Years ago, during my psychiatry clerkship in medical school, I learned to classify people with personality disorders as either “onions” or “garlics,” depending on their degree of self-knowledge. The “onions” were offensive to other people and knew they were offensive. The “garlics” were offensive to other people but didn’t know they were offensive. A person with a dependent personality was an “onion.” A narcissist was a “garlic.” Yet all of us are “onions” or “garlics” to one degree or another. People who purposely belch after big meals are “onions.” Leaf blowers who start work at the crack of dawn and dog-owners who run their big dogs off leash are “garlics.” Yet we don’t say these people have personality disorders, let alone herd them into therapy. The reason seems obvious, and yet that reason is hard to explain.
Similar confusion surrounds the issue of addiction. Addiction is defined as using a substance or engaging in behaviors in a compulsive manner despite harmful consequences. Opioid and alcohol addiction are classic examples. Over the years, the definition of addiction has expanded to include activities such as shopping and golf. But when one thinks about it, we all have compulsive behaviors that border on the harmful. Such behaviors are even central to our identities. We know people by what they love and what they hate, typically expressed in a sentence that begins with the word “I,” as in “I love this and I don’t love that.” This “I” of ours—including its peculiar property of loving one thing and not another with varying degrees of intensity, be it ice cream, work, or sexual partners—is how we distinguish one person from another in our minds.
The notion of addiction as a spectrum is not new. Shakespeare used the word addiction when referring to a “strong inclination” toward useless activities. But the notion has particular relevance today. Nicotine—once inhaled only through smoking, but now available in safer form through vaping—has thrown a monkey wrench into our understanding of what constitutes an addiction worth policing. When confined to adults, nicotine is less harmful than opioid or alcohol abuse, shopping to the point of bankruptcy, or golfing to the point of divorce. Yet government regulators spend an inordinate amount of time trying to regulate nicotine, while public health authorities hold sway on the issue by spreading anxiety among the public and arousing a consciousness of guilt.
If vaping nicotine sits on the safer end of the addiction spectrum, why does government pay so much attention to it? Indeed, the FDA recently proposed banning all JUUL vaping devices, pulling back only in response to public pressure. The answer is that regulators are using a half-century old model for policing addiction that has gone too far.
The Prohibition analogy
During the 19th century, religion gave America its first model for policing addiction, and alcohol became its first target. Although worried that alcohol might cloud a person’s God-given free will, religious activists quickly shifted their attention to alcohol-induced social pathologies, such as crime and family breakdown. In the early 20th century, social workers joined the movement. Prohibition passed in 1920.
Prohibition’s repeal in 1933 demonstrated the limits of the religious model. A fanatical bossiness tried to transform an entire country into a rigid obedience machine. Yet it is hard for religion to dictatorially impose a single world view on a country the size of America, as there are always enough people to resist such servitude and refuse to think in prescribed forms. It wasn’t just futile that religion aspired to do so; it was also banal. People missed drinking. Crime syndicates catering to their desire sprang up. Once state governments realized how much money in alcohol taxes they were losing, repeal became inevitable.
The religious model failed because, in the long run, the appeal of the sensual life is always stronger than that of any abstract teaching. While excessive drinking leads to ill health, modest drinking makes life pleasant. Because opiates lack this welcome upside, the 1914 Harrison Act restricting their use endured while Prohibition did not. President Franklin D. Roosevelt practically declared the triumph of the sensual life upon signing the bill to repeal Prohibition, when he teased, “I think this would be a good time for a beer.”
A more sustainable model for policing addiction ruled for the next 40 years. It swept into its net those substances that lacked redeeming qualities and caused serious social pathology. Alcohol’s pleasant upside shielded it from aggressive regulation. Although religious activists had succeeded in getting cigarettes banned in 15 states, the public resisted on that front, too. In 1964, when the Surgeon General published a report on smoking and health, 40 percent of Americans were regular smokers.
