Smoking is not bad

He had yellow nails, leather neck, stained teeth and a deep cough. He wheezed slightly, breathed too quickly and occasionally sprinkled the white handkerchief red. No surprise his ticket to my office was a lung mass to match. We talked about tests, treatment and prognosis.  About the future, probably short.  Devastated, he was not surprised.  He was reaping the reward of 30 smoking years.  He sadly admitted, “I knew better, but I was bad.”

Bad? Guilty?  At fault?   He had committed himself to a short life ending in misery.  Of course, he had been “bad.”  Someone had to be at fault for this sick 54-year-old man!  He had walked a short road to the grave.  He was an adult, after all.  An independent soul.  He had been weak, frail and bad. Now he would reap a horrid harvest.

This is a TV defense lawyer’s trick.  “She was wearing a short skirt.”  “The door was wide open.”  “There was no fire alarm.”  “He asked for it.”  Forget personal responsibility.  Lead humans like swine.  Blame the victim.

Does this make sense? Are smokers ”bad” because of the habit and the damage they do to their bodies?  Is there really “fault” in the tobacco tragedy?  I would propose that when it comes to smoking there is indeed bad.  There is evil.  There is murder, mayhem, and terror.  However, to convict smokers of personal homicide makes no more sense than to blame the house for the arsonist.

Smoking cigarettes is not like other “bad habits.”  It is not the same as sunburn in mid-day July, driving 90 mph on a mountain road or scaling an electric fence.   In these activities, there is choice.  No one is forcing stupid behavior upon us. We voluntarily, of free will, elect to test mortality.   For most “bad” behaviors, the attacker and attackee are one.  Not so tobacco.  Smoking cigarettes is entirely different.  It is a behavior beyond free will.  It is addictive.

Nicotine is one of the most addictive chemicals known to man.  Milligram for milligram, dose for dose it is more addictive than cocaine or heroin.  More then 90% of people exposed a single time cannot stop.  This addiction means that a biological change occurs in the victim’s brain.  A chemical tattoo to the cortex. This short-circuits free will.  It becomes chemically almost as important to a smoker as food, warmth or even breathing.

It makes no sense to blame the smoker for the behavior or the health consequences, which follow.  They are hooked junkie cigarette zombies.  Without massive efforts to quit or medical care, they will continue to smoke until they die 10 years too soon.   However, we are left with a quandary.  With millions of people world wide suffering and dying in a horror show that rivals the killing fields of both World Wars, someone must be to blame!

I say convict the pushers.   The suppliers of seed, the tillers of fields, the manufacturers, the packagers, the shippers, the marketers, and the sellers.  Any politician, who protects the murderous monopoly.  Any banker who payrolls mass slaughter.  This system of production, which uses an addictive product to reap dollars from death, is criminal.  Can we convict the 16-year-old high school student, as she is chemically mutated into 40-year cash machine?  How about the 34-year-old father, already stressed trying to support his family?  Perhaps accuse the gasping emphysema patient who still cannot quit.  The tobacco industry makes “bad” seem gentle.  They are monsters that commit murder with the immorality of the worst fascists in all history.

Tobacco users are victims and to blame them is to create false pariahs.  They need support, help and care.  They need to do everything possible to quit.  However, accusing smokers makes treating their addiction hard and their unneeded guilt delays therapy.  It also distracts us from the overwhelming need to destroy the drug dealers who sell nicotine products.  For them there should be no quarter, no mercy, and no consideration.  For them there should be nothing but blame.



