Tipping Point: How Little Things Can Make a Big Difference

SEVEN
Case Study
SUICIDE, SMOKING, AND THE SEARCH FOR THE UNSTICKY CIGARETTE

Not long ago, on the South Pacific islands of Micronesia, a seventeen-year-old boy named Sima got into an argument with his father, He was staying with his family at his grandfather's house when his father — a stern and demanding man — ordered him out of bed early one morning and told him to find a bamboo pole-knife to harvest breadfruit. Sima spent hours in the village, looking without success for a pole knife, and when he returned empty-handed, his father was furious. The family would now go hungry, he told his son, waving a machete in rage. "Get out of here and go find somewhere else to live."

Sima left his grandfather's house and walked back to his home village. Along the way he ran into his fourteen-year-old brother and borrowed a pen. Two hours later, curious about where Sima had gone, his brother went looking for him. He returned to the now empty family house and peered in the window. In the middle of a dark room, hanging slack and still from a noose, was Sima. He was dead. His suicide note read:

My life is coming to an end at this time. Now today is a day of sorrow for me, also a day of suffering for me. But it is a day of celebration for Papa. Today Papa sent me away. Thank you for loving me so little. Sima. Give my farewell to Mama. Mama you won't have any more frustration or trouble from your boy. Much love from Sima.

In the early 1960s, suicide on the islands of Micronesia was almost unknown. But for reasons no one quite understands, it then began to rise, steeply and dramatically, by leaps and bounds every year, until by the end of the 1980s there were more suicides per capita in Micronesia than anywhere else in the world. For males between fifteen and twenty-four, the suicide rate in the United States is about 22 per 100,000. In the islands of Micronesia the rate is about 160 per 100,000 — more than seven times higher. At that level, suicide is almost commonplace, triggered by the smallest of incidents. Sima took his own life because his father yelled at him. In the midst of the Micronesian epidemic, that was hardly unusual. Teens committed suicide on the islands because they saw their girlfriends with another boy, or because their parents refused to give them a few extra dollars for beer. One nineteen-year-old hanged him because his parents didn't buy him a graduation gown. One seventeen-year-old hanged him because he had been rebuked by his older brother for making too much noise. What, in Western cultures, is something rare, random, and deeply pathological, has become in Micronesia a ritual of adolescence, with its own particular rules and symbols. Virtually all suicides on the islands, in fact, are identical variations on Sima's story. The victim is almost always male. He is in his late teens, unmarried, and living at home. The precipitating event is invariably domestic: a dispute with girlfriends or parents. In three quarters of the cases, the victim had never tried — or even threatened — suicide before. The suicide notes tend to express not depression but a kind of wounded pride and self-pity, a protest against mistreatment. The act itself typically occurs on a weekend night, usually after a bout of drinking with friends. In all but a few cases, the victim observes the same procedure, as if there was a strict, unwritten protocol about the correct way to take one's own life. He finds a remote spot or empty house. He takes a rope and makes a noose, but he does not suspend himself, as in a typical Western hanging. He ties the noose to a low branch or a window or a doorknob and leans forward, so that the weight of his body draws the noose tightly around his neck, cutting off the flow of blood to the brain. Unconsciousness follows. Death results from anoxia — the shortage of blood to the brain.

In Micronesia, the anthropologist Donald Rubinstein writes, these rituals have become embedded in the local culture. As the number of suicides has grown, the idea has fed upon itself, infecting younger and younger boys, and transforming the act itself so that the unthinkable has somehow been rendered thinkable. According to Rubinstein, who has documented the Micronesian epidemic in a series of brilliant papers

Suicide ideation among adolescents appears widespread in certain Micronesian communities and is popularly expressed in recent songs composed locally and aired on Micronesian radio stations, and in graffiti adorning T-shirts and high school walls. A number of young boys who attempted suicide reported that they first saw or heard about it when they were 8 or 10 years old. Their suicide attempts appear in the spirit of imitative or experimental play. One 11-year-old boy, for example, hanged himself inside his house and when found he was already unconscious and his tongue protruding. He later explained that he wanted to "try" out hanging. He said that he did not want to die, although he knew he was risking death. Such cases of imitative suicide attempts by boys as young as five and six have been reported recently from Truk. Several cases of young adolescent suicide deaths recently in Micronesia were evidently the outcome of such experiments. Thus as suicide grows more frequent in these communities the idea itself acquires a certain familiarity if not fascination to young men, and the lethality of the act seems to be trivialized. Especially among some younger boys, the suicide acts appear to have acquired an experimental almost recreational element.

There is something very chilling about this passage. Suicide isn't supposed to be trivialized like this. But the truly chilling thing about it is how familiar it all seems. Here we have a contagious epidemic of self-destruction, engaged in by youth in the spirit of experimentation, imitation, and rebellion. Here we have a mindless action that somehow, among teenagers, has become an important form of self-expression. In a strange way, the Micronesian teen suicide epidemic sounds an awful lot like the epidemic of teenage smoking in the West.

Teenage smoking is one of the great, baffling phenomena of modern life. No one really knows how to fight it, or even, for that matter, what it is. The principal assumption of the anti-smoking movement has been that tobacco companies persuade teens to smoke by lying to them, by making smoking sound a lot more desirable and a lot less harmful than it really is. To address that problem, then, we've restricted and policed cigarette advertising, so it's a lot harder for tobacco companies to lie. We've raised the price of cigarettes and enforced the law against selling tobacco to minors, to try to make it much harder for teens to buy cigarettes. And we've run extensive public health campaigns on television and radio and in magazines to try to educate teens about the dangers of smoking.

