July 24, 2024

Mary Jo began smoking when she was 12 years old, sneaking behind her church and picking up cigarette butts off the ground. As she got a little older, she would steal cigarettes from her brother and, by 15, she was buying her own packs – a proud Marlboro smoker.

“I smoked for 30 years,” she tells me. “I smoked when I was pregnant.” She was desperate to quit, or at least cut down the number of cigarettes, but nothing worked. “The guiltier I felt, the more I smoked,” she continues. “I would just hide my belly so that people couldn’t see.” Her younger son was born premature at only 5lb. “I cried because he was so tiny.”

Mary Jo is now a 58-year-old housekeeper living in Wilmington, Massachusetts, and back in 2006, she finally quit smoking. It took her four tries. (On average, it takes smokers eight to 14 attempts to permanently quit.)

On her first try, she was crossing the street when an enormous truck came by. Mary Jo remembers thinking, “Go ahead and kill me. I don’t care.” Cigarettes, after all, were what got her out of bed. Without them, the depression was overwhelming, like a soaking wet blanket wringing her body. She’d hallucinate cigarettes flying past, her hand reflexively reaching out to grasp them.

In the end, the stop-smoking pill Chantix and a water bottle were what allowed her to quit. The medication helped with the depression while the water bottle – with a picture of “a good lung and a bad lung on the front and a picture of my boys on the back” – quenched her cravings, a sip for every time she needed a cigarette. She must have drunk three gallons a day.

“It was the hardest thing I ever did in my life,” Mary Jo says. “I would rather go through childbirth a hundred times over than quit smoking again.”

All this suffering will never happen to Mary Jo’s grandchildren – at least, if Katherine Silbaugh has her way.

Silbaugh is one of 255 town meeting members in Brookline, Massachusetts, an urban-suburban “island inside Boston” – its neighboring boroughs have long been swallowed into the city. The town’s 63,000 residents are 70% white, with a median household income of $122,000.

Two years ago, Silbaugh and her neighbor Anthony Ishak passed an ordinance banning anyone born after 1 January 2000 from ever buying cigarettes in their town. The measure took effect in September 2021. The idea was to curb youth smoking rates without yanking anything away from people already addicted, essentially grandfathering out tobacco. Every year, there’d be a smaller slice of the population that could buy cigarettes, until one day no one would be left. At least, that was the vision.

In tobacco’s heyday in the mid-20th century, 45% of US adults smoked. Fast-forward to 2020, after decades of aggressive anti-smoking campaigns, and the rate was down to 12.5%. It’s progress, to be sure, but cigarettes still kill roughly half a million people in the US every year – more than car accidents, alcohol, murders, suicides and illegal drugs combined. If current trajectories persist, tobacco will kill 1bn people in the 21st century, or one person every three seconds.

So it’s hard to imagine that a world without cigarettes would be a bad thing. Prohibition might fast-track it and help avoid needless suffering, as public health officials will remind you. But at what cost? There’s obviously no enumerated right to cigarettes, but there is a right to live our lives as we see fit, so long as we don’t infringe on others’ ability to do the same.

While the tobacco endgame – smoking rates below 5% – seems ultimately inevitable, getting the timeline right is the $1.85tn question. Should cigarettes die on their own, or at the hands of the state?

To light up a cigarette seems almost Promethean: the individual steals fire from the igniter and offers it to humanity via the smoldering tip. Although tobacco will continue combusting on its own, you must blast a current of air into the cigarette to feed its flames. During a puff, temperatures rise from 400C to 900C – think red-hot steel.

As the tobacco leaves and their additives burn, thousands of chemicals are released in a motley collection of gases and particulates known as cigarette smoke. This toxic fog gets vacuumed down the airway and into tiny air sacs in our lungs called alveoli – they look like clusters of grapes, surrounded by dense cobwebs of blood vessels.