  • Kathy Stevens
    You continue to amaze me~! I love reading Sunrise Rounds. Would love spending a day with you and your wife...talking, LISTENING~! Thank you!!
    • James Salwitz, MD
      Thank you very much. jcs
  • Salwitz, Richard
    Great, but I think you're preaching to the choir.
    • James Salwitz, MD
      Perhaps, but you cannot say it often enough or loud enough. One life saved? jcs
  • Bette Holmboe
    Thanks for educating those who think smokers are stupid I,m a victim of ttabacco
    • James Salwitz, MD
      It is a battle we all need to fight together. jcs
  • I have to say that I blame the government too. I used to smoke and one day I was introduced to an e-cig. I started with nicotine cartridges and then slowly came down to 0 nicotine carts before I totally gave up smoking. Now, I use my e-cig once in a blue moon. The American Association of Public Health Physicians endorse e-cigarettes to be a safe alternative to smoking. Why can't the government, particularly the FDA look into them as they have the potential to save millions of lives? Instead, it misinforms the public and promotes products like Chantix.
    • James Salwitz, MD
      You are absolutely correct. There can be no doubt that government at both the State and Federal level has failed in its obligation to protect the American people. Further, various governmental bodies have supplemented, coordinated and supported the tobacco industry. Thank you very much for your comment. Congratulations on quitting! jcs
      • Thank you for your kind words! I actually really enjoyed your article. I used to be one of those people who believed that smoking was a choice. But I've come to learn how wickedly addictive nicotine can be. Electronic cigarettes are quite an amazing invention, and I honestly wish that they be shown due attention. When you can make the world a better place (for everyone in it) why not try? The government is afraid that e-cigarettes can be influential to children to pick up smoking especially with the ease of availability (online) and the multiple flavors they come with. But hasn't the government been successful (for the most part)at controlling alcohol? And what about other drugs? If they really wanted to, they could easily bring e-cigarettes to the table.
  • Preach to the choir -- it reminds us when it's time to sing again. Thank you. I'm sharing this with my politically-minded friends. WW III
    • James Salwitz, MD
      I hope that if the choir sings loud enough we will bother the people in the next building. jcs
  • Adrienne Clark
    90% of people that smoke one cigarette become addicted? BS. My friends from college and I all smoked from time to time. None of us smoked at all after college. Reference please. While I do think cigarette smokers deserve comopassion and non-judgemental care, I do believe that there needs to be personal responsibility. Anyone over the age of 10 knows that cigarettes are dangerous. Smoking cigarette after cigarette after cigarette is a choice.
    • James Salwitz, MD
      I am thrilled that you have avoided long term cigarette use. I wish you were correct that cigarette smoking is most commonly an independent personal choice. However, as you point out, everyone over the age of 10 knows that cigarettes are dangerous, but 400,000 people die in this Country yearly from cigarette smoking and six million world wide. Only 3 - 7 percent of smokers who attempt to quit without assistance, succeed. I.E. the drug the so addictive that despite their wish to take personal responsibility for their health, they can not. jcs
  • strayan
    You are spreading misinformation. The vast majority of smokers quit and succeed without any medical of formal 'assistance' at all. In-fact unassisted quitting has the highest success rate based on overall numbers. You seem to forget that millions of people became ex-smokers before doctors began treating people for cigarette dependence. Please educate yourself: By the way, nicotine [on its own] has very weak habit forming qualities. Even the man himself Karl Fagerström (of Fagerström Test for Nicotine Dependence fame) now agrees: You might want to brush up on your knowledge on this subject.
    • James Salwitz, MD
      Thanks very much for your comment and links. The first article does come to the bizarre and otherwise unsupported claim that it is easy to quit smoking. It is a rather complex and dense piece of writing as the authors clearly have a bias. No major author or study has supported the concept that it is easy to quit smoking. I agree with you that the main way to stop smokers is by getting them never to start or to use education to help them to quit. That way doctors do not ever need to be involved at any end of the smoking spectrum (i.e. quitting or treating smoking's affects). The contribution of the second article to your argument confused me. It clearly states that nicotine is the main reason for tobacco addiction. It is just that Fagerstrom believes that there are other agents in tobacco which add to the addiction. Not very reassuring. Thanks again, jcs
