Teenage smoking isone of the great,baffling phenomena ofmodern life.

Malcolm Gladwell,“The Tipping Point”

Assumptions behind Teen Smoking Addiction

Market rationality – tobacco companiespersuade teens to smoke by “lying” to them, bymaking smoking sound a lot more desirableand a lot less harmful than it really is.

Basis of anti-smoking movements Restriction and policing of cigarette advertising Raise cigarette price, luxury tax Law enforcement against selling tobacco to minors Extensive public health campaigns on television, radio,

magazine, internet to educate teens about the danger ofsmoking.

It is fairly obvious thatthis approach isn’t very

effective.Why do we think, for example, that the

key to fighting smoking is educatingpeople about the risks of cigarettes?

We assume that people make therational choice.

Smokers aren’t smokersbecause they

underestimate the risks ofsmoking.

They smoke even though theyoverestimate the risk of smoking.

Smoking trends

Increase in the total number of teensmokers.

The anti-smoking movement has neverbeen louder or more prominent.

The anti-smoking message is backfiring. Why?

The Lesson: NOT to giveup trying to fight

cigarettes.

What if smoking, instead of following therational principles of the market-place,

follows the same kind of mysterious andcomplex social rules and rituals that govern

teen suicide?

If smoking really is an epidemic likeMicronesian suicide, how does that change

the way we ought to fight the problem?

Smoking seemed to evoke a particularkind of childhood memory – vivid,precise, emotionally, charged.

Smoking, overwhelmingly, wasassociated with the same thing to nearlyeveryone: sophistication even ofpeople who now hate smoking, whonow think of it as a dirty and dangeroushabit.

Shared language of smoking – rich andexpressive Respondents to the survey described the

particular individual who initiated them intosmoking in precisely the same way.

Common Smoking Personality:according to the influential British Psychologist,Hans Eysenck

He argued that serous smokers can be separated fromnon-smokers along very simple personality lines.

Heavy smokers have been shown to have a muchgreater sex drive than nonsmokers, more sexuallyprecocious, greater “need” for sex, and greaterattraction to the opposite sex.

Interestingly, smokers also seem to be more honestabout themselves than nonsmokers.

Theory – lack of deference and their surfeit ofdefiance combine to make them relatively indifferentto what people think of them.

Caveat: these measures do not apply to all smokers

Smoking Personality – Extroverts’ Traits

Defiance, sexual precocity, honesty,impulsiveness, indifference to theopinion of others, sensation seeking

An almost perfect definition of the kindof person many adolescents are drawnto.

But they weren’t cool because theysmoked.

They smoked because they were cool

Why has the war on smokingstumbled so badly? The very same character traits of rebelliousness,

impulsivity, risk taking, and indifference andprecocity that made them so compelling to theiradolescent peers – make it almost inevitable thatthey would also be drawn to the ultimateexpression of adolescent rebellion: the cigarette.

Anti-smoking movement has railed againsttobacco companies for making smoking cool andspent millions of currency of public money tryingto convince teenagers that smoking isn’t cool

BUT THAT’S NOT THE POINT

In this epidemic, as in all others, a very smallgroup – a select few – are responsible for

driving the epidemic forward.

SMOKING WAS NEVERCOOL.

SMOKERSARE

COOL.

FOCUSING ON THE PROBLEM – THE FACTTHAT HAS TURNED SMOKING INTO PUBLICHEATLH ENEMY NO. ONE

{Contagiousness} – NOT the problem – the factthat overwhelming number of teenagersexperiment with cigarettes as a result of theircontacts with other teenagers is NOT that scary.

{Stickiness} – the PROBLEM – many of thoseteenagers end up continuing their cigaretteexperiment until they get hooked.

The Habit Sticks – the smoking experience is somemorable and powerful for some people thatthey cannot stop smoking.

CONTAGIOUSNESS –IN LARGE PART A

FUNCTION OF THEMESSENGER.

STICKINESS IS PRIMARILYA PROPERTY OF THE

MESSAGE.

Recent University of Michigan Study – Whatsorts out the smokers-to-be from the never-again smokers

A large group of people were polled abouthow they felt when they smoked their firstcigarette.

For almost everyone their initial experience withtobacco was somewhat aversive.

Smokers-to-be derived overall pleasure fromthe experience – like the feeling of a buzz or aheady pleasurable feeling.

