When Habits Slip their Leash

For another, the addict’s thinking and perception change over time. In the end, he seems unable to interpret what he is doing realistically. Those close to him may be aware that he has a serious problem, and know exactly what that problem is. But the addict himself doesn’t seem to see it. He has lost his perspective. Clinicians call this acquired blindness denial.

How can we best account for all these quirky features – the loss of control, the persistence, and the denial? Here’s a way that’s not so obvious: compare addiction to another out-of-control process – cancer.

On the face of it, lining these two things up side by side may seem absurd. They’re obviously very different things. And yet they do share a common feature. They both result from a gradual loss of control, a loss that happens in a series of predictable phases. To be sure, cancer is a disorder of cells, and addiction is a disorder of habits. But the process through which these different disorders develop is virtually identical. Clarifying that common process is the objective of this essay.

A failure of understanding

How do experts understand addiction now? The conventional wisdom is that exposure to “addictive substances” changes the brain, creating a craving for those substances. According to a 2018 statement by NIDA, the National Institute on Drug Abuse,

Addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The initial decision to take drugs is voluntary for most people, but repeated drug use can lead to brain changes that challenge an addicted person’s self-control and interfere with their ability to resist intense urges to take drugs. These brain changes can be persistent … 1

Were this “brain changes” explanation adequate, we would expect it to reduce incidence and spawn effective interventions. Yet addictive disorders are rampant. In fact, they are on the rise. According to a US Department of Justice statement, “The abuse of several major illicit drugs, including heroin, marijuana, and methamphetamine, appears to be increasing, especially among the young.” 2 This failure is reason enough to doubt whether we really understand these abnormal habits.

Denial and distortion

The common denominator of all addictions, whether they involve substances or not, is denial.  Entering into the pattern somehow distorts the addict’s perception of what’s happening to him. To be specific, it changes his perception in a way that permits him to continue the habit.

To illustrate, most treatment professionals believe that unusually dense denial is “one of the defining characteristics of the chronic alcoholic.” 3 Though the havoc wreaked by alcoholism is generally obvious to others, the alcoholic himself often seems blind to the reality of what’s happening to him.

But “denial” doesn’t simply mean saying “I’m not an addict,” though many addicts do say things like that. It’s common for an addict to see a problem, but to see it in a strange way that allows them to continue what they’re doing. An alcoholic may think, “Okay, I guess I’m drinking too much. That’s because I’m under a lot of stress right now.” Another may tell a concerned spouse, “Fine! I drink too much! Mind your own business. You’ve got plenty of faults yourself!” The common thread among all the varieties of denial is a change in perception that allows the pattern to go on.

As author Albert LaChance emphasizes in his book Cultural Addiction, denial is the defining characteristic not just of alcoholism, but of all addictive processes. The specific form the addiction takes is not as important as the fact that it is without exception rooted in a retreat from the truth. And that retreat takes a form that allows the pattern to continue. 4

The conventional wisdom – the “brain changes” idea – doesn’t really explain denial. Nor does it account for purely behavioral addictions – the so-called “process addictions” manifested in excessive shopping, gambling, or pathological involvement with pornography. These behavioral addictions are quite similar to chemical addictions – including that mysterious denial. Yet they don’t involve exposure to any chemical substances at all.

Crossing a boundary

We need a better way to make sense of addictive behavior. At a minimum, the explanation must (1) account for the gradual emergence of denial; (2) make sense of the habit’s persistence in the face of the destruction it causes; (3) explain process addictions; and (4) point to ways of bringing addictive patterns under control. As it turns out, a better explanation is within reach. But there’s a catch. To grasp it we must step over a boundary that we aren’t used to crossing.

The line to cross is the one that has traditionally separated physical illness from behavioral illness We have been taught to believe that these things belong to different realms. We normally interpret diseases in terms of bodily dysfunction. And we commonly associate behavioral problems with defects in psychological constructs like morality or willpower. To truly understand addiction we must bring the two together. We must think in terms of behavioral disease – not just as a metaphor, but as a fact. If the idea that behavior could be diseased seems alien, that’s partly because of the limits built into the science of psychology itself.

An incomplete psychology

Our current psychology artificially and misleadingly divorces animal behavior from animal biology. But in truth animal physiology, behavior, and cognition are all different aspects of the same life processes. 5, 6 Similar disease processes can and do exist within each.

Is addiction an actual disease?

Lots of people – even professional people – interpret addiction as a moral failure. They believe indulgence is entirely voluntary, no more than a disgustingly irresponsible lifestyle choice. Psychologist Jeffrey Schaler, for example, says “Addiction is a behavior and thus clearly intended by the individual person. What is obvious to common sense has been corroborated by pertinent research for years.” Schaler believes it’s a mistake to tell addicts they have a disease, because it “may encourage them to abandon any attempt to take responsibility for their actions.” 7 If addiction is indeed just irresponsible behavior, this advice would make perfect sense.

But others reject this “moral failure” interpretation. 8 They correctly note that centuries of moral condemnation haven’t reduced the incidence of addiction. Further, they point out that not all behaviors are voluntary. Sneezing is a behavior, but it’s mostly involuntary. Many involuntary behaviors are caused by disease. Skipping work is a behavior. But there’s a big difference between skipping voluntarily because you’d rather go to the movies, and skipping involuntarily because you’re down with the flu. Could it be that the failures we associate with addiction are involuntary, rooted in illness? Is addiction some kind of actual disease? Is it a chronic, involuntary disease?

In a widely quoted 2001 review, researchers Thomas McLellan and his colleagues formally compared drug dependence to three chronic diseases – diabetes, hypertension, and asthma. They considered causes, heritability, and environmental factors. McLellan found a great deal of similarity, and concluded that drug dependence (including alcoholism) should be interpreted as chronic illness. 9

Other scientists aren’t committed to the “brain disease” explanation because they don’t believe we have accumulated enough evidence to support that idea. Psychologist Wayne Hall and colleagues write that at present the disease notion is pointless,  because it “is not supported by animal and neuroimaging evidence to the extent its advocates suggest; it has not helped to deliver more effective treatments for addiction; and its effect on public policies toward drugs and people with addiction has been modest.” 10

Diseased habits

Neither the “normal habit” nor the “brain disease” interpretation can explain the peculiar features of addictive behavior. Although few deny that addictions are habits, their frustratingly intractable character makes clear that they aren’t normal, voluntary habits. And though few deny that addictions have disease-like features, the reality of process addictions undermines the brain disease argument. Addictions have features of both diseases and habits. Maybe we should think of them as diseased habits.

But how can a habit come to be “diseased?” In the same way that one of our bodily cells comes to be cancerous.