It has become fairly obvious, however, that this approach isn't very effective. Why do we think, for example, that the key to fighting smoking is educating people about the risks of cigarettes? Harvard University economist W. Kip Viscusi recently asked a group of smokers to guess how many years of life, on average, smoking from the age of twenty-one onward would cost them. They guessed nine years. The real answer is somewhere around six or seven. Smokers aren't smokers because they underestimate the risks of smoking. They smoke even though they overestimate the risk of smoking. At the same time, it is not clear how effective it is to have adults tell teenagers that they shouldn't smoke. As any parent of a teenage child will tell you, the essential contrariness of adolescents suggests that the more adults inveigh against smoking and lecture teenagers about its dangers, the more teens, paradoxically, will want to try it. Sure enough, if you look at smoking trends over the past decade or so, that is exactly what has happened. The anti-smoking movement has never been louder or more prominent. Yet all signs suggest that among the young the anti-smoking message is backfiring. Between 1993 and 1997, the number of college students who smoke jumped from 22.3 percent to 28.5 percent. Between 1991 and 1997, the number of high school students who smoke jumped 32 percent. Since 1988, in fact, the total number of teen smokers in the United States has risen an extraordinary 73 percent. There are few public health programs in recent years that have fallen as short of their mission as the war on smoking.

The lesson here is not that we should give up trying to fight cigarettes. The point is simply that the way we have tended to think about the causes of smoking doesn't make a lot of sense. That's why the epidemic of suicide in Micronesia is so interesting and potentially relevant to the smoking problem. It gives us another way of trying to come to terms with youth smoking. What if smoking, instead of following the rational principles of the marketplace, follows the same kind of mysterious and complex social rules and rituals that govern teen suicide? If smoking really is an epidemic like Micronesian suicide, how does that change the way we ought to fight the problem?

The central observation of those who study suicide is that, in some places and under some circumstances, the act of one person taking his or her own life can be contagious. Suicides lead to suicides. The pioneer in this field is David Phillips, a sociologist at the University of California at San Diego, who has conducted a number of studies on suicide, each more fascinating and seemingly improbable than the last. He began by making a list of all the stories about suicide that ran on the front page of the country's most prominent newspapers in the twenty-year stretch between the end of the 1940s and the end of the 1960s. Then he matched them up with suicide statistics from the same period. He wanted to know whether there was any relationship between the two. Sure enough, there was. Immediately after stories about suicides appeared, suicides in the area served by the newspaper jumped. In the case of national stories, the rate jumped nationally. (Marilyn Monroe's death was followed by a temporary 12 percent increase in the national suicide rate.) Then Phillips repeated his experiment with traffic accidents. He took front-page suicide stories from the Los Angeles Times and the SanFrancisco Chronicle and matched them up with traffic fatalities from the state of California. He found the same pattern. On the day after a highly publicized suicide, the number of fatalities from traffic accidents was, on average, 5.9 percent higher than expected. Two days after a suicide story, traffic deaths rose 4.1 percent. Three days after, they rose 3.1 percent, and four days after, they rose 8.1 percent. (After ten days, the traffic fatality rate was hack to normal.) Phillips concluded that one of the ways in which people commit suicide is by deliberately crashing their cars, and that these people were just as susceptible to the contagious effects of a highly publicized suicide as were people killing themselves by more conventional means.

The kind of contagion Phillips is talking about isn't something rational or even necessarily conscious. It's not like a persuasive argument. It's something much more subtle than that. "When I'm waiting at a traffic light and the light is red, sometimes I wonder whether I should cross and jaywalk," he says. "Then somebody else does it and so I do too. It's a kind of imitation. I'm getting permission to act from someone else who is engaging in a deviant act. Is that a conscious decision? I can't tell. Maybe afterwards I could brood on the difference. But at the time I don't know whether any of us knows how much of our decision is conscious and how much is unconscious. Human decisions are subtle and complicated and not very well understood." In the case of suicide, Phillips argues, the decision by someone famous to take his or her own life has the same effect: it gives other people, particularly those vulnerable to suggestion because of immaturity or mental illness, permission to engage in a deviant act as well. "Suicide stories are a kind of natural advertisement for a particular response to your problems," Phillips continues. "You've got all these people who are unhappy and have difficulty making up their minds because they are depressed. They are living with this pain. There are lots of stories advertising different kinds of responses to that. It could be that Billy Graham has a crusade going on that weekend — that's a religious response. Or it could be that somebody is advertising an escapist movie — that's another response. Suicide stories offer another kind of alternative." Phillips's permission-givers are the functional equivalent of the Salesmen I talked about in chapter 2. Just as Tom Gau could, through the persuasive force of his personality, serve as a Tipping Point in a word-of-mouth epidemic, the people who die in highly publicized suicides — whose deaths give others "permission" to die — serve as the Tipping Points in suicide epidemics.

The fascinating thing about this permission-giving, though, is how extraordinarily specific it is. In his study of motor fatalities, Phillips found a clear pattern. Stories about suicides resulted in an increase in single-car crashes where the victim was the driver, Stories about suicide-murders resulted in an increase in multiple-car crashes in which the victims included both drivers and passengers. Stories about young people committing suicide resulted in more traffic fatalities involving young people. Stories about older people committing suicide resulted in more traffic fatalities involving older people. These patterns have been demonstrated on many occasions. News coverage of a number of suicides by self-immolation in England in the late 1970s, for example, prompted 82 suicides by self-immolation over the next year. The "permission" given by an initial act of suicide, in other words, isn't a general invitation to the vulnerable. It is really a highly detailed set of instructions, specific to certain people in certain situations who choose to die in certain ways. It's not a gesture. It's speech. In another study, a group of researchers in England in the 1960s analyzed 135 people who had been admitted to a central psychiatric hospital alter attempting suicide. They found that the group was strongly linked socially — that many of them belonged to the same social circles. This, they concluded, was not coincidence. It testified to the very essence of what suicide is a private language between members of a common subculture. The author's conclusion is worth quoting in full:

Many patients who attempt suicide are drawn from a section of the community in which self-aggression is generally recognized as a means of conveying a certain kind of information. Among this group the act is viewed as comprehensible and consistent with the rest of the cultural pattern… If this is true, it follows that the individual who in particular situations, usually of distress, wishes to convey information about his difficulties to others, does not have to invent a communicational medium de novo… The individual within the "attempted suicide subculture" can perform an act which carries a preformed meaning; all he is required to do is invoke it. The process is essentially similar to that whereby a person uses a word in a spoken language.