Of the heavy smokers, 78 percent rememberedgetting a good buzz from their first few puffs.

CRITICAL POINT: The questions of how stickysmoking ends up being to any single person,

depends a great deal on his or her ownparticular initial reaction to nicotine.

CRITICAL POINT often lost in the heavyrhetoric of the war on smoking.

The tobacco industry has beenpilloried for years for denying that

nicotine is addictive the position isridiculous!

But the opposite notion often put forth by anti-smoking advocacies – that nicotine is a deadlytaskmaster that enslaves all who come incontact with it – is equally ridiculous.

Nicotine may be highly addictive, but it is only addictivein some people, some of the time.

Smoking as contagious but not sticky – people whomanage to smoke regularly and not be hooked.

“Chippers” (University of Pittsburgh psychologist SaulShiffman) – someone who smokes no more than 5cigarettes a day but who smokers at least four days aweek. Chippers are not addicted to nicotine and thattheir smoking is not driven by withdrawal relief orwithdrawal avoidance.

What distinguishes chippers fromhard-core smokers? Probably genetic factors, according to Allan Collins of the

University of Colorado People who didn’t get a buzz from 1st cigarette people whose

bodies are acutely sensitive to nicotine, incapable of handling itin even the smallest doses.

Chippers – have the genes to derive pleasure from nicotine, butnot the genes to handle it in large doses.

Heavy smokers – may be people with the genes to do both. THIS IS NOT TO SAY THAT GENES PROVIDE A TOTAL

EXPLANATION FOR HOW MUCH PEOPLE SMOKE. Nicotine is also known to relieve boredom and stress, and

people who are in boring or stressful situations are always goingto smoke more than people who are not.

If we are looking for Tipping Pointsin the war on smoking, we need todecide which of those sides of the

epidemic we will have the mostsuccess attacking.

Should we try to make smoking lesscontagious, to stop the Salesmen who

spread the smoking virus?

Are we better off trying to make it lesssticky, to look for ways to turn all

smokers into chippers?

1

2

Should we try to makesmoking less contagious,to stop the Salesmen who

spread the smoking virus?

1

1. Issue of Contagion2 strategies for stopping the spread of smoking:1. Prevent the permission-givers – the “cool” people – from

smoking in the first place – most difficult - the mostindependent, rebellious teens are hardly likely to be the mostsusceptible to rational health advice.

2. Convince all those who look to “cool” people for permissionthat they should look elsewhere, to get their cues as to what iscool (adults).

1. Judith Harris, 1998 “The Nurture Assumption” – evidencesorely lacking Parents are powerfully invested in the ideathat they can shape their children’s personalities and behavior.

2. Whatever the environmental influence is, it doesn’t have a lotto do with parents – Harris: the environmental influence thathelps children become who they are – that shapes theircharacter and personality – is their peer group.

According to Rowe and Harris, theprocess by which teens get infected

with the smoking habit is entirelybound up in the peer group.

It’s not about mimicking adult behavior,which is why teenage smoking is rising at a

time when adult smoking is falling.

Well-known fact: the children of smokers aremore than twice as likely to smoke as the

children of nonsmokers. simply means thatsmokers’ children have inherited genes from

their parents that predispose them towardnicotine addiction.

Teenage smoking is about being a teenager,about sharing in the emotional experience andexpressive language and rituals of adolescence,which are as impenetrable and irrational tooutsiders as the rituals of adolescent suicide inMicronesia

Are we better off trying to make it lesssticky, to look for ways to turn all

smokers into chippers?

2

2. Stickiness Factor

Review: genetic factor – humanbeings may have very different

innate tolerances for nicotine.

In a perfect world – we would giveheavy smokers a pill that lowered

their tolerance to the level of, say, achipper - wonderful way of

stripping smoking of its stickiness!!

Some developments: Nicotine Patch Possible Tipping Point to combat Stickiness?

Delivers a slow and steady dose of nicotineso that smokers don’t have to turn to thedangers of cigarettes to get their fix.

Far from perfect most exhilarating wayfor an addict to get his fix – form of “hit” (ahigh dose delivered quickly, thatoverwhelms the senses)

Patch – boring way to ingest nicotine

2 Possibilities toCombat the

Stickiness Factor:1. Link to depression

2. Link to nicotine threshold

Recent discovery: correlationbetween smoking and depression Columbia University Psychologist

Alexander Glassman (1988) – 60 percent ofthe heavy smokers had a history of majordepression.

