Monday, 27 January 2014

Day 204: The Myth of Addiction

This morning, Eastern Canadian highways demonstrated that a small amount of very cold snow, if mixed with a large amount of wind, can remove meaning from an inter-city bus schedule.

And so it was that I arrived late to the Montreal tobacco trials today -- too late to witness first-hand how a small amount of indignation, if mixed with a lot of hot air, can liven up a Monday morning.

I am told that Mr. Simon Potter, who represents Philip Morris' Canadian operation, expressed his displeasure with the report published in Saturday's Montreal Gazette that the Non-Smokers' Rights Association was asking the Quebec college of physicians to review the appropriateness of Dr. Bourget's testimony at this trial.

Mr. Potter apparently felt that this was a form of "witness intimidation." 

Dr. Bourget has already testified, so I don't quite see how she could have been intimidated after the fact. Mr. Potter, on the other hand, has not. (In defiance of regular legal practice, he is slated to be both witness at this trial even though he is defence counsel in it.) Perhaps he felt that having the world learn that he was "inordinately fond” of roast beef, as the Gazette reported, was a way of intimidating him from making further such disclosures.

Nor is there any sign that 'witness intimidation' was the reason that two other Canadian medical professionals have been pulled from the defence list of  "addiction" witnesses. Mr. Potter recently informed the court that plans had changed and that Montreal psychologist Kieran O'Connor will no longer be testifying later this week. Dr. Alex (Dooley) Goumeniouk, a psychiatrist based in British Columbia, had been dropped from the list several weeks ago.

Pulled from the defence schedule:
Psychologist Kieran O'Connor
& Psychiatrist Alex Goumeniouk
The expert opinions they wrote for the trial remain public documents, as far as I know, although they are currently hard to access. Those who are interested in receiving a copy of their reports can contact me.  

Let's try again!

Today's witness, Mr. John Booth Davies, is thus the tobacco industry's second and the last chance at expert opinion to support their position that almost 1 million Quebec smokers do not suffer from addiction. 

Although his position is not that different than that expressed by Dr. Bourget last week (his conclusions are pasted to the end of this blog), in every other respect Mr. Booth left a very different impression than she did. 

Professor Emeritus
John Booth Davies
To begin with, Mr. Davies is very personable - like one of the eccentric-but-loveable characters in a British comedy like Marigold Hotel or Quartet. Although he is not much older than many other witnesses (he is not yet 70), his manners suggested he came from earlier distant times. (The accent didn't hurt!)

The choice of lawyer assigned to him accentuated this quality of old-worldliness. Ms. Sonia Bjorkquist has a charming and youthful affect. She put her questions to her witness with the same soft kindness that I have watched in social workers interviewing the frail elderly and journalists interviewing aging veterans. 

Justice Riodan echoed this deferential and sympathetic tone, addressing the witness as "sir" and making sure that his physical needs - like a handkerchief - were seen to. By their relaxed body language and gently-phrased questions, the plaintiffs also signaled their acceptance of this witness. I am sure that I was not the only one who thought Mr. Davies would make a fine dinner companion! 

During the voir dire, Ms. Bjorkquist and then Mssrs. Pierre Boivin and Philippe Trudel gave Mr. Davies the opportunity to outline his career as a psychology professor and addiction specialist at Glascow's Strathclyde University, including his many published books and articles. (His CV is Exhibit 21060.1). His most central view on the topic is laid out in his book the "Myth of Addiction", whose message is described by the bookseller Amazon as "addicted behaviour is therefore a form of learned helplessness, not an effect caused by narcotic intake."

Not exactly a friend of industry

Mr. Davies told the court that he was recruited to this trial because the "Myth of Addiction" had brought him to the attention of Mr. Dennis Neutze, a lawyer assigned to witness development for Imperial Tobacco's parent company, BAT. It was only after he finalized the paper commissioned by Mr. Neutze that Mr. Davies was put in contact with Imperial Tobacco's defence lawyers at Osler's. Left hanging was the question of how many other papers from other witnesses-in-development might have been commissioned before this one was selected.

The retired professor said he "had to think about it a long time," before agreeing to testify. His reasons for doing so suggest that he was motivated by end-of-career feelings of tasks not completed. "This case promises to be extremely influential," he said, and a way to "send a message to the world" which challenged the "deterministic pharmacological model on drug use."

Mr. Davies seemed startled by suggestions that his clients might have had any influence on what he wrote. "If there had been, I wouldn't be here."  "I would not wish to be any closer to the tobacco industry than I am at the moment."

Mr. Trudel  pointed out that this is not the first time he has been embroiled in questions about industry influence. As editor of a journal on addiction, Mr. Davies had declined to agree to the Farmington consensus (Exhibit 1686) developed by other addiction journal editors that they would require their authors to disclose their sources of financing. Mr. Davies repeated today the views he had earlier expressed (Exhibit 1687) that such requirements blurred the line between science and morality.