Cancer is a disease like no other. This disease is special, because it involves the gradual transformation of a normal and helpful part of ourselves into something abnormal and hurtful. A healthy cell becomes malignant. Unlike a disease caused by the invasion of an agent from outside ourselves – for example a foreign bacterium or virus – cancer arises from within. Addiction is like that too. It arises from within. An ordinary habit, a normal and helpful part of us, is gradually transformed into something abnormal and malignant. The uncanny similarity in the way this happens invites us to understand how habits can become diseased.

With that groundwork laid, let’s recount in detail the process by a normal habit becomes an addiction. Then we’ll compare that process to the way a normal cell turns cancerous.

The phases of alcoholism

Any addiction develops in stages. Take alcoholism, for instance. The late Vernon E. Johnson, a recovering alcoholic himself, found a good use for his intimate, first-person knowledge of the process. Johnson became an alcoholism expert, and wrote several insightful, practical books about it. He provided a detailed description of the phases through which a normal person passes on his way to being an alcoholic. Quite significantly, Johnson assigns a central role to denial, the alcoholic’s gradual loss of perspective on the pattern that is consuming him.

The three major phases Johnson describes are these: Discovery, Incubation, and Final Pattern. 11 Briefly, here’s what’s going on in each:

• Discovery. The person first experiences the benefits of the behavior that will later become addictive. The benefit could be relief – for example relief from stress or anxiety. Or it could be a new positive experience – for example uninhibited fun. The important thing is that upon experiencing this benefit, the individual has found a good reason to repeat the behavior. The hook, so to speak, has been set. Without Discovery, there could be no alcoholism.

• Incubation. The drinker adopts a normal, voluntary habit, one that he repeats often. As with any normal habit, with repetition the individual components of the drinking pattern are progressively adjusted so that they work together smoothly. Over time, the elements of the habit – what is drunk, how much, when and how it is drunk, and with whom – are fine-tuned to work with each other to support its continuation.
  
  During this second stage the drinking becomes a well-defined habit, but it is still voluntary. The individual may continue to meet most of his responsibilities. Even so, he has adopted a routine that revolves around drinking. It’s at this second stage that the vast majority of drinkers become aware that they are dancing on the edge of something dangerous. Significant drinking is not all fun and games. It has negative consequences – for example impaired functioning, hangovers, and miscarriage of responsibilities. Realizing the danger, the majority take steps to avoid falling into the bottomless pit of full alcoholism.
  
  Others fail to stop their descent. They find ways to deny, excuse, or minimize the negative consequences they experience. Though they may not know it, in discovering ways to quiet these concerns they are progressively yielding control of their drinking.

• Final Pattern. This is the phase of full alcoholism. Now the drinking is causing major problems in the alcoholic’s life – degradation of health, disruption of important relationships, and impairment of job performance. Before this point, drinking was something the drinker was doing. Now drinking is something that is doing the drinker. His problem is apparent to almost everyone. Bizarrely, though, the alcoholic’s perception is different. He can no longer recognize the problem because he has lapsed into full denial. His capacity to sort out what he is doing, the very basis for his supervisory control over his habit, has been broken. He is deeply in the grips of a malignant, self-perpetuating drinking pattern. At this point he is drinking to escape his misery; yet his drinking creates more misery. And his diminished awareness prevents him from coming to grips with the self-renewing cycle.

A problem that evolves

Alcoholism starts as something small and harmless – just an experiment, really. The drinker voluntarily adopts the harmless drinking as a regular habit. But over time that habit changes its form. It evolves to become something far more dangerous. A critical part of that evolution is a clouding of the drinker’s awareness of the growing problem. He gradually loses his perspective, finding it increasingly more difficult to evaluate what the habit is doing to him. In its final form alcoholism is literally destroying his life. The final alcoholic pattern renews itself endlessly outside the alcoholic’s awareness or control.

Although we have used alcohol addiction to illustrate the three major phases of addiction, these phases are common to addictions of any kind. Normal habits evolve into addictions as they progressively escape our ordinary means of regulating habits. When it comes to habits, our ordinary means of regulation is our ability to be fully aware of what we are doing.

What we call denial is simply the loss of our ability to be fully aware of what we are doing. Denial is a progressive failure of attention. When we can no longer snap to what’s going on, the habit is no longer under our control. It is the gradual failure of controls that turns a normal process into an abnormal one.

Now that we have outlined the process by which we lose control, we can formally compare it to cancer.

Comparing addiction to cancer

Cancer is the abnormal, uncontrolled growth of cells; addiction is the abnormal, uncontrolled growth of a habit. Though cells and habits are very different things, the process by which each becomes malignant is virtually identical. Both cells and habits become “diseased” when they escape their normal controls. Curiously, the escape comes about through a process of evolution.

Uncontrolled growth                            

A cancerous cell reproduces itself over and over to become the mass we call a tumor. These abnormal cells have escaped the regulation of the body that harbors them. No longer governed, cancerous cells replicate themselves endlessly at the body’s expense. They are no longer a part of the disciplined team of cells that makes up the body. We could say the cancerous cells have come to behave “selfishly,” in that they work to benefit themselves only. They have in fact turned into parasites, sapping the body’s resources to promote their own interests. So the term Rogue Cells describes them very well.

Compare this picture to what we see with addiction. An addiction is essentially the abnormal, uncontrolled growth of a habit. A habit has somehow escaped regulation, coming to reproduce itself endlessly at the expense of the behaving individual.

Normal habits serve the individual’s interests. Each normal habit plays a role in satisfying that person’s needs. But an addiction is far from normal. It has slipped away from the usual controls on habits, and has begun to repeat itself over and over. Like the cancerous cell, this kind of habit has come to behave as a parasite. It is selfishly sapping the individual’s resources (and the resources of friends and family) simply to keep itself going. The term Rogue Habit is descriptive.

blind evolution

Cancer demonstrates a strange disregard for the health of the cancer patient. Cancerous cells often end up killing the patient. But of course if the host dies, the cancer dies with it. By what logic would a cancer destroy itself? That’s an important question. The answer is that cancer’s rush to “go down with the ship” is the universal logic of diseases. All diseases exploit their hosts, and many are deadly.

Cancer cells don’t have eyes or brains to direct them. Cancers have no way to know they are killing their host. Neither do they know they will die with the host. The evolutionary process that produces them is blind and stupid. The growth of a cancer is guided only by natural selection. That is, what we call a tumor is a mass of cells that have survived and reproduced best within the body. The tumor can’t know that the process that created them will kill them in the long term.

The same is true of habits. During the incubation stage of addiction, the varieties of a habit that best provoke its repetition are the ones that come to prominence. Like the cancer cell, the evolution of an addiction is blind and stupid. The final form emerges guided only by natural selection. In the end, the variants of the habit that prove most resistant to supervisory control are the ones that are repeated. Knowing this, we can guess why addictions can be so destructive, yet persist so doggedly. The pattern exactly mirrors cancer.