This is what is going on in Micronesia, only at a much more profound level. If suicide in the West is a kind of crude language, in Micronesia it has become an incredibly expressive form of communication, rich with meaning and nuance, and expressed by the most persuasive of permission-givers. Rubinstein writes of the strange pattern of suicides on the Micronesian island of Ebeye, a community of about 6,000. Between 1955 and 1965, there wasn't a single case of suicide on the entire island. In May 1966, an eighteen-year-old boy hanged himself in his jail cell after being arrested for stealing a bicycle, but his case seemed to have little impact. Then, in November of 1966, came the death of R., the charismatic scion of one of the island's wealthiest families. R. had been seeing two women and had fathered a one-month-old child with each of them. Unable to make up his mind between them, he hanged himself in romantic despair. At his funeral, his two lovers, learning of the existence of the other for the first time, fainted on his grave.

Three days after R.'s death, there was another suicide, a twenty-two-year-old male suffering from marital difficulties, bringing the suicide toll to two over a week in a community that had seen one suicide in the previous twelve years. The island's medic wrote: "After R. died, many boys dreamed about him and said that he was calling them to kill themselves." Twenty-five more suicides followed over the next twelve years, mostly in clusters of three or four over the course of a few weeks. "Several suicide victims and several who have recently attempted suicide reported having a vision in which a boat containing all the past victims circles the island with the deceased inviting the potential victims to join them," a visiting anthropologist wrote in 1975. Over and over again, the themes outlined by R. resurfaced. Here is the suicide note of M., a high school student who had one girlfriend at boarding school and one girlfriend on Ebeye, and when the first girlfriend returned home from school, two girlfriends at once — a complication defined, in the youth subculture of Ebeye, as grounds for taking one's own life: "Best wishes to M. and C. [the two girlfriends]. It's been nice to be with both of you." That's all he had to say, because the context for his act had already been created by R. In the Ebeye epidemic, R. was the Tipping Person, the Salesman, the one whose experience "overwrote" the experience of those who followed him. The power of his personality and the circumstances of his death combined to make the force of his example endure years beyond his death.

Does teen smoking follow this same logic? In order to find out more about the reasons teenagers smoke, I gave several hundred people a questionnaire, asking them to describe their earliest experiences with cigarettes. This was not a scientific study. The sample wasn't representative of the United States. It was mostly people in their late twenties and early thirties, living in big cities. Nonetheless the answers were striking, principally because of how similar they all seemed. Smoking seemed to evoke a particular kind of childhood memory — vivid, precise, emotionally charged. One person remembers how she loved to open her grandmother's purse, where she would encounter "the soft smell of cheap Winstons and leather mixed with drugstore lipstick and cinnamon gum." Another remembers "sitting in the back seat of a Chrysler sedan, smelling the wonderful mixture of sulfur and tobacco waft out the driver's window and into my nostrils." Smoking, overwhelmingly, was associated with the same thing to nearly everyone: sophistication. This was true even of people who now hate smoking, who now think of it as a dirty and dangerous habit. The language of smoking, like the language of suicide, seems incredibly consistent. Here are two responses, both describing childhood memories:

My mother smoked, and even though I hated it — hated the smell — she had these long tapered fingers and full, sort of crinkly lips, always with lipstick on, and when she smoked she looked so elegant and devil-may-care that there was no question that I'd smoke someday. She thought people who didn't smoke were kind of gutless. Makes you stink, makes you think, she would say, reveling in how ugly that sounded.

My best friend Susan was Irish-English. Her parents were, in contrast to mine, youthful, indulgent, liberal. They had cocktails before dinner. Mr. O'Sullivan had a beard and wore turtlenecks. Mrs. O'Sullivan tottered around in mules, dressed slimly in black to match her jet-black hair. She wore heavy eye-makeup and was a little too tan and always, virtually always, had a dangerously long cigarette holder dangling from her manicured hands.

This is the shared language of smoking, and it is as rich and expressive as the shared language of suicide. In this epidemic, as well, there are also Tipping People, Salesmen, permission-givers. Time and time again, the respondents to my survey described the particular individual who initiated them into smoking in precisely the same way.

When I was around nine or ten my parents got an English au pair girl, Maggie, who came and stayed with us one summer. She was maybe twenty. She was very sexy and wore a bikini at the Campbells' pool. She was famous with the grownup men for doing handstands in her bikini. Also it was said her bikini top fell off when she dove — Mr. Carpenter would submerge whenever she jumped in. Maggie smoked, and I used to beg her to let me smoke too.

The first kid I knew who smoked was Billy G. We became friends in fifth grade, when the major distinctions ill our suburban N.J. town-jocks, heads, brains — were beginning to form. Billy was incredibly cool. He was the first kid to date girls, smoke cigarettes and pot, drink hard alcohol and listen to druggy music. I even remember sitting upstairs in his sister's bedroom — his parents were divorced (another first), and his mom was never home — separating the seeds out of some pot on the cover of a Grateful Dead album… The draw for me was the badness of it, and the adultness, and the way it proved the idea that you could be more than one thing at once.

The first person who I remember smoking was a girl named Pam P. I met her when we were both in the 10th grade. We rode the school bus together in Great Neck, L.I., and I remember thinking she was the coolest because she lived in an apartment. (Great Neck didn't have many apartments.) Pam seemed so much older than her 15 years. We used to sit in the back of the bus and blow smoke out the window. She taught me how to inhale, how to tie a man-tailored shirt at the waist to look cool, and how to wear lipstick. She had a leather jacket. Her father was rarely home.