Nicotine, the addictive chemical in cigarettes (but also found in tomatoes, eggplants and potatoes), can then pass through alveolar walls, hitch a ride on the circulatory system, and rapidly flood the body. Ten to 20 seconds after a puff, nicotine hits the head. “Inhalation is the fastest way of getting a drug into the brain,” says Scott Lukas, psychiatrist and director of the behavioral psychopharmacology lab at McLean hospital. “It’s faster than IV.”

Our brains are peppered with “nicotinic” receptors, parking spots typically reserved for the chemical messenger acetylcholine, which is involved in memory, movement and learning – but activated by this chemical impostor as well. It sprinkles the brain with adrenaline to improve alertness while also spotlighting neural circuits for better concentration, as the Stanford neuroscientist Andrew Huberman describes it.

Nicotine’s main claim to fame, however, is how it hijacks our brain’s reward system to increase levels of the pleasure neurotransmitter dopamine, both stepping on the gas and cutting the brakes. “One molecule that can trigger activation of all the circuits for focus and motivation in one fell swoop?” Huberman says. “That is remarkable.”

Over time, though, nicotinic receptors become less responsive to the drug, so the brain starts to create more of them. And these multiplying receptors are like petulant baby birds, incessantly crying to be fed. Go too long without a cigarette, and withdrawal’s sure to follow – irritability, depression and cravings galore. Of course, there’s no gun to the head, but smoking another cigarette takes the pain away and offers an immediate sense of pleasure, if only for a short while.

The biology is interesting and all, says Carl Hart, a neuroscientist and professor of psychology at Columbia University, but it alone can’t tell us what the boundaries of public health should be – whether prohibition is proper in the name of the collective good.

Known for his controversial views on drug use (he advocates for the legalization of all drugs and wrote a book in which he admits to having used heroin regularly for the past five years), Hart wears his hair in long dreadlocks, and his hands move prophetically, a beat or two ahead of his words. He gesticulates with indignation as he tells me that any vision of a tobacco endgame is that of sick or naive zealots.

“Our declaration of independence, the first founding principles of the country, says that we are free, and we have the right to these three birth rights: life, liberty and the pursuit of happiness. Now they’re trying to overturn those basic principles,” Hart says. “Public health is all around us to enhance safety, but not to take away the activity.”

He’s not advocating for a world without regulation – he believes in age restrictions, banning cigarettes indoors and eliminating harmful additives – but one with free choice. “I don’t smoke tobacco cigarettes, but it’s not up to me to decide what benefit other people get from that product,” Hart says. “I am not the ruler and lord of their domain.”

He adds that history is teeming with failures of similar policies. Alcohol prohibition was meant to reduce domestic violence and poverty but instead fueled unimaginable violence and organized crime, with homicide rates increasing by 78%. The “war on drugs” was similarly disastrous, incarcerating millions of Black and Hispanic Americans without reducing the availability of illegal drugs. “Now if we think about tobacco in the same way,” Hart says, “the people who are gonna pay the price are the same people who pay the price – poor people.”

Indeed, nearly three-fourths of all US smokers come from lower socioeconomic statuses, with those below the poverty line twice as likely to smoke as those above it. It’s not hard to explain why: the tobacco industry has long targeted underserved communities, from including cigarette coupons with food stamps to saturating low-income neighborhoods with tobacco retailers – five times as many as the highest-income ones. Smoking disparities are a large part of what drives the 15-year life expectancy gap between the richest and poorest Americans.

So one of birthdate bans’ selling points is equity, reducing high smoking rates in vulnerable communities, according to Silbaugh and Ishak, the Brookline town meeting members.

Hart dismisses that as a cruel joke. “This is what we do: we pretend to care about those communities and not really deal with the issues they face.” They need gainful employment, health insurance, and pensions, but public health exploits their deprivation to justify paternalistic bans instead.

“What the fuck,” Hart scowls. “It just blows my mind.”

Take any set of drugs – say marijuana, heroin, amphetamines and hallucinogens – and ask yourself which ones should be legal versus illegal. There are certainly places at the extremes: Portugal, for instance, has decriminalized all drug use, while Singapore has attached the death penalty to consumption. But what exactly does the US do?