Immortal cells

The normal cells of our bodies reproduce themselves by splitting. They are like bacteria in this respect. They replicate themselves by dividing in two. This is good, because tissues need to regenerate themselves. If you cut your hand, for instance, the cut needs to heal. It is able to heal because uninjured cells can split to replace the damaged ones.

But normal cells are allowed to divide only a limited number of times. Nature has built this limit into each cell. Every cell’s chromosomes are capped with a DNA strand called a telomere. With each division the telomere gets a little shorter, counting down to zero. When the count reaches zero the cell line is toast. Its reproducing days are over. If cells could somehow keep their telomeres from getting shorter, they could stay alive forever. Then they could continue to divide, replicating themselves without limit. Cancer cells do just that. They are immortal.

If immortality sounds impossible, it’s only because we’re used to thinking that living things die because they “wear out.” But cells don’t wear out. They merely wear out their welcome in the body. A line of cells passes away because they reach the built-in limit on the number of times they are permitted to divide. This is called programmed senescence.

The body limits cell division for a most excellent reason. The longer a cell keeps splitting, the more mutations it undergoes. Each mutation produces a variant cell. And some of these variants are pre-cancerous. Programmed senescence limits a cell’s opportunity to mutate its way into cancer. In other words, the limit on division is a limit on its chance to go rogue. In fact, cells cannot become fully cancerous without overcoming this natural barrier. They must first become immortal. This is one of the body’s major controls on cancer. Without immortality every pre-cancerous cell line naturally fizzles out as soon as it reaches the built-in limit on division. 

But some pre-cancerous cells manage to sidestep this limit. How? A rare mutation allows them to “rejuvenate” themselves after each division by activating a cellular enzyme called telomerase. As reported by cancer researcher Kunitoshi Chiba and colleagues at the University of California, Berkeley 12 the telomerase enzyme is a normal component of cells that “keeps chromosomes healthy in cells that divide frequently. The enzyme lengthens the caps, or telomeres, on the ends of chromosomes, which wear off during each cell division.” 13, 14 When the telomere caps get too short, cancer cells misuse telomerase to lengthen them. According to these researchers, about 90 percent of all malignant tumors use telomerase to achieve their immortality.

Immortal habits

Let’s compare this built-in limit on cells to the built-in limit on habits. The story is much the same. Addictions are habits that have found a way to endlessly provoke their own repetition. Each and every repetition opens the door to yet another repetition. We can compare such self-renewing habits to cells that have become immortal. Normal habits don’t provoke their own repetition, and they certainly don’t repeat themselves endlessly. Normal habits are activated when there is a need for them, and they are inactivated when that need is filled.

Think about playing a musical instrument. We may play a beautiful chord during a piece of music. Our fingers execute this chord by habit, filling our momentary need for it. With that temporary need filled, the execution of the habit stops. We move on to the next chord. We don’t get “stuck” in that chord, reproducing it endlessly.

But addictions are all about getting stuck. Endless reproduction is the essence of an addictive habit. It persists when there is no need for it – even when its continued execution is destroying our lives. If we can’t stop playing that single chord we have no chance of making beautiful music. An addiction is a habit that has found a way to live forever, without regard to any realistic need for it. Its immortality is what marks it as a rogue.

But how can a habit come to reproduce itself endlessly? The answer is the same as with cancerous cells. Occasionally a habit manages to throw off the built-in controls on its action. It slips its leash. The most important of those controls are limited lifespan and the immune function of attention. Addictions and other rogue habits first stumble upon a way to extend their lifespan – to get themselves repeated more often than normal.

Alcoholism, for example, is said to be a process revolving around the experience of misery. Indulgence provides temporary relief from misery; but at the same time indulgence creates more misery. It’s a self-invoking cycle. Over time, with frequent repetition, a habit evolves more and more effective ways to ensure its own continuation. One of these ways is disrupting our ability to snap to what we are doing. To the extent that we lose the awareness of what we are doing, we lose control. How can this happen?

On autopilot

Attention and habits are intimately related, a fact that has been recognized by theorists for hundreds of years. It is with attention to detail that we begin forging a new habit. In the 1890s famed American psychologist William James carefully described the interplay between attention and habit. “A strictly voluntary act,” he wrote, “has to be guided by idea, perception, and volition, throughout its whole course. In an habitual action, mere sensation is a sufficient guide, and the upper regions of brain and mind are set comparatively free.” 15 Once a habit is well-established we don’t have to pay much attention to it anymore. An established habit, in other words, runs pretty much on autopilot.

James believed that turning over routine behaviors to the autopilot of habit was much to be desired. As he put it, “The more of the details of our daily life we can hand over to the effortless custody of automatism, the more our higher powers of mind will be set free for their own proper work.” 16 In this sense the mindlessness of ingrained habits is an unequaled blessing. The ability to turn parts of our behavior over to semi-autonomous habits is a human capability without which the complexity of life would surely overwhelm us. It is learned habits that allow us to perform fluidly and effortlessly while managing the thousand threads of activity woven into the fabric of our daily lives.

The academics of our own time generally endorse James’ conclusion about the governing role of awareness. Consciousness theorists Gerald Edelman and Giulio Tononi say,

The pervasive automatization in our adult lives suggests that conscious control is exerted only at critical junctures, when a definite choice or a plan has to be made. In between, unconscious routines are continuously triggered and executed, so that consciousness can float free of all those details and proceed to plan and make sense of the grand scheme of things. In action as well as in perception, it appears as if only the last levels of control or of analysis are available to consciousness, while everything else proceeds automatically. 17

All habits must be constructed under our full attention. But once a habit has solidified we reduce our attention to a tiny sliver, just enough to turn it on and off according to our needs of the moment. We continue to be aware of what we’re doing, but that awareness is no longer full. Though born in the full light of attention, habits normally recede into the shadows to execute on their own. As a habit matures over time, our awareness of our actions becomes remote, distant – almost unconscious. Routine supervision requires only a trifling piece of our attention.

Yet the control sustained by that bit of attention is all that keeps our behavior working in our own interest. It is this shard of remaining awareness that ensures our habits function as intended. Research has shown that an operating habit can be altered only when it is returned to our full attention. When a habit starts to turn dysfunctional, it is only our ability to detect it, to bring it back to full awareness, that stops it from screwing everything up. Bringing it to awareness, we can make a conscious judgment as to how it should be altered, or whether it should be eliminated entirely.

Returning a bad habit to our attention is like noticing that our car is running poorly, and taking it into the shop. As long as we keep mindlessly driving the sputtering vehicle down the road, there will be no repair. But habits never decide on their own that they need to be changed. In the same way that cells become cancerous by evading the body’s normal controls, habits gain the ability to perpetuate themselves endlessly when they evade the governance of attention. If a habit can dodge attention it can’t be changed.