There is actually considerable support for this idea that there is a common personality to hard-core smokers. Hans Eysenck, the influential British psychologist, has argued that serious smokers can be separated from nonsmokers along very simple personality lines. The quintessential hard-core smoker, according to Eysenck, is an extrovert, the kind of person who

is sociable, likes parties, has many friends, needs to have people to talk to… He craves excitement, takes chances, acts on the spur of the moment and is generally an impulsive individual… He prefers to keep moving and doing things, tends to be aggressive and loses his temper quickly; his feelings are not kept under tight control and he is not always a reliable person.

In countless studies since Eysenck's groundbreaking work, this picture of the smoking "type" has been filled out. Heavy smokers have been shown to have a much greater sex drive than nonsmokers. They are more sexually precocious; they have a greater "need" for sex, and greater attraction to the opposite sex. At age nineteen, for example, 15 percent of nonsmoking white women attending college have had sex. The same number for white female college students who do smoke is 55 percent. The statistics for men are about the same according to Eysenck. They rank much higher on what psychologists call "anti-social" indexes: they tend to have greater levels of misconduct, and be more rebellious and defiant. They make snap judgments. They take more risks. The average smoking household spends 73 percent more on coffee and two to three times as much on beer as the average nonsmoking household. Interestingly, smokers also seem to be more honest about themselves than nonsmokers. As David Krogh describes it in his treatise Smoking: TheArtificial Passion, psychologists have what they call "lie" tests in which they insert inarguable statements — "I do not always tell the truth" or "I am sometimes cold to my spouse" — and if test-takers consistently deny these statements, it is taken as evidence that they are not generally truthful. Smokers are much more truthful on these tests. "One theory," Krogh writes, "has it that their lack of deference and their surfeit of defiance combine to make them relatively indifferent to what people think of them."

These measures don't apply to all smokers, of course. But as general predictors of smoking behavior they are quite accurate, and the more someone smokes, the higher the likelihood that he or she fits this profile. "In the scientific spirit," Krogh writes, "I would invite readers to demonstrate [the smoking personality connection] to themselves by performing the following experiment. Arrange to go to a relaxed gathering of actors, rock musicians, or hairdressers on the one hand, or civil engineers, electricians, or computer programmers on the other, and observe how much smoking is going on. If your experience is anything like mine, the differences should be dramatic."

Here is another of the responses to my questionnaire. Can the extroverted personality be any clearer?

My grandfather was the only person around me when I was very little who smoked. He was a great Runyonesque figure, a trickster hero, who immigrated from Poland when he was a boy and who worked most of his life as a glazier. My mother used to like to say that when she was first brought to dinner with him she thought he might at any moment whisk the tablecloth off the table, leaving the settings there, just to amuse the crowd.

The significance of the smoking personality, I think, cannot be overstated. If you bundle all of these extroverts' traits together — defiance, sexual precocity, honesty, impulsiveness, indifference to the opinion of others, sensation seeking — you come up with an almost perfect definition of the kind of person many adolescents are drawn to. Maggie the au pair and Pam P. on the school bus and Billy G. with his Grateful Dead records were all deeply cool people. But they weren't cool because they smoked. They smoked because they were cool. The very same character traits of rebelliousness and impulsivity and risk-taking and indifference to the opinion of others and precocity that made them so compelling to their adolescent peers also make it almost inevitable that they would also be drawn to the ultimate expression of adolescent rebellion, risk-taking, impulsivity, indifference to others, and precocity: the cigarette. This may seem like a simple point. But it is absolutely essential in understanding why the war on smoking has stumbled so badly. Over the past decade, the anti-smoking movement has railed against the tobacco companies for making smoking cool and has spent untold millions of dollars of public money trying to convince teenagers that smoking isn't cool. But that's not the point. Smoking was never cool. Smokers are cool. Smoking epidemics begin in precisely the same way that the suicide epidemic in Micronesia began or word-of-mouth epidemics begin or the AIDS epidemic began, because of the extraordinary influence of Pam P. and Billy G. and Maggie and their equivalents — the smoking versions of R. and Tom Gau and Gaetan Dugas. In this epidemic, as in all others, a very small group — a select few — are responsible for driving the epidemic forward.

The teen smoking epidemic does not simply illustrate the Law of the Few. However it is also a very good illustration of the Stickiness Factor. After all, the fact that overwhelming numbers of teenagers experiment with cigarettes as a result of their contacts with other teenagers is not, in and of itself, all that scary. The problem — the fact that has turned smoking into public health enemy number one — is that many of those teenagers end up continuing their cigarette experiment until they get hooked. The smoking experience is so memorable and powerful for some people that they cannot stop smoking. The habit sticks.

It is important to keep these two concepts — contagiousness and stickiness — separate, because they follow very different patterns and suggest very different strategies. Lois Weisberg is a contagious person. She knows so many people and belongs to so many worlds that she is able to spread a piece of information or an idea a thousand different ways, all at once. Lester Wunderman and the creators of Blue's Clues, on the other hand, are specialists in stickiness: they have a genius for creating messages that are memorable and that change people's behavior. Contagiousness is in larger part a function of the messenger. Stickiness is primarily a property of the message.