Mark Gottlieb, a public health lawyer at Northeastern University, describes how federal drug policy seems almost random, carved into stone by whoever’s in power, oddities of their own times.

Hart puts it more directly: “Whatever the white majority says is illegal, is illegal.”

The ideal, of course, would be to have society plot all drugs on a spectrum and legalize those whose benefits outweigh the harms. But it’s probably ridiculous to claim that harm reduction alone drives US drug policy, given that alcohol and cigarettes are not only legal but remarkably accessible. “I find it ironic that these two drugs collectively cause way more destruction, loss of life, loss of productivity than every other drug of abuse all combined,” says Lukas.

It might even be overly generous to lump cigarettes with alcohol. After all, when used exactly as its manufacturers intended, tobacco kills up to half its users, making cigarettes the deadliest object in the history of human civilization. And while 5% of individuals who drink are alcoholics, 90% of those who smoke are nicotinics, according to Robert Proctor, a professor of history at Stanford University. “But that’s not even a word, right? We don’t even have a word for nicotinics because almost everyone who smokes is addicted.”

Over the past 50 years, the national regulatory project has centered on shifting risk from institutions to individuals, with the tobacco industry leading the charge. Cigarettes themselves aren’t addictive, industry-funded scientists would parrot; it’s really that “certain people just can’t take it.”

Beyond the demerits of this seductively simple framework, cigarettes might also be the only consumer product where the people who use them wish they didn’t. Seven in 10 smokers say they want to quit, and 88% wish they had never started. “There’s never been a fish in the history of the world that wanted to bite the hook,” Proctor says. “They’re going for the bait.” Addiction is not about desire but rather the usurpation of desire.

Silbaugh thus sees cigarettes as being closer to lead and asbestos than to alcohol or marijuana. But at least those products had legitimate social uses: leaded gasoline helped engines run smoothly while asbestos’s strength made it great for construction. The cigarette, Silbaugh emphasizes, has no value beyond pernicious cycles of addiction.

“There was a time not that long ago,” says Gottlieb, “when the idea of advocating a tobacco endgame really couldn’t be discussed in professional circles.” Persuasion and regulation, sure, but prohibition was seen as excessive and, according to a former US surgeon general, riot-inducing. While a cold-turkey approach might still be off the table, a more incremental birthdate ban could chart out a middle ground between impact and feasibility.

Applying only to those born in the 21st century, the policy would help eliminate the highest-risk tobacco use – 99% of daily smokers begin before age 26 – while not denying cigarettes to people who have been legally using them (and find it almost impossible to quit). “This is designed to be a sympathetic approach with that need,” Silbaugh says, “but not let that need paralyze us.”

There are inevitably going to be some uncomfortable side-effects to the birthdate ban. After all, cigarettes are a “purchase driver” for gas stations, and the US gets over $12bn from tobacco taxes. What will happen to these small-business owners, and what’s going to fund education, infrastructure and everything else cigarette taxes bankroll? That’s not even to mention the potential dangers of the ensuing black market – smuggling, deadly additives and increasingly powerful crime syndicates – as Jacob Sullum, author of For Your Own Good: The Anti-Smoking Crusade and the Tyranny of Public Health, tells me.

But is the cure worse than the disease? Given the gradual implementation of birthdate bans, the economic hit would probably be spread pretty thin. Certainly, revenues would never increase, with future generations banned from buying cigarettes, but they’ll only fractionally decrease as existing smokers quit or die out.

And if birthdate bans aren’t affecting the existing market, who exactly is going to drive the contraband? I’m picturing 15-year-old dealers behind the school dumpster, packs of cigarettes laced under trench coats – but certainly not Al Capone. Of course, I know how creative teenagers can be: 22% of US high school students used marijuana and 29% drank alcohol in 2019. But the fearmongering that the harms of a black market would be nastier than cigarettes themselves seems overstated.

