Mental states of addiction: conceptions in the adult Norwegian population.
Past quantitative research on lay meaning of addiction, that is, how laypeople describe and characterize addiction, has typically focused on perceptions of addiction as a disease and perceptions of addiction as a result of intentional action. Two different approaches have been used. A recent survey in the Australian public adopted a direct approach, asking respondents whether alcohol/heroin addiction is a disease and whether it is a brain disease (Meurk, Partridge, et al., 2014). Schaler (1997), on the other hand, adopted an indirect approach by constructing the Addiction Belief Scale comprising 18 items assumed to tap into the disease model (addiction as compulsive actions) and the free will model (addiction as intentional action). One typical item assumed to tap into the disease model is, "Addicts cannot control themselves when they drink or take drugs," and 1 item of the free will model is, "The best way to overcome addiction is by relying on your own willpower." This scale has been applied in several studies among treatment providers, but factor analyses did not fully support a two-factor solution corresponding to the two models (see Russell, Davies, & Hunter, 2011). However, studies using the latter approach have not fully taken into consideration which addictive behaviors are coming to mind when people respond to statements about addiction. We extend this line of research by exploring similarities among defining, observable, features in terms of mental states assumed to be descriptive of addiction, across a number of addictive behaviors. In this way, one may explore whether the pattern of mental states descriptors constitute a generalized conception of an addiction across these behaviors. We employed descriptors of addictive states at the same conceptual level, that is, mental or psychological states, and excluded notions of addiction as a disease or a brain disease, since these imply anatomical and physiological states (cf. Morse, 2006).
The research literature provides a number of mental states which are used to describe addiction. First, there are the concepts derived from the common-sense phenomenology of addiction, where addiction is characterized by an overwhelming desire or craving to continue an activity, resulting in repetitive actions which appear to be compulsive, that is, out of control (Foddy, 2011; Morse, 2004). In addition, a number of mental states have been used to map laypeople's understanding of addiction: excessive appetite (Orford, 2001), strong appetite (Foddy & Savulescu, 2010), motivational conflict (Ainslie, 2001), obsessive passion (Vallerand et al., 2003), strong habit (Henden, 2013), diminished rationality (Morse, 2004, 2006), defect of the will (Wallace, 1999), reduced autonomy (Levy, 2006), and the more general idea of addiction as a moral failure or reduced moral competence (see Morse, 2004, about the moral model).
The purpose of the study was to explore how the general public characterize the mental states associated with being addicted. Is there a generalized conception of addiction mind-set across a number of addictive behaviors?
Material and Method
The data were derived from a web survey performed by TNS Gallup in March 2011 in the adult Norwegian population. Respondents were drawn from a web panel with members originally recruited via telephone. The age range in the present study was 20-69 years and the entire web panel comprised approximately 50,000 persons in this age range. In total, 2,964 of these were sent a questionnaire by e-mail. One reminder was given, and altogether 2,070 eventually responded giving a response rate of 67% (see Rise, Aaro, & Halkjelsvik, 2014, for more details). The sample comprised an equal number of men and women. One fourth of respondents were aged 60 and above, 31 % were aged 45-59, 28% aged 30-44, and 16% aged 15-29. Thirty percent had a high level of education (university or bachelor degree) and 6% a low level of education (primary and compulsory education). The rest had a medium level of education.
We selected a list of putative core addictions derived from Blomqvist (2009), comprising eight chemical addictions and one behavioral addiction, gambling, which seems to exhibit rather similar phenomenological features as the others (Rantala & Sulkunen, 2012). About half the respondents (n = 1,062) were given a rating task in the following form: "Addiction to [substance/behavior] is/represents [descriptive term]." For each of nine different behaviors, the respondents rated 11 descriptive terms (mental states associated with being addicted) on a 7-point response scale from 1 (completely disagree) to 7 (completely agree), and "don't know" (converted into missing data). The descriptive terms were "reduced self-determination," "an obsession," "a strong craving," "a strong appetite," "a strong urge," "reduced moral competence," "reduced ability for rational decision making," "a compulsion," "a habit," "a conflict between strong desires," and "reduced willpower." This sequence of descriptive terms was repeated for each of the following nine drugs and activities: cocaine, cannabis, alcohol, gambling, smoking, amphetamine, sedatives, snus, and heroin.
