choice binary dynamic. Instead, to fully appreciate the psychology behind addiction is to embrace that addiction is, indeed, a disease of the brain; but it is also a disease of choice. Making this approach part of the conversation about addiction will help patients much more than telling them that they have a disease they can do nothing about.40 

The Addiction Debate

In a perfect illustration of the debate on the psychology behind addiction, Psychiatry Today published two articles on the same day in October 2002 on the topic: one entitled “Addiction Is a Choice,” and, presented as a counterpoint, “Addiction Is a Disease.” 41, 42

In “Addiction Is a Choice,” Dr. Jeffrey A. Schaler (who was interviewed about his book of the same title by ABC News) states that there is no empirical support for the argument for addiction being a disease. Addiction, asserts Dr. Schaler, is a behavior, “and thus clearly intended by the individual person.” Among the evidence Dr. Schaler presents is the overtly religious nature of 12-Step groups like Alcoholics Anonymous. How can addiction be a disease, he asks, if “the best available treatment is religion?” If the philosophy of the 12-Step method is to be believed, addiction is an ethical problem, not a medical one. Even psychotherapy and counseling, which boils down to conversation and talk therapy, are based on the disease model; convincing the client that the substance abuse and resultant actions are the result of an illness, not a choice. If addiction is a disease, addicts cannot control what they do. Dr. Schaler warns that impressing this upon clients may give them the idea that they are absolved from responsibility for their actions; any wrongdoing they committed during their addiction can be blamed on the “disease.”

Addiction and Decisions

In “Addiction Is a Disease,” Dr. John Halpern uses cigarette smoking as an example. Despite “multiple warning labels” being printed on every pack of cigarettes that has been sold for decades that explain the toxicity of tobacco, 17.8 percent of Americans still make the choice to smoke.43 The anti-smoking lobby is huge in the United States, with graphic billboards and messages warning about the dangers of smoking, but figures of current tobacco use across the country have not significantly wavered since the turn of the 21st century.

This, Halpern says, suggests that “choice has little to do with the decision to continue tobacco use.” Every year, more than 1 million smokers attempt to quit, but less than 15 percent are successful in staying away from cigarettes for a full year. Most smokers are fully aware that smoking is risky and dangerous, and any benefits are fleeting at best; yet, they compulsively continue their smoking in a long-term fashion. Halpern argues that even though there is choice in their decision to pick up smoking, to continue smoking, and to engage in behaviors that encourage smoking, not all choices are equal; there is a wide array of genetic, environmental, and other factors that influence those choices.

Biological Abnormalities and the Psychology of Addiction

Other research has indicated that repeated exposure to drugs and other addictive substances (and behaviors) can permanently change the molecular and neurochemical structure and functioning of the brain. Even after detoxification, a person can be susceptible to relapsing because prior repeated use has affected the brain to such a critical degree. Tolerance, one of the defining characteristics of an addiction, is when increased amounts of the drug (or compulsive behavior) are taken to achieve the same effect; this, in turn, creates further changes in the brain. Since this is true, Halpern says, drug dependence takes place on the cellular level, not just in the addict’s mind, because the central nervous system is in a constant state of adjustment, trying to find the sweet spot for the drug exposure. The fact that abrupt termination of drug use results in observable and reproducible symptoms of withdrawal suggests that addiction is very medical in nature.

Halpern concludes by writing that all forms of data on the subject are in agreement, that addiction is defined across the board by biological abnormalities, so much so that “a simple hypothesis of choice” cannot explain the psychology behind addiction.