In the last decade or so researchers have been surprised to discover that Autism Spectrum Disorders (ASD), Attention Deficit Hyperactivity Disorders (ADHD), and Obsessive Compulsive Disorders (OCD) — syndromes marked by repetitive, nonsensical behaviors — have something in common. Although the superficial symptoms are different, say researchers, the affected individuals all have difficulties properly focusing their attention. 18 It is that inability that permits their unproductive habits to form and persist.

This is our Achilles heel. If a habit can somehow avoid the spotlight of attention, it can escape our control. The habit can become an addiction – or some other self-perpetuating behavior. Without governance, it can morph into a pattern that repeats itself without reason or limit, with destructive effect.

Attention and psychotherapy

Self-perpetuating patterns are a topic of special interest to psychotherapists. Many clients come into therapy because they are caught up in repeating patterns that make no sense. Focused attention often leads to positive change, so the job of the therapist is to help them shine the light of their awareness on what’s going on.

There are a variety of reasons why clients are unable to focus their attention. Sometimes renewed attention leads to overwhelming emotional pain. This is the case, for example, with post-traumatic stress. Traumatized individuals frequently develop post-traumatic stress disorder (PTSD), in which the memory of the traumatic event becomes a shadow that haunts and disrupts victims’ lives without ever coming to their full awareness.

As trauma expert Bessel van der Kolk notes, PTSD makes life a miserable experience. People who have experienced severe abuse as children, for example, have a 4 to 12 times greater risk for developing alcoholism, depression, drug abuse, and suicide attempts. Further, they are much more likely to succumb to physical diseases like heart disease, cancer, chronic lung problems, bone fractures, stroke, diabetes, and liver disease.

Worst of all, it’s common for the sufferer to be repeatedly re-traumatized in a similar way throughout her lifetime. She finds herself in the same fix over and over, without seeing why. For example, women physically abused as children unaccountably end up in relationships with batterers over and over. Psychoanalyst Sigmund Freud was “fascinated with the issue of patients’ apparent compulsion to arrange their lives in such a way that they would repeat their trauma over and over again.” 19

Research suggests that the symptoms of PTSD persist largely because the sufferer finds it almost impossible to focus her attention on the traumatic events without being overcome by emotional distress. She remains “stuck” in the trauma because she is unable to psychologically process it in a normal way. Her inability to bring it to full awareness becomes an almost insurmountable barrier to achieving a meaningful perspective on her experience, and communicating that perspective to others.

trauma resolution

Because this barrier is the reason for the repetition, one effective approach to resolution is preventing emotional overload from disrupting attention. Van der Kolk says,

In order to help traumatized individuals process their traumatic memories, it is critical that they gain enough distance from their sensory imprints and trauma-related emotions so that they can observe and analyze these sensations and emotions without becoming hyperaroused or engaging in avoidance maneuvers … In recent years, a variety of new techniques have been developed that have the potential of desensitizing patients with PTSD without requiring them to fully engage in a verbal reliving of the traumatic experience. Of these treatments, EMDR [eye movement desensitization and reprocessing] has been best studied. 20

PTSD is one example of the trouble caused by inability to focus attention. But it is just one example. More generally, habits are automatons. These little behavioral “robots” are normally a blessing, but their relative independence can turn them into a curse. A habit that escapes our attentional controls can wreak havoc on our lives.

Semi-autonomy

The “blessing and curse” of semi-autonomy is a principle that applies to our bodily cells just as surely as it does to our habits. A multicelled animal is a highly complex system. Each of the cells in our body largely controls its own activity. But it does so under the body’s remote supervision. You could compare a multicellular animal to the behavior of traffic. All the activity on the road is that of the discrete “vehicles” – the individual cells. Their collective action becomes the activity of the larger animal. All these cellular “vehicles” are operating semi-independently. This relative independence is the strength of any multicelled organism. With only minimal oversight each autonomously functioning cell does its part in maintaining the health of the larger animal.

Each cell type – liver, skin, muscle, etc. – is programmed to do its special thing more or less on its own, so it doesn’t require much direct control by the larger body. In fact, a complex multicelled organism could not possibly function unless almost all of the activity was managed locally, by the cells themselves. The traffic system wouldn’t work unless the drivers had control of their own vehicles. Only the individual drivers know where they are going, how to get there, why they are going there, and when they need to arrive. 21

That semi-independence is the strength of the system. But its weakness is the flipside of the same coin. Because they are only minimally supervised, individual cells are like dogs straining against flimsy leashes. They are able to break away. They can go rogue.

Our individual habits too are like drivers on a highway. As long as the road system is well-designed, the behavioral traffic will flow in an orderly way despite the semi-independent habits operating to suit their own needs and purposes. The flow will be orderly, that is, as long as the drivers behave lawfully, in keeping with the rules of the road.

But as we know, there are naughty drivers who disobey the rules – they speed, they drive recklessly, they drive drunk, they fix their attention on their cell phones instead of traffic. Because they are semi-independent, operators can drive irresponsibly. So law enforcement is needed to keep these troublemakers from ruining everything. Police are essential. And that brings us to the topic of the immune system.

The immune police

It isn’t possible to understand cancer without knowing something about the immune system. It’s one of the body’s most important tools for policing the activity of the individual cells. Immunity in fact serves as the body’s law enforcement agency. One of its many functions is to spot cells that seem to be getting out of hand, going rogue, and to deal with them. The human immune system is enormously capable at detecting pre-cancerous cells and eliminating the threat they pose to our bodies.

According to researcher Alka Bhatia and colleagues, cells that are just starting to misbehave are quickly recognized and killed by the immune system. This “enforcement” activity is routine, and can be regarded as part of the body’s business as usual. The system is largely effective. Yet pre-cancerous cells do occasionally find a way to slip past this first-line defense.

According to Bhatia, precancerous cells aren’t a concern until they escape immune regulation. 22 The word “escape” returns us to the central topic of this essay. It invites this question: how can a cell “escape” the immune system? The answer is provided by another research group, that of Kunitoshi Chiba. And that answer is nothing short of fascinating. Cells escape in phases similar to those we have just identified for rogue habits

Phases of cancer development

First, there is a mutation in the gene that regulates the cell’s use of telomerase. The mutation allows somewhat more liberal use of the enzyme, increasing the lifespan of pre-cancerous cells. These cells aren’t yet immortal, just living longer than they normally would. In this first phase, the mortality leash has been loosened a bit, but hasn’t yet been slipped entirely. That happens later.

