Smoking causes cancer. Cancer is a disease process that is both painful and potentially deadly.

Smoking multiplies by as much as 30 your chances of getting cancer. Therefore, the choice is obvious: don’t smoke.

That represents one perspective.

A small percentage of individuals get cancer. Multiplying that small percentage, even by a large number, still leaves a fairly small percentage of individuals with cancer. The fact is that the majority of people who smoke do not get cancer. Therefore, the likelihood that I will get cancer as a result of smoking is low.

That represents another perspective. This latter perspective is interesting as it represents an individual’s view of population statistics. Whereas epidemiologists are concerned with the overall health of the population, an individual is simply concerned with his or her own health, particularly when that individual is an adolescent. Let’s look closely at the thought process, as it really is a risk:benefit decision. Driving a car is clearly a dangerous activity. There is no question that a teenager driving a car is at far more risk than a teenager walking. Nevertheless, young people are encouraged to learn to drive. People also take flying lessons, rock climbing lessons, hang-gliding lessons, and training in other pursuits that have a relative risk for harm that is not insignificant. Benefits range from usefulness in today’s society (e.g., driving) to the purely pleasurable (e.g., hang-gliding).

If a young person is about to make a decision about whether to use a drug, or about whether to learn to hang-glide, there are two answers he seeks:

1) Will I obtain pleasure from this activity?

2) What are the chances that I personally will suffer due to this activity?

The truth is that we don’t know the answer to either question. Millions have over the years tried cigarettes, marijuana, alcohol, and have enjoyed their experience. Millions more have tried them, and have not enjoyed the experience. Of the former group, the majority does not personally suffer from the activity. That is to say that if you take a group of drug-naïve individuals and give them a cigarette to try, some will decide to never smoke again, some will decide to smoke again on occasion, some will smoke regularly and experience no significant difficulties, and some will smoke regularly, ultimately experiencing morbidity or mortality as a result.

Can we predict which of these groups a given individual is in for each available substance? Not yet, but I’m betting that in the next decade or two, we will have genomic solutions to this question. There are likely to be markers that will allow determination of which individuals are likely to enjoy the effects of a given substance. Markers allowing a determination as to which individuals are susceptible to the morbidity-causing effects of a given substance are also likely to be found. We might very well be able to say to Mike, “Feel free to smoke. You’re likely to enjoy it yet not suffer any difficult consequences,” while saying to Susan, “Don’t smoke as you are almost undoubtedly going to die 20 years earlier than you would otherwise as a result.”

A friend of mine was graduated from MIT shortly after I was. He has a successful career, owns his own business, and has a wonderful family. He writes of his drug use, “Taking MDMA has been part of some of the most memorable and pleasant experiences of my life, including my decision to marry my wife...it seems to me that the potential for such a dramatic positive life experience absolutely dwarfs the risks of a single MDMA experience. That’s why the risk has to be dramatized, by promulgating the idea that just one event will trigger incipient addictive behavior.”

I had asked my friend to look at the Web site http://teens.drugabuse.gov and to comment from his perspective. He wrote: “Consider that the makers of the Web site must consider all recreational drug use to be bad, and all drugs addictive. They must not call attention to the comparisons between the legal intoxicant alcohol, and the illegal ones featured prominently. They must ignore the fact that there is a body of commonsense knowledge about the results of smoking marijuana, just as there is one about the results of drinking too much. There are lots of things they must leave unsaid, and they dance around obvious facts to have their desired effect on their teen audience.”

With his comments in mind, I visited the site. I went to the “Ask Dr. NIDA” area prominently featured on the home page. The first part of that section contains a link to the most “frequently asked questions” about drugs. Within that area, alcohol isn’t listed prominently (it’s listed under “other drugs”), but marijuana is, with an indication that 21.5 percent of 12th graders have used the drug at least once in the past 30 days. This isn’t abuse, according to DSM-IV, however. This simply indicates that the drug is being used. Use doesn’t constitute abuse, nor does it indicate that addiction is present, nor does it mean any poor outcome is likely. In fact, while use constitutes a significant risk factor, the majority of those who simply use the drug may not suffer an undesirable outcome, just as the majority of those who use alcohol from time to time may suffer no harm. This and other similar sites prefer to use the statistics to indicate the relative risk, certainly of interest to clinicians but perhaps of less consequence to a single individual.

Staying within the “Ask Dr. NIDA” section, I then moved to the “Brain and Addiction” area in which drug addiction is defined as a “complex brain disease.” Yes and no. Substance Dependence, the disease state identified in our textbooks, is indeed a complex brain disease. Drug addiction is something that is inherent within the mammalian brain and can be developed by simply using an addictive drug repetitively with a specific degree of quantity and frequency that are dependent upon the drug being used. This is true with 100 percent of people and isn’t a disease at all. It’s normal.

Some of this is a terminology issue where I’m obviously begging our government to use accepted terminology from within the scientific field, but some of what I’m striving for is for our public sector to provide less obvious bias. My friend’s comments are right, particularly given the perspective the majority of adolescents bring to the table. If they’re the ones we want to convince, let’s be honest about it. We don’t know (yet) if you are the one who will be injured from your use of this substance. Here are the facts. Here are the things that could happen to you. Are these risks you want to take?

Stuart Gitlow, MD, MPH, is the author of Substance Use Disorders: A Practical Guide, from Lippincott Williams & Wilkins. He spoke at the Psychiatric Congress in Orlando in November 2003 on e-mail and the psychiatric patient.

This article is published in Counselor,The Magazine for Addiction Professionals, April 2004, v.5, n.2, pp. 76-77.

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