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 Benowitz, 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 England Journal 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 t
o the Tipping Points of the addiction process we can make that safer, less sticky form of smoking possible.
EIGHT
Conclusion
FOCUS, TEST, AND BELIEVE
Not long ago a nurse by the name of Georgia Sadler began a campaign to increase knowledge and awareness of diabetes and breast cancer in the black community of San Diego. She wanted to create a grassroots movement toward prevention, and so she began setting up seminars in black churches around the city. The results, however, were disappointing. “There’d be maybe two hundred people in church, but we’d get only twenty or so to stay, and the people who were staying were people who already knew a lot about those diseases and just wanted to know more. It was very discouraging.” Sadler couldn’t get her message to tip outside of that small group.
She realized she needed a new context. “I guess people were tired and hungry after the service,” she says. “We all have a busy life. People wanted to get home.” She needed a place where women were relaxed, receptive to new ideas, and had the time and opportunity to hear something new. She also needed a new messenger, someone who was a little bit Connector, a little bit Salesman, and a little bit Maven. She needed a new, stickier way of presenting the information. And she needed to make all those changes in such a way that she didn’t exceed the very small amount of money she’d cobbled together from various foundations and funding groups. Her solution? Move the campaign from black churches to beauty salons.
“It’s a captive audience,” Sadler says. “These women may be at a salon for anywhere from two hours to eight hours, if they’re having their hair braided.” The stylist also enjoys a special relationship with her client. “Once you find someone who can manage your hair, you’ll drive a hundred miles to see her. The stylist is your friend. She takes you through your high school graduation, your wedding, your first baby. It’s a long term relationship. It’s a trusting relationship. You literally and figuratively let your hair down in a salon.” There is something about the profession of stylist, as well, that seems to attract a certain kind of person—someone who communicates easily and well with others, someone with a wide variety of acquaintances. “They’re natural conversationalists,” Sadler says. “They love talking to you. They tend to be very intuitive, because they have to keep an eye on you and see how you’re doing.”
She gathered together a group of stylists from the city for a series of training sessions. She brought in a folklorist to help coach the stylists in how to present their information about breast cancer in a compelling manner. “We wanted to rely on traditional methods of communication,” Sadler says. “This isn’t a classroom setting. We wanted this to be something that women wanted to share, that they wanted to pass on. And how much easier is it to hang the hooks of knowledge on a story?” Sadler kept a constant cycle of new information and gossipy tidbits and conversational starters about breast cancer flowing into the salons, so that each time a client came back, the stylist could seize on some new cue to start a conversation. She wrote the material up in large print, and put it on laminated sheets that would survive the rough and tumble of a busy hair salon. She set up an evaluation program to find out what was working and to see how successful she was in changing attitudes and getting women to have mammograms and diabetes tests, and what she found out was that her program worked. It is possible to do a lot with a little.
Over the course of The Tipping Point we’ve looked at a number of stories like this—from the battle against crime in New York to Lester Wunderman’s Columbia Record Club treasure hunt—and what they all have in common is their modesty. Sadler didn’t go to the National Cancer Institute or the California State Department of Health and ask for millions of dollars to run some elaborate, multimedia public awareness campaign. She didn’t go door to door through the neighborhoods of San Diego, signing women up for free mammograms. She didn’t bombard the airwaves with a persistent call for prevention and testing. Instead she took the small budget that she had and thought about how to use it more intelligently. She changed the context of her message. She changed the messenger, and she changed the message itself. She focused her efforts.
This is the first lesson of the Tipping Point. Starting epidemics requires concentrating resources on a few key areas. The Law of the Few says that Connectors, Mavens, and Salesmen are responsible for starting word of mouth epidemics, which means that if you are interested in starting a word of mouth epidemic, your resources ought to be solely concentrated on those three groups. No one else matters. Telling William Dawes that the British were coming did nothing for the colonists of New England. But telling Paul Revere ultimately meant the difference between defeat and victory. The creators of Blue’s Clues developed a sophisticated, half hour television show that children loved. But they realized that there was no way that children could remember and learn everything they needed to remember and learn from a single viewing. So they did what no one had ever done in television before. They ran the same show five times in a row. Sadler didn’t try to reach every woman in San Diego all at once. She took what resources she had and put them all into one critical place—the beauty salon.
A critic looking at these tightly focused, targeted interventions might dismiss them as Band Aid solutions. But that phrase should not be considered a term of disparagement. The Band Aid is an inexpensive, convenient, and remarkably versatile solution to an astonishing array of problems. In their history, Band Aids have probably allowed millions of people to keep working or playing tennis or cooking or walking when they would otherwise have had to stop. The Band Aid solution is actually the best kind of solution because it involves solving a problem with the minimum amount of effort and time and cost. We have, of course, an instinctive disdain for this kind of solution because there is something in all of us that feels that true answers to problems have to be comprehensive, that there is virtue in the dogged and indiscriminate application of effort, that slow and steady should win the race. The problem, of course, is that the indiscriminate application of effort is something that is not always possible. There are times when we need a convenient shortcut, a way to make a lot out of a little, and that is what Tipping Points, in the end, are all about.
The theory of Tipping Points requires, however, that we reframe the way we think about the world. I have spent a lot of time, in this book, talking about the idiosyncrasies of the way we relate to new information and to each other. We have trouble estimating dramatic, exponential change. We cannot conceive that a piece of paper folded over 50 times could reach the sun. There are abrupt limits to the number of cognitive categories we can make and the number of people we can truly love and the number of acquaintances we can truly know. We throw up our hands at a problem phrased in an abstract way, but have no difficulty at all solving the same problem rephrased as a social dilemma. All of these things are expressions of the peculiarities of the human mind and heart, a refutation of the notion that the way we function and communicate and process information is straightforward and transparent. It is not. It is messy and opaque. Sesame Street and Blue’s Clues succeed, in large part, because of things they do that are not obvious. Who would have known, beforehand, that Big Bird had to be on the same set as the adult characters? Or who could have predicted that going from 100 to 150 workers in a plant isn’t a problem, but going from 150 to 200 is a huge problem? In the phone book names test that I gave, I’m not sure anyone would have predicted that the high scores would have been over 100 and the low scores under 10. We think people are different, but not that different.
The world—much as we want it to—does not accord with our intuition. This is the second lesson of the Tipping Point. Those who are successful at creating social epidemics do not just do what they think is right. They deliberately test their intuitions. Without the evidence of the Distracter, which told them that their intuition about fantasy and reality was wrong, Sesame Street would today be a forgotten footnote in television history. Lester Wunderman’s gold box sounded like a silly idea until he prov
ed how much more effective it was than conventional advertising. That no one responded to Kitty Genovese’s screams sounded like an open and shut case of human indifference, until careful psychological testing demonstrated the powerful influence of context. To make sense of social epidemics, we must first understand that human communication has its own set of very unusual and counterintuitive rules.
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