As long as the cells continue to split, they continue to evolve. The longer lifespan gives the abnormal cells extra time to discover ways to keep themselves alive. This is like the incubation phase of habit development. The process of natural selection itself pushes them toward extending their lifespan. As they evolve, some find a way to “turn up” the use of the telomerase enzyme even more. When that happens they qualify as fully cancerous – immortal, and free to reproduce themselves without limit. “If cells fail to turn up telomerase,” say these researchers, “they also fail to immortalize, and eventually die from short telomeres …” 23

So the initial mutation that extends lifespan does not immediately bring immortality. But it opens the door to the evolution of immortality. With the advantage of their longer lifespan, some of the pre-cancerous cells do evolve full immortality. And immortality makes possible the refinement of the cell line’s resistance to immunity. The new power of unlimited divisions removes all limits to evolution by natural selection. The rogue cells have all the time in the world to build their resistance to the body’s immune system.

Something like that happens with rogue habits. Normally, habits are active only for a limited time span. Under the distant control of attention, they are called as needed and dismissed when the need no longer exists. Execution isn’t normally repeated enough to allow change into something problematic.

But habits do normally evolve. The more frequently they are called, and the longer they are able to stick around, the greater is their opportunity to develop forms that resist going away. Given enough time, any habit will evolve ways of encouraging the frequency of its repetition.

The relationship between attention and habits closely resembles the relationship between immunity and cells. As noted, the only thing preventing an unruly habit from going completely rogue is our capacity to bring that habit fully into our attention in order to correct it. Part of attention’s “business as usual” is detecting habits that are becoming dysfunctional, bringing them to full awareness, and making adjustments. A dysfunctional habit is not a cause for concern unless it somehow bypasses this first line of defense.

An arms race                                                                   

There is a built-in tension between cancer cells and the immune system. Before it becomes cancerous, the cell and the body are on the same team. Their interests are identical. They’re pulling for the same survival goal. But the interests of a rogue cell diverge from those of the body. Now their interests conflict. In order to stay alive, the developing cancer must defeat the body’s immunity. On the other hand, immunity must defeat the cancer or the body will perish. This conflict of interests creates a high-stakes arms race between the cancer cells and immune defenses. It is widely recognized that arms races favor the development of new technology. The arms race is the topic of Matt Ridley’s enlightening book, The Red Queen. 24

Cancer is deadly. This creates a strong selection pressure that drives evolution. So over the generations, a species evolves better and better immune defenses against cancer. But within the body, the immortalized cancer cells are reproducing like crazy – and on a much faster timescale. The proliferating cells are racing through multiple generations at breakneck pace, and they are evolving at a breakneck pace. Cells with weak resistance to immunity are quickly eliminated. That leaves only cells having greater resistance.

So through natural selection the cancer cell line evolves better and better ways of dodging immunity. Despite the body’s immunity – or more precisely because immune surveillance creates strong selection pressure – the cancer cells evolve ever more sophisticated ways of resisting immunity. The bottom line is that once the cell really gets rolling toward becoming cancer, it naturally evolves better and better tools to keep it rolling.

invisibility

The most important of these tools is invisibility. Over time, the immortal cancer cells get better and better at slipping unseen past agents of the immune system. The body’s immune agents are looking hard for the spreading cancer, but they can see nothing, so they can do nothing to stop it. Invisibility in cancer is directly comparable to denial in addictions.

Rogue habits arise in pretty much the same sequence as rogue cells. Like cells, habits naturally evolve over time. Once created, their effectiveness is continually improved. The mechanism by which habits are polished was summarized long ago by psychologist Edward L. Thorndike. Every habit is continually improved through natural selection. Each begins its existence as a rather crude behavioral sequence that is progressively refined through reinforcement.

Any evolutionary process requires both variation and selection. The exact form of a habit does vary a little bit each time it is expressed. As Thorndike made clear, the variants that lead to greater satisfaction are more likely to be repeated. The less satisfying variants are crowded out. This unending process of habit refinement is what we know as learning.

As a semi-autonomous habit continues to evolve, it may occasionally stumble across some random feature that encourages its own repetition. By far the largest class of such influences consists of things that throw a monkey wrench into focal attention. The reason for this is easy to understand. In order to change an existing habit we must return it to focal attention. If focal attention is somehow derailed, then the habit will be able to continue uninterrupted. That’s good for the habit, but bad for the behaving animal.

Process addictions

As with cancerous cells, habits go rogue in phases. In the first phase the habit acquires some trick that gets it repeated more often. Sometimes the pattern involves a chemical substance. But focusing on substances is something of a red herring, because the number of process addictions – those that do not involve substances – is many times greater than the number of substance addictions. One increasingly common process addiction involves computer gaming. We can use this as an illustration.

There’s nothing unusual about trying a new game. Maybe our friends are playing this particular game, and they tell us how much fun it is. So we try it. Now, designers of games strive to make the games addictive – for the same reason that the manufacturers of junk foods try to make their products as addictive as they can. The most profitable industries are based upon addiction, in any of its many forms. Examples are the tobacco, alcohol, and pharmaceutical industries.

So we come back to play the game again, over and over. Gameplay becomes a voluntary, regular habit. We have entered the second stage of the addiction, Incubation. Each time we voluntarily repeat our gameplay, the habit evolves a little. According to firmly established laws of learning, those variants of our habit that lead to the strongest satisfaction become the most repeated. So as we continue to play, the specific way that we indulge our developing habit naturally evolves to make our indulgence more and more engaging.

This is a way of saying that the habit, through a process of variation and selection, comes to encourage its own repetition. Subtle changes in the perception of what we are doing is one of the primary factors that bias us toward its repetition. As with alcoholism, this “fun and games” habit isn’t all fun and games. The more we play the game the less frequently we do other things – things that are important to us.

Suppose one morning we find that we have stayed up so late playing the game that we feel horrible – bleary-eyed and achy all over. We are so sleep-deprived that we can’t function at work the next day. And yet, indulgence in more gameplay tends to temporarily distract us from such negative symptoms. So we find ourselves making excuses that allow us to continue our involvement with the game. We also find ourselves snapping irritably at friends and associates who suggest that we throttle back our obsessive play.

All such players eventually reach a critical threshold, sort of a one-way turnstile. There are signs that we are too obsessed with this game – that it is taking up too much of our time, that it is interfering too much with other aspects of our life. It is at this point that most of us snap to the cost of the pattern into which we are descending. We return our full attention to what we are doing, and we decide to do something about it. It is at this point that the vast majority of players impose limits on the habit, and put those limits into practice.

But a minority of players find ways to dismiss those obvious concerns. They continue to enlarge the time and energy they devote to the game, with their slide lubricated by their expanding denial. Finally, the unfortunate player reaches a point where most of the important activities in his or her life are being neglected in favor of gameplay. Despite this serious impairment, the player remains oblivious. This is the Final Pattern of the process addiction.