Principal components analysis (PCA) was used to explore the underlying structure of the 11 descriptive items for each of the addictive behaviors. The main purpose of PCA is to reduce a larger number of variables (in this case 11) into a smaller set of composite variables which contain as much information from the original variables as possible. The idea was that generalized conceptions of addiction should be reflected in factors with similar content across the nine addictive behaviors. Put differently, we were interested in whether we would find configural invariance for descriptors across addictive behaviors. We ran separate PCA for each of the addictive behaviors using orthogonal (varimax) rotation, and to determine the number of factors the criterion of eigenvalues above 1 was used. The results from these analyses are shown in Table 1 with the resulting loadings (correlations, ranging from 0 to 1) of each item on the extracted factors. The higher the loading, the better an item fits the factor. Since PCA does not take the level of endorsement of the items into account, we also inspected the level of endorsement of the items across the nine addictive behaviors. These results are displayed in Table 2.
Two items were excluded from the final PCA. The item "strong appetite" had inconsistent loadings on the two emerging factors and a high number of missing data across the nine behaviors (on average 269 missing). The item "conflicting desire" loaded moderately (around .40-.50) on both factors for most behaviors, which makes the factors difficult to interpret. In addition, the item showed a relatively high number of missing data (on average 188). In comparison, the number of missing data for other items ranged from 82 to 110.
The main factor pattern which emerged was the extraction of two factors (eigenvalue above 1). The only exception to this pattern was addiction to sedatives where only one factor emerged with this criterion (eigenvalue 0.88). The results of two-factor solutions for all behaviors can be seen in Table 1. A main pattern for Factor 1 (printed in bold) was identified in terms of the items "obsession," "strong craving," "strong urge," "habit," and "compulsion" loading more strongly on Factor 1 than on Factor 2. The only deviation from this pattern was that the item "compulsion" had higher loadings on Factor 2 than on Factor 1 for smoking, sedatives, and snus. It should be noted that our main interest was to explore the similarity of the factor pattern across the behaviors, and thus we did not test whether the strength of the single item loadings differed among the behaviors. Based on the content for six of the nine addictive behaviors, cannabis, cocaine, alcohol, gambling, heroin, and amphetamine, Factor 1 was denoted "Craving-compulsion." For Factor 2, the 4 items "reduced self-determination," "reduced moral competence," "reduced rational decision making," and "reduced willpower" tended to load more strongly on this factor than on Factor 1 and was denoted "Reduced agency," although, as noted above, the item "compulsion" loaded more strongly on "Reduced agency" than on "Craving-compulsion" for smoking, sedatives, and snus. This latter result suggests that the meaning of the state "compulsion" may be somewhat different for these three behaviors as compared to the six behaviors, cannabis, cocaine, alcohol, gambling, heroin, and amphetamine. Otherwise, the factor structures tended to be similar across the nine addictive behaviors.
As we will see below, the factor solution for the six behaviors can be given a more theoretically meaningful interpretation in terms of prevailing accounts in the addiction literature, than the solution for snus and smoking. Below, we refer to these six behaviors (cannabis, cocaine, alcohol, gambling, heroin, and amphetamine) as the core addictions.
In Table 2, it can be seen that the mean levels of endorsement of the items of Factor 1 (Craving-compulsion) showed variation across the addictive behaviors (on a scale from 1 to 7). For example, the mean level of "obsession" varied from 6.29 (gambling) to 3.43 (snus). The same was the case for "compulsion" in terms of 6.19 for heroin to 3.52 for snus. On the other hand, "strong urge," "strong craving," and "habit" all had relatively high mean levels for all behaviors (>5.14). It is also interesting to note that snus and smoking showed the lowest endorsement level of "compulsion" (3.52 and 4.31, respectively) and the highest endorsement levels of "habit" (5.99 and 6.29, respectively). Sedatives showed a somewhat intermediate position in terms of endorsement levels but fairly similar levels across items.