He hinted at strong reservations about the influence of the pharmaceutical industry on tobacco research. He pointed to the long line of pharmaceutical consultancies declared by Karl Fagerstrom and John Hughes (Exhibit 1682), but seemed reluctant to put on record his views on what impact this might have had on their conclusions. "You can read it for yourselves."

He did express concern about the promotion of varenicline (Champix) as a stop smoking medication, given its link with "suicide ideation and suicide attempts.”  I wondered if anyone had told him that the same lawyers who launched this class action are also fighting a class action against the makers of Champix for those same reasons. 

A defender of science

Mr. Davies made frequent suggestions that science was poorly served by other researchers in the field of addiction. 

An article by the head of the U.S. National Institutes of Drug Abuse ("Drug addiction: the neurobiology of disrupted self-control", Exhibit 21061) was denounced as a "sleight of hand." There was emotion in his voice as he claimed this paper "sacrifices science in the interests of making an argument that is ideological and not scientific."

He later pleaded that the rudiments of experimental science were being lost in modern times. "Science is not defined by long words we cannot spell. The principles of science can be written on the back of an envelope. I believe that sections of the population define science precisely in terms of those things -- here is a big machine and a man has a white coat on so it must be true!. That is a fundamental error."

He cautioned that others who researched addiction did not adequately understand the need for a measurable "outcome variable."  He included the opinion prepared for the plaintiffs by Dr.Juan Negrete, Exhibit 1470.1 and 1470.2, in this category. 

"You can't cross-reference addiction against dependence because they are both concepts – I can't see either of them." He also disagreed with Dr. Negrete's description of the impact on smokers. "Words are too emotional. It's not about feelings and emotions - science is about facts."

Attribution theory and the addicted state

At the core of Mr. Davies' views is a focus on "the explanations people give for their actions."  (Expert Report, Exhibit 21060)

He explains that Attribution Theory allows drug use to be examined in the context of the "discourse" that smokers offer as they explain why they use substances. To speak of addiction relieves individuals of the ability to quit, he argues, and to say someone "can't quit" is to be unscientific. "We cannot, however, observe that a person cannot stop; only that they failed to do so."

Mr. Davies suggested that there was no qualitative distinction between addicted and non-addicted substance use. "If we like a drink on occasion, we have something in common with those at the other end of the (alcoholic) spectrum."

It was not addiction or compulsion that drove smoking behaviour, he said, but the time-lag between the pleasure of smoking and its "negative reinforcers". "The satisfaction of smoking a cigarette now outweigh the possible valence of lung cancer late in life." 
He acknowledged the neurological properties of nicotine, and described the chemical bonding of nicotine to receptors in the brain. But such "brain changes" were not a form of disease. Going down the street would result in brain changes, he said, "but this does not mean that I can't stop going."

He qualified that such changes were very localized, and not a form of intoxication. "it is not as if the whole brain is subverted ... attitudes, beliefs, motives stay much the way they were before."

He looked to memory, not brain activity, as a reason that people returned to the behaviour. "Like a cat that has tasted fish, a human who has tasted cocaine may be reluctant to give up." 

He said that the suggestion that smoking resulted in loss of autonomy was "helpful if you are trying to sue the tobacco industry." It was not very beneficial to those who might as a result lose belief that they could stop smoking, and harmful to "youngsters in deprived parts of cities,"  who might otherwise "change their self damaging behaviour."

A philosophical hold-out

Although the word "existentialist" was never used, I felt that underpinning Mr. Davies' opinion was the heady humanism that defined the social sciences in the 1960s. 

Like other products of that era, he spoke with compassion and concern about those who were economically or socially deprived. He identified the gap between upper-class academics (although his accent suggests he could be considered one) and disadvantaged drug users. No other witness has brought class into this trial so acutely. 

He rooted his distinction between voluntary and involuntary actions in philosophy. "The philosophical difference between something that is impossible and something that is difficult to do is fundamental. ... difficulty is in a different phenomenological realm than impossibility."

Mr. Bjorkquist is expected to finish her questions for Mr. Davies tomorrow morning. The cross-examination will follow. On Wednesday, a few procedural issues will be discussed. 

John Booth Davies' conclusions

• Smoking can be a difficult behaviour to quit, but not an impossible one.

• Smoking is action. That is, it is goal directed and purposive; it does not simply 'happen to' people.

• The idea of smoking behaviour as deriving from a pharmacologically-driven compulsion over which there is no control does not fit the facts.

• Smokers have quit the smoking habit in very large numbers and continue to do so.

• By far the largest majority of smokers who quit smoking do so without help (e.g. psycho-therapy, counselling, nicotine replacement therapy, etc.) of any kind.

• Not all smokers experience withdrawal symptoms, and such symptoms do not predict either relapse or successful quitting.

• The pharmacology of nicotine explains brain processes, but does not explain the reasons why people smoke, nor does it predict future behaviour (i.e. continuing to smoke or quitting) with regard to smoking