80 percent of alcoholics smoke; 90 percent ofschizophrenics smoke.

As overall smoking rates decline, the habit isbecoming concentrated among the mosttroubled and marginal members of society.

2 Theories proposed as to why smokingmatches up so strongly with emotionalproblems:

The same kinds of things that would makesomeone susceptible to the contagiouseffects of smoking (low self-esteem or anunhealthy and unhappy home life) are alsothe kinds of things that contribute todepression.

MORE TANTALIZING: Preliminaryevidence that the two problems MIGHTHAVE THE SAME GENETIC ROOT.

2ND THEORY: GENETICCOMPONENT OF THE STICKYCIGARETTE Depression – a result, at least in part, of a problem

in the production of certain key brain chemicals neurotransmitters such as serotonin, dopamine, andnorepinephrine. These are the chemicals that regulate mood, contribute to

feelings of confidence, mastery, and pleasure. Drugs: Zoloft and Prozac - prompt the brain to produce

more serotonin

Nicotine appears to do the same things with theother two key neurotransmitters (dopamine andnorepinephrine) Nicotine – as anti-depressant!

Smokers who are depressed, in short,are essentially using tobacco as a cheap

way of treating their own depression, ofboosting the level of brain chemicals

they need to function normally.

Stickiness with a vengeance: not only dosome smokers find it hard to quit because

they are addicted to nicotine, but alsobecause without nicotine they run the

risk of a debilitating psychiatric illness.

SILVER LINING: IFYOU CAN TREAT

SMOKERS FORDEPRESSION, YOU

MAY BE ABLE TOMAKE THEIR HABIT

AN AWFUL LOTEASIER TO BREAK.

Mid 1980s – researchers from GlaxoWellcome Pharmaceutical Firm

Doing a big national trial of a newantidepressant called bupropion

Began getting reports about smokings Bupropion was functioning as a king of

nicotine substitute!

Why nicotine causesaddiction: Nicotine induces the release of the two

neurotransmitters Dopamine that nicotine releases goes to the

prefontal cortex of the brain (pleasure centerof the brain) responsible for the pleasure,sense of well-being associated with smoking

Nicotine increases norepinephrine whenyou quite smoking no longer get as muchnorepinephrine you get agitation andirritability.

Function of Bupropion Increases dopamine, so smokers don’t have

the desire to smoke Replaces some of the norepinephrine –

smokers don’t have the agitation and thewithdrawal symptoms

Glaxo Wellcome tested and marketed thedrug Zyban in heavily addicted smokers(more than 15 cigarettes a day) withremarkable effects.

2nd Potential TippingPoint on the stickiness

Question

Link to the Nicotine thresholdlevel

Some observations: It takes about three years for the teens to go

from casual to regular smoking. Nicotine addiction is far from an instant

development Nicotine addiction isn’t a linear phenomenon Suggests that there is an addiction Tipping

Point, a threshold

Chippers: they arepeople who simply

never smoke enough tohit that addiction

threshold.

A hardened smoker, on the otherhand, is someone who, at some

point, crosses that line.

What is the addictionthreshold? Benowitz and Jack Henningfield – probably the

leading nicotine experts in the world – made someeducated gusses.

4 to 6 cigarettes four and six milligrams ofnicotine

Proposal: tobacco companies should be required tolower the level of nicotine so that even the heaviestsmokers could not get anything more than five mgof nicotine within a 24-hour period.

New England Journal of Medicine: “that levelshould be adequate to prevent or limit thedevelopment of addiction in most young people.At the same time it may provide enough nicotinefor taste and sensory stimulation.”

Some Conclusions We only need to find the stickiness Tipping Points,

and those are the links to depression and the nicotinethreshold.

Experimentation DOES NOT = addiction We have to stop fighting this kind of experimentation.

We have to accept it and even to embrace it. Teens are always going to be fascinated by these

“cool” people, and they should be fascinated bypeople like that, if only to get past the adolescentfantasy that to be rebellious and truculent andirresponsible is a good way to spend your life.

What we should be doing instead of fightingexperimentation is making sure that experimentationdoesn’t have serious consequences.