As to the mean levels of endorsement of the items of Factor 2 (Reduced agency), the variation among the addictive behaviors was greater than for Factor 1. Thus, for "rational self-determination," the mean level varied from heroin (5.72) to snus (3.43), and for "reduced willpower," the variation was from 6.18 (heroin) to 3.93 (snus). For "moral competence," the mean levels varied from 5.72 (heroin) to 2.39 (snus), and for "reduced rational decision making," the levels varied from 6.25 to 2.66 (heroin and snus, respectively). In particular, snus and smoking showed low endorsement levels on the items "reduced moral competence" (2.39 and 2.74, respectively) and "reduced rational decision making" (2.66 and 3.01, respectively). Again, sedatives showed a somewhat intermediate position in terms of endorsement levels but fairly similar levels across items.
The results suggest that laypeople ascribe to a model of an addiction mind-set with two distinct versions of what it means to be addicted. This finding is based on PCAs of nine mental states for each of the nine selected addictive behaviors, which showed a rather similar two-factor pattern for the nine addictive behaviors. The only exception to this pattern was that the item "compulsion" loaded on Factor 1 (Craving-compulsion) for the six behaviors, while for sedatives, smoking, and snus "compulsion" loaded on Factor 2 (Reduced agency). This finding suggests that the state "compulsion" may carry somewhat different meanings for the two categories of behaviors and makes it more difficult to interpret the two factors for sedatives, smoking, and snus. Inspection of the levels of endorsement for the various mental states of the two factors supports this idea. Thus, the mental states loading on Factor 1 were fairly descriptive of what it means to be addicted, which adds validity to the generality of Factor 1, Craving-compulsion, as a lay account of addiction specifically for the six addictive behaviors, cocaine, cannabis, alcohol, gambling, amphetamine, and heroin. As reflected by levels of endorsement, the various mental states of Factor 2 were also fairly descriptive of what it means to be addicted to the six behaviors, while less so for smoking and snus. In particular, "reduced rational decision making" and "reduced moral competence" were not highly descriptive of what it means to be addicted to smoking and snus, with sedatives in an intermediate position. Thus, the validity of Factor 2, Reduced agency, as a lay account of addiction in particular for the six addictive behaviors, cocaine, cannabis, alcohol, gambling, amphetamine, and heroin, is supported. These six behaviors may hence be denoted prototypical or core addictions, while smoking, snus, and sedatives take on a slightly more peripheral position at least for the two lay accounts posited in this study.
What we have denoted the Craving-compulsion version of addiction bears some resemblance to the compulsion model derived from the common-sense phenomenology of addiction, which is characterized by a strong craving to continue with the activity which addicted individuals report to feel unable to control; the result is repetitive actions which appear to be compulsive, that is, out of control (Foddy, 2011; Morse, 2004, 2006). The finding that the state "obsession" turned out to load on the Craving-compulsion factor is consistent with the idea proposed by Vallerand et al. (2003) that individuals can be so immersed in certain activities that they take completely control over their everyday life, the so-called obsessive passion. That the item of habit finds its way into this factor underlines the link to the repetitive and automatic character of the behavior (Redish, Jensen, & Johnson, 2008; Verplanken, 2006).
A possible interpretation of the other factor, Reduced agency, is that laypeople recognize the possibility that addicted individuals are governed by the appeals of the strong desire, that is, they give in voluntarily. The content of this factor suggests a lay model where addiction involves diminished control but not total loss of control. More broadly, this account seemingly points to the larger idea that addicted individuals have agency over their actions and are morally responsible for their addiction. The source of their actions derives from within themselves and not from anything over which they have no control (Fischer & Ravizza, 1998; Uusitalo, 2011). Finally, the inclusion of the item "reduced moral competence" into the factor is indicative of the idea of addiction as a moral failure, that is, the moral model (Morse, 2004, 2006).
The present results indicate that laypeople can hold two apparently contradictory conceptions of addiction, that is, compulsive as well as agentic and autonomous, cognitively accessible at the same time. The two factors derived from the analyses were orthogonal, suggesting that the corresponding lay models are not mutually exclusive and may operate in parallel. Most likely their relative accessibility in people's mind depends upon which situational characteristics are salient, for example, which cognitive representation of an addicted person comes to mind. Accordingly, it may be important how addicted individuals are portrayed and described in various contexts. Depending on which version of addiction mind-set is elicited in a particular situation, laypeople may activate different beliefs about addicted individuals. In particular, this concerns beliefs about moral responsibility.