All habits evolve as they are repeated. And the more they are repeated, the greater the number of variants they run through. This increases the odds that one of those variants will by chance come to provoke its repetition even more strongly. Over time, any habit will become more entrenched even if it is dysfunctional, simply because it gets more and more effective at provoking its own repetition. The immune function of attention is the only thing preventing it.

denial: evolved invisibility

The reason denial is invariably associated with addiction is that the primary control on habits is focal attention – when it comes to behavior, attention plays the role of the immune system. Habits naturally vary as they are executed. Those variants that impair focal attention are the ones that persist. A runaway habit gets better and better at impairing focal attention, simply because the most persistent variants are those that impair attention. Again this is a process of variation and selection.

The wayward habit and its attentional controls slip into an arms race, paralleling what happens between rogue cells and bodily immunity. The predictable product of such an arms race is invisibility. That is, the variants best able to sidestep immunity are those that are difficult to bring to attention. Just as with cancer, the variants that escape the immune police are the ones that proliferate. But when it comes to habits invisibility takes the form of inability to attend to the problem behavior.

Parasites, cancer, and addictions

A team of researchers recently discovered that tumors nourish themselves by feeding on the “stromal” cells of the surrounding tissue. The proliferating tumor draws nutrients and energy from these structural cells. Alarmingly, cancers are employing the same biochemical tricks that infectious parasites use. “An in depth analysis of this phenomenon,” say the researchers, “reveals that aggressive cancer cells are ‘parasites’ that use oxidative stress as a ‘weapon’ to extract nutrients from surrounding stromal cells.” 25

As we have seen, cancer cells are rogues, focused on their own survival. Their interest lies in reproducing themselves, not contributing to the health of the body. Like parasites, they ruthlessly exploit the body’s healthy tissues to support themselves, often killing their host in the process. Should cancers actually be considered a kind of home-grown parasite? Is use of that label justified?

Whether or not to regard cancers as actual “parasites” is a matter of considerable controversy at present. The controversy is not about whether tumors act like parasites – everyone seems to agree that they do. Rather, the controversy is whether they are new species. In other words, scientists are uncomfortable with the idea that some of the host’s cells have evolved into a parasite species that is no longer the host species.

Cancer theorists have been toying with this admittedly creepy idea for at least half a century. As early as 1956 biologist Julian S. Huxley straightforwardly asserted that “All autonomous neoplasms can be regarded as the equivalents of new biological species.” 26 More recently Mark Vincent of the University of Western Ontario published an article in the journal Evolution arguing that the emergence of a cancer is a bona fide Darwinian speciation event. As he points out, almost no one denies that cancer cells evolve to successive levels of fitness within their hosts. It’s just that they find the implications distasteful. 27

The speciation idea also makes sense to theorist Peter Duesberg and colleagues. He argues that genetic instability within a cancer cell line produces many variants. “Most of these perish,” he writes, “but a very small minority acquires reproductive autonomy – the primary characteristic of cancer cells and species. Selection for autonomy stabilizes new cancer species …” 28

There’s even more to this story. Some types of cancer continue to develop, eventually evolving into a full-fledged, transmissible, parasitic disease that can infect other animals of the same type. Two strains of this kind of “contagious cancer” are currently decimating the Tasmanian Devil population.

For our purposes it doesn’t matter whether or not we consider tumors new species. The important point is that they act just like parasites.

Parasitic habits

Now let’s return our attention to habits. It’s clear that full-fledged addictions also perpetuate themselves by exploiting the addict’s resources – even going so far as to usurp the resources of family and friends. The beginning point of every addiction is an ordinary habit. The ending point is a malignant, self-reproducing disease process that behaves as a parasite behaves. A habit that begins as a normal “part of us” can go rogue, evolving as cancer evolves to become something that is “not part of us” – an alien parasitic behavior pattern that reproduces itself at our expense. Again, the pattern starts as “something we do,” but ends as “something that does us.”

A direction for recovery

One reason for pursuing the analogy between addiction and cancer is that it suggests a logical path toward intervention and constructive change. We already know something about prevention, management, and elimination of cancer and other physical diseases. This existing knowledge suggests ways of dealing with addictions and similar behavioral patterns. Here are a few of those suggestions.

1. Assign responsibility realistically. As mentioned, some of us have been all too ready to blame the addict for his or her addiction. But blaming the victim for the disease itself takes us in exactly the wrong direction. Blaming simply creates guilt within the sufferer – creating an extra motivation to deny or hide the reality of the problem. 29 And that, in turn, supports its continuation.

If we accept that addiction reflects disease rather than irresponsibility, our readiness to blame must be adjusted to match this reality. Though willingness to blame the disease is in no way a stamp of approval for the behavior, the addict’s denial and distortion should be understood for what it is – inability to perceive the problem provoked by the problem itself.

2. Support general immunity. Immunity is the single most important issue in the control of any disease, physical or behavioral, because it is our naturally evolved means of controlling what goes on within us. When it comes to physical disease, research has shown that the effectiveness of our inborn immune responses depends upon a variety of factors, many of which are under our control. Some things contributing to cancer risk are consumption of alcohol, use of tobacco products, chronic inflammation, radiation (including excessive sunlight), exposure to foreign chemicals, poor diet, and obesity. 30 Psychological factors such as depression also contribute to vulnerability. Chronic depression is associated with both increased cancer risk and shortened survival time. 31, 32

Similarly, risk factors have already been identified for addiction vulnerability. To illustrate, it is widely recognized that people whose lives are unsatisfying or painful are more likely to develop repetitive, unproductive habits, including drug addiction. Less well known is the fact that the same principle applies to every higher animal. Animal research shows the emergence of repetitive, stereotypical, addiction-like behavior is “an invariant consequence of experiential deprivation or restriction of all species tested.” 33 Recognizing the continuity between human addiction and this universal tendency toward the emergence of repetitive habits is a source of real insight.

A series of studies performed by psychologist Bruce K. Alexander confirms that frustration of natural, inborn impulses strongly biases animals toward the use of drugs. 34 It certainly makes sense that when drugs are available animals would learn to use them to escape misery, just as people do. Though some chemical substances undeniably carry addictive potential, that potential is most likely to be realized when life is otherwise bleak. When living conditions severely limit ability to satisfy inborn needs, any higher animal is likely to begin engaging in repetitive, unproductive, stereotypic behavior – the same kind of behavior we associate with drug addiction.

Working with animals, researchers Schenk et al confirmed that “environmental factors play a major role in determining individual differences in the propensity to self-administer cocaine and that, as such, they should be considered more seriously by those interested in the basis and treatment of drug abuse.” 35 Likewise, Solinas et al performed a very carefully controlled study comparing mice raised in enriching environments to mice raised in barren laboratory cages. Their results clearly suggested that “exposure to positive environmental conditions during early stages of life can greatly influence brain functioning and can provide protection against the effects of addictive drugs.” They conclude that mice raised in rich environments “are protected against the effects of cocaine.” 36

Taken as a whole, such studies suggest that one way to generally enhance behavioral immunity is to provide rich and satisfying living conditions. We can generally “immunize” people from addiction by supporting their ability to lead good lives. This is a point that is often neglected in the literature on addiction.