“We shouldn’t ban lead paint – that’ll create a black market,” says Proctor, mocking the freedom worrywarts. “We probably shouldn’t ban anything. In fact, we probably shouldn’t have any laws because laws are all bans. And bans erode freedom.”

“I’m going to give you an answer that I suspect you haven’t heard before,” Kenneth Warner says when I ask where birthdate bans should fit into the tobacco endgame. “I think it’s cute. I don’t think it’s very meaningful.”

How about Brookline’s policy?

“It’s almost silly.”

Warner is a world-renowned economist, former dean of the University of Michigan School of Public Health, and passionate advocate for tobacco control. He just doesn’t think birthdate bans would expedite cigarettes’ demise. After all, the policy would only affect young smokers or would-be smokers, and their cigarette use is already very low – about 2% of middle school students and 5% of high school students in 2020.

“Anything that affects a single birth year cohort takes many years to have an impact on the overall smoking rate,” he explains. What Silbaugh sees as regulatory cleverness, Warner considers a fatal flaw.

In Brookline’s case, Warner laughs at how easy it would be to bypass the ordinance: you could just bike over to Boston or Cambridge or Newton, or any other city in the county to purchase cigarettes – if you so desired. And with the town’s adult smoking at only 6.8%, “there aren’t that many people who are going to want to get them anyway,” he says.

Implemented only at the local level, the ban is probably a bit performative. But maybe that’s not such a bad thing. As Gottlieb, the public health lawyer, reminds me, the history of tobacco control is one of gradual progress, with local leadership pushing forward radical policies, from banning cigarettes in restaurants to raising the age of purchase to 21.

In fact, for seven years, Needham, Massachusetts, was the only town in the country to lift the smoking age, no one else daring to follow suit. But this bet paid off. As Gottlieb reported in the New England Journal of Medicine, Needham’s high school smoking rates were halved between 2005 and 2010, triple the reduction of its neighbors. Now, these students could also have biked over to Boston or Cambridge or Newton, but even incrementally raising the barrier to purchase was enough to dissuade many of them.

The Needham pediatrician Alan Stern, who first proposed raising the age of purchase, tells me that they had no specific evidence the policy would work, but “sometimes you make decisions because it seems like it’s the right thing to do”. In 2019, Tobacco 21 became federal law.

While Gottlieb can see Massachusetts adopting the birthdate ban, he’ll be the first to tell you that he can’t imagine Congress will follow suit. “Individual responsibility, individualism, pulling yourself up by your bootstraps, these are certainly baked into the American culture and politics,” he says, “and the most important thing that’s baked into American politics is the influence of money.”

But Proctor’s more bitterly optimistic. He tells me that, from 1890 to 1927, 15 states fully banned cigarette sales, and the power to do so is still vested in local communities and state governments. “What we’re starting to do is recover an imagination that was fully present 100 years ago,” Proctor says. “The history of the world is a history of corrupted imagination.”

Birthdate bans are far from perfect, and it’s impossible to say how much they will reduce smoking rates – if much at all. But at the very least, they could offer a start. Of course, we’ll still need to consider difficult questions like how e-cigarettes should fit into the endgame, or how this goal rubs against the broader drug decriminalization movement. And we’ll still need policies to reduce poverty and help existing smokers quit.

But none of these questions are insurmountable, and none of the efforts are mutually exclusive. New Zealand, for instance, plans to reach the tobacco endgame by 2025 by combining birthdate bans, very low-nicotine cigarettes and drastic sale restrictions to pummel tobacco from all directions.

Addiction is what really restricts freedom, Mary Jo says. It’s been 16 years since she quit smoking, but she still fights her cravings every single day. “Cigarettes are the worst drug,” she says, “because it stays with you.”

She’s excited about Brookline’s birthdate ban because it could protect her grandkids. But Mary Jo also says: “I pray to God that they just take it away, that they would never make one cigarette.”