Recent nonnative thinking about addiction has been dominated by two models, the disease (or medical) and the moral model (Foddy, 2011; Henden, 2013; Morse, 2004, 2006; Schaler, 2000; Uusitalo, Salmela, & Nikkinen, 2013). The fonner model considers addiction as following a disease-like course with behaviors that have taken control over the person. In contrast, the moral model holds that addictive behaviors are intentional actions, that is, addiction are indications of moral failures on the part of the individual. Not surprisingly, the two models adopt different theories about moral responsibility of addictive behaviors. Typically, we do not hold people morally responsible for the symptoms of a disease, whereas intentional, voluntary actions are considered appropriate objects of moral assessment (see Morse, 2004, 2006). However, addicted individuals may also be excused of responsibility if they act truly compulsive--in particular if they report strong desires which they feel unable to control (Foddy, 2011). In terms of moral responsibility, the Craving-compulsion version may be viewed as a variant of the medical model.
The issues of moral responsibility and the moral relevance of addiction are tricky in the literature of addiction (see Husak, 2004; Morse, 2004). For one, responsibility (and blame) may depend upon whether the concern is with becoming addicted, for being addicted, or the recovery from addiction. In a much cited philosophical account, Fischer and Ravizza (1998) link a person's moral responsibility to guidance control, that is, addicted individuals can fail to control a behavior by failing to respond or react to reasons for acting. Other authors have argued that the strong desire induces a high level of affect that makes it difficult for the addicted individual to think straight about reasons to quit and act on them (Morse, 2004, 2006; Uusitalo et al., 2013). Such affective states can be considered as excusing conditions which diminish responsibility (Morse, 2004, 2006). Levy (2011) has argued that the struggling of addicted individuals may lead to a temporary loss of control over their mental life due to depletion of mental resources (ego depletion) and may for that reason constitute an excusing condition. Both these instances tend to invalidate the pure moral model that assigns full moral responsibility on the part of the addicted person.
Smoking and snus did not fit so well into the present conceptions of addiction by showing a somewhat deviating factor pattern and lower endorsement levels of the mental states. This indicates that they are not prototypical addictive behaviors to the same extent as the other six behaviors. Interestingly, smoking and snus showed the highest endorsement levels of the item "habit" among all addictive behaviors, indicating that habits appear to be highly descriptive of what it means to be addicted to smoking and snus. This fits in with the novel conceptualization of habits as "learned sequences of acts which have become automatic responses to specific cues and are functional in obtaining certain goals and end states" (Verplanken, 2006, p. 640). By this account, automaticity implies that a behavior can be performed without awareness, be difficult to control and mentally efficient. Thus, habit as a mental construct allows for the idea that one can light up a cigarette to experience need satisfaction without being aware of it when in relevant contexts, and while doing other things in parallel. The results indicate that laypeople view smoking and snus as ingrained habits with strong motivational forces (desire or craving), but without the compulsive, disease-like features as observed for the six prototypical addictive behaviors. This latter idea is supported by the deviating loading pattern for compulsion.
It should be emphasized that the present results were obtained using only mental states and thus provides no complete account of addiction. It has been observed that when laypeople are given the opportunity to respond to a wider set of beliefs about addiction, for example, as a disease and as a consequence of the social environment, they understand addiction as a complex process with a number of overlapping causes (Meurk, Carter, Hall, et al., 2014), with the particular addictive behavior as a powerful predictor of beliefs (see Fraser, Moore, & Keane, 2014; Meurk, Carter, Partridge, et al., 2014). The latter observation seems to be supported by the present data, and these issues may be important to explore in subsequent studies. The same is the case for the finding that "conflicting desire" loaded on both factors which opens up a series of further issues to explore. Nevertheless, the present results suggest that we have managed to identify a model of an addiction mind-set among laypeople with two distinct versions which may account for two important dimensions of addiction in the scientific literature of addiction, the irresistible, involuntary (corresponding to the Craving-compulsion version) and the voluntary resistible dimension of addiction (corresponding to the Reduced agency version). Since the two lay versions are held in parallel, their cognitive accessibility is likely to be determined by situational characteristics and thus the portrayal of addicted persons may play a role for which model comes to mind. Another likely distinction between the two versions is that they adopt different theories of moral responsibility. Typically, one does not hold people responsible if they report strong desires to perform actions and feel unable to control them, whereas intentional, voluntary actions are considered appropriate objects of moral assessment (see Morse, 2004, 2006).