The common sense approach prevailed for the next few decades. Then another aggressive model for policing addiction arose—only not when people think. The seminal event was not the exposure of cigarettes as a health danger. American physicians had been discussing that problem since the late 18th century. Medical reports, actuarial studies, and epidemiological research in the middle of the 20th century simply confirmed it. That research culminated in the Surgeon General’s 1964 report declaring cigarette smoking a health hazard. Yet the addictive nature of smoking (and nicotine) was never addressed. The new warning labels on cigarette cartons and the new restrictions on tobacco advertising were meant to educate consumers and protect them from tobacco industry abuses, not from their own inclinations. Reformers saw smoking as nothing more than a bad habit. Their concept of addiction hardly differed from what Shakespeare had described four centuries before.
In the 1970s, neuroscience ushered in the modern concept of addiction—and with it a new model for policing addiction. Opioid receptors were discovered first. Research on neurotransmitters (especially dopamine) and brain circuitry followed, establishing the basis for addiction science, which quickly expanded beyond opioids to include alcohol and cigarettes, and, later, shopping and golf. Addiction science began to influence public policy in 1988, when the Surgeon General declared, “Cigarettes and other forms of tobacco are addicting.” During the 1990s, FDA commissioner David Kessler moved to regulate cigarettes more aggressively. The Supreme Court rebuffed his efforts, but in 2009, Congress gave the FDA the authority to proceed. Meanwhile, anti-smoking public health activists began to stigmatize cigarette smoking as a form of abnormal behavior.
The neuroscience model of policing addiction replicated the earlier religious model in tone but with some interesting twists. The older religious model believed in human free will and condemned alcohol for interfering with it. The new neuroscience model held that people lack free will and condemned addictive substances for exploiting their weakness. Neuroscience had already been arguing during this same period that the mind was an extension of the brain, and that human behavior originated not in free and independent decision-making, but in matter and energy relations that proceeded in a deterministic fashion. According to neuroscience, a person’s claim to identity, and even the feeling of “I” itself, were just illusions; a person’s inclination toward a particular substance or activity, which helped define that person, was a consequence of regularized neurotransmitter action and cellular processes rather than a free expression of individuality.
Although superficially less moralizing than religion, neuroscience’s understanding of addiction contained the same belief that people were fundamentally flawed, easily swayed, prone to illusion, and victimized by forces beyond their control. The big difference was that activists guided by the new neuroscience model saw the devil in more places, causing them to wage war on more fronts. They believed that people are so lacking in free will, so endangered by their irrationality and lusts, and so vulnerable to the dictates of neurotransmitter action, that they need to be closely watched in other areas of life—not just when consuming alcohol or cigarettes, but also, for example, when shopping or golfing. According to addiction science, all activities potentially lent themselves to addiction, since all activities can generate the necessary dopamine loops needed to turn an activity into a compulsion. The devil was now everywhere and potentially in everything.
Such thinking enabled activists to medicalize activities that Shakespeare had once casually referred to as “useless pursuits.” Because all useless pursuits threatened to rob people of their time or money, and since the inclination toward these pursuits supposedly had a biochemical basis beyond the person’s control, more regulations and mental health interventions were called for. What was once said of the husband who played too much golf—that it was “just his way”—was now a matter of “disease,” justifying counseling or other professional therapies.
The neuroscience model had a second twist on the old religious model. Early on, the religious model shifted its focus from the individual to social concerns. The neuroscience model, in contrast, stayed true to religion’s first intentions. It kept a watchful eye on the individual; it remained committed to perfecting the person. So, even when addiction failed to cause serious social pathologies, it remained a concern. Lifestyle addictions, which some people even boasted of having, ranging from eating to gaming to plastic surgery to thrill-seeking activities, were now pathologized through neuroscience despite lacking harmful social effects. Each addict, whatever the basis for his or her addiction, was now first and foremost a patient independent of whether or not he was also a troublemaker.
The neuroscience model inevitably led to pushback. Ideologues always underestimate the resistance rooted in the inertia of human beings; they always think that decisive reform can be realized quickly in real life as with their intellectual constructs. Critics called the new order the “nanny state.” They had no problem with government cracking down on addictions that caused serious social pathologies or that risked harm to others—for example, enforcing drunk driving laws or policing second-hand smoke in the workplace. But in private life, in sensual life, in the life of the individual, they wanted to be left alone to enjoy the little pleasures that made life easier, whether it involved eating fatty foods, playing video games, or smoking. One person’s addiction was another person’s preferred way of blissfully relaxing, they declared. They refused to fit into the pious, obedient herd, where all that was unique to them, and pleasant to them, threatened to be dissolved without a trace into the general order.