3. Educate the public. In dealing with a disease process of any kind, a bastion of immunity is public awareness of the nature of the disease, its manner of transmission, and ways of handling it. In this context education is a critical part of general immunization against rogue habits. Education creates awareness. And awareness is like bug spray to a disease-carrying bug. Education is absolutely essential for creating that awareness.

4. Deal with environmental factors. Environmental factors include such things as readily availability of drugs and other addictive products, unsatisfying and hopeless lives, models for use, and disinformation programs created by addiction-based industries. We have noted that addiction is not possible without the Discovery phase, in which the user first experiences benefits. The incidence of Discovery can be reduced by decreasing the availability of addictive products, by making lives more satisfying without the addictive product, by increasing public awareness of dangers, and by holding accountable industries that seek to profit from the deliberate creation of addiction.

Although it seems inconceivable, about 650 million individuals currently alive in the world will die from cigarette-related illnesses. That’s the equivalent of every single man, woman, and child in the United States, the United Kingdom, France, Germany, and Russia dead – a doomsday scenario more horrific than our worst nuclear nightmares. The World Health Organization projects that 450 million people will die from smoking in the next 50 years, and about a billion people in this century. That means more than 5 million people worldwide die each year from smoking—a number that will increase to more than 10 million a year by 2020. 37

That’s a death toll so immense that it’s hard to wrap one’s head around it. Within a single generation more lives will be lost than in a world-wide nuclear war. A recent study published in the New England Journal of Medicine estimates that 556,000 Americans die each year as a result of cigarette smoking. 38

Tobacco executives are killing more people than Hitler, with no meaningful change in sight. The absence of awareness or concern closely mirrors the denial so typical of addiction. Cigarettes are still readily available, and tobacco addiction is commonplace. Tobacco companies are still enormously profitable. A big environmental factor maintaining the status quo is the disinformation generated by tobacco companies themselves. In complete disregard of the facts, they continue to portray smoking as an individual lifestyle choice. The resulting illness and deaths are interpreted by the public as the fault of the consumer, who “should have known better.”

Such disinformation stymies our ability to expand our awareness to encompass the true problem. Expanded awareness is necessary for greater industry accountability, which would in turn reduce the availability of cigarettes and other nicotine-based addictive products, and stem the flow of industry disinformation. Of course, this principle applies to every other addiction-based industry as well – the alcohol, pharmaceutical, sugar, and pornography industries, to name just a few.

5. Immunize against specific addictions. We have noted that life satisfaction – the experience of personal fulfillment – confers general behavioral immunity. But it’s also possible to confer specific behavioral immunity. There is a good parallel here with inoculation, which protects against specific diseases. Just as we can teach our bodies to recognize and defend against specific pathogens, we can learn to recognize and avoid paths leading us toward specific forms of addiction.

In the past, tobacco companies tried to get children addicted to cigarettes as early as possible, 39 because they knew instilling the habit would be more difficult after they had learned the facts about nicotine addiction. It follows, logically enough, that awareness is enhanced by acquiring accurate information about tobacco addiction and its dangers. Absorbing this information can partially immunize potential smokers against adopting the habit. The same is true of any other specific addiction.

6. Strengthen immunity for recovery. The cornerstone of our resistance to addiction is the ability to become aware. Most effective addiction recovery programs strive to enhance awareness. They commonly call this “breaking through the denial.” 40 As we have seen, this amounts to reinvigorating awareness of the nature of the problem within which the addict has become enmeshed.

Certainly, invigorating awareness requires provision of accurate information about the addiction and how it came about. But often a restoration of attention and awareness involves activating a layer of attention that runs deeper than the addict’s superficial awareness that “I’m not happy.” This deeper layer is often experienced by the sufferer as a return to the wisdom of a “higher power.”

Although the addict’s superficial awareness can be manipulated by the addictive process, that deeper layer is not subject to corruption because it is based on inherited archetypes. The AA program, for instance, uses multiple techniques for re-establishing contact with one’s “higher power,” over time increasing awareness of the process into which the alcoholic has fallen, and absorbing information about recovery that others have found useful.