A few potential limitations should be noted. First, the questions were always asked in the same order, and thus the participants' responses of the first drugs might influence the responses to the subsequent. We believe that the great variation in responses which is observed both within addictive behaviors and across drug types (see Table 2) indicates that the order of questions may not have played a biasing role. Second, since the data are derived from an online panel survey and not a representative sample of the adult population, generalization of the absolute levels of the variables to the general population may not be warranted. Third, one may argue that a wider range of potential addictive behaviors should have been included; for example, only one behavioral addiction--gambling--was included. On the other hand, gambling was identified as one of the prototypical addictive behaviors alongside cannabis, cocaine, alcohol, gambling, heroin, and amphetamine, while sedatives, smoking, and snus did not fit so well into this dual pattern of addiction, and laypeople seem to view smoking and snus as functional habits with strong cravings. It should also be added that an obvious strength of the study was that it was based on a large nationwide survey in the adult population. Future research should also explore the antecedents and consequences of the models' activation in the mind of people. In particular, moral responsibility is a key issue in this context.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Jostein Rise is a former professor in social psychology and director of the Norwegian Institute for Alcohol and Drug Research. He currently works as a senior researcher at the institute and his research interests include topics such as attitudes, social cognition models, and addictions.
Torleif Halkjelsvik works as a senior researcher at the Norwegian Institute for Alcohol and Drug Research. His research interests include topics such as attitudes, intertemporal choices, and addictive behaviors.
Velibor Bobo Kovac works as a professor in the Department of Education at the University of Agder, Kristiansand, Norway. His research centers on the social-psychological aspects of addiction and tobacco use. His interests also include academic achievements and ethnic identity.
Jostein Rise (1), Torleif Halkjelsvik (1), and Velibor Bobo Kovac (2)
(1) Norwegian Institute for Alcohol and Drug Research, Oslo, Norway
(2) Department of Education, University of Agder, Kristiansand, Norway
Received April 15, 2015. Accepted for publication August 31, 2015.
Jostein Rise, SIRUS, PB 565, Sentrum, 0105 Oslo, Norway. Email: email@example.com
Table 1. Rotated Factor Loadings of 9 Descriptive Items for the Nine Addictive Behaviors Cocaine Cannabis F1 F2 F1 F2 Craving-compulsion Obsession .682* .314 .762* .381 Strong urge .759* .089 .836* .299 Strong craving .845* .048 .884* .229 Compulsion .623* .357 .619* .510 Habit .442* .267 .556* .179 Reduced agency Reduced self-determination .259 .529* .396 .665* Reduced moral competence .083 .839* .215 .852* Reduced rational decision making .181 .839* .261 .864* Reduced willpower .260 .794* .343 .788* Alcohol Gambling F1 F2 F1 F2 Craving-compulsion Obsession .752* .324 .784* .211 Strong urge .805* .210 .788* .296 Strong craving .790* .258 .786* .250 Compulsion .542* .377 .650* .357 Habit .437* .294 .536* .127 Reduced agency Reduced self-determination .405 .618* .298 .676* Reduced moral competence .215 .852* .129 .803* Reduced rational decision making .261 .864* .243 .804* Reduced willpower .343 .788* .335 .749* Smoking Amphetamine F1 F2 F1 F2 