Smoking is no different whether a teenager picks up the habit depends on whether he or she has contact with one of those Salesmen who give teenagers "permission" to engage in deviant acts. But whether a teenager likes cigarettes enough to keep using them depends on a very different set of criteria. In a recent University of Michigan study, for example, a large group of people were polled about how they felt when they smoked their first cigarette. "What we found is that for almost everyone their initial experience with tobacco was somewhat aversive," said Ovide Pomerleau, one of the researchers on the project. "But what sorted out the smokers-to-be from the never again smokers is that the smokers-to-be derived some overall pleasure from the experience — like the feeling of a buzz or a heady pleasurable feeling." The numbers are striking. Of the people who experimented with cigarettes a few times and then never smoked again, only about a quarter got any sort of pleasant "high" from their first cigarette. Of the ex-smokers — people who smoked for a while but later managed to quit — about a third got a pleasurable buzz. Of people who were light smokers, about half remembered their first cigarette well. Of the heavy smokers, though, 78 percent remembered getting a good buzz from their first few puffs. The questions of how sticky smoking ends up being to any single person, in other words, depends a great deal on his or her own particular initial reaction to nicotine.

This is a critical point, and one that is often lost in the heated rhetoric of the war on smoking. The tobacco industry, for instance, has been pilloried for years for denying that nicotine is addictive. That position, of course, is ridiculous. But the opposite notion often put forth by antismoking advocates — that nicotine is a deadly taskmaster that enslaves all who come in contact with it — is equally ridiculous. Of all the teenagers who experiment with cigarettes, only about a third ever goes on to smoke regularly. Nicotine may be highly addictive, but it is only addictive in some people, some of the time. More important, it turns out that even among those who smoke regularly, there are enormous differences in the stickiness of their habit. Smoking experts used to think that 90 to 95 percent of all those who smoked were regular smokers. But several years ago, the smoking questions on the federal government's national health survey were made more specific, and researchers discovered, to their astonishment, that a fifth of all smokers don't smoke every day. There are millions of Americans, in other words, who manage to smoke regularly and not be hooked — people for whom smoking is contagious but not sticky. In the past few years, these "chippers" — as they have been dubbed — have been exhaustively studied, with the bulk of the work being done by University of Pittsburgh psychologist Saul Shiftman.

Shiftman's definition of a chipper is someone who smokes no more than five cigarettes a day but who smokes at least four days a week. As Shiftman writes:

Chippers' smoking varies considerably from day to day, and their smoking patterns often include days of complete abstinence. Chippers reported little difficulty maintaining such casual abstinence and reportedly experienced almost no withdrawal symptoms when abstaining from smoking… Unlike regular smokers who smoke soon on waking to replenish the nicotine that has cleared overnight, chippers go several hours before smoking their first cigarette of the day. In short, every indicator examined suggests that chippers are not addicted to nicotine and that their smoking is not driven by withdrawal relief or withdrawal avoidance.

Shiftman calls chippers the equivalent of social drinkers. They are people in control of their habit. He says:

Most of these people had never been heavy smokers. I think of them as developmentally retarded. Every smoker starts out as a chipper, in the early period, but then graduates more heavily into more dependent smoking. When we collected data about the early period of smoking, the chippers look like everyone else when they start out. The difference is that over time, the heavy smokers escalated whereas the chippers stayed where they were.

What distinguishes chippers from hard-core smokers? Probably genetic factors. Allan Collins of the University of Colorado, for example, recently took several groups of different strains of mice and injected each with steadily increasing amounts of nicotine. When nicotine reaches toxic levels in a mouse (nicotine is, after all, a poison) it has a seizure — its tail goes rigid; it begins running wildly around its cage; its head starts to jerk and snap; and eventually it flips over on its back. Collins wanted to see whether different strains of mice could handle different amounts of nicotine. Sure enough, they could. The strain of mice most tolerant of nicotine could handle about two to three times as much of the drug as the strain that had seizures at the lowest dose. "That's about in the same range as alcohol," Collins says. Then he put all the mice into cages and gave them two bottles to drink from: one filled with a simple saccharin solution, one filled with a saccharin solution laced with nicotine. This time he wanted to see whether there was any relationship between each strain's genetic tolerance to nicotine and the amount of nicotine they would voluntarily consume. Once again, there was. In fact, the correlation was almost perfect. The greater a mouse's genetic tolerance for nicotine, the more of the nicotine bottle it would drink. Collins thinks that there are genes in the brains of mice that govern how nicotine is processed — how quickly it causes toxicity, how much pleasure it gives, what kind of buzz it leaves — and that some strains of mice have genes that handle nicotine really well and extract the most pleasure from it and some have genes that treat nicotine like a poison.

Humans, obviously, aren't mice, and drinking nicotine from a bottle in a cage isn't the same as lighting up a Marlboro. But even if there is only a modest correlation between what goes on in mice brains and ours, these findings do seem to square with Pomerleau's study. The people who didn't get a buzz from their first cigarette and who found the whole experience so awful that they never smoked again are probably people whose bodies are acutely sensitive to nicotine, incapable of handling it in even the smallest doses. Chippers may be people who have the genes to derive pleasure from nicotine, but not the genes to handle it in large doses. Heavy smokers, meanwhile, 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. Since nicotine is known to relieve boredom and stress, for example, people who are in boring or stressful situations are always going to smoke more than people who are not. It is simply to say that what makes smoking sticky is completely different from the kinds of things that make it contagious. If we are looking for Tipping Points in the war on smoking, then, we need to decide which of those sides of the epidemic we will have the most success attacking. Should we try to make smoking less contagious, to stop the Salesmen who spread the smoking virus? Or are we better off trying to make it less sticky, to look for ways to turn all smokers into chippers?

Let's deal with the issue of contagion first. There are two possible strategies for stopping the spread of smoking. The first is to prevent the permission-givers — the Maggies and Billy G.'s — from smoking in the first place. This is; clearly the most difficult path of all: the most independent, precocious, rebellious teens are hardly likely to be the most susceptible to rational health advice. The second possibility is to convince all those who look to people like Maggie and Billy G. for permission that they should look elsewhere, to get their cues as to what is cool, in this instance, from adults.

