One of the first programs launched under the aegis of the White House Cancer Moonshot in 2016 was an initiative to use new digital techniques and social media tools based on recent studies on the science of addiction. The program was created to tackle the high smoking rates in Washington, D.C. and Cleveland — two cities with above average smoking and lung cancer rates. Over the next few years, the National Cancer Institute expanded this program to more than 20 cities, giving thousands of individuals access to a program that could help them stop using tobacco products.
Sounds like progress. Until you read this:
Between 2017 and 2018 — the period when Juul rapidly grew to become the U.S. market leader — e-cigarette use among U.S. adults grew from 2.8% of the population to 3.2%, according to the C.D.C. But rates of cigarette smoking among adults barely budged, dropping from 14% to 13.7% — not enough to be statistically significant, according to the C.D.C. (For a graphic showing vaping trends for various age groups, see here.) Use of e-cigarettes by high-school students, by contrast, shot up by 78% over the same period — from 11.7% to 20.8% of students, data from the C.D.C and the F.D.A. show.
Just when we thought that 50 years of education had finally helped the nation finally turn away from smoking, only a few years of a massive marketing campaign built around “kid friendly” flavors and products has caused an entirely new generation to become addicted. In the fight between education and manipulation, manipulation wins every time.
We like to think that we are rational animals that do the right thing for the right reason, when in fact the new class of neuroscientists, psychologists, and behavioral economists, such as Dan Ariely, Adam Grant, and Jonathan Haidt, have compiled an impressive array of data that suggests we often do the right things for the wrong reasons, if we do them at all. Well-intentioned programs, such as the D.C.-Cleveland project, assume that people will stop smoking and get screened when given the right information and opportunity. However, there is little evidence that that actually happens without considerable in-person attention and “health bullying” that cannot really scale.
Put another way, this is a war in which the enemy manipulates us at a very deep gut level, not a debate that you can win with the facts aimed at the mind. I shudder when I think about how many times I was accosted by well-meaning advocates asking why the Cancer Moonshot didn’t focus more on nutrition. After all, if people only knew the benefits of — (your favorite weird food or supplement or fast here) — we could save so many lives.
My reply was true and tragic. The food industry has perfected the bliss point of salt, sugar, and fat — and no amount of nutritional labels or education will change your evolution-based attraction to them, or change people’s habit en masse. And the e-cigarette industry knows that 50 years of proving smoking causes cancer means little to an 18-year-old who doesn’t know what Vietnam was. Not to mention that smoking in movies — a topic I worked on with Vice President Gore in the ’90s — has actually gotten worse since then.
So, what is the answer? Well, it’s not education. Let’s try brute force. It was cigarette taxes and bans on where you could smoke, not surgeon generals’ reports, that lowered smoking rates. When you see people huddled outside in freezing weather smoking expensive cigarettes, you know they are truly addicted. These are the individuals we should help with addiction programs because they have run the gauntlet of social disapproval and still can’t stop.
But when you see Juul flavored pods everywhere that are clearly targeting children, and see the profits they are racking up, you have to move to brute force. This includes bans on flavored e-cigarettes, exorbitant taxes on e cigarettes, jail for people who sell to minors, and loss of corporate tax breaks for companies that sell products that are unsafe when used as intended — the definition of tobacco products.
The loss of another generation to tobacco addiction is the worst public health disaster in recent memory. We are not going to educate our way out of it. We will need to use every manipulative tool in nudging our behavioral economists to block the availability, attractiveness, and coolness of the Juul phenomenon.
And then we can work on high-fructose corn syrup and sugar subsidies.