Craving-compulsion Obsession .559* .468 .792* .322 Strong urge .833* .161 .846* .279 Strong craving .862* .117 .869* .208 Compulsion .337 .591* .702* .270 Habit .674* .016 .674* .016 Reduced agency Reduced self-determination .290 .657* .372 .668* Reduced moral competence -.033 .830* .216 .837* Reduced rational decision making -.083 .867* .267 .858* Reduced willpower .270 .712* .327 .794* Sedatives Snus F1 F2 F1 F2 Craving-compulsion Obsession .768* .367 .527* .531 Strong urge .794* .333 .839* .247 Strong craving .850* .255 .871* .197 Compulsion .453 .611* .341 .627* Habit .646* .242 .725* -.021 Reduced agency Reduced self-determination .496 .532* .201 .762* Reduced moral competence .277 .800* .038 .857* Reduced rational decision making .236 .881* -.027 .886* Reduced willpower .346 .752* .269 .740* Heroin F1 F2 Craving-compulsion Obsession .768 .362 Strong urge .825 .260 Strong craving .844 .211 Compulsion .710 .383 Habit .567* .200 Reduced agency Reduced self-determination .335 .729* Reduced moral competence .199 .835* Reduced rational decision making .304 .843* Reduced willpower .335 .768* Note. The strongest factor loading for each item is printed in boldface. Note: The strongest factor loading for each item is printed indicated with *. Table 2. Descriptive Statistics for the 11 Items (Means and SD) According to Nine Addictive Behaviors. Cocaine Cannabis Alcohol Reduced self-determination 5.27 (1.75) 4.99 (1.89) 5.37 (1.66) Obsession 5.77 (1.49) 5.20 (1.77) 5.48 (1.58) Strong urge 6.19 (1.24) 5.56 (1.58) 6.01 (1.27) Strong appetite 3.56 (2.01) 4.00 (2.00) 4.14 (2.00) Strong craving 6.03 (1.33) 5.40 (1.64) 5.87 (1.33) Reduced moral competence 5.00 (1.95) 4.91 (1.92) 5.07 (1.82) Reduced rational decision 5.82 (1.51) 5.44 (1.70) 5.78 (1.45) making Compulsion 5.47 (1.65) 4.78 (1.87) 5.29 (1.68) Habit 5.35 (1.82) 5.47 (1.65) 5.62 (1.59) Conflicting desires 4.89 (1.81) 4.60 (1.82) 5.24 (1.65) Reduced willpower 5.72 (1.57) 5.38 (1.71) 5.74 (1.49) Gambling Smoking Amphetamine Reduced self-determination 5.29 (1.73) 4.39 (2.05) 5.57 (1.65) Obsession 6.29 (1.13) 4.94 (1.84) 5.86 (1.46) Strong urge 5.85 (1.44) 6.23 (1.15) 6.16 (1.21) Strong appetite 3.85 (2.08) 3.82 (2.10) 4.40 (2.12) Strong craving 5.92 (1.36) 5.87 (1.40) 6.10 (1.26) Reduced moral competence 4.83 (1.92) 2.74 (1.92) 5.42 (1.77) Reduced rational decision 5.65 (1.52) 3.01 (2.08) 5.98 (1.34) making Compulsion 5.77 (1.48) 4.31 (2.09) 5.67 (1.56) Habit 5.57 (1.63) 6.29 (1.24) 5.45 (1.73) Conflicting desires 5.31 (1.62) 3.99 (1.97) 5.18 (1.73) Reduced willpower 5.82 (1.43) 4.62 (1.98) 5.88 (1.46) Sedatives Snus Heroin Reduced self-determination 4.79 (1.82) 3.43 (2.11) 5.97 (1.56) Obsession 4.73 (1.81) 4.08 (2.02) 6.26 (1.28) Strong urge 5.24 (1.67) 5.55 (1.54) 6.55 (.92) Strong appetite 3.89 (1.94) 3.44 (2.06) 4.67 (2.22) Strong craving 5.33 (1.64) 5.14 (1.70) 6.46 (1.03) Reduced moral competence 4.13 (1.99) 2.39 (1.80) 5.72 (1.75) Reduced rational decision 4.76 (1.84) 2.66 (1.98) 6.25 (1.23) making Compulsion 4.91 (1.79) 3.52 (2.09) 6.19 (1.31) Habit 5.37 (1.65) 5.99 (1.44) 5.81 (1.69) Conflicting desires 4.72 (1.75) 3.30 (1.93) 5.63 (1.67) Reduced willpower 5.10 (1.75) 3.93 (2.08) 6.18 (1.38) Note, n varied from 706 (strong appetite) to 947 (obsession and reduced rational decision making). Conflicting desires (n = 770) and compulsion (n = 864) had ns below n = 900.
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|Author:||Rise, Jostein; Halkjelsvik, Torleif; Kovac, Velibor Bobo|
|Publication:||Contemporary Drug Problems|
|Date:||Dec 22, 2015|
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