But this too is not easy. In fact, it may well be an even more difficult strategy than the first, for the simple reason that parents simply don't wield that kind of influence over children.

This is a hard fact to believe, of course. Parents are powerfully invested in the idea that they can shape their children's personalities and behavior. But, as Judith Harris brilliantly argued in her 1998 book The Nurture Assumption, the evidence for this belief is sorely lacking. Consider, for example, the results of efforts undertaken by psychologists over the years to try and measure this very question — the effect parents have on their children. Obviously, they pass on genes to their offspring, and genes play a big role in which we are. Parents provide love and affection in the early years of childhood; deprived of early emotional sustenance, children will be irreparably harmed. Parents provide food and a home and protection and the basics of everyday life that children need to be safe and healthy and happy. This much is easy. But does it make a lasting difference to the personality of your child if you are an anxious and inexperienced parent, as opposed to being authoritative and competent? Are you more likely to create intellectually curious children by filling your house with books? Does it affect your child's personality if you see him or her two hours a day, as opposed to eight hours a day? In other words, does the specific social environment that we create in our homes make a real difference in the way our children end up as adults? In a series of large and well-designed studies of twins — particularly twins separated at birth and reared apart — geneticists have shown that most of the character traits that make us who we are — friendliness, extroversion, nervousness, openness, and so on — are about half determined by our genes and hall determined by our environment, and the assumption has always been that this environment that makes such a big difference in our lives is the environment of the home. The problem is, however, that whenever psychologists have set out to look for this nurture effect, they can't find it.

One of the largest and most rigorous studies of this kind, for example, is known as the Colorado Adoption Project. In the mid-1970s, a group of researchers at the University of Colorado led by Robert Plomin, one of the worlds leading behavioral geneticists, recruited 245 pregnant women from the Denver area who were about to give up their children for adoption. They then followed the children into their new homes, giving them a battery of personality and intelligence tests at regular intervals throughout their childhood and giving the same sets of tests to their adoptive parents. For the sake of comparison, the group also ran the same set of tests on a similar group of 245 parents and their biological children. For this comparison group, the results came out pretty much as one might expect. On things like measures of intellectual ability and certain aspects of personality, the biological children are fairly similar to their parents. For the adopted kids, however, the results are downright strange. Their scores have nothing whatsoever in common with their adoptive parents: these children are no more similar in their personality or intellectual skills to the people who raised them, fed them, clothed them, read to them, taught them, and loved them for sixteen years than they are to any two adults taken at random off the street.

This is, if you think about it, a rather extraordinary finding. Most of us believe that we are like our parents because of some combination of genes and, more important, of nurture — that parents, to a large extent, raise us in their own image. But if that is the case, if nurture matters so much, then why did the adopted kids not resemble their adoptive parents at all? The Colorado study isn't saying that genes explain everything and that environment doesn't matter. On the contrary, all of the results strongly suggest that our environment plays as big — if not bigger — a role as heredity in shaping personality and intelligence. What it is saying is that whatever that environmental influence is, it doesn't have a lot to do with parents. It's something else, and what Judith Harris argues is that that something else is the influence of peers.

Why, Harris asks, do the children of recent immigrants almost never retain the accent of their parents? How it is the children of deaf parents manage to learn how to speak as well and as quickly as children whose parents speak to them from the day they were born? The answer has always been that language is a skill acquired laterally — that what children pick up from other children is as, or more, important in the acquisition of language as what they pick up at home. What Harris argues is that this is also true more generally, that the environmental influence that helps children become who they are — that shapes their character and personality — is their peer group.

This argument has, understandably, sparked a great deal of controversy in the popular press. There are legitimate arguments about where — and how far — it can be applied. But there's no question that it has a great deal of relevance to the teenage smoking issue. The children of smokers are more than twice as likely to smoke as the children of nonsmokers. That's a well-known fact. But — to follow Harris's logic — that does not mean that parents who smoke around their children set an example that their kids follow. It simply means that smokers' children have inherited genes from their parents that predispose them toward nicotine addiction. Indeed studies of adopted children have shown that those raised by smokers are no more likely to end up as smokers themselves than those raised by nonsmokers. "In other words, effects of rearing variation (e.g. parents' lighting up or not, or having cigarettes in the home or not) were essentially nil by the time the children reached adulthood," the psychologist David Rowe writes in his 1994 book summarizing research on the question. The Limits of Family Influence. "The role of parents is a passive one — providing a set of genes at loci relevant to smoking risk, but not socially influencing their offspring."

To Rowe and Harris, the process by which teens get infected with the smoking habit is entirely bound 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. Teenage smoking is about being a teenager, about sharing in the emotional experience and expressive language and rituals of adolescence, which are as impenetrable and irrational to outsiders as the rituals of adolescent suicide in Micronesia. How, under the circumstances, can we expect any adult intervention to make an impact?

"Telling teenagers about the health risks of smoking — it will make you wrinkled! It will make you impotent! It will make you dead! — is useless," Harris concludes. "This is adult propaganda; these are adult arguments. It is because adults don't approve of smoking — because there is something dangerous and disreputable about it — that teenagers want to do it."

If trying to thwart the efforts of Salesmen — if trying to intervene in the internal world of adolescents — doesn't seem like a particularly effective strategy against smoking, then what of stickiness? Here the search for Tipping Points is very different. We suspect, as I wrote previously, that one of the reasons some experimenters never smoke again and some turn into lifelong addicts is that human beings may have very different innate tolerances for nicotine. In a perfect world we would give heavy smokers a pill that lowered their tolerance to the level of, say, a chipper. That would be a wonderful way of stripping smoking of its stickiness. Unfortunately we don't know how to do that. What we do have is the nicotine patch, which delivers a slow and steady dose of nicotine so that smokers don't have to turn to the dangers of cigarettes to get their fix. That's an anti-sticky strategy that has helped millions of smokers. But it is fairly clear that the patch is far from perfect. The most exhilarating way for an addict to get his fix is in the form of a "hit" — a high dose delivered quickly, that overwhelms the senses. Heroin users don't put themselves on a heroin intravenous drip: they shoot up two or three or four times a day, injecting a huge dose all at once. Smokers, on a lesser scale, do the same. They get a jolt from a cigarette, then pause, then get another jolt. The patch, though, gives you a steady dose of the drug over the course of the day, which is a pretty boring way to ingest nicotine. The patch seems no more a Tipping Point in the fight against the smoking epidemic than SlimFast milkshakes are a Tipping Point in the fight against obesity. Is there a better candidate?