      • strayan
        Umm, "unsupported claim", how do you figure? Did you somehow miss the 71 supporting references? Please explain why the authors' arguments are unsound. Claiming "bias" without elaborating is not a valid rebuttal. Meanwhile, a clinical approach to tobacco cessation (which you are clearly pushing) has been an abysmal failure. Sales of NRT and bupropion and exposure to advertising of these products have had no detectable impact on the prevalence of smoking. Here's the supporting data: What you fail to understand in respect to the second article is that it is only nicotine IN TOBACCO that has habit forming qualities. Nicotine without tobacco does not; this is why becoming hooked on nicotine replacement therapy is a rarity. Fagerstrom proposes that his famous test ought to be renamed for precisely this reason. Your article neglects to make this distinction and I wanted to draw your attention to it.
        • James Salwitz, MD
          Thanks again, interesting thoughts. In reverse - Extensive studies have shown nicotene to be highly addictive by itself, in animals and humans. But, even if that were not true, the fact that it is addictive in cigarettes is the lethal key point. That is what kills people. I agree would agree with the general concept that techniques of smoke ending to date have been inadequate. 400,000 dead in the U.S.A. this year from cigarettes certainly prove that hypothesis. Your link supports increasing the cost (i.e. taxes) on cigarettes, as a valuable weapon. Your thought that I am "clearly pushing" medicinal intervention misses two points. First, in my blog I am "clearly pushing" going after the producers of cigarettes, not the victims. And secondly, you might have forgetten who I am ... I am the one who smokers visit when it is too late. My only bias is to put myself out of business. The plosmedicine article is a rambling, dense review of a wide scattering of often unrelated, uncontrolled data and opinion. However, at some level one hopes that it is at least partially correct. It would be encouraging to think that a continued aggressive education campaign, combined with increased tobacco taxation, clinical intervention and political pressure on producers might someday wipe out smoking. Until that day the reaper will continue to harvest the tobacco fields. jcs
  • I smoked. I chose to smoke and I enjoyed it immensely for many years. I did so full well knowing the health risks and accepting the trade-off for those risks as part of the way I wanted to live MY life. I tried to quit a few times because people wanted me to quit, although I still wanted to smoke, so that didn't work very well. However, when I no longer wanted to smoke, I stopped smoking and haven't smoked in 10 years. Perhaps I'm different than others. I don't know. But please don't call me a victim.
    • lisa delille bolton fnp
      I am intrigued by your experience with quitting and the power of personal choice. I am a new clinician in primary care, hoping to cut down on the number of patients who end up needing an oncologist, wonderful as this Dr S. sounds. I ask all pts about tobacco exposure while listening to lungs. Pts who smoke expect to be scolded; I go the other way. I validate that it is hard, I encourage any thoughts of quitting as a great first step, I praise past quitting as evidence of potential future success, I tell all patients that they have the power to choose to quit, and I am positive and kind. I'm testing the validity of behaviorial change theory aka parenting where you praise that which you would encourage and overlook the rest. Meanwhile, the same amoral corporate greed behind cigarettes also drives the processed food industry with its abysmal practices toward animals and low-wage employees alike. Some research suggests that foods with highly concentrated sugar/fat/salt contents trigger the same addiction centers in the brain as other drugs, suggesting a partial explanation of obesity. I would argue that obesity and poor nutrition are as hard on patients as smoking, and that like smokers, patients who overeat feel very "bed." Thank you Dr S for the perspective on fear and guilt and how to marshall these feelings constructively in practice.
      • lisa delille bolton fnp
        Bad, not bed.
      • James Salwitz, MD
        I suspect you are correct, that we are hard wired to "addict" to certain foods almost as readily as tobacco. Certainly the exploding obesity "epidemic" supports that theory. On the other hand there is no doubt in my mind that the intervention by a trusted primary care physician, especially early, can reverse or temper such destructive life styles. I agree that a supportive positive approach works much better than "yelling" at your patients. Thanks, jcs