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Notes and references

1. National Institute on Drug Abuse (a division of the National Institute of Health) Understanding Drug Use and Addiction. Revised June 2018. Available online at https://www.drugabuse.gov/publications/drugfacts/understanding-drug-use-addiction
2. U.S. Department of Justice National Drug Intelligence Center. National Drug Threat Assessment 2011. Product No . 2011-Q0317-001. Page 1. Available online at https://www.justice.gov/archive/ndic/pubs44/44849/44849p.pdf. Accessed 6/11/2019.
3. Vaillant G. The Natural History of Alcoholism Revisited. 1995, Harvard University Press, Cambridge. Page 170.
4. LaChance AJ. Cultural Addiction: The Greenspirit guide to recovery. North Atlantic Books, Berkeley, California, 1991. Page 3.
5. In 1985 neuroscientist Candace Pert insightfully concluded that, “the conceptual division between the sciences of immunology, endocrinology, and psychology / neuroscience is a historical artifact.” [Pert C, Ruff M, Weber R, Herkenham M. Neuropeptides and their receptors: A psychosomatic network. The Journal of immunology, 1985, 135, 2, 820-826. Page 824s.]
6. Fritjof Capra, in his insightful book The Web of Life stresses that immunity can’t really be separated from cognition. “Recent research,” he says, “indicates strongly that in the human organism the nervous system, the immune system, and the endocrine system, which traditionally have been viewed as three separate systems, in fact form a single cognitive network.” [Capra F. The Web of Life. Anchor books, New York, 1996. Page 176.]
7. Schaler JA. Addiction Is a Choice. Psychiatric Times, 2002, 19, 10. Available online at https://www.psychiatrictimes.com/addiction/addiction-choice.
8. Sack D. Does Willpower Play a Role in Addiction Recovery? Blog on Psychology Today website. Posted Nov 07, 2012. Available online at https://www.psychologytoday.com/us/blog/where-science-meets-the-steps/201211/does-willpower-play-role-in-addiction-recovery.
9. McLellan, AT; Lewis, DC; O’Brien, CP; Kleber, HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. The Journal of the American Medical Association, 2000, 284, 13, 1689–1695.
10. Hall W, Carter A, Forlini C. The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises? Lancet Personal View, 2015, 2, 1, 105-110.
11. Johnson, VE. Intervention: How to help someone who doesn’t want help. Johnson Institute books, 1986. “Incubation” is a medical term referring to the period between the time someone is exposed to an infectious disease and the time he or she becomes fully symptomatic. Although Johnson does not use the term Incubation himself, it fits his description of this phase. Johnson identifies sub-stages to each of the phases described here, but that level of detail is not required for this discussion.
12. Chiba K, Lorbeer F, Shain A, McSwiggen D, Schruf E, Oh A, Ryu J, Darzacq X, Bastain B, Hockemeyer D. Mutations in the promoter of the telomerase gene TERT contribute to tumorigenesis by a two-step mechanism. Science, 2017, 357, 1416-1420.
13. University of California – Berkeley. Two-step process leads to cell immortalization and cancer: Clearer view of the role telomere length and telomerase play in cell immortalization. Science Daily, August 17, 2017. Available online at www.sciencedaily.com/releases/2017/08/170817141528.htm.
14. The telomerase enzyme is most critical in normal cells whose function requires that they frequently divide. These cells routinely need “extra life” to function as intended by nature. But acquiring this extra life abnormally and unnecessarily through mutation makes a cell pre-cancerous.
15. James W. The Principles of Psychology, Volume 1. Henry Holt and Company, 1890. Pages 115-116.
16. James W, 1890. Page 122.
17. Edelman G and Tononi G. A Universe of Consciousness: How Matter Becomes Imagination. Basic Books, 2000. Page 58.
18. Vissera JC, Rommelseab NJ, Grevenacd CU, Buitelaarac  JK.  Autism spectrum disorder and attention-deficit hyperactivity disorder in early childhood: a review of unique and shared characteristics and developmental antecedents.  Neuroscience and Biobehavioral Reviews, 2016, 65, 229-263. Page 229.
19. van der Kolk BA. Posttraumatic stress disorder and the nature of trauma. Dialogues in Clinical Neuroscience, 2000, 2, 1, 7-22. Page 7. Article is available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181584/
20. van der Kolk BA, 2000. Page 19.
21. The “road traffic” metaphor is one of many that we could use here. Another is the World Wide Web. The Web works well only because the vast majority of the computing is handled locally, on the computers receiving information through the internet. The page displays are created autonomously and locally. They are constructed on our own computers, attractively presenting the downloaded information in the form of “web pages.” There is nowhere near enough bandwidth in our internet connections to transmit complete graphical web pages to us from a central source. Because the pages are constructed locally, different browsers yield different-looking pages. Sometimes the pages don’t look good at all. This is a well-known issue for content creators.
22. Bhatia A, Kumar Y. Cancer-immune equilibrium: Questions unanswered. Cancer Microenvironment, 2011, 4, 2, 209-217. Page 209.
23. University of California – Berkely, 2017.
24. Ridley M. The Red Queen: Sex and the evolution of human nature. Harper Perennial, 1993. Nick Lane’s book Life Ascending also deals adroitly with this topic: [Lane N. Life Ascending: The ten great inventions of evolution. W. W. Norton, New York, 2009]
25. Martinez-Outschoorn UE, Pavlides S, Howell, Anthony, Pestell, RG, Tanowitz HB, Sotgia F, Lisanti MP. Stromal–epithelial metabolic coupling in cancer: Integrating autophagy and metabolism in the tumor microenvironment. The International Journal of Biochemistry & Cell Biology, 2011, 43, 7, 1045-1051.
26. Huxley J. Cancer Biology: Comparative and Genetic. Biological Reviews, 1956, 21, 4, 474-513. Abstract available online at https://doi.org/10.1111/j.1469-185X.1956.tb01558.x
27. Vincent MD. The Animal Within: Carcinogenesis and the clonal evolution of cancer cells are speciation events sensu stricto. Evolution, 2010, 64, 4, 1173-1183. Page 1173.
28. Duesberg P, Mandrioli D, McCormack A, Nicholson JM. Is carcinogenesis a form of speciation? Cell Cycle. 2011, 10, 13, 2100-2114. Page 2100. Abstract available online at https://www.ncbi.nlm.nih.gov/pubmed/21666415
29. Interestingly, about 40% of tobacco smokers tell lies as part of their efforts to conceal their smoking.  [Christensen J, 2015.]
30. National Cancer Institute (a division of the National Institutes of Health). Risk Factors for Cancer. Fact sheet, last updated December 23, 2015. Available online at https://www.cancer.gov/about-cancer/causes-prevention/risk
31. Currier MB, Nemeroff CB. Depression as a risk factor for cancer: from pathophysiological advances to treatment implications. Annual Review of Medicine, 2014, 65, 203-221. Page 203.
32. Aldea M, Craciun L, Tomuleasa C, Crivii C. The role of depression and neuroimmune axis in the prognosis of cancer patients. Journal of the Balkan Union of Oncology, 2014, 19, 1, 5-14. Page 5.
33. Lewis M, et al. Animal models of restricted repetitive behavior in autism. Behavioural Brain Research, 2000, 176, 66-74. Page 68.
34. Alexander BK et al, 2008. Page 195.
35. Schenk S, Lacelle G, Gorman K, Amit Z. Cocaine self-administration in rats influenced by environmental conditions: implications for the etiology of drug abuse. Neuroscience Letters. 1987, 81, 1, 227-231.
36. Solinas M, Thiriet N, Rawas R, Lardeux V, Jaber M. Environmental enrichment during early stages of life reduces the behavioral, neurochemical, and molecular effects of cocaine. Neuropharmacology, 2009, 34, 1102-1111. Page 1108.
37. Rabinoff M. Ending the Tobacco Holocaust: How big tobacco affects our health, pocketbook, and political freedom – and what we can do about it. Elite Books, Santa Rosa California, 2006. Page 12.
38. Carter BD, Abnet CC, Feskanich D, et al. Smoking and mortality beyond established causes. New England Journal of Medicine, 2015, 372, 7, 631-640.
39. The collection of internal company documents assembled by Bates and Rowell shows that some companies researched groups of potential smokers as young as five years. [Bates C, Rowell A. Tobacco explained: The truth about the tobacco industry… In its own words. Originally developed for the London-based organization Action on Smoking and Health. Adapted for an annual event sponsored by the World Health Organization, “World No Tobacco Day,” first observed April 7, 1988. Page 24.] In response to a question as to which young people the company was targeting, one RJ Reynolds executive allegedly quipped, “They got lips, we want them.” [Bates C and Rowell A, 1988. Page 36.] Document is available online at  www.who.int/tobacco/media/en/TobaccoExplained.pdf
40. According to the Hazelden Betty Ford Foundation, denial is “the tendency of alcoholics or addicts to either disavow or distort variables associated with their drinking or drug use in spite of evidence to the contrary…” Penetrating the denial enables awareness of the truth about the havoc wreaked by the addiction. It is the first step in recovery. [Hazelden Betty Ford Foundation. Breaking through denial is an alcoholic’s first step in recovery. February 1, 2015. Online article available at http://www.hazeldenbettyford.org/articles/breaking-through-denial-is-first-step-in-recovery-for-alcoholic. Retrieved 8/20/2016]