I think there are two possibilities. The first can be found in the correlation between smoking and depression, a link discovered only recently. In 1986, a study of psychiatric outpatients in Minnesota found that half of them smoked a figure well above the national average. Two years later, Columbia University psychologist Alexander Glassman discovered that 60 percent of the heavy smokers he was studying as part of an entirely different research project had a history of major depression. He followed that up with a major study published in the Journal of theAmerican Medical Association in 1990 of 3,200 randomly selected adults. Of those who had at some time in their lives been diagnosed with a major psychiatric disorder, 74 percent had smoked at some point, and 14 percent had quit smoking of those who had never been diagnosed with a psychiatric problem, 53 percent had smoked at some point in their life and 31 percent had managed to quit smoking. As psychiatric problems increase, the correlation with smoking grows stronger. About 80 percent of alcoholics smoke. Close to 90 percent of schizophrenics smoke. In one particularly chilling study, a group of British psychiatrists compared the smoking behavior of a group of twelve- to fifteen-year-olds with emotional and behavioral problems with a group of children of the same age in mainstream schools. Half of the troubled kids were already smoking more than 21 cigarettes a week, even at that young age, versus 10 percent of the kids in the mainstream schools. As overall smoking rates decline, in other words, the habit is becoming concentrated among the most troubled and marginal members of society.

There are a number of theories as to why smoking matches up so strongly with emotional problems. The first is that the same kinds of things that would make someone susceptible to the contagious effects of smoking — low self-esteem, say, or an unhealthy and unhappy home life — are also the kinds of things that contribute to depression. More tantalizing, though, is some preliminary evidence that the two problems might have the same genetic root. For example, depression is believed to be the result, at least in part, of a problem in the production of certain key brain chemicals, in particular the neurotransmitters known as serotonin, dopamine, and norepinephrine. These are the chemicals that regulate mood, that contribute to feelings of confidence and mastery and pleasure. Drugs like Zoloft and Prozac work because they prompt the brain to produce more serotonin: they compensate, in other words, for the deficit of serotonin that some depressed people suffer from. Nicotine appears to do exactly the same thing with the other two key neurotransmitters — dopamine and norepinephrine. Those smokers who are depressed, in short, are essentially using tobacco as a cheap way of treating their own depression, of boosting the level of brain chemicals they need to function normally. This effect is strong enough that when smokers with a history of psychiatric problems give up cigarettes, they run a sizable risk of relapsing into depression. Here is stickiness with a vengeance: not only do some smokers find it hard to quit because they are addicted to nicotine, but also because without nicotine they run the risk of a debilitating psychiatric illness.

This is a sobering fact. But it also suggests that tobacco may have a critical vulnerability: if you can treat smokers for depression, you may be able to make their habit an awful lot easier to break. Sure enough, this turns out to be the case. In the mid-1980s, researchers at what is now the Glaxo Wellcome pharmaceutical firm were doing a big national trial of a new antidepressant called bupropion when, much to their surprise, they began getting reports about smoking from the field. "I started hearing that patients were saying things like, 'I no longer have the desire to smoke,' or 'I've cut down on the number of cigarettes I'm smoking,' or 'Cigarettes don't taste as good anymore,"' said Andrew Johnston, who heads the psychiatry division for the company. "You can imagine that someone in my position gets reports about everything, so I didn't put much stock in them. But I kept getting them. It was very unusual." This was in 1986, before the depression — smoking link was well understood, so the company was initially puzzled. But what they soon realized was that bupropion was functioning as a kind of nicotine substitute. "The dopamine that nicotine releases goes to the prefrontal cortex of the brain," explains Johnston. "That's the pleasure center of the brain. It's what people believe is responsible for the pleasure, the sense of wellbeing, associated with smoking, and that's one of the reasons it's so hard to quit. Nicotine also increases norepinephrine, and that's the reason that when you try to quit smoking and you no longer get so much norepinephrine, you get agitation and irritability. Bupropion does two things. It increases your dopamine, so smokers don't have the desire to smoke, then it replaces some of the norepinephrine, so they don't have the agitation, the withdrawal symptoms."

Glaxo Wellcome has tested the drug — now marketed under the name Zyban — in heavily addicted smokers (more than 15 cigarettes a day) and found remarkable effects. In the study, 23 percent of smokers given a course of anti-smoking counseling and a placebo quit after four weeks. Of those given counseling and the nicotine patch, 36 percent had quit after four weeks. The same figure for Zyban, though, was 49 percent, and of those heavily addicted smokers given both Zyban and the patch, 58 percent had quit after a month. Interestingly, Zoloft and Prozac — the serotonin drugs — don't seem to help smokers to quit. It's not enough to lift mood, in other words; you have to lift mood in precisely the same way that nicotine does, and only Zyban does that. This is not to say that it is a perfect drug. As with all smoking cessation aids, it has the least success with the heaviest smokers. But what the drug's initial success has proven is that it is possible to find a sticky Tipping Point with smoking: that by zeroing in on depression, you can exploit a critical vulnerability in the addiction process.