The problem of nicotine
At first, nicotine posed no real threat to the neuroscience model of policing addiction. Inhalable nicotine was trapped inside cigarettes, which were dangerous to individual smokers and to those who lived or worked in close proximity to them. That nicotine was also addictive seemed not to matter; the tar and carbon monoxide in cigarettes sufficed to condemn the whole carton. Although many smokers grumbled about the new restrictions and taxes placed on cigarettes, they accepted the reasoning behind them.
The problem arose in the first decade of the 21st century, when industry separated nicotine from tobacco and made it available for vaping in pure form. Government’s insistence on regulating nicotine as aggressively as it had regulated cigarettes flushed out the truth behind the neuroscience model of policing addiction. Although vaping nicotine was safer than smoking cigarettes, and second-hand nicotine vapor was safer than second-hand smoke, none of this seemed to matter to the regulators. What mattered was that nicotine was an addictive substance—perhaps one of the most addictive substances. To give nicotine a pass would be to undermine the neuroscience model of policing addiction, as it would mean that addiction was not the major concern after all—that instead serious disease and social pathologies were the concern. This would mean returning to the policy of the 1960s and letting people freely act out what Shakespeare had called their “strong inclinations” toward useless activities. Forgiving nicotine meant reinvigorating the sensual life at the expense of neuroscience’s abstract model of behavior.
The Biden administration’s recent demand that industry drop the nicotine level in cigarettes to minimal or non-addictive levels reveals how nicotine addiction rather than serious disease remains the neuroscience model’s primary concern. Lower nicotine levels in cigarettes will have no effect on dangerous tar or carbon monoxide levels. People will still be at risk if they smoke. Even if they avoid developing a smoking addiction, they will still be able to smoke as much as if they were addicted. Indeed, with less nicotine in cigarettes, smokers may feel free to smoke even more, creating more of a health hazard.
Yet for many regulators, nicotine’s addictiveness is the central issue. Much of the regulatory apparatus that has grown up over the last 30 years, along with much of the counseling industry that works in the area of lifestyle addictions, operates on the assumption that people are practically wired to be addicts—a hopeless, unruly mob of sinners. Viewed from this perspective, giving people freedom is risky, as it is inherent in people to abuse such freedom. It is why, according to adherents of the neuroscience model, people must be held on a tight leash. To do otherwise not only contributes to human fallibility, but also gives up on the goal of perfecting people.
Americans who vape nicotine, either to quit smoking or because they enjoy the experience, are fighting back. But their fight is really the old fight over Prohibition in a new guise. The religion-social worker axis is now the neuroscience-public health axis. The distinction that sensible people tried to draw in the 1920s, between the amiable social drinker and the bitter alcoholic who drinks alone, is today the distinction between the person who vapes and enjoys an innocent fix of pleasure, and the smoker who pants on home oxygen because his or her lungs are black with tar.
As during Prohibition, today’s regulators seem surprised by the rebellion. They do not understand why people refuse to be pressed down, shut up, plugged up, and obediently bottled. It is always the way of adherents devoted to a single idea, whether the idea is banning alcohol or banning nicotine: such people grow insensitive to any other thought than their own, even if it is a very human thought. They also forget that compulsion rarely makes people better, and that those who want to force others to behave the way they do are like doctors trying to push food into sick people’s mouths with a stick.
The sensual life is separate from neuroscience. In theory, all of us are addicts, and all of us could benefit from treatment. But the sensual life, although a realm of human fallibility, passions, and distractions, is vital to people’s wellbeing. It has a different purpose to that of neuroscience. Let us preserve this small oasis of sensual pleasure in a universe of scientific regulation. If the nicotine addict who vapes is neither seriously harmed nor a risk to society, let that person continue to enjoy a small portion of life the way our ancestors did, as they wish, relishing the sensual life as they have chosen. Let us agree there really is an “I” that loves this and doesn’t love that, not an illusion generated by neurotransmitters but a real entity deserving of respect, whose every carefree breath is not a sin.