Citations
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  2. “Counseling and Addiction — How Therapy Can Help.” (n.d.) Web MD. Accessed December 23, 2016.
  3. “How a Habit Becomes an Addiction.” (January 2015). Association for Psychological Science. Accessed December 23, 2016.
  4. “Neural and Psychological Mechanisms Underlying Compulsive Drug Seeking Habits and Drug Memories – Indications for Novel Treatments of Addiction.” (June 2014). European Journal of Neuroscience. Accessed December 23, 2016.
  5. “What Is Associative Learning in Psychology?” (n.d.) Seattle PI. Accessed December 23, 2016.
  6. “Four Effective Ways to Break Out of Sexual Ruts.” (July 2012). Psychology Today. Accessed December 23, 2016.
  7. Cocaine’s Effect on Mice May Explain Human’s Drug-Seeking Behavior.” (August 2013). UC Berkeley. Accessed December 23, 2016.
  8. Drugs, Brains and Behavior: The Science of Addiction.” (July 2014). National Institute on Drug Abuse. Accessed December 23, 2016.
  9. Domestic Violence.” (n.d.) American Psychiatric Association. Accessed December 24, 2016.
  10. “The PTSD Brains of Children and Soldiers.” (February 2016). BBC News. Accessed December 24, 2016.
  11. Trauma.” (n.d.) American Psychological Association. Accessed December 24, 2016.
  12. How PTSD and Addiction Can Safely Be Treated Together.” (August 2012). TIME. Accessed December 24, 2016.
  13. Abuse Victims Report Long-Term Poor Health, Depression.” (March 2009). CNN. Accessed December 24, 2016.
  14. Sex Differences in Fear Conditioning in Posttraumatic Stress Disorder.” (January 2013). Journal of Psychiatric Research. Accessed December 24, 2016.
  15. Posttraumatic Stress Disorder (PTSD).” (n.d.) Anxiety and Depression Association of America. Accessed December 24, 2016.
  16. “Brain Trauma Can Cause Compulsive Sexual Desires.” (March 2015). Psychology Today. Accessed December 24, 2016.
  17. “Building Therapeutic Staff: Client Relationships With Women Who Self-harm.” (March-April 1997). Women’s Health Issues. Accessed December 24, 2016.
  18. What is Trauma?” (n.d.) Center for Nonviolence and Social Justice. Accessed December 24, 2016.
  19. How Childhood Trauma May Make the Brain Vulnerable to Addiction, Depression.” (August 2012). TIME. Accessed December 24, 2016.
  20. How Childhood Trauma Creates Lifelong Adult Addicts.” (September 2011). The Fix. Accessed December 24, 2016.
  21. Substance Use, Childhood Traumatic Experience, and Posttraumatic Stress Disorder in an Urban Civilian Population.” (December 2010). Depression and Anxiety. Accessed December 24, 2016.
  22. “Traumatic Brain Injury: Causes, Symptoms and Diagnosis.”” (October 2014). Medical News Today. Accessed December 25, 2016.
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  24. “Drug Abuse in Athletes.” (August 2014). Substance Abuse and Rehabilitation. Accessed December 25, 2016.
  25. Returning Veterans with Addictions.” (July 2011). Psychiatric Times. Accessed December 25, 2016.
  26. “‘Prison Guards Can Never Be Weak’: The Hidden PTSD Crisis in America’s Jails.” (May 2015). The Guardian. Accessed December 25, 2016.
  27. “Brain Changes in an Addict Make It Hard to Resist Heroin And Similar Drugs.” (February 2014). Washington Post. Accessed December 23, 2016.
  28. “‘Unbroken Brain’ Offers New Insights on Addiction.” (April 2016). NPR. Accessed December 23, 2016.
  29. “Five Studies: New Approaches in Treating Addiction as a Disease.” (September 2015). Pacific Standard. Accessed December 23, 2016.
  30. “Alternative Models of Addiction.” (2015). Frontiers in Psychology. Accessed December 23, 2016.
  31. [32] “The Neural Basis of Addiction: A Pathology of Motivation and Choice.” (August 2005). American Journal of Psychiatry. Accessed December 23, 2016.
  32. “Is Addiction Just a Matter of Choice?” (n.d.) ABC News. Accessed December 25, 2016.
  33. “Surgeon General Report Tackles Addiction.” (November 2016). Scientific American. Accessed December 25, 2016.
  34. “Is Addiction Really a Disease?” (December 2011). Psychology Today. Accessed December 23, 2016.
  35. “Addiction Is Not a Disease: How AA and 12-Step Programs Erect Barriers While Attempting to Relieve Suffering.” (July 2015). Salon. Accessed December 23, 2016.
  36. “Is Addiction a Brain Disease?” (May 2016). The Conversation. Accessed December 23, 2016.
  37. “Addiction and the Brain-Disease Fallacy.” (2013). Frontiers in Psychiatry. Accessed December 24, 2016.
  38. “Why It’s Wrong to Call Addiction a Disease.” (June 2016). The Guardian. Accessed December 24, 2016.
  39. “Addiction Is Not a Disease — And We’re Treating Addicts Incorrectly.” (July 2015). New York Post. Accessed December 24, 2016.
  40. “Addiction Is a Choice.” (October 2002). Psychiatry Today. Accessed December 25, 2016.
  41. “Addiction Is a Disease.” (October 2002). Psychiatry Today. Accessed December 25, 2016.
  42. “Current Cigarette Smoking Among Adults in the United States.” (December 2016). Centers for Disease Control. Accessed December 25, 2016.

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