There is a second potential Tipping Point on the stickiness question that becomes apparent if you go back and look again at what happens to teens when they start smoking. In the beginning, when teens first experiment with cigarettes, they are all chippers. They smoke only occasionally. Most of those teens soon quit and never smoke again. A few continue to chip for many years afterward, without becoming addicted. About a third end up as regular smokers. What's interesting about this period, however, is that it takes about three years for the teens in that last group to go from casual to regular smoking — roughly from fifteen to eighteen years of age — and then for the next five to seven years there is a gradual escalation of their habit. "When someone in high school is smoking on a regular basis, he or she isn't smoking a pack a day," Neal Benowiu, an addiction expert at the University of California at San Francisco, says. "It takes until their twenties to get to that level."

Nicotine addiction, then, is far from an instant development. It takes time for most people to get hooked on cigarettes, and just because teens are smoking at fifteen doesn't mean that they will inevitably become addicted. You've got about three years to stop them. The second, even more intriguing implication of this, is that nicotine addiction isn't a linear phenomenon. It's not that if you need one cigarette a day you are a little bit addicted, and if you need two cigarettes a day you are a little bit more addicted, and if you need ten cigarettes you are ten times as addicted as when you needed one cigarette. It suggests, instead, that there is an addiction Tipping Point, a threshold — that if you smoke below a certain number of cigarettes you aren't addicted at all, but once you go above that magic number you suddenly are. This is another, more complete way of making sense of chippers: they are people who simply never smoke enough to hit that addiction threshold. A hardened smoker, on the other hand, is someone who, at some point, crosses that line.

What is the addiction threshold? Well, no one believes that it is exactly the same for all people. But Benowitz and Jack Henningfield — who are probably the leading nicotine experts in the world — have made some educated guesses. Chippers, they point out, are people who are capable of smoking up to five cigarettes a day without getting addicted. That suggests that the amount of nicotine found in five cigarettes — which works out to somewhere between four and six milligrams of nicotine — is probably somewhere close to the addiction threshold. What Henningfield and Benowitz suggest, then, is that tobacco companies be required to lower the level of nicotine so that even the heaviest smokers — those smoking, say, 30 cigarettes a day — could not get anything more than five milligrams of nicotine within a 24-hour period. That level, the two argued in an editorial in the prestigious New EnglandJournal of Medicine, "should be adequate to prevent or limit the development of addiction in most young people. At the same time it may provide enough nicotine for taste and sensory stimulation."' Teens, in other words, would continue to experiment with cigarettes for all the reasons that they have ever experimented with cigarettes — because the habit is contagious, because cool kids are smoking, because they want to fit in. But, because of the reduction of nicotine levels below the addiction threshold, the habit would no longer be sticky. Cigarette smoking would be less like the flu and more like the common cold: easily caught but easily defeated.

It is important to put these two stickiness factors in perspective. The anti-smoking movement has focused, so far, on raising cigarette prices, curtailing cigarette advertising, running public health messages on radio and television, limiting access of cigarettes to minors, and drilling anti-tobacco messages into schoolchildren, and in the period that this broad, seemingly comprehensive, ambitious campaign has been waged, teenage smoking has skyrocketed. We've been obsessed with changing attitudes toward tobacco on a mass scale, but we haven't managed to reach the groups whose attitude needs to change the most. We've been obsessed with foiling the influence of smoking Salesmen. But the influence of those Salesmen increasingly looks like something we cannot break. We have, in short, somehow become convinced that we need to tackle the whole problem, all at once. But the truth is that we don't. We only need to find the stickiness Tipping Points, and those are the links to depression and the nicotine threshold.

The second lesson of the stickiness strategy is that it permits a more reasonable approach to teenage experimentation. The absolutist approach to fighting drugs proceeds on the premise that experimentation equals addiction. We don't want our children ever to be exposed to heroin or pot or cocaine because we think that the lure of these substances is so strong that even the smallest exposure will be all it takes. But do you know what the experimentation statistics are for illegal drugs? In the 1996 Household Survey on Drug Abuse, 1.1 percent of those polled said that they had used heroin at least once. But only 18 percent of that 1.1 percent had used it in the past year, and only 9 percent had used it in the past month. That is not the profile of a particularly sticky drug. The figures for cocaine are even more striking. Of those who have ever tried cocaine, less than one percent — 0.9 percent — are regular users. What these figures tell us is that experimentation and actual hard-core use are two entirely separate things — that for a drug to be contagious does not automatically mean that it is also sticky. In fact, the sheer number of people who appear to have tried cocaine at least once should tell us that the urge among teens to try something dangerous is pretty nearly universal. This is what teens do. This is how they learn about the world, and most of the time — in 99.1 percent of the cases with cocaine — that experimentation doesn't result in anything bad happening. 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 people like Maggie the au pair and Billy G. and Pam P., and they should be fascinated by people like that, if only to get past the adolescent fantasy that to be rebellious and truculent and irresponsible is a good way to spend your life. What we should be doing instead of fighting experimentation is making sure that experimentation doesn't have serious consequences.

I think it is worth repeating something from the beginning of this chapter, a quote from Donald Rubinstein describing just how deeply embedded suicide had become in the teen culture of Micronesia.

A number of young boys who attempted suicide reported that they first saw or heard about it when they were 8 or 10 years old. Their suicide attempts appear in the spirit of imitative or experimental play. One 11-year-old boy, for example, hanged himself inside his house and when found he was already unconscious and his tongue protruding. He later explained that he wanted to "try" out hanging. He said that he did not want to die.

What is tragic about this is not that these little boys were experimenting. Experimenting is what little boys do. What is tragic is that they have chosen to experiment with something that you cannot experiment with. Unfortunately, there isn't ever going to be a safer form of suicide, to help save the teenagers of Micronesia. But there can be a safer form of smoking, and by paying attention to the Tipping Points of the addiction process we can make that safer, less sticky form of smoking possible.